Every finding on record at Maison D'Acadiens Care Center

Based on interviews and record reviews, the facility failed to ensure the discharge summary included a recapitulation of the resident's stay for 1 (Resident #66) of 3 closed records reviewed. Findings:Review of the facility's policy titled Discharge Summary and Plan with a revised date of 03/2025 read in part, When a resident's discharge is anticipated, a discharge summary is created and the discharge plan is finalized to assist the resident with plans for care after discharge. Discharge Summary: 1. a. discharge summary includes: a recapitulation of the resident's stay at the facility (a concise summary of the resident's stay and course of treatment in the facility). Review of Resident #66's medical record revealed an admission date of 03/31/2026 and a discharged date of 04/10/2026.Review of Resident #66's Discharge summary dated [DATE] revealed in part, Resident #66 was discharged to another facility. Further review of discharge summary revealed no recapitulation of Resident #66's stay in the current facility. Review of Resident #66's departmental facility progress notes revealed a nursing note documented on 04/10/2026 at 8:00 a.m., read in part, Resident #66 leaving at this time, 8:00 a.m., with staff driver in transport to new facility. Attempt made to call and give report, no answer. Message left on nursing facility's answering machine for call back.On 06/09/2026 at 11:31 a.m., requested Resident #66's recapitulation of his stay from S6 SSD. Interview on 06/09/2026 at 12:44 p.m., S6 SSD confirmed that Resident #66's discharge summary did not include a recapitulation of his stay.Interview on 06/09/2026 at 1:34 p.m., S3 ADON confirmed Resident #66's discharge summary didn't include a recapitulation of his stay at the facility but should have.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to ensure staff changed gloves and performed hand hygiene after touching contaminated areas during wound care for 1 (#10) of 2 (#4 and #10) residents observed for wound care. Findings: Review of the Facility's policy titled Wound Care with a revision date of 04/2026 read in part.Purpose: The Purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure:8. Put on exam glove. 9. Loosen tape and remove old dressing.10. Pull glove over dressing and discard into appropriate receptacle. Remove the second glove.11. Perform hand hygiene.12. Put on clean gloves. Review of Resident #10's medical record revealed an admission to the facility on 7/22/2024 with a readmission date of 12/30/2025 with the following diagnoses in part Hemiplegia and Hemiparesis following a CVA affecting the non-dominant side, Non-Pressure Chronic Ulcer to Left Heel, Cirrhosis of Liver, Type 2 Diabetes Mellitus, Traumatic Subdual Hemorrhage without loss of consciousness, and Chronic Viral Hepatitis C. Review of Resident #10's 06/2026 Physician Orders read in part:06/05/2026 - Apply Dakin's External Solution topically to left plantar heel and cover with dressing daily related to Diabetic foot ulcer. An observation on 06/09/2026 at 9:32 a.m. of Resident #10's wound care provided by S9 Treatment Nurse to left heel-Diabetic Ulcer revealed S9 Treatment nurse failed to remove soiled gloves after removing soiled bandage from the wound. S9 Treatment nurse then reached into the clean field with soiled gloves, obtained a clean 4x4 and cleaned the wound. S9 Treatment nurse then placed the soiled 4x4 onto the clean field and removed gloves. S9 Treatment nurse confirmed she did not remove gloves after removing the soiled bandage, cleaned the wound without changing soiled gloves, and placed a soiled 4x4 into the clean field, but should not have.

Based on observation, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. The facility census was 65. Findings: Review of the facility's policy on 06/09/2026 at 12:52 p.m. titled: Sanitization with a revised date of 11/2022 read in part . The food service area is maintained in a clean and sanitary manner. Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration.Observation of the facility's kitchen on 06/07/2026 at 8:44 a.m. accompanied by S5 [NAME] revealed: The kitchen's floor was heavily soiled with unknown brown substances and food items. Underneath the sink, was an uncovered crate that held multiple dirty and soiled towels. Observation of the facility's kitchen on 06/07/2026 at 10:45 a.m., accompanied by S4 Dietary Manager revealed: The kitchen's floor was heavily soiled with unknown brown substances and food items. Underneath the sink, was an uncovered crate that held multiple dirty and soiled towels.Interview on 06/07/2025 at 1:01 p.m., S4 Dietary Manager stated they threw used and dirty towels into the uncovered crate under the sink because they had nowhere else to place them. S4 Dietary Manager confirmed that the kitchen floor was dirty and the used and dirty towels should have been stored appropriately elsewhere, but had not.

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary services to maintain good grooming. The facility failed to provide proper hair grooming for 1 (#54) of 17 sampled resident. The current census was 65.Findings: Review of the facility's policy titled Activities of Daily Living, Supporting with a revised date of 03/2018 read in part.Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services will be provided for resident, including support and assistance with: a. Hygiene (bathing dressing grooming, and oral care) Review of Resident #54's medical record revealed an admit date of 05/06/2025 with the following diagnoses in part .Major Depressive Disorder, Anemia, Chronic Kidney Disease, and Mild Intellectual Disability. Review of Review #54's Annual MDS with an ARD date of 05/13/2026 revealed Client #54 has a BIMS score of 15 indicating intact cognition. Resident #54 required supervision/touch assistance with personal hygieneAn observation on 06/07/2026 at 10:05 a.m., Resident #54 observed with 4 inch long hair to back of head with little hair to top of his head. Resident #54 stated that he likes his hair cut short but does not think that they cut hair here at this facility. An observation on 06/08/2026 at 10:30 a.m., with Resident #54 observed sitting in room, resident continued with long hair around 4 inches long to back of head. An interview on 06/08/2026 at 10:48 a.m., S7 Activity Director stated that the facility does not have a hairdresser that comes out on a regular basis. S7 Activity Director revealed that she's never asked Resident #54 if he would like his hair cut. An interview on 06/08/2026 at 12:59 p.m., S8 [NAME] Clerk/CNA Supervisor accompanied this surveyor to Resident #54's room, S8 [NAME] Clerk/CNA Supervisor asked Resident #54 if he would like his hair cut today, and he stated that he would like for it to be cut short.

Based on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 62 residents who resided in the facility. Findings: Review of the facility's policy on 06/18/2025 at 4:00 p.m. titled Pest Control with revision date of 05/2008 read in part . Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is free of insects and rodents. Observation of the facility's kitchen on 06/16/2025 at 8:48 a.m. accompanied by S11 Dietary Manager revealed: There were multiple flies observed throughout the kitchen area with flies landing on the kitchen stove and food prep area. The dry food pantry contained 3 large storage bins and within the (1) flour bin there were 3 small black insects. Interview with S11 Dietary Manager on 06/16/2025 at 8:48 a.m. confirmed the above findings. S11 Dietary Manager stated the kitchen should be free of insects, but was not. Observation on 06/16/2025 at 11:14 a.m. of the facility dining area for lunch meal service revealed multiple flies landing on resident's food items during meal service. Observation on 06/17/2025 at 8:13 a.m. of X Hall revealed multiple flies within hallway and Room A. Interview with S8 LPN confirmed the findings and stated Room A almost always had flies within the room, but should not.

Based on observation, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. The facility census was 62. Findings: Review of the facility's policy on 06/18/2025 at 4:00 p.m. titled: Sanitization with a revised date of 11/2022 read in part . The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Observation of the facility's kitchen on 06/16/2025 at 8:48 a.m. accompanied by S11 Dietary Manager revealed: The kitchen's floor was heavily soiled with mud and food items. The kitchen's microwave was unsanitary with dried food splattered on the top and bottom. Interview with S11 Dietary Manager on 06/16/2025 at 8:48 a.m. confirmed the above findings. S11 Dietary Manager stated both the floor and microwave needed to be cleaned.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene by failing to provide ADL care for 1 (Resident #54) of 24 sampled residents. Findings: Review of the facility's policy titled Activities of Daily Living (ADL) with a revision date of 03/2018 read in part . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). Review of Resident # 54's Clinical Record revealed an admit date of 04/19/2024 with diagnoses which included: Alcohol Dependence with Alcohol-Induced Persisting Dementia; Extended Spectrum Beta Lactamase Resistance; Malignant Neoplasm of the Prostate; Cerebral Infarction due to Occlusion or Stenosis of Small Artery; Opioid Abuse; and Encephalopathy. Review of Resident #54's Quarterly MDS with ARD of 06/11/2025 revealed a BIMS score of 7 (indicating severe cognitive impairment). Resident #54 required substantial/ maximal assistance with showering/bathing and dressing his lower body. Review of Resident #54's Care Plan dated 04/19/2024 revealed in part . Resident #54 has an ADL self-care performance deficit. Resident #54 required one person assist with bathing, dressing, and grooming. Observation on 06/16/2025 at 10:02 a.m. revealed Resident #54 lying in bed wearing a hospital gown, dirty non-skid socks, and a hospital arm band to the left wrist. Resident #54's hair appeared oily and unkempt. Resident #54's fingernails were long and observed with brown substance under the nail. Resident #54 stated that he was unsure when he last received a bath. Observation on 06/17/2025 at 12:58 p.m. revealed Resident #54 lying in bed with the same dirty non-skid socks on his feet and continued with long fingernails with brown substance under them. Interview on 06/18/2025 at 11:52 a.m. with Resident #54 confirmed he received a bath yesterday and his gown was changed. Resident #54 reported staff did not change his socks at that time. Interview on 06/18/2025 at 12:10 p.m. with S18 CNA revealed activities of daily living (ADL) care included: bathing, dressing (including changing socks), and linen change. S18 CNA revealed nail care was included in ADLs for all residents except diabetics. Interview on 06/18/2025 at 12:50 p.m. with S19 CNA Supervisor confirmed that Resident #54 should receive a bed bath daily due to isolation precautions. S19 CNA Supervisor confirmed Resident #54's gown, linens, and socks should have been changed with every bath and were not.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by: 1. failing to ensure staff performed hand hygiene between residents while feeding dependent residents; and 2. failing to ensure staff followed enhanced barrier precautions while providing direct patient care for Resident #23. Findings: 1. Review of the facility's policy entitled, Assistance with Meals revised 03/2022 revealed, in part .all employees who provide resident assistance with meals shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Observation of the dining room on 06/16/2025 at 11:46 a.m. revealed S5CNA feeding two residents. S5CNA repeatedly touched the utensils, cups, and clothing protectors of the two residents, without performing hand hygiene. Interview with S5CNA on 06/16/2025 at 12:08 p.m. revealed she was to sanitize her hands between contact with residents, their utensils, cups, and clothing protectors, but did not. Interview with S3ADON on 06/17/2025 at 2:49 p.m. confirmed staff was to use hand sanitizer or hand hygiene between feeding and/or direct contact with residents. 2. Resident #23 On 06/18/2025 at 12:45 p.m. review of facility policy titled, Enhanced Barrier Precautions with revision date of December 2024 revealed in part . Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-resistant organisms (MDROs) to residents. Enhanced barrier precautions apply when a resident has an indwelling medical device. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include in part . dressing. Review of Resident #23's electronic medical record revealed an initial admit date of 06/01/2020 with admitting diagnoses of Spastic Diplegic Cerebral Palsy, Acute Cystitis without hematuria, Paroxysmal Atrial Fibrillation, Presence of cardiac pacemaker, Sick Sinus Syndrome, Combined Systolic and Diastolic (Congestive) Heart Failure, Severe Protein Calorie Malnutrition, Acute Respiratory Failure with Hypoxia, Acute Hepatitis C without Hepatic Coma, and Dysphagia following Cerebral Infarct. Review of Resident #23's Annual MDS with ARD of 05/28/2025 revealed Resident #23's cognition was severely impaired. Resident #23 was dependent on staff for dressing, transfers, and personal hygiene. Resident #23 had an abdominal Percutaneous Endoscopic Gastrostomy (PEG) tube. On 06/18/2025 at 10:13 a.m. observation revealed S9CNA dressing Resident #23 without wearing a disposable gown. On 06/18/2025 at 10:15 a.m. interview with S9CNA revealed she was familiar with Resident #23 and the care and precautions Resident #23 required. S9CNA confirmed she did not don a disposable gown prior to performing direct patient care for Resident #23 and should have. On 06/18/2025 at 1:20 p.m. interview with S3ADON, whom was also the facility Infection Preventionist (IP), revealed Resident #23 was on enhanced barrier precautions. S3ADON confirmed all staff were required to don gloves and a gown prior to performing direct patient care for Resident #23, dressing included.

Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (Resident #47) of 24 sampled residents. The facility failed to ensure all medical records regarding code status consistently reflected Resident #47's wishes to be a DNR (Do Not Resuscitate). Findings: Review of Resident #47's electronic medical record revealed an admit date of [DATE] with admitting diagnoses of Cellulitis of Right Lower Limb, Unspecified Neuralgia and Neuritis, Severe Sepsis with Septic Shock, Adult Failure to Thrive, Anemia, Moderate Protein Calorie Malnutrition, Hyperlipidemia, Depression, and Essential Primary Nutrition. Review of Resident #47's admission MDS with an ARD date of [DATE] revealed in part . Resident #47 had a BIMS score of 9, which indicated moderate cognitive impairment. On [DATE] at 11:02 a.m. review of Resident #47's [DATE] physician orders revealed an order dated [DATE], listing the code status as Full Code and an order dated [DATE], listing code status as DNR (Do Not Resuscitate). On [DATE] at 11:30 a.m. review of Resident #47's care plan revealed Resident #47 was a Full Code with interventions that included: if respiratory/cardiac arrest occurs perform Cardiopulmonary Resuscitation (CPR), continue CPR until resident responds or Emergency Medical Services (EMS) arrives and assumes code responsibilities, review code status with resident/family with each review to ensure wishes have not changed and wishes are respected. On [DATE] at 10:56 a.m. review of Resident #47's paper chart revealed a form titled Resident/Family Consent for Cardiopulmonary Resuscitation which read in part . Cardiopulmonary Resuscitation (CPR) SHOULD NOT be done on this Resident and was signed and dated by Resident #47 on [DATE], and signed by Resident #47's physician on [DATE]. On [DATE] at 12:08 p.m. interview with Resident #47 revealed she signed a DNR form with facility upon admission. Resident #47 confirmed her code status was DNR. Interview [DATE] at 12:15 p.m. with S3ADON and S10RNConsultant revealed there was conflicting Code Status information within Resident #47's medical records, and it should not have been.

Based on interview and record review, the facility failed to ensure the NOMNC Form CMS-10123 (Notice of Medicare Non-Coverage) was provided to the resident and/or the resident's representative prior to discharge from Medicare Part A services for 2 (Resident #115 and Resident #116) of 2 sampled residents for Advanced Beneficiary Notice (ABN). Findings: Review of the SNF Beneficiary Notification Review forms completed by the facility revealed the following: Resident #115- Medicare Part A Skilled Services Episode start date 12/20/2024; last covered day 01/06/2025. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. No evidence of NOMNC Form CMS 10123 being issued. Resident #116- Medicare Part A Skilled Services Episode start date 01/17/2025; last covered day 02/03/2025. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. No evidence of NOMNC Form CMS 10123 being issued. Interview on 06/18/2025 at 12:30 p.m. with S12 HR/BOM stated that Resident #115 and Resident #116 did not receive the NOMNC Form CMS 10123 prior to discharge from Medicare Part A services, but should have.

Based on interview and record review, the facility failed to document discharge planning for a resident who had expressed a desire to discharge. The facility failed to document a referral to an outside entity, and the responses received from the outside entity, for Resident #45. The total sample included 20 residents. Findings: Review of the facility's policy entitled Discharge Summary and Plan, revised 03/2025, revealed, in part .when a resident's discharge is anticipated, a discharge summary is created. The discharge summary includes information necessary for the care of the resident while residing in the facility, and after his/her discharge. The medical record contains a copy of the discharge summary. Referrals made for the purpose of discharge are documented in the medical record. Review of Resident #45's medical record revealed an admission date of 09/18/2023 with diagnoses including, in part .Encounter for surgical aftercare following surgery on the digestive system, MDD, Arthritis, Overactive Bladder, Acute Hepatitis C, Epilepsy, and Metabolic Encephalopathy. Review of Resident #45's Quarterly MDS with an ARD of 04/16/2025 revealed a BIMS Score of 15, indicating intact cognition. Resident #45 participated in the assessment and goal setting. Resident #45 wanted to leave the facility and return to the community. Review of Resident #45's Quarterly Social Services Assessments revealed, in part .Resident #45 indicated she wanted to return to the community with aides to provide assistance with medications and shopping on 10/04/2024, 01/22/2024, and 04/16/2025. Interview with Resident #45 on 06/16/2025 at 10:41 a.m. revealed she had been awaiting discharge since 12/2024. Interview with S4SSD on 06/17/2025 at 9:26 a.m. revealed Resident #45 did not have a documented discharge plan. S4SSD confirmed Resident #45 had requested discharge in 12/2024. S4SSD revealed she had referred Resident #45 to a program on 12/19/2024, and representatives from the program had screened the resident on 03/03/2025. S4SSD received an email from the program on 06/04/2025 which indicated Resident #45 was being assessed by their team to determine if she meets the requirements. S4SSD revealed two representatives from the program visited Resident #45 approximately one-and-a-half weeks ago. S4SSD confirmed Resident #45 did not have a documented discharge plan which included the referral to the program or any of the responses from the program, but should have.

Based on record review and interview the facility failed to offer the Pneumococcal Vaccine on admit to the facility for 1 (#45) of 5 (#19, #45, #46, #54 and #60) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations. Findings: Review of the facility's policy with a revision date of 04/2022 titled Pneumococcal Vaccine revealed in part .All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infection. Policy Interpretation and Implementation: 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated. Review of Resident #45's clinical record revealed an admission date of 09/18/2023 with diagnoses that included: Encounter for Surgical Aftercare, Major Depressive Disorder, Epilepsy, Chronic Obstructive Pulmonary Disease, and Chronic Viral Hepatitis C. Review of Resident #45's clinical record revealed no evidence that she had received the Pneumococcal vaccine. Resident #45's admission records revealed no consent or declination form for the Pneumococcal vaccine. Interview on 06/18/2025 at 2:20 p.m. with S3 ADON stated that Resident #45 was eligible for the Pneumococcal vaccine. S3 ADON confirmed that Resident #45 had no consent or declination form signed on admission for the Pneumococcal vaccine, but should have.

Based on observation, interview and record review, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Expired/ outdated items were not available for resident consumption; 2. Dry food storage room was clean and free from residue from insects; 3. Kitchen utensils/ scoops were stored under sanitary conditions; 4. Refrigerated food contents were labeled and dated; 5. Kitchen linens were clean and properly stored. The total facility census was 63 residents. Findings: Review of the facility's Policy and Procedure titled, Food Storage read in part . Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Procedure: 1. Storage areas will be free from rodent and insect infestation, and will be treated for pests and vermin on a regular basis. 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. 7. c. Date markings will be visible on all high-risk food to indicate the date by which a ready-to-eat. TCS food should be consumed, sold or discarded. 9. Scoops must be provided for bulk foods (such as sugar, flour and spices). Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. Scoops are washed and sanitized on a regular basis. Observation on initial tour of the kitchen on [DATE] at 6:05 a.m., accompanied by S4 DM, revealed the following items on the shelf available for use: 1. Four -12 pack of hamburger buns with an expiration date of [DATE]; 2. One opened bag undated with 6 hamburger buns left with an expiration date of [DATE]; and 3. One opened bag undated with 2 hamburger buns with expiration date of ,d+[DATE]. Observation during tour of the kitchen on [DATE] at 11:15 a.m. accompanied by S6 Cook revealed: 1. One laundry basket full of soiled kitchen linens; 2. One scoop noted inside of the (Fruit Loops) cereal bin; 3. One scoop noted inside of the flour bin; 4. One small bowl noted inside of the (corn flakes) cereal bin; 5. Two refrigerated containers of chicken noodle soup without a label or date; and 6. One metal container with cream colored batter without a label of contents or date in the refrigerator. Observation of the facility kitchen's dry food storage room on [DATE] at 11:15 a.m. accompanied by S5 Cook revealed multiple dark brown droplets of insect droppings noted on top of the storage shelves. S5 Cook confirmed the findings of insect droppings on the shelves in the dry food storage room. S5 cook revealed every Thursday after delivery truck comes, the staff put up food and supplies, vacuum the shelves, and move up closer dated items up front for sooner use. S5 Cook revealed the staff must not have cleaned the shelves in the dry food storage room. S5 Cook revealed the weekend staff had not taken the dirty kitchen towels to laundry to be cleaned. Interview on [DATE] at 12:08 p.m. with S4 DM confirmed the above findings. S4 DM confirmed the signs of pest residue noted on the shelves in the dry food storage area.

Based on observations and interviews and record review, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice had the potential to affect all 63 residents that resided in the facility. Findings: Review of the facility's policy titled, Pest Control read in part . Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. Observation during the initial tour of the kitchen on 04/15/2024 at 6:05 a.m. revealed multiple flies flying around in the kitchen. Interview at this time with S4 DM revealed that the weekend staff must have left the door open for the flies to have come in. Observation of the facility kitchen's dry food storage room on 04/15/2024 at 11:15 a.m. accompanied by S5 Cook revealed multiple dark brown droplets of insect droppings noted on top of the storage shelves. S5 Cook confirmed the findings of insect droppings on the shelves in the dry food storage room. Interview on 04/15/2024 at 12:08 p.m. with S4 DM confirmed the signs of pest residue noted on the shelves in the dry food storage area. Review of the facility's pest control service receipts revealed exterminating services were provided monthly with the last treatment provided on 04/12/2024. Observation on 04/16/2024 at 12:05 p.m. revealed flies flying around in the Activity room. Observation on 04/17/2024 at 7:55 a.m. in Room A revealed a fly flying around in a resident's room. Observation at this time revealed S8 LPN swatting the fly away and S8 LPN confirmed flies flying around the facility. Interview on 04/17/2024 at 5:35 p.m. with S1 Administrator confirmed above findings.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 2 (Resident #14 and Resident #43) of 2 sampled residents with MDS records over 120 days old. Findings: Review of the facility's MDS transmission report revealed Resident #14's Quarterly MDS Assessment with ARD (Assessment Reference Date) of 03/07/2024 had been submitted on 04/15/2024. Review of the facility's MDS transmission report revealed Resident #43's Annual MDS Assessment with ARD of 02/29/2024 had been submitted on 04/15/2024. Interview on 04/17/2024 at 11:10 a.m. with S3 Corporate RN confirmed Resident #14's and Resident #43's MDS Assessments had not been transmitted timely and should have been. Interview on 04/17/2024 at 12:00 p.m. with S1 Administrator revealed the facility had recently completed a QAPI plan regarding untimely transmissions of MDS Assessment after being cited and cleared. Review of the facility's MDS transmission performance improvement monitoring, accompanied by S1 Administrator, revealed several assessments had been transmitted on 03/22/2024. Review revealed Resident #14's and Resident #43's MDS Assessments had not been transmitted until 04/15/2024. Interview on 04/17/2024 at 12:05 p.m. with S1 Administrator revealed he was not sure why Resident #14 and Resident #43's MDS Assessments had not been transmitted on 03/22/2024. S1 Administrator confirmed Resident #14 and Resident #43's MDS Assessments had not been transmitted timely and should have been.

Based on interview and record review, the facility failed to ensure that a Resident Assessment accurately reflected the cognition status for 1 (Resident #26) Resident. The sample size was 31. Review of Resident #26's EHR revealed an admitted [DATE] with diagnoses that included: Polyneuropathy, Spinal Stenosis, Urine Retention, Transient Paralysis, and Rhabdomyolysis. Review of the Resident #26's Quarterly MDS with an ARD of 12/21/2023 revealed he was interviewable with a BIMS of 10. Review of the BIMS conducted revealed: Repetition of Three Words-2 words repeated; Temporal Orientation (orientation to year, month, and day) missed by 1 year; What month are we in right now? accurate within 5 days; What day of the week is today? Correct; Going back What was the 3 words I asked you to repeat? answered after cueing; Able to recall blue- yes; Able to recall bed- yes. Total score- 10. Review of Resident #26's Quarterly MDS with an ARD of 03/21/2024 revealed he was interviewable with a BIMS of 01. Review of the BIMS conducted revealed: Repetition of Three Words-2 words repeated; Temporal Orientation (orientation to year, month, and day) missed by 1 year; What month are we in right now? accurate within 5 days; What day of the week is today? Correct; Going back What was the 3 words I asked you to repeat? answered after cueing; Able to recall blue- yes; Able to recall bed- yes. Total score- 10. Interviews conducted on 04/15/2024 at 6:30 a.m., 9:50 a.m., and on 04/16/2024 at 9:00 a.m. and 9:45 a.m. with Resident #26 revealed he was interviewable, able to answer all questions with appropriate answers and able to recall events of his hospital stay and surgery in 12/2023. Interview on 04/16/2024 at 10:00 a.m. with S3 Corporate RN confirmed after reviewing and comparing the Quarterly MDS with an ARD of 03/21/2024 and the Quarterly MDS with an ARD of 12/21/2023, there was no difference and no change in Resident #26's cognition status. S3 confirmed there was a transcription error in data input of Resident #26's BIM score entered on 03/21/2924. S3 Corporate RN stated S7 SSD was responsible for conducting and inputting the BIMS information data into the MDS. S3 Corporate RN stated an Addendum would have to be made and the MDS would have to be re-submitted with the correct data. Interview on 04/17/2024 at 1:58 p.m. with S7 SSD revealed she was responsible for conducting the BIMS and entering the information on the MDS hard copy. S7 SSD confirmed she conducted a BIMS on Resident #26 on 03/21/2024 and the resident scored a 10. She confirmed the score of 01 that appeared on the Quarterly MDS with an ARD of 03/21/2024 was entered in error.

Based on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice as evidenced by failing to deliver oxygen therapy as ordered for 1 (Resident #2) of 1 resident reviewed for respiratory care. The facility census was 63 residents. Findings: Review of the facility's policy titled, Oxygen Administration read in part . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Review of Resident #2's Medical Record revealed an admitted [DATE] with diagnoses that included COPD with (Acute) Lower Respiratory Infection, Legal Blindness, as defined by USA, Dementia, Personal history of Transient Ischemic Attack and Cerebral Infarction, Essential Primary Hypertension, Hyperlipidemia, Angina Pectoris, Acute and Chronic Respiratory Failure unspecified whether Hypoxia or Hypercapnia. Review of Resident #2's Physician's Orders dated 03/28/2023 revealed the following orders in part . Oxygen at 2 liters per nasal cannula continuous every day and night shift and Oxygen concentrator at 2 liters/nasal cannula to maintain oxygen saturation above 92% every morning and at bedtime to maintain oxygenation. Review of Resident #2's MARs for April 2024 revealed documentation of oxygen administered at 2 liters/minute via nasal cannula continuous. Review of Resident #2's Annual MDS Assessment with an ARD of 03/21/2024 revealed a BIMS score of 00 and resident required oxygen therapy. Review of Resident #2's Care Plans with a target date of 07/06/2024 revealed resident with potential for ineffective breathing patterns related to COPD, decreased lung compliance and has oxygen therapy related to ineffective gas exchange related to respiratory illness with goal to have no signs and symptoms of poor oxygen absorption. Interventions included in part . Administer medications, respiratory treatments and oxygen as ordered and Oxygen settings: Oxygen via nasal prongs at 2 liters continuously. Observation on 04/15/2024 at 8:07 a.m. revealed Resident#2 lying in bed with her eyes closed with oxygen in progress at 3 liters per minute per nasal cannula via oxygen concentrator. Observation in Resident #2's room on 04/15/2024 at 2:15 p.m. accompanied by S2 DON verified resident's oxygen was in progress at 3 liters per minute via nasal cannula per oxygen concentrator. S2 DON revealed she would need to check Resident #2's orders, progress notes and with nurse to check if she had altered resident's oxygen concentrator. Interview in Resident #2's room on 04/15/2024 at 2:20 p.m. with S6 Agency LPN revealed that she was not reported any changes with Resident #2 from the nurse she had relieved this morning and she had not adjusted resident's oxygen concentrator today. S6 Agency LPN confirmed Resident #2's physician orders and confirmed that her oxygen concentrator should have been set at 2 liters per minute per nasal cannula continuously and was not. Interview on 04/15/2024 at 2:24 p.m. with S2 DON confirmed Resident #2's oxygen concentrator should have be set to deliver oxygen at 2 liters per minute via nasal cannula continuous as ordered and was not.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care and nail care to dependent residents for 3 (Resident #9, Resident #10, and Resident #26) of 3 (Resident #9, Resident #10, and Resident #26) residents sampled for ADL's Findings: Review of the Facility's policy titled: Activities of Daily Living (ADLs), with a revised date of March 2018 revealed in part: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for a resident who is unable to carry out ADLs independently, with the consent of the resident and in accordance with plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care). A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Resident #9 Review of Resident #9's EHR (Electronic Health Record) revealed an admitted [DATE], diagnosis included: Cerebral Infarction, Bipolar Disorder, DM, Intermittent Explosive Disorder, Bipolar Disorder, Unspecified, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #9's Quarterly MDS with an ARD of 01/29/2024 revealed Resident #9 had a BIMS of 05, indicating severely impaired cognition. Resident #9's functional status revealed he required the extensive, physical assistance of one to two persons with all ADLS. Observation of Resident #9 on 04/15/2024 at 9:10 a.m. revealed Resident #9 in a wheelchair in the hallway with 1/2 inch long, thick, gray, facial hair, and long untrimmed fingernails. Observation of Resident #9 on 04/15/2024 at 2:19 p.m. revealed Resident #9 in a wheelchair in the hallway with 1/2 inch long, thick, gray, facial hair, and long untrimmed fingernails. Interview on 04/15/2024 at 2:35 p.m., with S2 DON revealed all male residents were bathed and/or showered on Tuesday, Thursday and Saturday. S2 DON stated ADLs included AM care, oral care, skin/hair care, personal care, and nail care. Observation during this interview revealed Resident #9 approached S2 DON and told S2 DON that he needed to be shaved and his fingernails needed to be trimmed S2 DON confirmed that Resident #9 needed to be shaved and his fingernails needed to be trimmed. Resident #10 Review of Resident #10's EHR revealed an admitted [DATE], diagnosis included: Multiple Sclerosis, Neuromuscular Dysfunction of the Bladder, Quadriplegia, and Hydronephrosis. Review of Resident # 10's Care Plan with a target date of 05/06/2024 revealed Resident #10 has his own teeth and required 1 person staff to inspect and provide oral care and personal hygiene, and required 2 persons assistance with bathing. Review of Resident #10's Annual MDS with an ARD of 01/09/2024 revealed a BIMS score of 06, (severely impaired cognition), with no psychosis and/or behavioral issues. Resident #10 was assessed as being totally dependent on staff to provide care. Observation on 04/15/2024 at 9:50 a.m., revealed Resident #10 lying in bed. Resident #10 was noted to have a chalky colored film on his lips and in the corner of his mouth, with a foul mouth odor present. Resident #10 was also noted to have 1/2 inch black facial hair with long untrimmed fingernails. Interview with Resident #10 at the time of observation revealed Resident #10 was a quadriplegic and dependent on the staff to perform all of his ADLs. Resident #10 stated no one had offered to brush his teeth before or after breakfast. Observation on 04/15/2024 at 2:07 p.m. of Resident #10 accompanied by S2 DON confirmed Resident #10 needed oral care, nail care, and needed to be shaved. S2 DON stated the CNAs were responsible for providing nail care, oral care and shaving Resident #10 during baths and as needed. S2 DON stated the CNAs should have provided AM care which included oral care to Resident #10 before breakfast and had not. Resident #26 Review of Resident #26's EHR revealed an admitted [DATE] with diagnoses that included: Polyneuropathy, Spinal Stenosis, Urine Retention, Transient Paralysis, and Rhabdomyolysis. Review of Resident # 26's Care Plan with a target date of 06/28/2024 revealed Resident #26 had a self- care performance deficit with ADLs related to Dementia and Impaired Balance. Resident #26's interventions included: check nail length and trim, and clean on bath day as needed. Review of Resident #26's Quarterly MDS with an ARD of 03/21/2024 revealed a BIMS score of 01, severe cognitive impairment, with no psychosis and/or behavioral issues. Resident #26 was assessed as being totally dependent on staff. Interviews conducted with Resident #26 on 04/15/2024 at 6:30 a.m., 9:50 a.m., and on 04/16/2024 at 9:00 a.m. and 9:45 a.m. revealed Resident #26 was able to answer all questions with appropriate answers. Observation on 04/15/2024 at 6:30 a.m. revealed Resident #26 in bed with, thick, gray, facial hair that was 1/2 inch in length. Dark dried substance was observed around Resident #26's cuticles and under his fingernail beds. Interview with Resident #26 at the time of observation revealed it had been weeks since he was last shaved, and he was not certain the last time that his fingernails were cleaned. Observation of Resident #26 on 04/15/2024 at 2:12 p.m. accompanied by S2 DON confirmed Resident #26 needed to be shaved and his fingernails needed to be cleaned and had not been.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly. The total facility census was 63 residents. Findings: Review of facility's policy titled, Food-Related Garbage and Refuse Disposal read in part . Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state laws. Policy Interpretation and Implementation: 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. 6. Storage areas will be kept clean at all times, and shall not constitute a nuisance. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Observation on 04/15/2024 at 5:45 a.m. revealed the doors of the facility dumpster were open and several white trash bags were stacked inside. Observation at this time revealed several pieces of paper trash on the ground surrounding the facility's dumpster. Interview on 04/15/2024 at 7:55 a.m. with S4 DM confirmed the above findings. S4 DM confirmed that the facility's dumpster doors should have been closed and were not. S4 DM confirmed the area surrounding the dumpster should have been cleaned and was not. Observation on 04/15/2024 at 8:30 a.m. of the facility dumpster accompanied by S1 Administrator and S2 DON revealed the dumpster doors were open. Interview at this time with S1 Administrator confirmed the facility's dumpster doors were open and should have been closed.

Based on record review and interview, the facility failed to ensure resident assessments were electronically transmitted in a timely manner by failing to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#1) of 3 (#1, #2, and #3) Residents reviewed for resident assessments. Findings: Review of Resident #1's medical record revealed he was admitted to the facility on [DATE]. Resident #1 had diagnoses that included in part .Chronic Obstructive Pulmonary Disease, Dementia, Sleep Apnea, Cerebral Infarction, Depression, and Heart Failure. Review of Resident #1's Discharge/Return Anticipated MDS Assessment with ARD (Assessment Reference Date) of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 revealed the assessments had been completed but not transmitted. Interview on 02/29/2024 at 4:33 p.m. with S2 MDS LPN revealed she was responsible for completing and transmitting MDS Assessments. S2 MDS LPN confirmed Resident #1's Discharge/Return Anticipated MDS Assessment with ARD (Assessment Reference Date) of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 had been completed, but not transmitted. Review of the facility's MDS transmission reports dated 10/01/2023-03/04/2024 on 03/04/2024 at 12:30 p.m. revealed Resident #1's Discharge/Return Anticipated MDS Assessment with ARD of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 had not been transmitted. Interview on 03/04/2024 at 2:02 p.m. with S1 DON revealed Resident #1's Discharge/Return Anticipated MDS Assessment with ARD of 11/20/2023 and Quarterly MDS Assessment with ARD of 12/05/2023 had not been transmitted timely, and should have been.

Based on record review and interview the facility failed to follow the physician's orders for administration of an anti-convulsant (a medication ordered to reduce [MEDICAL CONDITION] activity) for a resident with new onset [MEDICAL CONDITION] for 1 (#2) of 3 (#1, #2, #4) sampled residents with [DIAGNOSES REDACTED].#1, #2, #3, #4, #5). According to the Resident Census and Conditions of Residents Report, the facility's current census was 57 residents. An Immediate Jeopardy was discovered for Resident #2 on 11/22/16 at 2:00 p.m. On 7/11/16 the resident returned to the facility from the hospital with a [DIAGNOSES REDACTED]. [MEDICATION NAME] doses were not administered on 7/11/16 at 5:00 p.m., 7/12/16 at 1:00 a.m. and 7/14/16 at 9:00 am. The resident was sent to the Wound Clinic on 7/14/16 at 9:15 a.m., and he experienced a [MEDICAL CONDITION]. The wound clinic sent the resident to the emergency room (ER) of a local hospital and returned to the facility with new orders to increase the [MEDICATION NAME] dosage. The resident returned to the facility and the nursing staff continued to not administer his [MEDICATION NAME] as ordered by the physician. On 10/17/16 the resident had another [MEDICAL CONDITION] and was sent to the ER. The resident's [MEDICATION NAME] level from the lab obtained in the ER revealed a [MEDICATION NAME] level of 1.4ug/ml (normal 10-20). The resident was returned to the facility and nursing staff continued to not administer his [MEDICATION NAME] as ordered by the physician. The Immediate Jeopardy was removed on 11/28/16 at 2:00 p.m. as a result of the following Plan of Removal: 1. To enhance currently compliant practices and under the direct supervision of the Administrator, Director of Nursing and Assistant Director of Nursing: 1. All nursing staff will receive immediate training regarding Medication Administration and protocols for medication ordering from the pharmacy; 2. All nursing staff will receive immediate training on proper notification to physicians regarding critical lab values; 3. All nursing will receive immediate education regarding protocol on obtaining missing resident medication; 4. All nursing staff will receive training on new policies/protocol on obtaining missing resident medications and notification of physicians; 5. Random audits will occur to ensure accuracy and immediate deficient practices will occur; 6. Policies and procedures are in place for Pharmaceutical medication ordering, ordering labs, and physician notification of labs. 2. Clinical Pharmacist will perform random medication pass observations 2 times per month for 3 months. Any deficient practices will be corrected on the spot and findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 3. Daily QA checks will be made by Administrative Nurses on all physician orders received 3 months. Then random thereafter. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 4. Daily QA checks will be made by Administrative Nurses on all Medication Administration Records for 3 months. Than random thereafter. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 5. A Root Cause Analysis will be conducted by a Registered Nurse and findings will be submitted to the Administrator and Director of Nursing. This deficient practice continued at a potential for harm for 3 of 3 (#1, #2, #4) residents residing in the facility with [DIAGNOSES REDACTED]. Findings: Review of resident #2's Face Sheet revealed an admission date of [DATE]. Further review revealed [DIAGNOSES REDACTED]. Review of resident #2's [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS of 3 (severe impairment). Further review of the MDS revealed the resident required extensive assistance for activities of daily living. Review of the Comprehensive Care Plan (dated 7/14/16 with a goal date of 1/22/17) for resident #2 revealed a problem of Potential for [MEDICAL CONDITION] Activity/Injury related to [MEDICAL CONDITION] Disorder with an approach to administer medications as ordered and observe for side effects and effectiveness. Review of Nurses' Notes dated 7/10/16 at 6:15 p.m. revealed the resident experienced a [MEDICAL CONDITION] that lasted one minute. The resident was transferred to the E.R. and returned to the facility on [DATE] at 12:40 a.m. Review of Physician's Orders dated 7/11/16 revealed [MEDICATION NAME] 100 mg one capsule by mouth every 8 hours for [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED] Review of Nurses' Notes dated 7/14/16 at 9:15 a.m. revealed the resident was transported to the Wound Clinic where he experienced a [MEDICAL CONDITION]. The Wound Clinic sent the resident to the E.R., and he returned to the facility on [DATE] at 5:15 p.m. Review of Physician's Orders dated 7/14/16 revealed [MEDICATION NAME] was increased to 100 mg every 6 hours. Review of laboratory values, obtain by the facility, dated 7/19/16 revealed the resident's [MEDICATION NAME] level was 4.9ug/ml. Review of MAR indicated [REDACTED] Review of laboratory values dated 7/26/16 revealed the resident's [MEDICATION NAME] level was 4.8. Review of resident's monthly Physician's Orders read: August 2016 - [MEDICATION NAME] 100 mg every 6 hours. September 2016 - [MEDICATION NAME] 100 mg every 6 hours. October 2016 - [MEDICATION NAME] 100 mg every 6 hours. Review of the MAR indicated [REDACTED] Review of the MAR indicated [REDACTED] Review of Transfer Form dated 10/17/16 (no time) revealed the resident was transferred to the E.R. for a [MEDICAL CONDITION]. Review of Nurses' Notes dated 10/17/16 at 7:15 p.m. revealed the resident returned to the facility with a low [MEDICATION NAME] level and no changes in medications. Review of E. R. laboratory values dated 10/17/16 revealed [MEDICATION NAME] level 1.4. Review of the MAR indicated [REDACTED] Review of Nurses' Notes dated 10/27/16 at 1:30 p.m. revealed the resident was admitted to the hospital for a [DIAGNOSES REDACTED]. Review of Physician's Orders dated 11/18/16 revealed [MEDICATION NAME] ([MEDICATION NAME]) Suspension (oral) 150 mg=6 ml at bedtime; and [MEDICATION NAME] ([MEDICATION NAME]) Suspension (oral) 125 mg=5 ml three times daily. Review of the MAR indicated [REDACTED]. The resident did not receive his first dose of [MEDICATION NAME] Suspension until 11/22/16 at 3:00 a.m. Interview with S3 ADON on 11/22/2016 at 10:51 a.m. and 11/23/16 at 9:12 a.m., revealed no one notified her that resident #2's [MEDICATION NAME] medication was not available in the facility when he returned on 11/18/16. She stated that she was not aware of resident #2's missing [MEDICATION NAME] doses from July to November 2016. Interview with S6 LPN on 11/22/16 at 12:45 p.m. and 3:29 p.m. revealed resident #2 returned to the facility from the hospital on Friday 11/18/16 at 6:30 p.m. with new orders to receive [MEDICATION NAME] Suspension 125 mg TID. She stated [MEDICATION NAME] Suspension was not available in the facility and had to be ordered. She further stated that she tried to notify S4 MD several times, but he never called back. S6 LPN then stated, What do you do when the physician won't call back? S6 LPN stated sometimes medications are not available. S6 LPN revealed she did not notify the RN in charge or S3 ADON that the [MEDICATION NAME] Suspension was not available. Interview with S2 Acting DON on 11/23/16 at 9:04 a.m. revealed she worked on Monday 11/21/2016. She stated that she was not aware that resident #2 did not receive his [MEDICATION NAME] medication. She stated that she was not aware the [MEDICATION NAME] was not available. She revealed the LPNs should have let the RN know that the medication as not available. Interview with S7 LPN on 11/23/16 at 9:43 a.m. revealed she worked Monday evening on 11/21/16, but no one reported to her that resident #2 had been out of his [MEDICATION NAME] all weekend. She stated that she opened a new bottle and administered the first dose on 11/22/16 at 3:00 a.m. Interview with S5 LPN on 11/23/2016 at 10:40 a.m. revealed that the pharmacy was bad about sending medications. She stated that she would have placed a (D) in the box if the medication was not available. She revealed that if she signed everything else she must have just forgotten to sign it. S5 LPN further revealed that she received medications from the pharmacy on Saturday 11/21/16 and signed the receipt form, but resident #2's [MEDICATION NAME] was not received because it was on order. She revealed that she did not call the weekend RN to notify her that resident #2's medication did not come in. She stated that she overheard S6 LPN and S13 LPN discussing that resident #2's [MEDICATION NAME] medication was not available in suspension form as it was ordered. Interview with S1 Administrator on 11/23/16 at 12:06 p.m. revealed that he was not aware of any residents missing their medication. He stated that he was not aware resident #2 was missing his medication [MEDICATION NAME]. He stated that it would be the DON or ADON's responsibility to check the MARs daily to make sure residents were receiving their medications. Further interview with S1 Administrator on the above date and time revealed there had been occasions when the pharmacy would say that they did not have medications or that the medication was on order. He stated that he had told all of the LPN's that if the pharmacy did not have a medication to call somewhere else to get the medications, to just get the medication. Review of nurses' assignment schedule dated from July to November 2016 revealed 8 LPN's were assigned medication administration for resident #2 during that time period: S5 LPN, S6 LPN, S7 LPN, S10 LPN, S11 LPN, S12 LPN, S13 LPN and S14 LPN. Attempts were made to contact S8 RN, S9 RN, S10 LPN, S11 LPN, S12 LPN, S13 LPN and S14 LPN, but were unsuccessful.

Based on record review and interview the facility failed to be administrated in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident, for 1 (#2) of 3 (#1, #2 and #4) residents with [DIAGNOSES REDACTED].#1, #2, #3, #4 and #5). The Administrator failed to: 1. ensure a resident was free of a significant medication error; 2. administered [MEDICATION NAME] (anti-convulsant) as ordered by the physician; 3. ensure the physician was notified of a resident's critical low [MEDICATION NAME] level of 1.4 on 10/17/16; 4. ensure pharmaceutical services were provided to meet the needs of the residents; 5. have policies and procedures in place to assure the receiving, dispensing and administering of [MEDICATION NAME]. An Immediate Jeopardy was discovered for Resident #2 on 11/22/16 at 2:00 pm. On 7/11/16 the resident returned to the facility from the hospital with a [DIAGNOSES REDACTED]. [MEDICATION NAME] doses were not administered on 7/12/16 at 1:00 a.m. and 7/14/16 at 9:00 am. The resident was sent to the Wound Clinic on 7/14/16 at 9:15 am. and he experienced a [MEDICAL CONDITION]. The wound clinic sent the resident to the emergency room (ER) of a local hospital with new orders to increase the [MEDICATION NAME] dosage. The resident returned to the facility and the nursing staff continued to not administer his [MEDICATION NAME] as ordered by the physician. On 10/17/16 the resident had another [MEDICAL CONDITION] and was sent to the ER. The resident's [MEDICATION NAME] level from the lab obtained in the ER revealed a [MEDICATION NAME] level of 1.4 ug/ml. (normal 10-20). The resident was returned to the facility and nursing staff continued to not administer his [MEDICATION NAME] as ordered by the physician. Immediate Jeopardy for Resident #2 was discovered on 11/22/16 at 2:00 p.m. S1 Administrator was informed of the Immediate Jeopardy on 11/23/16 at 12:07 p.m. The Immediate Jeopardy was removed on 11/28/16 at 2:00 p.m. when the S1 Administrator presented the surveyor with an acceptable Plan of Removal and the plan was being implemented. The Plan of Removal included the following: 1. To enhance currently compliant practices and under the direct supervision of the Administrator, Director of Nursing and Assistant Director of Nursing: 1. All nursing staff will receive immediate training regarding Medication Administration and protocols for medication ordering from the pharmacy; 2. All nursing staff will receive immediate training on proper notification to physicians regarding critical lab values; 3. All nursing will receive immediate education regarding protocol on obtaining missing resident medication; 4. All nursing staff will receive training on new policies/protocol on obtaining missing resident medications and notification of physicians; 5. Random audits will occur to ensure accuracy and immediate deficient practices will occur; 6. Policies and procedures are in place for Pharmaceutical medication ordering, ordering labs, and physician notification of labs. 2. Clinical Pharmacist will perform random medication pass observations 2 times per month for 3 months. Any deficient practices will be corrected on the spot and findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 3. Daily QA checks will be made by Administrative Nurses on all physician orders [REDACTED]. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 4. Daily QA checks will be made by Administrative Nurses on all Medication Administration Records for 3 months. Than random thereafter. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 5. A Root Cause Analysis will be conducted by a Registered Nurse and findings will be submitted to the Administrator and Director of Nursing. According to the Resident Census and Conditions of Residents Report, the facility's total census was 57. This deficient practice continues at a potential for harm for 3 of 3 (#1, #2, #4) residents residing in the facility with [DIAGNOSES REDACTED]. Findings: 1. Cross refer to F282 2. Cross refer to F 333 3. Cross refer to F425 Interview with S3 ADON on 11/22/16 at 10:51 a.m. revealed no one notified her that resident #2's [MEDICATION NAME] medication was not available in the facility when he returned on 11/18/16. She stated that she was not aware of resident #2's missing [MEDICATION NAME] doses from July to November 2016. She had presented the surveyors with all policies and procedures the facility had concerning medications, pharmacy, notification of MD and laboratory services. She revealed the policy was not specific and/or did not indicate what the nurses were to do when medications were not available in the facility and when attempts to contact the MD had failed. She stated it was the DON's responsibility to check the MAR for blank boxes or missed medications, but it was not in the written policy. Interview with S1 Administrator on 11/28/16 at 12:06 p.m. revealed that he was not aware of any residents missing their medication. He stated that he was not aware resident #2 was missing his medication [MEDICATION NAME]. He stated that it would be the DON or ADON's responsibility to check the MARs daily to make sure residents were receiving their medications. He said there had been occasions when the pharmacy would say that they did not have medications or that the medication was on order. He stated that he had told all of the LPN's that if the pharmacy did not have a medication to call somewhere else to get the medications, to just get the medication. S1 Administration further stated that he was sure the facility had a policy concerning acquisition of medications and auditing of the MAR and lab values for discrepancies; but if not, the facility would implement a policy.

Based on record review and interview the facility failed to provide routine drugs and biologicals to meet the needs of the residents. The facility further failed to ensure an anti-convulsant (a medication ordered to reduce seizure activity) medication ordered by the physician was dispensed and received in the facility for 1 (#2) of 3 (#1, #2, #4) sampled residents with [DIAGNOSES REDACTED].#1, #2, #3, #4, #5). According to the Resident Census and Conditions of Residents Report, the facility's current census was 57 residents. An Immediate Jeopardy was discovered for Resident on 11/22/16 at 2:00 p.m On 7/11/16 the resident returned to the facility from the hospital with a [DIAGNOSES REDACTED]. Dilantin doses were not administered as ordered on [DATE] at 5:00 p.m., 7/12/16 at 1:00 a.m. and again on 7/14/16 at 9:00 am. The resident was sent to the Wound Clinic on 7/14/16 at 9:15 a.m., and he experienced a seizure. The wound clinic sent the resident to the emergency room (ER) of a local hospital and he returned to the facility with new orders to increase the Dilantin dosage. The resident returned to the facility and the nursing staff continued to not administer his Dilantin. Between 7/11/16 and 10/25/16 Dilantin was not administered as ordered by the physician a total of 20 times. The resident ' s Dilantin level on 7/19/16 was 4.9 ug/ml and on 7/26/16 it was 4.8ug/ml. Resident # 2 was sent to the ER for a seizure again on 10/17/16 and at that time his Dilantin level was 1.4ug/ml. On 10/27/16 the resident was admitted to the hospital with [REDACTED]. On 11/18/16 at 6:30 p.m. the resident returned to the facility with new orders for Phenytoin (Dilantin) Suspension (oral) 150 mg=6 ml at bedtime; and Phenytoin (Dilantin) Suspension (oral) 125 mg=5 ml three times daily. There was no record in the facility that the Dilantin Suspension was delivered to the facility from the licensed pharmacist until 11/21/16 at 6:00 p.m. The resident did not receive his first dose of Dilantin Suspension until 11/22/16 at 3:00 a.m. Between 11/18/16 and 11/21/16 Dilantin were not administered as ordered for an additional 13 doses. This Immediate Jeopardy for Resident #2 was discovered on 11/22/16 at 2:00 p.m. The Immediate Jeopardy was removed on 11/28/16 at 2:00 p.m. as a result of the following Plan of Removal: 1. To enhance currently compliant practices and under the direct supervision of the Administrator, Director of Nursing and Assistant Director of Nursing: 1. All nursing staff will receive immediate training regarding Medication Administration and protocols for medication ordering from the pharmacy; 2. All nursing staff will received immediate training on proper notification to physicians regarding critical lab values; 3. All nursing will receive immediate education regarding protocol on obtaining missing resident medication; 4. All nursing staff will receive training on new policies/protocol on obtaining missing resident medications and notification of physicians; 5. Random audits will occur to ensure accuracy and immediate deficient practices will occur; 6. Policies and procedures are in place for Pharmaceutical medication ordering, ordering labs, and physician notification of labs. 2. Clinical Pharmacist will perform random medication pass observations 2 times per month for 3 months. Any deficient practices will be corrected on the spot and findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 3. Daily QA checks will be made by Administrative Nurses on all physician orders [REDACTED]. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 4. Daily QA checks will be made by Administrative Nurses on all Medication Administration Records for 3 months. Than random thereafter. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 5. A Root Cause Analysis will be conducted by a Registered Nurse and findings will be submitted to the Administrator and Director of Nursing. This deficient practice continues at a potential for harm for 3 of 3 (#1, #2, #4) residents residing in the facility with [DIAGNOSES REDACTED]. Findings: Review of resident #2's Face Sheet revealed an admission date of [DATE]. Further review revealed [DIAGNOSES REDACTED]. Review of resident #2's [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS of 3 (severe impairment). Further review of the MDS revealed the resident required extensive assistance for activities of daily living. Review of the MAR dated from July to November 2016 revealed 20 blank boxes noted for Dilantin by mouth as follows: 7/11/16 at 5:00 p.m., 7/12/16 at 1:00 a.m., 7/14/16 at 9:00 a.m., 7/21/16 at 11:00 p.m., 7/25/16 at 11:00 a.m., 8/1/16 at 5:00 a.m., 8/7/16 at 5:00 a.m., 8/11/16 at 5:00 a.m., 8/12/16 at 11:00 a.m. and 11:00 p.m., 8/14/16 at 11:00 p.m. 8/16/16 at 5:00 p.m. and 11:00 p.m., 9/28/16 at 11:00 p.m., and 9/30/16 at 5:00 a.m., 11:00 a.m. and 5:00 p.m., 10/25/16 at 5:00 a.m., 11:00 a.m. and 5:00 p.m. Further review of the MAR revealed 13 boxes were marked with a D from 11/18/16 to 11/21/16 for Dilantin (which indicated the medication was not administered). Further review of the blank boxes on the MAR and nurses' assignment schedule dated from July to November 2016 revealed 8 LPN's were assigned medication administration for resident #2 during that time period: S5 LPN, S6 LPN, S7 LPN, S10 LPN, S11 LPN, S12 LPN, S13 LPN and S14 LPN. Review of the facility's Prescription Manifest dated 11/19/16 revealed Phenytoin (Dilantin) 125 mg/5 ml Suspension for resident #2 was not received from the licensed pharmacist but was On Order. The form revealed S5 LPN signed the manifest. Interview with S3 ADON on 11/22/2016 at 10:51 a.m. and 11/23/16 at 9:12 a.m., revealed the S9 DON was on vacation. She revealed no one notified her that resident #2's Dilantin medication was not available in the facility when he returned on 11/18/16, and was not delivered from the pharmacy on 11/19/16. She stated that she was not aware of resident #2's missing Dilantin doses or blank boxes on the MAR. She stated the letter D on the MAR indicated the medication was not available, and there should not have been any blank boxes on the resident's MAR. She stated all boxes on the MAR should contain the nurses' initials to indicate administration of the medication at that time. She further stated it was the S9 DON's responsibility to check the MAR's for blank boxes. Interview with S6 LPN on 11/22/16 at 12:45 p.m. and 3:29 p.m. revealed resident #2 returned to the facility from the hospital on Friday 11/18/16 at 6:30 p.m. with new orders to receive Dilantin Suspension 125 mg TID. She stated Dilantin Suspension was not available in the facility and had to be ordered. She further stated that she tried to notify S4 MD several times, but he never called back. S6 LPN then stated, What do you do when the physician won't call back? S6 LPN stated sometimes medications are not available. S6 LPN revealed she did not notify the RN in charge or S3 ADON that the Dilantin Suspension was not available. There was no documentation of communication between facility staff and/or pharmacy by S6 LPN to ensure the resident's Dilantin Suspension was ordered and received from the facility's licensed pharmacist. Interview with S2 Acting DON on 11/23/16 at 9:04 a.m. revealed she worked on Monday 11/21/2016. She stated that she was not aware that resident #2 did not receive his Dilantin medication. She stated that she was not aware the Dilantin was not available. She revealed the LPNs should have let the RN know so they could have tried to get in touch with the physician or the pharmacy. Interview with S7 LPN on 11/23/16 at 9:43 a.m. revealed she worked Monday evening on 11/21/16, but no one reported to her that resident #2 had been out of his Dilantin all weekend. She stated that she opened a new bottle and administered the first dose on 11/22/16 at 3:00 a.m. Interview with S5 LPN on 11/23/2016 at 10:40 a.m. revealed that the pharmacy was bad about sending medications. She stated that she would have placed a (D) in the box if the medication was not available. She revealed that if she signed everything else she must have just forgotten to sign it. S5 LPN further revealed that she received medications from the pharmacy on Saturday 11/21/16 and signed the receipt form, but resident #2's Dilantin was not received because it was on order. She revealed that she did not call the weekend RN to notify her that resident #2's medication did not come in. She stated that she overheard S6 LPN and S13 LPN discussing that resident #2's Dilantin medication was not available in suspension form as it was ordered. Interview with S1 Administrator on 11/23/16 at 12:06 p.m. revealed that he was not aware of any residents missing their medication. He stated that he was not aware resident #2 was missing his medication Dilantin. He stated that it would be the DON or ADON's responsibility to check the MARs daily to make sure residents were receiving their medications. Further interview with S1 Administrator on the above date and time revealed there had been occasions when the pharmacy would say that they did not have medications or that the medication was on order. He stated that he had told all of the LPN's that if the pharmacy did not have a medication to call somewhere else to get the medications, to just get the medication. S1 Administration further stated that he was sure the facility had a policy concerning the licensed pharmacist delivery of medication, if not the facility would implement a policy. Attempts were made to contact S8 RN, S9 RN, S10 LPN, S11 LPN, S12 LPN, S13 LPN and S14 LPN, but were unsuccessful. A request was made with the S3 ADON on 11/22/16 to obtain a copy of the facility's policy and procedure concerning acquisition of medications from the licensed pharmacist. As of exit 11/28/16 at 2:00 p.m. no policy was presented.

Based on observation, record review and interview the facility failed to ensure a resident was free of any significant medication errors, by failing to ensure resident #2 received an anticonvulsant (a medication ordered to reduce [MEDICAL CONDITION] activity) by mouth as ordered by the physician, for 1(#2) of 3 sampled residents (#1 and #4) who had a [DIAGNOSES REDACTED].#1,2,3,4, and 5). The facility's census was 57 according to the 672 Residents Census and Conditions Form dated 11/21/16. An Immediate Jeopardy was discovered for Resident #2 on 11/22/16 at 2:00 pm. On 7/11/16 the resident returned to the facility from the hospital with a [DIAGNOSES REDACTED]. [MEDICATION NAME] doses were not administered on 7/11/16 at 5:00 p.m., 7/12/16 at 1:00 a.m. and 7/14/16 at 9:00 am. The resident was sent to the Wound Clinic on 7/14/16 at 9:15 am. and he experienced a [MEDICAL CONDITION]. The wound clinic sent the resident to the emergency room (ER) of a local hospital and he returned to the facility with new orders to increase the [MEDICATION NAME] dosage. The resident returned to the facility and the nursing staff continued to not administer his [MEDICATION NAME] as ordered by the physician. On 10/17/16 the resident had another [MEDICAL CONDITION] and was sent to the ER. The resident's [MEDICATION NAME] level from the lab obtained in the ER revealed a [MEDICATION NAME] level of 1.4 ug/ml (normal 10-20). On 11/18/16 at 6:30 p.m. the resident was returned to the facility with new orders for [MEDICATION NAME] Suspension at bedtime and TID for [MEDICAL CONDITION]. Further review of the resident's clinical record revealed that from 11/18/16 to 11/21/16 resident #2 was not administered 13 doses of [MEDICATION NAME]. S1 Administrator was notified of the IJ situation on 11/23/2016 at 12:07 p.m. The IJ was removed on 11/28/2016 at 2:00 p.m. after an acceptable plan of removal was submitted that included: PLAN 1. To enhance currently compliant practices and under the direct supervision of the Administrator, Director of Nursing and Assistant Director of Nursing: 1. All nursing staff will receive immediate training regarding Medication Administration and protocols for medication ordering from the pharmacy. 2. All nursing staff will received immediate training on proper notification to physicians regarding critical lab values. 3. All nursing will receive immediate education regarding protocol on obtaining missing resident medication. 4. All nursing staff will receive training on new policies/protocol on obtaining missing resident medications and notification of physicians. 5. Random audits will occur to ensure accuracy and immediate deficient practices will occur. 6. Policies and procedures are in place for Pharmaceutical medication ordering, ordering labs, and physician notification of labs. 2. Clinical Pharmacist will perform random medication pass observations 2 times per month for 3 months. Any deficient practices will be corrected on the spot and findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 3. Daily QA checks will be made by Administrative Nurses on all physician orders [REDACTED]. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 4. Daily QA checks will be made by Administrative Nurses on all Medication Administration Records for 3 months. Than random thereafter. Findings will be submitted to the Director of Nursing for further corrective action. All audits will be brought to the QA Committee for review. 5. A Root Cause Analysis will be conducted by a Registered Nurse and findings will be submitted to the Administrator and Director of Nursing. This deficient practice continues at a potential for harm, for 3 of 3 (#1, #2, #4) residents residing in the facility with [DIAGNOSES REDACTED]. Findings: Observation on 11/22/16 at 10:12 a.m. revealed resident #2 watching television in his room. Resident #2 was not interviewable, did not speak and required extensive assistance from staff for activities of daily living. Review of resident #2's Face Sheet revealed an admission date of [DATE]. Further review revealed [DIAGNOSES REDACTED]. Review of resident #2's [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS of 3 (severe impairment). Further review of the MDS revealed the resident required extensive assistance for activities of daily living. Review of Nurses' Notes dated 7/10/16 at 6:15 p.m. revealed resident #2 was lying in bed and experienced a [MEDICAL CONDITION] that lasted 1 minute. RP was notified and the resident was sent to the E.R. for an evaluation and treatment. On 7/11/16 at 12:40 a.m. resident #2 returned to the nursing facility with new orders to administer [MEDICATION NAME] 100 mg every 8 hours for [MEDICAL CONDITION]. Review of the MAR revealed on 7/11/16 resident #2 was not administered [MEDICATION NAME] 5 p.m., 7/12/2016 at 1:00 a.m. and again on 7/14/2016 at 9:00 a.m. Review of Nurses' Notes revealed on 7/14/16 at 9:15 a.m. resident #2 was out of the facility at wound clinic and while there experienced a [MEDICAL CONDITION]. The resident was sent to the E.R. for evaluation and treatment. He returned to the nursing facility on 7/14/16 at 5:15 p.m. with new orders to administer [MEDICATION NAME] 100 mg every 6 hours for [MEDICAL CONDITION]. Further review of the MARs revealed from 7/21/16 to 10/17/16 resident #2 was not administrated 15 doses of [MEDICATION NAME] 100 mg. The MAR revealed the following missed doses: 7/21/16 at 11:00 p.m., 7/25/16 at 11:00 a.m., 7/28/16 at 11:00 p.m. 8/1/16 at 5:00 a.m., 8/7/16 at 5:00 a.m., 8/11/16 at 5:00 a.m., 8/12/16 at 11:00 a.m. and 11:00 p.m., 8/14/16 at 11:00 p.m. 8/16/16 at 5:00 p.m. and 11:00 p.m., 9/28/16 11:00 p.m. 9/30/16 at 5:00 a.m., 11:00 a.m. and 5:00 p.m. Review of the facility's Transfer Form dated 10/17/16 (no time) revealed resident #2 was transferred to the E.R. for a [MEDICAL CONDITION]. Further review revealed the physician and RP were notified. Review of Nurses' Notes dated 10/17/16 at 7:15 p.m. revealed resident #2 returned to nursing facility with an order to follow-up with physician in 1-2 days, [DIAGNOSES REDACTED]. Further review of the MAR revealed on 10/25/16 at 5:00 a.m., 11:00 a.m. and 5:00 p.m. resident #2 was not administrated [MEDICATION NAME] as ordered by the physician. Review of the resident's Nurses' Notes revealed on 10/27/16 at 1:30 p.m. while at wound clinic, resident #2 was transferred and admitted to a local hospital due to wound infection. Further review of the Nurses' Notes revealed the physician and RP were made aware. Resident #2 was hospitalized from [DATE] to 11/18/16. On 11/18/16 at 6:30 p.m. resident #2 returned to the nursing facility with new orders to give [MEDICATION NAME] suspension 150 mg 6 ml by mouth at bedtime; and to give 125 mg 5 ml TID. Further review of the MAR revealed from 11/18/16 to 11/21/16, 13 boxes were marked with a D for [MEDICATION NAME] indicating [MEDICATION NAME] was not available. Review of the facility's Prescription Manifest dated 11/19/16 revealed [MEDICATION NAME] ([MEDICATION NAME]) 125 mg/5 ml Suspension for resident #2 was not received from the licensed pharmacist but was On Order. The form revealed S5 LPN signed the manifest. Further review of the blank boxes on the MAR and nurses' assignment schedule dated from July 2016 to November 2016 revealed 8 LPN's were assigned medication administration for resident #2 during that time period: S5 LPN, S6 LPN, S7 LPN, S10 LPN, S11 LPN, S12 LPN, S13 LPN and S14 LPN. Interview with S3 ADON on 11/22/16 at 10:51 a.m. and 11/23/16 at 9:12 a.m., revealed the S9 DON was on vacation. She revealed no one notified her that resident #2's [MEDICATION NAME] medication was not available in the facility when he returned on 11/18/16, and was not delivered from the pharmacy on 11/19/16. She stated that she was not aware of resident #2's missing [MEDICATION NAME] doses or blank boxes on the MAR. She stated the letter D on the MAR indicated the medication was not available, and there should not have been any blank boxes on the resident's MAR. She stated all boxes on the MAR should contain the nurses' initials to indicate administration of the medication at that time. She further stated it was the S9 DON's responsibility to check the MAR's for blank boxes. Interview with S6 LPN on 11/22/16 at 12:45 p.m. and 3:29 p.m. revealed resident #2 returned to the facility from the hospital on Friday 11/18/16 at 6:30 p.m. with new orders to receive [MEDICATION NAME] Suspension 125 mg TID. She stated [MEDICATION NAME] Suspension was not available in the facility and had to be ordered. She further stated that she tried to notify S4 MD several times, but he never called back. S6 LPN then stated, What do you do when the physician won't call you back? S6 LPN stated sometimes medications are not available. S6 LPN revealed she did not notify the RN in charge or S3 ADON that the [MEDICATION NAME] Suspension was not available. There was no documentation of communication between facility staff and/or pharmacy by S6 LPN to ensure the resident's [MEDICATION NAME] Suspension was ordered and received from the facility's licensed pharmacist. Interview with S2 Acting DON on 11/23/16 at 9:04 a.m. revealed she worked on Monday 11/21/16. She stated that she was not aware that resident #2 did not receive his [MEDICATION NAME] medication. She stated that she was not aware the [MEDICATION NAME] was not available. She revealed the LPNs should have let the RN know so they could have tried to get in touch with the physician or the pharmacy. Interview with S7 LPN on 11/23/16 at 9:43 a.m. revealed she worked Monday evening on 11/21/16, but no one reported to her that resident #2 had been out of his [MEDICATION NAME] all weekend. She stated that she opened a new bottle and administered the first dose on 11/22/16 at 3:00 a.m. Interview with S5 LPN on 11/23/16 at 10:40 a.m. revealed that the pharmacy was bad about sending medications. She stated that she would have placed a (D) in the box if the medication was not available. She revealed that if she signed everything else she must have just forgotten to sign it. S5 LPN further revealed that she received medications from the pharmacy on Saturday 11/21/16 and signed the receipt form, but resident #2's [MEDICATION NAME] was not received because it was on order. She revealed that she did not call the weekend RN to notify her that resident #2's medication did not come in. She stated that she overheard S6 LPN and S13 LPN discussing that resident #2's [MEDICATION NAME] medication was not available in suspension form as it was ordered. Interview with S1 Administrator on 11/23/16 at 12:06 p.m. revealed that he was not aware of any residents missing their medication. He stated that he was not aware resident #2 was missing his medication [MEDICATION NAME]. He stated that it would be the DON or ADON's responsibility to check the MARs daily to make sure residents were receiving their medications. Further interview with S1 Administrator, at on the above date and time revealed there had been occasions when the pharmacy would say that they did not have medications or that the medication was on order. He stated that he had told all of the LPN's that if the pharmacy did not have a medication to call somewhere else to get the medications, to just get the medication. S1 Administration further stated that he was sure the facility had a policy concerning the licensed pharmacist delivery of medication, if not the facility would implement a policy. Attempts were made to contact S8 RN, S9 RN, S10 LPN, S11 LPN, S12 LPN, S13 LPN and S14 LPN, but were unsuccessful. On 11/22/16 at 1:30 p.m. after surveyors intervention, S3 ADON notified S4 Physician and obtained new orders to increase [MEDICATION NAME] to 250 mg (10 ml) at night and obtain a [MEDICATION NAME] Level on 11/29/16.

Based on record review and interview the facility failed to ensure that staff were adequately trained and demonstrated competency in skills and techniques necessary to care for a resident's needs. The facility failed to have a system in place to ensure staff demontrated competency regarding the procedure to lock a resident's wheelchair in place and secure the seatbelt/harness devices in the facility's van according to the vehicle manufacturer's recommendations prior to transporting a resident for 1 (#1) of 20 (#1, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) residents who, according to a list provided by the facility, are wheelchair residents for who the facility provides transportation out of a total sample of 22 residents. This failed practiced placed resident #1 in an Immediate Jeopardy situation, which began on 6/6/16 at 9:25 p.m. when S3 CNA picked the resident up from the hospital. S3 CNA was not trained and did not demonstrate competency in skills and techniques necessary for transporting residents in the facility's van. During the transport, the facility's van came to a stop at a traffic light. Upon acceleration of the vehicle, resident #1 fell from her wheelchair. The resident sustained [REDACTED]. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 6/28/16 at 4:02 p.m. The Immediate Jeopardy ended for resident #1 when she was sent to the emergency roiagnom on [DATE] at 12:04 p.m. per EMS transport. The Immediate Jeopardy was removed on 6/29/2016 at 11:00 a.m. when the facility provided an acceptable plan of removal, which included the following: 1. The facility van was removed from use unitl formal written training and competency verification occurred. 2. All drivers will receive initial training and certified trainers will be retrained once a month times 3 months. Retraining will be conducted twice a year in March and September. 3. Only trained drivers will be allowed to drive the facility's van, with a list of certified trainers and certified drivers to be kept at the Nurses' Station and updated as applicable. 4. The van checklist will be done by a certified driver prior to each use of the van, and report to the North Hall nurse the status of the van. Any problems noted would require the vehicle to be removed from use and the keys given to administration for needed repairs. 5. The facility's van will not be used if there is not a certified driver or certified trainer working on the shift. 6. Maintenance staff will be trained to evaluate and service the facility's van weekly per manufacturer's recommendation, and will be required to be a certified driver. The maintenance worker is to notify administration immediately if any problems are encountered. 7. The Quality Assurance nurse will monitor the van checklist for proper functioning of components log. Any deficiency noted will be immediately reported to administration for follow-up action. This monitoring is to be conducted weekly for four week, then monthly thereafter. Any deficiency noted will be immediately reported to administration for follow-up action. This deficient practice continued at an actual harm for resident #1 and at a potential for more than minimal harm for the other 19 residents who, according to a list provided by the facility, are wheelchair residents for who the facility provides transportation. Findings: Review of the facility's Motor Vehicle Driving Policy revealed all employees and passengers will use seatbelts/shoulder harnesses at all times. There was no documentation in the policy that revealed the correct application of the seatbelt/shoulder harness. Review of Nurses' Notes dated 6/6/2016 revealed the following entries: 1:00 p.m. - The resident was noted having a [MEDICAL CONDITION] on the hallway. She was brought to room and she was put in bed lying on her side with O2 applied. Acadian Ambulance was notified to transport the resident to the ER for evaluation and treatment. 1:32 p.m. - The resident was out to the ER per ambulance service. 9:45 p.m. - The resident returned from the ER with [DIAGNOSES REDACTED]. The resident was transferred per wheelchair and had speech difficulties, but was able to express current needs. V/S: B/P - 132/74; P - 76; T - 97.6; R - 20; O2 saturation - 92%. The documentation revealed the resident had no complaints of pain. 11:00 p.m. - The resident was lying in bed with no distress noted. Will continue to monitor. Review of Nurses' Notes dated 6/7/2016 revealed the following entries: 8:00 a.m. - The resident was lying in bed with no signs of distress. The resident was sleepy, she would open her eyes, but she would close them right back. The documentation revealed the resident did not appear to be in any pain or discomfort, and staff would continue to monitor. 9:00 a.m. - The resident was awake and answered appropriately with nodding to verbal questions. The resident's medication was taken and tolerated well. The documentation revealed that staff would continue to monitor. 11:30 a.m. - The resident was sent to the ER for evaluation and tx due to her right leg being swollen, she was complaining of pain and she had not urinated on the 6/2 shift. The report was given. 12:04 p.m. The resident was out of the facility via EMS. Review of the Operative Report dated 6/9/16 revealed resident with right hip injury and sustained a right subtrochanteric femur fracture. The report also read that the resident sustained [REDACTED]. The report revealed the resident's clavicle fx could be treated non-operatively, but right trochanter was going to require open reduction and internal fixation. Interview on 6/27/16 at 12:10 p.m. with S2 DON revealed that S7 LPN/QA Nurse had given S3 CNA permission to go and pick up resident #1 from theER on ce she was ready for discharge back to the facility. She stated she was not at the facility at the time the CNA left to pick up the resident; however, she arrived to the facility after the CNA left to pick up the resident from the ER. Interview on 6/27/16 at 2:35 p.m. with S7 LPN/QA Nurse revealed she stayed over as the 2nd nurse on the shift on the evening of 6/6/16. She stated the hospital had called to report that the resident was ready for return to the facility. She stated she asked the CNAs who wanted to go and pick the resident up, and S3 CNA volunteered. She stated she didn't know if the CNA had been trained on properly securing a resident in the facility van, but that S5 CNA was going to train her before she left. She stated she (S7 LPN/QA Nurse) left the facility around 8:00 p.m. prior to the CNA leaving the facility, and that as she was leaving she saw S5 CNA and S3 CNA in the facility van. Further interview revealed S7 LPN/QA Nurse stated she had been instructed that anyone employed by the facility who had a driver's license, was covered by the facility insurance and could operate the vehicle. She stated she wasn't aware of any list of authorized drivers. When questioned as to whether she was aware S3 CNA had never transported any resident in the facility van and had not been trained on securing residents in the vehicle S7 LPN/QA Nurse stated she didn't know if the CNA had ever transported residents in the facility's van before or if she had been trained. Interview also on 6/27/16 at 2:35 p.m. with S5 CNA revealed that on 6/6/16 she instructed S3 CNA on how to properly secure the resident in the van, and showed her how to operate the vehicle prior to her leaving the facility to transport resident #1 back. She stated she asked S3 CNA why she had volunteered to transport the resident if she had never done so, and the CNA stated she just wanted to do it. She stated S3 CNA left the facility shortly after 8:00 p.m. on 6/6/16 to pick the resident up at the hospital. She stated the CNA was gone approximately 2 hours and she informed S2 DON, who was at the facility of how long the CNA had been gone. She stated S2 DON then called the hospital to see about S3 CNA's location. She stated the CNA returned to the facility with the resident around 10:00 p.m., as she (S5 CNA) was leaving the building. S5 CNA stated she had been trained on properly securing residents in the facility vehicle by the prior van drivers at the facility, and had been a van driver at a previous facility. She stated there was no documentation completed after she instructed S3 CNA to verify S3 CNA was proficient securing and transporting a resdient safely in the facility's van Review of S5 CNA's personnel file revealed there was no documentation to verify her competency in securing and transporting residents in the facility van. Further review revealed there was no documentation that she had been instructed on the facility's Motor Vehicle Driving Policy. Review of S3 CNA's personnel file revealed no documentation verifying her competency in securing and transporting resdients in the faciltiy van. Review of the facility's inservice documentation dated 2/12/16 revealed an inservice was conducted related to the wheelchair van hook-up. Review revealed documentation S5 CNA was present during the inservice, and that staff was instructed on how to operate the facility van when someone needed to be transported. Further review revealed no detailed instructions for the process and there was no documentation of verification of the staff's competency. Review of a facility inservice dated 6/14/16 revealed an inservice entitled Transportation Policy and Procedure. The documentation revealed the facility was to provide transportation to and from appointments as scheduled, and that in the event of an emergency, the ambulance would be called to transport a resident immediately to the emergency room . The inservice revealed that CNAs were designated to pick up residents in the facility van upon discharge from the hospital if they were not bed bound. Further review revealed that it was the CNAs responsibility to check for safety issues on transportation upon leaving and returning to the facility. There was no documentation to revealed facility staff was educated regarding the process for adequately and properly securing residents in the vehicle. There was also no documentation of how the facility was going to evaluate the competency of the staff in the task. Further interview on 6/28/16 at 10:45 a.m. with S7 LPN/QA Nurse revealed that the facility's normal process was that if a staff had not been trained on properly securing a resident in the facility's vehicle, another CNA who was trained would show the CNA how to properly secure the resident. S7 LPN/QA Nurse stated there was no paperwork to her knowledge that was completed to verify CNA competency in the task. She stated there had been other CNAs trained the same way and there had never been any problems. Further interview on 6/28/16 at 10:53 a.m. with S2 DON confirmed the facility had no process prior to the incident on 6/6/16 of ensuring staff were competent in properly and adequately securing and transporting a resident in the facility's van. She confirmed that if a staff was going to transport a resident and they had never done so, they were shown how to properly secure the resident in the vehicle prior to leaving the facility, but there was no documented competency check. She stated the facility was having to change their process since the 6/6/16 incident. Interview on 6/28/16 at 12:50 p.m. with S1 Administrator revealed he confirmed that staff was trained by CNAs who normally drove the transportation van, and were shown how to properly secure a resident. He stated the staff performing the training were competent staff. He stated there was no documentation or competency evaluation related to ensuring staff could properly and adequately secure residents in the vehicle. He stated the facility had no ongoing training/competency ensuring staff were able to properly secure residents in the facility van, and confirmed there had been no monitoring since the 6/6/16 incident. Interview on 6/28/16 at 3:40 p.m. with S8 Administrative Assistant confirmed there was no documentation in S5 CNA's personnel file to verify she had been instructed on the facility's Motor Vehicle Driving Policy.

Based on record review and interview the Administrator failed to administrate the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#1) of 20 (#1, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) residents who, according to a list provided by the facility, are wheelchair residents for who the facility provides transportation out of a total sample of 22 residents. The facility failed to: 1. have a policy and procedure in place that specified how to properly secure a resident and/or residents in the facility van prior to transport; 2. ensure that staff that transported wheelchair residents in the facility's van were properly trained and demonstrated competency in skills and techniques necessary for the transport of those wheelchair residents. This failed practiced placed resident #1 in an Immediate Jeopardy situation, which began on 6/6/16 at 9:25 p.m. when S3 CNA, who was not properly trained and did not demonstrate competency in skills and techniques necessary for transporting residents in the facilty's van was allowed to transfer a resident from the hospital. During the transport, the facility's van came to a stop at a traffic light. Upon acceleration of the vehicle, resident #1 fell from her wheelchair. The resident sustained [REDACTED]. The Immediate Jeopardy ended for resident #1 when she was sent out to the emergency roiagnom on [DATE] at 12:04 p.m. per EMS transport. S1 Administrator was informed of the deficient practice at the Immediate Jeopardy level on 6/28/16 at 4:02 p.m. The Immediate Jeopardy was removed on 6/29/2016 at 11:00 a.m. when the facility provided an acceptable plan of removal, which included the following: 1. The facility van was removed from use unitl formal written training and competency verification occurred. 2. All drivers will receive initial training and certified trainers will be retrained once a month times 3 months. Retraining will be conducted twice a year in March and September. 3. Only trained drivers will be allowed to drive the facility's van, with a list of certified trainers and certified drivers to be kept at the Nurses' Station and updated as applicable. 4. The van checklist will be done by a certified driver prior to each use of the van, and report to the North Hall nurse the status of the van. Any problems noted would require the vehicle to be removed from use and the keys given to administration for needed repairs. 5. The facility's van will not be used if there is not a certified driver or certified trainer working on the shift. 6. Maintenance staff will be trained to evaluate and service the facility's van weekly per manufacturer's recommendation, and will be required to be a certified driver. The maintenance worker is to notify administration immediately if any problems are encountered. 7. The Quality Assurance nurse will monitor the van checklist for proper functioning of components log. Any deficiency noted will be immediately reported to administration for follow-up action. This monitoring is to be conducted weekly for four week, then monthly thereafter. Any deficiency noted will be immediately reported to administration for follow-up action. This deficient practice continued at an actual harm for resident #1 and at a potential for more than minimal harm for the other 19 resident who, according to a list provided by the facility, are wheelchair residents for who the facility provides transportation. Findings: 1. Cross reference F323 2. Cross reference F498 Interview on 6/27/16 at 2:35 p.m. with S7 LPN/QA Nurse revealed she had stayed over as the 2nd nurse on the shift on the evening of 6/6/16. She stated the hospital had called to report that the resident was ready for return back to the facility. She stated she asked the CNAs who wanted to go and pick the resident up, and S3 CNA volunteered. She stated she didn't know if the CNA had been trained on properly securing a resident in the facility van, but that S5 CNA was going to train her before she left. She stated she (S7 LPN/QA Nurse) left the facility around 8:00 p.m. prior to the CNA leaving the facility, and that as she was leaving she saw S5 CNA and S3 CNA in the facility van. Further interview revealed S7 LPN/QA Nurse stated she had been instructed that anyone employed by the facility, who had a driver's license, was covered by the facility insurance and could operate the vehicle. She stated she wasn't aware of any list of authorized drivers. S7 LPN/QA Nurse was asked if she was aware S3 CNA had never transported any resident in the facility van and had not been trained on securing residents in the vehicle, S7 LPN/QA Nurse stated she didn't know if the CNA had ever transported residents before or had been trained. Further interview on 6/28/16 at 10:45 a.m. with S7 LPN/QA Nurse revealed that the facility's normal process was that if a staff had not been trained on properly securing a resident in the facility's vehicle, another CNA who was trained would show the CNA how to properly secure the resident. S7 LPN/QA Nurse stated there was no paperwork to her knowledge that was completed to verify CNA competency in the task. She stated there had been other CNAs trained the same way and there had never been any problems. Interview on 6/28/16 at 10:53 a.m. with S2 DON confirmed the facility had no process prior to the incident on 6/6/16 of ensuring staff were competent to properly and adequately secure and transport a resident in the facility van. She confirmed that if a staff that had never done a transport was going to transport a resident, they were shown how to properly secure the resident in the vehicle prior to leaving the facility. However, there was no documented competency check. She stated the facility was having to change their process since the 6/6/16 incident. Interview on 6/28/16 at 12:50 p.m. with S1 Administrator confirmed that staff was trained by CNAs who normally drove the transportation van and were shown how to properly secure a resident. He stated the staff performing the training were competent staff. He stated there was no documentation or competency evaluation related to ensuring the staff could properly and adequately secure residents in the vehicle. He stated inservices were started after the incident was discovered either the next day or a couple of days later. He confirmed he did the inservice and personally sat in the chair and instructed the staff present on how to properly secure residents in the vehicle. He stated the facility had no ongoing training/competency regarding ensuring staff were able to properly secure residents, and he confirmed there had been no monitoring since the 6/6/16 incident.

Based on record review and interview the facility failed to ensure a resident's environment was as free of accident hazards as possible for 1 (#1) of 20 (#1, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22) residents who, according to a list provided by the facility, are wheelchair residents for who the facility provides transportation out of a total sample of 22 residents. The facility failed to ensure that a CNA who transported wheelchair resident (#1) in the facility's van was properly trained and demonstrated competency in securing the resident for transport from the hospital back to the facility. This failed practice placed resident #1 in an Immediate Jeopardy situation, which began on 6/6/16 at 9:25 p.m. when S3 CNA, who was not properly trained and did not demonstrate competency in skills and techniques necessary for transporting residents in the facility's van, was allowed to transport a resident from the hospital. During the transport, the facility's van came to a stop at a traffic light. Upon acceleration of the vehicle, resident #1 fell from her wheelchair. The resident sustained [REDACTED]. The Immediate Jeopardy ended for resident #1 when she was sent to the emergency roiagnom on [DATE] at 12:04 p.m. per EMS transport. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 6/28/16 at 4:02 p.m The Immediate Jeopardy was removed on 6/29/2016 at 11:00 a.m. when the facility provided an acceptable plan of removal, which included the following: 1. The facility van was removed from use until formal written training and competency verification occurred. 2. All drivers will receive initial training and certified trainers will be retrained once a month times 3 months. Retraining will be conducted twice a year in March and September. 3. Only trained drivers will be allowed to drive the facility's van, with a list of certified trainers and certified drivers to be kept at the Nurses' Station and updated as applicable. 4. The van checklist will be done by a certified driver prior to each use of the van, and report to the North Hall nurse the status of the van. Any problems noted would require the vehicle to be removed from use and the keys given to administration for needed repairs. 5. The facility's van will not be used if there is not a certified driver or certified trainer working on the shift. 6. Maintenance staff will be trained to evaluate and service the facility's van weekly per manufacturer's recommendation, and will be required to be a certified driver. The maintenance worker is to notify administration immediately if any problems are encountered. 7. The Quality Assurance nurse will monitor the van checklist for proper functioning of components log. Any deficiency noted will be immediately reported to administration for follow-up action. This monitoring is to be conducted weekly for four week, then monthly thereafter. Any deficiency noted will be immediately reported to administration for follow-up action. This deficient practice continued at an actual harm for resident #1 and at a potential for more than minimal harm for the other 19 residents who, according to a list provided by the facility, are wheelchair residents for who the facility provides transportation. Findings: Review of Nurses' Notes dated 6/6/2016 revealed the following entries: 1:00 p.m. - The resident was noted having a seizure on the hallway. She was brought to room and she was put in bed lying on her side with O2 applied. Acadian Ambulance was notified to transport the resident to the ER for evaluation and treatment. 1:32 p.m. - The resident was out to the ER per ambulance service. 9:45 p.m. - The resident returned from the ER with [DIAGNOSES REDACTED]. The resident was transferred per wheelchair and had speech difficulties, but was able to express current needs. V/S: B/P - 132/74; P - 76; T - 97.6; R - 20; O2 saturation - 92%. The documentation revealed the resident had no complaints of pain. 11:00 p.m. - The resident was lying in bed with no distress noted. Will continue to monitor. Review of Nurses' Notes dated 6/7/2016 revealed the following entries: 8:00 a.m. - The resident was lying in bed with no signs of distress. The resident was sleepy, she would open her eyes, but she would close them right back. The documentation revealed the resident did not appear to be in any pain or discomfort, and staff would continue to monitor. 9:00 a.m. - The resident was awake and answered appropriately with nodding to verbal questions. The resident's medication was taken and tolerated well. The documentation revealed that staff would continue to monitor. 11:30 a.m. - The resident was sent to the ER for evaluation and tx due to her right leg being swollen, she was complaining of pain and she had not urinated on the 6/2 shift. The report was given. 12:04 p.m. The resident was out of the facility via EMS. Review of the Operative Report dated 6/9/16 revealed the resident had a right hip injury and sustained a right subtrochanteric femur fracture. The Operative Report revealed the resident also sustained a left distal 3rd clavicle fracture. The report read that the resident's clavicle fx could be treated non-operatively, but her right trochanter was going to require open reduction and internal fixation. Further review of the Nurses' Notes revealed that on 6/11/16 at 7:00 p.m. the resident was readmitted to the facility with [DIAGNOSES REDACTED]. The resident was toe touch with weight-bearing to the left leg. The body assessment revealed the resident with a bulk dressing to her right hip incision care. Interview on 6/27/16 at 12:10 p.m. with S2 DON revealed that S7 LPN/QA Nurse had given S3 CNA permission to go and pick up resident #1 from theER on ce she was ready for discharge back to the facility. She stated she was not at the facility at the time the CNA left to pick up the resident; however, she arrived to the facility after the CNA left to pick up the resident from the ER. S2 DON stated S3 CNA never reported the incident involving the resident having a fall in route from the hospital. S2 DON stated that her observation of the resident was that she was still post-ictal from the seizure. She stated the resident was mumbling some words and voiced no complaints. She stated there were no obvious signs that something had occurred, and that S3 CNA only stated that the resident had complaints of a headache from the seizure. S2 DON stated that the following morning (6/7/16) around 11:00 a.m., the resident was found to have swelling to the right leg. She stated she began questioning the staff on all shifts, because she thought the resident had an injury of unknown origin. She stated no one was able to tell her anything had happened to the resident. She stated the resident was sent to the ER and was diagnosed with [REDACTED]. Further interview with S2 DON revealed she obtained statements from all the staff who had worked over the course of the previous 3 shifts. She stated S3 CNA was called in to write a statement, and during that time she admitted to the S4 ADON the incident involving the resident falling from the wheelchair during transport from the hospital. S2 DON stated the only explanation S3 CNA gave for not reporting the incident when she returned to the facility with the resident was that she was scared and nervous. S2 DON stated S3 CNA admitted that she forgot to seatbelt the resident into the wheelchair. Interview on 6/27/16 at 2:35 p.m. with S7 LPN/QA Nurse revealed she stayed over as the 2nd nurse on the shift on the evening of 6/6/16. She stated the hospital had called to report that the resident was ready for return to the facility. She stated she asked the CNAs who wanted to go and pick the resident up, and S3 CNA volunteered. She stated she didn't know if the CNA had been trained on properly securing a resident in the facility van, but that S5 CNA was going to train her before she left. She stated she (S7 LPN/QA Nurse) left the facility around 8:00 p.m. prior to the CNA leaving the facility, and that as she was leaving she saw S5 CNA and S3 CNA in the facility van. Further interview revealed S7 LPN/QA Nurse stated she had been instructed that anyone employed by the facility, who had a driver's license, was covered by the facility insurance and could operate the vehicle. She stated she wasn't aware of any list of authorized drivers. S7 LPN/QA Nurse was asked if she was aware S3 CNA had never transported any resident in the facility van and had not been trained on securing residents in the vehicle S7 LPN/QA Nurse stated she didn't know if S3 CNA had ever transported residents before or had been trained. Interview on 6/27/16 at 2:35 p.m. with S5 CNA revealed that on 6/6/16 she instructed S3 CNA on how to properly secure a resident in the van, and showed her how to operate the vehicle prior to her leaving the facility to transport resident #1 back to the facility. She stated she asked S3 CNA why she had volunteered to transport the resident if she had never done so, and S3 CNA stated she just wanted to do it. She stated S3 CNA left the facility shortly after 8:00 p.m. on 6/6/16 to pick the resident up at the hospital. She stated S3 CNA was gone approximately 2 hours and she informed S2 DON, who was at the facility of how long S3 CNA had been gone. She stated S2 DON then called the hospital to see about S3 CNA's location. She stated S3 CNA returned to the facility with the resident around 10:00 p.m., as she (S5 CNA) was leaving the building. S5 CNA stated she (S5 CNA) had been trained on properly securing residents in the facility vehicle by the prior van drivers at the facility and had been a van driver at a previous facility. She stated there was no documentation completed after she instructed S3 CNA. Further interview on 6/28/16 at 10:45 a.m. with S7 LPN/QA Nurse revealed that the facility's normal process was that if a staff had not been trained on properly securing a resident in the facility's vehicle, another CNA who was trained would show the CNA how to properly secure the resident. S7 LPN/QA Nurse stated there was no paperwork to her knowledge that was completed to verify CNA competency in the task. She stated there had been other CNAs trained the same way and there had never been any problems. Further interview on 6/28/16 at 10:53 a.m. with S2 DON confirmed the facility had no process prior to the incident on 6/6/16 of ensuring staff were competent to properly and adequately secure and transport a resident in the facility van. She confirmed that if a staff was going to transport a resident and they had never done so, they were shown how to properly secure the resident in the vehicle prior to leaving the facility. However, there was no documented competency check. She stated the facility was having to change their process since the 6/6/16 incident. Interview on 6/28/16 at 12:50 p.m. with S1 Administrator revealed he confirmed that staff was trained by CNAs who normally drove the transportation van and were shown how to properly secure a resident. He stated the staff doing the training were competent staff. He stated there was no documentation or competency evaluation related to ensuring staff could properly and adequately secure residents in the vehicle. He stated the facility had no ongoing training/competency ensuring staff were able to properly secure residents in the facility van, and confirmed there had been no monitoring since the 6/6/16 incident. Review of the facility's Motor Vehicle Driving Policy revealed all employees and passengers will use seatbelts/shoulder harnesses at all times. There was no documentation in the policy that revealed the correct application of the seatbelt/shoulder harness Review of S3 CNA's personnel file revealed there was no documentation that verified her competency in securing and transporting residents in the facility van. Review of S5 CNA's personnel file revealed there was no documentation to verify her competency in securing and transporting residents in the facility van. Further review of S5 CNA's personnel file revealed no documentation she had been instructed on the facility's Motor Vehicle Driving Policy. Review of the facility's inservice documentation dated 2/12/16 revealed an inservice was conducted related to the wheelchair van hook-up. The inservice documentation revealed S5 CNA was present during the inservice. Further review of the documentation revealed staff was instructed on how to operate the facility van when someone needed to be transported. Further review revealed no detailed instructions for the process, and there was no documentation of verification of staff's competency. Interview on 6/28/16 at 3:40 p.m. with S8 Administrative Assistant confirmed there was no documentation in S5 CNA's personnel file to verify she had been instructed on the facility's Motor Vehicle Driving Policy.

Based on interview and record review the facility failed to provide the necessary care and services to maintain the resident's highest practicable physical, mental and psychosocial well-being for 1 (#5) of 5 (#1, #2, #3 and #4) residents reviewed for falls. The facility failed to: 1. Ensure that a resident who complained of pain and discomfort to her leg after a fall was reassessed by the nurse (#5), 2. Ensure nursing staff notified the physician of the resident's complaints of pain and discomfort in order to obtain orders for relief of pain and discomfort (5), 3. Ensure that the physician was notified of a resident who had been ambulatory, inability to use her left lower extremity to bear weight and ambulate (5). The total census of the facilty was 50 according to the Resident Census and Condition of Residents report dated 3/10/15. This failed practice resulted in actual harm for resident #5 who ambulated independently, tripped over the wheechair and fell and hit her left knee on the floor on 2/15/15. The resident was independent in ambulation at the time of admission, and continued to independently ambulate until 2/15/15 when she experienced a fall onto her left knee. The physician was notified and ordered an x-ray. The x-ray was done on 2/15/15 and the results reflected no definite acute [MEDICAL CONDITION]; however, the femeral neck region was somewhat obscured by technique, and the interpreting doctor recommended that if there remained a concern for occult [MEDICAL CONDITION] in the osteopenic patient, ensure nonweightbearing and follow-up with radiographs in 2-3 days to evaluate for interval change. The x-ray results were reported to the resident's physician and there were no additional orders at that time. The resident continued to experience an inability to use her left leg to stand and ambulate, and required a wheelchair for mobility from 2/15/15 through 3/4/15. The resident experienced a decline in her continence, had to wear diapers and was unable to attend the day program she had been enrolled in. The resident saw the physician on 3/3/15, an x-ray was done, with results of a left [MEDICAL CONDITION]. The resident was admitted to the hospital, and required an ORIF of the left proximal femur on 3/4/15. Findings: Review of the facility policy "Head-to-Toe Assessment" reflected the objective was to gather and organize comprehensive objective/subjective data from each resident in order to fully evaluate the current status/condition, update and implement appropriate changes to the plan of care, and to maintain the safety and well-being of each resident at all times. The assessment procedure included guidelines for 1) mental status, 2) eyes, 3) mucous membranes, 4) respiratory, 5) breath sounds, 6) cardiovascular, 7) GI, 8) GU, 9) integumentary, 10) musculoskeletal, 11) nutrition. Further review of the policy reflected the guidelines will be used to better assess the status of all residents and charting will reflect any change in status and included I&A. Review of resident #5's Physician's Orders dated 02/01/15 reflected [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE] reflected resident #5 was admitted to the nursing facility from a behavioral hospital, and ambulated into the facility accompanied by a behavioral hospital's staff member. Further review of the assessment reflected the resident transferred and ambulated independently, was continent of bladder and bowel, and had no complaints of pain. The assessment reflected the resident was oriented, cooperative, talkative, had good motivation and readily answered questions. Review of the MDS Discharge assessment dated [DATE] reflected the resident had a memory problem with moderately impaired cognitive skills for daily decision making. Further review of the assessment reflected the resident was independent with locomotion on and off the unit and was steady at all times. The assessment further reflected the resident was always continent. Review of the MDS Significant Change assessment dated [DATE] reflected the resident's Brief Interview for Mental Status cognitive assessment score was 6 (scale of 1- 15), which according to the MDS Data Collection tool, reflected severe impairment. Further review reflected the resident had experienced the behaviors of inattention, delusions, and disorganized thinking that fluctuated. The assessment reflected the resident reported it was very important for her to do her favorite activities, to do things with groups of people, and to go outside to get fresh air when the weather was good. The assessment reflected the resident was able to walk in her room, in the corridor, on and off the unit with supervision and set up help, and had no impairment in funtional ROM of the upper and lower extremities. Further documentation reflected the resident did not require the use of a mobility devise, was continent of bowels, and frequently incontinent of bladder. Review of the Bowel and Bladder Assessment Form dated 10/31/14 and 12/31/14 reflected the resident was physically active, coherent, and did not have any loss of bladder control. Further review reflected the resident was continent of bowel and bladder. Review of the nurses' notes dated 2/15/15 at 8:30 a.m. reflected the resident was walking into the day room, tried to go around a resident in a wheelchair, tripped over the wc, fell on to the floor, and hit her left knee on the floor. The nurse's note reflected a head to toe assessment was done, and a red area was noted on the left knee. A nurses' note dated 2/15/15 at 9:30 a.m. reflected the MD and POA were notified of the fall. Further review of the nurse's note on 2/15/15 at 12:30 p.m. reflected the MD was notified of the resident's continued pain, and an x-ray of the left hip and knee was ordered. Further review of the nurses' note dated 2/15/15 at 4:15 p.m. reflected the facility received the x-ray report of no acute fractures of knee or hip, if pain persist follow up in 2-3 days. Review of the left hip x-ray report dated 2/15/15 reflected the findings of no definite acute [MEDICAL CONDITION] with the femeral neck region somewhat obscured by technique, if there remains concern for occult [MEDICAL CONDITION] in this osteopenic patient, recommend non-weightbearing and follow-up radiographs in 2-3 days to evaluate for interval change. The nurses' note dated 2/16/15 at 4:00 p.m. reflected the resident was AAO X 2, seated in a chair in the Day Room, respirations even and unlabored, speech clear, required limited assistance with ADLs and transfers times 1 staff, voiced no complaints, moved all extremities without difficulty, and safety maintained. The nurse's note dated 2/17/15 at 8:00 a.m. reflected a new order for an evaluation by PT and OT services due to recent fall and hip pain. Review of the PT Rehabilitation Screen dated 2/19/15 reflected the resident had problems with orientation, dressing, grooming/hygiene, bed mobility, transfers and locomotion, and the therapist recommended therapy. Further review of the PT Rehabilitation Screen reflected the resident refused to participate with therapy services. Review of the Physician/Prescriber Order dated 2/20/15 reflected an order was sent to the MD to inform the physician the resident had refused therapy services. The nurses' note dated 2/20/15 at 1:00 p.m. reflected the order for PT and OT services was discontinued due to patient refused services. The nurses' note dated 2/27/15 at 2:00 p.m. reflected the nurse scheduled a physician's appointment for the resident on 3/3/15 for 10:30 a.m., and notified the resident's R.P. Further review of the nurses' notes reflected there was no documentation of a nursing assessment by the RN or LPN from 2/17/15 through 3/2/15. There was no documentation of a nursing assessment of the resident's mobility status after 2/16/15. Interview on 3/11/15 at 12:00 p.m. with S5 LPN revealed the resident experienced a change in her mobility status after the fall of 2/15/15 and required the use of a wc from 2/16/15 through 3/4/15 for mobility. Interview on 3/11/15 at 12:15 p.m. with S3 LPN revealed the resident had a change / decline in her mobility status after the fall on 2/15/15. Further interview with S3 LPN revealed the resident was no longer able to ambulate, and required the use of a wc for mobility after the above fall. Interview on 3/11/15 at 1:30 p.m. with S2 ADON revealed the resident had a significant change in her condition after she fell on [DATE], and stated she was ambulatory prior to the above fall. Further interview of S2 ADON confirmed the resident was wc bound after the fall of 2/15/15 and required more assistance with ADL care. Interview on 3/11/15 at 1:35 p.m. with S10 CNA revealed she provided care for the resident frequently on the day shift. The S10 CNA revealed prior to the fall on 2/15/15, the resident required occasional limited assistance to stand and to steady herself (approximately 50% of the time), then was able to ambulate throughout the building. S10 CNA stated that after the fall on 2/15/15, the resident could no longer stand up without assistance, and usually required a 2 person assist to stand and transfer to the wheelchair. The S10 CNA stated the resident was no longer able to walk and remained in a wc until she was transferred to the hospital on [DATE]. Further interview with S10 CNA revealed the resident complained of her left knee and leg hurting after the fall of 2/15/15. Interview with S10 CNA revealed that during care on the days after the fall of 2/15/15, the resident complained when she was assisted to stand and transfer, and had rubbed her left leg and said "this ol leg is giving me trouble". S10 CNA stated she had reported the complaints to the resident's nurse. Interview on 3/11/15 at 1:45 p.m. with S11 CNA revealed she worked with the resident on the day shift and confirmed the resident became more dependent on staff after her fall of 2/15/15. S11 CNA stated that after the 2/15/15 fall, the resident remained in a wheelchair and required a 2 person assist for transfer. Further interview with S11 CNA revealed the resident complained of her knee hurting after the fall and rubbed her left knee, and that she reported the complaint to the resident's nurse. Interview on 3/11/15 at 2:10 p.m. with S4 LPN revealed she was the LPN Med Nurse on duty on 2/15/15 when the resident fell . Interview with S4 LPN revealed the resident was ambulatory before the above fall, and was unable to ambulate after the fall. Further interview reflected S4 LPN and S2 ADON were concerned that the resident had decreased mobility, remained in a wc, had refused therapy, and had made an appointment with the MD for evaluation. Interview on 3/11/15 at 2:15 p.m. with S6 CNA revealed the resident was ambulatory prior to the fall of 2/15/15, and after the fall the resident required a wc for mobility, and was no longer able to walk. Further interview with S6 CNA revealed the resident complained of her left knee hurting with transfers, and had reported it to the resident's nurse. Interview on 3/11/15 at 2:20 p.m. with S7 CNA revealed the resident was more dependent on staff after the fall on 2/15/15, required 2 person assist for transfers, and confirmed this was a change for the resident. Interview on 3/11/15 at 2:30 p.m. with S8 CNA revealed the resident was ambulatory and "self-sufficient" prior to her fall of 2/15/15 (except for showers), and was able to stand up for most of her showers. Further interview with S8 CNA revealed the resident required 2 person assist to transfer, and a wc for mobility after the fall of 2/15/15. Interview on 3/11/15 at 2:35 p.m. with S9 CNA revealed the resident was able to walk at will prior to the fall on 2/15/15. Further interview with S9 CNA revealed that after the above fall the resident was no longer able to walk, became more dependent on staff for care, and required a 2 persons assist to help her stand and transfer to the wc. Interview on 3/11/15 at 2:50 p.m. with S2 ADON confirmed the resident had experienced a change in her mobility and continence status after she fell on [DATE]. Further interview with S2 ADON revealed a Comprehensive Significant Change MDS Assessment was not performed. Review of documentation provided by the facility reflected the resident attended a behavioral health day program on 1/29/15, 1/30/15, 2/2/15, 2/3/15, 2/4/15, 2/5/15, 2/6/15, 2/9/15, 2/10/15, 2/11/15, 2/13/15, 2/16/15 and 2/18/15. Interview on 3/11/15 at 3:15 p.m. with S2 ADON revealed the resident had attended a behavioral health day program on a regular basis prior to the fall of 2/15/15; however, after the 2/15/15 fall she was only able to go 1 or 2 times. Further interview with S2 ADON revealed she called the physician's office on 2/27/15, talked to the receptionist and made an appt for the resident to see the physician on 3/3/15. S2 ADON confirmed she did not talk to the physician between the dates of 2/16/15 and 3/3/15 concerning the resident. Further interview with S2 ADON confirmed there was no documentation in the medical record to reflect the resident continued to be unable to stand and ambulate, had increased incontinence, and was unable to attend the day program from 2/19/15 - 3/2/15. Review of the MD assessment dated [DATE] reflected the resident had not walked since the fall, and complained of knee and hip pain. Review of the order dated 3/3/15 reflected x-rays were ordered s/p fall with complaint of lateral pain, and now wc bound. Review of the left hip x-ray report dated 3/3/15 reflected the findings of Impacted Left Subcapital Hip femoral Fracture. Review of the hospital records reflected the resident was admitted to the hospital on [DATE] after referral from the PCP d/t left [MEDICAL CONDITION]. Review of the physician's H&P dated 3/4/15 reflected the resident had advanced dementia, had a fall 3 weeks prior and was then in wc all the time. Documentation in the H&P reflected the resident had decreased cognitive function, some shortening of the LLE, and still had some ROM of the left hip but seemed painful. Further review of the hospital record reflected the Orthopedic Surgeon's Consultation Report dated 3/4/15 reflected the resident had a history of [REDACTED]. The physician's physical exam reflected the resident had pain with log rolling of the left hip at the inguinal crease, that was restricted due to pain. Review of the Operative Report dated 3/4/15 reflected the resident underwent [REDACTED].

Based on interview and record review the facility failed to ensure a comprehensive assessment was conducted within 14 days after a resident (#5) who sustained a fall, experienced a significant change in mobility and continence status, in a total sample of 5 residents (#1, #2, #3, #4 and #5). This failed practice resulted in actual harm for resident #5, who ambulated independently, tripped over the wheelchair and fell and hit her left knee on the floor on 2/15/15. The physician was notified and ordered an x-ray. The x-ray was done on 2/15/15 and the results reflected no definite acute [MEDICAL CONDITION]; however, the femeral neck region was somewhat obscured by technique, and the interpreting doctor recommended that if there remained a concern for occult [MEDICAL CONDITION] in the osteopenic patient, ensure nonweightbearing and follow-up with radiographs in 2-3 days to evaluate for interval change. The x-ray results were reported to the resident's physician and there were no additional orders at that time. The resident continued to experience an inability to use her left leg to stand and ambulate, and required a wheelchair for mobility from 2/15/15 through 3/4/15. The resident experienced a decline in her continence, had to wear diapers and was unable to attend the day program she had been enrolled in. The resident saw the physician on 3/3/15, an x-ray was done, with results of a left [MEDICAL CONDITION]. The resident was admitted to the hospital, and required an ORIF of the left proximal femur on 3/4/15. Findings: Review of the facility policy "Incident/Accident/Medication Error Report" reflected the procedure instructions included - follow-up documentation was to be done by the licensed nurse on each shift until the condition of the resident was stable or a minimum of 3 days. Review of the facility policy "Head-to-Toe Assessment" reflected the objective was to gather and organize comprehensive objective/subjective data from each resident in order to fully evaluate the current status/condition, update and implement appropriate changes to the plan of care, and to maintain the safety and well-being of each resident at all times. The assessment procedure included guidelines for 1) mental status, 2) eyes, 3) mucous membranes, 4) respiratory, 5) breath sounds, 6) cardiovascular, 7) GI, 8) GU, 9) integumentary, 10) musculoskeletal, 11) nutrition. Further review of the policy reflected the guidelines will be used to better assess the status of all residents and charting will reflect any change in status and included I&A. Review of the Admission Nursing assessment dated [DATE] reflected resident #5 was admitted to the nursing facility from a behavioral hospital, and ambulated into the facility accompanied by a behavioral hospital's staff member. Further review of the assessment reflected the resident transferred and ambulated independently, was continent of bladder and bowel, and had no complaints of pain. The assessment reflected the resident was oriented, cooperative, talkative, had good motivation and readily answered questions. Review of the MDS Discharge assessment dated [DATE] reflected the resident had a memory problem with moderately impaired cognitive skills for daily decision making. Further review of the assessment reflected the resident was independent with locomotion on and off the unit and was steady at all times. Documentation reflected the resident was always continent. Review of the MDS Significant Change assessment dated [DATE] reflected the resident's Brief Interview for Mental Status cognitive assessment score was 6 (scale of 1- 15), which according to the MDS Data Collection tool, reflected severe impairment. Further review reflected the resident had experienced the behaviors of inattention, delusions, and disorganized thinking that fluctuated. The assessment reflected the resident reported it was very important for her to do her favorite activities, to do things with groups of people, and to go outside to get fresh air when the weather was good. The assessment reflected the resident was able to walk in her room, in the corridor, on and off the unit with supervision and set up help, and had no impairment in funtional ROM of the upper and lower extremities. Further documentation reflected the resident did not require the use of a mobility devise, was continent of bowels, and frequently incontinent of bladder. Review of the Bowel and Bladder Assessment Form dated 10/31/14 and 12/31/14 reflected the resident was physically active, coherent, and did not have any loss of bladder control. Further review reflected the resident was continent of bowel and bladder. Review of the nurses' notes dated 2/15/15 at 8:30 a.m. reflected the resident was walking into the day room, tried to go around a resident in a wheelchair, tripped over the wc, fell on to the floor, and hit her left knee on the floor. The nurse's note reflected a head to toe assessment was done, and a red area was noted on the left knee. A nurses' note dated 2/15/15 at 9:30 a.m. reflected the MD and POA were notified of the fall. Further review of the nurse's note on 2/15/15 at 12:30 p.m. reflected the MD was notified of the resident's continued pain, and an x-ray of the left hip and knee was ordered. Further review of the nurses' note dated 2/15/15 at 4:15 p.m. reflected the facility received the x-ray report of no acute fractures of knee or hip, if pain persist follow up in 2-3 days. Review of the left hip x-ray report dated 2/15/15 reflected the findings of no definite acute [MEDICAL CONDITION] with the femeral neck region somewhat obscured by technique, if there remains concern for occult [MEDICAL CONDITION] in this osteopenic patient, recommend non-weightbearing and follow-up radiographs in 2-3 days to evaluate for interval change. The nurses' note dated 2/16/15 at 4:00 p.m. reflected the resident was AAO X 2, seated in a chair in the Day Room, respirations even and unlabored, speech clear, required limited assistance with ADLs and transfers times 1 staff, voiced no complaints, moved all extremities without difficulty, and safety maintained. The nurse's note dated 2/17/15 at 8:00 a.m. reflected a new order for an evaluation by PT and OT services due to recent fall and hip pain. Review of the PT Rehabilitation Screen dated 2/19/15 reflected the resident had problems with orientation, dressing, grooming/hygiene, bed mobility, transfers and locomotion, and the therapist recommended therapy. Further review of the PT Rehabilitation Screen reflected the resident refused to participate with therapy services. Further review of the nurses' notes reflected there was no documentation of a nursing assessment by the RN or LPN from 2/17/15 through 3/2/15. Additionally, there was no documentation of a nursing assessment of the resident's mobility status after 2/16/15. Review of the Resident Care Flow Record for the month of January 2015 revealed the resident's bladder habits were monitored by the CNAs during 3 shifts each day. Further review reflected documentation the resident was continent for 91 of 92 shifts that were monitored in January. Review of the Resident Care Flow Record for the month of February 2015 reflected the resident was continent of bladder for 38 of the 40 shifts monitored from 2/1/15 to 2/14/15, and incontinent of bladder for 37 of 39 shifts monitored from 2/15/15 to 2/28/15. Interview on 3/11/15 at 12:00 p.m. with S5 LPN revealed the resident experienced a change in her mobility status after the fall of 2/15/15 and required the use of a wc from 2/16/15 through 3/4/15 for mobility. Interview on 3/11/15 at 12:15 p.m. with S3 LPN revealed the resident had a change / decline in her mobility status after the fall on 2/15/15. Further interview with S3 LPN revealed the resident was no longer able to ambulate, and required the use of a wc for mobility after the above fall. S3 LPN stated she reported the findings to S1 DON, and wrote the order for PT/OT evaluation as instructed by the S1 DON. Interview on 3/11/15 at 1:30 p.m. with S2 ADON revealed the resident had a significant change in her condition after she fell on [DATE], and stated she was ambulatory prior to the above fall. Further interview of S2 ADON confirmed the resident was wc bound after the fall of 2/15/15 and required more assistance with ADL care. S2 ADON reviewed the nurses' documentation and confirmed there was no documentation of a comprehensive nurse assessment by the RN from the time of the fall on 2/15/15 through the time the resident was transferred to the hospital on [DATE]. S2 ADON confirmed there was documentation of a nursing assessment on 2/15/15 at 8:30 a.m. and 12:30 p.m. during the day shift, on 2/16/15 at 4:00 p.m. on the evening shift, and no further documentation of a nursing assessment of the resident's condition until 3/3/15. Interview on 3/11/15 at 1:35 p.m. with S10 CNA revealed she provided care for the resident frequently on the day shift. The S10 CNA revealed prior to the fall on 2/15/15, the resident required occasional limited assistance to stand and to steady herself (approximately 50% of the time), then was able to ambulate throughout the building. S10 CNA stated that after the fall on 2/15/15, the resident could no longer stand up without assistance, and usually required a 2 person assist to stand and transfer to the wheelchair. The S10 CNA stated the resident was no longer able to walk and remained in a wc until she was transferred to the hospital on [DATE]. S10 CNA stated the resident became incontinent of urine after the fall of 2/15/15, and had previously been continent. Interview on 3/11/15 at 1:45 p.m. with S11 CNA revealed she worked with the resident on the day shift and confirmed the resident became more dependent on staff after her fall of 2/15/15. S11 CNA stated that after the 2/15/15 fall, the resident remained in a wheelchair and required a 2 person assist for transfer. Further interview with S11 CNA revealed the resident complained of her knee hurting after the fall and rubbed her left knee, and that she reported the complaint to the resident's nurse. Interview on 3/11/15 at 2:10 p.m. with S4 LPN revealed she was the LPN Med Nurse on duty on 2/15/15 when the resident fell . Interview with S4 LPN revealed the resident was ambulatory before the above fall, and was unable to ambulate after the fall. Interview on 3/11/15 at 2:15 p.m. with S6 CNA revealed the resident was ambulatory prior to the fall of 2/15/15, and after the fall the resident required a wc for mobility, and was no longer able to walk. Interview on 3/11/15 at 2:20 p.m. with S7 CNA revealed the resident was more dependent on staff after the fall on 2/15/15, required 2 person assist for transfers, and confirmed this was a change for the resident. Interview on 3/11/15 at 2:30 p.m. with S8 CNA revealed the resident was ambulatory and "self-sufficient" prior to her fall of 2/15/15 (except for showers), and was able to stand up for most of her showers. Further interview with S8 CNA revealed the resident required 2 person assist to transfer, and a wc for mobility after the fall of 2/15/15. Interview on 3/11/15 at 2:35 p.m. with S9 CNA revealed the resident was able to walk at will prior to the fall on 2/15/15. Further interview with S9 CNA revealed that after the above fall the resident was no longer able to walk, became more dependent on staff for care, and required a 2 persons assist to help her stand and transfer to the wc. Further interview with S9 CNA revealed the resident became incontinent and required diapers to keep her clothes dry. S9 CNA stated that prior to the above fall, the resident was able to stand up for her shower, and after the fall she had to sit on a shower chair to take a shower. Interview on 3/11/15 at 2:50 p.m. with S2 ADON confirmed the resident had experienced a change in her mobility and continence status after she fell on [DATE]. Further interview with S2 ADON revealed a Comprehensive Significant Change MDS Assessment was not performed. Interview by telephone on 3/11/15 at 3:05 p.m. with S1 DON revealed S1 DON had assessed the resident's back and legs for s/s of bruising and injury after the resident fell on [DATE]. S1 DON confirmed she did not document the assessment and should have. Interview with S1 DON confirmed a Comprehensive Significant Change Assessment had not been completed, and confirmed the RN should have documented a comprehensive assessment. The S1 DON revealed a nursing assessment should have been performed and documented every shift (3 shifts per day) for 3 days after the resident fell on [DATE]. Review of documentation provided by the facility reflected the resident attended a behavioral health day program on 1/29/15, 1/30/15, 2/2/15, 2/3/15, 2/4/15, 2/5/15, 2/6/15, 2/9/15, 2/10/15, 2/11/15, 2/13/15, 2/16/15 and 2/18/15. Interview on 3/11/15 at 3:15 p.m. with S2 ADON revealed the resident had attended a behavioral health day program on a regular basis prior to the fall of 2/15/15; however, after the 2/15/15 fall she was only able to go 1 or 2 times. Review of the MD assessment dated [DATE] reflected the resident had not walked since the fall, and complained of knee and hip pain. Review of the left hip x-ray report dated 3/3/15 reflected the findings of Impacted Left Subcapital Hip femoral Fracture. Review of the hospital records reflected the resident was admitted to the hospital on [DATE] after referral from the PCP d/t left [MEDICAL CONDITION]. Review of the physician's H&P dated 3/4/15 reflected the resident had advanced dementia, had a fall 3 weeks prior and was then in wc all the time. Documentation in the H&P reflected the resident had decreased cognitive function, some shortening of the LLE, and still had some ROM of the left hip but seemed painful. Further review of the hospital record reflected the Orthopedic Surgeon's Consultation Report dated 3/4/15 reflected the resident had a history of [REDACTED]. The physician's physical exam reflected the resident had pain with log rolling of the left hip at the inguinal crease, that was restricted due to pain. Review of the Operative Report dated 3/4/15 reflected the resident underwent [REDACTED].

Based on interview and record review the facility failed to ensure the resident's physician was immediately consulted with regarding the resident's continued inability to use her left lower extremity to stand and ambulate, and experienced a decline in her continence status, after she experienced a fall on 2/15/15 for 1 (#5) of 5 (#1, #2, #3, #4 and #5) sampled residents. This failed practice resulted in actual harm for resident #5 who ambulated independently, tripped over the wheelchair, and fell and hit her left knee on the floor on 2/15/15. The physician was notified and ordered an x-ray. The x-ray was done on 2/15/15 and the results reflected no definite acute [MEDICAL CONDITION]; however, the femeral neck region was somewhat obscured by technique, and the interpreting doctor recommended that if there remained a concern for occult [MEDICAL CONDITION] in the osteopenic patient, ensure nonweightbearing and follow-up with radiographs in 2-3 days to evaluate for interval change. The x-ray results were reported to the resident's physician and there were no additional orders at that time. The resident continued to experience an inability to use her left leg to stand and ambulate, and required a wheelchair for mobility from 2/15/15 through 3/4/15. The resident experienced a decline in her continence, had to wear diapers and was unable to attend the day program she had been enrolled in. The resident saw the physician on 3/3/15, an x-ray was done, with results of a left [MEDICAL CONDITION]. The resident was admitted to the hospital, and required an ORIF of the left proximal femur on 3/4/15. Findings: Review of resident #5's physician's orders [REDACTED]. Review of the Admission Nursing assessment dated [DATE] reflected resident #5 was admitted to the nursing facility from a behavioral hospital, and ambulated into the facility accompanied by a behavioral hospital's staff member. Further review of the assessment reflected the resident transferred and ambulated independently, was continent of bladder and bowel, and had no complaints of pain. The assessment reflected the resident was oriented, cooperative, talkative, had good motivation and readily answered questions. Review of the MDS Discharge assessment dated [DATE] reflected the resident had a memory problem with moderately impaired cognitive skills for daily decision making. Further review of the assessment reflected the resident was independent with locomotion on and off the unit and was steady at all times. Documentation reflected the resident was always continent. Review of the MDS Significant Change assessment dated [DATE] reflected the resident's Brief Interview for Mental Status cognitive assessment score was 6 (scale of 1- 15), which according to the MDS Data Collection tool, reflected severe impairment. Further review reflected the resident had experienced the behaviors of inattention, delusions, and disorganized thinking that fluctuated. The assessment reflected the resident reported it was very important for her to do her favorite activities, to do things with groups of people, and to go outside to get fresh air when the weather was good. The assessment reflected the resident was able to walk in her room, in the corridor, on and off the unit with supervision and set up help, and had no impairment in ROM of the upper and lower extremities. Further documentation reflected the resident did not require the use of a mobility devise, was continent of bowels, and frequently incontinent of bladder. Review of the Bowel and Bladder Assessment Form dated 10/31/14 and 12/31/14 reflected the resident was physically active, coherent, and did not have any loss of bladder control. Further review reflected the resident was continent of bowel and bladder. Review of the nurses' notes dated 2/15/15 at 8:30 a.m. reflected the resident was walking into the day room, tried to go around a resident in a wheelchair, tripped over the wc, fell on to the floor, and hit her left knee on the floor. The nurse's note reflected a head to toe assessment was done, and a red area was noted on the left knee. A nurses' note dated 2/15/15 at 9:30 a.m. reflected the MD and POA were notified of the fall. Further review of the nurse's note on 2/15/15 at 12:30 p.m. reflected the MD was notified of the resident's continued pain, and an x-ray of the left hip and knee was ordered. Further review of the nurses' note dated 2/15/15 at 4:15 p.m. reflected the facility received the x-ray report of no acute fractures of knee or hip, if pain persist follow up in 2-3 days. Review of the left hip x-ray report dated 2/15/15 reflected the findings of no definite acute [MEDICAL CONDITION] with the femeral neck region somewhat obscured by technique, if there remains concern for occult [MEDICAL CONDITION] in this osteopenic patient, recommend non-weightbearing and follow-up radiographs in 2-3 days to evaluate for interval change. The nurses' note dated 2/16/15 at 4:00 p.m. reflected the resident was AAO X 2, seated in a chair in the Day Room, respirations even and unlabored, speech clear, required limited assistance with ADLs and transfers times 1 staff, voiced no complaints, moved all extremities without difficulty, and safety maintained. The nurse's note dated 2/17/15 at 8:00 a.m. reflected a new order for an evaluation by PT and OT services due to recent fall and hip pain. Review of the PT Rehabilitation Screen dated 2/19/15 reflected the resident had problems with orientation, dressing, grooming/hygiene, bed mobility, transfers and locomotion, and the therapist recommended therapy. Further review of the PT Rehabilitation Screen reflected the resident refused to participate with therapy services. Review of the Physician/Prescriber Order dated 2/20/15 reflected an order was sent to the MD to inform the physician the resident had refused therapy services. The nurses' note dated 2/20/15 at 1:00 p.m. reflected the order for PT and OT services was discontinued due to patient refused services. The nurses' note dated 2/27/15 at 2:00 p.m. reflected the nurse scheduled a physician's appointment for the resident on 3/3/15 for 10:30 a.m., and notified the resident's R.P. Review of the Resident Care Flow Record for the month of January 2015 revealed the resident's bladder habits were monitored by the CNAs during 3 shifts each day. Further review reflected documentation the resident was continent for 91 of 92 shifts that were monitored in January. Review of the Resident Care Flow Record for the month of February 2015 reflected the resident was continent of bladder for 38 of the 40 shifts monitored from 2/1/15 to 2/14/15, and incontinent of bladder for 37 of 39 shifts monitored from 2/15/15 to 2/28/15. Interview on 3/11/15 at 12:00 p.m. with S5 LPN revealed the resident experienced a change in her mobility status after the fall of 2/15/15 and required the use of a wc from 2/16/15 through 3/4/15 for mobility. Interview on 3/11/15 at 12:15 p.m. with S3 LPN revealed the resident had a change / decline in her mobility status after the fall on 2/15/15. Further interview with S3 LPN revealed the resident was no longer able to ambulate, and required the use of a wc for mobility after the above fall. S3 LPN stated she reported the findings to S1 DON, and wrote the order for PT/OT evaluation as instructed by the S1 DON. Interview on 3/11/15 at 1:30 p.m. with S2 ADON revealed the resident had a significant change in her condition after she fell on [DATE], and stated she was ambulatory prior to the above fall. Further interview of S2 ADON confirmed the resident was wc bound after the fall of 2/15/15 and required more assistance with ADL care. S2 ADON reviewed the nurses' documentation and confirmed there was no documentation of a comprehensive nurse assessment by the RN from the time of the fall on 2/15/15 through the time the resident was transferred to the hospital on [DATE]. S2 ADON confirmed there was documentation of a nursing assessment on 2/15/15 at 8:30 a.m. and 12:30 p.m. during the day shift, on 2/16/15 at 4:00 p.m. on the evening shift, and no further documentation of a nursing assessment of the resident's condition until 3/3/15. Interview on 3/11/15 at 1:35 p.m. with S10 CNA revealed she provided care for the resident frequently on the day shift. The S10 CNA revealed prior to the fall on 2/15/15, the resident required occasional limited assistance to stand and to steady herself (approximately 50% of the time), then was able to ambulate throughout the building. S10 CNA stated that after the fall on 2/15/15, the resident could no longer stand up without assistance, and usually required a 2 person assist to stand and transfer to the wheelchair. The S10 CNA stated the resident was no longer able to walk and remained in a wc until she was transferred to the hospital on [DATE]. Further interview with S10 CNA revealed the resident complained of her left knee and leg hurting after the fall of 2/15/15. Interview with S10 CNA revealed that during care on the days after the fall of 2/15/15, the resident complained when she was assisted to stand and transfer, and had rubbed her left leg and said "this ol leg is giving me trouble". S10 CNA stated she had reported the complaints to the resident's nurse. S10 CNA stated the resident became incontinent of urine after the fall of 2/15/15, and had previously been continent. Interview on 3/11/15 at 1:45 p.m. with S11 CNA revealed she worked with the resident on the day shift and confirmed the resident became more dependent on staff after her fall of 2/15/15. S11 CNA stated that after the 2/15/15 fall, the resident remained in a wheelchair and required a 2 person assist for transfer. Further interview with S11 CNA revealed the resident complained of her knee hurting after the fall and rubbed her left knee, and that she reported the complaint to the resident's nurse. Interview on 3/11/15 at 2:10 p.m. with S4 LPN revealed she was the LPN Med Nurse on duty on 2/15/15 when the resident fell . Interview with S4 LPN revealed the resident was ambulatory before the above fall, and was unable to ambulate after the fall. Further interview reflected S4 LPN and S2 ADON were concerned that the resident had decreased mobility, remained in a wc, had refused therapy, and had made an appointment with the MD on 3/3/15 for evaluation. Interview on 3/11/15 at 2:15 p.m. with S6 CNA revealed the resident was ambulatory prior to the fall of 2/15/15, and after the fall the resident required a wc for mobility, and was no longer able to walk. Further interview with S6 CNA revealed the resident complained of her left knee hurting with transfers, and had reported it to the resident's nurse. Interview on 3/11/15 at 2:20 p.m. with S7 CNA revealed the resident was more dependent on staff after the fall on 2/15/15, required 2 person assist for transfers, and confirmed this was a change for the resident. Interview on 3/11/15 at 2:30 p.m. with S8 CNA revealed the resident was ambulatory and "self-sufficient" prior to her fall of 2/15/15 (except for showers), and was able to stand up for most of her showers. Further interview with S8 CNA revealed the resident required 2 person assist to transfer, and a wc for mobility after the fall of 2/15/15. Interview on 3/11/15 at 2:35 p.m. with S9 CNA revealed the resident was able to walk at will prior to the fall on 2/15/15. Further interview with S9 CNA revealed that after the above fall the resident was no longer able to walk, became more dependent on staff for care, and required a 2 persons assist to help her stand and transfer to the wc. Further interview with S9 CNA revealed the resident became incontinent and required diapers to keep her clothes dry. S9 CNA stated that prior to the above fall, the resident was able to stand up for her shower, and after the fall she had to sit on a shower chair to take a shower. Interview on 3/11/15 at 2:50 p.m. with S2 ADON confirmed the resident had experienced a change in her mobility and continence status after she fell on [DATE]. Review of documentation provided by the facility reflected the resident attended a behavioral health day program on 1/29/15, 1/30/15, 2/2/15, 2/3/15, 2/4/15, 2/5/15, 2/6/15, 2/9/15, 2/10/15, 2/11/15, 2/13/15, 2/16/15 and 2/18/15. Interview on 3/11/15 at 3:15 p.m. with S2 ADON revealed the resident had attended a behavioral health day program on a regular basis prior to the fall of 2/15/15; however, after the 2/15/15 fall she was only able to go 1 or 2 times. Further interview with S2 ADON revealed she called the physician's office on 2/27/15, talked to the receptionist and made an appt for the resident to see the physician on 3/3/15. S2 ADON confirmed she did not talk to the physician between the dates of 2/16/15 and 3/3/15 concerning the resident. Further interview with S2 ADON confirmed there was no documentation in the medical record to reflect the physician had been notified the resident had ongoing problems with immobility from 2/17/15 - 3/2/15, continued to be unable to stand and ambulate, had increased incontinence, and was unable to attend the day program from 2/19/15 - 3/2/15. Interview on 3/11/15 at 3:35 p.m. with S3 LPN confirmed she did not talk to the resident's physician when she wrote the order for PT / OT evaluation on 2/17/15, and did not make a report to the physician related to the changes in the resident's condition after her fall on 2/15/15 from 2/17/15 through 3/3/15. Review of the MD assessment dated [DATE] reflected the resident had not walked since the fall, and complained of knee and hip pain. Review of the order dated 3/3/15 reflected x-rays were ordered s/p fall with complaint of lateral pain, and now wc bound. Review of the left hip x-ray report dated 3/3/15 reflected the findings of Impacted Left Subcapital Hip femoral Fracture. Review of the hospital records reflected the resident was admitted to the hospital on [DATE] after referral from the PCP d/t left [MEDICAL CONDITION]. Review of the physician's H&P dated 3/4/15 reflected the resident had advanced dementia, had a fall 3 weeks prior and was then in wc all the time. Documentation in the H&P reflected the resident had decreased cognitive function, some shortening of the LLE, and still had some ROM of the left hip but seemed painful. Further review of the hospital record reflected the Orthopedic Surgeon's Consultation Report dated 3/4/15 reflected the resident had a history of [REDACTED]. The physician's physical exam reflected the resident had pain with log rolling of the left hip at the inguinal crease, that was restricted due to pain. Review of the Operative Report dated 3/4/15 reflected the resident underwent [REDACTED].

Based on observations, record reviews and interviews, the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection for 4 of 4 (#6, #39, #53, and # 56) residents. The facility failed to: 1. ensure a finger stick device (pen-like device) was not reused for more than one resident for point of care testing, 2. ensure the facility's Infection Control Program identified, developed, and implemented a plan that ensured blood glucose monitoring was administered in a manner that prevented cross contamination. The above failures effected 18 residents who required fingerstick blood glucose monitoring (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56, and #63). The survey sample size was 26. The facility's census was 46 residents as reflected on the facility's 802/Roster Sample Matrix. Observation on 5/28/14 at 5:25 a.m. during a medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56) using the same fingerstick(pen-like device) on 4 residents (#6, #39, #53 and #56). The S2 DON stated during an interview on 5/28/14 at 9:00 a.m. that 18 of the 46 facility residents (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56, and #63) required fingerstick blood glucose monitoring. Review of the May 2014 Physician's Orders for the 18 residents who required fingerstick blood glucose monitoring (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56 and #63), revealed they required fingerstick blood glucose monitoring either at 6:00 a.m., 9:00 a.m., 11:00 a.m., 4:00 p.m., 4:30 p.m., 8:00 p.m., or 9:00 p.m. Further review of the above dated Physician's Orders revealed that 1 (#6) resident had a [DIAGNOSES REDACTED]. An Immediate Jeopardy situation began 5/28/14 at 5:00 a.m. when the surveyor observed S5 LPN during medication pass, use a fingerstick device (pen-like device) to obtain a resident's (#56) blood glucose reading. Further observation during the above dated medication pass reflected the LPN used the same fingerstick device on residents #6, #39 and #53 to obtain blood glucose readings. The Administrator was notified of the Immediate Jeopardy on 5/28/14 at 9:20 a.m. The facility submitted a plan of removal that included: 1. the facility discarded the fingerstick device (pen-like device) that was on the medicine cart, and all nurses were to be in-serviced to use a single lancet alone (without a fingerstick device) to obtain blood glucose readings on each diabetic resident beginning at 11:00 a.m. on 5/28/14, 2. the facility identified each resident who required blood glucose monitoring with the use of a lancet, 3. monitoring to ensure compliance would be done on a weekly basis by a designated nurse. The Immediate Jeopardy was removed on 5/28/14 at 10:05 a.m. when observation revealed the plan was being implemented. The deficient practice remained at a level of more than minimal harm for all 18 residents who required blood glucose monitoring. Additionally, the facility failed to sanitize the glucose monitor between use for 4 residents (#6, #39, #53, and #56) during point of care testing, and failed to ensure staff sanitized hands prior to donning gloves and after removing gloves while providing point of care testing. Findings: 1. Review of CMS form ( Ref: S & C: 10-28-NH) dated August 27, 2010 reflected the reuse of fingerstick devices for more than one resident should be treated as Immediate Jeopardy. According to a CDS clinical reminder notice entitled, " Use of Fingerstick Devices on More than One Person Poses Risk for Transmitting Bloodborne Pathogen " , the notice reflected that finger stick devices should never be used for more than one person. Recommendations included; Fingerstick devices should never be used for more than one person and Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. Observation on 5/28/14 at 5:25 a.m. during a medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56). S5 LPN was observed to use the same fingerstick device on all 4 residents. Interview on 5/28/14 at 9:00 a.m. with S2 DON revealed of the 46 residents at the facility, 18 residents (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56 and #63) required blood glucose monitoring either at 6:00 a.m., 9:00 a.m., 11:00 a.m., 4:00 p.m., 4:30 p.m., 8:00 p.m., or 9:00 p.m. Review of the May 2014 Physician's Orders for the 18 residents who required fingerstick blood glucose monitoring (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56 and #63), revealed they required fingerstick blood glucose monitoring either at 6:00 a.m., 9:00 a.m., 11:00 a.m., 4:00 p.m., 4:30 p.m., 8:00 p.m., or 9:00 p.m. Further review of the above dated Physician's Orders revealed that 1 (#6) resident had a [DIAGNOSES REDACTED]. Interview on 5/28/14 at 5:55 a.m. with S2 DON revealed that she was not aware the fingerstick device could not be reused for more than one resident. An attempt was made to interview S5 LPN; however, she had left the facility. Further attempts to contact S5 LPN were unsuccessful. 2. Observation on 5/28/14 at 5:25 a.m. during a medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56) with the use of the facility's glucose monitoring machine. S5 LPN was observed not to disinfect the glucose monitoring machine between testing of each resident. Interview on 5/28/14 at 5:05 a.m. with S5 LPN confirmed she did not disinfect the glucometer between residents, and stated she only disinfected the machine with Clorox wipes once she had completed glucose monitoring. Interview on 5/28/14 at 5:55 a.m. with S2 DON revealed the glucometer should be cleaned with Clorox wipes between residents, and if that's not available use alcohol wipes. Review of the facility policy for Disinfecting Glucometers and Lancet Devices reflected disinfecting of Glucometers and Lancet Devices must be done before use on each resident. 3. Observation on 5/28/14 at 5:25 a.m. during the medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56). S5 LPN was observed not to wash her hands after removing gloves (according to the facility's Infection Control Policy and Procedure for Universal Blood Borne Pathogens) while providing blood glucose monitoring to 4 residents (#6, #39, #53 and #56). Review of the facility's Infection Control Policy & Procedure reflected for "Universal Blood Born Pathogens", recommended precautions were to wash hands after removing gloves. Interview on 5/28/14 at 5:55 a.m. with S2 DON revealed that staff should sanitize hands between residents when providing care. -

Based on observation and interview the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility failed to contain nebulizers, linen and/or bedpans for 2 Stage 2 sampled residents (# 10, and 14 ). There were a total of 50 residents residing in the facility according to the Resident Census and Conditions of Residents form provided by the facility. Findings: 1. Observation of resident #10's room on 3/10/14 at 4:06 p.m. revealed her nebulizer mask and tubing was not contained and part of the tubing was touching the floor. There was a bedside commode in the resident's room with a bed pillow and linen piled up on top. There was a bedpan on the floor in the bathroom that was unlabeled and not stored in a bag. Interview with S2 DON on 3/14/14 at 11:10 a.m. reveals nurses were responsible for ensuring nebulizers were contained. 2. During the initial tour of the facilty on 3/10/14 at 10:15 a.m. observation revealed there were 2 bed pans stored on the floor of the bathroom that were unlabeled and unbagged in the bathroom of resident #14. Interview with S17 CNA Supervisor at that time revealed the bedpans should not be kept on the floor of the residents room. She directed staff to remove the bedpans and reported they should be cleaned and bagged after each use. Interview with S2 DON on 3/14/14 at 11:10 a.m. revealed the CNA staff were responsible for ensuring that the bedpans were bagged and stored with the resident's name on the bag. She reported inservices were provided on infection control and Februrary they had addressed the cleaning and storage of bedpans.

Based on observations, record reviews and interviews, the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection for 4 of 4 (#6, #39, #53, and # 56) residents. The facility failed to: 1. ensure a finger stick device (pen-like device) was not reused for more than one resident for point of care testing, 2. ensure the facility's Infection Control Program identified, developed, and implemented a plan that ensured blood glucose monitoring was administered in a manner that prevented cross contamination. The above failures effected 18 residents who required fingerstick blood glucose monitoring (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56, and #63). The survey sample size was 26. The facility's census was 46 residents as reflected on the facility's 802/Roster Sample Matrix. Observation on 5/28/14 at 5:25 a.m. during a medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56) using the same fingerstick(pen-like device) on 4 residents (#6, #39, #53 and #56). The S2 DON stated during an interview on 5/28/14 at 9:00 a.m. that 18 of the 46 facility residents (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56, and #63) required fingerstick blood glucose monitoring. Review of the May 2014 Physician's Orders for the 18 residents who required fingerstick blood glucose monitoring (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56 and #63), revealed they required fingerstick blood glucose monitoring either at 6:00 a.m., 9:00 a.m., 11:00 a.m., 4:00 p.m., 4:30 p.m., 8:00 p.m., or 9:00 p.m. Further review of the above dated Physician's Orders revealed that 1 (#6) resident had a [DIAGNOSES REDACTED]. An Immediate Jeopardy situation began 5/28/14 at 5:00 a.m. when the surveyor observed S5 LPN during medication pass, use a fingerstick device (pen-like device) to obtain a resident's (#56) blood glucose reading. Further observation during the above dated medication pass reflected the LPN used the same fingerstick device on residents #6, #39 and #53 to obtain blood glucose readings. The Administrator was notified of the Immediate Jeopardy on 5/28/14 at 9:20 a.m. The facility submitted a plan of removal that included: 1. the facility discarded the fingerstick device (pen-like device) that was on the medicine cart, and all nurses were to be in-serviced to use a single lancet alone (without a fingerstick device) to obtain blood glucose readings on each diabetic resident beginning at 11:00 a.m. on 5/28/14, 2. the facility identified each resident who required blood glucose monitoring with the use of a lancet, 3. monitoring to ensure compliance would be done on a weekly basis by a designated nurse. The Immediate Jeopardy was removed on 5/28/14 at 10:05 a.m. when observation revealed the plan was being implemented. The deficient practice remained at a level of more than minimal harm for all 18 residents who required blood glucose monitoring. Additionally, the facility failed to sanitize the glucose monitor between use for 4 residents (#6, #39, #53, and #56) during point of care testing, and failed to ensure staff sanitized hands prior to donning gloves and after removing gloves while providing point of care testing. Findings: Review of CMS form ( Ref: S & C: 10-28-NH) dated August 27, 2010 reflected the reuse of fingerstick devices for more than one resident should be treated as Immediate Jeopardy. According to a CDS clinical reminder notice entitled, " Use of Fingerstick Devices on More than One Person Poses Risk for Transmitting Bloodborne Pathogen " , the notice reflected that finger stick devices should never be used for more than one person. Recommendations included; Fingerstick devices should never be used for more than one person and Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. 1. Observation on 5/28/14 at 5:25 a.m. during a medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56). S5 LPN was observed to use the same fingerstick device on all 4 residents. Interview on 5/28/14 at 9:00 a.m. with S2 DON revealed of the 46 residents at the facility, 18 residents (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56 and #63) required blood glucose monitoring either at 6:00 a.m., 9:00 a.m., 11:00 a.m., 4:00 p.m., 4:30 p.m., 8:00 p.m., or 9:00 p.m. Review of the May 2014 Physician's Orders for the 18 residents who required fingerstick blood glucose monitoring (#1, #5, #6, #7, #10, #11, #13, #16, #20, #21, #31, #32, #39, #46, #50, #53, #56 and #63), revealed they required fingerstick blood glucose monitoring either at 6:00 a.m., 9:00 a.m., 11:00 a.m., 4:00 p.m., 4:30 p.m., 8:00 p.m., or 9:00 p.m. Further review of the above dated Physician's Orders revealed that 1 (#6) resident had a [DIAGNOSES REDACTED]. Interview on 5/28/14 at 5:55 a.m. with S2 DON revealed that she was not aware the fingerstick device could not be reused for more than one resident. An attempt was made to interview S5 LPN; however, she had left the facility. Further attempts to contact S5 LPN were unsuccessful. 2. Observation on 5/28/14 at 5:25 a.m. during a medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56) with the use of the facility's glucose monitoring machine. S5 LPN was observed not to disinfect the glucose monitoring machine between testing of each resident. Interview on 5/28/14 at 5:05 a.m. with S5 LPN confirmed she did not disinfect the glucometer between residents, and stated she only disinfected the machine with Clorox wipes once she had completed glucose monitoring. Interview on 5/28/14 at 5:55 a.m. with S2 DON revealed the glucometer should be cleaned with Clorox wipes between residents, and if that's not available use alcohol wipes. Review of the facility policy for Disinfecting Glucometers and Lancet Devices reflected disinfecting of Glucometers and Lancet Devices must be done before use on each resident. 3. Observation on 5/28/14 at 5:25 a.m. during the medication pass reflected S5 LPN performed blood glucose monitoring on 4 residents (#6, #39, #53 and #56). S5 LPN was observed not to wash her hands after removing gloves (according to the facility's Infection Control Policy and Procedure for Universal Blood Born Pathogens) while providing blood glucose monitoring to 4 residents (#6, #39, #53 and #56). Review of the facility's Infection Control Policy & Procedure reflected for "Universal Blood Born Pathogens", recommended precautions were to wash hands after removing gloves. Interview on 5/28/14 at 5:55 a.m. with S2 DON revealed that staff should sanitize hands between residents when providing care.

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents by failing to obtain a urine specimen on for Urinalysis and Culture &Sensitivity on 1/25/13 and prior to initiating the ordered antibiotic for 1 of 49 stage 2 sampled residents (#3). According to the Resident Census / Condition of Residents there were a total of 49 residents in the facility. There were 4 residents identified with urinary tract infections on the facility's Roster/Sample Matrix report. 1. The facility failed to obtain a U/A and C&S on 1/25/13 as ordered by the physician prior to initiating antibiotic therapy on 1/25/13. The facility obtained the U/A and urine C&S on 1/31/13, six days after it was ordered by the physician. This resulted in the resident being transferred to the hospital, admitted to ICU and placed on a ventilator with a [DIAGNOSES REDACTED]. This resulted in an Immediate Jeopardy situation which began on 1/25/13 when the facility failed to obtain the U/A and C&S as ordered. The Immediate Jeopardy situation ended when the resident was transferred to the hospital on [DATE] at 11:00 a.m.. The facility S1 Director of Nurses was informed of the Immediate Jeopardy situation on 3/4/13 at 9:35 a.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "H". Findings: Review of resident #3's record revealed she was admitted to the facility on [DATE]. The cumulative [DIAGNOSES REDACTED]. Review of the physician's progress notes dated 1/25/13 revealed the physician had documented "s/s blood in urine, u/a". Review of the physician's orders [REDACTED]. BID. " Review of the MAR for January, 2013 revealed the first dose [MEDICATION NAME] started on 1/25/13 at 8:00 p.m. Review of the lab reports revealed the urine specimen was not collected and sent to the lab until 1/31/13, six days after starting the antibiotic. The record reflected that the final report of the C&S was not received until 2/4/13, after the resident had been hospitalized . Review of the C&S results dated 2/4/13 revealed 2 organisms were present, E. Coli. and [DIAGNOSES REDACTED] Pneumoniae. The report also indicated that both of the organisms identified in the culture were resistant to Cipro. Review of the hospital emergency room record dated 2/3/13 revealed the resident was admitted to the hospital with [REDACTED]. Review of the facility's policy for Laboratory Testing revealed "labs ordered after lab day will be drawn by DON/or Weekend RN or Charge Nurse if physician wants labs drawn prior to the next lab draw day". Interview with S1 DON on 2/27/13 at 12:10 p.m. revealed that routine lab tests were done every Thursday. She stated that when the U/A with C&S was ordered for the resident on Friday, 1/25/13, it was added to the list of labwork to be done on the following Thursday. She confirmed that the urine specimen should have been obtained prior to starting the antibiotic, Cipro, on 1/25/13 as ordered. She further confirmed that the urine was not obtained until 1/31/13, after the resident had been on the antibiotic for six days.

Based on interview and record review the facility failed to ensure it was administered in a manner that enabled it to use its resources to effectively and efficiently attain or maintain the highest practicable physical, mental and psychological well-being of each resident for 1 of 32 sampled residents (#3). The facility's census was 49 according to the Resident Census and Conditions form. 1. The facility failed to ensure Policies and Procedures were followed and that clinical supervision was provided to monitor staff and ensure staff followed physician orders [REDACTED]. 2. The facility failed to obtain a U/A and C&S on 1/25/13 as ordered by the physician prior to initiating antibiotic therapy on 1/25/13. The facility obtained the U/A and urine C&S on 1/31/13, six days after it was ordered by the physician. 3. The facility failed to follow the plan of care for notifying the physician of changes in the resident's condition by not notifying the physician when the resident exhibited altered mental status/level of consciousness, elevated temperature, and shortness of breath with decreased pulse oximetry on 2/3/13. This resulted in the resident being transferred to the hospital, admitted to ICU and placed on a ventilator with a [DIAGNOSES REDACTED]. This resulted in an Immediate jeopardy situation which began on 1/25/13 when the facility failed to obtain the U/A and C&S as ordered. The Immediate Jeopardy situation ended when the resident was transferred to the hospital on [DATE] at 11:00 a.m.. The facility S1 Director of Nurses was informed of the Immediate Jeopardy situation on 3/4/13 at 9:35 a.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "H". Findings: Review of resident #3's record revealed that she was admitted to the facility on [DATE]. The cumulative [DIAGNOSES REDACTED]. Review of the physician's progress notes dated 1/25/13 revealed the MD documented "s/s blood in urine, u/a". Review of the physician's orders [REDACTED]. BID. Review of the MAR for January, 2013 revealed the first dose [MEDICATION NAME] started on 1/25/13 at 8:00 p.m. Review of the lab reports revealed the urine specimen was not collected and sent to the lab until 1/31/13, six days after starting the antibiotic. The record reflected that the final report of the C&S was not received until 2/4/13, after the resident had been hospitalized . Review of the C&S results dated 2/4/13 revealed 2 organisms were present, E. Coli. and [DIAGNOSES REDACTED] Pneumoniae. The report also indicated that both of the organisms were resistant to Cipro. Review of a nurses' note dated 2/3/13 at an undocumented time, revealed the resident was noted "lying in bed, response verbally is low tone...not usually quiet". The note also reflected the residents O2 saturation level was 91%, and her temperature was 101 degrees Fahrenheit. The nurse documented that oxygen was started at 2 liters/min per nasal cannula, and "will monitor and pass info to oncoming nurse". Review of the MAR/PRN sheet revealed that [MEDICATION NAME] 600 mg. (an anti-[MEDICAL CONDITION] medication) was administered on 2/3/13 at 5:30 a.m. for elevated temperature. There was no documentation to reflect the MD was notified of the changes in the resident's condition. Telephone interview with S8 LPN on 2/27/13 at 2:10 p.m. revealed she was the nurse on duty at 5:30 a.m. on 2/3/13. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on 2/2/13. She stated the resident was not acting like her normal self at 5:30 a.m. and that it took her a long time to arouse the resident. She further stated the resident finally gave her a verbal response but she still did not "look right". She took the residents vitals and O2 saturation, and started her on oxygen. She further stated that she was able to crush the [MEDICATION NAME] and give it to the resident, but she did not administer her routine 6:00 a.m. medications because she did not feel comfortable giving them to her because of her altered mental status. She stated that she reported the findings to the oncoming shift. Review of the MAR for 2/3/13 revealed that the residents 8:00 a.m. medications also were not administered. S3 LPN documented that the medications were withheld secondary to the resident being difficult to arouse. Further review of the nurses' notes revealed the next entry was documented by S2 LPN and dated 2/3/13 at 10:10 a.m. The note reflected that a CNA reported that the resident's temperature was 101.1 ax. S2 LPN documented that the resident was unresponsive when spoken to and her O2 saturation level was 85%. Further documentation revealed that the MD was notified and an order was noted to send the resident to the ER. Interview with S3 LPN on 2/26/13 at 12:00 p.m. confirmed that S8 LPN had reported to him that the resident had a temperature and he was to monitor her. He confirmed that the 8:00 a.m. medications were not administered because he did not feel comfortable giving them. He further stated that when the treatment nurse (S2 LPN) arrived, they checked on the resident, called the physician and sent the resident to the hospital. Interview with S2 LPN on 2/27/13 at 12:05 p.m. confirmed that when she came on duty on 2/3/13, she assessed the resident and noted that she was unresponsive to verbal stimuli, and had an elevated temperature of 101.1 degrees Fahrenheit. She stated she called the MD and the resident was transferred to the hospital. She also stated that the resident had not required the use of oxygen prior to that morning. Review of the hospital emergency room record dated 2/3/13 revealed the resident was admitted to the hospital with [REDACTED]. Review of the resident's plan of care last updated on 12/22/12 revealed the resident was at risk for and had a history of [REDACTED]. Approaches included to obtain and monitor lab/diagnostic work as ordered and to report results to the MD, and to report to the MD shortness of breath, confusion or altered mental status. Review of the facility's policy for "Change in a Resident's Condition or Status" revealed that the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. The policy also reflects that the Nurse Supervisor would notify the resident's attending physician when there was a significant change in the resident's physical, mental or psychosocial status. Interview with S1 DON on 2/27/13 at 12:10 p.m. confirmed that the urine specimen should have been obtained prior to starting the antibiotic, Cipro, on 1/25/13 as ordered. She further confirmed that the urine was not obtained until 1/31/13, after the resident had been on the antibiotic for 6 days. Further interview with S1 DON also confirmed that the resident's physician had not been notified of the change in her condition until 10:10 a.m. on 2/3/13. She further stated that he should have been notified when the change in the resident's condition was noted at 5:30 a.m., and also at 8:00 a.m., when the medications were not given due to the resident's altered mental status and inability to take her medications.

Based on record review and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and care plan for 1 of 3 Stage 2 (#3) sampled residents with catheters (#3, 22, and 36) and 1 (#3) of 3 Stage 2 sampled resident reviewed for UTIs (#3, 8 and 28), in a total stage 2 sample of 32. According to the Resident Census/Condition of Residents there were a total of 49 residents in the facility. 1. The facility failed to obtain a U/A and C&S on 1/25/13 as ordered by the physician prior to initiating antibiotic therapy on 1/25/13. The facility obtained the U/A and urine C&S on 1/31/13, six days after it was ordered by the physician. 2. The facility failed to follow the plan of care for notifying the physician of changes in the residents' condition by not notifying the physician when the resident exhibited altered mental status/level of consciousness, elevated temperature, and shortness of breath with decreased pulse oximetry on 2/3/13. This resulted in the resident being transferred to the hospital, admitted to ICU and placed on a ventilator with a [DIAGNOSES REDACTED]. This resulted in an Immediate jeopardy situation which began on 1/25/13 when the facility failed to obtain the U/A and C&S as ordered. The Immediate Jeopardy situation ended when the resident was transferred to the hospital on [DATE] at 11:00 a.m.. The facility S1 Director of Nurses was informed of the Immediate Jeopardy situation on 3/4/13 at 9:35 a.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "H". Findings: Review of resident #3's record revealed that she was admitted to the facility on [DATE]. The cumulative [DIAGNOSES REDACTED]. Review of the physician's progress notes dated 1/25/13 revealed the MD documented "s/s blood in urine, u/a". Review of the physician's orders [REDACTED]. BID. Review of the MAR for January, 2013 revealed the first dose [MEDICATION NAME] started on 1/25/13 at 8:00 p.m. Review of the lab reports revealed the urine specimen was not collected and sent to the lab until 1/31/13, six days after starting the antibiotic. The record reflected that the final report of the C&S was not received until 2/4/13, after the resident had been hospitalized . Review of the C&S results dated 2/4/13 revealed 2 organisms were present, E. Coli. and [DIAGNOSES REDACTED] Pneumoniae. The report also indicated that both of the organisms were resistant to Cipro. Review of a nurses' note dated 2/3/13 at an undocumented time, revealed the resident was noted "lying in bed, response verbally is low tone...not usually quiet". The note also reflected the residents O2 saturation level was 91%, and her temperature was 101 degrees Fahrenheit. The nurse documented that oxygen was started at 2 liters/min per nasal cannula, and "will monitor and pass info to oncoming nurse". Review of the MAR/PRN sheet revealed that [MEDICATION NAME] 600 mg. (an anti-[MEDICAL CONDITION] medication) was administered on 2/3/13 at 5:30 a.m. for elevated temperature. There was no documentation to reflect the MD was notified of the changes in the resident's condition. Telephone interview with S8 LPN on 2/27/13 at 2:10 p.m. revealed she was the nurse on duty at 5:30 a.m. on 2/3/13. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on 2/2/13. She stated the resident was not acting like her normal self at 5:30 a.m. and that it took her a long time to arouse the resident. She further stated the resident finally gave her a verbal response but she still did not "look right". She took the residents vitals and O2 saturation, and started her on oxygen. She further stated that she was able to crush the [MEDICATION NAME] and give it to the resident, but she did not administer her routine 6:00 a.m. medications because she did not feel comfortable giving them to her because of her altered mental status. She stated that she reported the findings to the oncoming shift. Review of the MAR for 2/3/13 revealed that the residents 8:00 a.m. medications also were not administered. S3 LPN documented that the medications were withheld secondary to the resident being difficult to arouse. Further review of the nurses' notes revealed the next entry was documented by S2 LPN and dated 2/3/13 at 10:10 a.m. The note reflected that a CNA reported that the resident's temperature was 101.1 ax. S2 LPN documented that the resident was unresponsive when spoken to and her O2 saturation level was 85%. Further documentation revealed that the MD was notified and an order was noted to send the resident to the ER. Interview with S3 LPN on 2/26/13 at 12:00 p.m. confirmed that S8 LPN had reported to him that the resident had a temperature and he was to monitor her. He confirmed that the 8:00 a.m. medications were not administered because he did not feel comfortable giving them. He further stated that when the treatment nurse (S2 LPN) arrived, they checked on the resident, called the physician and sent the resident to the hospital. Interview with S2 LPN on 2/27/13 at 12:05 p.m. confirmed that when she came on duty on 2/3/13, she assessed the resident and noted that she was unresponsive to verbal stimuli, and had an elevated temperature of 101.1 degrees Fahrenheit. She stated she called the MD and the resident was transferred to the hospital. She also stated that the resident had not required the use of oxygen prior to that morning. Review of the hospital emergency room record dated 2/3/13 revealed the resident was admitted to the hospital with [REDACTED]. Review of the resident's plan of care last updated on 12/22/12 revealed the resident was at risk for and had a history of [REDACTED]. Approaches included to obtain and monitor lab/diagnostic work as ordered and to report results to the MD, and to report to the MD shortness of breath, confusion or altered mental status. Review of the facility's policy for "Change in a Resident's Condition or Status" revealed that the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. The policy also reflects that the Nurse Supervisor would notify the resident's attending physician when there was a significant change in the resident's physical, mental or psychosocial status. Interview with S1 DON on 2/27/13 at 12:10 p.m. confirmed that the urine specimen should have been obtained prior to starting the antibiotic, Cipro, on 1/25/13 as ordered. She further confirmed that the urine was not obtained until 1/31/13, after the resident had been on the antibiotic for 6 days. Further interview with S1 DON also confirmed that the resident's physician had not been notified of the change in her condition until 10:10 a.m. on 2/3/13. She further stated that he should have been notified when the change in the resident's condition was noted at 5:30 a.m., and also at 8:00 a.m., when the medications were not given due to the residents' altered mental status and inability to take her medications.

Based on record review and staff interview, the facility failed to meet professional standards of quality according to the Louisiana Administrative Code Title 46 Professional and Occupations Standards Part XLV11. Nurses. Chapter 39 Legal Standards of Nursing Practice; Sections 3907 and 3909 by failure to ensure that a U/A and C&S was done prior to initiating antibiotic therapy as ordered, and failure to follow the plan of care for notifying the physician of changes in the residents' condition, (altered mental status/level of consciousness, elevated temperature, shortness of breath with decreased pulse oximetry) for 1 of 32 Stage 2 sampled residents (#3). The facility obtained the U/A specimen six days after ordered (ordered 01/25/13 and obtained on 01/31/13), and after antibiotic therapy was initiated. This resulted in the resident being transferred to the hospital, admitted to ICU and placed on a ventilator with a [DIAGNOSES REDACTED]. According to the Resident Census/Condition of Residents there were a total of 49 residents in the facility. 1. The facility failed to ensure services met a professional standard of quality by failure to provide clinical supervision to monitor staff to ensure staff followed physician orders [REDACTED]. 2. The facility failed to obtain a U/A and C&S on 1/25/13 as ordered by the physician prior to initiating antibiotic therapy on 1/25/13. The facility obtained the U/A and urine C&S on 1/31/13, six days after it was ordered by the physician. 3. The facility failed to follow the plan of care for notifying the physician of changes in the resident's condition by not notifying the physician when the resident exhibited altered mental status/level of consciousness, elevated temperature, and shortness of breath with decreased pulse oximetry on 2/3/13. This resulted in the resident being transferred to the hospital, admitted to ICU and placed on a ventilator with a [DIAGNOSES REDACTED]. This resulted in an Immediate Jeopardy situation which began on 1/25/13 when the facility failed to obtain the U/A and C&S as ordered. The Immediate Jeopardy situation ended when the resident was transferred to the hospital on [DATE] at 11:00 a.m.. The facility S1 Director of Nurses was informed of the Immediate Jeopardy situation on 3/4/13 at 9:35 a.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "H". Findings: Review of resident #3's record revealed that she was admitted to the facility on [DATE]. The cumulative [DIAGNOSES REDACTED]. Review of the physicians' progress notes dated 1/25/13 revealed the MD documented "s/s blood in urine, u/a". Review of the physicians orders dated 1/25/13 revealed the physician ordered a U/A with C&S, [MEDICATION NAME](an antibiotic) 500 mg. BID. Review of the MAR for January, 2013 revealed the first dose [MEDICATION NAME] started on 1/25/13 at 8:00 p.m. Review of the lab reports revealed the urine specimen was not collected and sent to the lab until 1/31/13, six days after starting the antibiotic. The record reflected that the final report of the C&S was not received until 2/4/13, after the resident had been hospitalized . Review of the C&S results dated 2/4/13 revealed 2 organisms were present, E. Coli. and [DIAGNOSES REDACTED] Pneumoniae. The report also indicated that both of the organisms were resistant to Cipro. Review of a nurses' note dated 2/3/13 at an undocumented time, revealed the resident was noted "lying in bed, response verbally is low tone...not usually quiet". The note also reflected the resident's O2 saturation level was 91%, and her temperature was 101 degrees Fahrenheit. The nurse documented that oxygen was started at 2 liters/min per nasal cannula, and "will monitor and pass info to oncoming nurse". Review of the MAR/PRN sheet revealed that [MEDICATION NAME] 600 mg. (an anti-[MEDICAL CONDITION] medication) was administered on 2/3/13 at 5:30 a.m. for elevated temperature. There was no documentation to reflect the MD was notified of the changes in the residents condition. Telephone interview with S8 LPN on 2/27/13 at 2:10 p.m. revealed she was the nurse on duty at 5:30 a.m. on 2/3/13. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on 2/2/13. She stated the resident was not acting like her normal self at 5:30 a.m. and that it took her a long time to arouse the resident. She further stated the resident finally gave her a verbal response but she still did not "look right". She took the residents vitals and O2 saturation, and started her on oxygen. She further stated that she was able to crush the [MEDICATION NAME] and give it to the resident, but she did not administer her routine 6:00 a.m. medications because she did not feel comfortable giving them to her because of her altered mental status. She stated that she reported the findings to the oncoming shift. Review of the MAR for 2/3/13 revealed that the residents 8:00 a.m. medications also were not administered. S3 LPN documented that the medications were withheld secondary to the resident being difficult to arouse. Further review of the nurses' notes revealed the next entry was documented by S2 LPN and dated 2/3/13 at 10:10 a.m. The note reflected that a CNA reported that the resident's temperature was 101.1 ax. S2 LPN documented that the resident was unresponsive when spoken to and her O2 saturation level was 85%. Further documentation revealed that the MD was notified and an order was noted to send the resident to the ER. Interview with S3 LPN on 2/26/13 at 12:00 p.m. confirmed that S8 LPN had reported to him that the resident had a temperature and he was to monitor her. He confirmed that the 8:00 a.m. medications were not administered because he did not feel comfortable giving them. He further stated that when the treatment nurse (S2 LPN) arrived, they checked on the resident, called the physician and sent the resident to the hospital. Interview with S2 LPN on 2/27/13 at 12:05 p.m. confirmed that when she came on duty on 2/3/13, she assessed the resident and noted that she was unresponsive to verbal stimuli, and had an elevated temperature of 101.1 degrees Fahrenheit. She stated she called the MD and the resident was transferred to the hospital. She also stated that the resident had not required the use of oxygen prior to that morning. Review of the hospital emergency room record dated 2/3/13 revealed the resident was admitted to the hospital with [REDACTED]. Review of the resident's plan of care last updated on 12/22/12 revealed the resident was at risk for and had a history of [REDACTED]. Approaches included to obtain and monitor lab/diagnostic work as ordered and to report results to the MD, and to report to the MD shortness of breath, confusion or altered mental status. Review of the facility's policy for "Change in a Resident's Condition or Status" revealed that the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. The policy also reflected that the Nurse Supervisor would notify the resident's attending physician when there was a significant change in the resident's physical, mental or psychosocial status. Interview with S1 DON on 2/27/13 at 12:10 p.m. confirmed that the urine specimen should have been obtained prior to starting the antibiotic, Cipro, on 1/25/13 as ordered. She further confirmed that the urine was not obtained until 1/31/13, after the resident had been on the antibiotic for six days. Further interview with S1 DON also confirmed that the residents' physician had not been notified of the change in her condition until 10:10 a.m. on 2/3/13. She further stated that he should have been notified when the change in the residents' condition was noted at 5:30 a.m., and also at 8:00 a.m., when the medications were not given due to the resident's altered mental status and inability to take her medications.

Based on record view and interview the facility failed to immediately consult with a resident's physician when the resident developed a significant change in her physical and mental status for 1 (#3) of 3 Stage 2 sampled residents with catheters (#3, #36 and #45), and 1 (#3) of 3 Stage 2 sampled residents reviewed for UTIs (#3, 8 and 28), in a total Stage 2 sample of 32. The facility failed to immediately consult with the resident's physician when the resident: 1. Developed an elevated temperature of 101 F. on 2/3/13. 2. Exhibited shortness of breath and an 02 saturation reading of 91% that decreased to 85% on 2/3/13. 3. Exhibited an altered level of consciousness/mental status on 2/3/13, which prevented the resident's nurse from administering the resident's medications at 6:00 a.m. and 8:00 a.m.. This resulted in an Immediate Jeopardy situation which began on 1/25/13 when the facility failed to obtain the U/A and C&S as ordered and ended when the resident was transferred to the hospital on [DATE] at 11:00 a.m.. The resident was sent to the emergency room (ER) on 02/03/13 at 11:00 a.m. and directly admitted to ICU with [DIAGNOSES REDACTED]. According to the Resident Census and Condition of Residents form, there were a total of 49 residents residing in the facility. The facility S1 Director of Nurses was informed of the Immediate Jeopardy situation on 3/4/13 at 9:35 a.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "H". Findings: Review of resident #3's Face Sheet reflected she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's nurse's note dated 02/03/13 (no time documented), and documented by S8, revealed the resident was noted "lying in bed, response verbally in low tone, and not usually quiet". The note reflected the resident's temperature was 101 degrees F, an O2 Sat of 91%, and O2 in progress at 2L/NC. The S8 LPN further documented "will monitor and pass info to oncoming nurse". Review of the MAR for 02/3/13 reflected the nurse administered [MEDICATION NAME] (an anti-[MEDICAL CONDITION] agent) at 5:30 a.m. for an elevated temperature. There was no documentation to reflect the physician was immediately consulted with regarding the significant change in the resident's physical and mental status. Further review of the nurses' notes reflected on 02/03/13 at 10:10 a.m., a CNA reported to S2 LPN that the resident had an axillary temperature of 101.1, and was unresponsive to verbal stimuli. The note reflected the resident's O2 Sat was 85%, and Tylenol was given. The physician was contacted, and an order was received to send the resident to the emergency room for evaluation. Review of ER records dated 02/03/13 revealed the resident was admitted directly to ICU with [DIAGNOSES REDACTED]. Telephone interview with S8 LPN on 02/27/13 at 2:10 p.m. revealed she was the resident's nurse on the 10:00 p.m. to 6:00 a.m. shift on 02/02/13. She stated the resident was not acting like her normal self at 5:30 a.m., and it took a long time to arouse her. She stated the resident finally gave her a verbal response, but she still did not "look right". She stated she took the resident's vital signs, obtained a O2 Sat and started her on oxygen. She stated she was able to crush [MEDICATION NAME] and give it to the resident; however, she did not administer her routine medications because of her altered mental status. She further stated she reported the findings to S3 LPN, the oncoming nurse. Interview with S3 LPN on 02/26/13 at 12:00 p.m. confirmed S8 LPN reported to him on 02/03/13 that resident #3 had "run a fever" and he was to monitor her. He stated he did not administer the resident's 8:00 a.m. medications because he did not feel comfortable giving them, and confirmed that he documented at 8:00 a.m. that he did not give the medications because the resident was difficult to arouse. He stated he did not contact the resident's physician until the S2 LPN Treatment Nurse arrived, at which time, they checked the resident, called the physician, and sent the resident to the hospital. Interview with S2 LPN Treatment Nurse on 02/27/13 at 12:05 p.m. revealed she was the nurse who called the physician on 02/03/13 and sent the resident to the hospital. She stated a CNA asked her to check the resident. She stated the resident did not respond to verbal stimuli and had an elevated temperature of 101.1 degrees F. She called the physician and the resident was transferred to the hospital. She further stated the resident had not required the use of O2 prior to that morning (02/03/13). Interview with S1 DON on 02/26/13 at 11:00 a.m. confirmed resident #3's physician was not notified of the change in her condition until 02/03/13 at 10:10 a.m.. She stated S8 LPN should have notified the physician on 02/03/13 at 5:30 a.m. when the resident's change in condition was first noted. Additionally, she stated S3 LPN should have notified the physician on 02/03/13 of the change in the resident's condition. Review of the facility's Policy regarding "Change in a Resident's Condition or Status" revealed the nurse supervisor will notify the resident's attending physician when there is a significant change in the resident's physical, mental or psychosocial status.

Based on record review and interview, the facility failed to ensure that services provided or arranged by the facility were provided in accordance with each resident's written plan of care. The facility failed to follow a resident's written plan of care for obtaining lab/diagnostic work and reporting a resident's confusion/altered mental status and shortness of breath to the physician for 1 of 32 Stage 2 sampled residents (#3). 1. The facility failed to obtain a U/A and C&S on 1/25/13 as ordered by the physician prior to initiating antibiotic therapy on 1/25/13. The facility obtained the U/A and urine C&S on 1/31/13, six days after it was ordered by the physician. 2. The facility failed to follow the plan of care for notifying the physician of changes in the residents' condition by not notifying the physician when the resident exhibited altered mental status/level of consciousness, elevated temperature, and shortness of breath with decreased pulse oximetry on 2/3/13. This resulted in the resident being transferred to the hospital, admitted to ICU and placed on a ventilator with a [DIAGNOSES REDACTED]. This resulted in an Immediate jeopardy situation which began on 1/25/13 when the facility failed to obtain the U/A and C&S as ordered. The Immediate Jeopardy situation ended when the resident was transferred to the hospital on [DATE] at 11:00 a.m.. The facility S1 Director of Nurses was informed of the Immediate Jeopardy situation on 3/4/13 at 9:35 a.m. After removal of the Immediate Jeopardy situation, the deficiency remained at a S/S of "H". Findings: Review of resident #3's record revealed that she was admitted to the facility on [DATE]. The cumulative [DIAGNOSES REDACTED]. Review of the physicians' progress notes dated 1/25/13 revealed the MD documented "s/s blood in urine, u/a". Review of the physicians orders dated 1/25/13 revealed the physician ordered 1) U/A with C&S and 2)[MEDICATION NAME](an antibiotic) 500 mg. BID. Review of the MAR for January 2013 revealed the first dose [MEDICATION NAME] started on 1/25/13 at 8:00 p.m. Review of the lab reports revealed the urine specimen was not collected and sent to the lab until 1/31/13. The record reflected that the final report of the C&S was not received until 2/4/13, after the resident had been hospitalized . Review of the C&S results dated 2/4/13 revealed 2 organisms were present, E. Coli. and [DIAGNOSES REDACTED] Pneumoniae. The report also indicated that both of the organisms were resistant to Cipro. Review of a nurses' note dated 2/3/13 at an undocumented time, revealed the resident was noted "lying in bed, response verbally is low tone...not usually quiet". The note also reflected the residents O2 saturation level was 91%, and her temperature was 101 degrees Fahrenheit. The nurse documented that oxygen was started at 2 liters/min per nasal cannula, and "will monitor and pass info to oncoming nurse". Review of the MAR/PRN sheet revealed that [MEDICATION NAME] 600 mg. (an anti-[MEDICAL CONDITION] medication) was administered on 2/3/13 at 5:30 a.m. for elevated temperature. There was no documentation to reflect the MD was notified of the changes in the residents condition. Telephone interview with S8 LPN on 2/27/13 at 2:10 p.m. confirmed that she was the nurse on duty at 5:30 a.m. on 2/3/13. She stated she worked the 10:00 p.m. to 6:00 a.m. shift on 2/2/13. She stated the resident was not acting like her normal self at 5:30 a.m. and that it took her a long time to arouse the resident. She further stated the resident finally gave her a verbal response but she still did not "look right". She took the residents vital signs and O2 saturation, then started her on oxygen. She further stated that she was able to crush the [MEDICATION NAME] and give it to the resident. She revealed she did not administer the resident's routine 6:00 a.m. medications because she did not feel comfortable giving them to her because of her altered mental status. She stated that she reported the findings to the oncoming shift, but did not notify the MD. Review of the MAR for 2/3/13 revealed that the residents 8:00 a.m. medications also were not administered. S3 LPN documented that the medications were withheld secondary to the resident being difficult to arouse. There was no documentation to reflect that the MD was notified of the change in the resident's status. Further review of the nurses' notes revealed the next entry was documented by S2 LPN and dated 2/3/13 at 10:10 a.m. The note reflected that a CNA reported that the resident's temperature was 101.1 ax. S2 LPN documented that the resident was unresponsive when spoken to and her O2 saturation level was 85%. Further documentation revealed that the MD was notified and an order was noted to send the resident to the ER. Interview with S3 LPN on 2/26/13 at 12:00 p.m. confirmed that S8 LPN had reported to him that the resident had a temperature and he was to monitor her. S3 LPN confirmed that the 8:00 a.m. medications were not administered because he did not feel comfortable giving them. He further stated that when the treatment nurse (S2 LPN) arrived, they checked on the resident, called the physician and sent the resident to the hospital. Interview with S2 LPN on 2/27/13 at 12:05 p.m. confirmed that when she came on duty on 2/3/13, she assessed the resident and noted that she was unresponsive to verbal stimuli, and had an elevated temperature of 101.1 degrees Fahrenheit. She stated she called the MD and the resident was transferred to the hospital. She also stated that the resident had not required the use of oxygen prior to that morning. Review of the hospital emergency room record dated 2/3/13 revealed the resident was admitted to the hospital with [REDACTED]. Review of the resident's plan of care last updated on 12/22/12 revealed the resident was at risk for and had a history of [REDACTED]. Approaches included to obtain and monitor lab/diagnostic work as ordered and to report results to the MD, and to report to the MD shortness of breath, confusion or altered mental status. Review of the facility's policy for "Change in a Resident's Condition or Status" revealed that the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. The policy also reflected that the Nurse Supervisor would notify the resident's attending physician when there was a significant change in the resident's physical, mental or psychosocial status. Interview with S1 DON on 2/27/13 at 12:10 p.m. confirmed that the urine specimen should have been obtained prior to starting the antibiotic, Cipro, on 1/25/13 as ordered. She further confirmed that the urine was not obtained until 1/31/13, after the resident had been on the antibiotic for 6 days. Further interview with S1 DON also confirmed that the resident's physician had not been notified of the change in her condition until 10:10 a.m. on 2/3/13. She further stated that he should have been notified when the change in the residents' condition was noted at 5:30 a.m., and also at 8:00 a.m., when the medications were not given due to the residents' altered mental status and inability to take her medications.

Based on observation, record review and interview the facility failed to ensure that residents received adequate supervision and/or assistance devices to prevent accidents for 2 (#11 and #43) of 4 Stage 2 sampled residents (#11, #43, #31 and #38) reviewed for accidents. The facility failed to ensure recommendations from Physical Therapy were followed to prevent further falls for a resident (# 43). The facility also failed to: 1. Provide supervision while smoking for a resident (#11) who was cognitively impaired, who had been assessed by the facility to be an unsafe smoker and who had a history of [REDACTED]. 2. Review and revise the care plan for specific interventions to prevent the resident (#11) from smoking unsupervised. 3. Review and revise the care plan for specific interventions to prevent the resident (#11) from getting cigarettes from other residents. 4. Follow the facility's smoking policy regarding the need for supervision to be provided for residents assessed as unsafe smokers. Review of the facility's Smoking Policy, which was not dated, reflected that its purpose was to provide maximum safety to all residents at all times. The policy also reflected that physical and/or cognitively impaired residents must be accompanied by staff, family, or properly trained volunteers while smoking. Resident # 11 was assessed to be an unsafe smoker by the Smoking assessment dated [DATE]. He was assessed as not physically able to hold the smoking device while smoking, was required to wear a protective smoking vest/apron and/or to have direct supervision while smoking. Resident #11's history and physical dated 4/21/11 included the following Diagnoses: [REDACTED]. Further review of a significant change MDS dated [DATE] revealed the resident was totally dependent with all ADLs, had unclear speech and was able to follow simple commands. Resident #11 was placed in Immediate Jeopardy on 4/9/12 at 1:45 p.m. after he was observed to have multiple burn holes in his clothes, was observed smoking unsupervised in the smoke room and was observed to drop his lit cigarette on his shirt. He was observed to be unable to immediately remove the cigarette from his shirt. When he did retrieve the cigarette, it was no longer lit. The resident was examined and noted to have a 3rd degree burn to his abdomen and a blister to his left inner thigh. The facility was unaware of the burns. The facility's plan of removal for the IJ included reassessment of all residents to determine if they were safe or unsafe smokers. The facility determined that there were 22 residents in the facility that smoked and only 2 of those residents were assessed as unsafe smokers. The facility inserviced staff regarding residents who were identified as unsafe smokers. The staff were inserviced on providing supervision to these two unsafe smokers. Resident #11 was to be supervised at all times while he was out of bed and while he was smoking. The facility also designated a staff for each shift who would provide one to one supervision while resident #11 was out of bed. The staff was assigned to supervise the resident so that he did not obtain cigarettes from other residents and to supervise the resident while he smoked. : The Immediate Jeopardy was lifted on 4/9/12 at 3:45 p.m. when the facility implemented the plan to supervise residents assessed as being unsafe smokers while they are smoking. The deficiency remained at level 3 due to the resident sustaining a third degree burn. The facility's total census was 51 as reported on the Resident Census And Conditions of Residents form. Findings: 1. Review of resident #11's record revealed a history and physical dated 4/21/11 which reflected the following Diagnoses: [REDACTED]. Further review of a significant change MDS dated [DATE] revealed the resident was totally dependent with all ADLs, had unclear speech and was able to follow simple commands. Record review of the resident's Smoking assessment dated [DATE] revealed the resident was assessed to be an unsafe smoker. He was assessed as not physically able to hold the smoking device while smoking, was required to wear a protective smoking vest/apron and/or to have direct supervision while smoking. Review of the facility's Smoking Policy, which was not dated, reflected that its purpose was to provide maximum safety to all residents at all times. The policy also reflected that physical and/or cognitively impaired residents must be accompanied by staff, family, or properly trained volunteers while smoking. Observation on 4/9/12 at 11:50 a.m., as resident #11 was leaving the dining room, revealed that he had multiple burned areas to his shirt and pants. He was also observed to have a significant amount of cigarette ashes on his lap and the seat belt of his wheelchair. Observation on 4/9/12 at 12:00 p.m. revealed that resident #11 was in the smoke room with a lit cigarette and smoking unattended. There was no staff in the smoke room at that time. The resident was observed to drop his lit cigarette on his shirt. He was observed to be unable to immediately retrieve the cigarette from his shirt. When he did retrieve the cigarette from his shirt, it was no longer lit. Interview with S4 LPN on 4/9/12 at 12:15 p.m. revealed that he stated resident #11 should not be smoking without staff present as he was an unsafe smoker. He confirmed that the resident was in the smoke room alone at that time. When S4 LPN was asked who supervises resident #11 while he smokes, he stated sometimes resident #55 will sit in the smoke room with him. S4 LPN also stated that resident #55 has been known to give resident #11 a cigarette and light it for him without the staff's knowledge. Observation on 4/9/12 at 12:25 p.m. revealed the resident was in his room and S15 CNA was providing ADL care. Observation of the resident's skin at that time revealed a 3rd degree burn to his abdomen and a blistered area to his left inner thigh. The resident had multiple burn holes in his clothes. S15 CNA could not confirm how long the burn areas had been there but stated the resident was always burning himself with cigarettes. Interview and observation on 4/9/12 at 12:40 p.m. with S2 DON and S11 TX/LPN present in resident #11's room, verified the 3rd degree burn to the resident's abdomen and the blistered area to his left inner thigh. S2 DON stated that the weekend RN does the weekly skin assessments. She confirmed the weekly skin assessment dated [DATE] revealed no skin tears, rash, or pressure sores for resident, and they had not been aware of the resident's current burn areas. Review of the resident's TARS dated April 2012 revealed he had not been receiving any treatments to the area on his abdomen or left inner thigh. The TAR revealed that he had a previous blister area to his right thigh that had been treated with Silvadene cream. The area was documented as healed on 2/27/12. S2 DON and S11 LPN/TX nurse documented an assessment of the resident's skin after observing with the surveyor on 4/9/12. Review of the Wound Assessment documentation revealed that the resident had a third degree burn to his abdomen which measured 0.5 cm in length X 0.5 cm in depth. It was documented that it was red and dry. The current treatment was listed as clean with Normal Saline and apply Silvadene cream every day. Further review of an additional Wound Assessment form dated 4/9/12 revealed documentation that the resident had a blister to his left thigh. That area measured 0.2 cm in length X 0.2 cm in width. The area was documented to be pink and dry. The current treatment was listed as monitor every day. Interview on 4/9/12 at 12:55 p.m. with S11 Administrator and S2 DON confirmed that resident #11's cigarettes are kept at the nurse's station and that staff is supposed to go with the resident to monitor him while he smokes. They stated that there was no one specifically designated to monitor the resident while he smoked. They also stated that there are other residents in the facility who are allowed to hold their own cigarettes and lighter. Further interview at that time revealed that they were aware that other residents have been known to give resident #11 cigarettes and light them for him at times without the staff's knowledge. They also stated that resident #11 will beg other residents for cigarettes, and he refused to wear a smoke apron. Further interview with S1 Administrator at that time revealed that he had verbally told other residents not to give resident #11 cigarettes. However, he stated that he had no documentation to reflect that he had spoken with residents regarding this situation. Further interview with S2 DON on 4/9/12 at 1:00 p.m. revealed that resident #11's mother has asked resident #55 to provide him with cigarettes. She stated that she was aware of this and that she had talked with resident #55 and asked him not to give cigarettes to resident #11. She confirmed that it was resident #55 who had given resident #11 the lit cigarette after lunch on 4/9/12. Interview on 4/9/12 at 1:50 p.m. with S2 DON confirmed an order from the physician dated 4/9/12 to treat the 3rd degree burn to the stomach and monitor blisters to left thigh until healed. A new skin assessment was done on 4/9/12 to include the burned areas. Record review of the resident's care plan, initiated 8/3/11, with target date of 6/13/12 revealed an identified problem area of potential for impaired skin integrity related to burning self with cigarettes. Approaches included to monitor the resident's skin weekly, report any red or open areas and record in the progress notes. Further review of the Comprehensive Care Plan initiated 8/3/11 and with a target date of 6/13/12, revealed another identified problem of potential for trauma related to falls, poor balance, impaired mobility and resident dropping his cigarettes. The approaches that were documented for this identified problem were specifically directed to the falls. There were no specific approaches related to the resident dropping his cigarette. An additional identified problem on the Comprehensive Care Plan initiated 8/3/11 and with a target date of 6/13/12, was potential for safety hazard, injury related to smoking. Identified approaches included provide resident with a copy of the facility's smoking policy, smoking allowed only in designated smoking areas, no smoking allowed inside facility at any time, safe smoking assessment quarterly and nursing to keep all smoking materials at nurses' station. The Comprehensive Care Plan, initiated 8/3/11 and with a target date of 6/13/12, did not reflect documentation that the resident would be supervised by staff when smoking. It also did not address his begging other residents for cigarettes or any interventions to monitor and ensure that he did not get cigarettes from other residents and smoke unsupervised. There was also no documentation to reflect that the resident refused to wear a smoke apron. After the facility was notified of the Immediate Jeopardy, they reassessed all residents for safe or unsafe smoking. Interview on 4/9/12 at 2:00 p.m. with S2 DON revealed that there were 22 residents in the facility that smoked and only 2 residents were assessed as unsafe smokers. The staff were inserviced on providing supervision to these two unsafe smokers. Resident #11 was to be supervised at all times while he was out of bed and while he was smoking. 2. Observation on 4/10/12 at 12:30 p.m. revealed resident #43 was lying in her bed with the bed alarm in place. The bed was in a low position with one side pushed against the wall. The side rails were not in use, and a 2-3 inch fall mat was positioned on the floor next to the bed. There was no roll guard observed to the resident's bed. The resident was observed to shift and move in bed. The resident was observed to holler out in words that were not comprehendible. Observation on 4/10/12 at 3:15 p.m. revealed the resident was not in her bed. There was no roll guard noted to the bed or in the resident's closet or room. Review of the Fall Risk assessment dated [DATE] reflected the resident was at high risk for falls with a score of 12 (greater than 10= high risk). Review of the MDS reflected a significant change in status and an MDS was conducted on 2/7/12. Review of the Plan of Care reflected a problem dated 5/3/11 for Trauma, Potential r/t external factors, falls r/t physical mobility impaired r/t severe cognitively impaired r/t disease process. The care plan reflected an intervention to gather information on past falls and attempt to determine cause of falls, anticipate and intervene to prevent future recurrence and PT and OT to evaluate and treat as ordered or prn. Review of nurses' notes reflected the resident experienced the following actual falls: On 1/19/12 at 9:50 (no a.m. or p.m. documented) staff heard the resident's bed alarm going off and the resident calling for help. The resident was found lying on the fall mat next to the bed. The resident stated that she rolled out of bed. On 1/28/12 at 4:00 a.m. the resident was found on floor in her room. On 1/31/12 at 4:15 p.m. staff heard the bed alarm going off, and the resident was found sitting on the floor on the fall mat beside the bed. On 2/16/12 at 2:30 a.m. the resident was found sitting on the floor in her room. On 2/21/12 at 1300 staff was called to the resident's room, and the resident was sitting on the floor. On 2/23/12 at 1:00 p.m. staff was called to the resident's room per therapy staff passing by the resident's room. The resident was found sitting on the floor beside her bed on the fall mat. On 2/29/12 1:00 a.m. the bed alarm was heard going off, and the resident was found sitting on the floor. Review of Physical Therapy Screening Form dated 2/2/12 and 3/14/12 reflected the resident was evaluated for PT. The note reflected that PT was not recommended due to the resident unable to follow commands and will not participate with therapy. PT recommended to continue the bed/chair alarm, bedside fall mat and to apply a roll guard while the resident was in bed to decrease falls. Interview with S2 DON on 4/12/12 at 3:30 p.m. confirmed that a roll guard had not been applied to the resident's bed, and PT had not made her aware of the recommendation for a roll guard while the resident was in bed.

Based on observation, interview, and record review the facility failed to ensure the care plans were reviewed and revised for 2 of 31 stage 2 sampled residents (#'s 6 and 11). The facility failed to ensure the care plan was reviewed and revised for resident #11 to include interventions to ensure the resident's maximum safety while smoking and for resident #6 to include the extent of his need for assistance with oral hygiene. The facility had assessed resident #11 to be an unsafe smoker. However, the facility failed to ensure that resident #11's care plan was reviewed and revised to include specific interventions for safe smoking. The Facility failed to review and revise the care plan for resident (#11) to include: 1. Interventions to address the fact that the resident had a history of [REDACTED]. 2. Interventions for who would monitor the resident and when to ensure his safety. 3. Interventions to address and monitor the resident's behavior of begging other residents for cigarettes. 4. Specific interventions to prevent other residents from giving resident #11 lit cigarettes. Review of the facility's Smoking Policy, which was not dated, reflected that its purpose was to provide maximum safety to all residents at all times. The policy also reflected that physical and/or cognitively impaired residents must be accompanied by staff, family, or properly trained volunteers while smoking. Resident # 11 was assessed to be an unsafe smoker by the Smoking assessment dated [DATE]. He was assessed as not physically able to hold the smoking device while smoking, was required to wear a protective smoking vest/apron and/or to have direct supervision while smoking. Resident #11's history and physical dated 4/21/11 included the following Diagnoses: [REDACTED]. Further review of a significant change MDS dated [DATE] revealed the resident was totally dependent with all ADLs, had unclear speech and was able to follow simple commands. Resident #11 was placed in Immediate Jeopardy on 4/9/12 at 1:45 p.m. after he was observed to have multiple burn holes in his clothes, was observed smoking unsupervised in the smoke room and was observed to drop his lit cigarette on his shirt. He was observed to be unable to immediately remove the cigarette from his shirt. When he did retrieve the cigarette, it was no longer lit. The resident was examined and noted to have a 3rd degree burn to his abdomen and a blister to his left inner thigh. The facility was unaware of the burns. The facility's plan of removal for the IJ included reassessment of all residents to determine if they were safe or unsafe smokers. The facility determined that there were 22 residents in the facility that smoked and only 2 of those residents were assessed as unsafe smokers. The facility inserviced staff regarding residents who were identified as unsafe smokers. The staff were inserviced on providing supervision to these two unsafe smokers. Resident #11 was to be supervised at all times while he was out of bed and while he was smoking. The facility also designated a staff for each shift who would provide one to one supervision while resident #11 was out of bed. The staff was assigned to supervise the resident so that he did not obtain cigarettes from other residents and to supervise the resident while he smoked. The Immediate Jeopardy was lifted on 4/9/12 at 3:45 p.m. when the facility implemented the plant to supervise residents assessed as being unsafe smokers while they are smoking. The deficiency remained at level 3 due to the resident sustaining a third degree burn. The facility's total census was 51 as reported on the Resident Census And Conditions of Residents form. Findings: Findings: Review of the facility's Smoking Policy revealed that the facility would provide maximum safety to all residents at all times. The policy reflected that physical and/or cognitively impaired residents must be accompanied by staff, family, or properly trained volunteers while smoking. 1. Review of resident #11's record revealed a history and physical dated 4/21/11 which reflected the following Diagnoses: [REDACTED]. Further review of a significant change MDS dated [DATE] revealed the resident was totally dependent with all ADLs, had unclear speech and was able to follow simple commands. Record review of the resident's Smoking assessment dated [DATE] revealed the resident was assessed to be an unsafe smoker. He was assessed as not physically able to hold the smoking device while smoking, was required to wear a protective smoking vest/apron and/or to have direct supervision while smoking. Record review of the resident's care plan with target date of 6/13/12 revealed an identified problem area of potential for impaired skin integrity related to burning self with cigarettes. Approaches included to monitor the resident's skin weekly, report any red or open areas and record in the progress notes. Further review of the Comprehensive Care Plan revealed another identified problem of potential for trauma related to falls, poor balance, impaired mobility and resident dropping his cigarettes. The approaches that were documented for this identified problem were specifically directed to the falls. There were no specific approaches related to the resident dropping his cigarette. An additional identified problem on the Comprehensive Care Plan was potential for safety hazard, injury related to smoking. Identified approaches included provide resident with a copy of the facility's smoking policy, smoking allowed only in designated smoking areas, no smoking allowed inside facility at any time, safe smoking assessment quarterly and nursing to keep all smoking materials at nurses' station. The Comprehensive Care Plan did not reflect documentation that the resident would be supervised by staff when smoking. It did not address his behavior of dropping his cigarettes and burning himself. It also did not address his begging other residents for cigarettes or any interventions to monitor and ensure that he did not get cigarettes from other residents and smoke unsupervised. Observation on 4/9/12 at 11:50 a.m., as resident #11 was leaving the dining room, revealed that he had multiple burned areas to his shirt and pants. He was also observed to have a significant amount of cigarette ashes on his lap and the seat belt of his wheelchair. Observation on 4/9/12 at 12:00 p.m. revealed that resident #11 was in the smoke room with a lit cigarette and smoking unattended. There was no staff in the smoke room at that time. The resident was observed to drop his lit cigarette on his shirt. He was observed to be unable to immediately retrieve the cigarette from his shirt. When he did retrieve the cigarette from his shirt, it was no longer lit. Interview with S4 LPN on 4/9/12 at 12:15 p.m. revealed that he stated resident #11 should not be smoking without staff present as he was an unsafe smoker. He confirmed that the resident was in the smoke room alone at that time. When S4 LPN was asked who supervises resident #11 while he smokes, he stated sometimes resident #55 will sit in the smoke room with him. S4 LPN also stated that resident #55 has been known to give resident #11 a cigarette and light it for him without the staff's knowledge. Observation on 4/9/12 at 12:25 p.m. revealed the resident was in his room and S15 CNA was providing ADL care. Observation of the resident's skin at that time revealed a 3rd degree burn to his abdomen and a blistered area to his left inner thigh. The resident had multiple burn holes in his clothes. S15 CNA could not confirm how long the burn areas had been there but stated the resident was always burning himself with cigarettes. Interview and observation on 4/9/12 at 12:40 p.m. with S2 DON and S11 TX/LPN present in resident #11's room, verified the 3rd degree burn to the resident's abdomen and the blistered area to his left inner thigh. S2 DON stated that the weekend RN does the weekly skin assessments. She confirmed the weekly skin assessment dated [DATE] revealed no skin tears, rash, or pressure sores for resident, and they had not been aware of the resident's current burn areas. S2 DON and S11 LPN/TX nurse documented an assessment of the resident's skin after observing with the surveyor on 4/9/12. Review of the Wound Assessment documentation revealed that the resident had a third degree burn to his abdomen which measured 0.5 cm in length X 0.5 cm in depth. It was documented that it was red and dry. The current treatment was listed as clean with Normal Saline and apply [MEDICATION NAME] cream every day. Further review of an additional Wound Assessment form dated 4/9/12 revealed documentation that the resident had a blister to his left thigh. That area measured 0.2 cm in length X 0.2 cm in width. The area was documented to be pink and dry. The current treatment was listed as monitor every day. Interview on 4/9/12 at 1:50 p.m. with S2 DON confirmed an order from the physician dated 4/9/12 to treat the 3rd degree burn to the stomach and monitor the blister to the left thigh until healed. Interview on 4/9/12 at 12:55 p.m. with S11 Administrator and S2 DON confirmed that resident #11's cigarettes are kept at the nurses' station and that staff is supposed to go with the resident to monitor him while he smokes. They stated that there was no one specifically designated to monitor the resident while he smoked. They also stated that there are other residents in the facility who are allowed to hold their own cigarettes and lighter. Further interview at that time revealed that they were aware that other residents have been known to give resident #11 cigarettes and light them for him at times without the staff's knowledge. They also stated that resident #11 will beg other residents for cigarettes. Further interview with S1 Administrator at that time revealed that he had verbally told other residents not to give resident #11 cigarettes. However, he stated that he had no documentation to reflect that he had spoken with residents regarding this situation. Further interview with S2 DON on 4/9/12 at 1:00 p.m. revealed that resident #11's mother has asked resident #55 to provide him with cigarettes. She stated that she was aware of this and that she had talked with resident #55 and asked him not to give cigarettes to resident #11. She confirmed that it was resident #55 who had given resident #11 the lit cigarette after lunch on 4/9/12. 2. Review of the MDS for resident #6 dated 1/31/2012 reflected personal hygiene (brushing teeth) required extensive assistance. Review of the Comprehensive Care Plan with a goal date of 4/31/12 reflected an identified problem of bathing/hygiene deficit related to physical mobility impaired, disease process and cognitive impairment. Approaches included to set up supplies and cue to do own oral hygiene. Further review reflected assist as needed to complete task. Interview on 4/11/2012 at 10:45 a.m. with S2 DON stated that the resident's mouth care is done by the CNAs daily. She confirmed that the CNAs chart daily mouth care on the Resident Care Flow Record. Interview on 4/13/2012 at 11:45 a.m. with S3 MDS Nurse revealed that she stated she should have care planned the resident for extensive assistance with personal hygiene instead of set up help only.

Based on observation, interview and record review the facility failed to ensure that the Administration used its resources effectively to maintain the highest practical well-being of 1 of 31 Stage 2 sampled residents (#11). The facility failed to: 1. Follow their smoking policy regarding the need for supervision to be provided for physical and/or cognitively impaired residents while smoking for a resident (#11) who was cognitively impaired and who had been assessed by the facility to be an unsafe smoker and who had a history of [REDACTED]. 2. Have a system in place to ensure the care plan was reviewed and revised for specific interventions to prevent a cognitively impaired resident (#11) from smoking unsupervised. 3. Ensure monitoring of adequate supervision of cognitively impaired residents while smoking. Review of the facility's Smoking Policy, which was not dated, reflected that its purpose was to provide maximum safety to all residents at all times. The policy also reflected that physical and/or cognitively impaired residents must be accompanied by staff, family, or properly trained volunteers while smoking. Resident # 11 was assessed to be an unsafe smoker by the Smoking assessment dated [DATE]. He was assessed as not physically able to hold the smoking device while smoking, was required to wear a protective smoking vest/apron and/or to have direct supervision while smoking. Resident #11's history and physical dated 4/21/11 reflected the following Diagnoses: [REDACTED]. Further review of a significant change MDS dated [DATE] revealed the resident was totally dependent with all ADLs, had unclear speech and was able to follow simple commands. The facility was notified that resident #11 was placed in Immediate Jeopardy on 4/9/12 at 1:45 p.m. after he was observed to have multiple burn holes in his clothes, was observed smoking unsupervised in the smoke room and was observed to drop his lit cigarette on his shirt. He was observed to be unable to immediately remove the cigarette from his shirt. When he did retrieve the cigarette, it was no longer lit. The resident was examined and noted to have a 3rd degree burn to his abdomen and a blister to his left inner thigh. After the facility was notified of the Immediate Jeopardy, they reassessed all residents for safe or unsafe smoking. OF THE 22 residents in the facility that smoked, only 2 residents were assessed as unsafe smokers. The staff was in-serviced on providing supervision to these two unsafe smokers. Resident #11 was to be supervised at all times while he was out of bed. The Immediate Jeopardy was lifted on 4/9/12 at 3:45 p.m. when the facility inserviced staff regarding residents who were identified as unsafe smokers. The facility also designated a staff for each shift who would provide one to one supervision while resident #11 was out of bed. The staff was assigned to supervise the resident so that he did not obtain cigarettes from other residents and to supervise the resident while he smoked. After the IJ was lifted, the deficiency remained at a level "G" due to the resident sustaining burns. The facility's total census was 51 as reported on the Resident Census And Conditions of Residents form. Findings: Review of Resident #11 Smoking assessment dated [DATE] revealed the resident was assessed to be an unsafe smoker. He was assessed as not physically able to hold the smoking device while smoking, was required to wear a protective smoking vest/apron and/or to have direct supervision while smoking. Review of resident #11's record revealed a history and physical dated 4/21/11 which reflected the following Diagnoses: [REDACTED]. Further review of a significant change MDS dated [DATE] revealed the resident was totally dependent with all ADLs, had unclear speech and was able to follow simple commands. Review of the facility's Smoking Policy revealed that the facility would provide maximum safety to all residents at all times. The policy reflected that physical and/or cognitively impaired residents must be accompanied by staff, family, or properly trained volunteers while smoking. Record review of the resident's care plan with target date of 6/13/12 revealed an identified problem area of potential for impaired skin integrity related to burning self with cigarettes. Approaches included to monitor the resident's skin weekly, report any red or open areas and record in the progress notes. Further review of the Comprehensive Care Plan revealed another identified problem of potential for trauma related to falls, poor balance, impaired mobility and resident dropping his cigarettes. The approaches that were documented for this identified problem were specifically directed to the falls. There were no specific approaches related to the resident dropping his cigarette. An additional identified problem on the Comprehensive Care Plan was potential for safety hazard, injury related to smoking. Identified approaches included provide resident with a copy of the facility's smoking policy, smoking allowed only in designated smoking areas, no smoking allowed inside facility at any time, safe smoking assessment quarterly and nursing to keep all smoking materials at nurses' station. The Comprehensive Care Plan did not reflect documentation that the resident would be supervised by staff when smoking. It also did not address his begging other residents for cigarettes or any interventions to monitor and ensure that he did not get cigarettes from other residents and smoke unsupervised. Observation on 4/9/12 at 11:50 a.m., as resident #11 was leaving the dining room, revealed that he had multiple burned areas to his shirt and pants. He was also observed to have a significant amount of cigarette ashes on his lap and the seat belt of his wheelchair. Observation on 4/9/12 at 12:00 p.m. revealed that resident #11 was in the smoke room with a lit cigarette and smoking unattended. There was no staff in the smoke room at that time. The resident was observed to drop his lit cigarette on his shirt. He was observed to be unable to immediately retrieve the cigarette from his shirt. When he did retrieve the cigarette from his shirt, it was no longer lit. Interview with S4 LPN on 4/9/12 at 12:15 p.m. revealed that he stated resident #11 should not be smoking without staff present as he was an unsafe smoker. He confirmed that the resident was in the smoke room alone at that time. When S4 LPN was asked who supervises resident #11 while he smokes, he stated sometimes resident #55 will sit in the smoke room with him. S4 LPN also stated that resident #55 has been known to give resident #11 a cigarette and light it for him without the staff's knowledge. Observation on 4/9/12 at 12:25 p.m. revealed the resident was in his room and S15 CNA was providing ADL care. Observation of the resident's skin at that time revealed a 3rd degree burn to his abdomen and a blistered area to his left inner thigh. The resident had multiple burn holes in his clothes. S15 CNA could not confirm how long the burn areas had been there but stated the resident was always burning himself with cigarettes. Interview and observation on 4/9/12 at 12:40 p.m. with S2 DON and S11 TX/LPN present in resident #11's room, verified the 3rd degree burn to the resident's abdomen and the blistered area to his left inner thigh. S2 DON stated that the weekend RN does the weekly skin assessments. She confirmed the weekly skin assessment dated [DATE] revealed no skin tears, rash, or pressure sores for resident, and they had not been aware of the resident's current burn areas. Review of the resident's TARS dated April 2012 revealed he had not been receiving any treatments to the area on his abdomen or left inner thigh. The TAR revealed that he had a previous blister area to his right thigh that had been treated with [MEDICATION NAME] cream. The area was documented as healed on 2/27/12. S2 DON and S11 LPN/TX nurse documented an assessment of the resident's skin after observing with the surveyor on 4/9/12. Review of the Wound Assessment documentation revealed that the resident had a third degree burn to his abdomen which measured 0.5 cm in length X 0.5 cm in depth. It was documented that it was red and dry. The current treatment was listed as clean with Normal Saline and apply [MEDICATION NAME] cream every day. Further review of an additional Wound Assessment form dated 4/9/12 revealed documentation that the resident had a blister to his left thigh. That area measured 0.2 cm in length X 0.2 cm in width. The area was documented to be pink and dry. The current treatment was listed as monitor every day. Interview on 4/9/12 at 12:55 p.m. with S11 Administrator and S2 DON confirmed that resident #11's cigarettes are kept at the nurse's station and that staff is supposed to go with the resident to monitor him while he smokes. They stated that there was no one specifically designated to monitor the resident while he smoked. They also stated that there are other residents in the facility who are allowed to hold their own cigarettes and lighter. Further interview at that time revealed that they were aware that other residents have been known to give resident #11 cigarettes and light them for him at times without the staff's knowledge. They also stated that resident #11 will beg other residents for cigarettes. Further interview with S1 Administrator at that time revealed that he had verbally told other residents not to give resident #11 cigarettes. However, he stated that he had no documentation to reflect that he had spokeN with residents regarding this situation. Further interview with S2 DON on 4/9/12 at 1:00 p.m. revealed that resident #11's mother has asked resident #55 to provide him with cigarettes. She stated that she was aware of this and that she had talked with resident #55 and asked him not to give cigarettes to resident #11. She confirmed that it was resident #55 who had given resident #11 the lit cigarette after lunch on 4/9/12. Interview on 4/9/12 at 1:50 p.m. with S2 DON confirmed an order from the physician dated 4/9/12 to treat the 3rd degree burn to the stomach and monitor blisters to left thigh until healed. A new skin assessment was done on 4/9/12 to include the burned areas. Interview on 4/9/12 at 2:00 p.m. with S2 DON revealed that there were 22 residents in the facility that smoked and only 2 residents were assessed as unsafe smokers. The staff was in-serviced on providing supervision to these two unsafe smokers. Resident #11 was to be supervised at all times while he was out of bed.