Every finding on record at Park Place

Based on interviews and review of a document titled, [Facility Name] QAPI [Quality Assurance Performance Improvement] Plan, the facility failed to ensure the QAPI committee was composed of the required committee members. Specifically, the facility failed to provide evidence that a Medical Director (MD) or designee participated as a required QAPI committee member at least quarterly. Findings include: A review of the [Facility Name] QAPI Plan, dated 02/2017, revealed that QAPI membership included the MD, Administrator, and the Director of Nursing at a minimum. A review of the facility's QAPI Meeting sign-in sheets revealed an MD had not signed as present during a meeting since 07/16/2021. QAPI meetings beyond July of 2021 occurred on 08/20/2021, 09/23/2021, 10/21/2021, 11/23/2021, 12/28/2021, 01/25/2022, and 02/25/2022 with no evidence of at least quarterly attendance by an MD or designee. During an interview on 03/11/2022 at 12:15 PM, Employee Identifier (EI) #28, Medical Director, stated he had just started as the MD for the facility two months prior and had not yet attended a QAPI meeting. EI #28 stated a QAPI meeting had not come due since he became the MD. EI #28 noted he preferred to hold QAPI meetings monthly, but stated they needed to be held quarterly at a minimum. EI #28 stated he expected the facility to discuss different quality measures and any identified issues. Per EI #28, it was important to review quality measures and identified issues at each QAPI meeting to take care of the residents, prevent infections, make sure the needs of all residents were met. During an interview on 03/11/2022 at 4:25 PM, EI #14, Director of Clinical Operations, stated she expected EI #1, Administrator, to run QAPI and for the interdisciplinary team to participate. Per EI #14, QAPI's purpose was to review any identified issues, put improvement plans in place, and monitor improvements. EI #14 stated the MD should participate in QAPI meetings at least quarterly. During an interview on 03/11/2022 at 4:50 PM, EI #2, Director of Nursing, stated the department heads and the individual functioning in the capacity of MD participated in the QAPI meetings. Per EI #2, the current MD started in December of 2021 and had not yet attended a QAPI meeting. EI #2 noted the previous MD resigned in October of 2021 and no MD had attended a QAPI meeting since then. During an interview on 03/11/2022 at 5:03 PM, EI #1 stated QAPI met at least monthly with an ad hoc meeting added if something new was identified. Per EI #1, QAPI's purpose was to track and trend issues for a proactive rather than reactive response. EI #1 confirmed that an MD had not signed into or physically attended a QAPI meeting since July of 2021, noting the previous MD was notified of issues discussed during post-July of 2021 QAPI meetings telephonically. EI #1 stated such phone calls with the previous MD had not been documented.

Based on record review, interviews, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a comprehensive Significant Change in Status Minimum Data Set (MDS) was completed within fourteen days of Resident Identifier (RI) #55's discharge from hospice services. This affected RI #55, one of one resident reviewed for hospice services. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual revealed the following: .CH (Chapter) 3: MDS Items [A] . Coding Tips and Special Populations · If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS significant change in status assessment (SCSA). The nursing home is required to complete a SCSA when they come off the hospice benefit (revoke) . RI #55 was most recently readmitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Visit Note Report, dated 10/29/2021, revealed RI #55 was discharged from hospice services due to .NO LONGER TERMINALLY ILL . A review of RI #55's Order Summary Report, printed 03/11/2022, revealed no current orders for hospice services. However, review of RI #55's MDS assessments revealed no Significant Change in Status MDS assessment had been completed following RI #55's discharge from hospice. During an interview with Employee Identifier (EI) #14, Director of Clinical Operations, on 03/10/2022 at 11:01 AM, EI #14 stated RI #55 was discharged from hospice services in October or November of 2021. EI #14 stated an MDS should have been done at that time. During an interview with EI #3, one of the MDS Coordinators, on 03/11/2022 at 9:47 AM, EI #3 indicated a significant change MDS should be completed when a resident was admitted to or discharged from hospice services. EI #3 stated they checked the census for any payor source changes to indicate if an MDS needed to be completed. EI #3 stated RI #55 was a pro [NAME] case for the hospice company, so when hospice services were discontinued, RI #55's payor source did not change; therefore, EI #3 did not know to complete a significant change MDS. EI #3 stated this needed to be done so that the resident's status could be updated and their plan of care adjusted.

Based on interviews, record review, and review of a policy titled, [CONDITION(S)] Medication Use, the facility failed to attempt a gradual dose reduction (GDR) for Resident Identifier (RI) #90, one of five residents reviewed for unnecessary medications. Findings included: A review of the [CONDITION(S)] Medication Use policy, dated 12/01/2007, revealed, .Facility should ensure that the ordering physician reviews the medication plan and considers a GDR of [CONDITION(S)] medications for the purpose of finding the lowest effective dose unless a GDR is clinically contraindicated. Physician should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . A review of an Admission Record revealed the facility admitted RI #90 with diagnoses that included Dementia Without Behavioral Disturbance, Delusional Disorders, Anxiety Disorder, Major Depressive Disorder, and Arthritis. A review of RI #90's Annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating severe cognitive impairment. Per the MDS, RI #90 exhibited no physical or verbal behaviors directed toward others or any other behavioral symptoms not directed toward others. The MDS indicated RI #90 received an antipsychotic medication in the seven days prior to assessment and a GDR had not been attempted. A review of RI #90's March 2022 Physician Orders revealed RI #90 had current orders to receive [MEDICATION(S)] 25 mg in the morning and at night, both ordered on 02/23/2021. A review of RI #90's medical record on 03/08/2022 revealed no attempted GDR from 02/23/2021 to 03/08/2022. There was no physician documentation as to why a GDR was clinically contraindicated. During an interview on 03/08/2022 at 9:15 AM, Employee Identifier (EI) #9, Licensed Practical Nurse (LPN), stated RI #90 did not have any behaviors. During an interview on 03/08/2022 at 9:33 AM, EI #6, LPN, stated RI #90 did not have any behaviors. During an interview on 03/08/2022 at 11:00 AM, EI #12, LPN, stated RI #90 mostly stayed to themselves and did not have any behaviors towards others. During an interview on 03/08/2022 at 3:55 PM, EI #15, Pharmacist, stated that when a resident was on a [CONDITION(S)], a GDR should be attempted at least twice in the first year of use, not in the same quarter, and then at least annually. Per EI #15, if a GDR was clinically contraindicated, the physician should document it in progress notes or on the monthly medication reviews from the pharmacist. During an interview on 03/10/2022 at 8:45 AM, EI #16, Certified Nurse Aide, stated RI #90 did not have any behaviors but reacted if another resident was bothering them. EI #16 then stated RI #90 had no behaviors toward staff and did not instigate anything with other residents. During an interview on 03/10/2022 at 8:55 AM, EI #10, Psychiatrist, stated they did not do a GDR because RI #90 had intermittent behaviors. EI #10 further stated RI #90 was agitated and paranoid, noting any GDR documentation would be in EI #10's progress notes. A review of RI #90's Psychiatrist's Progress Notes revealed no documented rationale as to why a GDR for [MEDICATION(S)] had not been attempted since the 02/23/2021 start date. During an interview on 03/10/2022 at 9:05 AM, EI #3, MDS nurse, stated that when completing the MDS, EI #3 checked yes under antipsychotic medication review when a resident received an antipsychotic on a routine basis. EI #3, then checked no when a GDR was not attempted. When asked where it was documented that attempting a GDR on RI #90's [MEDICATION(S)] was clinically contraindicated, EI #3 stated there was no physician documentation. During an interview on 03/10/2022 at 11:20 AM, EI #2, Director of Nursing, stated she followed the pharmacist's recommendations when it came to [CONDITION(S)] use and initiated GDRs twice in the first year of use. Per EI #2, the psychiatrist made a note if a GDR had been done in the past or was contraindicated to try again. EI #2, then stated it was important to follow the GDR process because of the risk of [CONDITION(S)] side effects, and EI #2 did not want residents to be dependent on medications. During an interview on 03/10/2022 at 1:15 PM, EI #1, Administrator, stated GDRs should be attempted with [CONDITION(S)] use, but was unsure of how often. EI #1 then stated the psychiatrist did not like to adjust [CONDITION(S)] medications. EI #1 further stated a GDR should at least be attempted to reduce polypharmacy because psychotropics have side effects with long-term usage and should be used as a last resort. During an interview on 03/10/2022 at 1:45 PM, EI #14, Director of Clinical Operations, stated she expected facility staff to use psychotropics when needed and to attempt GDRs for psychotropics. EI #14 further stated it was important to prevent the facility from using unnecessary drugs and overmedicating residents.

Based on observations, record review, interviews, and a review of the facility policy titled, Medication Administration, the facility failed to ensure a medication administration error rate of less than 5%. The facility had 3 errors out of thirty-one opportunities, resulting in a medication error rate of 9.68%. Medication errors were observed for Resident Identifier (RI) #294, one of four residents reviewed who received medication administration from Employee Identifier (EI) #30, a Licensed Practical Nurse, one of four nurses observed passing medications. Findings include: A review of the facility's policy and procedure titled, Medication Administration, last revised 05/2004, indicated, Medications are administered in accordance with written orders of the attending physician . Prior to administration of each medication, the medication and dosage schedule on the residents ESR [Electronic Signature Record] is compared with the medication label. If the label and ESR are different and the container is not flagged to indicate a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. The Admission Record indicated RI #294 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #294's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 30 milligrams (mg); one capsule - [MEDICATION(S)] 20 mg; one tablet - Losartan 50 mg; one tablet - omeprazole 40 mg; one capsule - [MEDICATION(S)] XL 50 mg; one tablet - [MEDICATION(S)] ([MEDICATION(S)]) 5 mg; one tablet - budesonide-[MEDICATION(S)] aerosol 160-4.5 micrograms per actuation (mcg/act); two inhalations On 03/09/2022 at 8:01 AM, EI #30 was observed preparing and administering medication to RI #294. EI #30 obtained RI #294's medications from two plastic bags in the bottom drawer of the medication cart and stated the resident was a new admission and these medications were from the resident's home. A bottle of medication removed from the bag was Losartan/HCTZ ([MEDICATION(S)]) 50-12.5 mg. EI #30 removed one pill from the bottle and gave it to the resident. The resident's medical record did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in a total of three medication errors for RI #294. During an interview with EI #30 on 03/09/2022 at 12:59 PM, EI #30 stated she did not realize the bottle of Losartan contained HCTZ until later and that she needed to get a clarification order from the physician. EI #30 stated she thought she had given the [MEDICATION(S)] XL and the budesonide inhaler. When asked to see the inhaler, EI #30 was unable to locate it in the bags in the bottom drawer, then located the inhaler in a bag labeled with the resident's name in the second drawer of the medication cart. When reminded that she had pulled all the resident's 8:00 AM medications from the plastic bags in the bottom drawer, EI #30 stated she gave all the medications. During an interview with EI #18, a Registered Nurse (RN), on 03/11/2022 at 1:32 PM, EI #18 stated when passing medications, the nurse should follow the five rights which included the right resident, right medications, right dose, right time and right route. EI #18 stated if a medication was not available, the pharmacy should be called right away and sometimes it could be delivered in time for that medication pass; if not, then a note should be put in the chart and the physician notified During an interview with EI #2, the Director of Nursing (DON), on 03/11/2022 at 1:52 PM, EI #2 stated the nurses should be following the five rights of medication administration, which included the right resident, right dose, right form, right medications, and right time. EI #2 stated if a medication was not available, the nurse was to reach out to the pharmacist if it was not available in the emergency medication kit. EI #2 stated the nurse should not be using a resident's medications from home, especially if they were not ordered at the facility. During an interview with EI #24, an RN, on 03/11/2022 at 2:48 PM, EI #24 stated the nurses should always follow the five rights of medication administration to prevent medication errors and that these included the right resident, medication, time, dose and route.

Based on interviews, record reviews, document review, and review of the facility's policy, Physician's Orders, the facility failed to ensure Resident Identifier (RI) #244's diet orders were changed from regular to pureed upon readmission to the facility on [DATE]. This affected RI #244, one of three sampled residents reviewed for therapeutic diets. Findings include: A review of the facility policy titled, Physician Orders dated 08/01/2001, revealed, .It is the policy of this facility to have written physician orders for all therapeutic diets and texture modifications served to residents. Change in a diet order, diet orders changed by the physician should be transmitted in writing from nursing to dietary indicating a Change in Diet Order . A review RI #244's Admission Record revealed RI #244 was admitted to the facility on [DATE] with diagnoses including Gastritis, Personal History of Malignant Neoplasm of Tongue, Cognitive Communication Deficit, Type 2 Diabetes with Foot Ulcer, [CONDITION(S)], [CONDITION(S)] Left Ankle, and Gangrene, Unspecified. Review of a discharge Minimum Data Set assessment (MDS) dated [DATE] and an entry MDS dated [DATE] revealed RI #244 was discharged from the facility to the hospital on 08/19/2021 and returned on 08/23/2021. Review of RI #244's Order Summary Report that listed current orders at the time of his/her final discharge from the facility revealed a diet order, dated 08/06/2021, for a mechanical soft diet with ground meat texture. Review of hospital discharge/transfer orders from RI #244's readmission to the facility on [DATE], revealed RI #244's diet orders had been changed to pureed texture. However, there were no new orders or changes at the facility to reflect RI #244's need for the pureed therapeutic diet orders. An interview on 03/09/2022 at 9:47 AM with Employee Identifier (EI) #11, Licensed Practical Nurse (LPN), revealed the Admissions Coordinator entered in new orders for readmissions and brought the charts to the morning meetings, and staff compared the old orders with the new to ensure it all matched. An interview on 03/10/2022 at 11:01 AM with EI #38, Former Admissions Coordinator, stated she would have been the person responsible for reconciling orders in August 2021 when RI #244 was readmitted , but she could not guarantee she was working on 08/23/2021 during RI #244's readmission. EI #38 stated staff should have reviewed the orders the following day in the morning meeting to catch that the orders were or were not changed. An interview on 03/11/2022 at 1:50 PM with EI #2, the Director of Nursing (DON), revealed that after a resident was readmitted to the facility, nursing staff put in the new orders and the Interdisciplinary Team (IDT) reviewed the orders to ensure the correct orders were in place. EI #2 stated she expected staff to verify that correct orders were in place and being followed. An interview on 03/11/2022 at 4:45 PM with EI #1, Administrator, revealed she expected staff to follow discharge orders from the hospital and that order reconciliation should be caught in the morning meetings. This deficiency was cited as a result of AL 724.

Based on interviews, review of Resident Identifier (RI) #1's medical records, Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, and the facility's policy titled, Medication Errors, the facility failed to ensure RI #1, a kidney transplant resident taking anti-rejection medication, received [MEDICATION(S)] Anhydrous (an anti-rejection medication) from [DATE]-[DATE]. RI #1 was admitted to the facility on [DATE] from a local hospital. The transfer medication list from the hospital, listed [MEDICATION(S)] Anhydrous 0. 5 mg (milligrams) three tablets twice a day as a medication to be continued. On [DATE], RI #1 was transferred to the hospital due to facial and lower extremity swelling, where he/she presented with a critically high potassium level and required emergency [CONDITION(S)] due to acute [CONDITION(S)]. Subsequently, RI #1 was transferred to another hospital's Transplant Unit. Hospital records documented RI #1 was determined to have no intrarenal blood-flow on [DATE], and was at that time, considered to be in End Stage Renal Disease and would require ongoing [CONDITION(S)]. This deficient practice placed RI #1, one of three sampled residents reviewed for medications being given as ordered, in immediate jeopardy as this failure was likely to cause serious injury, harm, impairment or death. On [DATE] at 2:54 PM, the Administrator, Director of Nursing and the Director of Clinical Operations were notified of the finding of substandard quality of care at the immediate jeopardy level at past noncompliance in the area of Pharmacy Services/Residents Are Free of Significant Med Errors, F760. Findings Include: Review of Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, with a copyright date of 2017, pages ,d+[DATE] of Chapter 32 titled Medication Administration, revealed: . Medication Errors A medication error can cause or lead to inappropriate medication use or patient harm. Medication errors include .failing to administer a medication. Preventing medication errors is essential. Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. Review of a policy titled, Medication Errors, with a copyright date of 2021, revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Definitions: .Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: . ii. Medication omission . On [DATE] the Alabama State Survey Agency received a complaint which alleged the facility did not administer anti-rejection medications as ordered to RI #1, a resident with a past medical history including a renal transplant in 2011. RI #1 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #1's transfer paperwork from a local hospital to Park Place on [DATE] included the following: .PROVIDER DISCHARGE INSTRUCTIONS . Date: [DATE] .DISCHARGE INSTRUCTIONS AND PLAN .PLEASE CONTINUE OTHER MEDICATIONS AS PREVIOUSLY PRESCRIBED 1. [MEDICATION(S)] 0.5 MG (3 TABLETS) B.I.D. (twice a day) . RI #1's printed Order Summary Report listing ordered medications for May and [DATE] did not include the order for [MEDICATION(S)] Anhydrous. Review of RI #1's Medication Administration Records (MARs) for May and [DATE] confirmed RI #1's [MEDICATION(S)] Anhydrous had not been administered from [DATE] through [DATE]. RI #1's Progress Notes documented: . [DATE] 15:37 (3:37 PM) . Resident has [CONDITION(S)] noted to face and feet . [DATE] 13:40 (1:40 PM) . Change of Condition . [CONDITION(S)] noted, resident also stated (he/she) hasn't voided any today . Notified the on-call doctor and got an order to send the resident to ER (emergency room ) . [DATE] 22:48 (10:48 PM) . At 22:17 (10:17 PM) spoke with receptionist at (local hospital) and was told that resident was admitted with acute [CONDITION(S)] . RI #1's History and Physical from the local hospital documented the following: .HISTORY PHYSICAL . admitted : [DATE] . Date: [DATE] . Admission: [CONDITION(S)] Requiring Emergent HD (Hemodialysis) . History of Present Illness . presented to the emergency department with a chief complaint constant and worsening facial and lower extremity swelling that began a few days prior to presentation .HAND OFF NOTES: . rejected renal transplant HD today anticipate . transfer (to another hospital) in the a.m. (morning) . Patient is being transferred to (another hospital's) renal transplant services . RI #1's PROVIDER POST OPERATIVE NOTE, included in the local hospital records, documented .Date: [DATE] . TEMPORARY HEMODIALYSIS CATHETER PLACEMENT . Indication: Severe [CONDITION(S)] with potassium 8.1 (critical high result), acute on chronic [CONDITION(S)]. On [DATE] at 3:35 PM a phone interview was conducted with the facility's contracted Pharmacist. The Pharmacist was asked if a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1 upon admission to the facility on [DATE]. The Pharmacist stated they had not received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's stay in the facility from [DATE] through [DATE], the Pharmacist said no. On [DATE] at 9:46 AM an interview was conducted with Employee Identifier (EI) #4, Licensed Practical Nurse. EI #4 was asked about the facility's process for ordering medications for new admissions to facility. EI #4 said, once the facility receives the discharge summary from the hospital, the orders are put into the facility's computer system, then a face sheet and order listing summary are printed and faxed to the pharmacy. EI #4 was asked if she put RI #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #4 said, no she did not, RI #5, a Registered Nurse (RN)/Unit Manager did. EI #4 was asked if RI #1 received all medications that were ordered on admission. E #4 said, RI #1 did not receive the medication [MEDICATION(S)] Anhydrous. When asked if RI #1's medication [MEDICATION(S)] Anhydrous should have been ordered, EI #4 said yes. EI #4 further explained the medication was never put into the computer so when the medication list was printed out it was not on it, so the pharmacy did not know to send it. EI #4 was asked what was the potential harm of RI #1 not receiving his/her [MEDICATION(S)] Anhydrous from [DATE]-[DATE]. EI #4 said, his/her body could reject the kidney. On [DATE] at 10:24 AM an interview was conducted with EI #5, RN/Unit Manager. EI #5 was asked what was the facility's process for ordering medications for new admissions to the facility. EI #5 said the facility receives the orders from the hospital, puts the medication orders in the computer and once all the orders are put in, it is faxed to the pharmacy. When asked if she had entered RI #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] #5 said yes. Upon reviewing RI #1's discharge orders from the local hospital, EI #5 said, to her knowledge she had put all of the medications into the computer. EI #5 was asked should RI #1's medication [MEDICATION(S)] Anhydrous have been ordered. EI #5 said, yes it should have been ordered. EI #5 was asked what was the potential harm of RI #1 not receiving his [MEDICATION(S)] Anhydrous medication for 10 days. EI #5 said it could result in RI #1's body rejecting the kidney. During a follow-up interview with EI #5, RN, on [DATE] at 11:00 AM, EI #5 said RI #1's [MEDICATION(S)] Anhydrous medication had not been administered at all during the time he/she was in the facility, resulting in 20 missed doses of the medication. On [DATE] at 5:15 PM an interview was conducted with EI #2, RN/Director of Nursing. EI #2 was asked when she was made aware that RI #1 had not received the anti-rejection medication [MEDICATION(S)] Anhydrous for 10 days in [DATE]. EI #2 said she was a new employee of the facility but had been made aware this week of the concern about RI #1's anti-rejection medication. EI #2 explained the process for ordering medications for new admissions should consist of transcribing the orders from the hospital orders into the facility's computer system, which is in turn sent to the pharmacy to fill the medication orders. EI #2 was asked if RI #1 should have received the anti-rejection medications as prescribed. EI #2 said, yes, he/she should have. EI #2 was asked what was the potential harm with RI #1 not receiving his/her [MEDICATION(S)] Anhydrous medication as prescribed for 10 days. EI #2 said the potential for exacerbation of kidney disease. On [DATE] at 5:30 PM an interview was conducted with EI #1, the Administrator. EI #1 was asked when she became aware that RI #1 did not receive his/her [MEDICATION(S)] Anhydrous, an anti-rejection medication, as prescribed. EI #1, replied, she became aware of the incident when, EI #3, the Medical Director, called her on [DATE]. EI #1 further said, EI #3 told her there was an issue with RI #1. EI # 3 reported that it did not appear RI #1 received his/her [MEDICATION(S)] Anhydrous. EI #1 stated she notified the Clinical Regional Nurse and the corporate office who provided guidance on what they should do. EI #1 stated on [DATE], the facility created a four-point plan, printed the MARs from [DATE] on all new admissions and checked the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 said education was also started with the managers and monitoring was put in place. EI #1 was asked what the facility determined happened as to why RI #1 did not received his/her [MEDICATION(S)] Anhydrous for 10 days. EI #1 said from what she was able to determine, the medication was not entered/transcribed into the computer. EI #1 indicated this error was actually caught during the facility's daily clinical meeting the Monday after RI #1's admission ([DATE]), and one of the nurses in the meeting was supposed to enter it, but it never got put into the computer. EI #1 stated they could never determine who it was that was supposed to enter the order into the computer after the issue was identified, but they had altered their process and currently no staff are allowed to leave the daily clinical meeting until all identified issues have been addressed. EI #1 was asked what was the potential harm with RI #1 not receiving the [MEDICATION(S)] Anhydrous for 10 days, from [DATE]-[DATE]. EI #1 said his/her body may reject his/her kidney. EI #1 indicated EI #3, the Medical Director, told her RI #1 might have to go back on [CONDITION(S)]. EI #1 also reported that a family member of RI #1's later told her that he/she had lost the kidney. On [DATE] at 9:58 AM an interview was conducted with EI #3, the Medical Director. EI #3 was asked if she was familiar with RI #1. EI #3 said that she was the Medical Director for Park Place, and she had also provided care for RI #1 at the local hospital after he/she was sent to the emergency roiagnom on [DATE] for facial swelling. EI #3 was asked what was RI #1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #3 said she did see RI #1 while at the local hospital before he/she was transferred. EI #3 said RI #1's potassium was high and he/she was going to need [CONDITION(S)]. When asked why RI #1's potassium was high, EI #3 said, the Nurse Practitioner at the hospital told her RI #1 may not have received his/her anti-rejection medications while at Park Place. EI #3 said after becoming aware of that, she went to the facility on [DATE] and informed the Director of Nursing at the time and the Administrator about what she had been told. EI #3 said they then reviewed the medications RI #1 should have been receiving upon admission to Park Place and determined he/she had not received the [MEDICATION(S)] Anhydrous as ordered. EI #3 said, RI #1 was receiving two other medications in relation to the kidney transplant, but the [MEDICATION(S)] Anhydrous was not included on RI #1's MARs. EI #3 said it had been determined the medication order had not been transcribed from the hospital admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #3 said, yes, that was one of his/her prescribed medications. EI #3 was asked about the potential harm to RI #1 related to not receiving the [MEDICATION(S)] Anhydrous medication for 10 days. EI #3 said, there would be a concern about the function of the transplanted kidney, such as was the transplanted kidney going to be able to continue to work. EI #3 was asked if RI #1's transplanted kidney was working prior to admission to the facility on [DATE]. E #3 said on [DATE] the lab BUN (Blood urea [MEDICATION(S)]) was 19 and the lab creatinine was 1.3, which indicated to her that prior to admission RI #1's kidneys were working good. EI #3 was asked how RI #1's kidney function was on [DATE], after transferred to the emergency room . EI #3 said, it had worsened. (Note: Records from the hospital indicate RI #1's BUN had increased to 114 (abnormal high) as of [DATE]). Review of hospital records from the local hospital transplant unit RI #1 was transferred to on [DATE] revealed the following: . admitted : [DATE] . D/C (discharge) DATE: [DATE] .History and Physicals . History of Present Illness . came to the ER from rehab for worsening lower extremity [CONDITION(S)] and found to have acute kidney injury with creatinine of 9 BUN more than 100 and potassium of 8 .Professional Services . admitted with AKI (acute kidney injury) with high suspicious for rejection of transplant since (he/she) did not receive all of (his/her) immunosuppression for about 1 (one) week . admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Hospital Course . Acute kidney injury of renal allograft/ acute rejection ; Now [CONDITION(S)] . status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Renal transplant ultrasound with no intrarenal blood flow detected ,d+[DATE] ([DATE]). Officially diagnosed [CONDITION(S)] requiring long term iHD (intermittent Hemodialysis) . ************************* Once the facility became aware of the incident involving RI # 1's medication error on [DATE], the following corrective action plan was developed and implemented: *All new admissions since [DATE] had medical orders reviewed and compared to the MAR. All other new orders were compared to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] * New or revised orders to be reviewed in daily clinical start up. Medication reconciliation will be completed in daily clinical start up. Issues identified will be corrected prior to leaving the meeting. All nurses educated on Medication Reconciliation, including when new orders received, the nursing team will review the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Started [DATE] and completed on [DATE]. * Medication Order reconciliation audits will be conducted 3 x week for 60 days then weekly. Ongoing by DNS/Designee. *Results of audits will be discussed in daily clinical meetings and then in monthly QAPI (Quality Assurance Process Improvement) with follow up as needed. Ongoing by DNS/Designee. ************************* After review of the information provided in the facility's corrective action plan, in-service/education records, as well as staff interviews, the survey team determined the facility implemented corrective actions from [DATE]-[DATE]; thus immediate jeopardy past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 579.

Based on interviews and review of Resident Identifier (RI) #1's medical records, Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, the facility's policy titled, New/Re-Admit physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of this deficient practice, RI #1 did not receive the ordered medication during his/her stay at the facility from 5/21/2021-6/01/2021 and suffered a significant medication error. RI #1 was admitted to the facility on [DATE] from a local hospital. The transfer medication list from the hospital listed [MEDICATION(S)] Anhydrous 0.5 mg three tablets twice a day as a medication to be continued. On 6/01/2021, RI #1 was transferred to the hospital due to facial and lower extremity swelling, where he/she presented with a critically high potassium level and required emergency [CONDITION(S)] due to acute [CONDITION(S)]. Subsequently, RI #1 was transferred to another hospital's Transplant Unit. Hospital records documented RI #1 was determined to have no intrarenal blood-flow on 6/04/2021, and was at that time, considered to be in End Stage Renal Disease and would require ongoing [CONDITION(S)]. This deficient practice placed RI #1, one of three sampled residents reviewed for transcription of medications, in immediate jeopardy as this failure was likely to cause serious injury, harm, impairment or death. On 10/22/2021 at 2:54 PM, the Administrator, Director of Nursing and the Director of Clinical Operations were notified of the finding of immediate jeopardy past noncompliance in the area of Administration/Resident Records-Identifiable Information, F842. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, with a copyright date of 2017, page 632 of Chapter 32, documented . Receiving Transcribing, and Communicating Medication Orders. Nurses .check all MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . It is essential to verify the accuracy of every medication .If the medication order is incomplete, incorrect, .or if there is a discrepancy between the original order and the information on the MAR (Medication Administration Record), consult with the health care provider . Review of a facility pharmacy policy titled New/Re-Admit physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These orders will be printed out and faxed to pharmacy .Medications *Transcribe the medication order EXACTLY as prescribed . Review of a facility document titled, Daily Clinical Start-Up Process, dated February 2019, revealed: Purpose To provide a comprehensive overview of the care delivery every day. Items to review daily: . All new admission and re-admission documentation is reviewed including: Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/2021 the Alabama State Survey Agency received a complaint which alleged the facility did not administer anti-rejection medications as ordered to RI #1, a resident with a past medical history including a renal transplant in 2011. RI #1 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #1's transfer paperwork from a local hospital to Park Place on 5/21/2021 included the following: .PROVIDER DISCHARGE INSTRUCTIONS . Date: 5/21/21 .DISCHARGE INSTRUCTIONS AND PLAN .PLEASE CONTINUE OTHER MEDICATIONS AS PREVIOUSLY PRESCRIBED 1. [MEDICATION(S)] 0.5 MG (3 TABLETS) B.I.D. (twice a day) . RI #1's printed Order Summary Report listing ordered medications for May and June 2021 did not include the order for [MEDICATION(S)] Anhydrous. Review of RI #1's Medication Administration Records (MARs) for May and June 2021 confirmed RI #1's [MEDICATION(S)] Anhydrous had not been transcribed onto the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/20/2021 at 9:46 AM an interview was conducted with Employee Identifier (EI) #4, Licensed Practical Nurse. EI #4 was asked about the facility's process for ordering medications for new admissions to facility. EI #4 said, once the facility receives the discharge summary from the hospital, the orders are put into the facility's computer system, then a face sheet and order listing summary are printed and faxed to the pharmacy. EI #4 was asked if she put RI #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #4 said, no she did not, RI #5, a Registered Nurse (RN)/Unit Manager did. EI #4 was asked if RI #1 received all medications that were ordered on admission. E #4 said, RI #1 did not receive the medication [MEDICATION(S)] Anhydrous. When asked if RI #1's medication [MEDICATION(S)] Anhydrous should have been ordered, EI #4 said yes. EI #4 further explained the medication was never put into the computer so when the medication list was printed out it was not on it, so the pharmacy did not know to send it. On 10/21/21 at 10:47 AM, during a follow-up interview, EI #4 stated it was important to ensure all medication orders are transcribed into the computer system so that incidents like this do not happen, and so that residents receive the correct medications to maintain their health. On 10/20/2021 at 10:24 AM an interview was conducted with EI #5, RN/Unit Manager. EI #5 was asked what was the facility's process was for ordering medications for new admissions to the facility. EI #5 said the facility receives the orders from the hospital, puts/transcribes the medication orders in the computer system and once all the orders are put in, it is faxed to the pharmacy When asked if she had entered RI #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon reviewing RI #1's discharge orders from the local hospital, EI #5 said, to her knowledge she put all of the medication orders into the computer. EI #5 was asked should RI #1's medication [MEDICATION(S)] Anhydrous have been ordered. EI #5 said, yes it should have been ordered. On 10/21/2021 at 11:00 AM a follow up interview was conducted with EI #5. EI #5 was asked were all of RI #1's medications transcribed when he/she was admitted on [DATE]. EI #5 said all except the [MEDICATION(S)] Anhydrous. EI #5 was asked did RI #1 receive any doses of the [MEDICATION(S)] Anhydrous while a resident at the facility. EI #5 said, no, he/she did not receive any. EI #5 was asked what was the importance of transcribing all of a resident's medications. EI #5 said to make sure the doctor's orders are followed, and the resident receives the medication. On 10/20/2021 at 5:30 PM an interview was conducted with EI #1, the Administrator. EI #1 stated she became aware RI #1 did not receive his/her [MEDICATION(S)] Anhydrous, an anti-rejection medication, as prescribed on 6/04/2021 when EI #3, the Medical Director, called her. EI #1 explained the facility determined this incident happened because the the medication order was not entered/transcribed into the computer. EI #1 indicated this error was actually caught during the facility's daily clinical meeting the Monday after RI #1's admission (5/24/2021), and one of the nurses in the meeting was supposed to enter it, but it was never entered into the computer. EI #1 stated they could never determine who it was that was supposed to enter the order into the computer after the issue was identified, but they had altered their process and currently no staff are allowed to leave the daily clinical meeting until all identified issues have been addressed. A follow-up interview was conducted with EI #1 on 10/21/2021 at 11:20 AM. EI #1 was asked if RI #1's medication order for [MEDICATION(S)] Anhydrous was transcribed into the computer system. EI #1 said, no. EI #1 was asked why it was important to ensure all medication orders were transcribed. EI #1 said, so the resident can receive the medication as ordered. On 10/21/2021 at 12:24 PM an interview was conducted with EI #2, Director of Nursing. EI #2 was asked if all of RI #1's medications were transcribed into the computer system when he/she was admitted to the facility on [DATE]. EI #2 said, no, not the [MEDICATION(S)] Anhydrous. EI #2 was asked why it was important to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 was asked who was ultimately responsible for ensuring the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ************************* Once the facility became aware of the incident involving RI # 1's medication error on 6/04/2021, the following corrective action plan was developed and implemented: *All new admissions since 5/21/2021 had medical orders reviewed and compared to the MAR. All other new orders were compared to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] * New or revised orders to be reviewed in daily clinical start up. Medication reconciliation will be completed in daily clinical start up. Issues identified will be corrected prior to leaving the meeting. All nurses educated on Medication Reconciliation, including when new orders received, the nursing team will review the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Started 6/04/2021 and completed on 6/07/2021. * Medication Order reconciliation audits will be conducted 3 x week for 60 days then weekly. Ongoing by DNS/Designee. *Results of audits will be discussed in daily clinical meetings and then in monthly QAPI (Quality Assurance Process Improvement) with follow up as needed. Ongoing by DNS/Designee. ************************* After review of the information provided in the facility's corrective action plan, in-service/education records, as well as staff interviews, the survey team determined the facility implemented corrective actions from 6/04/2021-6/07/2021; thus immediate jeopardy past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 579.

Based on interview, medical record review and a review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, the facility failed to ensure RI (Resident Identifier) #1 a resident admitted to the facility on [DATE] received the ordered medication [MEDICATION NAME] Sodium ([MEDICATION NAME]) on 12/25/19 and 12/26/19 as ordered by the physician. This deficient practice affected RI #1, one of three sampled residents who physician's orders [REDACTED]. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, copyright 2013, revealed the following: Chapter 23 Legal Implications in Nursing Practice .Health Care Provider's Orders. The health care provider (physician .) is responsible for directing medical treatment. Nurses follow health care provider's orders unless they believe that the orders are in error . RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #1's Admission Minimum Data Set with an Assessment Reference Date of 12/31/19, revealed his/her Brief Interview of Mental Status score was a 15, indicating the resident was cognitively intact. A review of RI #1's Physician order [REDACTED].Order Date 12/24/2019 . On 09/10/20 at 3:21 p.m., an interview was conducted with EI #2, Director of Nurses. EI #2 was asked according to RI #1's December 2019's Medication Administration Record [REDACTED]. EI #2 said [MEDICATION NAME]. EI #2 was asked what was the reason why RI #1's [MEDICATION NAME] medication was not available in the facility. EI #2 said the issue was RI #1's medication orders were faxed at 2:53 p.m. and the cut off time on a holiday (12/24/19) was 2:00 p.m. EI #2 was asked was the nurse who put the medication orders in aware of the the cut off time of 2:00 pm. EI #2 said she was not sure if the nurse was aware of it (the cut off time ). EI #2 was asked who was responsible for informing the nurses of the Pharmacy hours during the holidays. EI #2 said she was ultimately responsible. EI #2 was asked what the facility did to get the medication in house. She replied when the nurse realized the medication did not come in the night of 12/24/19 she called the back up pharmacy on 12/25/19 to put in the order, however the medication was not delivered until 12/26/19. EI #2 was asked what was the potential harm of the resident not receiving [MEDICATION NAME] for two days. EI #2 said RI #1's therapeutic level would be altered. EI #2 was asked who was responsible for ensuring resident medications was available for administration. EI #2 said the nurse who gives the medications. This citation was written as a result of the investigation of complaint/report number AL 852.

Based on interviews, medical record review, review of a facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy and facility reported incidents, the facility failed to timely report three reported incidents to the State Agency. These incidents involved Resident Identifier (RI) #26, #60, #243 and #244. This deficient practice affected three of six allegations of abuse that were reviewed. Findings Include: A review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of 01/19, revealed: .Purpose: To prohibit and prevent abuse, neglect .and to ensure reporting .of alleged violations (to include injuries of unknown source .) in accordance with Federal and State Laws . Injuries of Unknown Source: When both of the following criteria are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g. (for example) the injury is located in an area not generally vulnerable to trauma) . 7. Reporting/Response Alleged violations/violations will be reported to the Administrator, designee immediately. Immediately reporting all alleged violations to the Administrator, designee, state agency .within specified timeframes . When .all alleged violations-immediately but not later than 1. 2 hours if the alleged violation involves abuse or results in serious bodily injury 2. 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury . 1) RI # 26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #26 was observed to have a bruise to the left thigh of unknown origin on 4/07/19. This was reported to Employee Identifier (EI) #3, Registered Nurse (RN) Treatment Nurse on 04/07/19 at 2:24 p.m. This injury of unknown origin was reported to the State Agency on 04/15/19 at 4:10 p.m. 2) RI #60 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #243 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #60 was struck on the head and hand by RI #243 on 12/03/18 at 10:30 p. m. This incident was reported to the State Agency on 12/04/18 at 9:51 a.m. 3) RI #244 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility was made aware RI #243 was left sitting on the toilet on 11/06/18 at 6:15 a.m. This incident was reported to the State Agency on 11/07/18 at 12:43 p.m. On 5/15/19 at 1:49 p.m., the surveyor conducted an interview with EI #4, RN. EI #4 was asked if she was familiar with RI #26. EI # 4 said yes she was. EI #4 was asked if she was the assigned nurse for RI #26 on 4/7/19, EI #4 said she was. EI #4 was asked what happened to RI #26 on 4/7/19. EI #4 said she was down the hall giving medications and doing vital signs. EI #4 said she was made aware of bruising to RI #26's thigh by EI #3, who was also the supervisor on that day. EI #4 said she went to assess the site. EI #3 said she also did vital signs,called the doctor and made the family aware. EI #4 was asked who else did she make aware of the bruising. EI #4 said those were the only ones and the supervisor was aware because she was the one that told her. EI #4 was asked what time did this happen. EI #4 said 7:15 a.m. EI #4 was asked when she did your assessment, what were the findings. EI #4 said RI #26 had a reddish purple bruise to the upper inner aspect of the left thigh. EI #4 was asked what treatment was started. EI #4 said there was no treatment, but they monitored the site and the pain level. EI # 4 was asked what did RI #26 say happened. EI #4 said RI #26 was not able to reveal how the bruising was made. EI #4 said the bruising was noted during morning care. EI #4 was asked who was the abuse coordinator. EI #4 said the administrator was the abuse coordinator. On 5/15/19 at 2:24 p.m., the surveyor conducted an interview with EI #3. EI #3 was asked if she was the supervisor on 4/7/19. EI #3 said she was. EI #3 was asked if she was made aware of the incident involving RI #26. EI #3 said yes, the certified nursing assistant made her aware the area was found during morning care, but she went to assess the area herself. EI #3 was asked what were her findings. EI #3 said she assessed bruising to RI #26's thigh. EI #3 was asked who did she make aware of this bruising to RI #26's thigh area. EI #3 said she told EI #4 to fill out an incident report. EI #3 was asked who was the abuse coordinator. EI #3 said the administrator. EI #3 was asked did she make the abuse coordinator aware of this incident on 4/7/19. EI #3 said no. EI # 3 was asked had she had an abuse in-service. EI #3 said yes. EI # 3 was asked should this incident have been reported to the state. EI #3 said she did not think at the time it was abuse. EI #3 was asked did the abuse in-service talk about injury of unknown origins. EI #3 said she did not remember. On 5/16/19 at 11:36 a.m., the surveyor conducted an interview with EI #1, Administrator. EI#1 was asked who was the abuse coordinator for that facility. EI #1 said he was. EI #1 was asked did the facility have a policy describing abuse and the reporting requirements. EI #1 said they used the abuse and fraud policy, 2019 version. EI #1 was asked how often were abuse in-services conducted. EI #1 said upon hire, semi-annually and as needed. EI #1 was asked how was he made aware of a resident having an incident. EI #1 said through the phone, reports, EMAR (Electronic Medication Administration Record) and person to person. EI #1 was asked who was responsible for reporting required incidents to the State Agency. EI #1 said he was. EI #1 was asked what system was set up to ensure the required information was being reported. EI #1 said they will send him a text or phone message and he will submit the information from his phone wherever he was through the portal. EI #1 was asked if he was aware of the required reporting time frame of each type of incidents that the facility may encounter. EI #1 said he was. EI #1 was asked why was the incident involving RI #243 and RI # 60 not reported in a timely manner. EI #1 said he was not notified in a timely manner. EI #1 was asked why was the incident involving RI #244 not reported in a timely manner. EI #1 said we reported it when we were made aware of the incident. EI # 1 was asked why was the incident involving RI #26 not reported in a timely manner. EI #1 said due to when it was first discovered, it did not appear suspicious in nature. EI#1 was asked what caused the team to suspect this injury was suspicious in nature. EI#1 said new information became available and when it was reassessed it looked like a hand print.

Based on interviews and review of residents' medical records, the facility failed to accurately code the Minimum Data Set (MDS) assessment of Resident Identifier (RI) #3, #16 and #20. This deficient practice affected RI #3, #16, and #20, three of 30 sampled residents. Findings Include: 1) RI #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #3's Order Summary Report dated 05/16/19, revealed the resident was ordered to be on a NPO (nothing by mouth) diet on 12/13/17, and ordered to receive enteral feedings of [MEDICATION NAME] 1.5 five times a day on 03/22/18. RI #3's Quarterly MDS, dated [DATE], coded RI #3 as receiving [MEDICATION NAME]/IV (intravenous) feedings, rather than enteral tube feedings. During an interview on 05/16/19 at 11:00 a.m., Employee Identifier (EI) #2, Registered Nurse (RN)/MDS Coordinator, validated this coding as an error. 2) RI #16 was re-admitted to the facility on [DATE], with End Stage [MEDICAL CONDITION] and Essential Hypertension. RI #16's Order Summary Report dated 05/16/19, revealed the resident was ordered [MEDICATION NAME] 75 mg (milligram) on 07/03/18. [MEDICATION NAME] is considered an antiplatelet medication. RI #16's Quarterly MDS assessment, dated 02/27/19, coded RI #16 as receiving an anticoagulation medication. An anticoagulant medication could not be found in the RI #16's current physician orders. On 05/16/19 at 8:49 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked who was responsible for ensuring RI #16's Quarterly MDS assessment, dated 02/27/19, was coded correctly. EI #2 said she was. EI #2 was asked what was coded on RI #16's 02/27/19 Quarterly MDS assessment for anticoagulation. EI #2 said it was coded for receiving an anticoagulation medication in the seven day look back period. EI #2 was asked when reviewing RI #16's medication profile, was there a medication listed for anticoagulation. EI #2 said not for anticoagulation, but an antiplatelet. EI #2 was asked would this Quarterly MDS assessment be a correct assessment. EI #2 said everything was correct, except for anticoagulation. 3) RI #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 5/15/19 at 5:29 p.m., a review of RI #20's Quarterly MDS assessment, dated 03/05/19, revealed the resident was coded as using an anticoagulation medication during the assessment period. A review of RI #20's medication profile revealed RI #20 was receiving [MEDICATION NAME] (an antiplatelet medication) 75 mg daily. On 05/16/19 at 8:40 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked who was responsible for ensuring RI #20's Quarterly MDS assessment, dated 03/05/19, was coded correctly. EI #2 said she was. EI #2 was asked what was coded on RI #20's Quarterly MDS assessment for anticoagulation. EI #2 said it was coded that RI #20 had received anticoagulation medication in the seven day look back period. EI #2 was asked when reviewing RI #20's medication profile, was there a medication listed as a anticoagulation medication. EI #2 said there was not for anticoagulation, but antiplatelet. EI #2 was asked if this Quarterly MDS assessment for anticoagulation was a correct assessment. EI #2 said everything except RI #20 did not receive anticoagulation.

Based on observation, interview, medical record review, and a review of Potter and Perry's, FUNDAMENTALS OF NURSING, the facility failed to ensure nursing staff wiped the perineal area and buttocks up toward the back during incontinence care for Resident Identifier (RI) #21. This affected one of one resident observed during incontinence care. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING, Ninth Edition, pages 858 and 859 revealed: . SKILL 40-1 BATHING AND PERINEAL CARE . STEP . (5) Clean buttocks and anus, washing front to back .Cleaning motion prevents contamination perineal area with fecal matter or microorganisms . RI #21 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 5/16/19 at 8:30 a.m., Employee Identifier (EI) #7, Certified Nursing Assistant (CNA) was observed wiping from the top of the buttocks, near RI #21's lower back, down toward the perineal area, four times while cleaning the buttocks. RI #21 had an incontinent bowel movement. An interview was conducted on 5/16/19 at 9:32 a.m. with EI #7. EI #7 was asked, while doing incontinence care and cleaning the buttocks, which way is staff supposed to wipe. EI #7 stated, Up from the (perineal area). (Another Staff member) told me I wiped the wrong way. EI #7 was asked, did she recall doing that. EI #7 stated, Yes. EI #7 was asked, what was the potential for harm. EI #7 stated, Bacterial infection.

Based on observation, interview, medical record review, and a review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure nursing staff disposed of the perineal wash bottle after it was handled with the same gloved hand used to remove stool from Resident Identifier (RI) #21's buttocks. This affected one of one resident observed for during incontinence care. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING Ninth Edition, page 443 revealed: CHAPTER 29 . Reservoir. A reservoir is a place where microorganisms survive, multiply, and await transfer to a susceptible host. Humans can transmit microorganisms . inanimate objects can also be reservoirs for infectious organisms. RI #21 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 5/16/19 at 8:30 a.m., the surveyor observed Employee Identifier (EI) #7, a Certified Nursing Assistant (CNA), touch the perineal wash bottle with the same gloved hand she used to wipe stool from RI #21's buttocks during incontinence care. EI #7 did not dispose of the bottle. On 5/16/19 at 9:32 a.m., the surveyor asked EI #7, while performing incontinence care, what happens to the perineal wash bottle after it had been touched with the same contaminated gloves used to clean stool from RI #21's buttocks. EI #7 stated, It gets contaminated. The surveyor asked EI #7 what was the potential for harm. EI #7 stated, Bacterial Infection.

Based on observations, interview, and review of a facility policy titled, Refrigerated Storage, the facility to ensure: 1) food items in the walk in cooler were labeled with an open and use by date; and 2) a bag of sliced roast beef was discarded after the use by date. These deficient practices had the potential to affect all 93 residents receiving meals from dietary: Findings Include: A review of a facility policy titled, Refrigerated Storage, with an effective date of 01/01/017 revealed: . POLICY It is the policy of this center to store, prepare, and serve food in accordance with federal, state, and local sanitary codes. PR[NAME]EDURE . 3. All foods should be . labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates . or discarded . On 05/16/18 at 8:05 a.m., Employee Identifier(EI) #2, the Dietary Supervisor accompanied the surveyor during the initial tour of the kitchen. In the walk in freezer, the surveyor observed the following: (1) a bag (Ziploc) of grated cheddar cheese on the shelf with no open or use by date; (2) a bag (Ziploc) with three blocks of cheddar cheese; and (3) a bag (Ziploc) that contained roast beef (slices), and was labeled open date 5/11/18-use by 5/13/18. An interview was conducted on 05/17/18 at 1:53 p.m.,with EI #2. EI #2 was asked, on 05/16/18 during the tour of the kitchen, what food items in the walk in cooler did not have an open and use by date. EI #2 said sliced and grated cheddar cheese. EI #2 was asked what food item in the walk in cooler should have been discarded. EI #2 said the sliced roast beef with the open date of 5/11/18, and a use by date of 5/13/18. EI #2 was asked when should food items be labeled. EI #2 said when a food item is opened, it is dated with an open date, the name of the food item and a used by date. EI #2 was asked when should food items be discarded. EI #2 said any sandwich meat should be discarded 7 days after opening, or the expiration date on it, which ever one comes first. EI #2 was asked what was the potential harm to residents when food items are not labeled or discarded (by the use by date). EI #2 replied, if you do not take the proper precautions when handling food, it can make residents sick or a food borne illness.

Based on observation, interview and record review, the facility failed to ensure a care plan was developed for the use of Resident Identifier (RI) #46's oxygen. This deficient practice affected RI #46, one of 35 sampled residents whose plans of care were reviewed. Findings Include: RI #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/22/18, revealed RI #46 was using oxygen during this assessment period. RI #46's (MONTH) (YEAR) Physician order [REDACTED].> . 02 via (by way of) Nasal cannula at 2 L (liters)/min (minute) . On 05/17/18 at 9:04 a.m., the surveyor observed RI #46's using his/her oxygen. On 05/17/18 at 2:54 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Registered Nurse/Assessment Coordinator. The surveyor asked EI #1 was RI #46 receiving oxygen. EI #1 said yes. The surveyor asked EI #1 was RI #46 care planned for the use of the oxygen. EI #1 said no. The surveyor asked EI #1, when a resident is receiving oxygen therapy, should they be care planned for the use of the oxygen. EI #1 replied, yes. When asked what would be the rational for a care plan, EI #1 said it was the plan of care to be used by everyone who is taking care of the resident.

Based on observation, record review and interview, the facility failed to ensure Resident Identifier (RI) # 1 was not physically restrained. RI #1 was observed restrained with a lap tray on 3/15/16 and 3/16/16. This affected one of two residents sampled for restraints. Findings Include: A review of facility policy titled: Physical Restraints with an effective date 8/5/12 revealed PURPOSE: for each resident to attain and maintain his/her highest .prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .STANDARD: .Using devices in conjunction with a chair, such as trays .that the resident cannot remove easily, that prevent the resident from rising or leaving the chair . RI #1 was readmitted to the facility 11/20/15 with [DIAGNOSES REDACTED]. A review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/29/16 revealed Restraints: Chair prevents rising used daily. Further review of a Significant Change MDS with an ARD of 12/2/15 revealed Restraints: Chair prevents rising used daily. On 3/15/15 at 2:15 PM until 2:45 PM during continuous observation RI #1 was observed sitting in the dayroom in a gerichair with a lap tray in place. RI #1 made no attempts to rise. At 2:45 PM staff sat next to the resident; from 2:45 PM until 3:16 PM. RI #1 continued to sit in the gerichair with the lap tray in place, making no attempts to rise. At 3:16 PM staff removed the lap tray. At 3:35 PM staff was observed attempting to put the lap tray on RI #1. RI #1 stated, No, No, No. At this time the staff did not place lap tray over the geri-chair. RI #1 leaned forward but made no attempts to rise; staff continued to sit next to resident. At 3:55 PM staff placed the lap tray on the gerichair. RI #1 was observed from 3:55 PM until 4:15 PM with the lap tray in place and staff sitting in chair next to RI #1. At 4:15 PM the lap tray was removed from RI #1, another staff sat next to RI #1. RI #1 was observed from 4:15 PM until 4:55 PM without the lap tray; no attempts were made to stand. On 3/16/16 at 2:30 PM an interview was conducted with Employee Identifier (EI) #2, Director of Nursing. EI #2 was asked, what was RI #1's [DIAGNOSES REDACTED]. EI #2 replied impaired cognition, impaired safety awareness, agitation, restlessness and confusion. EI #2 was asked if RI #1 could remove the lap tray. She replied she did not know. EI #2 was asked if the lap tray was considered a restraint. She replied the lap tray was considered a restraint. EI #2 was asked, why was the lap tray put in place. EI #2 replied for impaired safety concerns in September of 2015. EI #2 was asked, what was the potential for harm in using a restraint. EI #2 replied mobility and decreased socialization. On 3/17/16 at 11:45AM an interview was conducted with an Occupational Therapist contract employee of the facility. The employee was asked if she evaluated RI # 1 for the use of the lap tray. The employee stated back in September RI # 1 was on the therapy case load and nursing felt an evaluation for the lap tray was needed. The employee was asked if she felt the lap tray was the least restrictive restraint. The employee replied yes because RI # 1 was trying to get up. The employee was asked when the lap tray was recommended what did you mean. She replied a recommendation for restraint free time when supervised. The employee was asked if she felt RI# 1 would need a restraint if an employee was seated next to him. The employee stated no, that would be supervised time. The employee was asked if she had reviewed the restraint since the initial assessment. The employee replied no its usually yearly but we may need to look at RI # 1 in the near future.

Based on observation and interview the facility failed to ensure Resident Identifier (RI) #1 was removed from the gerichair during the lunch meal on 3/16/16. RI #1 was observed leaning forward to reach the table. This affected one of eleven sampled residents observed for meals. Findings Include: RI #1 was readmitted to the facility 11/20/15 with [DIAGNOSES REDACTED]. On 3/16/16 at 11:25 AM RI #1 was in the dining room in a gerichair waiting for lunch. At 11:30 AM lunch was served, RI #1 continued to sit in the gerichair. RI #1 was observed in the gerichair leaning forward to eat. RI #1 was able to eat unassisted. RI #1 was observed eating pie, having to hold the plate in his/her hand. On 3/16/16 at 2:15 PM an interview was conducted with Employee Identifier (EI) #2 Director of Nursing, she was asked why RI #1 seated in a gerichair for meals. EI #2 replied, that was what we normally do. EI #2 was asked if RI #1 was able to feed self without leaning forward. EI #2 replied if the gerichair was straight up. EI #2 was asked if RI #1 was able to reach the table in the gerichair. EI #2 replied she felt he could. EI #2 was asked if RI #1 could sit in a regular chair for meals. EI #2 replied we could try it.

Based on record review and interview the facility failed to ensure a care plan for hospice and a significant change MDS (Minimum Data Set) was completed upon admission to hospice for RI (Resident Identifier) #14. This affected 1 of 6 residents reviewed for hospice services. Findings Include: A review of the facility's policy titled, Care Plans with an Effective Date of 8/5/2012 revealed the following . PROCESS: 1.Comprehensive Plan of care Update-within 7 days of admission; CAA; (Care Area Assessment) quarterly and with a significant change of condition . RI #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/21/15 a physician's orders [REDACTED].#14 to be admitted to hospice services. A review of the medical record revealed a significant change MDS was not completed until 1/18/2016. Further review of the medical record revealed no hospice care plan was in place for RI #14. On 3/17/2016 at 1:35 PM an interview was conducted with EI (Employee Identifier) #1, MDS Coordinator. EI #1 stated there was an order for [REDACTED].#1 said from 7/21/2015 to 3/16/16 there was not a break in hospice care. When asked if there was a significant change MDS completed for hospice care, EI #1 said they realized they did not do a significant change on the July 2015 MDS but captured it on the 8/10/2015 quarterly MDS and did the significant change on 1/18/2016. EI #1 was asked when should the significant change have been done. EI # 1 replied during the 14 day time frame. EI #1 was asked why it was not done. EI #1 answered, human error. EI #1 was asked what was the potential for harm in not having a correct MDS completed. EI #1 said it did not harm the patient's care. It 's just paper work. On 3/17/2016 at 2:45 PM the surveyor interviewed EI #1 again regarding RI #14 not having a facility care plan for hospice. EI #1 was asked who was responsible for initiating a care plan for hospice. EI #1 replied, I am. EI #1 was asked why there was not a care plan initiated when RI #14 was admitted to hospice care. EI #1 said we missed it. EI #1 was asked what was the potential for harm was in RI #14 not having a care plan in place for hospice. EI #1said we are required to have it.

Based on observation, interview and record review the facility failed to ensure Resident Identifier (RI) #9 a resident with a history of urinary tract infection was checked and changed in a timely manner. RI #9 was not checked or changed from 1:00 PM until 4:06 PM during a period of continuous tracking. This affected one of 10 sampled residents who were observed for timely incontinent care. Findings Include: RI #9 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #9's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/2015 was reviewed. A Brief Interview for Mental Status (BIMS) documented the resident as 03 which indicated he/she is severly impaired for Cognition. Section G: Functional Status, documents RI #9 as needing extensive assist with one person for toileting. RI #9's current care plan related to the problem of incontinence included the approach .03/08/2016 TOILETING: incontinent, CHECK AND CHANGE Q (every) 2 HOURS. On 03/15/16, beginning at 1:00 PM RI #9 was observed continuously up in a geri chair until 4:06 PM. At 4:06 PM the surveyor observed Employee Identifier (EI) #8, a CNA and EI #9, a CNA assisting the resident back to bed to provide care. They were asked if the resident's brief was wet. EI #8 and 9 replied, yes. An interview was conducted with EI #8 on 03/16/2016 at 3:40 PM. EI #8 was asked what time she checked and changed RI #9. She replied, close to 4:00 PM. EI #8 was asked if she was aware RI #9 had not been checked or changed from 1:00 PM until 4:06 PM. She replied yes, that she asked EI #9 to help her before they went to change RI #9. EI #8 was asked what the potential for harm was if RI #9 had not been checked or changed for 3 hours and 6 minutes. She replied, pressure sores. EI #8 was asked if RI #9 was wet when they provided care. EI #8 replied yes.

Based on observation, interview and record review the facility failed to ensure staff removed her dirty gloves and washed her hands before applying Resident Identifier (RI)#8's clean brief and touching his/her clean linens. This affected one of two resident observed for incontinent care. Findings Include: A facility policy titled; Hand Washing .with and effective date of 7/15/2012 .documented PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of transmission of infections. STANDARD: Handwashing should be performed between procedures with residents. A facility policy titled; Incontinent Care Practice Guidelines with an effective date of 02/16/2015 documented Standard: .8. Wash hands with soap and water before procedure, after any interruption of procedure, whenever soiled with urine, feces or blood, when in doubt and after completion of procedure .17. Always maintain clean technique .19. When complete, remove gloves and wash hands. RI #8 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/03/2015 documented RI #8 as always incontinent of urine under section H. During an observation of incontinent care for RI #8 on 03/15/2016 at 1:25 PM, Employee Indentifier (EI) #10, a CNA, failed to remove her gloves and wash her hands after completing incontinent care and before applying the clean brief and pulling the clean blanket up over RI #8. During an interview on 03/16/2016 at 11:00 AM, EI #10 was asked by the surveyor why she used the same gloves that she provided incontinent care with to apply RI #8's clean brief. She replied, it was by mistake, and not intentional. EI #10 was asked by the surveyor if she should have removed her gloves and washed her hands before applying a clean brief and touching the resident's bed linens. EI #10 stated, Yes. EI #10 was asked what the potential for harm would be to the resident if she used the same gloves she provided incontinent care with to apply a clean brief and touch residents linens. EI #10 replied, germs and infections. When asked what the facility policy for incontinent care was related to changing gloves and washing hands, EI #10 replied, always wash hands and change gloves after you perform the incontinent care and before touching clean items.

Based on employee education files reviewed and staff interview the facility failed to ensure staff received the required 12 hours of education per year. Four Certified Nursing Assistants (CNAs) education files reviewed failed to meet the 12 hours of continuing education required each year. Findings Include: On 3/16/16 at 4:15 PM a review of employees files was conducted. A review of employee file of CNA #4 revealed only 10.5 hours of continuing education. A review of CNA #5 file revealed only 8.0 hours of continuing education. Review of CNA #6's file revealed only 9.5 hours of continuing education and CNA #7's file revealed evidence of only 9.75 hours of education received in the past year. On 3/16/16 at 4:00 PM an interview with Employee Identifier (EI) #12 the facility Administrator verified the facility had failed to provide the 12 hours of education required for the 4 staff reviewed. On 3/16/16 at 4:15 PM an interview was conducted with Employee Identifier (EI) # 3 Licensed Practical Nurse, Staff Development, she was asked if CNA's were getting 12 hours of continuing education. EI #3 replied evidently not, but they should be. EI #3 was asked how did she ensure CNA's received a minimum of 12 hours of continuing education. EI #3 replied in-services, we try at least one hour per month. EI #3 was asked if dementia care, abuse and neglect training was included in education. She replied, yes.