Every finding on record at McKinney Healthcare and Rehabilitation Center

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services.1.The facility failed to ensure items were dated in the freezer and dry storage. 2.The facility failed to ensure staff properly wore beard restraints.3.The facility failed to ensure staff sanitized the thermometer before taking food temperatures for the lunch meal on 07/15/2026.These failures could place residents at risk of cross contamination and foodborne illness.Findings include:Observation on 07/14/2026 at 9:06 AM, in the freezer, revealed an open and undated carton of ice cream. In the dry storage area was a package of spaghetti which was opened and in a resealable bag was undated.Observation on 07/15/26 at 11:53 AM, while [NAME] E was setting up food items on the steam table, the beard restraint was not covering all facial hair. [NAME] E had a mustache and the beard restraint was below the mouth not covering the mustache.Interview on 07/14/2026 at 9:15 AM, the Dietary Manager stated her expectation was for items should be dated and said staff probably forgot. She said it was the responsibility of whoever used the item, so if the cook made spaghetti, they should have dated it. She said if items were not labeled and dated residents could receive something outdated. She said staff dated items so they knew when the expiration date was and when to discard that item. Observation and interview on 07/15/26 at 11:53 AM, revealed [NAME] E took the temperature of stuffed peppers and did not sanitize the thermometer before use. He said he was supposed to so it would kill bacteria and said he did not sanitize it. [NAME] E said he had been trained to sanitize the thermometer before taking each temperature. Interview on 07/15/26 at 11:53 AM, the Dietary Manager stated she trained staff to sanitize the thermometer before use and between each temp. She said if not, the risk to residents was food borne illness. Interview on 07/15/26 at 12:25 PM, [NAME] E stated the beard restraint should cover all facial hair to keep hair follicles from getting in the food. Interview on 07/15/26 at 1:49 PM, the Dietary Manager stated her expectation was that all hair was covered when staff were wearing hair restraints to prevent hair from falling in foods. Record review of the U.S. FDA Food Code 2022 reflected: Section 3-501.17 Commercially processed foodOpen and hold cold. refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1;.(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.Section 2-402.11 Effectiveness.FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.Section 4-602.11 Equipment Food-Contact Surfaces and Utensils.(A) Equipment food-contact surfaces and utensils shall be cleaned: .(4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE; P and(5) At any time during the operation when contamination may have occurred.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to ensure the kitchen was free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.Findings include:Observation on 07/15/26 from 11:45 AM to 12:38 PM, in the kitchen near the steam table, revealed flies in the kitchen, landing on the bottom of upside down stacked plates, and near food items on the counter multiple times. Food items and utensils were on the counter were covered with plastic wrap. Interview on 07/15/26 at 11:45 AM, [NAME] E said he saw the flies on the counter. He stated normally when he saw them, he would kill them. He said he did not know where they came from but noticed them more in the last two weeks. He said the risk to residents was they could get sick from bacteria if flies touched the food. Interview on 07/15/26 at 11:53 AM, the Dietary Manager stated she saw one or two flies but not like this. She said she did not know if the door that went straight outside was left open or if they came in from the door in the dining room. She said the risk was flies could transfer illness to residents. She stated they kept all food products covered, plates inverted and utensils wrapped up. The Dietary Manager said if staff saw any pests, she expected them to contact Maintenance so he could contact pest control. Interview on 07/16/26 at 3:29 PM, the Administrator stated for pest sightings his expectation for staff was to report to Maintenance or himself and they would call pest control. He said pests in the kitchen could contaminate the food or utensils used. He said the pest control vendor had been contacted for the flies. Record review of pest sighting log for June and July 2026 revealed no entries for the kitchen.Record review of the facility's, undated Pest Control policy reflected: It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment. Facility staff will: 1. Report any pest sightings.4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information:a. Type of problemb. Locationc. Person reporting and time reported.1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc.

Based on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 (Resident #92) reviewed for transfer/discharge. The facility failed to notify Resident #92 and/or her representative in writing when the resident was transferred to the hospital on [DATE]. The facility also failed to send a notice to the Ombudsman. This failure could place residents at risk of not knowing their rights at the time of the transfer/discharge. Findings included:Review of Resident #92's discharge MDS, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included diabetes (condition where your blood sugar levels are too high), fracture of the lower femur (break in the thighbone), chronic pain syndrome, and heart disease. The MDS further reflected the resident required supervision/set up for most ADLs. Review of Resident #92's care plan, revised on 05/12/26, reflected the resident had ADL self-care performance deficit related to need for assistance with ADLs, and pain due to left femur fracture and chronic lower back pain. Interventions included using 1 staff member with transfers. Review of Resident #92's progress notes, dated 05/29/26, reflected the resident insisted in being transferred to the ER. The progress notes also reflected the ER physician, and family members were notified. Interview on 07/16/26 at 4:03 PM with Resident #92's family revealed they or the resident never received anything in writing about the resident's discharge at the time the resident left or after she had been transferred to the hospital. Interview on 07/16/26 at 4:15 PM with the DON revealed they were not aware they had to send information in writing with Resident #92 or their representative because they were expecting the resident to return from the hospital. The DON said Resident #92 and their representative were only notified verbally of the transfer. The DON further stated she was also not aware they were supposed to send a notice to the Ombudsman when resident was transferred to the hospital and only thought those notices were sent if a resident discharged from the facility without an expected return. Attempts to contact the Ombudsman on 07/16/26 at 4:30 PM were unsuccessful. Review of the facility's policy titled Admission/Transfer/Discharge, revised on 04/2025, reflected the following: .Prior to transfer or discharge, the Facility shall notify the resident and the resident's representative of the transfer or discharge and the reason for the transfer or discharge in writing in a language and manner they understand. a.The facility shall send a copy of the notice to the State Long-Term Care Ombudsman.c. The notice shall include the following: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; A statement of the resident's appeal rights, including the name, address (mailing and email), and entity which receives the requests; Information on how to obtain an appeal form and assistance in completing and submitting the hearing request; Name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals; and establishes a system of records of receipt and disposition all controlled drugs in sufficient detail to enable an accurate reconciliation) to meet the needs of each resident for 1 of 3 medication carts (200 Hallway cart) reviewed for pharmacy services. The facility failed to ensure the 200 Hallway medication aide cart had accurate narcotic counts for Residents #63 and #72. This failure could place residents at risk for medication errors, drug diversion, and delay in medication administration. Findings include:1. Record review of Resident #63's face sheet, dated 07/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE].Record review of Resident #63's Quarterly MDS, dated [DATE], revealed he had the following diagnoses: Non-Alzheimer's Dementia (cognitive decline caused by conditions other than Alzheimer's Disease), right knee Osteoarthritis (degenerative join disease where the protective cartilage that cushions the ends of bones gradually wears down), and Cognitive Communication Deficit (difficulty communicating effectively due to brain processing). Resident #63 BIMS score was 15, which indicated he was cognitively intact. The MDS further revealed Resident #63 received pain medication. Record review of Resident #63's care plan, revised on 07/10/26, revealed he has acute/chronic pain due to osteoarthritis with an intervention to administer pain medication per orders. Record review of Resident #63's physician orders, dated 07/16/26, revealed an order for Tramadol 50 mg (medication used to treat moderate to severe pain) two times a day for pain. Record review of Resident #63' July 2026 MAR, dated 07/16/26, revealed Tramadol had been administered on 07/15/26 at 7:00 AM by MA A. 2. Record review of Resident #72's face sheet, dated 07/16/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #72's Quarterly MDS, dated [DATE], revealed the following diagnoses: Non-Alzheimer's Dementia (cognitive decline caused by conditions other than Alzheimer's Disease) and Anxiety Disorder (mental health condition characterized by persistent and uncontrollable fear or worry). Resident #72's BIMS score was 3, which indicated severe cognitive impairment. Record review of Resident #72's care plan, revised on 07/02/26, revealed she used anti-anxiety medication due to her anxiety disorder. Record review of Resident #72's physician orders, dated 07/16/26, revealed an order for Clonazepam 0.5 mg (medication used for anxiety or panic disorders) two times a day. Record review of Resident #72's July 2026 MAR, dated 07/16/26, revealed that Clonazepam had been administered on 07/15/26 at 7:00 AM by MA A. Observation and record review on 07/15/26 at 8:38 AM of the 200 Hallway medication aide cart and Narcotic Administration Record with MA A, revealed Resident #62's Tramadol had 48 tablets in the blister pack, while the Narcotic Administration Record revealed 49 tablets remaining. Observation and record review further revealed Resident #72's Clonazepam had 48 tablets in the blister pack, while the Narcotic Administration Record revealed 49 tablets remaining. During an interview on 07/15/26 at 8:47 AM with MA A, she stated she gave the Tramadol and Clonazepam earlier this morning and forgot to sign them out in the Narcotic Record. MA A stated she did administer the medications and signed them off in the computer, but she forgot to sign them out in the narcotic log because it was the first medications she gave that shift. [TF6.1]She stated she should be signing out the narcotic medications when getting the medication out of the cart. She stated it was important to sign out the narcotics for accurate counting and tracking. MA A stated the risk of not signing out the medications in the Narcotic Record timely was forgetting to sign off or not administering the medications. During an interview on 07/16/26 at 12:41 PM with ADON B, she stated she worked at the facility for 3 years. She stated when staff were giving controlled substances or narcotics, she expected them to sign the MAR and sign out sheet in the Narcotic Record binder. She stated the sign out sheets were important because that was how the staff tracked to ensure the medication administration was accurate with no discrepancies. She stated the risk of not signing off was the following shift may not know what narcotic medications were administered and the resident may not receive the medications. [TF7.1]During an interview on 07/16/26 at 1:08 PM with ADON C, he stated he had worked at the facility since 2009 and has been the ADON since October 2025. He stated he expected his staff to follow the guidelines and to count and sign the narcotic book and computer for any controlled substances. He stated it was important to sign out the book to ensure the medications were not being abused. ADON C stated the risk of not signing off the narcotic log/book was the residents may not get the medication and it was important to ensure residents were getting what was ordered. During an interview on 07/16/26 at 2:16 PM with the DON, she stated she worked at the facility for 5 years. She stated she expected her staff to make sure all controlled substances were charted in the computer system, and when the medication was removed from the cart, they were expected to sign it out in the narcotic count binder. The DON stated it was important to sign out for inventory counting and to prevent the misuse of narcotics. The DON stated the risk of not completing it was misuse of the medication or medication errors. She stated she started in-services with staff to ensure staff were following the guidelines. The DON stated the nurses were responsible for ensuring the narcotics were being signed out properly and the ADONs completed spot checks and were also responsible for oversight. Record review of the facility's Controlled Medications policy, revised 12/2019, revealed the following: .6. When a controlled medication is administered, the licensed nurse administering the medication enters all of the following information on the accountability record: Date and time of administration. Amount administered. Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 8.11%, based on 3 errors out of 37 opportunities, which involved 1 of 5 residents (Resident #5) and 1 of 4 staff (RN D) observed during medication administration reviewed for medication error. RN D failed to administer all the crushed medications in medication cups leading to 3 cups being left with residual medication. This failure could place residents at risk of not receiving proper medication doses leading to an altered therapeutic response.Findings include: Record review of Resident #5's face sheet, dated 07/16/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #5's Annual MDS, dated [DATE], revealed he had the following diagnoses: Parkinsonism (neurological condition that causes movement problems) and Hypertension (high blood pressure). Resident #5 cognitive skills had a score of 3, which indicated he had severe cognitive impairment. The MDS further revealed Resident #5 required a feeding tube for nutrition. Record review of Resident #5's care plan, revised 06/05/26, revealed he required a feeding tube due to dysphagia (difficulty swallowing). Observation on 07/16/26 at 7:15 AM revealed RN D prepared medications outside of Resident #5's room. She sanitized her hands and prepared the following medications:Vitamin C (Ascorbic Acid) 500 mg 1 tablet daily via G-tubeCholecalciferol 1000 unit 1 tablet daily via G-tubeDocusate Sodium 100 mg 1 tablet two times a day via G-tubeMultiple Vitamins-Minerals 1 tablet daily via G-tubeFamotidine 20 mg 1 tablet two times a day via G-tubeCarbidopa-Levodopa 25-100 MG 1 tablet three times a day via G-tubeDoxazosin Mesylate 4 mg 1 tablet daily via G-tubeEliquis 5 mg 1 tablet two times a day via G-tube RN D put each medication in an individual cup and crushed each medication. RN D washed her hands, applied PPE, and entered Resident #5's room. Each medication was mixed with 15 ml of water. RN D positioned Resident #5 with HOB elevated and checked the feeding tube placement. She flushed the tube with 60 ml of water, administered each medication individually, and flushed with 10 ml of water in-between. After administration, RN D flushed with 60 ml of water. Observation of medication cups revealed 3 cups with residual medication at the bottom and sides of medication cup. RN D rinsed the medication cups which contained residual medication on the bottom and edges with water and discarded. She removed her PPE and washed her hands before exiting room. During an interview on 07/16/26 at 7:19 AM with RN D, she stated it was normal for there to be medication sediment in the cup and she would throw it away. RN D stated she felt it was not a lot of medication left in the cup and Resident #5 would get most of the medication. RN D stated she should be giving Resident #5 all the medication, so the medication was effective. RN D stated the risk of not administering all the medication was, he may not get the full dose. She stated she should have mixed the medication with more water so Resident #5 would get all his medications. RN D stated she was trained on G-tube administration but was nervous. During an interview on 07/16/26 at 12:46 PM with ADON B, she stated she expected the nurses to crush each medication in an individual cup and to ensure the medication was well crushed and mixed to prevent any residuals with G-tube administration. ADON B stated the staff were expected to administer the whole medication. She stated the risk of leaving residual medication in the cup was the resident may not get the appropriate dose of medication. During an interview on 07/16/26 at 1:11 PM with ADON C, he stated he expected the nurses to follow orders. He stated all medications should be given and the full dose with G-tube administration. ADON C stated there should be no medication left in the cup, so the resident got the correct dose. He stated the risk if there was residual medication in the cup was the resident may not get the medication and it was a medication error. During an interview on 07/16/26 at 2:20 PM with the DON, she stated she expected the nurses to administer all the medications completely with G-tube administration. She stated there should not be any residual in the cup and that was important, so the resident got the proper dose. The DON stated the risk of having residual medication was the resident may not get all the medication for the proper dose. She stated the nurses were responsible for ensuring accurate administration, but her and the ADON were overall responsible. Record review of the facility's Medication Administration via Feeding Tube policy, dated 01/22, revealed the following: .7. Tablets are crushed and capsules are opened to facilitate mixing and administration. Tablets should be crushed to a fine consistency. Powder from crushed tablets or capsule contents should be dispersed well in 15-20ml of water or other prescribed diluent. All the particles must be in solution prior to administering the medication.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for four of fifteen residents (Resident #1, #2, #3, and #4) reviewed for medication storage. 1. The facility failed to ensure a wound cleanser, an antiseptic (substance that stops the growth of microorganisms) skin cleanser, tubes of barrier creams (used to prevent skin irritation), a bottle of nystatin powder (antifungal medication), and sachets of povidone-iodine (solution used to prevent wound infection) were not left within reach inside Resident #1's room on 11/25/2025. 2. The facility failed to ensure there was no squeeze eye drop bottle, a tube of hemorrhoid (swollen veins in the anus) ointment, a tube of hydrocortisone (used to treat inflammation) ointment, and a tube of triple antibiotics (antibiotics used to kill bacteria in the skin) were not left inside Resident #2's room on 11/25/2025. 3. The facility failed to ensure sachets of barrier cream were not left inside Resident #3's room on 11/25/2025. 4. The facility failed to ensure containers of wound cleanser were not left inside Resident #4's room on 11/25/2025. These failures could place residents at risk of misuse of medications that could lead to adverse reactions.Findings include: 1. Record review of Resident #1's Face Sheet, dated 11/25/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves) and reduced mobility. Record review of Resident #1's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 09/01/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 15. The Comprehensive MDS Assessment indicated the resident had a surgical wound. Record review of Resident #1' Physician Order, dated 07/31/2025, reflected Sacral surgical dehisced wound: Cleansed with N/S, pat dry, apply Gent, collagen, cover with dry dressing. every day shift every Mon, Wed, Fri for surgical graft wound. Record review of Resident #1's Assessment Notes on 11/25/2025, reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. During an observation and interview on 11/25/2025 at 8:13 AM revealed several items for wound care were observed on top of Resident #1's dresser and were in plain sight. On top of the dresser was a wound cleanser, an antiseptic skin cleanser, tubes of barrier creams, a bottle of nystatin powder, and sachets of povidone-iodine. Resident #1 stated she had a wound on her bottom and the nurse would clean her wound every other day. The resident said no one talked to her regarding the risks of having the wound care items inside the room. 2. Record review of Resident #2's Face Sheet, dated 11/25/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia and assistance of personal care. The resident did not have any diagnosis for dry eyes, hemorrhoids, or any skin condition. Record review of Resident #2's Comprehensive MDS Assessment, dated 11/05/2025, reflected the resident had moderate impairment (resident may need additional support and monitoring) with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident had dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #2's Comprehensive Care Plan, dated 11/13/2025, reflected the resident had impaired cognitive function/dementia one of the interventions was to give step by step instructions. Record review of Resident #2' Physician Order, on 11/25/2025, reflected no order for eye drops, hemorrhoid ointment, hydrocortisone ointment. Ther resident did not have an order for wound care that would require a triple antibiotics. Record review of Resident #2's Assessment Notes, on 11/25/2025, reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. An observation on 11/25/2025 at 8:21 AM revealed Resident #2 was not inside her room. A plastic rectangular basket was observed on top of her overbed table with a container of eye drops on it. The container of eye drops was in plain view. During an observation and interview on 11/25/2025 at 1:12 PM revealed Resident #2 was in her bed, awake. When asked about the medications found inside her room, the resident did not reply. 3. Record review of Resident #4's Face Sheet, dated 11/25/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with multiple sclerosis and major depressive disorder (persistent feeling of sadness or loss of interest). Record review of Resident #4's Comprehensive MDS Assessment, dated 09/22/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate any skin issue. Record review of Resident #4's Physician Order, on 11/25/2025, reflected no order for wound care. During an observation and interview on 11/25/2025 at 8:40 AM revealed two containers of wound cleanser inside Resident #4's room. The containers of wound cleansers were on top of the dresser and was in plain sight. The resident said it had been on top of her dresser for some time. The resident said she did not have any wound recently that needed cleaning. She said she did not know who left the wound cleansers. During an observation and interview on 11/25/2025 starting at 9:59 AM, RN B stated there should be no medications inside the rooms of the residents unless they had an assessment that they could self-administer their medications. She said residents #1, #2, and #4 did not have any assessment that they could administer their medication, do their wound care, or apply the barrier cream. She said it might result in overmedication or misuse of medications. She said there were some confused residents in the facility that might enter the room and might get hold of the medication. She went inside Resident #1's room and saw a wound cleanser, an antiseptic skin cleanser, tubes of barrier creams, a bottle of nystatin powder, and sachets of povidone-iodine. She said those should be inside the wound care cart. She said if the resident wanted them inside her room, then it should be placed where it would not be accessed by other residents. She said she did not know exactly why those were inside Resident #1's room. She took the wound cleanser, an antiseptic skin cleanser, tubes of barrier creams, a bottle of nystatin powder, and sachets of povidone-iodine and said she would put them in the treatment cart. She then went to Resident #2's room and saw the eye drops in the plastic basket. She said she did not notice it when she did her morning round. She took the eye drops and said Resident #2 did not have an order for the eye drops. RN B saw a tube of hemorrhoid ointment, a tube of hydrocortisone ointment, and a tube of triple antibiotics in the plastic basket. She said she did not notice the said medications when she would go inside Resident #2's room. She said those medications should not be inside the room because the resident might use them aside from what was recommended. She said Resident #2 might mistakenly use the ointments as toothpaste. She said ingesting them might cause stomach upset or even poisoning. She said Resident #2 did not have any wound that would require triple antibiotics. She said she would check if Resident #2 needed the medications so she could request orders for those medications. She then went inside Resident #4's room and saw the wound cleanser on the dresser. She took the wound cleansers and said she would put a name on them and would put them inside the treatment cart. She said Resident #4 did not have any wound that needed to be cleaned. She said she would also contact the resident's family member to know if they brought the medication and educate them about letting them know if they were bringing any medication. She said a confused resident might get hold of it and spray it in their eyes. In an interview on 11/25/2025 at 10:48 AM, CNA D stated the tube and sachets of barrier creams should not be inside the room because the resident might mistakenly consume it. She said it should be somewhere secured so the resident did not have any access to it. She said the skin protectant was applied on the skin and might have adverse effects if consumed by the resident. She said they already checked the rooms of the residents, took the skin barriers left inside the residents' rooms. She said if staff were done using the sachet of skin barrier, the staff should have thrown it in the trash can. She said another option would be putting the barrier ointment along with the briefs and wipes, inside the drawers. 4. Record review of Resident #3's Face Sheet, dated 11/25/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia, overactive bladder (a bladder control problem which leads to a sudden urge to urinate), and need for assistance for personal care. Record review of Resident #3's Comprehensive MDS Assessment, dated 11/10/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had urinary and bowel incontinence. During an observation and interview on 11/25/2025 at 8:33 AM revealed Resident #3 was sitting in her wheelchair. Sachets of skin barrier ointments were observed on the resident's side table. One of the sachets was ripped open on one side with some remains of the ointment still visible from the open side. She said the CNAs used the ointment every time they cleaned and changed her. She said that would not be the first time the CNAs left sachets or tubes of skin barrier ointment on her side table. In an interview on 11/25/2025 at 12:34 PM, LVN C stated zinc oxide was a form of medication because it was applied topically to prevent any skin issues. She said it should not be inside the room because confused residents might consume it or put it in their eyes. She said the ointment should be stored in the cart or somewhere not accessible to any residents. She said once the CNAs were done with the skin barrier, they should throw the sachet because the resident might lick it. She said she would check the rooms assigned to her to see if they had any skin barrier ointments inside. In an interview on 11/25/2025 at 12:42 PM, the DON stated Resident #1 wanted her wound care supplies to be inside her room. She said she would talk to Resident #1 to let her know that the wound care supplies should be inside the treatment cart. She said if Resident #1 insisted, she said she would instruct the nurse to secure them and put them inside the drawer of the Resident #1's dresser where they would not be accessible to any of the residents. She said RN B also showed her the medications she found inside Resident #2's room and the wound cleanser from Resident #3's room. She said the staff would not know if the medications were inside the drawer but if they were in plain view, the staff should have seen them. She said those medications were not supposed to be inside the resident's room because the residents might use them inappropriately or consume them instead of applying topically. She said the wound cleanser should be stored in the treatment cart. She said she would check if Resident #2 needed the medications found inside her room so she could get an order for the said medications. She said the risk could be the resident using it without any assessment and might be using it more than as ordered and nobody would know. She said skin barrier creams should not be accessible to the residents for the same reason. She said she already started an in-service about medication storage. In an interview on 11/25/2025 at 12:52 PM, ADON A stated she was also the wound care nurse. She said she did not know why Resident #1's wound care supplies were inside her room. She said she would get the things needed for her wound care from her treatment cart. She said Resident #1 was bed-bound and would not be able to access the wound care supplies, but other residents might be able to use them aside from what they were intended to. She said the supplies could be secured by putting them inside a plastic bag and put them inside the drawer. She said Resident #4 did not have any wound and she did not know why she had wound cleansers inside the room. She said medications should not be inside the room because the residents might eat, drink, or use them improperly. She said other residents, who were suffering from psychological disorder, might enter the room and use the medication as well. She said the staff should be aware that medications should not be inside the rooms of the residents. She said she would collaborate with the DON with regards to the issue. In an interview on 11/25/2025 at 1:28 PM, the Administrator-in-Training stated what he knew was there should be no medications inside the rooms of the residents for safety reasons. He said the expectation was for the staff to scan the rooms of the residents when they did their rounds because medications inside the rooms of the residents could be harmful for the residents. He said the DON already started an in-service. Record review of the facility's policy entitled, Medication Access and Storage, E kit access Policy/Procedure - Nursing Clinical revised 07/2019 reflected POLICY: It is the policy of this facility to store all drugs and biological in locked compartments . The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #13) of 15 residents on 100 hall reviewed for resident rights. 1. The Housekeeping Supervisor did not knock on Resident #13's room door and bathroom door before entering. 2. The Housekeeping Supervisor did not inform Resident #13 that he was in her room or of the service he was to provide. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings include: Review of Resident # 13's admission record revealed a [AGE] year-old female with a diagnosis which included Alzheimer's (a brain disease that slowly destroys memory and thinking skills, making it hard to do everyday tasks), aphasia (a condition that makes it hard to speak, understand, read, or write, usually after a stroke or brain injury), end stage renal disease (When the kidneys stop working well enough to keep you alive, often requiring dialysis or a kidney transplant), dysphagia (difficulty swallowing liquids and/or solid food and drink). Review of Resident #13's quarterly Minimum Data Set, dated dated dated [DATE] revealed a brief interview for mental status (BIMS) summary score of 9 indicating moderate cognitive impairment. Section titled Functional Status documented the need for assistance with personal care. Observation on 05/06/2025 at 9:50 a.m. During an interview with Resident #13 in her room, the Housekeeping Supervisor entered Resident #13's room without knocking or announcing himself. Once he entered the room, he opened the bathroom door without knocking or announcing himself. During an interview on 05/06/2025 at 9:52 a.m. Resident #13 stated that staff will usually knock before entering and it bothered her that the Housekeeping Supervisor did not. During an interview on 05/06/25 at 10:00 a.m. The Housekeeping Supervisor stated he usually knocks before entering resident's room. He stated he saw Resident #13's door open so he went in looking for the other housekeeper. He stated he just peeped in the bathroom. During an interview with Director of Nursing (DON) on 05/07/25 at 2:05 p.m. DON reported prior to entering a resident's room, staff knock on the door, identify themselves, ask permission to enter, and explain the reason for entering. The DON stated that was the expectation for all staff who go into a resident's room. The DON stated that would include housekeeping staff. Review of facility policy titled Resident Rights/Dignity and Respect, dated 02/2020 stated Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by. People not involved in the care of the Resident shall not be present without the resident's consent while they are being examined or treated. Staff members shall knock before entering the Resident's room.

Based on observation, interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for one (Resident #32) of five residents reviewed for personal property. The Activity Director utilized residents' personal inventories of crayons/markers for the purpose of group activities. This failure could place residents at risk of not being able to retain and use personal property. Findings included: Review of Resident #32's Face Sheet, dated 05/08/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including Attention-Deficit/Hyperactivity Disorder (a type of brain difference that can make it hard to pay attention, finish tasks and sit still) and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Observation of an interaction between Resident #32 and the Activity Director on 05/06/25 at 10:30AM revealed the Activity Director asked Resident #32 if he could borrow from her personal inventory of crayons/markers for resident activities. Resident #32 stated she was very particular about her crayons/markers and did not want them to return broken after being used by other residents. The Activity Director agreed that broken crayons/markers had been an issue at the facility, and he told Resident #32 to disregard the request. During an interview with Resident #32 on 05/06/25 at 10:36AM, she stated this was the first time the Activity Director had requested to utilize her personal belongings for resident activities. She stated she was not bothered by this request. During an interview with the Activity Director on 05/06/25 at 12:50PM, he stated he had been requesting and utilizing residents' personal inventories of crayons/markers for resident activities for the past week. He stated the facility's inventory of crayons/markers were smashed up and/or broken. The Activity Director stated he did not feel as though there was an issue or a risk in asking to utilize residents' personal belongings for wide-spread group activities. During an interview with the Director of Nursing on 05/07/25 at 2:00PM, she stated the expectation was for the Activity Director to utilize the facility's supplies for activities. She stated it was not appropriate for the Activity Director to request to utilize a resident's personal inventory of crayons/markers for a wide-spread group activity. The Director of Nursing stated the risk in doing so was that the request could be misconstrued as misappropriation of resident property. Review of the facility's Resident Rights policy, dated 07/2017, reflected, .As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #61) observed for infection control. A COTA failed to perform hand hygiene while providing incontinence care to Resident #61. The failures could place the residents at risk for infection. Findings include: Record review of Resident #61's face sheet dated 05/08/25 reflected a [AGE] year-old male. He was admitted to the facility 03/06/25. Admitting diagnoses included muscle weakness, hypertension (high blood pressure), hypothyroidism (Hypothyroidism happens when the thyroid gland doesn't make enough thyroid hormone), and cellulitis (is a bacterial infection of the skin and underlying tissues). Review of Resident #61's Admission MDS record dated 03/10/25 reflected the resident had a BIMS (Brief Interview of Mental Status) score of 13, indicative of no cognitive impairment. He was always incontinent of bowel and occasionally incontinent of bowels. Review of Resident #61's care plan initiated 03/09/25 reflected Resident #61 required assistance with activities of daily living. Observation on 05/08/25 at 10:49 AM revealed the COTA providing incontinent care to Resident #61. A COTA was observed completing hand hygiene and gloved before care, then she informed the resident she was providing incontinent care. The COTA then positioned the resident and unfastened the brief and proceeded to clean Resident #61's front area, then positioned the resident on his side and cleaned his bottom area. Resident #61 was minimally soiled with urine. After cleaning the resident, the COTA proceeded to apply barrier cream and apply clean brief with the same gloves she used to clean the resident. The COTA did not complete any hand hygiene or change gloves after cleaning the resident. In an interview on 05/08/25 at 12:42 PM with the COTA she stated normally she did not provide incontinent care to the residents, but the resident was ready to get out of bed that was why she offered to assist the resident. She stated she failed to complete hand hygiene and change gloves after care because she was caught in the moment and forgot to complete hand hygiene and change gloves after cleaning the resident. The COTA stated she was expected to complete hand hygiene and change gloves after cleaning the resident before applying the clean brief to prevent cross contamination and for infection control. In an interview on 05/08/25 at 12:59 PM with the DON she stated the staff was expected to clean hands and change gloves after providing incontinent care the resident. After providing incontinent care the gloves were considered dirty and the staff was supposed to complete hand hygiene and change gloves before applying the barrier cream and clean brief. The DON stated the facility had completed basic infection control training with all staff to prevent cross contamination and for infection control. Review of the facility policy revised on 05/2007 and titled Hand Washing reflected, It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff. Review of the facility policy revised 09/2017 and titled Infection Prevention and Control Program reflected, a. The Infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. b. The elements of the Infection Prevention and Control Program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in a locked cart or under the direct observation of authorized staff in an area where residents could access it for one (Wound Care Cart) of five carts reviewed for pharmacy services The facility failed to ensure that LVN A locked the wound care cart after providing wound care on 05/01/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications. Findings included: Observation on 05/01/2025 at 8:25 AM revealed a cart was parked in the hallway in front of the nurses' station. The cart was not locked and there were some keys on top of the cart. The drawers of the cart were facing the hallway and several staff and residents were passing in front of the cart. All the drawers of the cart could be easily opened and the contents of each drawer could be easily taken. The drawers of the cart contained different types and sizes of dressings, wound cleansers, normal saline, ointments, creams, iodine, collagen, gauze pads, bandages, tongue depressors, tape measures, and disinfecting wipes. During an observation and interview on 05/01/2025 at 8:29 AM, the ADON stated the carts should be locked everytime they were left unattended. She opened one of the drawers of the unlocked cart to check what was inside and what was the cart for. She said the cart was used for wound care. The ADON said the staff should lock the carts before leaving to prevent unauthorized individuals from opening them. She said residents might open them and access or ingest something to which they were allergic. She said, if the carts were left unlocked, any resident, staff, or visitor could open them and get some medications. She said the keys should not be left on top of the carts because even though the carts were locked, others could take the keys and easily open the carts. She said she did not notice the wound care cart was not locked when she came in that morning. She said she would try to find out who left the cart unlocked and the left the keys on top of the wound care cart to educate them of the significance of locking the carts and securing the keys of the carts. She took the keys from the top of the cart and them and placed them in her pockets. In an interview on 05/01/2025 at 9:57 AM, the DON stated any cart should always be locked when left unattended to prevent any residents from opening it and taking something from it. She said the wound care cart had wound cleanser and ointments that could be accidentally drank or ingested that could result to allergic reactions. She said if it was the medication cart that was left unlocked, residents could take and ingest some pills, and could result to choking and accidental overdose. She said it was the night nurse that left the wound care cart unlocked and left the keys on top of the cart. She said the expectation was for staff to lock the carts and secure the keys everytime the carts were left unattended. The DON stated she already started an in-service about the importance of locking the cart. In an interview on 05/01/2025 at 10:18 AM, the Administrator stated all the carts should always be locked in protection of the residents. He said the carts should be locked and the keys secured so that no unauthorized individuals could access them. He said the DON already started an in-service pertaining to locking the carts. In an interview on 05/01/2025 at 1:04 PM, LVN A said she did a wound care early morning because a resident was about to go out of the facility for a procedure. She said the wound care coincided with her med pass and some treatments that was why she forgot to make sure that the wound care cart was locked and the keys were secured when she was done with wound care. She said being busy was not an excuse for leaving the cart unlocked and the keys on top of the cart. She said somebody might open the cart and access ointment and creams and accidentally ingest them. She said, next time, she would make sure the carts were locked and the keys were with her before leaving the carts. Record review of the facility's policy, Medication Access and Storage/Drug Destruction Care and Treatment/Pharmacy revised 7/2023 revealed POLICY: It is the policy of this facility to store all drugs and biological in locked compartments . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medications are kept and stored in these containers.

Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six (Resident #5) residents reviewed for infection control. 1. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #5 on 03/06/2025. This failure could place residents at risk of cross-contamination and development of infections. The findings included: 1. Record review of Resident #5's Face Sheet, dated 03/06/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included urinary tract infection (infection in any part of the urinary system) and the need for assistance with personal care. Record review of Resident #5's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 03/02/2025, reflected a BIMS (screening tool used to assess cognitive status) assessment was not completed for the resident. Section H reflected Resident #5 was always incontinent of bowel and bladder. Record review of Resident #5's Comprehensive Care Plan, dated 02/26/2025, reflected a potential for pressure ulcer development related to hypertension (high blood pressure), the use of pain medication, and the need for assistance with ADLs (collective term for all the basic skills needed in regular daily life) and personal care. One intervention was notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. On 03/06/2025 at 1:40 PM, CNA B was observed providing incontinence care for Resident #5. There were wipes, gloves, and a clean brief on Resident #5's bedside table. CNA B washed her hands in the resident's restroom. CNA B pulled the privacy curtain around Resident #5's bed and told the resident she was going to change her brief. CNA B put on clean gloves, pulled back the sheet and blanket to uncover Resident #5, and unfastened the tabs on the sides of the brief. CNA B used wipes to clean the front of the resident, wiping from the top down. CNA B dropped the wipes into the wastebasket next to her. CNA B removed the wet brief, dropped it into the wastebasket, and changed her gloves. CNA B did not use hand sanitizer or wash her hands when changing gloves. CNA wiped the residents bottom with a clean wipe and dropped it into the wastebasket. The CNA changed gloves, picked up a clean wipe, and wiped the resident's bottom again. CNA B kept the hand she used to wipe the resident's bottom to her side and did not touch anything with that hand. She used the other gloved hand to place the clean brief under Resident #5. The resident rolled to her back and CNA B secured the brief on each side. CNA B removed her gloves and used hand sanitizer from a pump on the wall near Resident #5's bathroom. CNA B took a pair of clean gloves from a box near the resident's door. CNA B put on the gloves and then put a pair of pants on Resident #5. CNA B removed her gloves and used hand sanitizer from the pump on the wall to clean her hands. CNA B carried the bag of trash out of Resident #5's room and disposed of it. During an interview on 03/06/2025 at 1:55 PM, CNA B stated she should have used hand sanitizer or washed her hands each time she changed her gloves. CNA B stated it was important for infection control and she did not want to transmit urine to other surfaces. CNA B stated she usually had a small container of hand sanitizer on the bedside table with the other supplies. When asked about facility training, CNA B stated the facility provided in-services often about handwashing and the use of hand sanitizer when caring for residents. She stated it wasn't long ago staff was in-serviced about hand hygiene. CNA B stated she wasn't sure how often to change her gloves when a brief just had urine and not stool on it and ran out of gloves before she put the clean brief on. She stated she was nervous about being watched and missed steps. During an interview on 03/06/2025 at 2:10 PM, the DON stated CNA B should have used hand sanitizer or washed her hands each time she changed gloves. The DON stated CNA B had worked in the facility for several years and knew how to provide incontinence care properly. The DON stated CNA B was nervous while being observed providing incontinence care. The DON stated CNA B probably changed gloves too frequently when cleaning the resident and used all her gloves before putting on the clean brief. The DON stated she would in-service staff immediately. Review of the facility's policy Perineal Care, revised 05/2007, reflected steps to wash, rinse, and thoroughly dry the resident's skin. The policy did not reflect the use of gloves while providing perineal care. Review of the facility's policy Infection Control, revised 10/2022, reflected Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four of 18 (Residents #6, #16, #49 and #287) reviewed for comprehensive care plans. 1. The facility failed to include in the care plan on 01/16/24 Resident #6's contractures to her right hand with interventions required to prevent further decline. 2. The facility failed to include in the care plan dated 03/28/24 Resident #16's contractures to her hands with interventions required to prevent further decline. 3. The facility failed to create a care plan on 03/26/24 for Resident #49's scoop mattress. 4. The facility failed to ensure Resident #287's care plan dated 02/21/2024 was revised to reflect discontinued use of BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and did not represent a person-centered coordination of care. Findings included: 1. Record review of Resident #6's annual MDS assessment dated [DATE] reflected a [AGE] year-old female with a BIMS of 0 which indicated she was severely cognitively impaired but could sometimes make herself understood and could sometimes understand others. She had functional limitation in range of motion both upper and lower to one side and had received occupation therapy services until the end date of 03/08/24. She required extensive assistance with ADL care and had current diagnoses of aphasia (language disorder that affects ability to communicate), cerebral vascular accident (stroke), dementia, and seizure disorder. Record review of Resident #6's care plan revised on 01/19/24 did not address the residents' contractures or any interventions to help prevent further decline. Record review of Resident #6's physician orders summary report for April 2024, reflected, Occupational Therapy Clarification: Skilled Occupational therapy services 5x/week for 4 weeks with emphasis on Self-care management, Therapeutic activities, UE (upper extremity) therapeutic excises, Neuromuscular reeducation and Patient/Caregiver education . with a start date of 01/07/23. There were no recent orders indicating Occupation therapy was currently active. An observation on 04/09/24 at 9:15 AM revealed Resident #6 up in wheelchair with mechanical lift sling under her. Resident had a contracted right hand. No hand rolls or splints were in use. Resident self-propelling her wheelchair in the hallways with the use of her feet and left hand. An observation on 04/09/24 at 2:15 p.m. revealed CNAs E and D perform mechanical lift transfer on Resident #6. Hand splint was observed on the resident's bedside table. In an interview with CNA E on 4/10/24 at 12:40 a.m. she stated she does not place any splint on Resident #6' hand. She stated therapy placed the splints on the residents. In an interview with the DOR on 04/10/24 at 12:50 p.m. she stated they had Resident #6 on case load as of 04/04/24. She stated it was a mixture of nursing and therapy when it comes to splint placement. She stated therapy will do the splints until they train the nursing staff that will be managing the splints. She stated there should be a current order for Occupational therapy services and would see why there was not an order. She stated they review the residents they have on case load at stand morning meetings with clinical team. She stated they have a contracture management book on all residents with contractures and those residents are re-evaluated every quarter and would be placed back on case load if they saw a decline. 2. Record review of Resident #16's Quarterly MDS assessment dated [DATE], reflected a [AGE] year-old female with an admitted [DATE]. Resident #16 was severely cognitively impaired and unable to complete the interview for mental status. Resident #16 had functional limitation in Range of Motion on both sides in his upper and lower extremities. She was totally dependent of one-to-two-person assistance with all ADLs and was always incontinent of bowel and bladder. She had received occupation therapy services with a start date 04/17/23. Her diagnoses included aphasia (disorder that affects communication), cerebral vascular accident (stroke), and contractures to bilateral elbows and hands. Record review of Resident #16's care plan revised on 03/28/24 did not address the residents' contractures to her hands or elbows or any interventions that had been put into place to help prevent further decline. Record review of Resident #16's physician order summary for April 2024 reflected, Patient to wear bilateral c-splint as determined by OT staff or as patient tolerates in order to manage wrist, finger contractures. Skin assessment to be completed prior to and after don/doff splint. Therapist to document were time/skin condition in daily notes . with a start date of 03/07/23. In an observation on 04/10/24 at 11:15 a.m. Resident #16 observed in bed with no hand splints in use. In an interview with LVN B on 04/10/24 at 11:20 a.m. she stated Resident #16 had splints for both her hands that she puts on at 7 am and takes off at 11 am. She stated therapy had determined this was about length of time the resident could tolerate the splints for now. In an interview with MDS D on 04/11/24 at 10:30.m., she stated she was responsible for updating the comprehensive care plan. She stated the contracture on Resident #6 and Resident #16 should have been care planned and they should document what prevention had been put into place. She stated the care plan should reflect when a resident's intervention were no longer effective or if they had refused. She stated the care plan was supposed to be a comprehensive approach to what the needs of the resident were or what their wishes were. An interview with the DON on 04/11/23 at 12:00 p.m. revealed the MDS Coordinator was responsible for updating the care plan. She stated all contractures should have been care planned with interventions in place. She stated if a resident had splinting ordered, it should be placed on the physician's orders. The DON stated if a resident refused the required splint, then it should be documented on the care plan. She stated failing to have interventions in place, put residents at risk of further decline and decreased range of motion and by not updating the care plan, they had no evidence of what attempts had been made to prevent a resident's decline. 3. Review of Resident #49's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE]. The resident's cognition was severely impaired. Her diagnoses included non-Alzheimer's dementia. Review of Resident #49's Order Summary Report, dated April 2024, reflected there was not an order for a scoop mattress. Review of Resident #49's Comprehensive Care Plans, not dated, reflected she did not have a care plan for a scoop mattress. Review of Resident #49's Hospice Order, dated 03/26/24, reflected she had an order for a scoop mattress. An observation and interview on 04/09/24 at 1:20 PM revealed the resident was sitting in a wheelchair. Her family was at the bedside. The resident had a scoop mattress on her bed. The family member said the resident had a scoop mattress because she had a history of falls. An interview on 04/10/24 at 1:48 PM with CNA N revealed the resident had a history of falls but did not know why Resident #49 had a scoop mattress. She said maybe Hospice had placed the mattress. An interview on 04/10/24 at 3:33 PM with the DON for Resident #49 revealed the resident did not have falls very often. She said the resident had a scoop mattress because Hospice provided it. She said she did not know if there was an order for the scoop mattress. She said she did not know if there was a care plan for the scoop mattress. An observation and record review on 04/11/24 at 9:46 AM with RN M revealed there was not an order for Resident #49's scoop mattress in her Hospice binder. RN N walked to the resident's room and saw the scoop mattress. She said she did not know the resident had a scoop mattress. A follow-up interview on 04/11/24 at 12:38 PM with the DON revealed she received the Hospice order for Resident #49's scoop mattress on 04/11/24. She said without the order, a care plan could not be generated. She said if the facility did not know about Hospice orders, then there could be a safety risk to the resident. An interview on 04/11/24 at 1:28 PM with the Hospice Nurse revealed she received the order for Resident #49's scoop mattress and faxed it to the facility. She said she did not know if she talked to the facility staff, but usually she did. 4. Review of Resident #287's Face Sheet dated 04/09/2024 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and iron deficiency anemia (deficiency of healthy red blood cells that carry oxygen to all parts of the body). Review of Resident #287's Comprehensive MDS assessment dated [DATE] reflected resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment also indicated one of the primary medical issues was chronic obstructive pulmonary disease. The Comprehensive MDS Assessment did not indicate resident was on BiPAP. Review of Resident #287's Comprehensive Care Plan dated 02/21/2024 reflected Resident #287 used BiPAP at bedtime. Review of Resident #287's Physician Order on 04/09/2024 reflected no order for BiPAP. Review of resident #287's Order Summary Report on 04/09/2024 reflected BiPAP was discontinued on 03/05/2024. Observation and interview with Resident #287 on 04/09/2024 at 11:05 AM revealed Resident #287 was in her wheelchair awake. It was noted that resident still had a BiPAP machine on the side table. According to Resident #287, she used BiPAP before but had stopped using it because she does not need it anymore. Observation and interview with LVN K on 04/09/2024 at 1:32 PM, LVN K confirmed that Resident #287 does not use the BiPAP anymore. LVN K checked the system and verified that the resident did not have any order for BiPAP. She then checked the care plan and saw that the resident was still care planned for BiPAP. LVN K said the care plan should had been revised because it did not reflect the current need of the resident. LVN K added the care plan should be updated or revised to show the present health condition of the resident. She said if the care plan were not updated, it would be a suggestion that the staff were not assessing the health status of the resident in order to see if the planned care was still applicable and appropriate. She added if the care plan was not updated, there could be a confusion on the care of the residents and the residents might not receive the treatment needed. Observation and interview with the DON on 04/10/2024 at 10:52 AM, the DON stated the Resident #287 did not use a BiPAP when she came back from the hospital. The DON said the BiPAP was discontinued because the resident was not using it anymore. The DON checked the resident's profile and confirmed that there was no order for the BiPAP and it was discontinued on 03/05/2024. The DON then checked the resident's care plan and verified she was still care planned for BiPAP. The DON further added if the resident's BiPAP was discontinued, the care plan should be revised. The DON said the care plan should reflect the current status of the resident to be able to provide appropriate interventions. She said if the care plan was not revised, there could be confusion on the resident's care and the resident might not be able to receive the required care. The DON said there was an oversight on her part because the care plan was not reviewed and revised. The DON said she was not concluded that the expectation was the care plans should be checked to see if the plan needed revisions. The DON concluded she would revise Resident #287's care plan to prevent confusion about his care. In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated residents care plans should be accurate in reflecting the needs of the residents. The Administrator said without the care plan, the needs of the residents won't be met. The Administrator added the care plan should be evaluated and revised if needed to prevent confusion among the staff about the care needed by the residents. The Administrator said the expectation was the staff to do their due diligence, have a conscious effort to make sure that the residents' care plans were revised, updated, and reflect the current need of the residents. In an interview with the MDS Coordinator on 04/11/2024 at 10:42 AM, the MDS Coordinator stated she was responsible in doing the care plan but everybody that was involved in her care should communicate and contribute to make a person-centered care plan. She said if the BiPAP was used by the resident or the use of the BiPAP had been resolved, then the resident's care plan should had been revised. The MDS Coordinator said the care plan should reflect the plan of care needed by a resident. She further explained the main purpose of the care plan was to address the current needs of the residents and for the staff to have a guide on how to care for the resident. If the care was not applicable to the resident, the care plan must be revised to indicate the accurate and personal care of the resident. She further said that the care plan should also reflect if the resident was refusing the BiPAP. The MDS Coordinator said she would check Resident 287's care plan and do the necessary revisions so that the resident could have the treatment needed. Review of the facility policy, Comprehensive Person-Centered Care Planning, revised December 2023, reflected, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . 37028

Based observation, interview, and record review, the facility failed to ensure that five (Resident #289, Resident #290, Resident #61, Resident # 79, and Resident #16) of ten residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. 1.The facility failed to ensure MA L re-ordered medications in a timely manner for Residents #289 (Lasix ), Resident #290 (Lasix), and Resident #61 (Entresto). 2.The facility failed to ensure MA J re-ordered medications in a timely manner for Residents #79 (Metoprolol). 3.The facility failed to ensure LVN B re-ordered medications in a timely manner for Resident #16 (Famotidine). This failure placed the residents at risk of not receiving medications as ordered by the physician. Findings included: 1.Review of Resident #289's Face Sheet dated 04/10/2024 reflected resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included pleural effusion (accumulation of excessive fluid on the space that surrounds each lung), acute systolic congestive heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs), and fluid overload (too much fluid in the body). Review of Resident #289's Quarterly MDS assessment dated [DATE] reflected Residetn#289 had congestive heart failure and was taking diuretics (medications that help reduce fluid buildup in the body). Review of Resident #289's Comprehensive Care Plan dated 04/08/2024 reflected resident was on diuretic and one of the interventions was to administer medication as ordered. Review of Resident #289's Physician's Order for Lasix dated 03/28/2024 reflected, Lasix Oral Tablet 20 MG (Furosemide). Give 1 tablet by mouth one time a day for CHF (congestive heart failure). Review of Resident #290's Face Sheet dated 04/10/2024 reflected that resident was a [AGE] year-old male admitted on [DATE]. One of the diagnoses was acute kidney failure. Review of Resident #290's Quarterly MDS assessment dated [DATE] reflected Resident #290 was cognitively intact. The Quarterly MDS Assessment also indicated that the resident had renal failure (kidney stopped working). Review of Resident #290's Comprehensive Care Plan dated 04/09/2024 reflected resident was on diuretic and one of the interventions was to administer medication as ordered. Review of Resident #290's Physician Order for Lasix dated 03/29/2024 reflected Lasix Oral Tablet (Furosemide). Give 10 mg by mouth one time a day for Diuretic. Review of Resident #61's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. One of the relevant diagnoses was biventricular heart failure (combination of symptoms associated with both left heart failure and right-side failure). Review of Resident #61's Comprehensive MDS assessment dated [DATE] reflected Resident #61 had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment also indicated resident had heart failure. Review of Resident #61's Comprehensive Care Plan on 04/09/2024 reflected resident had congestive heart failure and one of the interventions was give cardiac medications as ordered. Review of Resident #61's Physician Order for Entresto dated 03/13/2024 reflected Sacubitril-Valsartan Oral Tablet 24-26 MG (Sacubitril-Valsartan). Give 1 tablet by mouth two times a day for CHF. Observation and interview with MA L on 04/10/2024 at 11:26 AM revealed MA L opened her cart for inspection. Three blister packs were noted running low. Residents #289's Lasix 20 mg (milligrams) only had one tablet, Resident #290's Lasix 10 mg only had two tablets, and Resident #61's Entresto 24-26 mg only had three tablets. MA L confirmed both Lasix were to be administered once daily and Entresto was to be administered twice daily. When asked if the medications were already re-ordered, MA L checked the cart and said there were no other blister packs for Residents #289's Lasix 20 mg, Resident #290's Lasix 10 mg, and Resident #61's Entresto 24-26 mg. MA L checked the system, and the system showed the three medications where not re-order yet. MA L said she was not able to re-order the medications. MA L then clicked the re-order button on the system for the three medications. She said the medications should have been re-ordered when the medication reach the light blue portion of the blister pack. MA L said medication should be re-ordered four to five days before the medications were consumed. MA L stated whichever nurse saw that the tablets were running low should re-order the medications. MA L added if the medications were not re-ordered, the residents would not have any medications to take. She stated skipping Lasix could result to fluid retention and skipping Entresto could result to exacerbation of the symptoms of the heart failure. 2.Review of Resident #79's Face Sheet dated 04/10/2024 reflected resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was hypertension. Review of Resident #79's Comprehensive MDS assessment dated [DATE] reflected Resident #79 had a moderate impairment in cognition. The Comprehensive MDS Assessment also indicated resident had hypertension. Review of Resident #79's Physician Order for metoprolol reflected Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate). Give 1 tablet by mouth two times a day for hypertension Hold SBP (systolic blood pressure) less than 110, DBP (diastolic blood pressure) less than 60 and HR (heart rate) less than 60. Observation and interview with MA J on 04/10/2024 at 1:04 PM revealed MA J opened her medication cart for inspection. It was noted that the blister pack for Resident #61's metoprolol was running low with only one tablet. MA J checked the cart and confirmed there were no other blister pack for Resident #61's metoprolol. She also confirmed that the resident was to take the anti-hypertensive tablet twice a day. MA J checked the system and the system showed Resident #61's metoprolol was not yet re-ordered. MA J proceeded to re-order the medication. MA J added if the residents do not have their medications, their medical concerns could get worse. MA J said she would audit her cart to check if there were medications that needed to be re-ordered. 3.Review of Resident #16's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was gastro-esophageal reflux disease. Review of Resident #16's Comprehensive MDS assessment dated [DATE] reflected Resident #16 had a severe impairment in cognition. The Comprehensive MDS Assessment also indicated resident had heart failure. Review of Resident #16's Comprehensive Care Plan on 04/12/2024 reflected resident had GERD (gastro-esophageal reflux disease: stomach acid repeatedly flows back into the tube connecting the mouth and stomach) without esophagitis (inflammation of the esophagus). Review of Resident #16's Physician Order for Famotidine reflected Famotidine Tablet 20 MG Give 1 tablet . two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS. Observation and interview with LVN B on 04/11/2024 at 7:06 AM revealed LVN B was preparing Resident #16's medication. She said she would prepare first the resident's famotidine that she took from the e-kit. LVN B said she gave the last one yesterday. LVN B said the medication was re-ordered the night before, but the pharmacy was not able to deliver because of the weather. She added medications should be re-ordered as soon as the medications reached the part of the blister pack that says refill to ensure enough supply. She said it should not be re-ordered last minute because the residents would not have adequate supply of medication in circumstances that the delivery was late or was not able to come. LVN B said they had an e-kit (emergency kit) but it was supposed to be for new admissions and STAT (urgent) medications. She said it was not proper for a medication to be taken from the e-kit just because the medication was not re-ordered timely. In an interview with the DON on 04/11/2024 at 8:07 AM, the DON stated medications should be re-ordered 3 to 4 days before the pills were consumed. The DON said it could be done through the system or by calling the pharmacy. The DON added if the medications were not re-ordered in a timely manner, the resident would run out of medications, and they would not have any medications to take especially if the order was to take the medications routinely. The DON stated the medication aide, and the nurses were responsible for re-ordering the medications. The DON further added if the resident will not have their medications, their condition could get worse. The DON said the expectation was to re-order the medications in a timely manner. She said she would remind the medication aides and the nurses to re-order timely to ensure there was enough supply of medications and to always audit the carts for the needed medications. In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated the staff must make sure that the medications were re-ordered on a timely manner to make sure that the residents have the medications they need. He said that moving forward, he and the clinical managers would educate and monitor if the staff were following the policy and procedures. Record review of facility policy, Medication Ordering and Receiving from Pharmacy Provider revealed Procedures . 2. Repeat medications (refill) are written on a medication order . a. Reorder medication (seven) days in advance of need to assure an adequate supply is on hand.

Based 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 and transmission of communicable diseases and infections for five of sixteen residents (Resident #50, Resident #77, Resident #6, Resident #8, and Resident #47) observed for infection control. 1. The facility failed to ensure that LVN K capped Resident #50's PICC (peripherally inserted central catheters) line while not in use on 04/09/24. 2. The facility failed to ensure that CNA I changed her gloves and perform hand hygiene while providing incontinence care to Resident #77 on 04/09/24 3. The facility failed to ensure that CNA E changed her gloves and perform hand hygiene while providing incontinence care to Resident #6 on 04/11/24 4. The facility failed to ensure LVN B changed her gloves and perform hand hygiene while providing incontinence care to Resident #8 on 04/09/24 5. The facility failed to ensure NA C changed his gloves and perform hand hygiene while providing incontinence care to Resident #47 04/09/24. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Review of Resident #50's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. One of the relevant diagnoses was acute hematogenous osteomyelitis (a bone infection that spreads through the bloodstream from a distant source) of the left ankle and foot. Review of Resident #50's Comprehensive MDS assessment dated [DATE] reflected Resident #50 had a moderate impairment in cognition. The Comprehensive MDS Assessment also indicated Resident #50 was on IV (intravenous) medications while a resident of the facility. Review of Resident #50's Care Plan dated 04/09/2024 reflected resident had an infection of the skin/bone related to osteomyelitis (bone infection) and one of the interventions was to maintain standard precautions when providing care. Review of Resident #50's Physician Order dated 03/26/2024 reflected Daptomycin Intravenous Solution Reconstituted (Daptomycin). Use 550 mg (milligrams) intravenously in the morning for Osteomyelitis until 04/11/2024 23:59. Review of Resident #50's Physician Order dated 03/26/2024 reflected PICC line flushing to RUE (right upper extremity): Flush with 10 cc (cubic centimeter) 0.9 % NS (normal saline) IV Solution every shift. Observation and interview with Resident #50 on 04/09/2024 at 9:14 AM revealed Resident #50 was on his bed awake. It was noted that resident had a single lumen (with only one port) PICC line connected to an IV bag with approximately 10 milliliters of fluid, infusing well. The IV bag with label, time and initial. The IV insertion site to right upper extremity clean, dry, and intact. The dressing IV site was covered with dressing dated 04/09/2024. Resident #50 stated he was on antibiotics because of his foot. He said he would be on antibiotics for a couple of days more. Observation and interview with Resident #50 on 04/09/2024 at 1:19 PM revealed resident was sitting in the activity room. Resident #50 said he just finished lunch. He said LVN K already disconnected him to the IV bag because it was already done. He added he will have another one in the afternoon. Resident #50 then rolled his sleeve on his right arm and showed his PICC line. The end of the PICC line was not capped. Interview with LVN K on 04/09/2024 at 1:31 PM, LVN K stated she already disconnected Resident #50's IV and flushed it afterwards. She said she did not put a cap on the PICC line. She said she would find one and put it at the port of the PICC line. She said the PICC line should be capped when not in use to reduce the risk of contamination and infection. She said the resident was already in antibiotics because of infection on his foot and she had to make sure that there would be no complication. Record review of facility's policy, Peripherally Inserted Central Catheters revealed 1. Purpose: To safely care for . PICC lines . Guidelines . m. maintain a closed system 2. Review of Resident #77's Face Sheet dated 04/10/2024 reflected resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included severe sepsis (infection of the blood stream) with septic shock (extreme reaction to an infection) and retention of urine. Review of Resident #77's Comprehensive MDS assessment dated [DATE] reflected Resident #77 had a moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment also indicated Resident #77 needed assistance with personal care. Resident #77 was dependent for toileting hygiene and was always incontinent for urinary and bowel. Review of Resident #77's Care Plan dated 01/08/2024 reflected resident had a bowel/bladder incontinence related to history of history of foley for urinary retention and one of the interventions was to check for incontinence. Observation on 04/09/2024 at 10:35 AM revealed ADON H and CNA I were about to do incontinent care for Resident #77. ADON H and CNA I washed their hands and put on clean gloves. CNA I prepared the things needed for incontinent care and positioned herself on the left side of the bed and ADON H on the right side of the bed. ADON H unfastened the tape on both sides of the soiled brief, rolled the front portion and pushed it downward in between the resident's legs. ADON H removed her gloves, performed hand hygiene, and put on a new pair of gloves. ADON H then cleaned Resident #77's front part. ADON H instructed and assisted Resident #77 to roll towards CNA I. ADON H proceeded to clean the resident's buttocks. ADON H then pulled the soiled brief and threw it on the trash can. ADON H removed her gloves, performed hand hygiene, and donned new gloves. ADON H went ahead and took the clean brief and placed it on the resident's buttocks and instructed the resident to roll towards her. After the resident rolled towards ADON H, CNA I noticed the resident still had some feces on the left buttock. CNA I pulled some wipes and cleaned Resident #77's left buttock. CNA I then fixed the new brief without changing her gloves and performing hand hygiene. Resident #77 was instructed to roll back. CNA I then fastened the tape on both sides. ADON H and CNA I then pulled the resident up, pulled the blanket to Resident #77's chest. ADON H and CNA I removed their gloves, threw the soiled gloves to the trash can, and washed their hands. Interview with CNA I on 04/09/2024 at 11:00 AM, CNA I stated she did not change her gloves after she cleaned the other side of the buttocks. She said she noticed the resident still had feces when he was turned towards ADON H that was why she took some wipes and wiped it. She added did not change nor washed her hands after doing it and eventually touched the new brief. CNA I said it was important to wash hands and change gloves before touching the clean brief because the dirty gloves could contaminate the clean brief and this could result to infection. Interview with ADON H on 04/09/2024 at 11:12 AM, ADON H stated she did not notice CNA I did not change her gloves after cleaning the bottom of Resident #77. ADON H said she should had prompted CNA I to take off her gloves and wash her hands after cleaning the resident. ADON H said she should had known better. She said it was important to change gloves after cleaning the bottom of the resident and touching the new brief to prevent cross contamination and development of infection. 3. Review of Resident #6's Face Sheet dated 04/11/2024 reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included spastic hemiplegia (paralysis on one side of the body) affecting right dominant side and hemiplegia and hemiparesis (weakness on one side of the body) following unspecified cerebrovascular (relating to the brain and its blood vessels) disease. Review of Resident #6's Comprehensive MDS assessment dated [DATE] reflected Resident #6 had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment also indicated Resident #6's needed maximal assistance with toileting hygiene. personal care. Resident #6 was also always incontinent for urinary and bowel. Review of Resident #6's Care Plan dated 03/01/2024 reflected resident had a bowel/bladder incontinence related to impaired mobility and the interventions were to check for incontinence, wash, rinse, and dry perineum. Observation and interview with CNA E on 04/11/2024 at 7:22 AM revealed Resident #6 was on her bed awake. CNA E then told Resident #6 that she would prepare her for breakfast. CNA E said she would clean her first before transferring her to her wheelchair. CNA E prepared the things needed for incontinent care. CNA E washed her hands and put on clean gloves and then proceeded with incontinent care. CNA E unfastened the tape on both sides of the soiled brief, rolled the front portion and pushed it downward on the center. CNA E cleaned Resident #6's front part. CNA E then instructed and assisted Resident #6 to roll towards the wall. CNA E continued to clean the resident's buttocks. CNA E pulled the soiled brief and threw it on the trash can. CNA E then went ahead and took the clean brief without changing her gloves or performing hand hygiene. CNA E placed the new brief on resident's buttocks and instructed the resident to roll back. CNA E fastened the tape on both sides. CNA E then put on clean pants and t-shirt. Resident #6 was then transferred to her wheelchair. CNA E removed her gloves, threw them on the trash can. CNA E acknowledged she did not wash her hands and change her gloves after she pulled the soiled brief, before she touched the new brief, before she put on the pants and t-shirt, and before transferring the resident to her wheelchair. CNA E said it was important to wash hands and change gloves before touching the clean brief because the dirty gloves could contaminate the clean brief, and this could result to infection. 4. Record review of Resident #8's quarterly MDS assessment, dated 01/22/24, reflected a [AGE] year-old female with an admitted d of 03/25/17. She had a BIMS of 14, indicating she was cognitively intact. She had no behaviors documented and not resisted care. Resident #8 required extensive assistance with toileting and personal hygiene and was always incontinent of urinary bladder and bowel. Resident #8 was at risk of pressure ulcers with no current skin issues. Her active diagnoses included atrial fibrillation (fast irregular heart rate), depression, and bipolar disorder (mental disorder that cause extreme mood swings). Record review of Resident #8's Comprehensive Care Plan initiated on 09/06/22, reflected, . Has bowel/bladder incontinence r/t dementia, decrease/impaired mobility Interventions .Change as required for incontinence. Wash, rinse, and dry perineum .Monitor/document for s/sx of UTI: pain, burning .urinary frequency .foul smelling urine . An observation on 04/09/24 at 2:40 PM reveled LVN B and CNA D entered Resident #8's room with a stand assist lift. LVN B attached the lift sling around the resident's waist and slowly lifted her to a standing position which revealed the resident was soaked in urine with the front and back of her pants wet. Resident was transferred to the bed and both staff removed the residents' wet pants and opened the wet brief. LVN B wiped from front to back and down the middle and with assistance from CNA D rolled the resident onto her side, revealing she had also had a bowel movement. Resident #6 stated her butt was burning. Residents' buttocks was slightly red but no skin breakdown. LVN B removed the soiled brief and placed a clean brief under the resident before completion of incontinence care. LVN B wiped the resident's anal area and buttocks from front to back until all bowel movement had been removed. LVN B then opened a packet of barrier cream without removing her soiled gloves or performing hand hygiene and was about to apply to the resident buttocks, when the resident stated she needed to turn on her other side. LVN B handed the barrier cream to CNA D, and they assisted the resident onto her other side. CNA C applied the barrier cream to the resident's buttocks and the staff rolled the resident back onto her back and fastened the brief. LVN B and CNA D then removed their gloves and performed hand hygiene and redressed the resident transferred her back into her wheelchair. In an interview with LVN B on 04/09/24 at 3:05 PM she stated she was supposed to change her gloves when they were visibly soiled. She stated she placed the clean brief under the resident in case she had more bowel movement. She stated she should have changed her gloves and performed hand hygiene before moving to the clean aspect of care, the clean brief, and the residents clothing. She stated the risk was infection and spread of germs. 5. Record review of resident #47's quarterly MDS assessment, dated 02/25/24, reflected a [AGE] year-old male with an admitted [DATE]. Staff assessed residents' cognition as severely impaired. He required extensive assistance with personal hygiene and toileting and was frequently incontinent of urine and always incontinent of bowel. Active diagnoses included diabetes, cerebral vascular accident (stroke) and dementia. Review of Resident #47's care plan, initiated on 10/03/23, reflected .Has bowel/bladder incontinence r/t impaired mobility, post CVA, hemiplegia .Interventions .use disposable briefs. Change as needed . An observation on 04/09/24 at 1:30 PM revealed NA C with assistance from therapy staff transferring Resident #47 from his wheelchair to the bed so he could provide incontinence care. Resident #47 was observed to have wet pants from front to back. NA C performed hand hygiene and put on gloves and removed the resident wet pants and unfasted the wet brief and took a peri wipe and wiped up and down residents' groin without changing the surface of the wipe with each stroke. NA C did not clean the resident's penis or scrotum or pull back the foreskin to clean the tip of the penis. NA C rolled the resident over onto his side and wiped the back of the resident's thighs and wiped the anal area from front to back with a clean peri-wipe. NA C placed a clean brief under the resident without changing his gloves and performing hand hygiene. NA C fastened the brief and repositioned the resident and then removed his gloves and gathered the trash and dirty linens and left the room without performing hand hygiene and walked across the hall and entered the soiled linen closet to deposit the trash and linens, and then performed hand hygiene. In an interview with NA C on 04/09/24 at 01:55 PM he was unsure about the proper steps of peri-care for a male resident and was not sure what steps he had missed. After a few minutes he stated he should have cleaned the penis and scrotum. He stated the foreskin needed to be pulled back to clean the tip of the penis. He stated failing to do this could cause skin breakdown and infections. He stated he should have changed gloves and performed hand hygiene before he left the room and during care after he finished cleaning the resident. In interview with the DON on 04/10/2024 at 10:52 AM, the DON stated the staff should change the gloves after cleaning the resident's bottom. She added the staff should also wash their hands or sanitize them before, during, and after incontinent care. She said she expected the staff to perform hand hygiene properly and change their gloves after cleaning the bottom of the resident and before touching the clean brief. She added she would do an in-service about hand hygiene and changing of gloves. She also said the end of the PICC line should be capped when not in use. She added it could contaminate the PICC line and could result to additional infections. She said she would try to find out what happened. She concluded that the expectation was the staff would change their gloves and wash their hands before, during, and after incontinent care. Interview with the DON on 04/11/2024 at 8:07 AM, she stated they do not have a policy about the PICC line being capped but agreed it should be capped to prevent further infection. In interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated the expectation was the staff to perform hand hygiene and change their gloves when needed. He said when the hands were not washed and the gloves were not changed, there could be a possibility of contamination and infection. He said they do not have a policy that says the end of the PICC line should be capped. Review of the facility's policy titled, Hand Hygiene, dated October 2022, reflected, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accept standards .Wash hands with soap and water for the following situations .When hands are visibly soiled .Use an alcohol-based hand rub .for the following situations .Before and after direct contact with residents .Before moving from a contaminated body site to a clean body site during resident care .After contact with blood or bodily fluids .After removing gloves .After removing and disposing of personal protective equipment .

Based on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one (Resident # 138) of six residents reviewed for misappropriation of property. The Administrator failed to start thoroughly investigating a misappropriation of property on 01/11/2024, after the facility filed a report to the state regarding Resident # 138's [NAME] Of Attorney misappropriating her property. Failure to timely investigate misappropriation of property placed residents at risk for unidentified misappropriation of property. Findings included: Review of Resident #138's face sheet reflected she was a [AGE] year-old female with an original admitted [DATE] and she was discharged to an assisted living facility on 02/15/2024. Resident was diagnosed with dementia (loss of cognitive functioning), schizophrenia (a chronic brain disorder), cognitive communication deficit (difficulty with thinking and use of language), end stage renal disease ( kidney failure). MDS assessment dated [DATE] reflected Resident had a BIMS score of 09 which indicated resident's cognition was moderately impaired. Resident required moderate assistance with toilet/shower transfers, and she was occasionally incontinent of bowel and urine. Review of the Adult Protective Services report dated 01/09/2024 and facility self-reported incident dated 01/11/2024 reflected the facility staff had concerns of misappropriation of property by resident # 138's friend who obtained a [NAME] Of Attorney that included financial access. Further review revealed the facility failed to investigate this allegation of misappropriation of property to ensure her finances were safe. Record review of progress note dated 01/09/2024 reflected the Social Services Staff made and Adult Protective Services report of suspicious activity against Resident 138's friend who was enquiring about finances and document being signed. Interview with the facility Social Services staff on 04/10/2024 at 9:41 AM revealed resident's friend started asking Social Services staff about reimbursement for his visits to the facility and the Resident #138 had recently signed a Power Of Attorney over to the friend Social Services staff stated Resident's friend's had a sudden interest in resident's finances and his (Power Of Attorney-friend) access to her (Resident #138) finances made her suspicious of Power Of Attorney friend and she filed an Adult Protective Services report to investigate and find out what exactly was going on. Social Services Staff stated the facility received a copy of the Power Of Attorney document, she stated she did not read the Power Of Attorney document prior to making the Adult Protective Services report. An attempted call to Resident #138 at her cell phone listed in the admission record was not answered on 04/10/24 at 9: 50 AM. Interview with Business Office Manager on 04/10/24 at 10:52 AM revealed she was familiar with Resident #138 and resident's friend was the only point of contact at the time of her admission. She stated the friend was listed as the Resident #138's Medical Power Of Attorney and that document (Medical Power Of Attorney) was signed on 05/21/2022. She stated at the time of Resident #138's admission, the Power Of Attorney did not want to be involved in her financial matters, but he started showing interest in her finances by the end of December 2023. She stated the facility wanted to apply for Medicaid for the Resident # 138 and the friend was contacted for Resident's financial documents. The friend informed the Business Office Manager that resident received a lump sum amount from her brother who passed away and the friend obtained a guardianship of the resident. Business Office Manager stated the Power Of Attorney friend brought a guardianship document to her on 01/09/2024, he started showing interest in Resident #138's finances and asked about her social security income and status of resident's trust fund account. Business Office Manager stated the friend wanted reimbursement for his expenses towards the visit such as gas, food purchases for the resident, she reimbursed him from the resident's trust fund for food. Business Office Manager stated his sudden interest in resident's finances made her suspicious of his intentions. Business Office Manager stated she discussed her concerns about Resident #138's finances with the social services staff and the administrator. Business Office Manager stated the social services staff made an Adult Protective Services report against resident's friend/Power Of Attorney for financial exploitation, Business Office Manager stated she did not know the outcome of the Adult Protective Services report. Business Office Manager stated the resident was discharged on [DATE]. Business Office Manager stated she was able to identify misappropriation of property, the recent in-service training she received on misappropriation of property was 2 weeks ago. Business Office Manager stated if she came to know about a misappropriation of property, she would immediately report it to Adult Protective Services, also notify the social worker and the administrator, and the facility would investigate the allegation. Business Office Manager stated not investigating an allegation of misappropriation of property would place a resident at the risk of the continuation of misappropriation. Business Office Manager stated whoever made the report was responsible to follow up and ensure an investigation was completed and resident's assets were safe. A second attempted telephone call on 04/10/2024 at 10:26 AM to Resident #138 was not answered. A follow up interview with the Social Services staff on 04/10/2024 at 11:02 AM revealed she had received in services on misappropriation of property and the last in service she received was a year ago. She stated she would report to Adult Protective Services and administrator whenever she learned that an individual was taking advantage of a resident financially. She stated she made the report to make sure the Resident 138's finances were safe, and she was not taken advantage of by his friend/Power Of Attorney. She stated the risk for the resident for not investigating misappropriation of property was her safety, her stay at the facility and her finances. She stated in this case she was responsible to ensure an investigation was completed. She stated she was not aware of any other state agency report regarding exploitation other than the one she made to Adult Protective Services. Interview with the administrator on 04/10/2024 at 12:55 PM revealed he was familiar with Resident #138 and her friend/Power Of Attorney. He stated the friend's sudden interest in her finances made the facility Business Office Manager and Social Services staff suspicious of his intention and the Inter Disciplinary Team meeting discussed and determined the issue was more appropriate for Adult Protective Services to investigate. Administrator stated he was not aware if the Adult Protective Services completed the investigation, the staff who reported was responsible to follow up and ensure an investigation was completed. Administrator stated the staff were provided training on misappropriation of property at least once a month and he expect his staff to immediately notify him and report to the state if there was a concern of misappropriation of property. He stated he was the only one who has access to Tulip to file a state report and he did not report it because he did not fell this case was appropriate for misappropriation. He stated not investigating a misappropriation of property could affect the finances of a resident. An interview with DON on 04/11/2024 at 10:38 AM revealed she was familiar with Resident #138 and his friend. DON stated resident's friend did not have any responsibility at the time of her admission. DON stated his sudden interest in resident's finances and his demand for reimbursement for any visits and purchases towards resident made the facility staff suspicious of his intention. The friend brought a Power Of Attorney document on the resident and the facility staff made an Adult Protective Services report to investigate financial exploitation. DON stated she did not know the outcome of the investigation. DON stated she was not aware of the incident reported to any other state agency than Adult Protective Services. DON stated the business office was responsible to do the due diligence, she stated she could not say who was responsible to ensure an investigation was completed. DON sated she did not know the risk for the resident if a misappropriation of property report was not investigated. Review of the hospital document from dated 05/21/2022 reflected Resident #138 appointed her friend as her Medical Power Of Attorney. Review of the Probate Court document reflected Resident #138 did not need a guardian and Resident #138's friend was appointed as her durable Power Of Attorney on 12/14/2023 based on the Power Of Attorney Resident signed on 08/03/2023. Review of the facility policy dated 10/1/2022 reflected It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment . Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Misappropriation of resident property - means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. PROCEDURES: In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: o Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: o Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury o Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury o Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: o The Administrator of the Facility o The State Survey Agency o Adult Protective Services (as appropriate) o Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). o Ensure that the results of all investigations are reported within five (5) working days of the incident to: o The Administrator o The State Survey Agency o Ensure that, if the alleged violation is verified, appropriate corrective action is taken. GUIDELINES FOR FACILITY COMPLIANCE In order to comply with the Facility's obligations as set forth in 42 CFR Section 483.12, it will: o Make all staff aware of the applicable reporting requirements. o Educate all staff on the definitions of abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. Policy / Procedure - Nursing Administration Revised 10/1/2022 Page 4 o Educate all staff on the types of conduct which might meet the definition of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. o Support an environment in which staff and others freely and without hesitation report situations which may be or are consistent with abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. o Conduct a prompt, thorough and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property. o Maintain evidence that all allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property are thoroughly investigated. o Depending on the nature of the allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment, exploitation, or misappropriation of resident property does not occur while the investigation is in process. o Take corrective action as appropriate given the results of the investigation. o Assess the corrective action taken, if any, in response to the results of the investigation to determine its effectiveness.

Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who was unable to carry out activities of daily living for one of six residents (Resident #8) reviewed for ADL care. The facility failed to provide Resident #8, who required extensive assistance, with timely incontinence care on 04/09/24 from 9:30 a.m. to 3:00 p.m. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity. Findings included: Record review of Resident #8's quarterly MDS assessment, dated 01/22/24, reflected a [AGE] year-old female with an admitted d of 03/25/17. She had a BIMS of 14, indicating she was cognitively intact. She had no behaviors documented and not resisted care. Resident #8 required extensive assistance with toileting and personal hygiene and was always incontinent of urinary bladder and bowel. Resident #8 was at risk of pressure ulcers with no current skin issues. Her active diagnoses included atrial fibrillation (fast irregular heart rate), depression, and bipolar disorder (mental disorder that cause extreme mood swings). Record review of Resident #8's Comprehensive Care Plan initiated on 09/06/22, reflected, . Has bowel/bladder incontinence r/t dementia, decrease/impaired mobility Interventions .Change as required for incontinence. Wash, rinse and dry perineum .Monitor/document for s/sx of UTI: pain, burning .urinary frequency .foul smelling urine . In an interview with Resident #8 on 04/09/24 at 2:30 p.m. she stated she was not getting changed throughout the day. She stated she was gotten up around 9:30 a.m. so she can make the first smoke break. She stated she was not laid back down and changed until after the last smoke break which was at 6:30 p.m. She stated it may be close to 7:30 p.m. before she gets changed. She stated she cannot make staff understand that she wants to be gotten back up so she can have her smoke breaks, so they just leave her up the whole time. She stated by the time they laid her down at night she was soaked in urine. She stated she was wet right now and would like to be changed, but stated she wanted to make sure they knew she wanted to get back up. On 04/09/24 at 2:35 p.m. LVN B was notified Resident #8 was wet and had requested to be changed. She stated she would let the CNAs know and they would be in to change her. An observation on 04/09/24 at 2:40 p.m. reveled LVN B and CNA D entered Resident #8's room with a stand assist lift. Resident stated, after I get changed, I want to be gotten back up, LVN B attached the lift sling around the resident's waist and slowly lift her to a standing position which revealed the resident was soaked in urine with the front and back of her pants wet. Resident was transferred to the bed and both staff removed the residents' wet pants and opened the wet brief. LVN B wiped from front to back and down the middle and with assistance from CNA D rolled the resident onto her side, revealing she had also had a bowel movement. Resident #6 stated her butt was burning. Residents' buttocks was slightly red but no skin breakdown. LVN B removed the soiled brief and placed a clean brief under the resident before completion of incontinence care. LVN B wiped the resident's anal area and buttocks from front to back until all bowel movement had been removed. LVN B then opened a packet of barrier cream without removing her soiled gloves or performing hand hygiene and was about to apply to the resident buttocks, when the resident stated she needed to turn on her other side. LVN B handed the barrier cream to CNA D, and they assisted the resident onto her other side. CNA C applied the barrier cream to the resident's buttocks and the staff rolled the resident back onto her back and fastened the brief. LVN B and CNA D then removed their gloves and performed hand hygiene and redressed the resident, transferred her back into her wheelchair. In an interview with LVN B on 04/09/24 at 3:15 p.m. she stated incontinent residents were supposed to be checked and changed every two hours. She stated she was not sure if the resident had been changed earlier in the shift or not. She stated she knew the resident wanted to be up before the first smoke break which was at 10:00 a.m. In an interview with CNA D on 04/09/24 at 3:50 p.m. she stated she works the 2 p.m. to 10 p.m. shift. She stated they do not check Resident #8 for incontinences until after she goes to bed after the last smoke break. She stated the resident can let them know if she wants to be changed. She stated she was not sure if day shift changed her after she was gotten up in the morning. In an interview with CNA E on 04/10/24 at 12:40 a.m. she stated she was not assigned to Resident #8 on 04/09/24 but does assist with getting her up and incontinent care when asked. She stated she does not recall getting asked on 04/09/24 to assist with providing any incontinence care to Resident #8. She stated she knows she likes to be up before 10:00 a.m. so she can go for the first smoke break. She stated Resident #8 was always incontinent. In an interview with the DON on 04/10/24 at 2:00 p.m. she stated incontinent residents were to be checked and changed every two hours. She stated failing to do this could cause skin breakdown and puts them at risk of urinary tract infections. Review of the facility's policy titled, Incontinent Care, dated May 2007, reflected, It is the policy of this facility to remove urine or feces from skin, cleanse and lubricate skin, provide dry, odor free perineal care system .Check for wetness at least every two hours.

Based on observations, interviews, and record review, the facility failed to ensure medication was labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for one (Resident #81) of two residents reviewed for labelling of drugs and biologicals. The facility failed to ensure MA L placed a change of instruction label for Resident #81's Sertraline blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) after the order was changed. This failure could place residents at risk for wrong medication administration, mismanagement of care, adverse effects, and physical harm. Findings included: Review of Resident #81's Face Sheet dated 04/10/2024 reflected the resident was an [AGE] year-old female admitted on [DATE]. One of the relevant diagnoses was depression. Review of Resident #81's Quarterly MDS assessment dated [DATE] reflected resident had a moderately impaired cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated the resident had depression. Review of Resident #81's Comprehensive Care Plan dated 04/09/2023 reflected resident was taking antidepressant medication and one of the interventions was to administer antidepressant medications ordered by physician. Review of Resident #81's Physician's order for Sertraline dated 04/09/2024 reflected Zoloft Oral Tablet 100 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED. Review of Resident #81's discontinued Physician's order for Sertraline on 04/09/2024 reflected Zoloft Oral Tablet 50 MG (Sertraline HCl). Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED. Observation and interview on 04/10/2024 at 11:26 AM revealed MA L was checking Resident #81's blister pack for sertraline. It was noted that the blister pack's instruction was to give 50 mg (milligrams) once a day while the instruction in the eMAR (electronic medication administration record) was to give 100 mg once a day. MA L acknowledged that the instruction on the blister pack was different from the instruction in the system. MA L stated the dose for the sertraline was increased from 50 mg to 100 mg. MA L said the staff use a sticker that says change in instruction, check the eMAR or the staff could write a note on the blister pack to denote the change in order. MA L said since there was a change in instruction, she should had placed a change in instruction note or sticker on the sertraline 50 mg blister pack while waiting for the sertraline 100 mg blister pack. MA L opened her medication cart and looked for the sticker. She said she had no change of direction sticker so she would just write a note on the blister pack to ensure the right dosage of medication was administered and avoid medication error. In an interview with MA J on 04/10/2024 at 1:04 PM, MA J stated the staff giving the medications should make sure they were reading the order and comparing the blister pack with the order in the system. She said the MAs and nurses were responsible in placing a change of direction sticker on blister pack if there was a change in direction. MA J said if there was change in order, the blister pack should have a note of change of direction to avoid medication error, undermedication, overmedication, or confusion among the staff. In an interview with the DON on 04/10/2024 at 10:52 AM, the DON stated whoever staff that received the new order should have placed a change in order instruction on the blister pack to avoid confusion. The DON said the risk were overmedication or undermedication which could have an adverse effect for the residents. The DON said the expectation was to provide the right dosage of medication as per order and make sure the medications correlate with the eMAR and the order in the package. In an interview with the Administrator on 04/11/2024 at 8:23 PM, the Administrator stated whatever the procedure was in giving the medications, it should have been followed to prevent any errors. Record review of facility's policy Medication Orders revealed Procedures . g. orders . 2. The following steps are initiated . d). Transcribe newly prescribed medications on the MAR . When a new order changes the dosage of a previously prescribed medication, discontinue the previous entry by (writing DC'd [discontinued] .).

Based on interview and record review, the facility failed to ensure physician orders were obtained for lab services and failed to promptly notify the physician of laboratory results that fall outside of clinical reference ranges in accordance with facility policy and procedures for notification of a practitioner or per the ordering physician orders for one of two (Resident #6) reviewed for labs. 1. The Facility failed to transcribe the physician orders for a lab draw to obtain a Dilantin (medication used for seizure control) level on 02/13/24 and 03/28/24 into Resident #6's clinical record. 2. The Facility failed to provide timely notification to the physician or nurse practitioner of laboratory results that fell outside of clinical reference ranges of the Dilantin level drawn on 02/13/24 for Resident #6 and failed to document notification of results obtained on 03/29/24 for the repeat Dilantin level request for Resident #6. This failure could affect residents by placing them at risk for ineffective treatment of seizure control or side effects from toxicity. Findings included: Record review of Resident #6's annual MDS assessment dated [DATE] reflected a [AGE] year-old female with a BIMS of 0 which indicated she was severely cognitively impaired but could sometimes make herself understood and could sometimes understand others. She required extensive assistance with ADL care and had current diagnoses of aphasia (language disorder that affects ability to communicate), cerebral vascular accident (stroke), dementia, and seizure disorder. Record review of Resident #6 's care plan imitated on 09/14/22 reflected, Has seizure disorder (unspecified) .Interventions .Give Medications as ordered .Obtain and monitor lab/diagnostic work as ordered. Report results to ME and follow up as indicated . Record review of Resident #6's Order Summary Report for February 2024 through April 2024 did not reflect orders for Dilantin Level lab request. Record review of Laboratory results for Resident #6 reflected: 1. Therapeutic Phenytoin (Dilantin), Total Serum- Results 22.4 (H) Reference Ranges- 10.0-20.0 - note Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity. - Lab was drawn on 02/13/24 and was reported to the facility on [DATE] at 05:13 a.m. 2. Therapeutic Phenytoin (Dilantin), Total Serum- Results 20.8 (H) Reference Ranges- 10.0-20.0 - note Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity. - Lab was drawn on 03/28/24 and was reported to the facility on [DATE] at 06:13 a.m. Record review of Resident #6's Nurse's Progress notes for February 2024 did not reflect physician notification of the laboratory results received on 02/14/24. Record review of Resident #6 Nurse Progress note written by ADON A on 03/27/24 at 12:58 p.m. reflected, New orders to repeat Dilantin level d/t previous high levels . Record review of Resident #6's Nurse Progress notes from 03/29/24 through 04/11/24 did not reflect notification to the physician or nurse practitioner of the lab results received on 03/29/24. In an interview with the DON on 04/10/24 at 1:55 p.m. she stated the nurses were responsible for checking the lab portal each day for any lab updates and were responsible for notifying the physician at that time. She stated most of the laboratory results are received on the morning shift. She stated there should be an order for the laboratory test requested and would check to see if the orders had not been scanned into the electronic record. In an interview with LVN B on 04/10/24 at 2:15 p.m. she stated she had received the laboratory results on 03/29/24 and had notified the NP for Resident #6 but stated she had not documented the notification. She stated she was the primary day shift charge nurse for Resident #6. She stated she was aware there was delay in the notification of the lab results for the Dilantin level drawn on 02/13/24, which was why a new request to repeat the lab draw was ordered on 03/28/24. She stated when they get an order for a lab, they placed it into the laboratory portal. She stated only recently had they had the system connect with the resident's electronic record which allowed the physician to be able to view the lab results as soon as the lab posted them into the portal. She stated she did not realize the orders did not transcribe over into the resident clinical record, and assumed when they put the order request into the lab portal it created the physician's order. She stated they also used a secured communication portal on a separate electronic device where they updated the physicians on lab results or changes in the resident's condition. She stated those notifications do not show up in the electronic record. She stated she realized now she needed to update the progress notes on any notifications to the physician and needed to place the order into the electronic record. She stated these failures could result in delays of notifications of lab results and any necessary follow up for the oncoming shifts. In an interview with the NP for Resident #6 on 04/10/24 at 4:33 p.m. she stated she had requested some Dilantin levels but could not recall when she had requested them. She stated if she had been contacted about a Dilantin level that was outside of the reference range, she would have requested a re-draw of the lab to ensure it was a correct range before making any changes to the residents' medications. She stated since there was no request for a re-draw in February, she most likely was not made aware of the laboratory results. She stated she does not get excited when the lab is outside of the reference range, until it gets into the 30's or if the resident is having seizures. She stated Resident #6 had been stable and was not showing any signs or symptoms of toxicity and had not had any reported seizures. In an interview with the DON on 04/11/24 at 8:55 a.m. she stated she was not able to locate an order for the labs that were requested on 02/13/24 and 03/28/24. She stated she was also unable to locate any documentation that the physician or NP had been notified of the lab results. She stated failure to notify the physician regarding lab results could result in a delay in treatment or the need to adjust a medication depending on which labs were drawn. She stated all lab requests had to have a physician order. Interview with ADON A on 04/11/24 at 9:32 a.m. stated she was the one who had spoken to the NP for Resident #6 on 03/27/24. She stated the resident had been starting to pocket her food when eating, so she had reviewed the labs the resident had done and discovered the lab drawn on 02/13/24 did not indicate the physician had not been notified. She stated she spoke with the NP who was in the building that day and informed her about the previous lab results and she stated the NP requested the lab to be re-drawn. She stated she had informed the charge nurse but did not write an order for the lab. She stated she should have written the odor for the request. She stated it was the nurse's responsibility to check the labs every day. She stated the lab will contact the facility by phone if there was a critical lab level and will document who they gave those critical levels to. Review of the facility's policy titled, Diagnostic Test Results Notification, dated January 2022, reflected, It is the policy of this facility to obtain laboratory and radiology services when ordered by a Physician, Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) and to promptly notify the ordering provider of test results .Results of laboratory, radiological, and diagnostic test outside the clinical reference ranges shall be reported to the resident's attending physician, PA, NP or CNS promptly or as specified in the order. Notification of test results will be documented in the resident's clinical record. Results of lab, radiology, & diagnostic services shall be made a part of the resident's medical record.

Based on observation, interview and record review, the facility failed to provide each resident with a nourishable, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences for 1 (Resident # 31) of 24 residents reviewed for needs and preferences. The facility failed to ensure Resident # 31 was offered alternative meal options. This failure placed residents at risk of not having their needs and preferences honored. Findings included: A record review of Resident #31's face sheet dated 04/12/2024 reflected she was an [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. During an interview on 4/09/24 at 11:30 am., Resident #31 stated the food was not appetizing. Resident #1 stated she was unaware of available options, so she does not ask for any. Resident #1 stated she does not eat much. The confidential group meeting on 4/10/24 at 10:00 am., revealed, if a food item is not on the menu, it's not an option. The residents stated they were unaware of alternative food options. During an observation and interview on 4/10/24 at 11:45 am., Resident #1 was observed sitting in the dining room with her lunch plate sitting on the table. Resident #1 stated, I like the okra but not the seasoned beans and potatoes. Resident #1 stated she requested and was provided a chef salad instead. Observation on 04/10/24 at 9:44am revealed the facility meal times and menu were posted on the wall near the dining room and the facility meals times were posted. Observation revealed there was no posting of the alternative meal option, snacks, or the availability of snacks between mealtimes. Interview with the Dietary Manager on 04/11/24 at 9:45 am revealed the Fall/Winter menu cycle contained alternative meal options but the Spring menu does not have alternative meal options. The Dietary Manager stated the Spring menu recently started. A record review of the facility's policy titled Policy/Procedure-Section: Dietary Services, Subject: Menus and Food dated June 2017 revealed the policy did not reflect alternative meal options for residents.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of six residents (Resident #47) reviewed for incontinence care. The facility failed to ensure NA C provided appropriate perineal care for Resident # 47 after an incontinent episode when he failed to clean the resident's scrotum, and penis on 04/09/24. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Record review of resident #47's quarterly MDS assessment, dated 02/25/24, reflected a [AGE] year-old male with an admitted [DATE]. Staff assessed residents' cognition as severely impaired. He required extensive assistance with personal hygiene and toileting and was frequently incontinent of urine and always incontinent of bowel. Active diagnoses included diabetes, cerebral vascular accident (stroke) and dementia. Review of Resident #47's care plan, initiated on 10/03/23, reflected .Has bowel/bladder incontinence r/t impaired mobility, post CVA, hemiplegia .Interventions .use disposable briefs. Change as needed . An observation on 04/09/24 at 1:30 p.m. revealed NA C with assistance from therapy staff transferring Resident #47 from his wheelchair to the bed so he could provide incontinence care. Resident #47 was observed to have wet pants from front to back. NA C performed hand hygiene and put on gloves and removed the resident wet pants and unfasted the wet brief and took a peri wipe and wiped up and down residents' groin without changing the surface of the wipe with each stroke. NA C did not clean the resident's penis or scrotum or pull back the foreskin to clean the tip of the penis. NA C rolled the resident over onto his side and wiped the back of the resident's thighs and wiped the anal area from front to back with a clean peri-wipe. NA C placed a clean brief under the resident without changing his gloves and performing hand hygiene. NA C fastened the brief and repositioned the resident and then removed his gloves and gathered the trash and dirty linens and left the room without performing hand hygiene and walked across the hall and entered the soiled linen closet to deposit the trash and linens, and then performed hand hygiene. In an interview with NA C on 04/09/24 at 01:55 p.m. he was unsure about the proper steps of peri-care for a male resident and was not sure what steps he had missed. After a few minutes he stated he should have cleaned the penis and scrotum. He stated the foreskin needed to be pulled back to clean the tip of the penis. He stated failing to do this could cause skin breakdown and infections. Review of NA C's skill check off for Male Perineal care dated 03/09/24 reflected he was competent in providing this care. In an interview on 04/10/24 at 02:00 p.m., the DON stated when providing incontinent care staff were to clean the peri area including penis and scrotum for male residents then moving toward the buttocks. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated NA C was very nervous and stated she knew he knew how to provide proper care. Record review of the facility's procedure check off titled, Male Perineal Care, dated 2019, reflected, .Wash hands .Put on disposable gloves .Use a different section of the washcloth or disposable wipe for each stroke .Hold penis upright .pull back the foreskin of the uncircumcised penis. Wash the urinary meatus (tip of penis) in a circular motion .Return the foreskin to the natural position .wet and sop a new washcloth. With downward strokes(away from the urinary meatus), wash down the shaft of the penis, then scrotum, perineum, and thigh creases .Wash the perineum and the anal area .Wash from front to back .Change gloves and perform hand hygiene if apply peri cream .Apply incontinent brief .Remove gloves and wash hands .Tie up bags of soiled linen and trash .Wash hands .

Based on observation, interview and record review, the facility failed to ensure residents were free from accident hazards for one (Resident #26) of five residents reviewed for accidents. The facility failed to contact emergency services when Resident #26 had choking incident which lasted for approximately 30 minutes, became unresponsive, and staff were unable to clear the obstruction. Resident #26 was pronounced dead at the facility by the DON. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator was provided the IJ template on [DATE] at 4:15 PM. This failure placed residents at risk for a delay in intervention and life-saving treatments, which could result in death. Findings included: Review of Resident #26's face sheet, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's MDS Assessment, dated [DATE], revealed the resident had a BIMS score of 10, indicating the resident had moderate cognitive impairment. The resident required extensive assistance with a two person assist with bed mobility, personal hygiene with one-person assist, and was totally dependent on staff with a two person assist with transfers and dressing, eating, and toilet use with a one-person assist. Review of Resident #26's Care Plan, dated [DATE], revealed the following: -I am participating in the Restorative Nursing Program related to ROM, eating, and grooming. Interventions included: Resident approach eating: hand-to-hand assistance with spoon secondary to tremors at all meals in dining room. Every day shift. Resident approach eating: Resident to be sitting upright at 90 degrees in dining room at all meals at least for ,[DATE] minutes 6 days/week. Every day shift related to muscle weakness (generalized) . -The resident has potential for alteration of nutritional and/or weight due to need for mechanically altered therapeutic diet, [MEDICAL CONDITION] and [DIAGNOSES REDACTED].Monitor/document/report PRN any signs/symptoms of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . Review of Resident #26's progress notes, dated [DATE] 8:50 AM revealed, Staff called nurse to room due to resident coughing and with possible aspiration. Nurse and CNA performed [MEDICATION NAME] x 2. Called code blue to room. Resident is a DNR. Staff members came to room to assist. Applied oxygen at 10 LPM via (nasal cannula). Suctioned x 2 with no sputum. Turned resident onto her side and no change. (Bilateral) hands cyanotic and face ashy. No change in condition. Called DON to room to assess resident. Resident with no blood pressure, no (respiration) and no pulse. Pronounced at 9 AM, signed by LVN C. The progress note reflected no documentation that 911 was contacted. In an interview on [DATE] at 1:40 PM CNA A revealed Resident #26 required assistance with feeding. She stated she was assisting in feeding Resident #26 on Tuesday, [DATE], during breakfast, around 8:30 AM. CNA A stated Resident #26 coughed after that bite and CNA A gave Resident #26 a drink. After drinking some coffee, CNA A asked Resident #26 to cough again in order to clear out what was obstructing the resident's airway. CNA A stated Resident #26 attempted to cough but was unable to. CNA A stated she called in CNA B for assistance and was unsure if Resident #26 was choking or not. CNA A stated LVN C came into the room shortly after to assess the resident and begin the [MEDICATION NAME] maneuver. CNA A stated the resident was instructed to try coughing again. She stated Resident #26 attempted to cough but was unable to fully cough. CNA A stated LVN C instructed her to get the resident's chart. CNA A retrieved the resident's chart and the crash cart with emergency medical supplies. CNA A stated LVN C was joined by LVN D and LVN E in taking turns to perform the [MEDICATION NAME] maneuver on Resident #26. CNA A stated she did not call 911 nor was she aware if anyone else contacted 911 during the incident. In an interview on [DATE] at 1:30 PM LVN C revealed on Tuesday, [DATE], CNA B called for help during breakfast, around 8:30 AM, to respond to a code blue to Resident #26's room. LVN C stated she entered the room and Resident #26 appeared to be choking and was turning blue. LVN C stated she and CNA B immediately performed the [MEDICATION NAME] maneuver, and she asked CNA A to grab Resident #26's chart to check the resident's code status. LVN C stated she was sure the resident had a DNR code status. LVN C stated more nurses, including LVN D and LVN E, came into the room to assist, applying oxygen to the resident and utilizing a suctioning machine in an attempt to dislodge what was obstructing the resident's airway. LVN C stated she had the resident lie down on her side in an attempt to have the resident vomit. She stated the other nurses and she were unable to get out whatever was obstructing the resident's airway. LVN C stated the resident was still breathing and not grasping at her throat or making gasping noises, which would typically indicate choking, but the resident was unable to respond to any prompting. LVN C stated she called in the DON to pronounce the resident dead when the resident was no longer responding, and the DON came in around 9:00 AM to pronounce the resident was deceased . LVN C stated since the time she had come into the room to respond to the choking incident until the time the DON came into the room to pronounce the resident dead around 9:00 AM, LVN C did not call 911. LVN C stated she did not call because it did not cross her mind, nor did any of the staff in the room with her call 911 to her knowledge. She did not think to instruct someone to call 911 either. She stated she should have called 911 when the resident was turning blue. In an interview on [DATE] at 1:55 PM LVN D revealed she came into Resident #26's room to assist with a code blue on Tuesday, [DATE], in the morning, close to 9:00 AM. She stated she assisted LVN C with taking turns performing the [MEDICATION NAME] maneuver on Resident #26 when LVN C got too tired. LVN D stated LVN E also came into the room and they all took turns performing the [MEDICATION NAME] maneuver on Resident #26. LVN D stated they attempted to provide the resident oxygen and to suction out whatever was obstructing the resident's airway with no success. LVN D stated the resident was still breathing and not grasping at her throat or making gasping noises, which would typically indicate choking, but the resident was unable to respond to any prompting. LVN D stated the DON came after the resident was no longer responsive to pronounce the resident was deceased . LVN D stated she did not contact 911, nor was she aware if anyone else in the room contacted 911. LVD D stated she could not recall the exact training or who instructed her to not call 911 during in-services prior to this incident. In an interview on [DATE] at 2:15 PM CNA B revealed CNA A had called CNA B for help with a resident on the morning of Tuesday, [DATE] around 8:30 AM. CNA B entered Resident #26's room and Resident #26 appeared to be choking. CNA B immediately went to get LVN C. LVN C entered the room and started to perform the [MEDICATION NAME] maneuver. CNA B assisted LVN C in performing the [MEDICATION NAME] maneuver when LVN C got too tired. CNA B stated additional staff entered the room, including LVN D and LVN E. CNA B stated she stepped aside for the nurses to assist and resumed caring for the other residents assigned to her. CNA B stated she did not contact 911 since the moment Resident #26 started to choke/aspirate to when the resident expired and was unsure if the other staff in the room contacted 911 . In an interview on [DATE] at 3:00 PM the DON revealed when she came into the facility on Tuesday, [DATE], around 9:00 AM LVN C asked her to pronounce a resident deceased . The DON stated she entered Resident #26's room and checked her vital signs before pronouncing the resident deceased . The DON stated she did not contact 911 and stated she expected staff to have contacted 911 during Resident #26's choking/aspirating incident and stated her staff most likely confused what the DNR code status meant. The DON stated the code status DNR did not mean staff should not contact 911 in the event of an emergency such as a resident choking/aspirating. The DON clarified 911 did not have to be contacted for a resident with a code status of DNR if the resident was already unresponsive with no pulse upon discovery. The DON revealed staff reviewed advanced directives and what to do in the event of an emergency, such as choking, at least quarterly through in-services. The in-services regarding choking prior to this incident were not provided prior to exit. Observation of the facility's Choking posting, undated, revealed no instruction on contacting 911 in the event of a choking/aspirating episode if the [MEDICATION NAME] maneuver was unsuccessful. Review of the facility's Emergency Procedure - Choking policy, dated [DATE], revealed, .If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility . On [DATE] the Administrator and DON were notified an Immediate Jeopardy was identified and a Plan of Removal was requested. The IJ template was provided. The facility's Plan of Removal was accepted on [DATE] at 9:50 AM and reflected the following: (Facility name) Abatement Plan [DATE] Immediately, on [DATE], RN F and RN G, in-serviced DON on 1. Emergency response. 2. Contacting 911 during an emergency. 3. How to respond to a resident who is choking. 4. Identifying situations when 911 should be contacted on a DNR resident such as choking, fall with head injury, suspected fractures, diabetic coma, acute stroke,[MEDICAL CONDITION], uncontrollable pain, chest pain and uncontrolled bleeding. 5. Identifying situations when DNR patients do not require 911 to be contacted such as absence of vital signs or no sign of life. Competency was established via return verbalization and quizzing. Training and competencies for DON were completed on [DATE]th, 2020. On [DATE]th, 2020 DON and RN G initiated in-services with facility staff on 1. Emergency response. 2. Contacting 911 during an emergency. 3. How to respond to a resident who is choking. 4. Identifying situations when 911 should be contacted on a DNR resident such as choking, fall with head injury, suspected fractures, diabetic coma, acute stroke,[MEDICAL CONDITION], uncontrollable pain, chest pain and uncontrolled bleeding. 5. Identifying situations when DNR patients do not require 911 to be contacted such as absence of vital signs or no sign of life. Competency was established via return verbalization and quizzing. Completion date for the licensed nurses in-services and competency will be [DATE]th, 2020. No employee will be allowed to work without receiving the in-service and competency validation. The above training material will be incorporated into the new hire nursing orientation by DON effective [DATE]th (2020) and ongoing. The facility has ensured choking posters are in plain view in the dining room, bistro, employee break room, rehab gym and each hallway. This was completed on [DATE]. On [DATE]th, 2020 an audit was conducted by RN G and DON to identify other DNR residents who may have potential emergent conditions and situations when 911 should be contacted on a DNR resident such as choking, fall with head injury, suspected fractures, diabetic coma, acute stroke,[MEDICAL CONDITION], uncontrollable pain, chest pain and uncontrolled bleeding. Via direct observation, staff interviews, and record review, no other residents were identified as having an emergency condition. In order to monitor current DNR residents for potential risk, DON, and ADON will monitor DNR residents beginning [DATE]th, 2020 for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents who are DNR to ensure any emergent conditions such as Identifying situations when 911 should be contacted on a DNR resident such as choking, fall with head injury, suspected fractures, diabetic coma, acute stroke,[MEDICAL CONDITION], uncontrollable pain, chest pain and uncontrolled bleeding are managed appropriately. DON's compliance will be monitored weekly by RN F, for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of the Plan of Removal included: Review of the facility's in-service records revealed the facility nursing staff including CNAs, LVNs and RNs, had completed in-services, covering all shifts, for the following topics on [DATE] (24 staff) and [DATE] (23 staff), prior to working: -Emergency Response/Calling 911 -Choking residents/[MEDICATION NAME] Maneuver/CPR -Identifying situations when DNR patients do not require 911 to be contacted such as absence of vital signs or no signs of life -DNR -Always calling 911 during an emergency In an observation on [DATE] at 10:10 AM of the facility's four hallways, break room, dining room, and conference room revealed updated choking posters were posted. Review of the facility's Choking First Aid for Adults updated posting revealed instructions to contact 911 in an emergency. Interviews conducted on [DATE] from 8:15 AM to 4:30 PM with staff from all three shifts, including weekend staff, revealed staff were knowledgeable about situations in which 911should be contacted, such as choking, severe bleeding, falls with fractures, chest pains, and etc, regardless of code status. Staff were knowledgeable of when they did not have to contact 911, such as when a resident with a DNR was found unresponsive or did not have a pulse. Staff were able to identify where the choking posters were located in the facility and were able to demonstrate the [MEDICATION NAME] maneuver. The interviewed staff included: CNA H, LVN I, LVN D, LVN E, LVN J, CNA K, CNA L, LVN M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, RN T, CNA U, and the DON. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #22) of three residents reviewed for supervision. CNA A failed to ensure Resident #22 was provided the appropriate level of assistance and assistive devices during a transfer. Resident #22 fell and sustained a fracture to her left tibia and fibula. This failure had the potential to affect residents by resulting in pain and injury. Findings included: Review of Resident #22's face sheet dated 0[DATE] revealed that Resident #22 was a [AGE] year-old female that was admitted to the facility initially on 0[DATE] then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's Minimum Data Set (MDS) assessment dated [DATE] reflected a BI[CONDITION] (Brief Interview for Mental Status) score of thirteen (13) indicating intact cognition. The assessment also reflected a functional status for transfers at a three, indicating the resident required assistance with two or more people for activities of daily living. Review of Resident #22's undated Care Plan reflected, The Resident has an ADL Self Care Performance Deficit. The intervention/tasks for transfers reflected the resident required Mechanical Lift with 2 staff for transfers due to the resident's history of [MEDICAL CONDITION] disorder and for resident and staff safety. Review of a facility generated incident report for Resident #22, dated 0[DATE], reflected: Nursing Description: Patient yelling and crying. This nurse and staff nurse run to her room. Observed patient sitting. Resident description: patient crying loud not able to describe situation. CNA described patient leg gave up during transfer. Review of Resident #22's X-ray report dated 0[DATE] reflected, Impression, oblique [MEDICAL CONDITION] left tibia with displaced cortical fracture involving the medial distal tibia. (slanted [MEDICAL CONDITION], ankle-end of the tibia due to force with an accompanying bone-end, shifted fracture) Non-displaced [MEDICAL CONDITION] distal fibula. Review of a typed statement from CNA A dated 02/24/20 reflected, I was putting _ (Resident #22) in bed. _ (Resident #22) grabbed the side rail with her left hand, my right arm goes under her right arm, she counts to three and then pulls up with my assistance. Her right hand grabs a hold of the refrigerator and that allows me to pull her pants off of her. Then I grabbed under her right arm again and we pivot to bed. The arm rest was not up, where it normally is, I try to lift it up and __ (Resident #22) lost balance and I braced her fall. A telephone interview with CNA A, who no longer worked at the facility, was attempted on 02/27/20 at 3:15 PM. CNA A could not be reached. A message was left for her. Interview and observation of Resident #22 on 02/27/20 at 5:15 PM revealed that the resident was observed to have a cast to her left leg. The resident stated that she had just come from an appointment with the orthopedic doctor. She stated that they placed a new cast. She stated that she fell when a CNA attempted to transfer her by herself. She said normally it took two CNAs with a hoyer lift to transfer her, but CNA A tried to transfer her by herself. When asked if she knew why CNA A was transferred her by herself, Resident #22 stated, I don't know. She said no one else had done that. She stated staff had been using a hoyer lift. Interview with DON on 02/27/20 at 4:00 PM revealed that she was notified that Resident #22 had an assisted fall. They did an X-ray and it showed that the resident had a tibia and fibula fracture. The resident was sent to the hospital and came back with a cast to her leg. She stated that CNA A was terminated because the resident required a hoyer lift for transfers, but she attempted to transfer the resident by herself. In the process, the resident sustained [REDACTED]. The information was then given to the nurses who placed it in the resident's care plan. She stated that CNAs were expected to follow the resident's care plan for transfers. She stated that Resident #22 tended to refuse the hoyer lift, but the CNA was still expected to explain to the resident about the importance of using the hoyer lift. If the resident continued to refuse, the CNA should have notified the nurse. Interview with the ADM on 02/27/20 at 4:45 PM revealed that CNA A went against the resident's care plan that specified that the resident required a hoyer lift with all transfers. She stated that CNA A admitted that she tried to transfer the resident against the resident's care plan because she wanted to make the resident happy. She stated that Resident #22 always tried to get everyone not to use a hoyer lift, but since the incident the resident was compliant with the use of the hoyer lift. Review of the facility's policy on safe patient handling and moving protocol, revised on 07/18/18, revealed that the nursing staff will communicate immediately to nursing administration or rehab designee, any concerns that arise from current assigned level of assistance. The licensed nurse/therapist will reassess the resident's abilities and determine appropriate level of assistance required to minimize risk of injury to resident and staff .

Based on observation, interview and record review, the facility failed to ensure care was provided for residents in a manner and an environment, which maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for one (Resident #11) of 16 residents reviewed for dignity. On 02/16/2014, Resident #11 was required by the DON to undergo a "strip search" before being allowed to go on overnight leave to visit family members. Resident #11 felt "violated," like she was in "prison" and did not feel "safe or comfortable" with the DON. Resident #11 might leave the facility due to the incident. This failure resulted in Resident #11 feeling "violated" and like she was "in prison" and no longer "safe or comfortable" around the DON. This failure could affect any of the 80 residents at the facility who were leaving the facility having to undergo a "strip search," affecting their dignity and peace of mind and in violation of their residents' rights. Findings included: Resident #11 was a [AGE] year-old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. The face sheet also indicated Resident #11 was her own responsible party. Resident #11 attended the confidential group interview on 03/04/2014 at 4:00 PM. In response to a question regarding treatment from staff, Resident #11 stated she had recently been required to undress in front of the DON and RN D before being allowed to go on overnight leave to visit family members. Resident #11 gave permission for the surveyors to investigate this and interview staff members in regard to the situation described by Resident #11. During an interview on 03/05/14 at 11:30 AM, Resident #11 stated she was getting ready to go on overnight leave to visit a family member on 02/16/14. She stated another family member had come to pick her up to take her to a family member's house. She stated she was wheeling herself in her wheelchair down the 400 Hall in the facility and was about to leave when the DON stopped her and told her to go back to her room. Resident #11 stated she complied with this request and returned to her room. She stated the DON and RN D came into her room with her, and Resident #11's family member also came in. She stated the DON still did not explain what was going on, and the DON told her family member to leave the room. When Resident #11's family member did not leave the room, Resident #11 stated the DON stomped her foot and said to come get her when they were ready to cooperate and then started to leave the room. Resident #11 stated she followed the DON out of her room and told her it was okay for her family member to stay. She stated the DON then came back into her room and shut the door. She stated the DON told her she had to submit to a "full body symptom check" as this was a new policy all residents had to undergo before going on leave from the facility and after returning from leave. Resident #11 stated she had never had to do this before, and that she was confused and was not really sure what was going on. She stated the DON and RN D did not explain the purpose of this. Resident #11 stated she thought perhaps she had done something wrong. Resident #11 stated her family member explained to her they were looking for bruises or other injuries. Resident #11 stated she was not given a choice in the matter, as the DON termed the search "mandatory." Resident #11 stated she reluctantly submitted to the search, as she was wanting to leave and she felt the DON was not going to let her leave without undergoing the search as evidenced by the DON's "attitude" and "body language." Resident #11 stated the DON had her stand up from her wheelchair on her recently fractured ankle. During this interview, Resident #11's left ankle was observed to be in a walking boot. The DON told Resident #11 to take her shirt off. Resident #11 stated she took her shirt off. Resident #11 stated the DON then asked her to lift up her bra, and she also complied with this request. She stated the DON then told her to take her pants off. Resident #11 stated she was wearing leggings and pulled them down but was wearing no underwear. She stated that she had to stand there, on a fractured ankle with her leggings down and no underwear and only a bra on top while the DON and RN D looked at her body front and back. Resident #11 stated afterward, the DON told her to take her shoes and socks off so they could look at her feet, and she complied with this request. Resident #11 stated after all that, she was finally allowed to leave the facility. Resident #11 stated she returned to the facility from her family visit on 02/20/14 and was expecting to have to undergo another body search, but she never did. Resident #11 stated this made her question the validity of the policy and that she was not aware of any other residents who were searched in this manner prior to being allowed to go on leave. She stated the body search made her feel "violated" and like she was "in prison." She stated she became upset while undergoing the search and had cried. She stated it was a "detrimental kind of feeling." She stated she no longer felt "safe or comfortable" around the DON, and was considering moving out of the facility if the DON was not fired. She stated she was starting to get upset about it again, just talking about it for this interview. She stated she had no problems with RN D, as she felt RN D was just acting under orders from the DON. During a telephone interview with Resident #11's family member on 03/05/14 at 12:00 PM, she stated she had come to the facility to pick up Resident #11 a couple weeks prior to take her on overnight leave to their family member's house. She stated she could not remember the exact date but it was on a weekend and on the facility's sign-in/sign-out sheet, she had marked an asterisk next to the date of this incident. She stated she had been carrying some of Resident #11's belongings out to her truck for the visit when the DON approached her. She stated she did not know who this person was at the time, as the DON had recently been hired and the DON did not introduce herself. She stated the DON told her Resident #11 needed a physician's orders [REDACTED]. She also stated Resident #11 now had to undergo a "full body symptom check" prior to leaving overnight and after returning. She stated the DON told her the body checks were a new policy. She stated she was a rule-follower and wanted to adhere to the facility's policies, even though Resident #11 had never had to undergo this before when leaving the facility. She stated she went into Resident #11's room with Resident #11, the DON, and RN D. She stated the DON told her to leave, but she refused. She stated the DON then stomped her foot and told Resident #11 to let her know when she was ready to leave. She stated Resident #11 told the DON her family member could stay, and they then closed the door and proceeded with the body search. She stated the purpose of this search was never explained and Resident #11 was confused and did not know what was going on and thought that she might have been in trouble. She stated that Resident #11's eyes were "huge" and "full of tears." She stated she had to explain to Resident #11 they were looking for bruises or other body marks on her. She told Resident #11 the DON said this was a new policy and no one could now leave the building without being checked from head to toe. She stated that she (the family member) was not sure what to do at the time and was not sure what Resident #11's rights were in this situation. She decided to let Resident #11 be searched as she wanted to comply with the facility's policy and did not think they would be allowed to leave without undergoing the body search. She stated the DON told Resident #11 to take her shirt off, and she complied. She stated the DON then told Resident #11 to lift her bra up, and she did this as well. She stated she then told Resident #11 to take her pants off. She stated that Resident #11 complied with this request also but was wearing leggings and no underwear and Resident #11 had to stand in her room on her broken ankle with her leggings pulled down and no underwear and only a bra on top while the DON and RN #1 looked over her body front and back. She stated the DON then had Resident #11 take her shoes and socks off, and Resident #11 complied with this request. She stated Resident #11 was very upset during this body search and that she had "tears streaming down her face," and it felt like Resident #11 was "in prison." She stated they were allowed to leave after undergoing the search. She stated Resident #11 was not searched after returning from her family visit like she had been told she would be. She stated she called the ADM after Resident #11 had returned to ask about the policy for overnight leave. She stated the ADM transferred her to the SW, who was not aware of the policy requiring residents to undergo full body searches prior to leaving the facility. She stated she then spoke again with the ADM. After the ADM learned about the search, the ADM told her there was no such policy. She stated she filed a complaint with the facility's corporate complaint hotline, but she had not yet heard back from them. She stated she wanted to move Resident #11 to another facility. During an interview on 03/05/14 at 1:17 PM with the ADM and Corporate Nurse, the ADM stated Resident #11's family member had contacted her to inquire about the facility's policies for overnight leave for residents. The ADM stated it was a very general question and she transferred her to the SW. She stated the SW came back to her and said Resident #11's family member told her Resident #11 had been "strip searched" by the DON and RN D. The ADM stated they immediately suspended the DON and RN D and the ADM and the Corporate Nurse investigated the incident. The ADM stated the DON was informed there was no such policy, and residents could leave whenever they wanted, although it was ideal to have advance notice. She stated the DON had a legitimate reason for conducting the search. She stated Resident #11 had recently broken her ankle while on overnight leave from the facility and that they did not find out about the injury until after she returned. She stated the DON also had concerns about the facility being sued if Resident #11 had other unknown injuries, and she wanted to search her for any injuries prior to her leaving and she thought this was standard procedure. The Corporate Nurse stated searching residents before and after overnight outings was not facility policy, and the DON was informed this was not acceptable practice. She stated the DON was given a formal write-up and required to undergo one-on-one supervision with the Corporate Nurse. The Corporate Nurse stated she did not think the DON had any willful intention to harm Resident #11, but the search was conducted in a way, which was not "dignified" and violated Resident #11's resident rights and violated facility policy. The Corporate Nurse stated residents undergo weekly head-to-toe assessments but that they are conducted in a dignified way, with residents never being completely exposed and staff communicating with residents about the purpose and about what was going on throughout the assessment. The ADM stated she had followed up with Resident #11's family member and had also followed up with Resident #11; and Resident #11 had communicated to her she was "ok" now. The ADM and Corporate Nurse expressed surprise after being told Resident #11 had told surveyors she did not feel "safe" around the DON. In an interview on 03/05/14 at 2:48 PM, the DON stated she had required Resident #11 to undergo a "head-to-toe" assessment prior to going on overnight leave on 02/16/14, indicating to Resident #11 and Resident #11's family member it was facility policy. She stated she had RN D conduct the assessment and she (the DON) was just a "witness" to it, but that the assessment was conducted under her orders. The DON stated she thought this was standard procedure at all facilities. She stated it was the policy at a previous facility where she had worked. She stated her most recent job prior to this was at a psychiatric facility and patients there were routinely "strip searched" prior to and after overnight leave. The DON stated she wanted to protect the facility being sued. She stated she was informed by the ADM and Corporate Nurse it was not facility policy to body search residents before and after overnight leave. Asked about the actual search, the DON stated even though she called it a head-to-toe assessment, she really just wanted to look at Resident #11's arms and legs. She stated Resident #11 consented to the search, and Resident #11's family member was present at the request of Resident #11. She stated Resident #11 took her shirt off on her own with no prompting. The DON denied Resident #11 was asked to lift up her bra and stated she never lifted up her bra during the search. The DON denied Resident #11 was asked to take off her leggings and stated Resident #11 never pulled her leggings down. She stated Resident #11 rolled her leggings up so the DON and RN D could examine her legs. She stated Resident #11 was compliant with the search and had no problem with it, but Resident #11's family member "egged her on" and got her upset about it. The DON stated the body search was "harmless" and the resident was never completely exposed and only had her shirt off, because she decided to take it off herself. The DON stated Resident #11 and her now got along "fine," and that they went outside together every day to smoke. In an interview on 03/05/14 at 3:44 PM, RN D stated she was the weekend supervisor at the facility. She stated that on 02/1614, Resident #11 was preparing to go on overnight leave. She stated Resident #11 regularly went on overnight leave. For every overnight visit, they were required to complete discharge paperwork and then complete paperwork to "readmit" her to the facility. She stated she approached the DON and asked about creating a care plan for this situation, so they did not have to go through this process every week. She stated the DON approached her a short time later and did not mention anything about care planning for Resident #11's overnight visits, but instead stated they needed to conduct a full body assessment on Resident #11 before allowing her to leave. She stated the DON said this was a new policy. She stated she complied as the DON was her boss but felt this was an unusual order as residents were never required to undergo full body assessments prior to going on leave. She stated she went into Resident #11's bathroom to wash her hands and when she came out, Resident #11, Resident #11's family member, and the DON were standing in Resident #11's room. She stated Resident #11 was out of her wheelchair, standing on her broken ankle, and topless, wearing only a bra when she walked out of the bathroom. She stated neither she nor the DON explained to Resident #11 what was going on or what the purpose of this search was, and she realized they should have done that. She stated the DON told Resident #11 to lift up her bra, and she did. She stated Resident #11 then asked the DON if she needed to take off her leggings, and the DON told her "yes," as it was a "full body assessment." She stated Resident #11 put her shirt back on and then pulled down her leggings. She stated she could not recall if Resident #11 had any underwear on but believed she did. She stated the DON then told Resident #11 to take her socks and shoes off so they could examine her feet. RN D stated she offered and attempted to help Resident #11 with this request. She stated Resident #11 was compliant with the search and did not appear upset but Resident #11's family member appeared much more upset about it. She stated she thought the search was handled in a professional manner, other than one instance during which she said the DON told Resident #11's family member she needed four days notice prior to Resident #11 going on overnight leave. RN D stated she knew this was "wrong" and that residents could leave the facility whenever they wanted. In an interview on 03/06/14 at 11:40 AM, Resident #9 revealed she was Resident #11's roommate. She stated she was not present for Resident #11's body search, but she entered their room right after the search had been completed and had passed the DON and RN D in the hall outside their room. She stated Resident #11 appeared "distraught" and was "on the verge of tears." She stated Resident #11 told her she had been "strip searched" before being allowed to go on overnight leave and this was a new facility policy. Resident #9 stated she expressed concern that she and other residents would have to undergo a similar search prior to being allowed to leave the facility, and she did not want this to happen. Review of an unsigned, undated witness statement written by the DON reflected the following: The DON asked (RN D) to do a head to toe assessment on any resident going out of the facility. The DON was present to witness Resident #11's head to toe assessment. Resident #11 gave permission as well as her family member. It was explained to the resident and family member she was not being singled out but this was a new requirement for residents leaving the facility. This implementation was being followed in several facilities. The DON had shared this story with the nurses and they agreed they would rather be safe. The DON knew the majority of the family members and they know her. The DON would never want to think the resident's family members could harm the resident, but the DON felt it was just precautionary. A witness statement signed by Resident #11 on 02/20/14 reflected she was preparing to go out on overnight leave when the DON told her to go back to her room. She wrote that the DON "stomped her foot" when Resident #11's family member refused to leave the room and said, "When you're done, come and get me." Resident #11 wrote she convinced the DON to let her family member stay in the room with them. She wrote the DON closed the room door and told her to "take off your shirt. We're searching you." She wrote that the DON told her "We're doing this to everybody. You have to strip down when you leave and when you return," and it was a new facility policy and it did not matter even "if you're [AGE] years old." She wrote that the DON asked her to lift up her bra and take off her shoes and pants. She wrote that the DON and RN D looked her over "from front to back" and she "felt very violated, confused, and (her) anxiety went through the roof." She wrote she was "very upset about the situation" and was "emotionally distressed." She wrote she was not searched after returning to the facility from the family visit. A witness statement signed by Resident #9 on 02/20/14 reflected she returned to her room just after Resident #11 had undergone a body search. She wrote that Resident #11 "was very upset." She wrote she later asked the DON about this new policy and expressed her concerns about it, and the DON told her "they could make an allowance for (her)." A witness statement signed on 02/21/14 by Resident #11's family member reflected she went to pick up Resident #11 for overnight leave on 02/16/14. She wrote that when she arrived at the facility a staff member she did not recognize (later identified to be the DON) approached her and told her Resident #11 needed a physician's orders [REDACTED]. She wrote she later heard the DON say to RN D Resident #11 needed to undergo a "head to toe symptom check" prior to being allowed to leave. She wrote this had never happened before, and the DON told her this was a new policy. She wrote that the DON wanted her to leave the room during the body search but Resident #11 allowed her to stay. She wrote neither the DON nor RN D fully explained to Resident #11 what was going on, and Resident #11 appeared "distressed." She wrote the DON said residents would now have to be searched anytime they left the facility, even if just for a short outing. She stated she was not sure at the time if Resident #11 was required to submit to this but stated she was convinced the DON was not going to let her leave otherwise. She wrote Resident #11 reluctantly consented to the search and the DON then told Resident #11 to remove her shirt. She wrote Resident #11 was "frustrated and upset and shaking and confused and almost in tears." She wrote that RN D asked Resident #11 to stand up on her broken foot and asked her to lift her bra up. She wrote that the DON asked Resident #11 to take her pants off and she was then standing topless with her bra lifted up and her pants at her ankles, and she was not wearing any underwear. She wrote they let her put her clothes back on but then had her take her shoes and socks off as well as the walking boot on her broken foot. She wrote after the search concluded, Resident #11 began crying and said she was humiliated and felt like she was in prison. Review of a witness statement from RN D dated 02/21/14 reflected on 02/16/14 she approached the DON about writing a care plan for Resident #11's frequent overnight outings. She wrote that about 30 minutes after this, the DON told her she needed to do a head-to-toe assessment on Resident #11, and from now on, this needed to happen to all residents prior to leaving the facility. She wrote that she washed her hands in Resident #11's bathroom and when she stepped out, Resident #11 was standing in her room without a shirt on, along with the DON and Resident #11's family member. She stated the DON was standing behind Resident #11 at that time doing the assessment. She wrote that Resident #11 asked if she needed to take her pants off and the DON responded, "Yes, it's a full assessment." She wrote that after that, the DON had Resident #11 take off the walking boot from her broken foot. She wrote Resident #11 was "not crying or complaining" during the assessment. She wrote that the DON completed the assessment and she was only in the room because the DON asked her to come. Review of the Sign-In/Sign-Out Sheet for Resident #11 revealed Resident #11 was signed out of the facility on 02/16/14 by her family member, and there was an asterisk next to the date as indicated by Resident #11's family member. A social services note signed on 02/25/14 at 1:16 PM by the SW reflected Resident #11 "reported she continues to be upset about the incident that occurred on 2/16/14, when the resident was given a head-to-toe skin assessment." The note indicated Resident #11 was considering moving out of the facility due to the incident. Review of a disciplinary action record revealed the DON received a written reprimand for "failure to follow policy regarding residents going out on pass," and it was noted "there is no such policy" to search residents coming and going from the facility. Review of a payroll changes data entry form indicated the DON was suspended from 02/21/14 to 02/24/14. Review of in-service training reports indicated nursing staff received an in-service training on 02/24/14, which included different types of abuse, providing dignity and privacy to residents, obtaining consent from residents, and explaining procedures to residents. Review of the current policy on "Leaving the Health Care Center" included in the facility's undated Admissions Handbook reflected, "You may leave the Health Care Center with a family member or friend during the day provided you have prior permission from your doctor. For overnight or longer periods, permission must be obtained from your physician and proper insurance coverage checked beforehand. It is essential that you inform the charge nurse or supervisor whenever you are going to be leaving the premises, and it is also important that you notify her when you when you will be returning. The required procedure is to sign in and out at the nursing station when coming and going." Review of Resident #11's physician's orders [REDACTED].#11 "may go on pass with therapeutic medications." The facility's Resident Census and Conditions of Residents Form, CMS-672, completed and signed on 03/04/2014, reflected the facility had a census of 80 residents.

Based on interview record review and observation it was determined the facility failed to ensure residents were free of any significant medication errors for one resident (Resident #2) of 20 residents reviewed for medications. Staff failed to administer to Resident #2, who had T ,[DATE] Discitis with Osteo[DIAGNOSES REDACTED], her antibiotic at the rate ordered by the physician. This failure resulted in Resident #2 not receiving all of her antibiotic as ordered by her physician, which could result in the infection spreading up her spinal cord and into her brain or causing the bacteria to become antibiotic-resistant. Six IV bags of her antibiotic were in the Medication Room and were expired. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the two residents with PICC and central lines, including Resident #2, by placing them at risk for worsening infections and increased debility due to infection. Findings included: http://www.drugs.com/pro/[MEDICATION NAME].html reflected "...Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by [MEDICATION NAME] for Injection or other antibacterial drugs in the future...." (retrieved on [DATE]). Resident #2's Face Sheet, dated [DATE], reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Osteo[DIAGNOSES REDACTED] is an infection in the bones), [MEDICAL CONDITION], Hypertension, Chronic Pai[DIAGNOSES REDACTED], [MEDICAL CONDITION]. Resident #2's Resident Summary Admission, dated [DATE], reflected she admitted on that date with [MEDICATION NAME] (antibiotic) continuously at 20.8 cc/hr via PICC line in her left upper arm. The Summary also reflected she was cognitively intact, needed assistance with turning and repositioning every two hours. There was no Care Plan regarding Resident #2's PICC line or her need for antibiotics. Resident #2's physician's orders [REDACTED]. The formula to calculate the drops per minute to run at 20.8 cc/hr was the following: 20.8 cc/hr X 20 (drops per ml- found on IV tubing bag) / 60 min = 6.93 gtt/min, which would be rounded to 7 gtts/min An observation on [DATE] at 10:30 AM of the Medication Room with the facility's Clinical Nurse Consultant revealed six IV bags of [MEDICATION NAME] 4.5 gm/250 ml NS for Resident #2 on the counter. The prescription label on the IV bags reflected the medication was prepared on [DATE] and expired on [DATE]. Five more IV bags of [MEDICATION NAME] 4.5 gm./250 cc NS for Resident #2 were found in the refrigerator. These IV bags were prepared on [DATE] and would expire on [DATE]. An observation, on [DATE] at 9:10 AM, revealed Resident #2's IV [MEDICATION NAME] infusing into the resident's PICC line at between 1 and 2 drops per minute. The surveyor timed the drip rate using a cell phone stopwatch for 2 minutes. The prescription label on the [MEDICATION NAME] reflected 4.5 g in 250 ml NS at 20.8 ml continuously. The IV flow rate was controlled by a "Dial A Flow" (Dial A Flow, which is a brand name, is a regulator designed to control the infusion rate through gravity intravenous administration infusion sets. These regulators typically consist of a mechanism that regulates the flow using a calibrated dial that permits control of the flow rate in a given range) regulator. Drip rates are the amount of medicine that should pass through an IV to a patient over a given period of time. An interview with LVN A on [DATE] at 11:00 AM revealed when asked how he determined how fast Resident #2's [MEDICATION NAME] IV was infusing, he replied, "(Resident #2) had a pump for the first week or so, but it kept alarming. Someone took it (the pump) off and put on a 'Dial A Flow.' I set the 'Dial A Flow' to 21 ml (cc)/hr. I don't have to count the drops because its gravity flow." LVN A was asked to calculate the drip rate per minute for the [MEDICATION NAME] and the surveyor handed him Resident #2's [MEDICATION NAME] IV bag. The prescription label on the IV bag reflected the rate was 20.8 cc/hr. Handwritten on the label was + 22.5 ml, which was the amount of fluid that was added to the IV bag. LVN A wrote the formula for calculating the drip rate on note paper and gave it to the surveyor. The formula performed by LVN A was as follows: 22.5 x 20 = 450 gtts (drops) ,[DATE] = 7.5 gtts/min LVN A stated, "The rate of 7.5 gtts/min would result in the doctor's ordered rate of 20.8 cc/hr." LVN A again stated he did not have to count the drops because the medication was given with a rate controller. While LVN A had the right formula for calculation, he had the wrong rate (he used 22.5 not 20.8 cc/hr). LVN A obtained the 22.5 cc/hr from the prescription label. An interview on [DATE] at 12:00 PM with facility's contracted pharmacist via telephone revealed 6 IV bags of Resident #2's [MEDICATION NAME] were sent on [DATE] and another 6 IV bags of [MEDICATION NAME] were sent on [DATE]. He stated 6 bags were needed every three days. When asked about an IV pump, the pharmacist replied a pump was sent to the facility on [DATE] with the first order. He stated IV pump tubing was sent as part of the order. The Pharmacist was not aware the IV pump was not functioning. When asked if he sent a "Dial A Flow" tubing was sent as part of the order, he replied, "No." He revealed he did not know there was a "Dial A Flow" controlling her IV rate. The DON, who was present during the interview, requested the pharmacy to send another pump as quickly as possible. An observation on [DATE] at 8:50 AM revealed Resident #2's IV [MEDICATION NAME] was infusing into the PICC line via "Dial A Flow" at three drops per minute. The surveyor observed the drip rate using a cell phone stop watch for a full minute. The "Dial A Flow" was set to 20 cc/hr. An observation on [DATE] at 10:00 AM revealed Resident #2 resting in her bed with her IV of [MEDICATION NAME] through her PICC line with a Dial-a-flow controller set between 20 ml/hr and 30 ml/hr. The IV prescription label reflected [MEDICATION NAME] 4.5 g in 250 ml NS at 20.8 cc/hr continuously. The IV [MEDICATION NAME] was observed to be infusing at three drops per minute and was timed using the cell phone stop watch for a full minute. An interview with LVN K, on [DATE] at 1:00 PM revealed when asked what her initials on Resident #2's [DATE] MAR meant, LVN K replied, "That means this antibiotic was running at this rate." LVN K pointed to the order which reflected [MEDICATION NAME] 4.5 gm/ 250 ML NS IV at 20.8 cc/hr continuously. The surveyor asked LVN K to calculate Resident #2's drip rate for her IV and provided a piece of paper and pencil to the LVN. LVN K did not attempt to calculate the drip rate. When asked if she verified the administration rate of Resident #2's IV when she assessed the IV site, LVN K replied, "Yes, I verify the rate with a 'Dial A Flow'. I set the Dial A Flow' to 21 and then it is calibrated." The facility's current policy, "Medication Administration" effective February 2013 reflected the following procedure for calculating drops per minute using the hourly rate: (Hourly rate)(Drop factor)/time in minutes or (ml)(gtts)(1 hour)/60 minutes = gtts/minute. The facility's undated list of of LVNs reflected 25 LVNs working in the facility full-time, part-time, and as needed. The LVNs' personnel files reflected of the 25 LVNs only six LVNs had their Central Line IV training and competency checks. LVN A's personnel file did not reflect Central Line training and competency checks. The facility's In-Service Training records from [DATE] to [DATE] did not reflect training for LVNs on the management of IVs. The records were provided by the DON as the most current and complete. An IJ was identified on [DATE]. The Administrator, DON, and Clinic Nurse Consultant were notified of the IJ on [DATE] at 2:20 PM, and a Plan of Removal was requested at that time. During an interview on [DATE] at 2:30 PM the DON was asked what type of procedures were in place to make sure the nursing needs of residents were being met. The DON stated, "We have training and in-services to train nurses for IV use. No one (staff) has done an in-service since last year." When asked how she ensured nurses were competent in their skills to care for residents with IVs, central lines, and PICC lines, she replied she had not done any return demonstrations or competency checklists for the nurses. The DON stated they were trained by a local company. She revealed she was going to start competency check-offs soon. When asked if there had been any in-services on IV therapy since admitting residents with PICC lines and central lines, she answered, "Not recently." When the DON was asked how she thought the IJ occurred, she replied, "I don't know." During an interview on [DATE] at 2:30 PM the Administrator was asked what types of procedures were in place to ensure the nursing needs of residents were being met. The Administrator replied he used a combination of systems. He stated, "We use nursing reports daily. We have 24-hour report systems, and nurses use shift to shift reports, I reply on the constant oral reports of the staff, and I have good communication with the residents and families I also use personal observation." When asked how he monitored his staff to ensure the systems they were responsible for met the needs of residents, he replied, "I rely on the Corporate Nurse Consultants with their knowledge of the systems to help us. I also use personal observation." When asked what factors he thought contributed to the situation and how the IJ developed, the Administrator replied, "I think I have no idea at the moment but your investigation will show the contributing factors." An interview with the Medical Director, who was also Resident #2's attending physician, on [DATE] at 12:35 PM revealed he was informed of the IJ and the significant medication error. The Medical Director stated he was informed that day ([DATE]) at the QA meeting. When asked if he knew how many nurses in the facility were IV trained, he replied, "I just came to know during the QA meeting this morning that only six nurses were IV certified for central lines and PICCs. I feel the facility should have some experienced nurses and they should know how to calculate drip rates and make sure residents are getting their medications." When asked if he had seen an IV pump in Resident #2's room, he replied he could not recall. When asked if he was aware the nurses could not calculate drip rates of IVs and were not IV certified, the Medical Director answered he was notified during the QA meeting that day. He revealed, "I depend on the DON to do these things. We are not trained in medical school to calculate drip rates." When asked if the significant medication error would harm Resident #2, the Medical Director replied he had spoken to the surgeon and the Infectious Diseases physician, and "The resident had been receiving the IV for all about 10 weeks. We are not sure yet but we might give her extra days of antibiotics. Missing these doses should be okay because she's already had it for 10 weeks. I see her one to two times a week. I never noticed a pump in her room." The Plan of Removal was accepted on [DATE] and reflected: Resident specific: IV orders for Resident #2 were clarified by the DON and physician at 4:00 PM on [DATE]. The flow rate was set at 21. A new IV pump arrived on [DATE] at 4:45 PM and was applied by an RN to ensure Resident #2 received the correct amount of antibiotic. The IV was functioning as ordered and would be monitored by an RN on her shift, LVNs on the night shift and, the day shift tomorrow. These LVNs had the required PICC line certification. The DON supervised the shifts. Resident #2 was notified by the DON at 7:35 PM on [DATE] the flow rate was not administered as ordered. The resident's family member was notified by the DON via telephone on [DATE] at 8:00 PM. Physician notification occurred at 4:00 PM on [DATE] by the DON. A Medication Error Report was completed by the DON on [DATE]. System: An audit conducted by the DON on [DATE] at 6:00 PM revealed Resident #12 also had an IV. An RN reviewed the resident's IV order and the IV was functioning appropriately. Resident #12 had a Mediport IV. In services have been and will be given to each nurse before being allowed to care for a resident with an IV, then they will have the competency test and go through skills check-offs by return demonstration and successfully passed before they can care for a resident with an IV. If the staff member fails any of these tests, they will be allowed to retake the test a second time. If a staff member failed the second time, they will be required to take the class again. The DON will be notified to ensure the staff member did not work on the floor until they have successfully passed the skills competency test. First in-service was given on [DATE] at 3:00 PM, the next in-service was held on [DATE] at 10:00 PM, the third in-service was held on [DATE] at 6:00 AM. Information given by the DON and the topic was IV administration, management and pump operation. In-service was held on [DATE] at 10:00 PM was an IV refresher course conducted by an outside company. The information for the IV refresher courses was included and was in the form of the skills checklist. An IV certification class was being conducted by the outside company on [DATE] at 9:30 AM and ongoing for all nurses, who have been identified as not already having picc certification. Lists of staff members who were scheduled to take the class have been provided. Staffing had been and will be modified to ensure qualified coverage on the floor while others were in the class. Only one staff member had a schedule change to be in the class. Until all nurses were certified, administration would assure only nurses with IV certification care for residents with IVs. All RNs, LVNs, the DON and a weekend supervisor would complete IV certification. Then they will have the competency test and go through the skills check-off by return demonstration and successfully pass before they could care for a resident with an IV. If the staff member failed any of the testing, the staff member would be allowed to take the test a second time. If the staff member failed the second time, they would be required to take the class again. The DON would be notified to ensure the staff member did not work on the floor until they had successfully passed the skills and competency test. Return demonstrations would be completed by the director of nursing for the outside education group. All licensed staff would be certified by [DATE] except two staff members who were on vacation out of the country. All staff would have the competency test and would go through skills check-off by return demonstration and successfully pass before they can care for a resident with an IV Nurse's Notes documentation would now include indication of time and day for each new IV bag that was started. In-service was held for this issue on [DATE] at 8:15 PM and is ongoing until all licensed staff have received this information. In services will be concluded by 3:00 PM on [DATE]. In-service was conducted by the DON. Monitoring of the documentation will be done by the DON, and weekend supervisor on a continuing basis by reviewing the IV documentation weekly to assure compliance. No staff member would be allowed to care for a resident with IVs until in-serviced. Annual skills checks would be given to assess the licensed staff's IV skills. Monitoring: IV operation will be monitored on a daily basis during the facility's morning routine which will include observation of the IV and accuracy of flow rate by the DON, ADONs, and weekend supervisor. Continuous observation of the IV would be conducted by IV certified staff. Review of the IVs would be included in the morning meeting. IV operation would be monitored on a weekly basis by the DON or ADONs by auditing the clinical record and observation of the IVs for operation and accuracy of flow rate. Caring for and administering IV medications to residents who have picc lines would only be done by LVNs and RNs who had certifications for picc line care. Licensed staff would have skills checks on an annual basis, and the DON would be responsible. Newly hired licensed staff would be be picc line certified prior to caring for residents with IVs. The DON would be responsible. Any and all problems in the operation of the IV would be reviewed by the QA committee either by special session or during normal quarterly sessions. Problems and incidents that occurred with the IVs would be documented in the incident log system and be reviewed during the normal QA meeting when the IV section was reviewed. Direction from the QA committee would then be put into plans and delivered to the staff via in-service and monitored. On [DATE] at 12:00 PM, a special session was held by the QA committee to approve Plan of Removal. The committee included the Medical Directors, Administrator, DON, a DON, and all Department Heads and consultants. An observation on [DATE] at 7:45 AM revealed Resident #2's [MEDICATION NAME] was infusing through her PICC line at 22 cc/hr via a pump. Resident #2's Nurse's Notes Late Note dated [DATE] and timed at 4:45 PM reflected the resident's antibiotic was hung via pump at 21 cc/hr. Resident #2's Nurse's Notes dated [DATE] and timed at 2:30 AM reflected the resident's antibiotic was running continuously at 21 cc/hr with no problems. Of the 19 LVNs, who did not have PICC line training, three were certified in PICC lines prior to exit. The IJ was removed on [DATE] at 5:30 PM. The Administrator, the DON, and the Clinical Nurse Consultant were notified at that time the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. An observation on [DATE] at 9:10 AM revealed Resident #2 had a PICC line. An observation on [DATE] at 10:00 AM revealed Resident #12 had a Mediport in her left upper chest area.

Based on observation, interview, and record review, the facility failed to provide pharmacy services, including procedures that assure the accurate receiving, dispensing, administering, and disposition of all drugs, to meet the needs of each resident for six (Residents #2, #3, #18, #19, #24, and #26) of 33 residents reviewed for medications. 1. LVNs A and K failed to calculate Resident #2's IV antibiotic drip rate accurately. These failures resulted in Resident #2 not receiving her IV antibiotic as ordered by the physician. Her IV was running too slowly. An IJ was identified on 03/20/13. While the IJ was removed on 03/22/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the two residents with PICC and central lines, including Resident #2, by placing them at risk for worsening infections and and increased debility due to infection. Non-IJ 2. The facility failed to destroy the following residents' expired IV antibiotics: Residents #3, #18, #19, and #24. 3. The facility failed to destroy Resident #26's 10 vials of Haldol injectable, when the resident was discharged on [DATE]. 4. The facility failed to keep the medications, which needed to be destroyed, including expired medications, separate from residents' current medications. 5. The facility failed to store personal items and broken oxygen concentrators in a room other than the Medication Room. These failures could affect all 91 residents by placing them at risk for receiving medications which were expired, and receiving the wrong medication. Findings included: 1. http://www.drugs.com/pro/nafcillin.html reflected "...Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by Nafcillin for Injection or other antibacterial drugs in the future...." (retrieved on 04/05/13). 3. Resident #2's Face Sheet, dated 03/03/13, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Osteo[DIAGNOSES REDACTED] is an infection in the bones), [DIAGNOSES REDACTED], Hypertension, Chronic Pai[DIAGNOSES REDACTED], Deep Vein Thrombosis. Resident #2's Resident Summary Admission, dated 02/26/13, reflected she admitted on that date with Nafcillin (antibiotic) continuously at 20.8 cc/hr via PICC line in her left upper arm. The Summary also reflected she was cognitively intact, needed assistance with turning and repositioning every two hours. There was no Care Plan regarding Resident #2's PICC line or her need for antibiotics. Resident #2's physician's orders [REDACTED]. The formula to calculate the drops per minute to run at 20.8 cc/hr was the following: 20.8 cc/hr X 20 (drops per ml- found on IV tubing bag) / 60 min = 6.93 gtt/min, which would be rounded to 7 gtts/min An observation on 03/20/13 at 10:30 AM of the Medication Room with the facility's Clinical Nurse Consultant revealed six IV bags of Nafcillin 4.5 gm/250 ml NS for Resident #2 on the counter. The prescription label on the IV bags reflected the medication was prepared on 03/15/13 and expired on 03/19/13. Five more IV bags of Nafcillin 4.5 gm./250 cc NS for Resident #2 were found in the refrigerator. These IV bags were prepared on 03/18/13 and would expire on 03/21/13. An observation, on 03/19/13 at 9:10 AM, revealed Resident #2's IV Nafcillin infusing into the resident's PICC line at between 1 and 2 drops per minute. The surveyor timed the drip rate using a cell phone stopwatch for 2 minutes. The prescription label on the Nafcillin reflected 4.5 g in 250 ml NS at 20.8 ml continuously. The IV flow rate was controlled by a "Dial A Flow" (Dial A Flow, which is a brand name, is a regulator designed to control the infusion rate through gravity intravenous administration infusion sets. These regulators typically consist of a mechanism that regulates the flow using a calibrated dial that permits control of the flow rate in a given range) regulator. Drip rates are the amount of medicine that should pass through an IV to a patient over a given period of time. An interview with LVN A on 03/20/13 at 11:00 AM revealed when asked how he determined how fast Resident #2's Nafcillin IV was infusing, he replied, "(Resident #2) had a pump for the first week or so, but it kept alarming. Someone took it (the pump) off and put on a 'Dial A Flow.' I set the 'Dial A Flow' to 21 ml (cc)/hr. I don't have to count the drops because its gravity flow." LVN A was asked to calculate the drip rate per minute for the Nafcillin and the surveyor handed him Resident #2's Nafcillin IV bag. The prescription label on the IV bag reflected the rate was 20.8 cc/hr. Handwritten on the label was + 22.5 ml, which was the amount of fluid that was added to the IV bag. LVN A wrote the formula for calculating the drip rate on note paper and gave it to the surveyor. The formula performed by LVN A was as follows: 22.5 x 20 = 450 gtts (drops) 450/60 = 7.5 gtts/min LVN A stated, "The rate of 7.5 gtts/min would result in the doctor's ordered rate of 20.8 cc/hr." LVN A again stated he did not have to count the drops because the medication was given with a rate controller. While LVN A had the right formula for calculation, he had the wrong rate (he used 22.5 not 20.8 cc/hr). LVN A obtained the 22.5 cc/hr from the prescription label. An interview on 03/20/13 at 12:00 PM with facility's contracted pharmacist via telephone revealed 6 IV bags of Resident #2's Nafcillin were sent on 03/15/13 and another 6 IV bags of Nafcillin were sent on 03/18/13. He stated 6 bags were needed every three days. When asked about an IV pump, the pharmacist replied a pump was sent to the facility on [DATE] with the first order. He stated IV pump tubing was sent as part of the order. The Pharmacist was not aware the IV pump was not functioning. When asked if he sent a "Dial A Flow" tubing was sent as part of the order, he replied, "No." He revealed he did not know there was a "Dial A Flow" controlling her IV rate. The DON, who was present during the interview, requested the pharmacy to send another pump as quickly as possible. An observation on 03/20/13 at 8:50 AM revealed Resident #2's IV Nafcillin was infusing into the PICC line via "Dial A Flow" at three drops per minute. The surveyor observed the drip rate using a cell phone stop watch for a full minute. The "Dial A Flow" was set to 20 cc/hr. An observation on 03/20/13 at 10:00 AM revealed Resident #2 resting in her bed with her IV of Nafcillin through her PICC line with a Dial-a-flow controller set between 20 ml/hr and 30 ml/hr. The IV prescription label reflected Nafcillin 4.5 g in 250 ml NS at 20.8 cc/hr continuously. The IV Nafcillin was observed to be infusing at three drops per minute and was timed using the cell phone stop watch for a full minute. An interview with LVN K, on 03/21/13 at 1:00 PM, revealed when asked what her initials on Resident #2's March 2013 MAR meant, LVN K replied, "That means this antibiotic was running at this rate." LVN K pointed to the order which reflected Nafcillin 4.5 gm/ 250 ML NS IV at 20.8 cc/hr continuously. The surveyor asked LVN K to calculate Resident #2's drip rate for her IV and provided a piece of paper and pencil to the LVN. LVN K did not attempt to calculate the drip rate. When asked if she verified the administration rate of Resident #2's IV when she assessed the IV site, LVN K replied, "Yes, I verify the rate with a 'Dial A Flow'. I set the Dial A Flow' to 21 and then it is calibrated." The facility's current policy, "Medication Administration" effective February 2013 reflected the following procedure for calculating drops per minute using the hourly rate: (Hourly rate)(Drop factor)/time in minutes or (ml)(gtts)(1 hour)/60 minutes = gtts/minute. An IJ was identified on 03/20/13. The Administrator, DON, and Clinic Nurse Consultant were notified of the IJ on 03/20/13 at 2:20 PM, and a Plan of Removal was requested at that time. During an interview on 03/20/13 at 2:30 PM the DON was asked what type of procedures were in place to make sure the nursing needs of residents were being met. The DON stated, "We have training and in-services to train nurses for IV use. No one (staff) has done an in-service since last year." When asked how she ensured nurses were competent in their skills to care for residents with IVs, central lines, and PICC lines, she replied she had not done any return demonstrations or competency checklists for the nurses. The DON stated they were trained by a local company. She revealed she was going to start competency check-offs soon. When asked if there had been any in-services on IV therapy since admitting residents with PICC lines and central lines, she answered, "Not recently." When the DON was asked how she thought the IJ occurred, she replied, "I don't know." During an interview on 03/20/13 at 2:30 PM the Administrator was asked what types of procedures were in place to ensure the nursing needs of residents were being met. The Administrator replied he used a combination of systems. He stated, "We use nursing reports daily. We have 24-hour report systems, and nurses use shift to shift reports, I reply on the constant oral reports of the staff, and I have good communication with the residents and families I also use personal observation." When asked how he monitored his staff to ensure the systems they were responsible for met the needs of residents, he replied, "I rely on the Corporate Nurse Consultants with their knowledge of the systems to help us. I also use personal observation." When asked what factors he thought contributed to the situation and how the IJ developed, the Administrator replied, "I think I have no idea at the moment but your investigation will show the contributing factors." An interview with the Medical Director, who was also Resident #2's attending physician, on 03/21/13 at 12:35 PM revealed he was informed of the IJ and the significant medication error. The Medical Director stated he was informed that day (03/21/13) at the QA meeting. When asked if he knew how many nurses in the facility were IV trained, he replied, "I just came to know during the QA meeting this morning that only six nurses were IV certified for central lines and PICCs. I feel the facility should have some experienced nurses and they should know how to calculate drip rates and make sure residents are getting their medications." When asked if he had seen an IV pump in Resident #2's room, he replied he could not recall. When asked if he was aware the nurses could not calculate drip rates of IVs and were not IV certified, the Medical Director answered he was notified during the QA meeting that day. He revealed, "I depend on the DON to do these things. We are not trained in medical school to calculate drip rates." When asked if the significant medication error would harm Resident #2, the Medical Director replied he had spoken to the surgeon and the Infectious Diseases physician, and "The resident had been receiving the IV for all about 10 weeks. We are not sure yet but we might give her extra days of antibiotics. Missing these doses should be okay because she's already had it for 10 weeks. I see her one to two times a week. I never noticed a pump in her room." The plan of removal of the IJ concerning an IV administration was accepted on 03/21/12 and reflected: Resident specific: IV orders for Resident #2 were clarified by the DON and physician at 4:00 PM on 03/20/13. The flow rate was set at 21. A new IV pump arrived on 03/20/13 at 4:45 PM and was applied by an RN to ensure Resident #2 received the correct amount of antibiotic. The IV was functioning as ordered and would be monitored by an RN on her shift, LVNs on the night shift and, the day shift tomorrow. These LVNs had the required PICC line certification. The DON supervised the shifts. Resident #2 was notified by the DON at 7:35 PM on 03/20/13 the flow rate was not administered as ordered. The resident's family member was notified by the DON via telephone on 03/20/13 at 8:00 PM. Physician notification occurred at 4:00 PM on 03/20/13 by the DON. A Medication Error Report was completed by the DON on 03/20/13. System: An audit conducted by the DON on 03/20/13 at 6:00 PM revealed Resident #12 also had an IV. An RN reviewed the resident's IV order and the IV was functioning appropriately. Resident #12 had a Mediport IV. In services have been and will be given to each nurse before being allowed to care for a resident with an IV, then they will have the competency test and go through skills check-offs by return demonstration and successfully passed before they can care for a resident with an IV. If the staff member fails any of these tests, they will be allowed to retake the test a second time. If a staff member failed the second time, they will be required to take the class again. The DON will be notified to ensure the staff member did not work on the floor until they have successfully passed the skills competency test. First in-service was given on 03/20/13 at 3:00 PM, the next in-service was held on 03/20/13 at 10:00 PM, the third in-service was held on 03/21/13 at 6:00 AM. Information given by the DON and the topic was IV administration, management and pump operation. In-service was held on 03/20/13 at 10:00 PM was an IV refresher course conducted by an outside company. The information for the IV refresher courses was included and was in the form of the skills checklist. An IV certification class was being conducted by the outside company on 03/21/13 at 9:30 AM and ongoing for all nurses, who have been identified as not already having picc certification. Lists of staff members who were scheduled to take the class have been provided. Staffing had been and will be modified to ensure qualified coverage on the floor while others were in the class. Only one staff member had a schedule change to be in the class. Until all nurses were certified, administration would assure only nurses with IV certification care for residents with IVs. All RNs, LVNs, the DON and a weekend supervisor would complete IV certification. Then they will have the competency test and go through the skills check-off by return demonstration and successfully pass before they could care for a resident with an IV. If the staff member failed any of the testing, the staff member would be allowed to take the test a second time. If the staff member failed the second time, they would be required to take the class again. The DON would be notified to ensure the staff member did not work on the floor until they had successfully passed the skills and competency test. Return demonstrations would be completed by the director of nursing for the outside education group. All licensed staff would be certified by 03/24/13 except two staff members who were on vacation out of the country. All staff would have the competency test and would go through skills check-off by return demonstration and successfully pass before they can care for a resident with an IV Nurse's Notes documentation would now include indication of time and day for each new IV bag that was started. In-service was held for this issue on 03/24/13 at 8:15 PM and is ongoing until all licensed staff have received this information. In services will be concluded by 3:00 PM on 03/24/13. In-service was conducted by the DON. Monitoring of the documentation will be done by the DON, and weekend supervisor on a continuing basis by reviewing the IV documentation weekly to assure compliance. No staff member would be allowed to care for a resident with IVs until in-serviced. Annual skills checks would be given to assess the licensed staff's IV skills. Monitoring: IV operation will be monitored on a daily basis during the facility's morning routine which will include observation of the IV and accuracy of flow rate by the DON, ADONs, and weekend supervisor. Continuous observation of the IV would be conducted by IV certified staff. Review of the IVs would be included in the morning meeting. IV operation would be monitored on a weekly basis by the DON or ADONs by auditing the clinical record and observation of the IVs for operation and accuracy of flow rate. Caring for and administering IV medications to residents who have picc lines would only be done by LVNs and RNs who had certifications for picc line care. Licensed staff would have skills checks on an annual basis, and the DON would be responsible. Newly hired licensed staff would be be picc line certified prior to caring for residents with IVs. The DON would be responsible. Any and all problems in the operation of the IV would be reviewed by the QA committee either by special session or during normal quarterly sessions. Problems and incidents that occurred with the IVs would be documented in the incident log system and be reviewed during the normal QA meeting when the IV section was reviewed. Direction from the QA committee would then be put into plans and delivered to the staff via in-service and monitored. On 03/21/13 at 12:00 PM, a special session was held by the QA committee to approve Plan of Removal. The committee included the Medical Directors, Administrator, DON, a DON, and all Department Heads and consultants. An observation on 03/21/13 at 7:45 AM revealed Resident #2's Nafcillin was infusing through her PICC line at 22 cc/hr via a pump. Resident #2's Nurse's Notes Late Note dated 03/20/13 and timed at 4:45 PM reflected the resident's antibiotic was hung via pump at 21 cc/hr. Resident #2's Nurse's Notes dated 03/21/13 and timed at 2:30 AM reflected the resident's antibiotic was running continuously at 21 cc/hr with no problems. Of the 19 LVNs, who did not have PICC line training, three were certified in PICC lines prior to exit. The IJ was removed on 03/22/13 at 5:30 PM. The Administrator, the DON, and the Clinical Nurse Consultant were notified at that time the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. An observation on 03/19/13 at 9:10 AM revealed Resident #2 had a PICC line. An observation on 03/20/13 at 10:00 AM revealed Resident #12 had a Mediport in her left upper chest area. Non-IJ Findings: 2. An observation of the facility's only Medication Room on 03/20/13 at 10:30 AM with the DON and the Clinical Nurse Consultant revealed personal items were stored on the floor, medications were all over the shelves, and bins in the room. The bins and shelves were not labeled. Clean utility supplies, IV tubing, dressing supplies, IV medication bags, and some tube feeding containers were piled on the shelves and in the bins. The facility's Emergency Kit was opened and had opened empty plastic packages and some empty saline for injection vials on the lid. A large re-sealable plastic bag, with IVs, was on the counter. There were two large, opened, cardboard boxes, with medication bottles and boxes of medications, in the middle of the floor. It was difficult to determine if the medications were new or if they were discarded medications. Two oxygen concentrators, with a sign which reflected they were not working, were stored in the room. One suit case, a black plastic trash bag with two portable oxygen tanks, a wrist brace, two pairs of trousers, two blouses, a pair of eye glasses, and shoes were also stored in the Medication Room. An interview with the Clinical Nurse Consultant at the time of the observation on 03/20/13 at 10:30 AM revealed, "I don't know why these are stored this way." An interview with the DON at the time of the observation on 03/20/13 at 10:30 AM revealed, "All the discontinued medications are supposed to go in the white box. There were no more white boxes, so we used this box." The DON pointed to one of the opened cardboard boxes with medications. When asked who was responsible for maintaining the Medication Room, the DON replied the nurses were supposed to take care of it. The DON stated the last drug destruction was 02/19/13. 3. Resident #3's one dose of IV Ceftriaxone (antibiotic) 1 gm NS, which expired on 01/20/12, was still in the Medication Room. 4. Resident #18's one dose of Vancomycin (antibiotic) 1.5 gm/500 ml, which expired on 07/10/12, and one dose of Vancomycin 1.25 gm in 250 cc NS, which expired on 07/31/12 were in the Medication Room. 5. Resident #19's one dose of Vancomycin 1 gm in 250 ml, which expired on 08/16/12, and one dose of Vancomycin 1.5/ 250 ml, which expired on 08/10/12 was in the Medication Room. 6. Resident # 24's Vancomycin 1 gm/ in 250 ml NS, which expired on 09/06/12, was still in the Medication Room. Resident #24's Face Sheet dated 03/21/13 reflected the resident was discharged home on[DATE]. 7. Resident #26's 10 vials of Haldol 5 mg /ml for injection were stored in a bin with IV medications for other residents. Resident #26's Face Sheet dated 03/22/13 reflected the resident was discharged home on[DATE]. 8. The facility's Form CMS-672, Resident Census and Conditions of Residents, signed by the DON and dated 03/19/13, reflected a census of 91 residents.

Based on interview and record review, it was determined the facility was not administered 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 one resident (Resident #2) of two residents reviewed for IV therapy. 1. The Administrator failed to supervise the DON to ensure nursing services were provided in a manner to promote the overall well-being of residents who received IV therapy services. 2. The DON failed to train LVNs to be competent in PICC line and other Central Line IV therapy care and services. Staff failed to administer to Resident #2, who had T ,[DATE] Discitis with Osteo[DIAGNOSES REDACTED], her antibiotic at the rate ordered by the physician, which resulted in the resident not receiving all of her antibiotic as ordered by her physician, which could result in the infection spreading up her spinal cord and into her brain. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the two residents, including Resident #2, who had Central lines, by placing them at risk for worsening infections, antibiotic resistant infections and debility due to infection. Findings included: http://www.drugs.com/pro/[MEDICATION NAME].html reflected "...Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by [MEDICATION NAME] for Injection or other antibacterial drugs in the future...." (retrieved on [DATE]). Resident #2's Face Sheet, dated [DATE], reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Osteo[DIAGNOSES REDACTED] is an infection in the bones), [MEDICAL CONDITION], Hypertension, Chronic Pai[DIAGNOSES REDACTED], [MEDICAL CONDITION]. Resident #2's physician's orders [REDACTED]. The formula to calculate the drops per minute to run at 20.8 cc/hr was the following: 20.8 cc/hr X 20 (drops per ml- found on IV tubing bag) / 60 min = 6.93 gtt/min, which would be rounded to 7 gtts/min An observation on [DATE] at 10:30 AM of the Medication Room with the facility's Clinical Nurse Consultant revealed six IV bags of [MEDICATION NAME] 4.5 gm/250 ml NS for Resident #2 on the counter. The prescription label on the IV bags reflected the medication was prepared on [DATE] and expired on [DATE]. Five more IV bags of [MEDICATION NAME] 4.5 gm./250 cc NS for Resident #2 were found in the refrigerator. These IV bags were prepared on [DATE] and would expire on [DATE]. An observation, on [DATE] at 9:10 AM, revealed Resident #2's IV [MEDICATION NAME] infusing into the resident's PICC line at between 1 and 2 drops per minute. The surveyor timed the drip rate using a cell phone stopwatch for 2 minutes. The prescription label on the [MEDICATION NAME] reflected 4.5 g in 250 ml NS at 20.8 ml continuously. The IV flow rate was controlled by a "Dial A Flow" (Dial A Flow, which is a brand name, is a regulator designed to control the infusion rate through gravity intravenous administration infusion sets. These regulators typically consist of a mechanism that regulates the flow using a calibrated dial that permits control of the flow rate in a given range) regulator. Drip rates are the amount of medicine that should pass through an IV to a patient over a given period of time. An interview with LVN A on [DATE] at 11:00 AM revealed when asked how he determined how fast Resident #2's [MEDICATION NAME] IV was infusing, he replied, "(Resident #2) had a pump for the first week or so, but it kept alarming. Someone took it (the pump) off and put on a 'Dial A Flow.' I set the 'Dial A Flow' to 21 ml (cc)/hr. I don't have to count the drops because its gravity flow." LVN A was asked to calculate the drip rate per minute for the [MEDICATION NAME] and the surveyor handed him Resident #2's [MEDICATION NAME] IV bag. The prescription label on the IV bag reflected the rate was 20.8 cc/hr. Handwritten on the label was + 22.5 ml, which was the amount of fluid that was added to the IV bag. LVN A wrote the formula for calculating the drip rate on note paper and gave it to the surveyor. The formula performed by LVN A was as follows: 22.5 x 20 = 450 gtts (drops) ,[DATE] = 7.5 gtts/min LVN A stated, "The rate of 7.5 gtts/min would result in the doctor's ordered rate of 20.8 cc/hr." LVN A again stated he did not have to count the drops because the medication was given with a rate controller. While LVN A had the right formula for calculation, he had the wrong rate (he used 22.5 not 20.8 cc/hr). LVN A obtained the 22.5 cc/hr from the prescription label. An interview on [DATE] at 12:00 PM with facility's contracted pharmacist via telephone revealed 6 IV bags of Resident #2's [MEDICATION NAME] were sent on [DATE] and another 6 IV bags of [MEDICATION NAME] were sent on [DATE]. He stated 6 bags were needed every three days. When asked about an IV pump, the pharmacist replied a pump was sent to the facility on [DATE] with the first order. He stated IV pump tubing was sent as part of the order. The Pharmacist was not aware the IV pump was not functioning. When asked if he sent a "Dial A Flow" tubing was sent as part of the order, he replied, "No." He revealed he did not know there was a "Dial A Flow" controlling her IV rate. The DON, who was present during the interview, requested the pharmacy to send another pump as quickly as possible. An interview with LVN K, on [DATE] at 1:00 PM with the Medical Director present revealed when asked what her initials on Resident #2's [DATE] MAR meant, LVN K replied, "That means this antibiotic was running at this rate." LVN K pointed to the order which reflected [MEDICATION NAME] 4.5 gm/ 250 ML NS IV at 20.8 cc/hr continuously. The surveyor asked LVN K to calculate Resident #2's drip rate for her IV and provided a piece of paper and pencil to the LVN. LVN K did not attempt to calculate the drip rate. When asked if she verified the administration rate of Resident #2's IV when she assessed the IV site, LVN K replied, "Yes, I verify the rate with a 'Dial A Flow'. I set the Dial A Flow' to 21 and then it is calibrated." When asked if she wrote the order for the PICC Line dated [DATE], she replied, "Yes, I did." When asked if she called the physician to get an order for [REDACTED]." At this time, the Medical Director stated to LVN K, "I checked this. I didn't see any verification that I told you this order." When asked why she changed the PICC line, LVN K replied, "It looked old. I thought it needed changing. I felt part of it was hanging." When asked what was hanging, LVN K replied, "Part of it looked like it was pulled out. I called to the pharmacy and the pharmacist said it needed changing. I called the PICC company and they replaced it." At this time, the Medical Director told LVN K, "You still need to call the doctor to get an order. It's under my name." LVN K said, "I'm sorry doctor. I know better." The facility's current policy, "Medication Administration" effective February 2013 reflected the following procedure for calculating drops per minute using the hourly rate: (Hourly rate)(Drop factor)/time in minutes or (ml)(gtts)(1 hour)/60 minutes = gtts/minute. The facility's undated list of of LVNs reflected 25 LVNs working in the facility full-time, part-time, and as needed. The LVNs' personnel files reflected of the 25 LVNs only six LVNs had their Central Line IV training and competency checks. LVN A's personnel file did not reflect Central Line training and competency checks. The facility's In-Service Training records from [DATE] to [DATE] did not reflect training for LVNs on the management of IVs. The records were provided by the DON as the most current and complete. An IJ was identified on [DATE]. The Administrator, DON, and Clinic Nurse Consultant were notified of the IJ on [DATE] at 2:20 PM, and a Plan of Removal was requested at that time. During an interview on [DATE] at 2:30 PM the DON was asked what type of procedures were in place to make sure the nursing needs of residents were being met. The DON stated, "We have training and in-services to train nurses for IV use. No one (staff) has done an in-service since last year." When asked how she ensured nurses were competent in their skills to care for residents with IVs, central lines, and PICC lines, she replied she had not done any return demonstrations or competency checklists for the nurses. The DON stated they were trained by a local company. She revealed she was going to start competency check-offs soon. When asked if there had been any in-services on IV therapy since admitting residents with PICC lines and central lines, she answered, "Not recently." When the DON was asked how she thought the IJ occurred, she replied, "I don't know." During an interview on [DATE] at 2:30 PM the Administrator was asked what types of procedures were in place to ensure the nursing needs of residents were being met. The Administrator replied he used a combination of systems. He stated, "We use nursing reports daily. We have 24-hour report systems, and nurses use shift to shift reports, I reply on the constant oral reports of the staff, and I have good communication with the residents and families I also use personal observation." When asked how he monitored his staff to ensure the systems they were responsible for met the needs of residents, he replied, "I rely on the Corporate Nurse Consultants with their knowledge of the systems to help us. I also use personal observation." When asked what factors he thought contributed to the situation and how the IJ developed, the Administrator replied, "I think I have no idea at the moment but your investigation will show the contributing factors." An interview with the Medical Director, who was also Resident #2's attending physician, on [DATE] at 12:35 PM revealed he was informed of the IJ and the significant medication error. The Medical Director stated he was informed that day ([DATE]) at the QA meeting. When asked if he knew how many nurses in the facility were IV trained, he replied, "I just came to know during the QA meeting this morning that only six nurses were IV certified for central lines and PICCs. I feel the facility should have some experienced nurses and they should know how to calculate drip rates and make sure residents are getting their medications." When asked if he had seen an IV pump in Resident #2's room, he replied he could not recall. When asked if he was aware the nurses could not calculate drip rates of IVs and were not IV certified, the Medical Director answered he was notified during the QA meeting that day. He revealed, "I depend on the DON to do these things. We are not trained in medical school to calculate drip rates." When asked if the significant medication error would harm Resident #2, the Medical Director replied he had spoken to the surgeon and the Infectious Diseases physician, and "The resident had been receiving the IV for all about 10 weeks. We are not sure yet but we might give her extra days of antibiotics. Missing these doses should be okay because she's already had it for 10 weeks. I see her one to two times a week. I never noticed a pump in her room." The plan of removal of the IJ concerning an IV administration was accepted on [DATE] and reflected: System: An audit conducted by the DON on [DATE] at 6:00 PM revealed Resident #12 also had an IV. An RN reviewed the resident's IV order and the IV was functioning appropriately. Resident #12 had a Mediport IV. In services have been and will be given to each nurse before being allowed to care for a resident with an IV, then they will have the competency test and go through skills check-offs by return demonstration and successfully passed before they can care for a resident with an IV. If the staff member fails any of these tests, they will be allowed to retake the test a second time. If a staff member failed the second time, they will be required to take the class again. The DON will be notified to ensure the staff member did not work on the floor until they have successfully passed the skills competency test. First in-service was given on [DATE] at 3:00 PM, the next in-service was held on [DATE] at 10:00 PM, the third in-service was held on [DATE] at 6:00 AM. Information given by the DON and the topic was IV administration, management and pump operation. In-service was held on [DATE] at 10:00 PM was an IV refresher course conducted by an outside company. The information for the IV refresher courses was included and was in the form of the skills checklist. An IV certification class was being conducted by the outside company on [DATE] at 9:30 AM and ongoing for all nurses, who have been identified as not already having picc certification. Lists of staff members who were scheduled to take the class have been provided. Staffing had been and will be modified to ensure qualified coverage on the floor while others were in the class. Only one staff member had a schedule change to be in the class. Until all nurses were certified, administration would assure only nurses with IV certification care for residents with IVs. All RNs, LVNs, the DON and a weekend supervisor would complete IV certification. Then they will have the competency test and go through the skills check-off by return demonstration and successfully pass before they could care for a resident with an IV. If the staff member failed any of the testing, the staff member would be allowed to take the test a second time. If the staff member failed the second time, they would be required to take the class again. The DON would be notified to ensure the staff member did not work on the floor until they had successfully passed the skills and competency test. Return demonstrations would be completed by the director of nursing for the outside education group. All licensed staff would be certified by [DATE] except two staff members who were on vacation out of the country. All staff would have the competency test and would go through skills check-off by return demonstration and successfully pass before they can care for a resident with an IV Nurse's Notes documentation would now include indication of time and day for each new IV bag that was started. In-service was held for this issue on [DATE] at 8:15 PM and is ongoing until all licensed staff have received this information. In services will be concluded by 3:00 PM on [DATE]. In-service was conducted by the DON. Monitoring of the documentation will be done by the DON, and weekend supervisor on a continuing basis by reviewing the IV documentation weekly to assure compliance. No staff member would be allowed to care for a resident with IVs until in-serviced. Annual skills checks would be given to assess the licensed staff's IV skills. Monitoring: IV operation will be monitored on a daily basis during the facility's morning routine which will include observation of the IV and accuracy of flow rate by the DON, ADONs, and weekend supervisor. Continuous observation of the IV would be conducted by IV certified staff. Review of the IVs would be included in the morning meeting. IV operation would be monitored on a weekly basis by the DON or ADONs by auditing the clinical record and observation of the IVs for operation and accuracy of flow rate. Caring for and administering IV medications to residents who have picc lines would only be done by LVNs and RNs who had certifications for picc line care. Licensed staff would have skills checks on an annual basis, and the DON would be responsible. Newly hired licensed staff would be be picc line certified prior to caring for residents with IVs. The DON would be responsible. Any and all problems in the operation of the IV would be reviewed by the QA committee either by special session or during normal quarterly sessions. Problems and incidents that occurred with the IVs would be documented in the incident log system and be reviewed during the normal QA meeting when the IV section was reviewed. Direction from the QA committee would then be put into plans and delivered to the staff via in-service and monitored. On [DATE] at 12:00 PM, a special session was held by the QA committee to approve Plan of Removal. The committee included the Medical Directors, Administrator, DON, a DON, and all Department Heads and consultants. An observation on [DATE] at 7:45 AM revealed Resident #2's [MEDICATION NAME] was infusing through her PICC line at 22 cc/hr via a pump. Resident #2's Nurse's Notes Late Note dated [DATE] and timed at 4:45 PM reflected the resident's antibiotic was hung via pump at 21 cc/hr. Resident #2's Nurse's Notes dated [DATE] and timed at 2:30 AM reflected the resident's antibiotic was running continuously at 21 cc/hr with no problems. Of the 19 LVNs, who did not have PICC line training, three were certified in PICC lines prior to exit. The IJ was removed on [DATE] at 5:30 PM. The Administrator, the DON, and the Clinical Nurse Consultant were notified at that time the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. 14. An observation on [DATE] at 9:10 AM revealed Resident #2 had a PICC line. An observation on [DATE] at 10:00 AM revealed Resident #12 had a Mediport in her left upper chest area.

Based on observation, interview and record review, it was determined the facility failed to ensure the services provided by two (LVNs A and K) of 25 LVNs met professional standards of quality for one (Resident #2) of two residents reviewed for IV therapy. 1. LVNs A and K failed to calculate Resident #2's IV antibiotic drip rate accurately. These failures resulted in Resident #2 not receiving her IV antibiotic as ordered by the physician. Her IV was running too slowly. 2. LVN K failed to consult with Resident #2's physician when she thought the resident needed a new PICC line, and she wrote a Physician's Telephone Order to replace the resident's PICC line without the physician's approval. 3. LVN A failed to have IV training and competency checks in Central Lines (including PICC lines). LVN A provided care to Resident #2 and her PICC line. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the two residents with PICC and central lines, including Resident #2, by placing them at risk for worsening infections and and increased debility due to infection. Findings included: 1. The Texas Administrative Code Title 22 Examining Boards, Part 11 Texas Board of Nursing, Chapter 217 Licensure, Peer Assistance and Practice, Rule 217.11 Standards of Nursing Practice reflected: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice...(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same... (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and...(iv) implementing appropriate aspects of care within the LVN's scope of practice...." The Texas Board of Nurse Examiner's Position Statement 15.3 LVNs Engaging in Intravenous Therapy, Venipuncture, or PICC Lines last reviewed on [DATE] by the Board reflected: "The basic educational curriculum for Licensed Vocational Nurses (LVNs) does not mandate teaching of principles and techniques of insertion for peripheral intravenous catheters, or the administration of fluids and medications via the intravenous route. Knowledge and skills relating to maintaining patency and performing dressing changes of central line intravenous catheters is also not mandated as part of basic LVN education. As such, basic competency in management of intravenous lines/intravenous therapy is not a given for any specific LVN licensee. Applicable Nursing Standards LVN practice is guided by the Nursing Practice Act (NPA) and Board Rules. Rule 217.11, Standards of Nursing Practice, is the rule most often applied to nursing practice issues. Two standards applicable in all practice scenarios include...217.11(1)(T) accept only those assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability. Additional standards in Rule 217.11 that may be applicable when a LVN chooses to engage in an IV therapy-related task include (but are not limited to): ...(1)(C) Know the rationale for and effects of medications and treatments and shall correctly administer the same...(1)(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices...(2)(C) ...perform other acts that require education and training as prescribed by board rules and policies, commensurate with the LVN's experience, continuing education, and demonstrated LVN competencies." The Texas Board of Nurse Examiners' Position Statement 15.27 last reviewed [DATE] by the Board reflected: "The Licensed Vocational Nurse Scope of Practice provides additional clarification of the Standards Rule as it applies to LVN Scope of Practice. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow a LVN to expand his/her scope of practice to include intravenous therapy. It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN's IV therapy practice. The BON does not define or set qualifications for an "IV Validation Course" or for "LVN IV certification." The LVN who chooses to engage in intravenous therapy must first have been instructed in the principles of intravenous therapy congruent with prevailing nursing practice standards... Administration of IV Fluids and Medications The ability of a LVN to administer specific IV fluids or drugs, to prepare and/or administer IV "piggy-back" or IV "push" medications, or to monitor and titrate "IV drip" medications of any kind is up to facility policy. The LVN's practice relative to IV therapy must also comply with any other regulations that may exist under the jurisdiction of other regulatory agencies or entities. The LVN who accepts an assignment to engage in any aspect of intravenous therapy is responsible for adhering to the NPA and the Board rules, particularly 217.11 Standards of Nursing Practice, including excerpted standards listed above and any other standards or rules applicable to the individual LVN's practice. All nursing actions related to peripheral and/or central intravenous lines, as well as IV administration of medications, must be completed in accordance with the orders of the prescribing practitioner, as well as written policies, procedures and job descriptions approved by the health care employer." 2. http://www.drugs.com/pro/[MEDICATION NAME].html reflected "...Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by [MEDICATION NAME] for Injection or other antibacterial drugs in the future...." (retrieved on [DATE]). 3. Resident #2's Face Sheet, dated [DATE], reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Osteo[DIAGNOSES REDACTED] is an infection in the bones), [MEDICAL CONDITION], Hypertension, Chronic Pai[DIAGNOSES REDACTED], [MEDICAL CONDITION]. Resident #2's Resident Summary Admission, dated [DATE], reflected she admitted on that date with [MEDICATION NAME] (antibiotic) continuously at 20.8 cc/hr via PICC line in her left upper arm. The Summary also reflected she was cognitively intact, needed assistance with turning and repositioning every two hours. There was no Care Plan regarding Resident #2's PICC line or her need for antibiotics. Resident #2's physician's orders [REDACTED]. The formula to calculate the drops per minute to run at 20.8 cc/hr was the following: 20.8 cc/hr X 20 (drops per ml- found on IV tubing bag) / 60 min = 6.93 gtt/min, which would be rounded to 7 gtts/min An observation on [DATE] at 10:30 AM of the Medication Room with the facility's Clinical Nurse Consultant revealed six IV bags of [MEDICATION NAME] 4.5 gm/250 ml NS for Resident #2 on the counter. The prescription label on the IV bags reflected the medication was prepared on [DATE] and expired on [DATE]. Five more IV bags of [MEDICATION NAME] 4.5 gm./250 cc NS for Resident #2 were found in the refrigerator. These IV bags were prepared on [DATE] and would expire on [DATE]. An observation, on [DATE] at 9:10 AM, revealed Resident #2's IV [MEDICATION NAME] infusing into the resident's PICC line at between 1 and 2 drops per minute. The surveyor timed the drip rate using a cell phone stopwatch for 2 minutes. The prescription label on the [MEDICATION NAME] reflected 4.5 g in 250 ml NS at 20.8 ml continuously. The IV flow rate was controlled by a "Dial A Flow" (Dial A Flow, which is a brand name, is a regulator designed to control the infusion rate through gravity intravenous administration infusion sets. These regulators typically consist of a mechanism that regulates the flow using a calibrated dial that permits control of the flow rate in a given range) regulator. Drip rates are the amount of medicine that should pass through an IV to a patient over a given period of time. An interview with LVN A on [DATE] at 11:00 AM revealed when asked how he determined how fast Resident #2's [MEDICATION NAME] IV was infusing, he replied, "(Resident #2) had a pump for the first week or so, but it kept alarming. Someone took it (the pump) off and put on a 'Dial A Flow.' I set the 'Dial A Flow' to 21 ml (cc)/hr. I don't have to count the drops because its gravity flow." LVN A was asked to calculate the drip rate per minute for the [MEDICATION NAME] and the surveyor handed him Resident #2's [MEDICATION NAME] IV bag. The prescription label on the IV bag reflected the rate was 20.8 cc/hr. Handwritten on the label was + 22.5 ml, which was the amount of fluid that was added to the IV bag. LVN A wrote the formula for calculating the drip rate on note paper and gave it to the surveyor. The formula performed by LVN A was as follows: 22.5 x 20 = 450 gtts (drops) ,[DATE] = 7.5 gtts/min LVN A stated, "The rate of 7.5 gtts/min would result in the doctor's ordered rate of 20.8 cc/hr." LVN A again stated he did not have to count the drops because the medication was given with a rate controller. While LVN A had the right formula for calculation, he had the wrong rate (he used 22.5 not 20.8 cc/hr). LVN A obtained the 22.5 cc/hr from the prescription label. An interview on [DATE] at 12:00 PM with facility's contracted pharmacist via telephone revealed 6 IV bags of Resident #2's [MEDICATION NAME] were sent on [DATE] and another 6 IV bags of [MEDICATION NAME] were sent on [DATE]. He stated 6 bags were needed every three days. When asked about an IV pump, the pharmacist replied a pump was sent to the facility on [DATE] with the first order. He stated IV pump tubing was sent as part of the order. The Pharmacist was not aware the IV pump was not functioning. When asked if he sent a "Dial A Flow" tubing was sent as part of the order, he replied, "No." He revealed he did not know there was a "Dial A Flow" controlling her IV rate. The DON, who was present during the interview, requested the pharmacy to send another pump as quickly as possible. An observation on [DATE] at 8:50 AM revealed Resident #2's IV [MEDICATION NAME] was infusing into the PICC line via "Dial A Flow" at three drops per minute. The surveyor observed the drip rate using a cell phone stop watch for a full minute. The "Dial A Flow" was set to 20 cc/hr. An observation on [DATE] at 10:00 AM revealed Resident #2 resting in her bed with her IV of [MEDICATION NAME] through her PICC line with a Dial-a-flow controller set between 20 ml/hr and 30 ml/hr. The IV prescription label reflected [MEDICATION NAME] 4.5 g in 250 ml NS at 20.8 cc/hr continuously. The IV [MEDICATION NAME] was observed to be infusing at three drops per minute and was timed using the cell phone stop watch for a full minute. An interview with LVN K, on [DATE] at 1:00 PM revealed when asked what her initials on Resident #2's [DATE] MAR meant, LVN K replied, "That means this antibiotic was running at this rate." LVN K pointed to the order which reflected [MEDICATION NAME] 4.5 gm/ 250 ML NS IV at 20.8 cc/hr continuously. The surveyor asked LVN K to calculate Resident #2's drip rate for her IV and provided a piece of paper and pencil to the LVN. LVN K did not attempt to calculate the drip rate. When asked if she verified the administration rate of Resident #2's IV when she assessed the IV site, LVN K replied, "Yes, I verify the rate with a 'Dial A Flow'. I set the Dial A Flow' to 21 and then it is calibrated." The facility's current policy, "Medication Administration" effective February 2013 reflected the following procedure for calculating drops per minute using the hourly rate: (Hourly rate)(Drop factor)/time in minutes or (ml)(gtts)(1 hour)/60 minutes = gtts/minute. 4. The facility's undated list of of LVNs reflected 25 LVNs working in the facility full-time, part-time, and as needed. The LVNs' personnel files reflected of the 25 LVNs only six LVNs had their Central Line IV training and competency checks. LVN A's personnel file did not reflect Central Line training and competency checks. The facility's In-Service Training records from [DATE] to [DATE] did not reflect training for LVNs on the management of IVs. The records were provided by the DON as the most current and complete. 5. An interview with LVN K, on [DATE] at 1:00 PM with the Medical Director present, revealed when asked if she wrote the order for the PICC Line dated [DATE], she replied, "Yes, I did." When asked if she called the physician to get an order for [REDACTED]." At this time, the Medical Director stated to LVN K, "I checked this. I didn't see any verification that I told you this order." When asked why she changed the PICC line, LVN K replied, "It looked old. I thought it needed changing. I felt part of it was hanging." When asked what was hanging, LVN K replied, "Part of it looked like it was pulled out. I called to the pharmacy and the pharmacist said it needed changing. I called the PICC company and they replaced it." At this time, the Medical Director told LVN K, "You still need to call the doctor to get an order. It's under my name." LVN K said, "I'm sorry doctor. I know better." 6. An IJ was identified on [DATE]. The Administrator, DON, and Clinic Nurse Consultant were notified of the IJ on [DATE] at 2:20 PM, and a Plan of Removal was requested at that time. 7. During an interview on [DATE] at 2:30 PM the DON was asked what type of procedures were in place to make sure the nursing needs of residents were being met. The DON stated, "We have training and in-services to train nurses for IV use. No one (staff) has done an in-service since last year." When asked how she ensured nurses were competent in their skills to care for residents with IVs, central lines, and PICC lines, she replied she had not done any return demonstrations or competency checklists for the nurses. The DON stated they were trained by a local company. She revealed she was going to start competency check-offs soon. When asked if there had been any in-services on IV therapy since admitting residents with PICC lines and central lines, she answered, "Not recently." When the DON was asked how she thought the IJ occurred, she replied, "I don't know." 8. During an interview on [DATE] at 2:30 PM the Administrator was asked what types of procedures were in place to ensure the nursing needs of residents were being met. The Administrator replied he used a combination of systems. He stated, "We use nursing reports daily. We have 24-hour report systems, and nurses use shift to shift reports, I reply on the constant oral reports of the staff, and I have good communication with the residents and families I also use personal observation." When asked how he monitored his staff to ensure the systems they were responsible for met the needs of residents, he replied, "I rely on the Corporate Nurse Consultants with their knowledge of the systems to help us. I also use personal observation." When asked what factors he thought contributed to the situation and how the IJ developed, the Administrator replied, "I think I have no idea at the moment but your investigation will show the contributing factors." 9. An interview with the Medical Director, who was also Resident #2's attending physician, on [DATE] at 12:35 PM revealed he was informed of the IJ and the significant medication error. The Medical Director stated he was informed that day ([DATE]) at the QA meeting. When asked if he knew how many nurses in the facility were IV trained, he replied, "I just came to know during the QA meeting this morning that only six nurses were IV certified for central lines and PICCs. I feel the facility should have some experienced nurses and they should know how to calculate drip rates and make sure residents are getting their medications." When asked if he had seen an IV pump in Resident #2's room, he replied he could not recall. When asked if he was aware the nurses could not calculate drip rates of IVs and were not IV certified, the Medical Director answered he was notified during the QA meeting that day. He revealed, "I depend on the DON to do these things. We are not trained in medical school to calculate drip rates." When asked if the significant medication error would harm Resident #2, the Medical Director replied he had spoken to the surgeon and the Infectious Diseases physician, and "The resident had been receiving the IV for all about 10 weeks. We are not sure yet but we might give her extra days of antibiotics. Missing these doses should be okay because she's already had it for 10 weeks. I see her one to two times a week. I never noticed a pump in her room." 10. The plan of removal of the IJ concerning an IV administration was accepted on [DATE] and reflected: Resident specific: IV orders for Resident #2 were clarified by the DON and physician at 4:00 PM on [DATE]. The flow rate was set at 21. A new IV pump arrived on [DATE] at 4:45 PM and was applied by an RN to ensure Resident #2 received the correct amount of antibiotic. The IV was functioning as ordered and would be monitored by an RN on her shift, LVNs on the night shift and, the day shift tomorrow. These LVNs had the required PICC line certification. The DON supervised the shifts. Resident #2 was notified by the DON at 7:35 PM on [DATE] the flow rate was not administered as ordered. The resident's family member was notified by the DON via telephone on [DATE] at 8:00 PM. Physician notification occurred at 4:00 PM on [DATE] by the DON. A Medication Error Report was completed by the DON on [DATE]. System: An audit conducted by the DON on [DATE] at 6:00 PM revealed Resident #12 also had an IV. An RN reviewed the resident's IV order and the IV was functioning appropriately. Resident #12 had a Mediport IV. In services have been and will be given to each nurse before being allowed to care for a resident with an IV, then they will have the competency test and go through skills check-offs by return demonstration and successfully passed before they can care for a resident with an IV. If the staff member fails any of these tests, they will be allowed to retake the test a second time. If a staff member failed the second time, they will be required to take the class again. The DON will be notified to ensure the staff member did not work on the floor until they have successfully passed the skills competency test. First in-service was given on [DATE] at 3:00 PM, the next in-service was held on [DATE] at 10:00 PM, the third in-service was held on [DATE] at 6:00 AM. Information given by the DON and the topic was IV administration, management and pump operation. In-service was held on [DATE] at 10:00 PM was an IV refresher course conducted by an outside company. The information for the IV refresher courses was included and was in the form of the skills checklist. An IV certification class was being conducted by the outside company on [DATE] at 9:30 AM and ongoing for all nurses, who have been identified as not already having picc certification. Lists of staff members who were scheduled to take the class have been provided. Staffing had been and will be modified to ensure qualified coverage on the floor while others were in the class. Only one staff member had a schedule change to be in the class. Until all nurses were certified, administration would assure only nurses with IV certification care for residents with IVs. All RNs, LVNs, the DON and a weekend supervisor would complete IV certification. Then they will have the competency test and go through the skills check-off by return demonstration and successfully pass before they could care for a resident with an IV. If the staff member failed any of the testing, the staff member would be allowed to take the test a second time. If the staff member failed the second time, they would be required to take the class again. The DON would be notified to ensure the staff member did not work on the floor until they had successfully passed the skills and competency test. Return demonstrations would be completed by the director of nursing for the outside education group. All licensed staff would be certified by [DATE] except two staff members who were on vacation out of the country. All staff would have the competency test and would go through skills check-off by return demonstration and successfully pass before they can care for a resident with an IV Nurse's Notes documentation would now include indication of time and day for each new IV bag that was started. In-service was held for this issue on [DATE] at 8:15 PM and is ongoing until all licensed staff have received this information. In services will be concluded by 3:00 PM on [DATE]. In-service was conducted by the DON. Monitoring of the documentation will be done by the DON, and weekend supervisor on a continuing basis by reviewing the IV documentation weekly to assure compliance. No staff member would be allowed to care for a resident with IVs until in-serviced. Annual skills checks would be given to assess the licensed staff's IV skills. Monitoring: IV operation will be monitored on a daily basis during the facility's morning routine which will include observation of the IV and accuracy of flow rate by the DON, ADONs, and weekend supervisor. Continuous observation of the IV would be conducted by IV certified staff. Review of the IVs would be included in the morning meeting. IV operation would be monitored on a weekly basis by the DON or ADONs by auditing the clinical record and observation of the IVs for operation and accuracy of flow rate. Caring for and administering IV medications to residents who have picc lines would only be done by LVNs and RNs who had certifications for picc line care. Licensed staff would have skills checks on an annual basis, and the DON would be responsible. Newly hired licensed staff would be be picc line certified prior to caring for residents with IVs. The DON would be responsible. Any and all problems in the operation of the IV would be reviewed by the QA committee either by special session or during normal quarterly sessions. Problems and incidents that occurred with the IVs would be documented in the incident log system and be reviewed during the normal QA meeting when the IV section was reviewed. Direction from the QA committee would then be put into plans and delivered to the staff via in-service and monitored. On [DATE] at 12:00 PM, a special session was held by the QA committee to approve Plan of Removal. The committee included the Medical Directors, Administrator, DON, a DON, and all Department Heads and consultants. 11. An observation on [DATE] at 7:45 AM revealed Resident #2's [MEDICATION NAME] was infusing through her PICC line at 22 cc/hr via a pump. Resident #2's Nurse's Notes Late Note dated [DATE] and timed at 4:45 PM reflected the resident's antibiotic was hung via pump at 21 cc/hr. Resident #2's Nurse's Notes dated [DATE] and timed at 2:30 AM reflected the resident's antibiotic was running continuously at 21 cc/hr with no problems. 12. Of the 19 LVNs, who did not have PICC line training, three were certified in PICC lines prior to exit. 13. The IJ was removed on [DATE] at 5:30 PM. The Administrator, the DON, and the Clinical Nurse Consultant were notified at that time the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "potential for more than minimal harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. 14. An observation on [DATE] at 9:10 AM revealed Resident #2 had a PICC line. An observation on [DATE] at 10:00 AM revealed Resident #12 had a Mediport in her left upper chest area.

Based on observation, interview and record review, it was determined the facility failed to ensure one of one resident (Resident #5), who had a [MEDICAL CONDITION], received the proper treatment and care including respiratory care. The facility failed to: 1) Ensure all emergency equipment to be used in case of a respiratory/cardiac emergency was kept at Resident #5's bedside for timely and easy access by the staff. There was no ambu bag in the resident's room on [DATE]. 2) Ensure there was an ambu bag on the emergency cart. The cart was checked each night by the night shift nurses who had been writing in a "?" (no or none) to indicate there was no ambu bag available on the cart for approximately nine days. 3) Ensure there was an adequate supply of ambu bags available in the facility. There were no ambu bags in the Central Supply, on the emergency cart, or in Resident #5's room for approximately one day. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 50 residents, including Resident #5, who were a Full Code, by placing them at risk for not receiving emergency respiratory care and assistance with breathing, which could result in brain damage and/or death. Findings included: According to the Significant Change in Status MDS assessment, dated [DATE], Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #5 was aphasic, severely cognitively impaired and dependent on staff for all needs. The assessment also reflected Resident #5 required the assistance of two staff members for bed mobility and dressing. The assessment reflected Resident #5 was bedfast and required the assistance of one staff member for hygiene and bathing. The assessment reflected Resident #5 had impairment on both sides of his upper and lower extremities. The assessment also reflected Resident #5 had a gastrostomy tube, Foley catheter, [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The Face Sheet, dated [DATE], reflected Resident #5 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #5's current Care Plan, dated [DATE], reflected the resident had impaired gas exchange related [MEDICAL CONDITION] and respiratory infection, and he was a Full Code. The plan reflected the approaches to the Full Code were "To perform CPR if indicated i.e. [MEDICAL CONDITION], Respiratory Arrest, To continue CPR until Resident responds or EMS arrives to take over the code." The Nurse's Notes, dated [DATE] at 4:00 PM, reflected Resident #5 was admitted to Hospice services. The Nurse's Notes, dated [DATE] at 9:30 AM, reflected Resident #5's inner cannula for the [MEDICAL CONDITION] came out. Resident #5 was alert and responsive, according to the Notes. The notes further reflected when the Hospice nurse was contacted and asked the facility staff if there was another cannula. The facility nurse said there was not another cannula and the resident was transferred to the emergency room for re-insertion of the [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 8:45 AM, reflected Resident #5'[MEDICAL CONDITION] was out of the ostomy ([MEDICAL CONDITION] stoma site-which is a surgical opening into the windpipe to allow for [MEDICAL CONDITION] to be placed and air exchange) and the nurse contacted the Hospice nurse. The Notes reflected the resident was responsive and alert. The Notes reflected when the Hospice nurse arrived, she attempted to reinsert the tube, but was unable to gain access due to resistance. The Notes reflected 911 was notified and when the EMS personnel entered the resident's room, his oxygen saturation was down to 86% (normal range 96% - 100%) and the resident was transferred to the hospital for re-insertion of [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 2:15 AM, reflected Resident #5 pulled [MEDICAL CONDITION] out and his oxygen saturation level was 77% and going down. The Notes reflected staff called 911 and used the ambu bag (medical device used to provide assisted ventilation to people who are either not breathing or are having difficulty breathing) to oxygenate the resident until emergency personnel arrived and transferred the resident to the emergency room . The Notes reflected Resident #5 returned to the facility at 4:00 AM. The Nurse's Notes, dated [DATE] at 8:15 PM, reflected Resident #5 was having a [MEDICAL CONDITION], which lasted for less than a minute. The Notes reflected after the [MEDICAL CONDITION], the [MEDICAL CONDITION] was out. The Notes also reflected the facility notified the Nurse Practitioner and obtained orders to send the resident to the hospital. The Notes reflected Resident #5's oxygen saturation levels fluctuated between 88 to 90%. The Notes reflected Resident #5 returned to the facility at 11:00 PM with the same temporary [MEDICAL CONDITION] reinserted. The Patient Transfer Form, dated [DATE], reflected the following: "Patient in bed, he had convulsion for less than a minute that (sic) when the [MEDICAL CONDITION] came out, Pulse ox (oximeter) 90%, ? acute distress noted, MD made aware new order initiated to transport patient to (Hospital) for [MEDICAL CONDITION] replacement/placement." On [DATE] at 2:45 PM , LVN H was observed providing [MEDICAL CONDITION] care to Resident #5. LVN H cleaned the stoma and reapplied [MEDICAL CONDITION]. LVN H was asked if there was an ambu bag or an [MEDICAL CONDITION] in the room. He checked in the closet where all the respiratory supplies were kept and on the wall and he could not find either. On [DATE] at 3:30 PM, the surveyor notified Corporate RN A there was no ambu bag or extra [MEDICAL CONDITION] in Resident #5's room. Corporate RN A also went to check the resident's room and could not find either an ambu bag or replacement [MEDICAL CONDITION]. On [DATE] at 3:40 PM, Corporate RN A revealed she found the extra Shiley #[MEDICAL CONDITION] in the top drawer of the cabinet in Resident #5's room and it was now taped to the wall beside his bed. She stated there were no ambu bags found in the facility and she sent a nurse to the hospital to obtain an ambu bag. She stated the emergency services provider the facility used was bringing two more "ASAP" (as soon as possible). On [DATE] at 3:45 PM, the emergency cart was checked and there was no ambu bag on the cart. At this time, the Crash Cart Checklist for February and [DATE] was also checked. The section for the ambu bag was filled in with an "?" for the following dates: [DATE], [DATE], and [DATE] through [DATE]. On [DATE] at 4:05 PM, the DON provided a list of the nurses who worked the 10:00 PM to 6:00 AM shift and initialed the Crash Cart Checklist from [DATE] through [DATE]. The list reflected the three nurses who checked and documented there was no ambu bag on the crash cart were LVNs I, J and K. On [DATE] at 4:40 PM, an interview was conducted with LVN I. He stated he remembered the 2:00 PM to 10:00 PM nurse told LVN J they used the ambu bag and needed another one. LVN I was not sure who the resident was who used the ambu bag nor did he remember when it was used. He stated LVN J left a note for Central Supply indicating there was no ambu bag on the crash cart. He also stated they did not go to Central Supply to check for one. He stated if there was a zero with a line drawn through it that meant there was no ambu bag on the cart. LVN I stated there had not been an ambu bag on the cart since the last part of February 2012. He stated he called the Central Supply/Medical Records Director the morning of [DATE] and reported there was no ambu bag on the emergency cart. On [DATE] at 4:58 PM, an interview was conducted with LVN K. He stated he did not work on the 100 and 200 Halls. He stated the nurse, who worked those halls, was usually responsible for checking the emergency cart. LVN K stated if he needed equipment or supplies, he would go to Central Supply and look for them, because he had a key to Central Supply. He stated if he did not find the supplies, he would alert the DON, sign the list in Central Supply, write it on the 24-hour Report or drop a note to the DON or Central Supply person. LVN K stated he remembered somewhere around the middle of February 2012, Resident #5 pulled his [MEDICAL CONDITION] out, they called 911, and they used the ambu bag until EMS arrived and the ambu bag went with the resident to the hospital. On [DATE] at 9:45 PM, an interview was conducted with LVN J. She stated she noticed about a week ago there was no ambu bag on the emergency cart. She stated she went to Central Supply and checked for one, but did not find one. She stated she wrote a note on the paper kept in Central Supply. LVN J stated central supply was to restock the equipment and since she wrote a note, she did not tell anyone about not having an ambu bag available on the crash cart. On [DATE] at 4:10 PM, the Social Worker provided the survey team with a list of residents who were "Full Codes." Review of the list revealed there were 50 residents in the facility, including Resident #5, identified with "Full Code" status and who would require CPR be initiated in the case of a cardiac or respiratory arrest. On [DATE] at 4:15 PM, Corporate RN A stated the facility now had two ambu bags/masks and connectors for the [MEDICAL CONDITION] in the building. On [DATE] at 4:22 PM, an interview was conducted with the Central Supply/Medical Records Director. She stated the night shift nurses had a key to Central Supply and could replenish the items they needed from the stock. When asked how staff let her know if stock was low or needed to be replaced, she stated they would call her at home at night or they would slip her a note under the door to Medical Records. She stated there was also a sheet in the Central Supply room where they could write down what items they needed. During this same interview with the Central Supply/Medical Records Director, she stated LVN I came in that morning around 10:00 AM and told her they needed an ambu bag for the crash cart. She stated she just got staffing information for the State, and she wrote a note on a piece of paper and placed it on her desk. She stated she thought there was an extra ambu bag in Central Supply. The Central Supply/Medical Records Director stated when the surveyor notified facility staff there were no ambu bags on the emergency cart, she went to check in Central Supply and verified there was not one in there. She stated as soon as she became aware of the situation, she immediately went to work on it and within 20 minutes she had two ambu bags in the facility and four more on the way. On [DATE] at 4:36 PM, Corporate RN A stated the DON had two blue ambu bags locked in the closet in her office where she kept the discontinued/expired narcotic medications and they were now available for use for residents. On [DATE] at 4:38 PM, the DON confirmed the ambu bags were locked in the closet in her office where she kept the discontinued/expired narcotic medications. She also stated she had the only keys to the locked closet in her office and when she left the building, she locked her office. On [DATE] an IJ was identified. On [DATE] at 5:34 PM, the Administrator, DON and Corporate RN A were notified of the IJ in the area of Quality of Care for Resident #5 and a Plan of Removal was requested at that time. On [DATE] at 5:30 PM, an interview was conducted with the Central Supply/Medical Records Director who stated she was not aware the DON had two ambu bags in her office. She stated she did not find out until she went into the DON's office and reported to the DON she thought she had a blue ambu bag in Central Supply, but could not find it. She stated then the DON told her she thought she had seen some ambu bags in her closet. She stated the DON found two ambu bags in her locked closet. On [DATE] at 6:38 PM, an interview was conducted with the DON. When asked when she became aware there were no ambu bags available in the facility, she replied she had not known about it until the surveyor informed her. The DON stated she periodically checked the emergency cart, but she had not done that in a while. She stated it was the 10:00 PM to 6:00 AM shift nurses' responsibility to check the crash cart and do the checklist, and refill it with what supplies were needed. The DON stated the staff would usually call her if they needed anything or sent her a note. She confirmed she had not received any notes from the staff or been contacted by the staff regarding ambu bags not being available. The DON stated they would in-service all staff as to what to do if they did not find supplies or equipment. She stated they were to look for the supplies in Central Supply and if they could not find them, they were to call her. She stated she lived close. She stated she would check the emergency cart each morning, Monday through Friday, and the weekend supervisor would check the cart on Saturday and Sunday. On [DATE] at 10:00 AM, an interview was conducted with the Central Supply/Medical Records Director. She stated she would check the supplies on the emergency cart and in Resident #5's room each morning. She stated she now had eight ambu bags available in the facility. She showed the surveyor the four ambu bags currently in Central Supply, but stated she was going to take one of them and place it on a hook in the medication room. She stated there was one on the emergency cart, one in Resident #5's room, one in the Administrator's office and one in the DON's office. On [DATE] at 8:45 AM, an interview was conducted with the Administrator. When she was asked why she thought the IJ occurred with the emergency equipment not being available, she stated it was a "process breakdown." She stated the night nurses did not follow through by telling someone the equipment was not available. The Administrator stated there was no accountability from Central Supply or the DON. She stated Central Supply should have been checking the crash cart each morning for supplies needed. The Administrator stated the facility's new process should ensure the situation never happened again. She stated Central Supply would check the crash cart each morning and replace all equipment that was needed. She stated the DON would check the crash cart each morning, and on the weekend the weekend supervisor would be responsible for checking it. The Administrator stated the facility did not have a "back-up par plan" (a backup plan for extra supplies to be kept on hand). She stated the facility now had a policy requiring three items as a backup for all supplies needed on the crash cart. When the Administrator was asked when she became aware of the situation, she replied she had no knowledge of it until the surveyor informed the facility about it. A Plan of Removal was accepted on [DATE] at 11:45 AM and reflected the following: " Concern: Facility has [MEDICAL CONDITION] who is a full code and Ambu bags (not) accessible. Immediate Resolve: Ambu bags were located and made accessible to staff. Interventions: 1. Inventory of Crash Cart completed at 6:15 pm on [DATE] to assure all supplies are available. 2. Crash Cart Inventory will be monitored every night by night nurse. 3. DON/Designee will review Crash Cart Inventory log daily to ensure all supplies are available. 4. Facility will maintain a backup 3 items for all items in crash cart at all times. 5. Central Supply will check ensure backup items are available.. 6. Weekend Supervisor will check Crash Cart inventory log to ensure all supplies available and contact Nursing Administration immediately on weekends.. 7. For further emergency backup, an ambu bag will be kept in the medication room, DON office, Administration Office. 8. Charge Nurse will check resident room nightly to ensure ambu bag [MEDICAL CONDITION] are available. 9. Ambu Bag Procedure added to daily start-up procedures. In-services: 1. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies not available, to contact DON and Admin immediately. This will be completed by [DATE]. 2. Central Supply Supervisor in serviced on maintaining par level of supplies in the central supply room. 3. One on one inservice completed with DON on [DATE]" Review of the facility's new "Crash Cart Protocol," reflected the following: "Procedure: 1. Central supply Manager will ensure adequate supplies are in facility at all times. This will be accomplished by daily validation of minimum par levels of at least 3 of each item on crash cart checklist inventory. Central supply manager will review crash cart checklist daily to ensure there are no needed supplies. 2. Charge Nurse will complete crash cart inventory log nightly to ensure supplies are available. If any item is missing off the crash cart, nurse will restock from central supply. If there is any item found to be unavailable the DON/ADMIN will be notified immediately. 3. Charge nurses will validate nightly each resident room that requires alternative means of Emergency respiratory supplies. 4. Nursing Admin will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 5. Weekend supervisor will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 6. To ensure Ambu bags are available at all times, extra bags will be kept in medication room, DON office and ADMIN office. 7. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies are not available, to contact DON and ADMIN immediately. This process will be added to facility orientation packet. Nursing staff will not be allowed to work until all in servicing and new employee orientation is completed." The facility's current form entitled "The Daily Nursing Management Tool," dated [DATE], reflected the following: "Upon nurse manager arrival to unit- check staffing, receive report from the charge nurse and make extensive rounds. Assure that all residents have eaten breakfast." One of the Focus Areas for the nurse to complete was "Check Crash Cart Inventory log daily and restock as needed." The facility's current CPR policy, dated [DATE], reflected the following: "Guidelines:...C. Nurses Responding: Establish a patent airway. a. Use lift, jaw lift technique or nasal airway. Do not hyperextend neck of any resident. b. Remove dentures if they are obstructing the airway. c. Begin CPR - one person rate in accordance with the current American Heart Association/American Red Cross Standards use single use resuscitation mask mouth-to-mouth or mouth to nose until ambu bag is obtained." Administration provided a copy of the newly developed Crash Cart Protocol and Procedures to the survey staff with their Plan of Removal on [DATE]. Review of an In-Service Training Report, dated [DATE], revealed the subject of the training was "CRASH CART INVENTORY LOG," and 29 nursing and administrative staff were provided the training. Review of the staff sign-in sheet for the training revealed the three nurses (LVNs I, J and K) who worked the night shift from 10:00 PM to 6:00 AM and who were responsible for checking the crash cart inventory, attended the training. Interviews were conducted with facility staff to determine if they had been in-serviced and had knowledge of what to do if emergency equipment was not available in the resident's room or on the crash cart. The following staff were interviewed: On [DATE] at 3:35 PM, an interview was conducted with LVN P. He stated if there was no ambu bag on the cart, he would go to the Central Supply room and the medication room. He stated he knew there was one ambu bag in the DON's office and the Administrator's office. He stated if supplies were not on the crash cart or available for them, staff were to call the DON or Administrator immediately. LVN P stated he never had a problem with supplies not being on the crash cart and he expected the equipment would be there. On [DATE] at 4:25 PM, an interview was conducted with LVN R. She stated if there was no ambu bag on the crash cart she would go to Central Supply or the medication room. She stated if there were no ambu bags, she would call the DON or Administrator immediately. On [DATE] at 4:35 PM, an interview was conducted with LVN H. He stated if there was no ambu bag in Resident #5's room or on the crash cart, he would go to the medication room or the Central Supply room to retrieve one. He stated staff had been instructed to call the DON or Administrator if they were unable to find the needed equipment right away. On [DATE] at 11:15 PM, an interview was conducted with LVN K. He stated if he did not find an ambu bag in Resident #5's room or on the cart, he would go to the Central Supply room and get one. He confirmed he had a key to the central supply room. He stated if he could not find one there, he would check in the medication room and if none were found, he would call the DON or Administrator immediately. On [DATE] at 11:20 PM, an interview was conducted with LVN I. He stated if he did not find an ambu bag on the crash cart, he would go to Central Supply and get one. He stated if he did not find one in the Central Supply room, he would call the DON or Administrator immediately. The IJ was removed on [DATE]. While the IJ was removed, the facility remained out of compliance a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy." On [DATE] at 10:17 AM, the Administrator and Corporate RN A were notified the IJ was removed. The Resident Census and Conditions of Residents form, dated [DATE], reflected there was one resident who had a [MEDICAL CONDITION]. On [DATE], a list of residents provided by the facility reflected 50 residents were a "Full Code."

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for two (Residents #5 and #16) of 16 residents reviewed/observed for abuse/neglect. The facility failed to: 1) Ensure all emergency equipment to be used in case of a respiratory/cardiac emergency was kept at Resident #5's bedside for timely and easy access by the staff. There was no ambu bag in the resident's room on [DATE]. 2) Ensure there was an ambu bag on the emergency cart. The cart was checked each night by the night shift nurses who had been writing in a "?" (no or none) to indicate there was no ambu bag available on the cart for approximately nine days. 3) Ensure there was an adequate supply of ambu bags available in the facility. There were no ambu bags in the Central Supply, on the emergency cart, or in Resident #5's room for approximately one day. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 50 residents, including Resident #5, who were a Full Code, by placing them at risk for not receiving emergency respiratory care and assistance with breathing, which could result in brain damage and/or death. 4) Ensure they followed suicide precautions for Resident #16 when a family member called and reported the resident made the statement he was going to kill himself if the family did not come and get him. This failure created the potential for Resident #16 to have had the time and opportunity to carry out his threat of suicide and could have resulted in serious injury and/or death. This failure could affect the 37 residents in the facility with Depression. Findings included: 1) According to the Significant Change in Status MDS assessment, dated [DATE], Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #5 was aphasic, severely cognitively impaired and dependent on staff for all needs. The assessment also reflected Resident #5 required the assistance of two staff members for bed mobility and dressing. The assessment reflected Resident #5 was bedfast and required the assistance of one staff member for hygiene and bathing. The assessment reflected Resident #5 had impairment on both sides of his upper and lower extremities. The assessment also reflected Resident #5 had a gastrostomy tube, Foley catheter, [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The Face Sheet, dated [DATE], reflected Resident #5 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #5's current Care Plan, dated [DATE], reflected the resident had impaired gas exchange related [MEDICAL CONDITION] and respiratory infection, and he was a Full Code. The plan reflected the approaches to the Full Code were "To perform CPR if indicated i.e. [MEDICAL CONDITION], Respiratory Arrest, To continue CPR until Resident responds or EMS arrives to take over the code." The Nurse's Notes, dated [DATE] at 4:00 PM, reflected Resident #5 was admitted to Hospice services. The Nurse's Notes, dated [DATE] at 9:30 AM, reflected Resident #5's inner cannula for the [MEDICAL CONDITION] came out. Resident #5 was alert and responsive, according to the Notes. The notes further reflected when the Hospice nurse was contacted and asked the facility staff if there was another cannula. The facility nurse said there was not another cannula and the resident was transferred to the emergency room for re-insertion of the [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 8:45 AM, reflected Resident #5'[MEDICAL CONDITION] was out of the ostomy ([MEDICAL CONDITION] stoma site-which is a surgical opening into the windpipe to allow for [MEDICAL CONDITION] to be placed and air exchange) and the nurse contacted the Hospice nurse. The Notes reflected the resident was responsive and alert. The Notes reflected when the Hospice nurse arrived, she attempted to reinsert the tube, but was unable to gain access due to resistance. The Notes reflected 911 was notified and when the EMS personnel entered the resident's room, his oxygen saturation was down to 86% (normal range 96% - 100%) and the resident was transferred to the hospital for re-insertion of [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 2:15 AM, reflected Resident #5 pulled [MEDICAL CONDITION] out and his oxygen saturation level was 77% and going down. The Notes reflected staff called 911 and used the ambu bag (medical device used to provide assisted ventilation to people who are either not breathing or are having difficulty breathing) to oxygenate the resident until emergency personnel arrived and transferred the resident to the emergency room . The Notes reflected Resident #5 returned to the facility at 4:00 AM. The Nurse's Notes, dated [DATE] at 8:15 PM, reflected Resident #5 was having a [MEDICAL CONDITION], which lasted for less than a minute. The Notes reflected after the [MEDICAL CONDITION], the [MEDICAL CONDITION] was out. The Notes also reflected the facility notified the Nurse Practitioner and obtained orders to send the resident to the hospital. The Notes reflected Resident #5's oxygen saturation levels fluctuated between 88 to 90%. The Notes reflected Resident #5 returned to the facility at 11:00 PM with the same temporary [MEDICAL CONDITION] reinserted. The Patient Transfer Form, dated [DATE], reflected the following: "Patient in bed, he had convulsion for less than a minute that (sic) when the [MEDICAL CONDITION] came out, Pulse ox (oximeter) 90%, ? acute distress noted, MD made aware new order initiated to transport patient to (Hospital) for [MEDICAL CONDITION] replacement/placement." On [DATE] at 2:45 PM , LVN H was observed providing [MEDICAL CONDITION] care to Resident #5. LVN H cleaned the stoma and reapplied [MEDICAL CONDITION]. LVN H was asked if there was an ambu bag or an [MEDICAL CONDITION] in the room. He checked in the closet where all the respiratory supplies were kept and on the wall and he could not find either. On [DATE] at 3:30 PM, the surveyor notified Corporate RN A there was no ambu bag or extra [MEDICAL CONDITION] in Resident #5's room. Corporate RN A also went to check the resident's room and could not find either an ambu bag or replacement [MEDICAL CONDITION]. On [DATE] at 3:40 PM, Corporate RN A revealed she found the extra Shiley #[MEDICAL CONDITION] in the top drawer of the cabinet in Resident #5's room and it was now taped to the wall beside his bed. She stated there were no ambu bags found in the facility and she sent a nurse to the hospital to obtain an ambu bag. She stated the emergency services provider the facility used was bringing two more "ASAP" (as soon as possible). On [DATE] at 3:45 PM, the emergency cart was checked and there was no ambu bag on the cart. At this time, the Crash Cart Checklist for February and [DATE] was also checked. The section for the ambu bag was filled in with an "?" for the following dates: [DATE], [DATE], and [DATE] through [DATE]. On [DATE] at 4:05 PM, the DON provided a list of the nurses who worked the 10:00 PM to 6:00 AM shift and initialed the Crash Cart Checklist from [DATE] through [DATE]. The list reflected the three nurses who checked and documented there was no ambu bag on the crash cart were LVNs I, J and K. On [DATE] at 4:40 PM, an interview was conducted with LVN I. He stated he remembered the 2:00 PM to 10:00 PM nurse told LVN J they used the ambu bag and needed another one. LVN I was not sure who the resident was who used the ambu bag nor did he remember when it was used. He stated LVN J left a note for Central Supply indicating there was no ambu bag on the crash cart. He also stated they did not go to Central Supply to check for one. He stated if there was a zero with a line drawn through it that meant there was no ambu bag on the cart. LVN I stated there had not been an ambu bag on the cart since the last part of February 2012. He stated he called the Central Supply/Medical Records Director the morning of [DATE] and reported there was no ambu bag on the emergency cart. On [DATE] at 4:58 PM, an interview was conducted with LVN K. He stated he did not work on the 100 and 200 Halls. He stated the nurse, who worked those halls, was usually responsible for checking the emergency cart. LVN K stated if he needed equipment or supplies, he would go to Central Supply and look for them, because he had a key to Central Supply. He stated if he did not find the supplies, he would alert the DON, sign the list in Central Supply, write it on the 24-hour Report or drop a note to the DON or Central Supply person. LVN K stated he remembered somewhere around the middle of February 2012, Resident #5 pulled his [MEDICAL CONDITION] out, they called 911, and they used the ambu bag until EMS arrived and the ambu bag went with the resident to the hospital. On [DATE] at 9:45 PM, an interview was conducted with LVN J. She stated she noticed about a week ago there was no ambu bag on the emergency cart. She stated she went to Central Supply and checked for one, but did not find one. She stated she wrote a note on the paper kept in Central Supply. LVN J stated central supply was to restock the equipment and since she wrote a note, she did not tell anyone about not having an ambu bag available on the crash cart. On [DATE] at 4:10 PM, the Social Worker provided the survey team with a list of residents who were "Full Codes." Review of the list revealed there were 50 residents in the facility, including Resident #5, identified with "Full Code" status and who would require CPR be initiated in the case of a cardiac or respiratory arrest. On [DATE] at 4:15 PM, Corporate RN A stated the facility now had two ambu bags/masks and connectors for the [MEDICAL CONDITION] in the building. On [DATE] at 4:22 PM, an interview was conducted with the Central Supply/Medical Records Director. She stated the night shift nurses had a key to Central Supply and could replenish the items they needed from the stock. When asked how staff let her know if stock was low or needed to be replaced, she stated they would call her at home at night or they would slip her a note under the door to Medical Records. She stated there was also a sheet in the Central Supply room where they could write down what items they needed. During this same interview with the Central Supply/Medical Records Director, she stated LVN I came in that morning around 10:00 AM and told her they needed an ambu bag for the crash cart. She stated she just got staffing information for the State, and she wrote a note on a piece of paper and placed it on her desk. She stated she thought there was an extra ambu bag in Central Supply. The Central Supply/Medical Records Director stated when the surveyor notified facility staff there were no ambu bags on the emergency cart, she went to check in Central Supply and verified there was not one in there. She stated as soon as she became aware of the situation, she immediately went to work on it and within 20 minutes she had two ambu bags in the facility and four more on the way. On [DATE] at 4:36 PM, Corporate RN A stated the DON had two blue ambu bags locked in the closet in her office where she kept the discontinued/expired narcotic medications and they were now available for use for residents. On [DATE] at 4:38 PM, the DON confirmed the ambu bags were locked in the closet in her office where she kept the discontinued/expired narcotic medications. She also stated she had the only keys to the locked closet in her office and when she left the building, she locked her office. The facility's current Abuse Program, dated [DATE], was identified by the Administrator as the current facility policy covering the areas of neglect, abuse, misappropriation and involuntary seclusion. The policy reflected the following: "POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents... Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." "Prevention: 4. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is a risk for occurring." On [DATE] an IJ was identified. On [DATE] at 5:34 PM, the Administrator, DON and Corporate RN A were notified of the IJ in the area of Quality of Care for Resident #5 and a Plan of Removal was requested at that time. On [DATE] at 5:30 PM, an interview was conducted with the Central Supply/Medical Records Director who stated she was not aware the DON had two ambu bags in her office. She stated she did not find out until she went into the DON's office and reported to the DON she thought she had a blue ambu bag in Central Supply, but could not find it. She stated then the DON told her she thought she had seen some ambu bags in her closet. She stated the DON found two ambu bags in her locked closet. On [DATE] at 6:38 PM, an interview was conducted with the DON. When asked when she became aware there were no ambu bags available in the facility, she replied she had not known about it until the surveyor informed her. The DON stated she periodically checked the emergency cart, but she had not done that in a while. She stated it was the 10:00 PM to 6:00 AM shift nurses' responsibility to check the crash cart and do the checklist, and refill it with what supplies were needed. The DON stated the staff would usually call her if they needed anything or sent her a note. She confirmed she had not received any notes from the staff or been contacted by the staff regarding ambu bags not being available. The DON stated they would in-service all staff as to what to do if they did not find supplies or equipment. She stated they were to look for the supplies in Central Supply and if they could not find them, they were to call her. She stated she lived close. She stated she would check the emergency cart each morning, Monday through Friday, and the weekend supervisor would check the cart on Saturday and Sunday. On [DATE] at 10:00 AM, an interview was conducted with the Central Supply/Medical Records Director. She stated she would check the supplies on the emergency cart and in Resident #5's room each morning. She stated she now had eight ambu bags available in the facility. She showed the surveyor the four ambu bags currently in Central Supply, but stated she was going to take one of them and place it on a hook in the medication room. She stated there was one on the emergency cart, one in Resident #5's room, one in the Administrator's office and one in the DON's office. On [DATE] at 8:45 AM, an interview was conducted with the Administrator. When she was asked why she thought the IJ occurred with the emergency equipment not being available, she stated it was a "process breakdown." She stated the night nurses did not follow through by telling someone the equipment was not available. The Administrator stated there was no accountability from Central Supply or the DON. She stated Central Supply should have been checking the crash cart each morning for supplies needed. The Administrator stated the facility's new process should ensure the situation never happened again. She stated Central Supply would check the crash cart each morning and replace all equipment that was needed. She stated the DON would check the crash cart each morning, and on the weekend the weekend supervisor would be responsible for checking it. The Administrator stated the facility did not have a "back-up par plan" (a backup plan for extra supplies to be kept on hand). She stated the facility now had a policy requiring three items as a backup for all supplies needed on the crash cart. When the Administrator was asked when she became aware of the situation, she replied she had no knowledge of it until the surveyor informed the facility about it. A Plan of Removal was accepted on [DATE] at 11:45 AM and reflected the following: " Concern: Facility has [MEDICAL CONDITION] who is a full code and Ambu bags (not) accessible. Immediate Resolve: Ambu bags were located and made accessible to staff. Interventions: 1. Inventory of Crash Cart completed at 6:15 pm on [DATE] to assure all supplies are available. 2. Crash Cart Inventory will be monitored every night by night nurse. 3. DON/Designee will review Crash Cart Inventory log daily to ensure all supplies are available. 4. Facility will maintain a backup 3 items for all items in crash cart at all times. 5. Central Supply will check ensure backup items are available.. 6. Weekend Supervisor will check Crash Cart inventory log to ensure all supplies available and contact Nursing Administration immediately on weekends.. 7. For further emergency backup, an ambu bag will be kept in the medication room, DON office, Administration Office. 8. Charge Nurse will check resident room nightly to ensure ambu bag [MEDICAL CONDITION] are available. 9. Ambu Bag Procedure added to daily start-up procedures. In-services: 1. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies not available, to contact DON and Admin immediately. This will be completed by [DATE]. 2. Central Supply Supervisor in serviced on maintaining par level of supplies in the central supply room. 3. One on one inservice completed with DON on [DATE]" Review of the facility's new "Crash Cart Protocol," reflected the following: "Procedure: 1. Central supply Manager will ensure adequate supplies are in facility at all times. This will be accomplished by daily validation of minimum par levels of at least 3 of each item on crash cart checklist inventory. Central supply manager will review crash cart checklist daily to ensure there are no needed supplies. 2. Charge Nurse will complete crash cart inventory log nightly to ensure supplies are available. If any item is missing off the crash cart, nurse will restock from central supply. If there is any item found to be unavailable the DON/ADMIN will be notified immediately. 3. Charge nurses will validate nightly each resident room that requires alternative means of Emergency respiratory supplies. 4. Nursing Admin will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 5. Weekend supervisor will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 6. To ensure Ambu bags are available at all times, extra bags will be kept in medication room, DON office and ADMIN office. 7. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies are not available, to contact DON and ADMIN immediately. This process will be added to facility orientation packet. Nursing staff will not be allowed to work until all in servicing and new employee orientation is completed." The facility's current form entitled "The Daily Nursing Management Tool," dated [DATE], reflected the following: "Upon nurse manager arrival to unit- check staffing, receive report from the charge nurse and make extensive rounds. Assure that all residents have eaten breakfast." One of the Focus Areas for the nurse to complete was "Check Crash Cart Inventory log daily and restock as needed." The facility's current CPR policy, dated [DATE], reflected the following: "Guidelines:...C. Nurses Responding: Establish a patent airway. a. Use lift, jaw lift technique or nasal airway. Do not hyperextend neck of any resident. b. Remove dentures if they are obstructing the airway. c. Begin CPR - one person rate in accordance with the current American Heart Association/American Red Cross Standards use single use resuscitation mask mouth-to-mouth or mouth to nose until ambu bag is obtained." Administration provided a copy of the newly developed Crash Cart Protocol and Procedures to the survey staff with their Plan of Removal on [DATE]. Review of an In-Service Training Report, dated [DATE], revealed the subject of the training was "CRASH CART INVENTORY LOG," and 29 nursing and administrative staff were provided the training. Review of the staff sign-in sheet for the training revealed the three nurses (LVNs I, J and K) who worked the night shift from 10:00 PM to 6:00 AM and who were responsible for checking the crash cart inventory, attended the training. Interviews were conducted with facility staff to determine if they had been in-serviced and had knowledge of what to do if emergency equipment was not available in the resident's room or on the crash cart. The following staff were interviewed: On [DATE] at 3:35 PM, an interview was conducted with LVN P. He stated if there was no ambu bag on the cart, he would go to the Central Supply room and the medication room. He stated he knew there was one ambu bag in the DON's office and the Administrator's office. He stated if supplies were not on the crash cart or available for them, staff were to call the DON or Administrator immediately. LVN P stated he never had a problem with supplies not being on the crash cart and he expected the equipment would be there. On [DATE] at 4:25 PM, an interview was conducted with LVN R. She stated if there was no ambu bag on the crash cart she would go to Central Supply or the medication room. She stated if there were no ambu bags, she would call the DON or Administrator immediately. On [DATE] at 4:35 PM, an interview was conducted with LVN H. He stated if there was no ambu bag in Resident #5's room or on the crash cart, he would go to the medication room or the Central Supply room to retrieve one. He stated staff had been instructed to call the DON or Administrator if they were unable to find the needed equipment right away. On [DATE] at 11:15 PM, an interview was conducted with LVN K. He stated if he did not find an ambu bag in Resident #5's room or on the cart, he would go to the Central Supply room and get one. He confirmed he had a key to the central supply room. He stated if he could not find one there, he would check in the medication room and if none were found, he would call the DON or Administrator immediately. On [DATE] at 11:20 PM, an interview was conducted with LVN I. He stated if he did not find an ambu bag on the crash cart, he would go to Central Supply and get one. He stated if he did not find one in the Central Supply room, he would call the DON or Administrator immediately. The IJ was removed on [DATE]. While the IJ was removed, the facility remained out of compliance a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy." On [DATE] at 10:17 AM, the Administrator and Corporate RN A were notified the IJ was removed. 2) The MDS assessment, dated [DATE], reflected Resident #16 was a [AGE] year-old male who was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Resident #16's MDS assessment also reflected he required supervision with setup help only with his ADLS and the assessment did not reflect any concerns with his mood or behavior. A Social Services Progress Note dated [DATE], reflected the following: "SS (Social Services) was informed that resident (Resident #16) told his (family member) that if (he/she) didn't take him home, that he would kill himself. SS then called (Resident #16's family member), and discussed sending him to (psychiatric hospital) to be evaluated. (Family member) said that was fine. Nursing called the physician, and he gave the order. SS called (psych hospital), and they said to send him to the ER and they would evaluate him to see if he was appropriated (sic) for admission. When the ambulance arrived to take the resident, he refused to go. He stated that he didn't mean what he said; he was just saying it to get his (family member) to take him home. His (family member)stated that he did this sort of thing often. The ambulance driver and SS talked with the resident at length, and he stated he had no plan to hurt himself, and he was not suicidal. He promised SS that if he ever had thoughts of hurting himself, he would report it to SS. SS suggested having the psychologist talk with the resident, but he refused, stating he was fine. SS informed the DON and Administrator of all of this." An interview on [DATE] at 10:00 AM with the Social Worker revealed he was told by someone (unable to recall who told him of the incident) after lunch on [DATE] (unable to recall exact time) about Resident #16's statement to his family member. The Social Worker stated he then told the Administrator and DON, and called Resident #16's family member. He stated Resident #16's family member told him Resident #16 always did that. The Social Worker stated he told Resident #16's family member the facility wanted to send the resident to a psychiatric hospital. The Social Worker stated the ambulance arrived around 3:00 PM or 3:30 PM. He stated the EMS worker talked with Resident #16, because the resident was refusing to go to the ER. The Social Worker stated Resident #16 told him he would not hurt himself. He stated Resident #16 also refused a psychiatric evaluation at the facility. He stated he was unable to explain why Resident #16 was not placed on one to one observation. The Social Worker stated one to one observation was when one person was assigned to one resident and stayed with the resident at all times. The Social Worker was unable to recall if a room search was done on Resident #16's room. The Social Worker did not know if an incident report was completed. The Social Worker stated he did not talk with Resident #16 until EMS was talking to the resident. He stated he honestly did not know how much time had elapsed from the time he learned of the incident until the time EMS arrived. The Social Worker stated he did not document the times in his notes. The Social Worker stated he assessed Resident #16 after the incident sometime in late [DATE], early February 2012. A Nurse's Note, dated [DATE] at 10:45 AM and written by the DON, reflected Resident #16's family member called the Administrator and told the Administrator Resident #16 told him/her he would kill himself if his wife did not take him home. The note also reflected Physician V was notified and an order was received to send the resident to the ER for evaluation. A Nurse's Note, dated [DATE] at 3:00 PM by the DON, reflected Resident #16's family member came to visit Resident #16. The note reflected the DON talked to Resident #16 and his family member, and explained to them the facility was sending the resident to the hospital for evaluation. The note reflected both the resident and his family member verbalized understanding. A Nurse's Note, dated [DATE] at 6:30 PM, reflected Resident #16 refused to go to the ER for evaluation. Incident/Accident Reports for [DATE], [DATE] and February 2012 were reviewed and there was not a Report regarding Resident #16's statement. Review of Resident #16's clinical record revealed there was no assessment completed on Resident #16 on [DATE] between 10:45 AM and 3:00 PM. The facility's current, undated Policy/Procedure for Suicide Precaution reflected the following: "Purpose: was to prevent injury to patient by maximizing environmental safety. Procedure: Suicide Precautions were to be implemented for patients/residents who have either harmed themselves, verbalized intent to do so, or indicated, in an overt or covert manner, a wish to do so. If the nurse is concerned about the patient's potential for suicide, the following steps are to be implemented: 1. Immediately place the resident on Constant Supervision. At no time should the resident be left unattended. 2. Notify the resident's physician and family of the resident's suicidal ideation 3. Follow physician orders 4. If a psychiatric consult is ordered it should be completed the same day as the request. 5. Search the patient's belongings, clothing, luggage, and packages at the time precautions are instituted...Remove all medications and other items considered unsafe, including call light, all cords, miniblinds, radios, belts, shoelaces, all clothing items, knives, plastic trash liners glass or sharp items, nail polish remover or other alcohol-containing solutions, matches or lighter, and any aerosol spray cans...Similar items belonging to the patient's roommate must also be removed. 6. If possible, transfer the resident to a private room close to the nurses' station, that affords the best protection and is devoid of all items that resident could utilize in a suicide attempt. 7. Until resident is transferred to a psychiatric facility/hospital, they must remain confined to their room under constant supervision. 8. Meals should be provided in resident room with disposable utensils (no knives/forks/napkins) 9. Resident must be transferred to psychiatric facility/hospital ASAP so that the appropriate treatment can be initiated. 10. If an immediate transfer to a psychiatric facility is not possible, contact 911 and inform them that resident is in imminent danger of harming self. 11. Documentation: Incident report should be initiated for suicidal ideation and nurse's notes completed every shift. Constant supervision should also be documented." An interview with the Administrator on [DATE] at 11:00 AM revealed she could not recall what time she found out about Resident #16 calling his family member and telling him/her he was going to kill himself. The Administrator stated she was told of the incident by the Social Worker. The Administrator was unable to explain why the facility's policy and procedure for Suicide Precautions was not followed. The Administrator stated the Social Worker was very involved in the situation. The Administrator stated Resident #16 told her his family member blew this type of stuff out of proportion. When asked if Resident #16's room was searched, the Administrator stated she did not know. When asked who would be responsible to do the room search, the Administrator stated probably nursing, social services, or maintenance. When asked if Resident #16 was placed on one to one observation, the Administrator stated the resident was at the front desk all the time. When asked what one to one observation was, the Administrator stated it was when someone was with the resident all the time. In an interview with the DON on [DATE] at 10:45 AM, she stated Resident #16 did not tell facility staff about wanting to kill himself, but his family member did. The DON stated the Administrator was informed of the incident around mid-morning. The DON stated it all happened quickly. The DON stated she stayed with Resident #16 for about 15 minutes and dressed the resident. The DON was unable to recall which nurse was taking care of Resident #16 that day. The DON was unable to recall if an accident/incident report was completed. An interview with LVN D on [DATE] at 2:00 PM revealed she was the nurse on duty on [DATE] taking care of Resident #16. LVN D stated she did not know anything about Resident #16 saying he was going to kill himself. LVN D stated that day ([DATE]) was the first time she heard of any of it. LVN D stated no one told her Resident #16 needed to be watched that day. An interview with Resident #16's family member on [DATE] at 2:15 PM, with Resident #16 present, revealed he/she was unable to recall the day or the time the incident occurred. Resident #16's family member stated the resident had done this one or two times in the past. At this time, Resident #16 stated he had no intentions of killing himself. Resident #16 stated that if he was going to kill himself, he would have done it a long time ago. 12) The Resident Cen

Based on observation, interview and record review, it was determined the Administrator and DON failed to ensure the facility was administered 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 two residents (Residents #5 and #16) of 16 residents reviewed for neglect. 1) The Administrator failed to: a. implement the facility's abuse/neglect policy. There was not an ambu bag in Resident #5's room in case his [MEDICAL CONDITION] was dislodged and there were no ambu bags in the Central Supply room or on the emergency cart. Three nurses knew there were no ambu bags on the emergency cart for nine days. b. implement the facility's policy for Suicide Prevention for Resident #16. When Resident #16 expressed a threat of suicide, he was not under constant supervision, his room was not searched, and an Incident/Accident Report was not completed. c. notify LVN D, Resident #16's charge nurse on [DATE], that the resident expressed a threat of suicide on [DATE]. 2) The DON failed to: a. monitor the emergency cart to ensure there were ambu bags available for residents in case of an emergency. b. supervise LVNs I, J, and K to ensure they kept the emergency cart stocked with ambu bags. c. notify LVN D, Resident #16's charge nurse on [DATE], that Resident #16 expressed a threat of suicide on [DATE]. 1) Ensure all emergency equipment to be used in case of a respiratory/cardiac emergency was kept at Resident #5's bedside for timely and easy access by the staff. There was no ambu bag in the resident's room on [DATE]. 2) Ensure there was an ambu bag on the emergency cart. The cart was checked each night by the night shift nurses who had been writing in a "?" (no or none) to indicate there was no ambu bag available on the cart for approximately nine days. 3) Ensure there was an adequate supply of ambu bags available in the facility. There were no ambu bags in the Central Supply, on the emergency cart, or in Resident #5's room for approximately one day. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 50 residents, including Resident #5, who were a Full Code, by placing them at risk for not receiving emergency respiratory care and assistance with breathing, which could result in brain damage and/or death. 4) Ensure they followed suicide precautions for Resident #16 when a family member called and reported the resident made the statement he was going to kill himself if the family did not come and get him. This failure created the potential for Resident #16 to have had the time and opportunity to carry out his threat of suicide and could have resulted in serious injury and/or death. This failure could affect the 37 residents in the facility with Depression. Findings included: 1) According to the Significant Change in Status MDS assessment, dated [DATE], Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #5 was aphasic, severely cognitively impaired and dependent on staff for all needs. The assessment also reflected Resident #5 required the assistance of two staff members for bed mobility and dressing. The assessment reflected Resident #5 was bedfast and required the assistance of one staff member for hygiene and bathing. The assessment reflected Resident #5 had impairment on both sides of his upper and lower extremities. The assessment also reflected Resident #5 had a gastrostomy tube, Foley catheter, [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The Face Sheet, dated [DATE], reflected Resident #5 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #5's current Care Plan, dated [DATE], reflected the resident had impaired gas exchange related [MEDICAL CONDITION] and respiratory infection, and he was a Full Code. The plan reflected the approaches to the Full Code were "To perform CPR if indicated i.e. [MEDICAL CONDITION], Respiratory Arrest, To continue CPR until Resident responds or EMS arrives to take over the code." The Nurse's Notes, dated [DATE] at 4:00 PM, reflected Resident #5 was admitted to Hospice services. The Nurse's Notes, dated [DATE] at 9:30 AM, reflected Resident #5's inner cannula for the [MEDICAL CONDITION] came out. Resident #5 was alert and responsive, according to the Notes. The notes further reflected when the Hospice nurse was contacted and asked the facility staff if there was another cannula. The facility nurse said there was not another cannula and the resident was transferred to the emergency room for re-insertion of the [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 8:45 AM, reflected Resident #5'[MEDICAL CONDITION] was out of the ostomy ([MEDICAL CONDITION] stoma site-which is a surgical opening into the windpipe to allow for [MEDICAL CONDITION] to be placed and air exchange) and the nurse contacted the Hospice nurse. The Notes reflected the resident was responsive and alert. The Notes reflected when the Hospice nurse arrived, she attempted to reinsert the tube, but was unable to gain access due to resistance. The Notes reflected 911 was notified and when the EMS personnel entered the resident's room, his oxygen saturation was down to 86% (normal range 96% - 100%) and the resident was transferred to the hospital for re-insertion of [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 2:15 AM, reflected Resident #5 pulled [MEDICAL CONDITION] out and his oxygen saturation level was 77% and going down. The Notes reflected staff called 911 and used the ambu bag (medical device used to provide assisted ventilation to people who are either not breathing or are having difficulty breathing) to oxygenate the resident until emergency personnel arrived and transferred the resident to the emergency room . The Notes reflected Resident #5 returned to the facility at 4:00 AM. The Nurse's Notes, dated [DATE] at 8:15 PM, reflected Resident #5 was having a [MEDICAL CONDITION], which lasted for less than a minute. The Notes reflected after the [MEDICAL CONDITION], the [MEDICAL CONDITION] was out. The Notes also reflected the facility notified the Nurse Practitioner and obtained orders to send the resident to the hospital. The Notes reflected Resident #5's oxygen saturation levels fluctuated between 88 to 90%. The Notes reflected Resident #5 returned to the facility at 11:00 PM with the same temporary [MEDICAL CONDITION] reinserted. The Patient Transfer Form, dated [DATE], reflected the following: "Patient in bed, he had convulsion for less than a minute that (sic) when the [MEDICAL CONDITION] came out, Pulse ox (oximeter) 90%, ? acute distress noted, MD made aware new order initiated to transport patient to (Hospital) for [MEDICAL CONDITION] replacement/placement." On [DATE] at 2:45 PM , LVN H was observed providing [MEDICAL CONDITION] care to Resident #5. LVN H cleaned the stoma and reapplied [MEDICAL CONDITION]. LVN H was asked if there was an ambu bag or an [MEDICAL CONDITION] in the room. He checked in the closet where all the respiratory supplies were kept and on the wall and he could not find either. On [DATE] at 3:30 PM, the surveyor notified Corporate RN A there was no ambu bag or extra [MEDICAL CONDITION] in Resident #5's room. Corporate RN A also went to check the resident's room and could not find either an ambu bag or replacement [MEDICAL CONDITION]. On [DATE] at 3:40 PM, Corporate RN A revealed she found the extra Shiley #[MEDICAL CONDITION] in the top drawer of the cabinet in Resident #5's room and it was now taped to the wall beside his bed. She stated there were no ambu bags found in the facility and she sent a nurse to the hospital to obtain an ambu bag. She stated the emergency services provider the facility used was bringing two more "ASAP" (as soon as possible). On [DATE] at 3:45 PM, the emergency cart was checked and there was no ambu bag on the cart. At this time, the Crash Cart Checklist for February and [DATE] was also checked. The section for the ambu bag was filled in with an "?" for the following dates: [DATE], [DATE], and [DATE] through [DATE]. On [DATE] at 4:05 PM, the DON provided a list of the nurses who worked the 10:00 PM to 6:00 AM shift and initialed the Crash Cart Checklist from [DATE] through [DATE]. The list reflected the three nurses who checked and documented there was no ambu bag on the crash cart were LVNs I, J and K. On [DATE] at 4:40 PM, an interview was conducted with LVN I. He stated he remembered the 2:00 PM to 10:00 PM nurse told LVN J they used the ambu bag and needed another one. LVN I was not sure who the resident was who used the ambu bag nor did he remember when it was used. He stated LVN J left a note for Central Supply indicating there was no ambu bag on the crash cart. He also stated they did not go to Central Supply to check for one. He stated if there was a zero with a line drawn through it that meant there was no ambu bag on the cart. LVN I stated there had not been an ambu bag on the cart since the last part of February 2012. He stated he called the Central Supply/Medical Records Director the morning of [DATE] and reported there was no ambu bag on the emergency cart. On [DATE] at 4:58 PM, an interview was conducted with LVN K. He stated he did not work on the 100 and 200 Halls. He stated the nurse, who worked those halls, was usually responsible for checking the emergency cart. LVN K stated if he needed equipment or supplies, he would go to Central Supply and look for them, because he had a key to Central Supply. He stated if he did not find the supplies, he would alert the DON, sign the list in Central Supply, write it on the 24-hour Report or drop a note to the DON or Central Supply person. LVN K stated he remembered somewhere around the middle of February 2012, Resident #5 pulled his [MEDICAL CONDITION] out, they called 911, and they used the ambu bag until EMS arrived and the ambu bag went with the resident to the hospital. On [DATE] at 9:45 PM, an interview was conducted with LVN J. She stated she noticed about a week ago there was no ambu bag on the emergency cart. She stated she went to Central Supply and checked for one, but did not find one. She stated she wrote a note on the paper kept in Central Supply. LVN J stated central supply was to restock the equipment and since she wrote a note, she did not tell anyone about not having an ambu bag available on the crash cart. On [DATE] at 4:10 PM, the Social Worker provided the survey team with a list of residents who were "Full Codes." Review of the list revealed there were 50 residents in the facility, including Resident #5, identified with "Full Code" status and who would require CPR be initiated in the case of a cardiac or respiratory arrest. On [DATE] at 4:15 PM, Corporate RN A stated the facility now had two ambu bags/masks and connectors for the [MEDICAL CONDITION] in the building. On [DATE] at 4:22 PM, an interview was conducted with the Central Supply/Medical Records Director. She stated the night shift nurses had a key to Central Supply and could replenish the items they needed from the stock. When asked how staff let her know if stock was low or needed to be replaced, she stated they would call her at home at night or they would slip her a note under the door to Medical Records. She stated there was also a sheet in the Central Supply room where they could write down what items they needed. During this same interview with the Central Supply/Medical Records Director, she stated LVN I came in that morning around 10:00 AM and told her they needed an ambu bag for the crash cart. She stated she just got staffing information for the State, and she wrote a note on a piece of paper and placed it on her desk. She stated she thought there was an extra ambu bag in Central Supply. The Central Supply/Medical Records Director stated when the surveyor notified facility staff there were no ambu bags on the emergency cart, she went to check in Central Supply and verified there was not one in there. She stated as soon as she became aware of the situation, she immediately went to work on it and within 20 minutes she had two ambu bags in the facility and four more on the way. On [DATE] at 4:36 PM, Corporate RN A stated the DON had two blue ambu bags locked in the closet in her office where she kept the discontinued/expired narcotic medications and they were now available for use for residents. On [DATE] at 4:38 PM, the DON confirmed the ambu bags were locked in the closet in her office where she kept the discontinued/expired narcotic medications. She also stated she had the only keys to the locked closet in her office and when she left the building, she locked her office. The facility's current Abuse Program, dated [DATE], was identified by the Administrator as the current facility policy covering the areas of neglect, abuse, misappropriation and involuntary seclusion. The policy reflected the following: "POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents... Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." "Prevention: 4. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is a risk for occurring." On [DATE] an IJ was identified. On [DATE] at 5:34 PM, the Administrator, DON and Corporate RN A were notified of the IJ in the area of Quality of Care for Resident #5 and a Plan of Removal was requested at that time. On [DATE] at 5:30 PM, an interview was conducted with the Central Supply/Medical Records Director who stated she was not aware the DON had two ambu bags in her office. She stated she did not find out until she went into the DON's office and reported to the DON she thought she had a blue ambu bag in Central Supply, but could not find it. She stated then the DON told her she thought she had seen some ambu bags in her closet. She stated the DON found two ambu bags in her locked closet. On [DATE] at 6:38 PM, an interview was conducted with the DON. When asked when she became aware there were no ambu bags available in the facility, she replied she had not known about it until the surveyor informed her. The DON stated she periodically checked the emergency cart, but she had not done that in a while. She stated it was the 10:00 PM to 6:00 AM shift nurses' responsibility to check the crash cart and do the checklist, and refill it with what supplies were needed. The DON stated the staff would usually call her if they needed anything or sent her a note. She confirmed she had not received any notes from the staff or been contacted by the staff regarding ambu bags not being available. The DON stated they would in-service all staff as to what to do if they did not find supplies or equipment. She stated they were to look for the supplies in Central Supply and if they could not find them, they were to call her. She stated she lived close. She stated she would check the emergency cart each morning, Monday through Friday, and the weekend supervisor would check the cart on Saturday and Sunday. On [DATE] at 10:00 AM, an interview was conducted with the Central Supply/Medical Records Director. She stated she would check the supplies on the emergency cart and in Resident #5's room each morning. She stated she now had eight ambu bags available in the facility. She showed the surveyor the four ambu bags currently in Central Supply, but stated she was going to take one of them and place it on a hook in the medication room. She stated there was one on the emergency cart, one in Resident #5's room, one in the Administrator's office and one in the DON's office. On [DATE] at 8:45 AM, an interview was conducted with the Administrator. When she was asked why she thought the IJ occurred with the emergency equipment not being available, she stated it was a "process breakdown." She stated the night nurses did not follow through by telling someone the equipment was not available. The Administrator stated there was no accountability from Central Supply or the DON. She stated Central Supply should have been checking the crash cart each morning for supplies needed. The Administrator stated the facility's new process should ensure the situation never happened again. She stated Central Supply would check the crash cart each morning and replace all equipment that was needed. She stated the DON would check the crash cart each morning, and on the weekend the weekend supervisor would be responsible for checking it. The Administrator stated the facility did not have a "back-up par plan" (a backup plan for extra supplies to be kept on hand). She stated the facility now had a policy requiring three items as a backup for all supplies needed on the crash cart. When the Administrator was asked when she became aware of the situation, she replied she had no knowledge of it until the surveyor informed the facility about it. A Plan of Removal was accepted on [DATE] at 11:45 AM and reflected the following: " Concern: Facility has [MEDICAL CONDITION] who is a full code and Ambu bags (not) accessible. Immediate Resolve: Ambu bags were located and made accessible to staff. Interventions: 1. Inventory of Crash Cart completed at 6:15 pm on [DATE] to assure all supplies are available. 2. Crash Cart Inventory will be monitored every night by night nurse. 3. DON/Designee will review Crash Cart Inventory log daily to ensure all supplies are available. 4. Facility will maintain a backup 3 items for all items in crash cart at all times. 5. Central Supply will check ensure backup items are available.. 6. Weekend Supervisor will check Crash Cart inventory log to ensure all supplies available and contact Nursing Administration immediately on weekends.. 7. For further emergency backup, an ambu bag will be kept in the medication room, DON office, Administration Office. 8. Charge Nurse will check resident room nightly to ensure ambu bag [MEDICAL CONDITION] are available. 9. Ambu Bag Procedure added to daily start-up procedures. In-services: 1. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies not available, to contact DON and Admin immediately. This will be completed by [DATE]. 2. Central Supply Supervisor in serviced on maintaining par level of supplies in the central supply room. 3. One on one inservice completed with DON on [DATE]" Review of the facility's new "Crash Cart Protocol," reflected the following: "Procedure: 1. Central supply Manager will ensure adequate supplies are in facility at all times. This will be accomplished by daily validation of minimum par levels of at least 3 of each item on crash cart checklist inventory. Central supply manager will review crash cart checklist daily to ensure there are no needed supplies. 2. Charge Nurse will complete crash cart inventory log nightly to ensure supplies are available. If any item is missing off the crash cart, nurse will restock from central supply. If there is any item found to be unavailable the DON/ADMIN will be notified immediately. 3. Charge nurses will validate nightly each resident room that requires alternative means of Emergency respiratory supplies. 4. Nursing Admin will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 5. Weekend supervisor will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 6. To ensure Ambu bags are available at all times, extra bags will be kept in medication room, DON office and ADMIN office. 7. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies are not available, to contact DON and ADMIN immediately. This process will be added to facility orientation packet. Nursing staff will not be allowed to work until all in servicing and new employee orientation is completed." The facility's current form entitled "The Daily Nursing Management Tool," dated [DATE], reflected the following: "Upon nurse manager arrival to unit- check staffing, receive report from the charge nurse and make extensive rounds. Assure that all residents have eaten breakfast." One of the Focus Areas for the nurse to complete was "Check Crash Cart Inventory log daily and restock as needed." The facility's current CPR policy, dated [DATE], reflected the following: "Guidelines:...C. Nurses Responding: Establish a patent airway. a. Use lift, jaw lift technique or nasal airway. Do not hyperextend neck of any resident. b. Remove dentures if they are obstructing the airway. c. Begin CPR - one person rate in accordance with the current American Heart Association/American Red Cross Standards use single use resuscitation mask mouth-to-mouth or mouth to nose until ambu bag is obtained." Administration provided a copy of the newly developed Crash Cart Protocol and Procedures to the survey staff with their Plan of Removal on [DATE]. Review of an In-Service Training Report, dated [DATE], revealed the subject of the training was "CRASH CART INVENTORY LOG," and 29 nursing and administrative staff were provided the training. Review of the staff sign-in sheet for the training revealed the three nurses (LVNs I, J and K) who worked the night shift from 10:00 PM to 6:00 AM and who were responsible for checking the crash cart inventory, attended the training. Interviews were conducted with facility staff to determine if they had been in-serviced and had knowledge of what to do if emergency equipment was not available in the resident's room or on the crash cart. The following staff were interviewed: On [DATE] at 3:35 PM, an interview was conducted with LVN P. He stated if there was no ambu bag on the cart, he would go to the Central Supply room and the medication room. He stated he knew there was one ambu bag in the DON's office and the Administrator's office. He stated if supplies were not on the crash cart or available for them, staff were to call the DON or Administrator immediately. LVN P stated he never had a problem with supplies not being on the crash cart and he expected the equipment would be there. On [DATE] at 4:25 PM, an interview was conducted with LVN R. She stated if there was no ambu bag on the crash cart she would go to Central Supply or the medication room. She stated if there were no ambu bags, she would call the DON or Administrator immediately. On [DATE] at 4:35 PM, an interview was conducted with LVN H. He stated if there was no ambu bag in Resident #5's room or on the crash cart, he would go to the medication room or the Central Supply room to retrieve one. He stated staff had been instructed to call the DON or Administrator if they were unable to find the needed equipment right away. On [DATE] at 11:15 PM, an interview was conducted with LVN K. He stated if he did not find an ambu bag in Resident #5's room or on the cart, he would go to the Central Supply room and get one. He confirmed he had a key to the central supply room. He stated if he could not find one there, he would check in the medication room and if none were found, he would call the DON or Administrator immediately. On [DATE] at 11:20 PM, an interview was conducted with LVN I. He stated if he did not find an ambu bag on the crash cart, he would go to Central Supply and get one. He stated if he did not find one in the Central Supply room, he would call the DON or Administrator immediately. The IJ was removed on [DATE]. While the IJ was removed, the facility remained out of compliance a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy." On [DATE] at 10:17 AM, the Administrator and Corporate RN A were notified the IJ was removed. 2) The MDS assessment, dated [DATE], reflected Resident #16 was a [AGE] year-old male who was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Resident #16's MDS assessment also reflected he required supervision with setup help only with his ADLS and the assessment did not reflect any concerns with his mood or behavior. A Social Services Progress Note dated [DATE], reflected the following: "SS (Social Services) was informed that resident (Resident #16) told his (family member) that if (he/she) didn't take him home, that he would kill himself. SS then called (Resident #16's family member), and discussed sending him to (psychiatric hospital) to be evaluated. (Family member) said that was fine. Nursing called the physician, and he gave the order. SS called (psych hospital), and they said to send him to the ER and they would evaluate him to see if he was appropriated (sic) for admission. When the ambulance arrived to take the resident, he refused to go. He stated that he didn't mean what he said; he was just saying it to get his (family member) to take him home. His (family member)stated that he did this sort of thing often. The ambulance driver and SS talked with the resident at length, and he stated he had no plan to hurt himself, and he was not suicidal. He promised SS that if he ever had thoughts of hurting himself, he would report it to SS. SS suggested having the psychologist talk with the resident, but he refused, stating he was fine. SS informed the DON and Administrator of all of this." An interview on [DATE] at 10:00 AM with the Social Worker revealed he was told by someone (unable to recall who told him of the incident) after lunch on [DATE] (unable to recall exact time) about Resident #16's statement to his family member. The Social Worker stated he then told the Administrator and DON, and called Resident #16's family member. He stated Resident #16's family member told him Resident #16 always did that. The Social Worker stated he told Resident #16's family member the facility wanted to send the resident to a psychiatric hospital. The Social Worker stated the ambulance arrived around 3:00 PM or 3:30 PM. He stated the EMS worker talked with Resident #16, because the resident was refusing to go to the ER. The Social Worker stated Resident #16 told him he would not hurt himself. He stated Resident #16 also refused a psychiatric evaluation at the facility. He stated he was unable to explain why Resident #16 was not placed on one to one observation. The Social Worker stated one to one observation was when one person was assigned to one resident and stayed with the resident at all times. The Social Worker was unable to recall if a room search was done on Resident #16's room. The Social Worker did not know if an incident report was completed. The Social Worker stated he did not talk with Resident #16 until EMS was talking to the resident. He stated he honestly did not know how much time had elapsed from the time he learned of the incident until the time EMS arrived. The Social Worker stated he did not document the times in his notes. The Social Worker stated he assessed Resident #16 after the incident sometime in late [DATE], early February 2012. A Nurse's Note, dated [DATE] at 10:45 AM and written by the DON, reflected Resident #16's family member called the Administrator and told the Administrator Resident #16 told him/her he would kill himself if his wife did not take him home. The note also reflected Physician V was notified and an order was received to send the resident to the ER for evaluation. A Nurse's Note, dated [DATE] at 3:00 PM by the DON, reflected Resident #16's family member came to visit Resident #16. The note reflected the DON talked to Resident #16 and his family member, and explained to them the facility was sending the resident to the hospital for evaluation. The note reflected both the resident and his family member verbalized understanding. A Nurse's Note, dated [DATE] at 6:30 PM, reflected Resident #16 refused to go to the ER for evaluation. Incident/Accident Reports for [DATE], [DATE] and February 2012 were reviewed and there was not a Report regarding Resident #16's statement. Review of Resident #16's clinical record revealed there was no assessment completed on Resident #16 on [DATE] between 10:45 AM and 3:00 PM. The facility's current, undated Policy/Procedure for Suicide Precaution reflected the following: "Purpose: was to prevent injury to patient by maximizing environmental safety. Procedure: Suicide Precautions were to be implemented for patients/residents who have either harmed themselves, verbalized intent to do so, or indicated, in an overt or covert manner, a wish to do so. If the nurse is concerned about the patient's potential for suicide, the following steps are to be implemented: 1. Immediately place the resident on Constant Supervision. At no time should the resident be left unattended. 2. Notify the resident's physician and family of the resident's suicidal ideation 3. Follow physician orders 4. If a psychiatric consult is ordered it should be completed the same day as the request. 5. Search the patient's belongings, clothing, luggage, and packages at the time precautions are instituted...Remove all medications and other items considered unsafe, including call light, all cords, miniblinds, radios, belts, shoelaces, all clothing items, knives, plastic trash liners glass or sharp items, nail polish remover or other alcohol-containing solutions, matches or lighter, and any aerosol spray cans...Similar items belonging to the patient's roommate must also be removed. 6. If possible, transfer the resident to a private room close to the nurses' station, that affords the best protection and is devoid of all items that resident could utilize in a suicide attempt. 7. Until resident is transferred to a psychiatric facility/hospital, they must remain confined to their room under constant supervision. 8. Meals should be provided in resident room with disposable utensils (no knives/forks/napkins) 9. Resident must be transferred to psychiatric facility/hospital ASAP so that the appropriate treatment can be initiated. 10. If an immediate transfer to a psychiatric facility is not possible, contact 911 and inform them that resident is in imminent danger of harming self. 11. Documentation: Incident report should be initiated for suicidal ideation and nurse's notes completed every shift. Constant supervision should also be documented." An interview with the Administrator on [DATE] at 11:00 AM revealed she could not recall what time she found out about Resident #16 calling his family member and telling him/her he was going to kill himself. The Administrator stated she was told of the incident by the Social Worker. The Administrator was unable to explain why the facility's policy and procedure for Suicide Precautions was not followed. The Administrator stated the Social Worker was very involved in the situation. The Administrator stated Resident #16 told her his family member blew this type of stuff out of proportion. When asked if Resident #16's room was searched, the Administrator stated she did not know. When asked who would be responsible to do the room search, the Administrator stated probably nursing, social services, or maintenance. When asked if Resident #16 was placed on one to one observation, the Administrator stated the resident was at the front desk all the time. When asked what one to one observation was, the Administrator stated it was when someone was with the resident all the time. In an interview with the DON on [DATE] at 10:45 AM, she stated Resident #16 did not tell facility staff about wanting to kill himself, but his family member did. The DON stated the Administrator was informed of the incident around mid-m

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for two (Residents #5 and #16) of 16 residents reviewed/observed for abuse/neglect. The facility failed to: 1) Ensure all emergency equipment to be used in case of a respiratory/cardiac emergency was kept at Resident #5's bedside for timely and easy access by the staff. There was no ambu bag in the resident's room on [DATE]. 2) Ensure there was an ambu bag on the emergency cart. The cart was checked each night by the night shift nurses who had been writing in a "?" (no or none) to indicate there was no ambu bag available on the cart for approximately nine days. 3) Ensure there was an adequate supply of ambu bags available in the facility. There were no ambu bags in the Central Supply, on the emergency cart, or in Resident #5's room for approximately one day. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still monitoring its Plan of Removal. These failures could affect the 50 residents, including Resident #5, who were a Full Code, by placing them at risk for not receiving emergency respiratory care and assistance with breathing, which could result in brain damage and/or death. 4) Ensure they followed suicide precautions for Resident #16 when a family member called and reported the resident made the statement he was going to kill himself if the family did not come and get him. This failure created the potential for Resident #16 to have had the time and opportunity to carry out his threat of suicide and could have resulted in serious injury and/or death. This failure could affect the 37 residents in the facility with Depression. Findings included: 1) The facility's current Abuse Program, dated [DATE], was identified by the Administrator as the current facility policy covering the areas of neglect, abuse, misappropriation and involuntary seclusion. The policy reflected the following: "POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents... Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." "Prevention: 4. Facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is a risk for occurring." 2) According to the Significant Change in Status MDS assessment, dated [DATE], Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #5 was aphasic, severely cognitively impaired and dependent on staff for all needs. The assessment also reflected Resident #5 required the assistance of two staff members for bed mobility and dressing. The assessment reflected Resident #5 was bedfast and required the assistance of one staff member for hygiene and bathing. The assessment reflected Resident #5 had impairment on both sides of his upper and lower extremities. The assessment also reflected Resident #5 had a gastrostomy tube, Foley catheter, [MEDICAL CONDITION] and a [MEDICAL CONDITION]. The Face Sheet, dated [DATE], reflected Resident #5 was a [AGE] year-old male who was originally admitted to the facility on [DATE]. Resident #5's current Care Plan, dated [DATE], reflected the resident had impaired gas exchange related [MEDICAL CONDITION] and respiratory infection, and he was a Full Code. The plan reflected the approaches to the Full Code were "To perform CPR if indicated i.e. [MEDICAL CONDITION], Respiratory Arrest, To continue CPR until Resident responds or EMS arrives to take over the code." The Nurse's Notes, dated [DATE] at 4:00 PM, reflected Resident #5 was admitted to Hospice services. The Nurse's Notes, dated [DATE] at 9:30 AM, reflected Resident #5's inner cannula for the [MEDICAL CONDITION] came out. Resident #5 was alert and responsive, according to the Notes. The notes further reflected when the Hospice nurse was contacted and asked the facility staff if there was another cannula. The facility nurse said there was not another cannula and the resident was transferred to the emergency room for re-insertion of the [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 8:45 AM, reflected Resident #5'[MEDICAL CONDITION] was out of the ostomy ([MEDICAL CONDITION] stoma site-which is a surgical opening into the windpipe to allow for [MEDICAL CONDITION] to be placed and air exchange) and the nurse contacted the Hospice nurse. The Notes reflected the resident was responsive and alert. The Notes reflected when the Hospice nurse arrived, she attempted to reinsert the tube, but was unable to gain access due to resistance. The Notes reflected 911 was notified and when the EMS personnel entered the resident's room, his oxygen saturation was down to 86% (normal range 96% - 100%) and the resident was transferred to the hospital for re-insertion of [MEDICAL CONDITION]. The Nurse's Notes, dated [DATE] at 2:15 AM, reflected Resident #5 pulled [MEDICAL CONDITION] out and his oxygen saturation level was 77% and going down. The Notes reflected staff called 911 and used the ambu bag (medical device used to provide assisted ventilation to people who are either not breathing or are having difficulty breathing) to oxygenate the resident until emergency personnel arrived and transferred the resident to the emergency room . The Notes reflected Resident #5 returned to the facility at 4:00 AM. The Nurse's Notes, dated [DATE] at 8:15 PM, reflected Resident #5 was having a [MEDICAL CONDITION], which lasted for less than a minute. The Notes reflected after the [MEDICAL CONDITION], the [MEDICAL CONDITION] was out. The Notes also reflected the facility notified the Nurse Practitioner and obtained orders to send the resident to the hospital. The Notes reflected Resident #5's oxygen saturation levels fluctuated between 88 to 90%. The Notes reflected Resident #5 returned to the facility at 11:00 PM with the same temporary [MEDICAL CONDITION] reinserted. The Patient Transfer Form, dated [DATE], reflected the following: "Patient in bed, he had convulsion for less than a minute that (sic) when the [MEDICAL CONDITION] came out, Pulse ox (oximeter) 90%, ? acute distress noted, MD made aware new order initiated to transport patient to (Hospital) for [MEDICAL CONDITION] replacement/placement." On [DATE] at 2:45 PM , LVN H was observed providing [MEDICAL CONDITION] care to Resident #5. LVN H cleaned the stoma and reapplied [MEDICAL CONDITION]. LVN H was asked if there was an ambu bag or an [MEDICAL CONDITION] in the room. He checked in the closet where all the respiratory supplies were kept and on the wall and he could not find either. On [DATE] at 3:30 PM, the surveyor notified Corporate RN A there was no ambu bag or extra [MEDICAL CONDITION] in Resident #5's room. Corporate RN A also went to check the resident's room and could not find either an ambu bag or replacement [MEDICAL CONDITION]. On [DATE] at 3:40 PM, Corporate RN A revealed she found the extra Shiley #[MEDICAL CONDITION] in the top drawer of the cabinet in Resident #5's room and it was now taped to the wall beside his bed. She stated there were no ambu bags found in the facility and she sent a nurse to the hospital to obtain an ambu bag. She stated the emergency services provider the facility used was bringing two more "ASAP" (as soon as possible). On [DATE] at 3:45 PM, the emergency cart was checked and there was no ambu bag on the cart. At this time, the Crash Cart Checklist for February and [DATE] was also checked. The section for the ambu bag was filled in with an "?" for the following dates: [DATE], [DATE], and [DATE] through [DATE]. On [DATE] at 4:05 PM, the DON provided a list of the nurses who worked the 10:00 PM to 6:00 AM shift and initialed the Crash Cart Checklist from [DATE] through [DATE]. The list reflected the three nurses who checked and documented there was no ambu bag on the crash cart were LVNs I, J and K. On [DATE] at 4:40 PM, an interview was conducted with LVN I. He stated he remembered the 2:00 PM to 10:00 PM nurse told LVN J they used the ambu bag and needed another one. LVN I was not sure who the resident was who used the ambu bag nor did he remember when it was used. He stated LVN J left a note for Central Supply indicating there was no ambu bag on the crash cart. He also stated they did not go to Central Supply to check for one. He stated if there was a zero with a line drawn through it that meant there was no ambu bag on the cart. LVN I stated there had not been an ambu bag on the cart since the last part of February 2012. He stated he called the Central Supply/Medical Records Director the morning of [DATE] and reported there was no ambu bag on the emergency cart. On [DATE] at 4:58 PM, an interview was conducted with LVN K. He stated he did not work on the 100 and 200 Halls. He stated the nurse, who worked those halls, was usually responsible for checking the emergency cart. LVN K stated if he needed equipment or supplies, he would go to Central Supply and look for them, because he had a key to Central Supply. He stated if he did not find the supplies, he would alert the DON, sign the list in Central Supply, write it on the 24-hour Report or drop a note to the DON or Central Supply person. LVN K stated he remembered somewhere around the middle of February 2012, Resident #5 pulled his [MEDICAL CONDITION] out, they called 911, and they used the ambu bag until EMS arrived and the ambu bag went with the resident to the hospital. On [DATE] at 9:45 PM, an interview was conducted with LVN J. She stated she noticed about a week ago there was no ambu bag on the emergency cart. She stated she went to Central Supply and checked for one, but did not find one. She stated she wrote a note on the paper kept in Central Supply. LVN J stated central supply was to restock the equipment and since she wrote a note, she did not tell anyone about not having an ambu bag available on the crash cart. On [DATE] at 4:10 PM, the Social Worker provided the survey team with a list of residents who were "Full Codes." Review of the list revealed there were 50 residents in the facility, including Resident #5, identified with "Full Code" status and who would require CPR be initiated in the case of a cardiac or respiratory arrest. On [DATE] at 4:15 PM, Corporate RN A stated the facility now had two ambu bags/masks and connectors for the [MEDICAL CONDITION] in the building. On [DATE] at 4:22 PM, an interview was conducted with the Central Supply/Medical Records Director. She stated the night shift nurses had a key to Central Supply and could replenish the items they needed from the stock. When asked how staff let her know if stock was low or needed to be replaced, she stated they would call her at home at night or they would slip her a note under the door to Medical Records. She stated there was also a sheet in the Central Supply room where they could write down what items they needed. During this same interview with the Central Supply/Medical Records Director, she stated LVN I came in that morning around 10:00 AM and told her they needed an ambu bag for the crash cart. She stated she just got staffing information for the State, and she wrote a note on a piece of paper and placed it on her desk. She stated she thought there was an extra ambu bag in Central Supply. The Central Supply/Medical Records Director stated when the surveyor notified facility staff there were no ambu bags on the emergency cart, she went to check in Central Supply and verified there was not one in there. She stated as soon as she became aware of the situation, she immediately went to work on it and within 20 minutes she had two ambu bags in the facility and four more on the way. On [DATE] at 4:36 PM, Corporate RN A stated the DON had two blue ambu bags locked in the closet in her office where she kept the discontinued/expired narcotic medications and they were now available for use for residents. On [DATE] at 4:38 PM, the DON confirmed the ambu bags were locked in the closet in her office where she kept the discontinued/expired narcotic medications. She also stated she had the only keys to the locked closet in her office and when she left the building, she locked her office. On [DATE] an IJ was identified. On [DATE] at 5:34 PM, the Administrator, DON and Corporate RN A were notified of the IJ in the area of Quality of Care for Resident #5 and a Plan of Removal was requested at that time. On [DATE] at 5:30 PM, an interview was conducted with the Central Supply/Medical Records Director who stated she was not aware the DON had two ambu bags in her office. She stated she did not find out until she went into the DON's office and reported to the DON she thought she had a blue ambu bag in Central Supply, but could not find it. She stated then the DON told her she thought she had seen some ambu bags in her closet. She stated the DON found two ambu bags in her locked closet. On [DATE] at 6:38 PM, an interview was conducted with the DON. When asked when she became aware there were no ambu bags available in the facility, she replied she had not known about it until the surveyor informed her. The DON stated she periodically checked the emergency cart, but she had not done that in a while. She stated it was the 10:00 PM to 6:00 AM shift nurses' responsibility to check the crash cart and do the checklist, and refill it with what supplies were needed. The DON stated the staff would usually call her if they needed anything or sent her a note. She confirmed she had not received any notes from the staff or been contacted by the staff regarding ambu bags not being available. The DON stated they would in-service all staff as to what to do if they did not find supplies or equipment. She stated they were to look for the supplies in Central Supply and if they could not find them, they were to call her. She stated she lived close. She stated she would check the emergency cart each morning, Monday through Friday, and the weekend supervisor would check the cart on Saturday and Sunday. On [DATE] at 10:00 AM, an interview was conducted with the Central Supply/Medical Records Director. She stated she would check the supplies on the emergency cart and in Resident #5's room each morning. She stated she now had eight ambu bags available in the facility. She showed the surveyor the four ambu bags currently in Central Supply, but stated she was going to take one of them and place it on a hook in the medication room. She stated there was one on the emergency cart, one in Resident #5's room, one in the Administrator's office and one in the DON's office. On [DATE] at 8:45 AM, an interview was conducted with the Administrator. When she was asked why she thought the IJ occurred with the emergency equipment not being available, she stated it was a "process breakdown." She stated the night nurses did not follow through by telling someone the equipment was not available. The Administrator stated there was no accountability from Central Supply or the DON. She stated Central Supply should have been checking the crash cart each morning for supplies needed. The Administrator stated the facility's new process should ensure the situation never happened again. She stated Central Supply would check the crash cart each morning and replace all equipment that was needed. She stated the DON would check the crash cart each morning, and on the weekend the weekend supervisor would be responsible for checking it. The Administrator stated the facility did not have a "back-up par plan" (a backup plan for extra supplies to be kept on hand). She stated the facility now had a policy requiring three items as a backup for all supplies needed on the crash cart. When the Administrator was asked when she became aware of the situation, she replied she had no knowledge of it until the surveyor informed the facility about it. A Plan of Removal was accepted on [DATE] at 11:45 AM and reflected the following: " Concern: Facility has [MEDICAL CONDITION] who is a full code and Ambu bags (not) accessible. Immediate Resolve: Ambu bags were located and made accessible to staff. Interventions: 1. Inventory of Crash Cart completed at 6:15 pm on [DATE] to assure all supplies are available. 2. Crash Cart Inventory will be monitored every night by night nurse. 3. DON/Designee will review Crash Cart Inventory log daily to ensure all supplies are available. 4. Facility will maintain a backup 3 items for all items in crash cart at all times. 5. Central Supply will check ensure backup items are available.. 6. Weekend Supervisor will check Crash Cart inventory log to ensure all supplies available and contact Nursing Administration immediately on weekends.. 7. For further emergency backup, an ambu bag will be kept in the medication room, DON office, Administration Office. 8. Charge Nurse will check resident room nightly to ensure ambu bag [MEDICAL CONDITION] are available. 9. Ambu Bag Procedure added to daily start-up procedures. In-services: 1. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies not available, to contact DON and Admin immediately. This will be completed by [DATE]. 2. Central Supply Supervisor in serviced on maintaining par level of supplies in the central supply room. 3. One on one inservice completed with DON on [DATE]" Review of the facility's new "Crash Cart Protocol," reflected the following: "Procedure: 1. Central supply Manager will ensure adequate supplies are in facility at all times. This will be accomplished by daily validation of minimum par levels of at least 3 of each item on crash cart checklist inventory. Central supply manager will review crash cart checklist daily to ensure there are no needed supplies. 2. Charge Nurse will complete crash cart inventory log nightly to ensure supplies are available. If any item is missing off the crash cart, nurse will restock from central supply. If there is any item found to be unavailable the DON/ADMIN will be notified immediately. 3. Charge nurses will validate nightly each resident room that requires alternative means of Emergency respiratory supplies. 4. Nursing Admin will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 5. Weekend supervisor will validate crash cart inventory log daily via start up process to ensure all supplies are available. If items are found to be missing they will be restocked immediately. 6. To ensure Ambu bags are available at all times, extra bags will be kept in medication room, DON office and ADMIN office. 7. Nursing staff will be in serviced on restocking crash cart immediately after use and if supplies are not available, to contact DON and ADMIN immediately. This process will be added to facility orientation packet. Nursing staff will not be allowed to work until all in servicing and new employee orientation is completed." The facility's current form entitled "The Daily Nursing Management Tool," dated [DATE], reflected the following: "Upon nurse manager arrival to unit- check staffing, receive report from the charge nurse and make extensive rounds. Assure that all residents have eaten breakfast." One of the Focus Areas for the nurse to complete was "Check Crash Cart Inventory log daily and restock as needed." The facility's current CPR policy, dated [DATE], reflected the following: "Guidelines:...C. Nurses Responding: Establish a patent airway. a. Use lift, jaw lift technique or nasal airway. Do not hyperextend neck of any resident. b. Remove dentures if they are obstructing the airway. c. Begin CPR - one person rate in accordance with the current American Heart Association/American Red Cross Standards use single use resuscitation mask mouth-to-mouth or mouth to nose until ambu bag is obtained." Administration provided a copy of the newly developed Crash Cart Protocol and Procedures to the survey staff with their Plan of Removal on [DATE]. Review of an In-Service Training Report, dated [DATE], revealed the subject of the training was "CRASH CART INVENTORY LOG," and 29 nursing and administrative staff were provided the training. Review of the staff sign-in sheet for the training revealed the three nurses (LVNs I, J and K) who worked the night shift from 10:00 PM to 6:00 AM and who were responsible for checking the crash cart inventory, attended the training. Interviews were conducted with facility staff to determine if they had been in-serviced and had knowledge of what to do if emergency equipment was not available in the resident's room or on the crash cart. The following staff were interviewed: On [DATE] at 3:35 PM, an interview was conducted with LVN P. He stated if there was no ambu bag on the cart, he would go to the Central Supply room and the medication room. He stated he knew there was one ambu bag in the DON's office and the Administrator's office. He stated if supplies were not on the crash cart or available for them, staff were to call the DON or Administrator immediately. LVN P stated he never had a problem with supplies not being on the crash cart and he expected the equipment would be there. On [DATE] at 4:25 PM, an interview was conducted with LVN R. She stated if there was no ambu bag on the crash cart she would go to Central Supply or the medication room. She stated if there were no ambu bags, she would call the DON or Administrator immediately. On [DATE] at 4:35 PM, an interview was conducted with LVN H. He stated if there was no ambu bag in Resident #5's room or on the crash cart, he would go to the medication room or the Central Supply room to retrieve one. He stated staff had been instructed to call the DON or Administrator if they were unable to find the needed equipment right away. On [DATE] at 11:15 PM, an interview was conducted with LVN K. He stated if he did not find an ambu bag in Resident #5's room or on the cart, he would go to the Central Supply room and get one. He confirmed he had a key to the central supply room. He stated if he could not find one there, he would check in the medication room and if none were found, he would call the DON or Administrator immediately. On [DATE] at 11:20 PM, an interview was conducted with LVN I. He stated if he did not find an ambu bag on the crash cart, he would go to Central Supply and get one. He stated if he did not find one in the Central Supply room, he would call the DON or Administrator immediately. The IJ was removed on [DATE]. While the IJ was removed, the facility remained out of compliance a scope of "pattern" and a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy." On [DATE] at 10:17 AM, the Administrator and Corporate RN A were notified the IJ was removed. 3) The MDS assessment, dated [DATE], reflected Resident #16 was a [AGE] year-old male who was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. Resident #16's MDS assessment also reflected he required supervision with setup help only with his ADLS and the assessment did not reflect any concerns with his mood or behavior. A Social Services Progress Note dated [DATE], reflected the following: "SS (Social Services) was informed that resident (Resident #16) told his (family member) that if (he/she) didn't take him home, that he would kill himself. SS then called (Resident #16's family member), and discussed sending him to (psychiatric hospital) to be evaluated. (Family member) said that was fine. Nursing called the physician, and he gave the order. SS called (psych hospital), and they said to send him to the ER and they would evaluate him to see if he was appropriated (sic) for admission. When the ambulance arrived to take the resident, he refused to go. He stated that he didn't mean what he said; he was just saying it to get his (family member) to take him home. His (family member)stated that he did this sort of thing often. The ambulance driver and SS talked with the resident at length, and he stated he had no plan to hurt himself, and he was not suicidal. He promised SS that if he ever had thoughts of hurting himself, he would report it to SS. SS suggested having the psychologist talk with the resident, but he refused, stating he was fine. SS informed the DON and Administrator of all of this." An interview on [DATE] at 10:00 AM with the Social Worker revealed he was told by someone (unable to recall who told him of the incident) after lunch on [DATE] (unable to recall exact time) about Resident #16's statement to his family member. The Social Worker stated he then told the Administrator and DON, and called Resident #16's family member. He stated Resident #16's family member told him Resident #16 always did that. The Social Worker stated he told Resident #16's family member the facility wanted to send the resident to a psychiatric hospital. The Social Worker stated the ambulance arrived around 3:00 PM or 3:30 PM. He stated the EMS worker talked with Resident #16, because the resident was refusing to go to the ER. The Social Worker stated Resident #16 told him he would not hurt himself. He stated Resident #16 also refused a psychiatric evaluation at the facility. He stated he was unable to explain why Resident #16 was not placed on one to one observation. The Social Worker stated one to one observation was when one person was assigned to one resident and stayed with the resident at all times. The Social Worker was unable to recall if a room search was done on Resident #16's room. The Social Worker did not know if an incident report was completed. The Social Worker stated he did not talk with Resident #16 until EMS was talking to the resident. He stated he honestly did not know how much time had elapsed from the time he learned of the incident until the time EMS arrived. The Social Worker stated he did not document the times in his notes. The Social Worker stated he assessed Resident #16 after the incident sometime in late [DATE], early February 2012. A Nurse's Note, dated [DATE] at 10:45 AM and written by the DON, reflected Resident #16's family member called the Administrator and told the Administrator Resident #16 told him/her he would kill himself if his wife did not take him home. The note also reflected Physician V was notified and an order was received to send the resident to the ER for evaluation. A Nurse's Note, dated [DATE] at 3:00 PM by the DON, reflected Resident #16's family member came to visit Resident #16. The note reflected the DON talked to Resident #16 and his family member, and explained to them the facility was sending the resident to the hospital for evaluation. The note reflected both the resident and his family member verbalized understanding. A Nurse's Note, dated [DATE] at 6:30 PM, reflected Resident #16 refused to go to the ER for evaluation. Incident/Accident Reports for [DATE], [DATE] and February 2012 were reviewed and there was not a Report regarding Resident #16's statement. Review of Resident #16's clinical record revealed there was no assessment completed on Resident #16 on [DATE] between 10:45 AM and 3:00 PM. The facility's current, undated Policy/Procedure for Suicide Precaution reflected the following: "Purpose: was to prevent injury to patient by maximizing environmental safety. Procedure: Suicide Precautions were to be implemented for patients/residents who have either harmed themselves, verbalized intent to do so, or indicated, in an overt or covert manner, a wish to do so. If the nurse is concerned about the patient's potential for suicide, the following steps are to be implemented: 1. Immediately place the resident on Constant Supervision. At no time should the resident be left unattended. 2. Notify the resident's physician and family of the resident's suicidal ideation 3. Follow physician orders 4. If a psychiatric consult is ordered it should be completed the same day as the request. 5. Search the patient's belongings, clothing, luggage, and packages at the time precautions are instituted...Remove all medications and other items considered unsafe, including call light, all cords, miniblinds, radios, belts, shoelaces, all clothing items, knives, plastic trash liners glass or sharp items, nail polish remover or other alcohol-containing solutions, matches or lighter, and any aerosol spray cans...Similar items belonging to the patient's roommate must also be removed. 6. If possible, transfer the resident to a private room close to the nurses' station, that affords the best protection and is devoid of all items that resident could utilize in a suicide attempt. 7. Until resident is transferred to a psychiatric facility/hospital, they must remain confined to their room under constant supervision. 8. Meals should be provided in resident room with disposable utensils (no knives/forks/napkins) 9. Resident must be transferred to psychiatric facility/hospital ASAP so that the appropriate treatment can be initiated. 10. If an immediate transfer to a psychiatric facility is not possible, contact 911 and inform them that resident is in imminent danger of harming self. 11. Documentation: Incident report should be initiated for suicidal ideation and nurse's notes completed every shift. Constant supervision should also be documented." An interview with the Administrator on [DATE] at 11:00 AM revealed she could not recall what time she found out about Resident #16 calling his family member and telling him/her he was going to kill himself. The Administrator stated she was told of the incident by the Social Worker. The Administrator was unable to explain why the facility's policy and procedure for Suicide Precautions was not followed. The Administrator stated the Social Worker was very involved in the situation. The Administrator stated Resident #16 told her his family member blew this type of stuff out of proportion. When asked if Resident #16's room was searched, the Administrator stated she did not know. When asked who would be responsible to do the room search, the Administrator stated probably nursing, social services, or maintenance. When asked if Resident #16 was placed on one to one observation, the Administrator stated the resident was at the front desk all the time. When asked what one to one observation was, the Administrator stated it was when someone was with the resident all the time. In an interview with the DON on [DATE] at 10:45 AM, she stated Resident #16 did not tell facility staff about wanting to kill himself, but his family member did. The DON stated the Administrator was informed of the incident around mid-morning. The DON stated it all happened quickly. The DON stated she stayed with Resident #16 for about 15 minutes and dressed the resident. The DON was unable to recall which nurse was taking care of Resident #16 that day. The DON was unable to recall if an accident/incident report was completed. An interview with LVN D on [DATE] at 2:00 PM revealed she was the nurse on duty on [DATE] taking care of Resident #16. LVN D stated she did not know anything about Resident #16 saying he was going to kill himself. LVN D stated that day ([DATE]) was the first time she heard of any of it. LVN D stated no one told her Resident #16 needed to be watched that day. An interview with Resident #16's family member on [DATE] at 2:15 PM, with Resident #16 present, revealed he/she was unable to recall the day or the time the incident occurred. Resident #16's family member stated the resident had done this one or two times in the past. At this time, Resident #16 stated he had no intentions of killing himself. Resident #16 stated that if he was going to kill himself, he would have done it a long time ago. 12) The Resident