Every finding on record at Orchard Rehabilitation & Healthcare Center

Based on record review, interviews, and review of a facility policy titled Diagnostic Testing Services, the facility failed to ensure Resident Identifier (RI) #5's lab orders for a Comprehensive Metabolic Profile (CMP), Liver Panel, Lipid Panel, [MEDICATION NAME] Acid and Complete Blood Count (CBC) were collected and run in (MONTH) as ordered by the physician. Further, the facility failed to ensure RI #5's [MEDICATION NAME] Acid was collected in (MONTH) as ordered by the physician. This affected 1 of 15 sampled residents for whom labwork was reviewed. Findings include: A review of the facility's policy titled, Diagnostic Testing Services, with an effective date of (MONTH) 2004, revealed the following: . Purpose: Each resident has the right to receive diagnostic services, . Standard: Diagnostic testing should be scheduled by a physician's orders [REDACTED].>RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's (MONTH) (YEAR) physician's orders [REDACTED]. A review of RI #5's lab reports from (MONTH) (YEAR) through (MONTH) 2019 revealed the CMP, Liver Panel, Lipid Panel, and CBC were all performed in March, but not in September. The [MEDICATION NAME] Acid was drawn in (MONTH) and June, but was not performed in (MONTH) and December. On 01/31/19 at 11:10 a.m., Employee Identifier (EI) #2, Registered Nurse (RN) Supervisor, was asked about RI #5's missing labs. EI #2 stated they did not have them, and did not know if they had been done. EI #2 said RI #5 should have had a CMP, Liver Panel, Lipid Panel, [MEDICATION NAME] Acid and CBC completed in (MONTH) and December. When asked why it was important to monitor labs as ordered by the physician, EI #2 explained the physician's orders [REDACTED]. EI #4, the Director of Nursing, was interviewed on 01/31/2019 at 11:44 a.m EI #4 reviewed RI #5's lab orders and stated RI #5 should have had a CMP, Liver Panel, Lipid Panel, [MEDICATION NAME] Acid and CBC completed every six months in (MONTH) and September. She also said RI #5 should have had a [MEDICATION NAME] Acid completed in December. After reviewing all of RI #5's lab reports from (MONTH) (YEAR) until (MONTH) (YEAR), EI #4 said the labs were not collected as ordered. EI #4 said it was important to monitor labwork as ordered by the physician for treatment purposes.

Based on interviews and review of Resident Identifier (RI) #215's medical record, the facility's investigation file, the (Name) AMBULANCE Patient Care Report and a complaint submitted the Alabama State Survey Agency, the facility failed to honor the wishes of RI #215, a resident with Full Code status. Code status describes what type of intervention a health care facility would conduct should a resident stop breathing and/or their heart stop beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to activate the emergency response system and initiate Cardiopulmonary Resuscitation (CPR) in an attempt to revive the resident. During the 11:00 PM to 7:00 AM shift that began on [DATE], Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) entered RI #215's room and found the resident unresponsive. EI #4 informed EI #3, the Registered Nurse (RN), who was certified in CPR. EI #3 assessed the resident and found RI #215 did not have a pulse or respiration. After the assessment, EI #3 left the resident's room to activate the emergency response system. EI #3 did not return to the resident's room to initiate CPR. According to the (Name) AMBULANCE Patient Care Report, CPR was not being performed when they arrived. This deficient practice placed RI #215, one of 21 sampled residents, in immediate jeopardy of serious injury, harm, or death. On [DATE] at 4:15 PM, the Administrator and Director of Nursing were notified of the findings of immediate jeopardy in the area of Resident Rights, F 578. Findings include: On [DATE] at 12:21 PM, the facility submitted to the Alabama State Survey Agency an allegation of neglect. According to the report, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform Cardiopulmonary Resuscitation (CPR) on RI #215, a resident with Full Code status, who was found unresponsive on [DATE] at 5:45 AM. A typed statement on facility letterhead dated [DATE] signed by EI #2, the Director of Nursing (DON) documented Orchard Rehabilitation & Healthcare Center's Procedure for Identifying Residents Code Status In each resident's chart there is a form labeled; Resident Information Sheet. A Do Not Resuscitate (DNR) sticker is placed on this form indicating to the clinical staff that the resident has a DNR order and no CPR is warranted in the event the resident is found with no pulse, no respirations, no heartbeat or unconsciousness. Otherwise, the resident is a Full Code and CPR should be initiated. The nurses may but, is not required to write the Resident Information Sheet the words Full code which indicates CPR is to be provided if indicated. RI #215 was admitted to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. RI #215's undated RESIDENT INFORMATION SHEETS indicated the resident was a Full Code. The facility's 5-Day Investigation for (RI #215) dated [DATE], documented . On [DATE] around 5:45am, (EI #3), RN was informed by (EI #4), CNA that the resident was unresponsive and wasn't breathing. According to the nurse's notes after (EI #3) assessed the resident and found no pulse, no rise or fall in chest. Then, (EI #3) called the ambulance and informed them of resident's status. At 5:50 a.m., the ambulance arrived at the facility, EKG (electrocardiogram) strip obtained, indicating no signs of life . On [DATE], approximately 9:30a.m., the director of nursing (DON) audited the resident's medical record and upon reviewing the nurse's notes regarding the occurrences of events involving resident's expiration. During the audit, the initiation of CPR was not documented in the notes . around 10:30 a.m. DON asked her (EI #3) if CPR was performed on resident and nurse stated, No, I forgot . The facility substantiated that CPR was not performed by (EI #3), RN. On [DATE] at 11:20 AM, a telephone interview was conducted with EI #3, the RN who was notified that RI #215 was found unresponsive. EI #3 was asked, what did the American Heart Association CPR guidelines instruct staff to do when a person was found unresponsive. EI #3 said staff should check the pulse, check to see if the resident is breathing and initiate CPR. EI #3 was asked, what actions she took when she was informed RI #215 was unresponsive. EI #3 said she went into RI #215's room, checked the resident's pulse and looked to see if RI #215 was breathing. EI #3 said, RI #215's skin was cool to touch. After assessing RI #215, EI #3 left the resident's room to call the ambulance. EI #3 was asked if she had called a code or initiated CPR on RI #215. EI #3 said, no. When asked why she did not initiate CPR or call a code, EI #3 replied she panicked and forgot. When asked what RI #215's code status was, EI #3 stated she thought RI #215 was a Full Code. EI #3 explained that she had RI #215's medical record when she called the ambulance, but she did not check it to see what RI #215's code status was. EI #3 stated she did not think to check the resident's code status. When asked why not, EI #3 stated she panicked and forgot. In a follow-up telephone interview on [DATE] at 3:53 PM, EI #3 was asked what the harm was in failing to initiate CPR on RI #215, a resident withe Full Code status. EI #3 replied, the resident's wishes were not followed. RI #215's Departmental Notes, written by EI #3 and dated [DATE] 8:53 AM, documented: . 545AM Called to room by CNA. Resident lying in bed with eyes slightly open and mouth open with yellowish colored substance noted on gown and sheet. Unable to obtain pulse, no rise or fall of chest noted. (Name) Ambulance called and informed of resident status. 550 AM . (Name) Ambulance in facility, EKG strip ran, no sign of life noted. (Name) Ambulance exited building @ (at) 6AM . The (Name) AMBULANCE Patient Care Report indicated on [DATE] at 5:37 AM, EMS received an emergency call that RI #215 was found unresponsive in bed. According to the report, EMS arrived on scene at 5:45 AM and to the resident at 5:53 AM. The report further indicated . Arrived to find pt (patient) unresponsive in bed. Eyes dry pupils fixed and dialated (dilated), pulseless and apnic (apneic). Skin cool to touch color normal. No JVD (Jugular Vein Distention) or [MEDICAL CONDITION]. Asystole times 3 leads pacing spikes. Rigor starting to set in. No CPR being performed . No ACLS (Advanced Cardiac Life Support) pronounced at 0600 . In an interview on [DATE] at 9:50 AM, EI #1, the Administrator, was asked what should be done when a resident was found unresponsive. EI #1 said, CPR should be initiated. When asked if the facility's protocol was followed when RI #215 was found unresponsive on [DATE], EI #1 said no. EI #1 was asked, what should EI #3, the RN, have done when she was informed RI #215 was unresponsive, EI #1 said, EI #3 should have started CPR. When asked what the harm was in failing to provide CPR to RI #215, a resident with Full Code status, EI #1 said the resident's wishes were not followed. Contained within the facility's investigation was a document titled . ACTION PLAN TOOL . DATE: [DATE] PROBLEM IDENTIFIED: CPR not initiated ACTION PLAN Discussion in Interdisciplinary morning meeting regarding facility's current procedure to perform CPR, if indicated, providing the resident is not a DNR status. A DNR sticker is found on the Resident Information Sheet to alert the nurse of a DNR status. Discussion was if facility needed to add another sticker that says Full Code to all charts that are not a DNR. Plan at this time is not to change the current procedure for identifying a resident's code status. However, there is a QAPI opportunity to train & re-educate all nurses on proper procedure on when to perform CPR. Training in progress since [DATE], regarding when to perform CPR . COMPLETION DATE [DATE] DATE COMPLETION FINALIZED [DATE]. ****************************** On [DATE] at 2:15 PM the facility submitted an acceptable Allegation of Credible Compliance (A[NAME]C), which documented: . F578=IJ 1. On [DATE], RI#215 was admitted to the facility with a full code status. 2. On [DATE], RN did not perform Cardio [MEDICAL CONDITION] Resuscitation (CPR) on RI#215 after she accessed the resident and found that the resident was unresponsive. 3. On [DATE], RN received 1:1 training by the DON on performing CPR on a resident who is found unresponsive or no signs of life. The residents code status should be determined and the code status is followed according to the resident's Advance Directive. If the resident is a full code, the nurse should perform CPR. A resident is a full code unless, there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means that CPR is not warranted. All RNs received training on performing CPR by the DON on [DATE] which included: if a resident is found unresponsive or no sign of life the resident code status should be determined and code status is followed according to their Advance Directive. The nurse should perform CPR on a resident who is a full code. A resident is a full code unless, there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means CPR is not warranted. 4. On [DATE], DON reviewed all residents' current charts to ensure the code is status clearly indicated for quick access by staff. 5. On [DATE], all charts were reviewed and found code status accurate. 6. On [DATE], the RN who failed to perform CPR was placed on suspension for 5 days and then placed on administrative leave [DATE]. RN has not worked between the suspension and the administrative leave. 7. On [DATE], the RN that failed to perform CPR was reported to the Alabama Board of Nursing. 8. On [DATE], an inservice was conducted for all licensed staff on ,[DATE] shift, ,[DATE] shift and ,[DATE] shift prior to the beginning of their shift. The training included, performing CPR on full code residents who are found unresponsive or no sign of life. The resident's code status should be determined and the code status followed according to their Advance Directive. The nurse should perform CPR on a resident who is a full code. A resident is a full code unless, there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means CPR is not warranted. This training was conducted by the DON. 9. On [DATE], all licensed staff have received training on when to perform CPR when a resident found unresponsive or no sign of life. The resident code status should be determine and code status followed according to their advance directive. The nurse should perform CPR on a resident who is a full code. A resident is a full code unless there is a Do not resuscitate (DNR) sticker in front of the chart on the Patient Information sheet. A DNR sticker on the chart means CPR is not warranted. New hired licensed staff will receive CPR training during orientation. ************************ After reviewing the facility's information provided in their A[NAME]C and verifying the immediate actions had been implemented, the scope/severity level of F 578 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of an investigation of complaint/report number AL 599.

Based on interviews, review of Resident Identifier (RI) #215's medical record, the facility's policy with a subject of Advance Directives and Refusal of Treatment, the HIGHLIGHTS of the (YEAR) American Heart Association Guidelines Update for CPR (Cardiopulmonary Resuscitation) and ECC (Emergency Cardiovascular Care), the (Name) AMBULANCE Patient Care Report and a complaint submitted the Alabama State Survey Agency, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform CPR on RI #215, a resident with Full Code status, who was found unresponsive, without a pulse or respiration, on [DATE]. Code status describes what type of intervention a health care facility would conduct should a resident stop breathing and/or their heart stops beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to activate the emergency response system and initiate CPR in an attempt to revive the resident. During the 11:00 PM to 7:00 AM shift that began on [DATE], EI #4, a Certified Nursing Assistant (CNA) entered RI #215's room and found the resident unresponsive. EI #4 informed EI #3, the RN, who was certified in CPR. EI #3 assessed the resident and found RI #215 did not have a pulse or respiration. After the assessment, EI #3 left the resident's room to activate the emergency response system. EI #3 did not return to the resident's room to initiate CPR. According to the (Name) AMBULANCE Patient Care Report, CPR was not being performed when they arrived. This deficient practice placed RI #215, one of 21 sampled residents, in immediate jeopardy of serious injury, harm, or death. On [DATE] at 4:15 PM, the Administrator and Director of Nursing were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality Life, F 678. Findings include: On [DATE] at 12:21 PM, the facility submitted to the Alabama State Survey Agency an allegation of neglect. According to the report, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform Cardiopulmonary Resuscitation (CPR) on RI #215, a resident with Full Code status, who was found unresponsive on [DATE] at 5:45 AM. The facility's undated BALL HEALTH CARE SERVICES INC. ADMINISTRATIVE POLICY with a subject of Advance Directives and Refusal of Treatment documented: . STANDARD: . Prior to the arrival of EMS, Cardiopulmonary resuscitation (CPR) will be initiated for residents when [MEDICAL CONDITION] occurs, for residents who have requested CPR in their advanced directives, for residents who do not have a valid DNR order . The American Heart Association's HIGHLIGHTS of the (YEAR) American Heart Association Guidelines Update for CPR and ECC with a copyright date of (YEAR) documented . Summary of High-Quality CPR Components for BLS (Basic Life Support) Providers . Check for responsiveness No breathing or only gasping (ie, no normal breathing) No definite pulse felt within 10 seconds . If you are alone with no mobile phone, leave the victim to activate the emergency response system and get the AED (Automatic External Defibrillator) before beginning CPR Otherwise, send someone and begin CPR immediately . RI #215 was admitted to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. RI #215's undated RESIDENT INFORMATION SHEETS indicated the resident was a Full Code. The facility's 5-Day Investigation for (RI #215) dated [DATE], documented . On [DATE] around 5:45am, (EI #3), RN was informed by (EI #4), CNA that the resident was unresponsive and wasn't breathing. According to the nurse's notes after (EI #3) assessed the resident and found no pulse, no rise or fall in chest. Then, (EI #3) called the ambulance and informed them of resident's status. At 5:50 a.m., the ambulance arrived at the facility, EKG (electrocardiogram) strip obtained, indicating no signs of life . On [DATE], approximately 9:30a.m., the director of nursing (DON) audited the resident's medical record and upon reviewing the nurse's notes regarding the occurrences of events involving resident's expiration. During the audit, the initiation of CPR was not documented in the notes . around 10:30 a.m. DON asked her (EI #3) if CPR was performed on resident and nurse stated, No, I forgot . The facility substantiated that CPR was not performed by (EI #3), RN. On [DATE] at 11:05 AM, a telephone interview was conducted with EI #4, the CNA assigned to care for RI #215 during the 11:00 PM to 7:00 AM shift, beginning on [DATE]. EI #4 stated she was unsure of the time, but it was during her last rounds, she discovered RI #215 was unresponsive. When asked what she did, EI #4 stated she left the room to inform the Charge Nurse, EI #3. After notifying the Charge Nurse, EI #4 stated she and the Charge Nurse went to RI #215's room. According to EI #4, EI #3 assessed the resident. After assessing the resident, EI #3 left the resident's room and went to the nurses' station. EI #4 stated she was unsure what the Charge Nurse, EI #3, did at the nurses' station. Then EI #4 stated she noticed the paramedics came to the facility and hooked RI #215 up to a machine. When asked what RI #215's code status was, EI #4 said she did not know. When asked if a code was called, EI #4 said no. On [DATE] at 11:20 AM, a telephone interview was conducted with EI #3, the RN who was notified that RI #215 was found unresponsive. EI #3 acknowledged she was CPR certified. EI #3 was asked, what did the American Heart Association CPR guidelines instruct staff to do when a person was found unresponsive. EI #3 said staff should check the pulse, check to see if the resident is breathing and initiate CPR. EI #3 was asked, what actions she took when she was informed RI #215 was unresponsive. EI #3 said she went into RI #215's room, checked the resident's pulse and looked to see if RI #215 was breathing. EI #3 said, RI #215's skin was cool to touch. After assessing RI #215, EI #3 left the resident's room to call the ambulance. EI #3 was asked if she had called a code or initiated CPR on RI #215. EI #3 said, no. When asked why she did not initiate CPR or call a code, EI #3 replied she panicked and forgot. When asked what RI #215's code status was, EI #3 stated she thought RI #215 was a Full Code. EI #3 explained that she had RI #215's medical record when she called the ambulance, but she did not check it to see what RI #215's code status was. EI #3 stated she did not think to check the resident's code status. When asked why not, EI #3 stated she panicked and forgot. In a follow-up telephone interview on [DATE] at 3:53 PM, EI #3 was asked did she have a cell phone or any other communication device to call for assistance. EI #3 replied she had a cell phone. When asked if she used her cell phone to call the ambulance/Emergency Medical Service (EMS), EI #3 said no, she used the telephone at the nurses' station. EI #3 was asked what she did after she called EMS. EI #3 replied she was in panic mode. She did not know if she went back in RI #215's room or if she went into the office. EI #3 stated she knew she went in the office and made a copy of RI #215's face sheet for EMS. RI #215's Departmental Notes, written by EI #3 and dated [DATE] 8:53 AM, documented: . 545AM Called to room by CNA. Resident lying in bed with eyes slightly open and mouth open with yellowish colored substance noted on gown and sheet. Unable to obtain pulse, no rise or fall of chest noted. (Name) Ambulance called and informed of resident status. 550 AM . (Name) Ambulance in facility, EKG strip ran, no sign of life noted. (Name) Ambulance exited building @ (at) 6AM . The (Name) AMBULANCE Patient Care Report indicated on [DATE] at 5:37 AM, EMS received an emergency call that RI #215 was found unresponsive in bed. According to the report, EMS arrived on scene at 5:45 AM and to the resident at 5:53 AM. The report further indicated . Arrived to find pt (patient) unresponsive in bed. Eyes dry pupils fixed and dialated (dilated), pulseless and apnic (apneic). Skin cool to touch color normal. No JVD (Jugular Vein Distention) or [MEDICAL CONDITION]. Asystole times 3 leads pacing spikes. Rigor starting to set in. No CPR being performed . No ACLS (Advanced Cardiac Life Support) pronounced at 0600 . On [DATE] at 10:04 AM, an interview was conducted with EI #2, the Director of Nursing (DON). When asked what RI #215's code status was, EI #2 replied the resident was Full Code. When asked if a code was called when RI #215 was found unresponsive, EI #2 said no, not according to the nurse's note. When asked was CPR initiated when RI #215 was found unresponsive, EI #2 said no. When asked was the facility's policy followed and correct actions taken when RI #215 was found unresponsive, EI #2 said no. In a follow-up interview on [DATE] at 3:31 PM, EI #2 was asked what steps staff should take when a resident is found unresponsive. EI #2 said, assess the resident, and check the resident's chart to see if the resident is a Full Code. If a Full Code, initiate CPR. When asked if CPR was initiated on RI #215, EI #2 said no. In an interview on [DATE] at 9:50 AM, EI #1, the Administrator, was asked what should be done when a resident was found unresponsive. EI #1 said, CPR should be initiated. When asked if the facility's protocol was followed when RI #215 was found unresponsive on [DATE], EI #1 said no. EI #1 was asked, what should EI #3, the RN, have done when she was informed RI #215 was unresponsive, EI #1 said, EI #3 should have started CPR. Contained within the facility's investigation was a document titled . ACTION PLAN TOOL . DATE: [DATE] PROBLEM IDENTIFIED: CPR not initiated ACTION PLAN Discussion in Interdisciplinary morning meeting regarding facility's current procedure to perform CPR, if indicated, providing the resident is not a DNR status. A DNR sticker is found on the Resident Information Sheet to alert the nurse of a DNR status. Discussion was if facility needed to add another sticker that says Full Code to all charts that are not a DNR. Plan at this time is not to change the current procedure for identifying a resident's code status. However, there is a QAPI opportunity to train & re-educate all nurses on proper procedure on when to perform CPR. Training in progress since [DATE], regarding when to perform CPR . COMPLETION DATE [DATE] DATE COMPLETION FINALIZED [DATE]. *************************** On [DATE] at 2:15 PM, the facility submitted an acceptable Allegation of Credible Compliance (A[NAME]C), which documented: F678=IJ 1. On [DATE], RI #215 was admitted to the facility with a full code status. 2. On [DATE], RI#215 was found unresponsive by the RN and CPR was not initiated. 3. On [DATE], the RN was educated and then reeducated on [DATE] on performing CPR on residents that are full code. The code status is located in the front of the medical records on the Patient Information sheet. Education provided by the DON. 4. On [DATE], all other RNs were educated on when to performing CPR on a resident who are full code status. The code status is located in the front of the medical records on the Patient Information sheet. Education provided by the DON. 5. On [DATE], the DON implemented a weekly monitoring tool titled Deaths Facility to identify if CPR was performed on residents who were full code. 6. On [DATE], all other licensed staff was educated on performing on full code. The code status is located in the front of the medical records on the Patient Information sheet. The education was provided by the DON. 7. On [DATE], the DON reviewed all resident records using the facility census to determine which residents were full code and those who were DNR and that the code status was clearly identified in the medical records. 8. On [DATE], ,[DATE] and ,[DATE] were in-serviced prior to the beginning of the shift on Neglect and goods and service to care for the resident including CPR. All licensed staff will be in serviced by [DATE] by the DON or Designee. All other licensed nursing will be in serviced prior to the beginning of their shifts. Based on a review of the facility's in-service record, as of [DATE], nine of nine Registered Nurses and 10 of 11 Licensed Practical Nurses had been in-serviced on Performing CPR on residents. *************************** After reviewing the facility's information provided in their A[NAME]C and verifying the immediate actions had been implemented, the scope/severity level of F 678 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 599.

Based on interview, review of the facility's policy with a subject of Abuse, Neglect, and Exploitation, a report submitted to the Alabama State Survey Agency and Resident Identifier (RI) #1's medical record, the facility failed to timely report an allegation of neglect to the Alabama State Survey Agency. This deficient practice affected RI #215, one of 21 sampled residents and involved one of five reportable allegations of abuse and/or neglect. Findings include: The facility's policy titled, BALL HEALTHCARE SERVICES INC. ADMINISTRATIVE POLICY with a subject of Abuse, Neglect, and Exploitation, revised (MONTH) (YEAR), revealed: . PR[NAME]EDURE: In response to alleged or suspected incidents involving abuse, neglect . the Facility will take the following steps: . 3. If determined to be reportable, the event will be reported to the Alabama Department of Public Health, Division of Health Care Facilities (DHCF) via the Online Incident Reporting System for Nursing Homes within two (2) hours of the incident if the event involves abuse or results in serious bodily injury, or not later than twenty-four (24) hours if the event does not involve abuse or serious bodily injury . RI #215 was admitted to the facility on [DATE], with an admitting [DIAGNOSES REDACTED]. On [DATE] at 12:21 PM, the facility submitted to the Alabama State Survey Agency (Alabama Department of Public Health, DHCF) an allegation of neglect. According to the report, Employee Identifier (EI) #3, a Registered Nurse (RN) failed to perform Cardiopulmonary Resuscitation (CPR) on RI #215, a resident with Full Code status, who was found unresponsive on [DATE] at 5:45 AM. Refer to F 678. During an interview on [DATE] at 9:50 AM, EI #1, the Administrator was asked what date did the failure of a licensed staff member to initiate CPR on RI #215, a resident with Full Code status, occur. EI #1 said, [DATE]. When asked when the incident should have been reported to the Alabama State Survey Agency, EI #1 said within two hours of the incident. EI #1 was asked why the incident was not reported within the two hours. EI #1 said, she did not know it was a reportable event. When EI #1 was asked what made the event a reportable incident, EI #1 said, neglect. This deficiency was cited as a result of the investigation of complaint/report number AL 599.

Based on observation, interview and review of a facility policy titled Food Storage Labeling, the facility failed to ensure two opened containers of thickened liquids located inside the walk-in cooler were labeled with an open and use by date. This had the potential to affect 4 of 4 residents who received thickened liquids from Dietary. Findings Include: A review of a facility policy titled Food Storage Labeling, with a revised date of 04/2009, revealed the following: POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. PROCEDURE 1. Labeling a. Information included on the label: . ii. Date and time of storage iii. Date by which it should be eaten or discarded (USE BY DATE) . On 02/07/17 at 1:41 p.m., an observation was made in the walk-in cooler of a 46 ounce container of Thickened Lemon Flavored Water and a 46 ounce Thickened Orange Juice. Each container was opened, and there was no label with an open and use by date. On 02/07/17 at 1:47 p.m., EI (Employee Identifier) #8, the Dietary Manager, was asked to pick up the two containers. EI #8 was asked had both containers been opened. EI #8 said yes. On 02/09/17 at 8:49 a.m., an interview was conducted with EI #8. EI #8 was asked why should opened items in the walk-in cooler be labeled with an open and use by date. EI #8 said someone needs to put the date it was opened and the product needs to be used before the product is discarded. EI #8 was asked who was responsible for ensuring all opened items in the walk-in cooler were labeled with an open and use by date. EI #8 said it was a group effort. EI #8 was asked why was one container of Thickened Lemon Flavored Water and one container of Thickened Orange Juice opened and without a label with an open and use by date. EI #8 explained she was not aware they did not have an open and use by date label. EI #8 was asked should they have been labeled. EI #8 said Yes Ma'am. EI #8 was asked what was the potential harm in having opened and used items in the walk-in cooler not labeled with an open and use by date. EI #8 said it could become unsafe.

Based on observations, interviews, review of facility policies titled Perineal Care and Hand Hygiene and review of a facility Skills Validation: Perineal Care check-off form, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) did not clean Resident Identifier (RI) #8's buttocks area then clean the front area without changing gloves on 02/08/17, 2) a CNA washed her hands after removing gloves and before applying a clean pair of gloves during RI #5's incontinent care on 2/8/17; and 3) a Licensed Practical Nurse (LPN) sanitized her hands after resident contact and before returning to the medication cart and signing the Electric Medication Administration Record (EMAR). This affected two of two residents observed for incontinent care, and one of four nurses observed during the medication pass administration. Findings Include: 1) A review of a facility policy titled Perineal Care, with an effective date of February 1, 2004, revealed: PURPOSE: Good perineal care helps prevent infection, . III. a. Wash perineal area . d) Turn resident on . side and wipe from front to back . A review of a facility form titled Skills Validation: Perineal Care (Female/Male) revealed: . 3. Wash hands and put on gloves 4. Remove brief and discard. 5. Expose perineal area. Gently wipe . 7. Roll resident unto side wipe rectal area . 8. Removes gloves, wash your hands, reapply gloves . RI #8 was readmitted to the facility 10/27/16, with a [DIAGNOSES REDACTED]. A review of RI #8's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/17, revealed RI #8 was totally dependant for toileting needs. On 02/08/17 at 4:45 p.m., Employee Identifier (EI) #5, a CNA was observed performing perineal care for RI #8. EI #5 removed the brief after washing her hands and putting on gloves. EI #5 turned RI #8 onto the resident's side and cleaned the buttocks area. EI #5 then positioned RI #8 on the back and cleaned the perineal area with the same soiled gloves she had on while cleaning the buttocks area. On 02/08/17 at 5:15 p.m., an interview was conducted with EI #5. EI #5 was asked how was she trained to do pericare. EI #5 replied, wash hands put on gloves, clean bowel movement then change gloves and clean the front. EI #5 was asked if she cleaned RI #8's buttocks area then cleaned the front with the same gloves. EI #5 replied yes. EI #5 was asked if she should have changed gloves before she cleaned the front. EI #5 replied yes. EI #5 was asked what was the potential for harm in using the same gloves and cleaning the buttocks area then cleaning the front area. EI #5 replied infection could be spread. On 02/09/17 at 11:55 a.m., an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked what was the procedure of providing incontinent care. EI #3 replied, gather supplies, provide privacy, wash hands and put on gloves, remove the soiled brief and clean the front side first, cleaning front to back, change gloves and clean the buttocks area. EI #3 was asked if the CNA should clean the buttocks area then clean the perineal area with the same gloves. EI #3 replied no. EI #3 was asked what was the potential for harm it the staff cleans the resident's buttocks area, then with the same gloves, cleans the perineal area. EI #3 replied there would be risks of urinary tract infections and possibly introducing germs. 2) A facility policy titled Hand Washing, dated 02/2012, documented: . SUBJECT: Hand Washing PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARDS: Hand Washing should be performed between procedures with residents . RI #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Significant Change MDS assessment, with an ARD of 11/23/16, assessed RI #5 as having long and short term memory problems and to have severely impaired cognitive skills for daily decision making. RI #5 was assessed to be always incontinent of bowel and to be totally dependent on staff for personal hygiene. On 02/08/17 at 10:23 a.m., the surveyor observed EI #9, a CNA, clean bowel movement from RI #5's rectum area. EI #5 wiped the the rectum four different times, using different wipes, and threw the wipes in the garbage can. EI #9 removed her contaminated gloves, and without washing her hands, put on a clean pair of gloves. On 02/09/17 at 2:14 p.m., the surveyor conducted an interview with EI #9. The surveyor read back the above observation to EI #9 and asked EI #9 what should she had done after she cleaned bowel movement from RI #5, and before putting a clean pair of gloves on. EI #9 replied, Washed my hands. The surveyor asked EI #9 what was it called when hands are not washed between procedures on the same resident or what is there a potential for when hands are not washed after removing gloves. EI #9 said, Infection Control. On 02/09/17 at 3:04 p.m., the surveyor conducted an interview with EI #3, the Infection Control Nurse. The surveyor asked EI #3, what should the CNA do after they have cleaned bowel movement off of a resident, and before putting on new gloves. EI #3 replied, Wash their hands. The surveyor asked EI #3, what could an incident like this one be considered. EI #3 replied, As an infection control issue. 3) On 02/09/17 at 8:14 a.m., during observation of the medication pass, EI #10, a Licensed Practical Nurse, did not sanitize or wash her hands after administering medication to RI #9, and before returning to medication cart and signing off on the E-Mar. On 02/09/17 at 2:40 p.m., the surveyor conducted an interview with EI #10. The surveyor asked EI #10 what should she have done when she returned to the medication cart, and before signing off that she had administered medications to RI #9. EI #10 replied, Cleaned my hands. The surveyor asked EI #10 what procedure did the facility have as far as washing hands. EI #10 said, We can use hand sanitizer three times and then wash. The surveyor asked EI #10 what was there a potential for when hands are not sanitized before touching something after a procedure has been performed. EI #10 replied, Passing germs to the next resident. The surveyor asked EI #10 what was that called. EI #10 replied, Infection control.

Based on observation and interview, and record reveiw the facility failed to ensure a CNA (Certified Nursing Assistant), Employee Identifier (EI) #6 did not stand to feed RI (Resident Identifier) #11 the lunch meal on 2/08/17. This affected one of three residents observed for meals who required assistance with feeding. Findings Include: RI #11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 11/28/16, assessed RI #11 as having a 3 on the Brief Interview for Mental Status, indicating RI #11 was severely impaired never/rarely made decisions. On 02/08/17 at 12:20 p.m., EI #6 was observed standing while feeding RI #11. EI #6 began to feed RI #11 at 12:20 p.m., and finished feeding the resident at 12:40 p.m. On 02/08/17 at 12:40 p.m., an interview was conducted with EI #6. EI #6 was asked how was she to be positioned while feeding a resident. EI #6 replied sitting down. EI #6 was asked should you stand to feed a resident. EI #6 replied no. EI #6 was asked if she stood the entire meal while feeding RI #11. EI #6 replied yes. EI #6 was asked what was the harm in standing while feeding a resident. EI#6 replied it was a dignity issue. On 02/09/17 at 1:50 p.m., an interview was conducted with EI #3, the Staff Development Nurse. EI #3 was asked how should staff be positioned while feeding a resident. EI #3 replied sitting down. EI #3 was asked what was the concern with staff standing while feeding a resident. EI #3 replied when standing over a resident it could be a dignity issue. EI #3 further stated when you sit, it indicates one-on-one attention. EI #3 said standing could make the resident feel rushed.

Based on observations, interview, and review of a facility policy titled DIRECTOR OF MAINTENANCE JOB DESCRIPTION, the facility failed to ensure the tiles on the floor and baseboards in Room Locator (RL) #1 were not broken or loose, the vent in RL #2 was not missing a screw and loose, and the vent in RL #3 was free of an accumulation of dirt and dust. This deficient practice affected one of two shower units, and two rooms on one of three units in the facility. Findings Include: A facility job description titled, DIRECTOR OF MAINTENANCE JOB DESCRIPTION . General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring the facility is maintained in a safe, comfortable condition. Essential Job Functions: A. Maintenance Functions: Duties: Plan, develop and direct the Maintenance Department; coordinate maintenance services with other departments; .assist in establishing and maintaining a preventative maintenance program; .and ensure proper maintenance of the facility . 1) On 02/07/17 at 2:15 p.m., during the initial tour, the surveyor observed the vent in the ceiling of RL #2 to be loose and missing a screw. On 02/08/17 at 9:10 a.m., the surveyor again observed the vent in the ceiling of RL #2 to be loose and missing a screw. On 02/09/17 at 9:05 a.m., an observation was again made by the surveyor of the vent in the ceiling of RL #2. The vent remained loose and missing a screw. 2) On 02/07/17 at 1:50 p.m., the baseboard tiles in RL #1 were observed to be loose and cracked. On 02/07/17 at 2:00 p.m., during the initial tour, the tiles in RL#1 were observed to be broken and loose at the base. Also the vent area in RL #3 was observed to have dark areas around the vent. On 02/08/17 at 12:05 p.m., the baseboard tiles in RL #1 were observed to be loose and cracked. On 02/09/17 at 8:50 a.m., the baseboard tiles in RL #1 were observed to be loose and cracked. On 02/09/17 at 9:00 a.m., the ceiling in RL #3 was observed to have a discolored, black substance on it. On 02/09/17 at 4:05 p.m., during a walking tour with Employee Identifier (EI) #7/the Maintenance Director, the following observations were made and an interview was conducted with EI #7. When touring on RL #1, EI #7 was asked what did he see concerning the tile around the baseboards. EI #7 replied, they were loose. EI #7 was asked what he saw concerning the tiles near the tub and one of the shower stalls. EI #7 replied, the tiles were broken. EI #7 was the asked to look at the vent in RL #2 and inform the surveyor what he saw. EI #7 replied, the screw is out and the vent is loose. The surveyor asked EI #7 what he saw concerning the vent in RL #3. EI #7 replied, it is dusty and dirty. EI #7 was asked who was responsible for the overall maintenance of the facility. EI #7 replied he was. When asked what potential concerns can come from the broken and loose tiles, the loose vent and the dusty,dirty vent; EI #7 replied, the vent could fall and the tiles could cut somebody.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessments for Resident Identifier (RI) #11, dated 11/28/16, 08/29/16 and 05/30/16 were coded to reflect RI #11 was receiving Hospice services. This affected one of 13 sampled residents whose MDSs were reviewed. Findings Include: RI #11 was readmitted to the facility 6/1/15, with a [DIAGNOSES REDACTED]. A review of RI #11's February 2017 physician's orders [REDACTED].> . 5/11/16 admitted to . Hospice . A review of RI #11's MDS's dated 5/30/16, 8/29/16 and 11/28/16 revealed the three assessments were not coded for Hospice. On 02/09/17 at 3:00 p.m., an interview was conducted with Employee Identifier (EI) # 4, the MDS Coordinator. EI #4 was asked if RI #11 was on hospice. EI #4 replied yes, it was ordered 06/01/15. EI #4 was asked to review each of the last 3 MDS's and then asked if Hospice was coded. EI #4 replied, no Hospice was not coded and it should be. EI #4 was asked who was responsible for coding Hospice on the MDS. EI #4 replied the MDS Coordinator. EI #4 was asked with Hospice not being coded on the last three MDS's would those assessments be accurate. EI #4 replied no.

Based on observation, record review, interview and review of a facility policy titled Care Plans, the facility failed to develop a care plan for Resident Identifier (RI) #5's Tube Feeding. This affected RI #5, one of 13 sampled residents whose plan of care was reviewed. Findings Include: Review of a facility policy titled Care Plans, with a revised date of 09/2009, documented: SUBJECT: Care Plans PURPOSE: Plans of care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident . RI #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 11/23/16, assessed RI #5 as having a Feeding Tube while a resident at the facility. A review of RI #5's January 2017 Physician Orders, with an order start date of 12/28/16, documented: . [MEDICATION NAME] 1.5 VIA (by way of) TUBE @ (at) 60cc (centimeters)/HOUR . On 02/07/17 at 5:00 p.m., RI #5 was observed receiving [MEDICATION NAME] tube feeding 1.5 calorie at 60 ml (milliliters)/ hour. On 020/8/17 at 9:08 a.m., RI #5 was observed receiving [MEDICATION NAME] tube feeding 1.5 calorie at 60 ml/hour. On 02/09/17 at 9:05 a.m., RI #5 was observed receiving [MEDICATION NAME] tube feeding 1.5 calorie at 60 ml/hour. On 02/09/17 at 3:28 p.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the MDS/Care Plan Coordinator. The surveyor asked EI #4 how long had RI #5 been receiving the tube feeding. EI #4 said since 11/16/16. The surveyor asked EI #4, when a resident is receiving a tube feeding, should the resident be care planned for the tube feeding. EI #4 replied, Yes Maam. The surveyor asked EI #4 did RI #5 have a care plan for the tube feeding. EI #4 looked at RI #5's care plans and stated, I don't see one. The surveyor asked EI #4 what was the purpose for developing a care plan for the resident. EI #4 said so the facility could make sure care is being done properly. EI #4 said having a care plan was a form of communication as well.

Based on record review, interviews, review of a facility policy titled Monthly Physician's Orders, and Potter and Perry's Fundamentals of Nursing, the facility failed to provide evidence a physicians order was obtained for RI (Resident Identifier) #14 to be discharged from the facility on 12/26/16. This affected one of two residents whose physicians orders were reviewed for discharge. Findings Include: A review of a facility policy titled Monthly Physician's Orders, with an effective date of February 1, 2004, revealed the following: . PURPOSE: To provide a documented review of the medical plan of care . by the physician . A review of Potter and Perry's Fundamentals of Nursing, 9 edition, page 311, Health Care Providers' Orders, the following was documented: . Make sure all the health care provider orders are in writing, dated and timed . On 02/09/17, during Phase II of the survey, the surveyor reviewed RI #14's closed medical record and could not find evidence of the resident's physicians order for discharge for 12/26/16. RI #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #14's discharge MDS ( Minimal Data Set) with an ARD (Assessment Reference Date) of 12/26/16, revealed the resident had a BIMS (Brief Interview of Mental Status) score of 14, indicating the resident was cognitively intact. On 02/09/17 at 4:46 p.m., an interview was conducted with EI (Employee Identifier) # 11, a RN (Registered Nurse, Supervisor). EI #11 was asked what was the facility's policy and procedure regarding discharging residents. EI #11 said we must have the doctors orders to discharge. EI #11 was asked who discharged RI #14. EI #11 said she did. EI #11 was asked to locate RI #14's physician's order for discharge. EI #11 said, No ma'am. EI #11 was asked why was she not able to locate the orders. EI #11 said she did not know. EI #11 was asked why should there have been physician orders for RI #14's discharge. EI #11 said they had to make sure the resident was stable for discharge and it had to be approved by the physician. EI #11 was asked, what was the potential harm in not having a physician's order for RI #14's discharge. EI #11 said it could be viewed as the doctor did not give the order. On 02/09/17 at 5:28 p.m., an interview was conducted with EI #12, RI #14's physician. EI #12 was asked did he write an order to discharge RI #14. EI #12 said no.

Based on record review, interview and review of a facility policy titled Discharge Summary and Plan of Care, the facility failed to provide evidence a discharge summary was completed for RI ( Resident Identifier) #14. This affected one of two residents who were reviewed for discharge. Findings Include: A review of a facility policy titled Discharge Summary and Plan of Care, with a revised date of 10/2013, revealed: . Process . II. The Discharge Summary should include: . a) Completion of form NM.III-10 (a) by the nurse caring for the resident . A review of RI #14's closed records revealed a Discharge Summary had not been completed. RI #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #14's discharge MDS ( Minimum Data Set) with a ARD (Assessment Reference Date) of 12/26/16, revealed the resident had a BIMS (Brief Interview of Mental Status) score of 14, indicating the resident was cognitively intact. On 02/09/17 at 4:46 p.m., an interview was conducted with EI (Employee Identifier) #11, a RN (Registered Nurse) Supervisor. EI #11 was asked who was responsible for ensuring the discharge summary was completed for RI #14. EI #11 said the nurse that discharged the resident. EI #11 was asked who discharged RI #14. EI #11 said she did. EI #11 was asked when should the discharge summary be completed. EI #11 said it should be completed after the resident is discharged on the date of discharge. EI #11 was asked why should the discharge summary be completed. EI #11 explained it should be completed because they want to capture the resident's status upon the resident leaving the facility. EI #11 was asked upon her reviewing RI #14's closed record, did she locate RI #14's Discharge Summary. EI #11 said, No ma'am. EI #11 was asked why the Discharge Summary was not in RI #14's chart. EI #11 said she felt it was misplaced. EI #11 was asked what was the potential harm in not having RI #14's Discharge Summary. EI #11 explained if the Discharge Summary could not be found, the family could blame the facility for anything.

Based on interview and review of a facility policy titled, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, the facility failed to ensure the appropriate number of signatures of witnesses and date of destruction was on the Controlled Drug Destruction Logs for controlled drugs for the months of March 2016 and October 2016. This deficient practice affected two of 10 months of Controlled Drug Destruction Logs reviewed. Finding Include: A facility policy titled DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, with a revised date of August 2014, documented: . CONTROLLED SUBSTANCE DISPOSAL Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations. Procedures A. The director of nursing, in collaboration with the consultant pharmacist, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled mediations . E. The . nurses(s) and /or pharmacist witnessing the destruction ensures that the following information is entered on the (individual controlled substance accountability record/book): 1) Date of destruction . 6) Signatures of witnesses. On 02/09/17 at 1:15 p.m., the surveyor reviewed the facility's Controlled Drug Destruction Logs, which included the months of February, March, April, May, July, August, September, November and December 2016, and January 2017. However, the facility failed to obtain three witness signatures and dates of destruction on three of four Controlled Drug Destruction logs for the month of March 2016, and obtain three witness signatures and date on one of two Controlled Drug Destruction logs for the month of October 2016. On 2/09/17 at 4:35 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Director Of Nursing (DON). The surveyor asked EI #2 who was responsible for conducting drug destructions. EI #2 said the Pharmacist came in and did the destructions with the Registered Nurse. The surveyor asked EI #2, how many signatures are required for narcotic destruction. EI #2 replied, Three. The surveyor asked EI #2, how many signatures did she see on the March 2016 Narcotic Destructions sheet. EI #2 replied, Two, the Pharmacist Consultant didn't sign. The surveyor asked EI #2 how many signatures did she see on the October 2016 Narcotic Destruction sheets. EI #2 replied, Just two. The surveyor asked EI #2 should the date of destruction also be on the destruction sheets. EI #2 said yes. On 02/09/17 at 5:00 p.m., an attempt was made, without success, to contact the facility's Consulting Pharmacist.

Based on record review, interview, review of facility policies titled Charting and Documentation Guidelines and Resident Incident Report, the facility failed to ensure a licensed staff documented RI ( Resident Identifier) #6's physician was notified of a fall occurring on 04/16/16. This affected one of six residents sampled for falls. Findings Include: A review of a facility policy titled Charting and Documentation Guidelines, with an effective date of February 1, 2004, revealed the following: . (page 1) . Process . b) Be concise, accurate . (page 3) . IX Miscellaneous Documentation Documentation of various events occurs in the nurses notes . a) Any time a physician . is contacted about a resident . RI #6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #6's Resident Incident Report, dated 04/16/2016, had a blank area for notification of the physician and family. A review of RI #6's Departmental Notes, dated 04/16/16, revealed there was no documentation of the physician being notified. A review of RI # 6's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 12/02/16, revealed RI #6 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. On 02/09/17 at 1:42 p.m., an interview was conducted with EI (Employee Identifier) # 13, a RN (Registered Nurse) Supervisor. EI #13 was asked was she familiar with RI #6. EI #13 said yes. EI #13 was asked who does the facility notify if a resident has a fall. EI #13 said the family/sponsor and the doctor. EI #13 was asked where would the evidence be if the sponsor or the medical doctor were notified. EI #13 said on the Incident Report and the nurse's note. EI #13 was asked when she reviewed her documentation for a fall RI #6 had on 04/16/16, what evidence did she have for notifying the doctor. EI #13 explained it was not in the note. EI #13 reviewed the Incident Report for RI #6's fall on 04/16/16. EI #13 was asked did she document the doctor was notified. EI #13 said it was not there. EI #13 was asked was RI #6's doctor notified/made aware of RI #6's fall on 04/16/16. EI #13 explained she was sure he was told but she did not write it out on the Incident Report. EI #13 was asked did she document the physician was notified in her nurse's note. EI #13 said no. EI #13 was asked why was this not documented. EI #13 explained she just forgot. EI #13 was asked what evidence did she have for RI #6's doctor being notified of RI #6's fall on 04/16/16. EI #13 said none. EI #13 was asked why should she have documented the doctor was notified of the fall on 04/16/16. EI #13 explained so the doctor would have known what happened. EI #13 was asked should notifying RI #6's doctor have been documented. EI #13 said yes. EI #13 was asked what was the potential harm in not documenting RI #6's doctor was notified of RI #6's fall on 04/16/16. EI #13 explained if something would have happened there would not have been a way the doctor would have known about it in the first place. On 02/09/17 at 2:04 p.m., a telephone interview was conducted with EI #12, RI #6's medical doctor. EI #12 was asked when residents fall at the facility, what was expected of the nursing staff. EI #12 said notify us in a timely manner and sometimes they write it down.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was 5% (percent) or less. Four nurses were observed, on two of three halls for thirty-six opportunities. Three errors were observed, which resulted in a medication error rate of 8.3%. This affected RI #9 and RI # 16, two of seven residents observed during medication pass. Findings include: Review of an undated facility document titled Medication Pass revealed the following: . Basic Components of Medication Administration - Right Resident - Right Drug - Right Dose . - Right Time - Right Route A review of the facility's policy titled, Oral Medication Administration with an effective date of 6/1/2004, revealed the following: . PURPOSE: To administer oral medications in an organized and safe manner. PROCESS: . 3. Open medication book to the appropriate resident, and note the first medication to administer . 5. Read label three times before pouring medication . 6. Pour the correct number of tablets or capsules into the medication cup . 1.) RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's most recent Quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 11/26/2015 revealed moderately impaired cognitive skills and extensive to total dependence on staff for most Activities of Daily Living. During medication pass on 1/14/2016 at 9:00 AM, EI (Employee Identifier) #3, LPN (Licensed Practical Nurse) prepared, administered, and signed off 11 total medications for RI #9, one of which included, AZO-[MEDICATION NAME] 95 mg (milligrams) one tablet. A record review of RI #9's physician orders [REDACTED]. RI #9's physician orders [REDACTED]. [MEDICATION NAME] Sodium was not administered during the 9:00 AM medication pass. On 1/14/2016 at 2:00 PM, EI #3 was asked how she ensured medications were given as ordered during medication pass. EI #3 replied, according to the MAR (Medication Administration Record). When asked what time AZO-[MEDICATION NAME] was due, EI #3 reviewed the MAR and said, every eight hours, at 6:00 AM, 2:00 PM, and 10:00 PM. When asked why she had given AZO-[MEDICATION NAME] at 9:00 AM, EI #3 said she confused the six with a nine. When asked why the [MEDICATION NAME] Sodium had not been given at 9:00 AM, EI #3 said she overlooked that medication, but admitted that it was due at 9:00 AM. EI #3 said it was important to administer medications as ordered to prevent residents from getting sick. 2.) A review of the facility's policy and procedure titled, Administrative Policy dated 04/2014, revealed the following: SUBJECT: . Nasal . Inhalation . PURPOSE: To administer . nasal . inhalation medications in a safe and accurate manner. STANDARD: . nasal . inhalants should be administered by a licensed nurse . PROCESS: . II Nasal Inhalation . d) . carefully insert nozzle into one nostril and close the other nostril with one finger. e) While resident gently inhales through open nostril, press medication . RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's Quarterly MDS dated [DATE], revealed RI #16's BIMS (Brief Interview for Mental Status) was 4, indicating severe impairment in cognitive skills. On 01/14/16 at 8:35 AM, during medication pass observation, the surveyor observed the following: EI #4 (LPN) administered [MEDICATION NAME] two sprays to RI #16's nostril. After EI #4 administered the nasal sprays to each nostril, RI #16 depressed the opposite nostril and inhaled. EI #4 was not observed to depress each nostril during the administration of the nasal sprays. On 01/14/16 at 8:41 AM, during an interview with EI #4, the surveyor asked how should nasal sprays be administered. EI #4 replied when administering the spray, give one spray to the nostril and usually the patient will sniff during the administration of the spray. The surveyor asked was that done. EI #4 replied no. The surveyor asked who was responsible to ensure the resident gets the prescibed medication dose. EI #4 stated she was and stated she (EI #4) should tell the resident each time to inhale with the spray, but that was not what she had done.

Based on observations, interviews and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA): 1. Wiped Resident Identifier (RI) #8 groin; 2. Did not use the same area of the peri-wipe more than once for each area wiped; and 3. Wiped until RI #8 did not have stool left on the buttock. This affected RI #8, one of two residents observed during incontinent care. Findings Include: A review of the facility's policy and procedure titled, Perineal Care dated 02/2014, revealed the following: . PURPOSE: Proper perineal care helps prevent infection, irritation and skin breakdown. STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed . A review of the facility's skills validation form titled, PERINEAL/CATHETER SKILLS VALIDATION, dated 02/2014, revealed the following: . 3. Wash upper and inner thighs using single stokes (strokes). 4. Use a different/clean corner or new wipe with each stroke. 9. Using single [MEDICAL CONDITION] clean rectal area & (and) buttocks wiping away from anus . RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed RI #8 had short and long term memory loss and was severely impaired in cognition. The MDS also documented RI #8 required total assistance with toileting and personal hygiene. The MDS documented RI #8 was always incontinent of bowel. The MDS also documented RI #8 was at risk for developing pressure sores. On 01/12/16 at 4:16 PM, the following was observed during incontinent care: Employee Identifier (EI) #1 and #2 (CNAs) washed their hands and applied gloves. EI #1 opened RI #8's brief and stated RI #8's brief was wet with a moderate amount of urine. EI #1 then obtained separate peri-wipes and wiped the perineal area. EI #1 did not wipe RI #8's groin. RI #8 was positioned on the left side and EI #1 removed the brief and stated the resident had a small bowel movement (bm). EI #1 wiped the rectal area three times without changing the position of the peri-wipe. After EI #1 wiped RI #8's rectal area the third time, bm was observed on the peri-wipe. RI #8 was observed to have a tannish colored substance on the left buttock. EI #1 then applied a clean brief to RI #8. On 01/12/16 at 4:31 PM, during an interview with EI #1, the surveyor asked how many times should the same area of the peri-wipe be used. EI #1 replied once. The surveyor asked EI #1 was that what she had done. EI #1 replied she hoped that was what she had done. EI #2 (CNA) was asked was that what EI #1 had done. EI #2 stated no. The surveyor asked EI #1 was the resident clean. EI #1 replied no, because she did not have enough peri-wipes to clean the resident. The surveyor asked how did she (EI #1) know when a resident was clean. EI #1 stated until nothing was seen on the wipes. The surveyor asked what areas should she have wiped. EI #1 replied the buttock and the peri-rectal area, but that was not what she had done. EI #1 stated the resident needed to be cleaned again. Repeat incontinent care was observed. EI #1 wiped the left groin and the buttock and stated the peri-wipes had bm on them. EI #1 stated the potential for harm to RI #8 would be a Urinary Tract Infection and skin breakdown.

Based on record review, observation, and interview the facility failed to ensure on 1-6-15 and 1-8-15 that rice, meal, egg noodles, black-eyed peas and elbow macaroni that was removed from it's original container and placed in a large container on the bottom shelf in dry storage was labeled with an open by date and a used by date. This deficient practice had the potential to affect 67 of 68 residents who receive meals from the kitchen. Findings Include: A review of the the facility's policy titled, "(NAME OF FACILITY) ADMINISTRATIVE POLICY" with a revised date of 04/2009 revealed: "...l. Labeling... Information included on the label: i. Name of the Food ii. Date and time of storage iii. Date by which it should be eaten or discarded (USE BY DATE) ..." On 1-6-2015 at 9:30 am, during tour and 1-8-2014 at 8:40 am, during an observation the surveyor observed rice, meal, egg noodle, black-eyed peas and elbow macaroni that was removed from it's original container and placed in a large container. There was no opened date or use by date on the large containers. On 1-8-2015 at 8:46 am, EI #9, Employee Identifier, Dietary Manager, was asked who was responsible for labeling items. EI #9 replied we all are and whoever put it in dry storage should label it. EI # 9 was asked what was the facility policy on labeling. EI #9 replied label all items after it is opened. EI #9 was asked how should items be labeled. EI #9 replied the items name should be on it, the date it was used and the use by date should be on it. EI #9 was asked when should items be labeled. EI #9 replied when opened. EI #9 was asked what were the items in the large containers on the bottom shelf in dry storage. EI # 9 replied rice, meal, elbow macaroni, black-eyed peas and egg noodles. EI #9 was asked was there an open date and use by date on the rice, meal, elbow macaroni, black-eyed peas and egg noodles. EI #9 replied no ma'am.

Based on record reviews, observations and interviews, the facility failed to ensure the interdisciplinary team assessed RI (Resident Identifier) # 11 for the ability to self-administer medications safely. On 1/7/14 at 8:35 AM, RI #11 was allowed to self-adminster a breathing treatment, after Employee Identifier (EI) #17, Licensed Practical Nurse (LPN), left the resident's room to continue adminstering medications to others. This deficient practice affected one of 6 residents observed during medication pass administration. Findings Include: A review of a facility policy titled, "Self Administration of Drugs" with an effective date of February 1, 2004 revealed: "PURPOSE: The resident has the right to self administer medications, when the interdisciplinary team has determined this practice is safe.... PROCESS: 1. Residents will not be permitted to self-administer medications, unless so ordered by the attending physician, and approved by the care planning team...." RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/02/14 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. On 1/7/14 at 8:35 AM, the surveyor observed EI (Employee Identifier) #17, LPN (Licensed Practical Nurse) set up an Atrovent breathing treatment, give it to RI #11 and instruct the resident to call when the treatment was finished. EI # 17 washed her hands and exited the room. On 1/8/15 at 2:45 PM, an interview was conducted with EI #17. EI #17 was asked when she administered breathing treatments, what steps should she follow. EI #17 said she should stay in room with resident to ensure resident received all of the medication that was ordered. EI #17 was asked if RI #11 had been assessed in order to self administer medications. EI #17 said she was not sure. EI #17 was asked what was the potential harm in RI #11 self administering medications without being assessed to do so. EI #17 said the resident could drop the medication in the bed and may not get all of the medication. On 1/8/15 at 2:54 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked if RI #11 had been assessed to determine if she could self administer medication. EI #1 said no. EI #1 was asked if RI #11 had been given permission to self administer medication. EI #1 said no. On 1/8/15 at 2:59 PM, an interview was conducted with EI #1. EI #1 was asked if there were any residents in the facility that self-administered medications. EI #1 said no. EI #1 was asked what was the potential harm in a resident who had not been assessed to self administer medications to in fact self administer medication. EI #1 said the nurse would not be following physician's orders [REDACTED].

Based on observations and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) knocked on the door of Room Locator (RL) #1, #2, #3 and #4 before entering on 1/5/15. A CNA was observed, 5:30 PM to 5:41 PM, entering four resident's rooms without knocking. This deficient practice affected four of 15 residents' rooms located on A-Wing. Findings Include: Employee Identifier (EI) #5, CNA was observed to enter the following rooms without knocking: 1) RL #1 at 5:30 PM 2) RL #2 at 5:35 PM 3) RL #3 at 5:40 PM; EI #5 brought tray out of the room and entered the room again without knocking 4) RL #4 at 5:41 PM On 1/5/15 at 6:05 PM, an interview was conducted with EI #5. EI #5 was asked what was supposed to be done before entering resident's rooms. EI #5 said knock on door first and wait for resident to answer. EI #5 was asked if he had done that. EI #5 said no ma'am. EI #5 was asked why he did not knock on the doors before entering. EI #5 said normally when the doors were open he did not think about it but he did understand about privacy. EI #3 was asked what the facility policy said about knocking on resident's doors. EI #5 said, "It says before you walk in you are supposed to knock on the door, wait for them to tell you to enter and close door behind you if giving care." EI #2 was asked what was the potential harm if he entered resident's rooms without knocking. EI #5 said he may not be respecting their privacy if he doesn't knock on the door. On 1/8/15 at 9:10 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked what did the facility policy say about entering a resident's room. EI #1 said knock on the door. EI #1 was asked if was an acceptable practice for that facility for a CNA to enter 4 resident's rooms without knocking. EI #1 said no. EI #1 was asked what was the potential harm if a CNA entered a resident's room without knocking. EI #1 said, "You should let them know you are coming in. That's their room, their privacy, you should let them know you are coming in their space."

Based on observation, interview, and record review the facility failed to provide in room activities for Resident Identifier (RI #9) on four days of the survey, 1/5/15 to 1/8/15. The Activity Director, Employee Indentifer (EI) #11 confirmed through an interview that she had not offered or provided activities for resident who did not attend group activities. This deficient practice affected one of 1 sampled resident who were observed for in room activities. Findings Include: RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's most current Quarterly (Minimum Data Set) MDS with (Assessment Reference Date) ARD of 12/17/14 revealed the resident was moderately cognitively impaired for daily decision making. The MDS also revealed RI #9 required extensive assistance with 2 + (plus) persons physical assist with bed mobility and transfer. The MDS further revealed RI #9 did not walk in room or corridor. A review of RI #9's 5-day MDS revealed the resident enjoyed listening to music, spending time outdoors and participating in religious activities. A "Potential for social isolation secondary to: indicators of depression/anxiety, use of psychoactive medications, cognitive deficits, incontinence/pain and socially inappropriate behaviors" plan of care, developed 1/23/2014 listed approaches of " Provide one on one interventions at least___ (not filled in) times weekly to include: Provide music, reading and prayer for spiritual support in room ..." and "Visit with resident to determine appropriate in-room activities that may be provided ... Document resident responses to interventions ..." On 1/8/15 the resident profile in RI #9's closet that the (Certified Nurse Assistants) CNAs use for their care plan was observed and did not show that RI #9 was care planned for one-on-one in room activities. On 1/5/15, 1/6/15, 1/7/15, and 1/8/15, the surveyor did not observe RI #9 with any music playing in her room, listening to any religious services, or spending time outside. An interview was conducted with (Employee Identifier) EI#11, the activity director on 1/7/15 at 5:30 PM and 1/8/15 at 9:25 AM. EI #11 was asked if a resident did not want to participate in group activities, are they offered in room activities. EI #11 stated that she had not at this time, but she was definitely working on it now. EI #11 was asked if she had kept any notes on the residents who did not participate in group activities. EI #11 said since she started working there in July 2014 she has not kept notes. EI #11 was asked if she had documentation that RI #9's care plan for social isolation was being implemented. EI #11 said she did not have the documentation.