Every finding on record at Parkwood Health Care Facility

Based on observations, interviews, and a facility policy title Cleaning Dishes/Dish Machine: the facility failed to ensure sanitary conditions were maintained in the dishwashing area to prevent cross contamination. Specifically, staff were observed working on both the soiled (dirty) side and the clean side of the dish room without changing gloves between tasks.This practice had the potential to affect 71 of 71 residents who received meals from the kitchen.Findings Include: A facility policy titled, Cleaning Dishes/Dish Machine dated 2023 revealed: . Procedure: Staff will follow these procedures for washing dishes: . 2. The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash their hands thoroughly before moving from dirty to clean dishes. On 02/10/2026 at 5:25 PM the surveyor observed Dietary Aide (DA) #17 on the dirty side of the dish room. DA #17 put approximately 20 glasses in a crate and pushed them into the dish machine. DA #17 then proceeded to the clean side of the dish room and pulled dishes out of the dish machine without changing his gloves. On 02/12/2026 at 10:38 AM DA #17 was asked what area of the dish room he worked in on 02/10/2026. DA #17 said both the dirty and clean side. DA #17 stated he was putting the dirty dishes in the machine and pulling them out of the machine after they were cleaned and putting the dishes up. DA #17 said he did not change gloves when moving from the dirty side of the dish room to the clean side of the dish room. DA #17 said he worked both the dirty and clean side when he was the only staff working is the dish room. DA #17 was asked what the potential harm to the residents was when staff use the same gloves on the dirty and clean side of the dish room. DA #17 stated cross contamination and it could make the residents sick. On 2/12/2026 at 11:10 AM District Manager (DM) #18 was asked what side of the dish room did DA #17 work on and he stated DA #17 worked on the dirty side. DM #18 was asked to describe what tasks were performed by DA #17 while in the dish room. DM #18 stated DA #17 came over on the dirty side of the dish room and pushed glasses through the dish machine. DM #18 was asked why staff should change their gloves when working on the dirty side of the dish room and then moving to the clean side of the dish room. DM #18 stated to prevent cross contamination. DM #18 said he did not observe DA #17 change his gloves when he moved from the dirty to the clean side. DM #18 was asked what the potential harm to residents was when staff worked on the dirty and clean side of the dish room without changing their gloves. DM #18 stated cross contamination. DM #18 was asked what the facility policy was when working in the dish room on the clean and dirty side. DM #18 stated if staff was working on the dirty side they should stay on the dirty side and if working on the clean side they should stay on the clean side.

Based on observation, interviews, and the facility's policy titled Housekeeping the facility failed to ensure a safe, clean, and comfortable environment for three of 21 residents reviewed.Specifically Resident Identifier (RI) #3's, RI #41's, and RI #51's rooms had scrapes and holes in the drywall and cracks in the ceiling. Additionally, RI #3's and RI #41's room had brown stains observed on the ceiling, and the window blinds in RI #41's room were not functioning properly. These conditions had the potential to negatively impact residents' comfort and overall homelike environment. Findings Include:An undated policy titled Housekeeping documented: . Housekeeping is one of the most important environmental services since it plays a major role in providing a healthy, comfortable environment. OBRA requires housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior. This service makes a significant contribution to facility-wide sanitary practices and prevents the spread of disease causing organisms. An orderly interior means an uncluttered physical environment in which residents and staff can function safely. Orderliness involves not only housekeeping but also nursing and maintenance . Includes: . (3) no peeling paint, visible water leaks, and plumbing problems. Orderliness may be involved in making a room homelike .RI #3 was admitted to the facility on [DATE].RI #41 was admitted to the facility on [DATE].RI #51 was admitted to the facility on [DATE].On 02/10/2026 at 9:29 AM the surveyor observed that in RI #41's room there was uneven drywall over patches, holes present in the drywall, a brown substance on the ceiling, and a broken window blind. RI #41 stated he/she had informed maintenance about the broken blind approximately one year prior. RI #41 stated he/she was told it would be replaced once it was received by the facility. On 02/10/2026 at 11:31 AM the surveyor observed the ceiling above RI #51's bed needed paint and cracks were observed in the ceiling.On 02/12/2026 at 10:50 AM the surveyor noted that the wall behind the bed of RI #3 was black and marked with scratches.On 02/12/2026 at 11:00 AM the Maintenance Director (MTD) was asked about the concerns in the rooms of RI #3, RI #41, and RI #51. The MTD said the blinds in RI #41's room did not open, the ceiling was stained brown and there were holes in the dry wall. When asked about the brown stain he said it looked like food and housekeeping needed to address it. The MTD said it was not homelike. When asked about RI #51's room the MD said it was not homelike and he would not want to stay in the room. On 02/12/2026 at 11:52 AM the Housekeeping Supervisor (HS) was asked about the concerns in RI #3 and RI #41's room. The HS said she was not aware of the stained ceiling or the malfunctioning blind. The HS did not know what the brown substance on the ceiling was and said the ceiling should be clean and free of stains. The HS said the blinds should be working properly and it was not a homelike environment.

Based on interviews, resident's medical records, review of Facility Reported Incidents (FRIs) received by the State Agency, the facility's investigative files, the facility's policies titled ABUSE POLICY and Behavior Management Program Policy and Procedures the facility failed to protect the residents' right to be free from physical abuse perpetrated by other residents. Specifically:1. On 06/08/2024 the facility failed to protect Resident Identifier (RI) #39's right to be free from physical abuse perpetrated by RI #78. On 06/08/2024 Registered Nurse (RN) #9 witnessed RI #78 slap RI #39 on the head. RI #78 had a history of aggressive behaviors, which included verbal and physical aggression. The facility failed to provide adequate supervision and interventions for RI #78 to prevent other residents from being abused.This was cited as a result of the investigation of Facility Reported Incident (FRI) / report number 461495.2. On 10/13/2025 the facility failed to protect RI #38's right to be free from physical abuse perpetrated by RI #5. RN #11 witnessed RI #5 slap RI #38 on his/her chest as RI #5 was passing by RI #38. In the weeks before the incident, RI #5 had documented episodes of delusions and on 10/10/2025 RI #5 had documented episodes of agitation/ screaming at othersThis was cited as a result of the investigation of Facility Reported Incident (FRI) / report number 2648556.These deficient practices affected four of ten residents reviewed for abuse concerns during the survey. Findings Include: The facility's policy titled Abuse Policy dated of October 2022 and the facility's policy titled Abuse Policy dated May 2025 documented: . ABUSE PREVENTION POLICY It is the policy . to ensure that each resident is free from . physical . abuse . In an effort to eliminate or minimize the risk of a resident being subjected to. physical. abuse, . [the facility] has an ongoing abuse prevention program which includes the following practices and procedures: . Behavior Management programs will be implemented, when necessary, to prevent occurrences and staff will monitor residents for changes that may trigger abusive behavior. These management programs shall be monitored on a regular basis by our Social Services staff. Definitions . Physical Abuse - Physical abuse includes, but is not limited to, hitting, slapping, pinching, or kicking. 1) On 06/08/2024 at 12:47 PM the State Agency received a FRI alleging Physical Abuse. It was reported that RN #9 witnessed RI #78 slap RI #39 on the head. The facility's policy titled Behavior Management Program Policy and Procedure with a reviewed date of April 2019 documented: Policy It is the policy of this facility to utilize non-pharmacological behavioral intervention and pharmacological intervention when medically necessary to meet the needs of residents with targeted behaviors that may cause harm or impairment in functional capacity. Purpose To make attempts to manage targeted behaviors exhibited by a resident in order to improve their quality of life. Procedure 1. Identify residents with abnormal behavior, i.e., physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, other behavioral symptoms not directed at others (such as hitting or scratching self or vocal symptoms like screaming, rejection of care that is necessary to achieve the resident's goals for health and well being or wandering. 2. When an abnormal behavior is identified, staff will begin an evaluation to attempt to determine the cause of the behavior . 3. Social Services staff/behavior management designee will initiate a Behavior Tracking log for seven days to determine the frequency of the behavior, to include the behavior(s) exhibited, the time of day, what the staff/resident was doing when the behavior was exhibited, the intervention used and the effectiveness of the intervention. The Behavior Tracking Log will contain the known targeted behavior(s) and suggested interventions based on the residents preferences and choices that may be effective in reducing or controlling each known targeted behavior . RI #39 was admitted to the facility on [DATE] with diagnoses to include Shaken infant syndrome. RI #39's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/19/2024 documented long- and short-term memory problems and daily decision making was severely impaired. RI #78 was admitted to the facility on [DATE] and discharged on 06/11/2024. RI #78 was admitted with diagnoses to include Generalized anxiety disorder. RI #78's quarterly MDS with an ARD of 03/22/2024 documented a RI #78 had Brief Interview of Mental Status (BIMS) score of 2 out of 15 which indicated severe cognitive impairment. The care plan for RI #78, initiated on 12/23/2022, identified a risk for delusions, obsessive symptoms, anxiety, agitation, disorientation regarding time and place, and a lack of awareness of recent events. The objectives of the care plan included prevention of behaviors that could impact others negatively. The interventions outlined included providing assistance in a calm manner, offering fluids and snacks, ensuring the availability of a baby doll, and in instances of tearfulness, providing a magazine, pictures, stuffed animals, an activity blanket, or other activities that offered comfort and reassurance. RI #78's 7 Day Observation Tracking Log Form for the month of May 2024 documented that RI #78 had behaviors of biting and cussing staff. During an interview conducted on 02/12/2026 at 3:21 PM with the Social Service Designee (SSD) she was asked about the behavior of RI #78 in May 2024. The SSD indicated that based on the seven-day observation tracking form, RI #78 exhibited behaviors such as biting and cursing at staff. The SSD noted that following each incident the resident would have been observed for a duration of seven days. When asked whether the seven-day tracking form included information on the level of supervision, she responded no, stating that it focused on behaviors and interventions instead. The SSD said that all residents were monitored every two hours, and she was uncertain about the specific level of supervision required for RI #78 in May and June of 2024. On 02/11/2026 at 10:47 AM RI #60 stated he/she had a vague recollection of the incident and said RI #78 used an open hand to hit RI #39 on the right side of the his/her. On 02/11/2026 at 11:15 AM, RN #9 recalled the incident that occurred in June 2024, involving RI #78 and RI #39. RN #9 reported that she witnessed RI #78 strike RI #39 on the back of the head with an open hand. RN #9 said the incident involving RI #78 and RI #39 was physical abuse. On 02/11/2026 at 4:22 PM, Former Licensed Practical Nurse (FLPN) #10 stated she remembered the incident involving RI #78 and RI #39 that occurred in June 2024. FLPN #10 said a resident hitting another resident was physical abuse and would likely cause a reasonable person to experience pain or fear. FLPN #10 said RI #78 exhibited signs of agitation at times. On 02/11/2026 at 2:19 PM during an interview the Administrator (ADM) he was asked about the incident involving RI #78 and RI #39 that occurred in June 2024. The ADM stated that the incident was reported to the state agency as a case of physical abuse and was substantiated, as it was witnessed by both a staff member and a resident. The ADM recalled that RI #78 had struck RI #39 with an open hand. When questioned about how a reasonable person might feel after being hit in the head he indicated it would depend on individual interpretation. The ADM was asked about the level of supervision RI #78 had at the time of the incident. He said RI #78 did not require any special supervision. 2.) On 10/13/2025 at 5:13 PM, the facility notified the State Agency of an allegation of physical abuse when Activity Assistant (AA) #12 and RN #11 witnessed RI #5 slap RI #38 on the chest while passing by each other in the hallway near the nurse's station. The facility's titled Behavior Management Program Policy and Procedures, policy dated 10/2025 documented: Policy It is the policy of this facility to utilize non-pharmacological behavioral intervention and pharmacological intervention when medically necessary to meet the needs of residents with targeted behaviors that may cause harm . Purpose To make attempts to manage targeted behaviors exhibited by a resident in order to improve their quality of life. Procedure. 2. Identify behaviors that may provoke a reaction by residents or others, which include, but are not limited to: *Verbally aggressive behavior, such as screaming, cursing, bossing . *Physically aggressive behavior, such as biting, spitting, threatening gestures . 3. When abnormal behavior is identified, staff will begin a Behavior Tracking Evaluation observation to determine the cause of the behavior. 4. If the targeted behavior continues and interventions are found that reduce the behaviors or effect of the targeted behavior on the residents or others, the tracking will be discontinued . Behavior tracking will be re-initiated for behaviors identified with ineffective interventions . RI #38 was admitted to the facility on [DATE] and had diagnoses that included Dementia, severe with behavioral disturbances and Mood disorder due to known physiological condition with depressive features. RI #38's Quarterly MDS with an ARD of 08/19/2025 revealed intact cognition. RI #38's delirium care plan with a start date of 05/26/2025 indicated RI #38 had a history of being at risk for emotional distress. RI #38 would repeatedly yell out when he/she wanted or needed something. RI #38 would yell random things to anyone in his/her sight. RI #5 was admitted to the facility on [DATE] and had diagnoses to include Dementia, moderate with agitation. RI #5's MDS with an ARD of 09/03/2025 revealed RI #5 had severe cognitive deficits. RI #5 had a behavior care plan in place with a start date of 10/09/2025 that revealed RI #5 would exhibit physical behavioral symptoms directed at others such as hitting, kicking and pushing. RI #5 would become agitated or aggressive toward other, exhibit verbal behaviors directed at others, would wander around looking for his/her children and would become agitated or emotional when unable to find them. Interventions included keeping RI #5 out of arms reach from other. A review of a facility document titled Resident Progress Notes dated 09/30/2025 at 3:38 PM revealed RI #5 had an episode of emotional distress over a missing child and dog. That same day, RI #5 was placed on behavior tracking due to medication changes and increased emotional distress. The notes documented that RI #5's behavior tracking ended on 10/07/2025 and interventions were effective. A review of a facility document titled Medication Administration Record (MAR) indicated RI #5 had 5 episodes of Delusions on 10/08/2025. On 10/09/2025 the MAR indicated RI #5 had episodes of Delusions on all shifts. A review of a facility document titled Point of Care History indicated on 10/10/2025 RI #5 had episodes of agitation/ screaming at others. Interventions used by staff to provide redirection were documented as not effective. RI #5's MAR documented that on 10/11/2025 RI #5 had 1 episode of Delusions on the evening shift. The facility's investigative file included a signed handwritten witness statement from RN #11 dated 10/13/2025 at 5:45 PM. That statement documented that RN #11 was at the nurses' station and witnessed RI #5 get up to walk. RN #11 went to assist RI #5 to keep him/her from falling. At that same time, AA #12 was assisting RI #38 back to his/her room. When they passed by RI #5, RI #38 yelled at RI #5 you gotta get in your chair, which seemed to have triggered RI # 5, who reached over and hit RI #38 on his/her left chest wall with his/her hand. Staff immediately separated RI #5 and RI #38 and reported the incident to the Administrator. On 02/11/2026 at 11:13 AM an interview was conducted with RN #11 who verified the written statement of events that occurred on 10/13/2025. RN #11 said the incident would be considered physical abuse. On 02/11/2026 at 10:45 AM an interview was conducted with AA #12 regarding the incident on 10/13/2025. AA #12 said she was pushing RI #38 after the dinner meal back to his/ her room. When passing the nurses station they met RI #5 and RI #38 told RI #5 to sit down. AA #12 said RI #5 hit RI #38 in the chest with an open hand. AA #12 said that being hit in the chest would make someone feel upset. On 02/11/2026 at 3:42 PM an interview was conducted with the Administrator (ADM) regarding the incident on 10/13/2025. The ADM said he was notified of the allegation of physical abuse at 5:00 PM on 10/13/2025 by RN #11. The ADM said the incident was investigated by the facility and substantiated for physical abuse. ******************************* The facility implemented corrective actions before the survey team entered; thus, the deficient practice was cited at past non-compliance. ******************************* The facility took immediate action to correct the noncompliance including: On 06/08/2024 the facility immediately separated RI #78 and RI #39. Both residents were assessed and had no injury. The facility implemented enhanced supervision for RI #78. The facility reported the incident timely to the State Agency, Ombudsman, and resident representatives. The facility completed a thorough investigation of the incident. On 06/11/2024 the facility discharged RI #78 to an inpatient psychiatric facility. On 10/21/2024 the facility trained staff on prevention of resident on resident abuse and responding to abuse. On 11/11/2024 the facility educated all staff on starting Behavior Tracking, Proper Interventions, and location of the Behavior Tracking forms. On 12/31/2024 the facility educated staff on the Abuse and Dementia Care CMS Hand in Hand module 5) preventing and responding to abuse. 02/10/2025 Behavior management team met for QA and identified a concern regarding incomplete documentation on paper behavior tracking logs. Administration staff met with CNAs for feedback and determined that the electronic system is more assessable and allows for consistent and efficient documentation compared to the paper logs. New electronic system to track behaviors in working state. 02/27/2025 Teams meeting training held with corporate nurses on new electronic behavior management process. Training completed. 03/10/2025 through 03/12/2025 Training on new behavior management process: Identify behavior concern, notify SS- who is to create a new care plan to target identified behaviors, coordinate with staff on new approaches, add to weekly nursing focus report, physician order placed by Unit Manager, Behavior binder at nurses' station for reference. Training competed on 03/12/2025. On 04/22/2025 during the quarterly QA meeting, the QA Committee reviewed facility Behavior Management PIP. The review included review of 02/2025 in-service on how to diffuse conflict between residents, communication with residents who may be upset or unable to communicate their needs. 05/08/2025 Training provided company wide on new behavior monitoring process – Part 1 completed. 1) Behavior Concern Report document 2) Behavior Focused Observation Document 3) Weekly Focus Resident Report document 4) Behavior Tracking Evaluation document 5) Medication Regime Review Document 6) Quarterly Psychotropic Evaluation document 7) Training/ QA Guide for BHV Managing Team document. 05/19/2025 Training provided to Nursing staff/ Administration on Revised Abuse Policy adding QAPI/ QAA completed. 05/20/2025 Training provided to Nursing/ All Staff on Dementia Training/MAPS – Behavioral changes in the skilled nursing facility setting, suggested activities based on GDS score 05/28/2025 Training provided to Nursing on Q & A Part 2 Behavior Tracking and Training consents for psychotropics. 05/28/2025 Training provided to Nursing/ Activity on GDS scores, what are they? How to find them on the care plan; Activity drawers locked in activity and family room. In July of 2025 Training to staff on Dementia Care: CMS Hand in Hand Module 1) Understanding the world of Dementia; the person and disease. 08/2025 Training to staff Dementia Care: CMS Hand in Hand Module 4) Being a person with Dementia. Making a Difference 08/15/2025 Training to CNA- reeducated on Behavior tracking; Check the Care Plan – Pull interventions from Care plan and type in comment section the intervention used and if successful On 10/13/2025 after the incident, RI #5 and RI #38 were immediately separated. A body audit was performed by an RN and no injury was identified. The incident was reported to administrative staff timely and an investigation was initiated. The facility immediately notified both residents' representatives and primary care provider and placed both residents on behavior monitoring program. Both residents were evaluated by a psychiatric clinician which recommended inpatient Geri-Psych evaluation for RI #5. On 10/13/2025 at 5:13 PM the facility reported the incident to the State Agency. On 10/14/2025 the facility notified the Ombudsman. On 10/14/2025 an emergency QA meeting was conducted. During chart review it was identified that RI #5 had been placed on Behavior Monitoring for medication changes, but not for the targeted behaviors he/she had been displaying. The facility had not initiated a Behavior Tracking Care Plan. On 10/14/2025 through 10/24/2025 the facility educated all staff on the facility's abuse policy and abuse prevention. On 10/20/2025 the facility completed their investigation and substantiated the incident of abuse involving RI #5 and RI #38. On 10/20/2025 the facility submitted their investigation to the State Agency. On 10/21/2025 through 10/31/2025 the facility completed an audit of all current residents' medical records for the past 30 days to determine if any resident had new behaviors, worsening behaviors, or behaviors with ineffective interventions and ensure residents with new behaviors, worsening behaviors, or behaviors with ineffective interventions had a behavior tracking order initiated for the target behaviors and an appropriate behavior tracking care plan initiated. The audit included a review of the behavior management care plan to ensure the care plan had been revised with effective interventions upon completion of behavior tracking. The review was documented in the Plan of Correction, progress notes, and EMAR. All concerns were addressed with appropriate corrective action. On 10/21/2025 the facility implemented a new system where a newly created Behavior Management QA Checklist was implemented to ensure all components of behavior tracking had been completed when new behaviors, worsening behaviors, or behaviors with ineffective interventions were identified. The QA Checklist included order for behavior tracking, the behavior tracking care plan, and revisions of behavior management care plan at the completion of tracking. The IDT team utilizes the checklist daily when reviewing residents' behaviors and review of daily documentation. 10/21/2025 Training on Behavior Monitoring with all staff completed. On 10/21/2025 through 10/31/2025 the facility educated the members of the IDT team on the updated behavior management system. On 10/21/2025 the facility began monitoring their corrective actions. The QA Nurse/designee monitored for compliance by reviewing documentation in resident's plan of care, progress notes, and EMAR for the past 30 days. Monitoring weekly for 4 weeks and then months for 5 months to determine any residents with documented new behaviors, worsening behaviors, or behaviors with ineffective interventions and verify a Behavior Management QA Checklist was completed for the resident as is included in the facility's binder. The review was documented on a monitoring tool and submitted to the Administrator responsible for implementing an appropriate plan of correction. 01/01/2025 -12/31/2025 Training to staff on Dementia Care: CMS Hand in Hand Module 2) Being a Person with Dementia: Listening and Speaking and Module 5) Preventing and Responding to Abuse ***************************************************** After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 11/11/2024 to 12/31/2025 and past non-compliance was cited.

Based on interview, medical record review and a facility policy titled, Care Planning Policy and Procedure, the facility failed to develop a comprehensive care plan to address Resident Identifier (RI) #53 use of PRN (as needed) oxygen. Record review indicated the resident received oxygen as needed however, there was no care plan in place to address the use of PRN oxygen, including indications, monitoring or staff interventions. This failure had the potential to result in inconsistent implementation of care and unmet respiratory needs.This deficient practice affect RI #53 one of one resident sampled for respiratory care.Findings Include: A policy titled Care Planning Policy and Procedure with a revised date of October 2022 documented: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well-being. The care plan will be written in accordance with professional standards of practice and documentation. Communication about care plan changes should be ongoing among interdisciplinary team members.Procedure: 1. Facility staff will complete a care plan to meet the basic care needs of the resident within the first 48 hours of admission . This care plan will be updated as indicated to meet resident health/safety needs and used by the interdisciplinary team in formulation of the comprehensive care plan using the RAI process.RI #53 was admitted to the facility on [DATE] with diagnoses to include Hypertensive heart and Chronic kidney disease with heart failure.Physician Order's for RI #53 documented: . start date 11/03/2025 . O2(Oxygen) @ 2L(Liters)/Min(minute) Per Nasal Cannula PRN for SOB (Shortness of Breath), PAD Behind Ears, Check behind ears Q (every) shift when in use. As Needed .RI #53's Care Plan was reviewed by the surveyor and no care plan for as needed oxygen use was identified.On 02/13/2026 at 8:52 AM the surveyor observed RI #53 sitting in a chair in his/her room. RI #53's oxygen machine was observed but it was not in use. On 02/13/2026 at 8:29 AM the Minimum Data Set (MDS) Coordinator was asked about the care plan for RI #53's oxygen use. The MDS Coordinator said RI #53 had a current physician's order for oxygen dated 11/03/2025.The MDS Coordinator stated there was no current care plan in place for RI #53's oxygen use. She said she was responsible for developing the care plan for the use of oxygen and it was important so staff would know the resident needed oxygen and the purpose of its use.

Based on observation, interview, record review and review of facility policies titled Incontinent Care and Catheter Care Using Disposable Wipes and Hand Hygiene Policy and Procedure, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands between glove changes during perineal care and prior to the application of a moisture barrier and a clean brief to Resident Identifier (RI) #46, a resident who required staff assistance with both toileting and personal hygiene. This affected one of one resident observed for incontinence care. Findings include: Review of a facility policy titled Incontinent Care and Catheter Care Using Disposable Wipes, with a revised date of 12/2012, revealed the following: OBJECTIVE: To cleanse the perineum . 2. Wash hands. Apply gloves. 9. Remove and dispose of gloves, wash hands. Apply clean gloves. 12. Remove gloves and wash hands prior to leaving the room. Review of a facility policy titled Hand Hygiene Policy and Procedure, with a revised date of 6/2017, revealed the following: Purpose: Hand hygiene is recommended to reduce the transmission of infection to residents, staff and visitors in the health-care setting. Procedure: . 3. prior to donning and after gloves are removed, . RI #46 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #46's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/22/19 revealed RI #46 was always incontinent of bowel and bladder and required extensive assistance of staff for toileting and personal hygiene. On 12/4/19 at 08:15 AM, Employee Identifier (EI) #1, Certified Nursing Assistant (CNA), performed Hand Hygiene (HH) and applied gloves. EI #1 wiped RI #46's perineal area front to back. EI #1 changed gloves (without washing her hands) and cleaned the resident's buttocks front to back. EI #1 then changed gloves (without washing her hands) and applied a barrier cream. After applying the cream, EI #1 again changed gloves (without washing hands) and placed a clean brief on RI #46. EI #1 then changed gloves (without washing hands) and applied more barrier cream to the front of the resident's perineum. EI #1 then changed gloves again (with out washing hands) and closed the brief. On 12/4/19 at 8:28 AM, an interview was conducted with EI #1. EI #1 was asked to explain the facility policy for hand washing. EI #1 stated they were to wash hands before and after giving service. EI #1 was asked if the policy stated anything about hand hygiene after glove changes. EI #1 replied, yes, after you change your gloves. EI #1 was asked if she washed her hands after changing gloves while giving care to RI #46. EI #1 replied no, she did not. EI #1 was asked what was the concern for the resident. EI #1 stated the resident would not get proper care. On 12/5/19 at 2:54 PM, an interview was conducted with EI #2, Registered Nurse (RN)/Staff Development/Infection Control. EI #2 was asked to explain the process for hand hygiene during incontinence care. EI #2 replied, wash hands, apply gloves then do perineal care on the front, remove gloves, wash hands and apply new gloves. EI #1 continued and said staff should then clean the back, remove gloves, wash hands again, apply gloves, place the brief, remove gloves, wash hands and take soiled items to the soiled utility. EI #1 said after taking the soiled items to the soiled utility, staff should then wash hands or use hand sanitizer.

Based on observation, interview, resident record review and review of a facility document titled F550 Resident Rights, the facility failed to ensure Resident Identifier (RI) #112 and RI #9 were not left in the hall for 25 minutes, lined up parallel to the wall, in their wheel chairs, wrapped in sheets, while waiting for showers near the front entrance of the facility. This affected two of 23 sampled residents. Findings include: Review of an undated facility document titled F550 Resident Rights revealed the following: .Resident Rights. The resident has a right to a dignified existence, . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. RI #112 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #112's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 11/12/19 revealed RI #112 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated RI #112 had intact cognition for daily decision making. Review of the MDS also revealed RI #112 required one person physical assistance for transfer, locomotion on and off the unit, dressing, personal hygiene and bathing. RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #9's quarterly MDS assessment with an Assessment Reference Date of 8/29/19 revealed RI #9 had a BIMS score of 15 of 15, which indicated RI #9 had intact cognition for daily decision making. Review of the MDS also revealed RI #9 required one person physical assistance for transfer, locomotion off the unit, dressing, personal hygiene and bathing. On 12/4/19 at 9:15 AM, RI #112 and RI #9 were observed in the hall outside the shower room, in view of the facility entrance, in wheel chairs, lined up parallel to the wall and wrapped in sheets. RI #112 was wearing a hospital gown under the sheet. RI #112's lower legs were exposed. RI #112 stated, he/she was having to hold stuff. RI #112 was holding the sheet up and clothes to put on after the shower. RI #112 stated, he/she was hoping it would not be much longer. RI #9 was wearing a t-shirt under the sheet. Staff were in the hall, walking and going about their work. At 9:23 AM, a staff member came out of the shower room wheeling another resident, wrapped in a sheet, down the hall. There was a male visitor in the lobby waiting to see a resident. RI #112 and RI #9 remained lined up in the hall wrapped in sheets, outside of the shower room until 9:40 AM (25 minutes later) when RI #112 was taken into the shower room and RI #9 was taken back to his/her room to wait while RI #112 received a shower. On 12/5/19 at 11:30 AM, RI #112 and RI #9, who were roommates, were asked how they felt about waiting in the hall wearing sheets. RI #9 stated, it was not right and he/she did not know why they could not wait in their room instead of in the hall. When asked how often it happened, RI #9 said, five or six people were often lined up in the hall outside the shower room. When asked how it made them feel to sit in the hall wrapped in a sheet near the entrance of the facility, RI #112 said, it was like someone coming into your house uninvited and it affected his/her self worth. RI #9 said the facility staff should know it was not right. On 12/5/19 at 2:11 PM, Employee Identifier (EI) #3, Certified Occupational Therapy Assistant who was observed speaking to the residents in the hall while they waited for their shower on 12/4/19, was interviewed. EI #3 was asked how well she knew RI #112 and RI #9. EI #3 replied, she had worked with both of them for a while, so, fairly well. When asked if there was anything in particular she discussed with the residents when she saw them in the hallway on 12/4/19, EI #3 said, nothing in particular, she was just being friendly. When asked who in the facility was responsible for ensuring the dignity of residents was maintained, EI #3 said, everyone that came in contact with a resident. EI #3 was asked to describe how she saw RI #112 and RI #9. EI #3 said, she knew RI #112 and RI #9 were waiting for showers because of the sheets in which they were wrapped. When asked how she thought they would feel about sitting in the hall for 25 minutes like that, EI #3 said, not good, and she could not imagine why a Certified Nursing Assistant (CNA) would let them sit that long draped in a sheet in the busy area in front of the front door with people coming in and out of the facility. EI #3 said, that would be too long. On 12/5/19 at 2:54 PM, EI #4, CNA, was asked why RI #112 and RI #9 were parked, in the hall in sheets before their shower on 12/4/19. EI #4 said, because it was their shower day and their CNA brought them while she already had a resident for the shower. When asked if it was the facility practice for residents to line up in the hallway to wait for showers, EI #4 said, it had happened. When asked who was responsible to ensure the dignity of residents was maintained, EI #4 said, everyone. On 12/05/19 at 3:57 PM, EI #, CNA, was asked what the facility procedure was for taking residents to the shower room. EI #5 said, get them up, usually in a gown, wrap them in a sheet or blanket, and take them to the shower room door. When asked how many residents are usually waiting in line, EI #5 replied, two and they may wait for 10 to 15 minutes. EI #5 was asked how long RI #112 and RI #9 waited in the hall on 12/4/19. EI #5 said, she was not sure, she took them up there and went to start her other residents. When asked why she took them to wait at the shower room entrance, EI #5 stated, that was what they normally did, and that is where they park them. When asked why they waited for 25 minutes, EI #5 said, she did not know. EI #5 said, the shower team told them who they were ready for and they take the residents to sit near the shower room. EI #5 said she thought the facility should find a different way of getting residents to the shower. When asked who was responsible to ensure dignity was maintained, EI #5 said, everybody. When asked how it could affect their dignity, EI #5 replied, they could be embarrassed while sitting there waiting.

Based on observation, interviews, review of the facility policy related to the cleaning of food carts, and recommendations from the manufacturers of the Auto-Chlor dish machine, the facility failed to ensure: 1) staff sanitized a cart used for transporting resident trays after use; and 2) resident dishes/trays were consistently washed at recommended water temperatures. This had the potential to affect all 70 residents for whom meals were prepared and served at the time of this survey. Findings include: 1) The facility policy related to the cleaning and sanitization of food carts (undated) states the carts will be cleaned and sanitized immediately after each use. The procedure specifies: .2. The inside and outside of all food carts will be cleaned and sanitized after each meal 3. Food carts are to be washed inside and outside to remove all residual debris with soapy water 4. Each food cart is to be rinsed 5. Each food cart will then be sprayed or wiped down with sanitizer solution. The sanitizer solution is to remain on the cart to dry. On 10/23/18 at 8:35 AM, the Diet Aide (Employee Identifier) EI #1, was observed washing a standing, open-sided aluminum rack (Speed Rack) with a rag dipped into a bucket of soapy water. In response, the surveyor asked EI #1 what solution she was using to wipe the rack. EI #1 responded, Soapy water. On 10/23/18 at 8:40 AM, the surveyor asked the Dietary Manager, EI #2, to explain the department's procedure. EI #2 stated staff were to wipe down the racks with soapy water, then use sanitizer, usually D-33; but they had no D-33. When asked the purpose of the sanitizer, EI #2 stated it was to kill germs. When asked the purpose of the speed rack, EI #2 stated it was to transport resident trays to the dining room. The surveyor asked EI #1 how she had been taught to clean the Speed Rack, to which EI #1 replied, Soap and water only. When asked what the purpose of the of the sanitizer was, EI #1 responded, To kill germs with the sanitizer and wipe off the dirt with soap and water. When asked why the speed rack was not sanitized, EI #1 explained if they sprayed with the sanitizer, most of the spray would go on the floor. 2) Specifications of the facility's low energy dishmachine include a minimum water temperature of 120 degrees Fahrenheit (F). On 10/23/18 at 8:45 AM, staff were processing dirty dishes from the breakfast meal. Two cycles of dish racks were processed by staff at a wash temperature of 110 degrees F. The surveyor asked EI #1 (who was at the clean end of the dishmachine) what the temperature of the wash water was supposed to be. EI #1 responded 150 degrees F. The surveyor then asked the Diet Aide, EI #3, who was putting the dirty dishes into the dishmachine, what happened if the wash temperature was not hot enough. EI #3 explained she would lift up the door of the dishmachine and lower it (run the rack through another cycle) until the temperatures got to be 150 degrees for the wash and 180 degrees for the rinse. The data plate affixed to the side of the dishmachine specified a wash temperature of 120 degrees F, and chlorine concentration of 50 parts per million. The staff did not re-wash the two racks of trays which had been processed at a wash temperature below the manufacturer's recommendations.

Based on observation, interview, record review and a review of the facility's policies titled, ENTERAL TUBE ADMINISTRATION and MEDICATION ADMINISTRATION - GENERAL GUIDELINES, the facility failed to ensure licensed staff provided privacy to Resident Identifier (RI) #167, during an observation of medication administration via (by) G (Gastrostomy) Tube (GT). This affected one of one sampled resident observed for medications administered via GT. Findings Include: A review of the facility's policy titled, ENTERAL TUBE ADMINISTRATION dated 01/12, revealed the following: . Procedures 1. Explain the procedure and screen the resident for privacy . A review of the facility's policy titled, MEDICATION ADMINISTRATION - GENERAL GUIDELINES dated 01/12, revealed the following: . Procedures . 18. Provide privacy for resident . RI #167 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/24/18 at 9:00 AM, Employee Identifier (EI) #4, Registered Nurse (RN) was observed preparing the following medications for administration to RI #167 via GT. 1. Multivitamin one per GT QD (every day) 2. [MEDICATION NAME] Acid 500 mg (milligram) one per GT QD 3. [MEDICATION NAME] 25 mg give 1/4 tablet (6.25 mg) one per GT BID (twice a day) EI #4 placed the crushed medications and cups of water on a white tray and entered RI #167's room. EI #4 washed her hands. RI #167's roommate was seated in the wheelchair and the therapist was at the resident's bedside. EI #4 checked RI #167's GT placement, administered the medications, clamped RI #167's GT and discarded the syringe. RI #167's room door was left opened. RI #167's bathroom door was opened. RI #167's window blinds were left opened and RI #167's curtain was not pulled completely around RI #167. Other residents and staff were observed in the hallway. On 10/24/18 at 9:25 AM, during an interview with EI #4, the surveyor asked what was left open when she administered RI #167's medications via GT. EI #4 stated, The resident's curtain wasn't pulled, blinds were opened, the doors to the bathroom and the resident's room were left opened. The surveyor asked what type of issue would this be. EI #4 stated, Privacy.

Based on observation, interview, record review, review of a Walmart receipt and a review of the facility's policy titled, ABUSE POLICY, the facility failed to ensure RI #62's 32 inch LED (Light Emitting Diodes) television (TV) was mounted in his/her room after purchase with RI #62's funds on 9/18/18. This affected one of one sampled resident whose purchases were reviewed. Findings Include: A review of the facility's policy titled, ABUSE POLICY dated (MONTH) (YEAR), revealed the following: . Misappropriation of Resident's Property - Misappropriation of resident property is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of resident's belongings, property . without the resident's consent. Acts that constitute the misappropriation of resident property include, but are not limited to, the theft or attempted theft of a resident's . personal property, . or the inappropriate use of a resident's funds or property. RI #62 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #62's current Quarterly Minimum Data Set (MDS), dated [DATE] revealed RI #62 had a Brief Interview for Mental Status (BIMS) score of 13, indicating cognition was intact. A review of a Walmart receipt for RI #62 revealed the purchase of a 32 LED HD (High Definition) TV, Product Serial #LAUSUVNKU 39 and a 2YR (year) PROTECTPL (Protection Plan), for a total of a $186.00 on 9/18/18. On 10/25/18 at 11:30 AM, RI #62's resident's trust account was reviewed. At that time, an observation of RI #62's TV, positioned on a dresser in his/her room, revealed a smaller TV than the one purchased on 09/18/18. On 10/25/18 at 11:35 AM, the surveyor requested that Employee Identifier (EI) #11, Maintenance Assistant, measure the TV in RI #62's room. The TV in RI #62's room measured 19 inches. The surveyor asked who was responsible for placing TVs in the residents' room. EI #11 stated, Social Service usually will come and verbally tell us that a TV needs to be placed in a specific resident's room. When Social Service purchases the TV, I get that (TV) from the Social Service office and I put (it) in which ever room they asked me to. If the TV has a wall mount, we put it on the wall. If the TV does not have a mount, it goes on the dresser or the night stand. The surveyor asked EI #11 who put the TV up in RI #62's room. EI #11 stated, I believe (Maintenance Director) did, I don't believe I did. The surveyor asked EI #11 was Social Services the department that would give him the directive as to who the item belonged to and what room to put the item in. EI #11 stated, Yes ma'am, only for items that require the use of tools and things too heavy to lift, even if a TV sits on the night stand or dresser, we have to put the base on, we would still handle or put up the TVs. A review of a facility document signed by the Director of Nursing, EI #12 and EI # 8, Administrator, revealed the following: 10/25/18 After our initial investigation of checking every TV in resident's room, we were unable to locate the missing TV serial #LAUSVMKU 39. The resident's TV has been replaced with a comparable TV. We will continue or (our) investigation in regards to the missing TV serial #LAUSVMKU 39. We will speak with the resident and sponsor and offer to replace funds of the missing TV and protection plan. (signed by EI #12 and EI #8) On 10/25/18 at 6:04 PM, an interview was conducted with EI #8 and EI #12. The surveyor asked EI #8 and EI #12, regarding the property that the facility purchased with RI #62's funds, which the facility could not locate, what type of issue would this be considered. EI #8 stated, Missing items issue. The surveyor asked EI #8 and EI #12 when were they made aware that RI #62's TV was not in his/her room and by whom. EI #8 stated, Today, 10/25 by surveyor The surveyor asked EI #8 and EI #12 where was RI #62's TV. EI #8 stated, Currently it is missing. The surveyor asked EI #8 and EI #12 where was the TV when it was first purchased. EI #8 stated, It was brought into the front, in the Social Service office with the rest of the purchases. The surveyor asked EI #8 and EI #12 were all the purchases delivered to RI #62. EI #8 stated, Everything but the TV, it appears all items were placed in the resident's room at this time but the TV. The surveyor asked EI #8 and EI #12 had they located the TV in the facility or anywhere on the grounds. EI #8 stated, No ma'am not yet. The surveyor asked EI #8 and EI #12 was the TV in the facility's possession after the purchase was made at Walmart. EI #8 stated, Yes ma'am it was.

Based on observation, interview and record review the facility failed to ensure licensed staff did not leave Resident Identifier (RI) #167's medications unattended and out of licensed staff's line of sight. This affected one of eight residents observed during medication administration. Findings Include: RI #167 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/24/18 at 9:00 AM, Employee Identifier (EI) #4, Registered Nurse (RN) was observed preparing the following medications for administration to RI #167 via GT. 1. Multivitamin one per GT QD (every day) 2. [MEDICATION NAME] Acid 500 mg (milligram) one per GT QD 3. [MEDICATION NAME] 25 mg give 1/4 tablet (6.25 mg) one per GT BID (twice a day) EI #4 entered RI #167's room. RI #167's roommate was seated in the wheelchair and the therapist was at the resident's bedside. EI #4 placed RI #167's medications and water on RI #167's bedside table and entered RI #167's bathroom. The medications were left unattended and out of EI #4's visual line of sight. EI #4 washed her hands, exited the room to get additional water and obtained the tray containing the medications. EI #4 returned to RI #167's room, placed the tray of medications on RI #167's bedside table and entered RI #167's bathroom. RI #167's tray of medications were left unattended and out of EI #4's visual line of sight. RI #167's door was left opened. Other residents and staff were observed on the hallway. On 10/24/18 at 9:25 AM, during an interview with EI #4, the surveyor asked when she entered RI #167's bathroom both times to wash her hands, were RI #167's medications in her visual sight at all times. EI #4 stated, No ma'am. The surveyor asked who else was in the room when she left RI #167's medications unattended and out of her view or vision. EI #4 stated, The other resident and the therapist. The surveyor asked what would be a potential harm, EI #4 stated, Another resident or staff could take the medications.

Based on observations, interviews, record reviews, and a review of the facility's policy titled, Glove Use and Policy and Procedure for Aseptic Technique With Dressing Changes, the facility failed to ensure licensed staff washed their hands after removing unclean gloves and before applying clean gloves during an observation of medication administration and wound care. This affected Resident Identifier (RI) #167, who was one of eight residents observed during medication administration and one of three residents observed during wound care. Findings Include: A review of the facility's policy titled, Glove Use with a revised date of 6/17, revealed the following: . PR[NAME]EDURE: . 9. Hand hygiene is necessary prior to donning (putting on) and after gloves are removed. A review of the facility's policy titled, Policy and Procedure for Aseptic Technique With Dressing Changes dated (MONTH) (YEAR), revealed the following: . II. Procedure . J. Apply topical treatment . K. Place all contaminated items in trash bag, including gloves. Tie bag and remove . Wash your hands . RI #167 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/24/18 at 9:00 AM, Employee Identifier (EI) #4, Registered Nurse (RN) was observed preparing the following medications for administration to RI #167 via GT. 1. Multivitamin one per GT QD (every day) 2. [MEDICATION NAME] Acid 500 mg (milligram) one per GT QD 3. [MEDICATION NAME] 25 mg give 1/4 tablet (6.25 mg) one per GT BID (twice a day) EI #4 removed a crush bag, placed her left thumb inside the crush bag and opened the crush bag. EI #4 placed the pill in the crush bag by placing her left thumb inside the bag to open the crush bag. EI #4 crushed the pill and opened the crush bag by placing her left thumb inside the crush bag. EI #4 repeated the process with the crush bag for the [MEDICATION NAME] Acid and the [MEDICATION NAME] when crushing the medications. EI #4 administered the medications to RI #167. On 10/24/18 at 9:25 AM, during an interview with EI #4, the surveyor asked what did she place on the inside of the crush bag to open it before placing the medication in the bag and after crushing the medication. EI #4 stated, My finger, my thumb. The surveyor asked what type of concern was that. EI #4 stated, Contamination. On 10/24/18 at 9:05 AM, EI #13, Licensed Practical Nurse(LPN)/Treatment Nurse and EI #14, Registered Nurse/RN, were observed during the wound care of RI #167. EI #13 and EI #14 washed their hands and applied gloves. EI #13 obtained a measuring device from the medication cart, removed her gloves and applied clean gloves. EI #13 did not wash her hands after removing gloves and before applying clean gloves. EI #13 lowered RI #167's head of bed, removed RI #167's sock, then removed her unclean gloves and applied clean gloves. EI #13 did not wash her hands after removing unclean gloves and before applying clean gloves. EI #13 provided care to RI #167's right heel wound. EI #13 replaced RI #167's sock, removed her unclean gloves and applied clean gloves. EI #13 did not wash her hands after removing unclean gloves and before applying clean gloves. EI #13 and EI #14 repositioned RI #167 in bed. On 10/24/18 at 9:17 AM, during an interview with EI #13, the surveyor asked what should be done after removing unclean gloves and before applying clean gloves. EI #13 stated, Wash hands. The surveyor asked was that what she had done every time she removed her unclean gloves and before applying clean gloves. EI #13 stated, No. The surveyor asked what was the potential for harm. EI #13 stated, Infection.

Based on interviews, record reviews and a review of the Resident Handbook, the facility failed to ensure resident personal funds/petty cash was available after business hours and on the weekends. This affected three of eleven residents, Resident Identifier (RI) #24, #26 and #39, who attended resident council/group meeting. Findings Include: A review of the Resident Handbook revealed the following: . You should anticipate your cash needs for weekends and withdraw funds accordingly on Friday before the business office closes . RI #24 was admitted to the facility on [DATE]. RI #26 was admitted to the facility on [DATE]. RI # 39 was admitted to the facility on [DATE]. On 10/24/18 at 11:00 AM, during the group meeting, residents were asked if funds were available on evenings and weekends. RI #39 said he/she was told to get money by Friday because no one was at the facility on Friday after the office closed, so he/she would see Employee Identifier (EI) #9/Human Resources Employee, on Friday before the office closed. RI #26 said approximately one month ago he/she wanted 20-30 dollars, but could not get any money because it was on a weekend and EI #9 was not working. RI #24 said he/she asked one of the staff members about his/her money approximately a month ago and was told the front office was not open on the weekend. On 10/24/18 at 10:50 AM, during an interview with EI #9, the surveyor asked who was responsible for the residents' personal funds. EI #9 stated, Would be me, for resident's trust. The surveyor asked what was the process for residents who requested money. EI #9 stated, They come see me, tell me what they want or how much they want, fill out a slip, sign the slip and I give them cash, that goes into my lock box. The surveyor asked when can residents get their money. EI #9 stated, Immediately everyday, and on the weekends cash left on the cart. The surveyor asked which cart. EI #9 stated, A med cart. The surveyor asked which one. EI #9 stated, Lets do south hall. The surveyor asked who was responsible for placing the money in the medication cart. EI #9 stated, I do, I give it to the nurse. The surveyor asked how long was the money there. EI #9 stated, From Friday afternoon until Monday morning. The surveyor asked, so the money is placed there on Friday afternoon and removed on Monday morning, would that be correct. EI #9 stated, Yes ma'am. The surveyor asked when was the next time money would be placed on the medication cart for residents. EI #9 stated, The next Friday. The surveyor asked was that a weekly process. EI #9 stated, Yes ma'am. The surveyor asked what time do you leave in the evenings. EI #9 stated, 4 PM. The surveyor asked what do residents get if they want money after 4 PM. EI #9 stated, They would have to wait and see me the next morning. On 10/24/18 at 11:36 AM, a telephone interview was conducted with EI #7, Licensed Practical Nurse/LPN. EI #7 was asked did she work on the weekend of 10/20/18. EI #7 said, Saturday and Sunday, Yes. EI #7 was asked what resident's monies were on her medication cart. EI #7 said, I never had any resident's monies on my cart during my shift. EI #7 was asked what resident requested monies from her medication cart. EI #7 said, No resident. On 10/24/18 at 11:37 AM, a telephone interview was conducted with EI #4, Registered Nurse/RN. EI #4 was asked did she work on the weekend of 10/20/18. EI #4 said, Saturday. EI #4 was asked were resident's monies on her medication cart. EI #4 said, No ma'am. EI #4 was asked what resident requested monies from her medication cart. EI #4 said, Nobody, no resident asked. On 10/24/18 at 11:44 AM, a telephone interview was conducted with EI #6, LPN. EI #6 was asked did she work on the weekend of 10/20/18. EI #6 said, Yes, Saturday and Sunday. EI #6 was asked what resident's monies were on her medication cart. EI #6 said, I wasn't handed any money to put on my cart . EI #6 was asked what resident requested monies from her medication cart. EI #6 said, No resident requested any monies. On 10/24/18 at 12:15 PM, a telephone interview was conducted with EI #5, RN Supervisor. EI #5 was asked did she work on the weekend of 10/20/18. EI #5 said, Saturday and Sunday. EI #5 was asked what resident's monies were on her medication cart. EI #5 said, I didn't have any money on either cart. I worked a split cart on Sunday, East and North cart and no monies on my cart. EI #5 was asked what resident requested monies from her medication cart. EI #5 said, Nobody requested money.

Based on interviews and a review of the facility's Resident Handbook, the facility failed to ensure resident's received mail on Saturdays and received mail unopened. This affected eleven of eleven residents who attended the Resident Council meeting on 10/24/18, who said they did not receive mail on Saturday and three of eleven residents who received mail that had been opened. This deficient practice had the potential to affect all residents in the facility who receive mail. Findings Include: A review of the facility's Resident Handbook revealed the following: .11. Mail. You have the right to privacy in written communications, including the right to . promptly receive mail that is unopened . On the morning of 10/24/18, during the resident council meeting, eleven out of eleven residents in attendance stated they did not receive mail on Saturdays and three of eleven residents stated they received their mail opened. On 10/24/18 at 10:50 AM, during an interview with Employee Identifier (EI) # 9, Human Resources, the surveyor asked who got the resident's mail. EI #9 stated,Between me and the business office across the hall. The surveyor asked who in the business office. EI #9 stated, the business office staff she was referring to was on vacation. EI #9 said if mail came on the weekend, EI #10, Activities Director, would get the mail and disperse it. The surveyor asked what residents' mail was opened and reviewed. EI #9 stated, Anything that looks like a statement or a bill is opened. The surveyor asked even if the resident's name is on it, do you still open the mail. EI #9 stated, Yes ma'am. On 10/24/18 at 11:13 AM, during an interview with EI #9 and EI #10, the surveyor asked EI #10 when was the last time she delivered mail to residents on Saturday or on the weekend. EI #10 stated, I'm not usually here on the weekends, the mailman does run on weekends and I pick the mail up from my mailbox on Monday to deliver the mail. It's delivered Monday through Friday. EI #9 stated, The mailman does run on Saturday and the mail is left in the mailbox out front until Monday morning; either I or (business office staff) pick the mail up from the mail box and if it is a resident's mail, I give it to (EI #10) to deliver to the residents. The surveyor asked EI #10 was that correct. EI #10 stated, That's correct.

Based on observation and interviews, the facility failed to ensure a notice was posted to indicate the availability of the most recent survey results. This deficient practice had the potential to affect all 72 residents who currently reside in the facility, as well as visitors and other individuals who visit the facility. Findings Include: On 10/23/18 at 10:30 AM, the survey results were observed in a plastic binder outside of and adjacent to Employee Identifier (EI) #8's, Administrator, office which was located in the front lobby. There was a label on the binder that documented the following: The last 3 annual ADPH (Alabama Department of Public Health) survey results. There were no postings or signs observed in the facility as to the location of the survey results. On 10/24/18 at 10:00 AM, the survey results were observed in a plastic binder outside of and adjacent to EI #8's office which was located in the front lobby. There was a label on the binder that documented the following: The last 3 annual ADPH (Alabama Department of Public Health) survey results. No postings or signs observed in the facility as to the location of the survey results. On 10/24/18 at 11:00 AM, during the Resident Council meeting, eleven of eleven residents did not know the location of the survey results. On 10/24/18 at 3:49 PM, during an interview with the EI #8, the surveyor asked who was responsible for the sign that indicated where the survey results were located. EI #8 stated, I am. The surveyor asked where was the sign located. EI #8 stated, Right outside my door. The surveyor informed EI #8 the only document that was posted was the actual survey result booklet, and asked where was the sign that told where the survey results were located. The surveyor and EI #8 observed where the survey results were located and asked what did the document say and what was it attached to. EI #8 stated, It says the last 3 ADPH annual ADPH survey results and it is attached to the binder holding the survey results. The surveyor informed EI #8 that none of the residents that attended the Resident council meeting at 11 AM knew where the location of the survey results were, and asked if he could explain why. EI #8 stated, I can't explain why they didn't know.

Based on observations, interviews and a review of facility policies titled, Cleaning Dishes/Dish Machine, Hand Washing, Food Temperatures, and a Temperature Log Sheet, the facility failed to ensure: 1) dietary staff removed soiled plastic gloves and washed hands prior to removing hot food from the oven, 2) dietary staff took the temperature of the milk and recorded the temperature of the mashed potatoes, 3) plates, bowls, and trays were free of food and 4) a container of peanut butter in dry storage was free of peanut butter on the outside of the container. This had the potential to affect 67 of 72 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Cleaning Dishes/Dish Machine with a date of 2013 revealed: .Procedure: . 10. Remove the dishes, inspect for cleanliness . and put them away if clean . On 10/4/2017 at 10:40 a.m., the surveyor observed the Cook, (Employee Identifier) EI #1 plating food. EI #1 placed food on three plates with food debris already in the plate. One plate had a large amount of food debris in it. EI #1 placed food in one bowl with food debris already in it and four trays with food debris in them. On 10/4/2017 at 12:50 p.m., the surveyor conducted an interview with EI #1. EI #1 was asked what was the substance in some of the bowls, plates and trays on the trayline. EI #1 replied, food. EI #1 was asked did she put food in some of the plates. EI #1 replied, she did but the surveyor caught her. EI #1 was asked why she put food in the plates with the substance in it. EI #1 replied, really she did not see it until you ask what is that right there. EI #1 was asked what did the facility policy say about putting food in a plate with food substance in it. EI #1 replied, they were not supposed to do it. EI #1 added it was cross contamination. EI #1 was asked what was the potential harm to the residents when putting food in plates with food debris. EI #1 replied, cross contamination. On 10/4/2017 at 5:00 p.m., an interview was conducted with EI #2, Dietary Manager. EI #2 was asked what was the substance in some of the plates and trays. EI #2 replied, it looked like food particles and one particle looked like a piece of bacon. EI #2 was asked why was it there. EI #2 replied, an employee did not look at it when pulling dishes from the dish room to stack. EI #2 was asked what did the facility policy say about putting food in plates with food debris already in the plate. EI #2 replied, the food should be discarded and the plate taken back to the dish room. EI #2 was asked what was the potential harm to the residents when plating food in plates with food debris already in the plate. EI #2 replied, it can cause the residents to get sick if it has already gone through the dish machine. 2) A review of a facility policy titled, Hand Washing with a date of 2013 revealed: . Procedure: .1. When to Wash Hands: . After engaging in other activities that contaminate the hands. On 10/4/2017 at 10:40 a.m., the surveyor observed EI #1 pulling a black binder out with plastic gloves on. EI #1 flipped from page to page trying to find the utensil size she should use for a food item. There was food on her gloves and white spots on the inside of the binder. After flipping pages in the binder with the plastic gloves on, she went to the oven and put on a pair of cloth gloves over the plastic gloves and pulled food out of the oven. On 10/4/2017 at 12:53 p.m., the surveyor conducted an interview with EI #1. EI #1 was asked when should she wash her hands in the kitchen. EI #1 replied, any time she went to a dirty place or before putting on clean gloves. EI #1 was asked should she wash her hands after touching a binder and taking food out of the oven. EI #1 replied, yes. EI #1 was asked what was the potential harm in not changing her gloves after turning pages in a binder and taking food out of the oven. EI #1 replied, cross contamination. EI #1 was asked when was the last time she was inservice on infection control. EI #1 replied, a month ago. On 10/4/2017 at 5:10 p.m., the surveyor conducted an interview with EI #2. EI #2 was asked when should she wash her hands in the kitchen. EI #2 replied, before starting a job, soon as she came into the kitchen, and touching something that was dirty. EI #2 was asked should she wash her hands after touching a binder and taking food out of the oven. EI #2 replied, yes. EI #2 was asked what was the potential harm in not changing her gloves after turning pages in a binder and taking food out of the oven. EI #2 replied, she did not know where the binder and paper had been and EI #2 stated that EI #1 was cross contaminating. EI #2 was asked when was the last time staff was inserviced on infection control. EI #2 replied, they have not had one recently. On 10/4/2017 at 5:30 p.m., the surveyor conducted an interview with EI #3, RN (Registered Nurse), infection control. EI #3 was asked when should staff wash their hands in the kitchen. EI #3 replied, before preparing a meal, having become contaminated and before and after gloving. EI #3 was asked why should staff wash their hands in the kitchen. EI #3 replied, to prevent food borne illness or contaminate food. EI #3 was asked should staff wash their hands after taking a binder off a shelf, flipping through the pages and taking food out of the oven. EI #3 replied, yes. 3) A review of a policy titled, Food Temperatures with a date of 2013 revealed: Policy: The temperatures of the food items will be taken and properly recorded for each meal. 2. All cold food items must be maintained and served at a temperature of 41 (degrees) F (Fahrenheit) or below. A review of a facility temperature log listed the food items served for breakfast, lunch and dinner. The surveyor reviewed the lunch meal section. The milk section of the form was blank on 10/4/2017. There was no temperature recording for the mashed potatoes. On 10/4/2017 at 10:40 a.m., the surveyor observed EI #1 taking food temperatures on the tray line. The surveyor observed no one taking the temperature of the milk and no one recorded the temperature of the mashed potatoes. On 10/4/2017 at 5:23 p.m., the surveyor conducted an interview with EI #2. EI #2 was asked where was the temperature recording for the mashed potatoes on the temperature log. EI #2 replied, it was not recorded. EI #2 was asked where was the temperature for the milk recorded on the temperature log. EI #2 replied, it was not recorded. EI #2 was asked what was the facility policy on taking food temperatures on the trayline. EI #2 replied, temperatures should be taken prior to meal service of all the foods including the milk. EI #2 was asked who was responsible for taking food item temperatures on the tray line. EI #2 replied, the Cook and Dietary Aide that put the milk in the cooler. EI #2 was asked who took the milk temperature. EI #2 replied, no one. EI #2 was asked who took the temperature of the mashed potatoes. EI #2 replied, the Supervisor took it but did not record it. 4) A review of a facility policy titled, Dry Storage Areas with a date of 2013 revealed: Policy: Dry storage areas will be kept in a condition which protects stored foods from infestation. On 10/3/2017 at 5:10 p.m., the surveyor observed a five pound container of peanut butter in dry storage. The container had a large amount of peanut butter under the lid, in the middle and at the bottom of the container. On 10/5/2017 at 11:05 a.m., the survey conducted an interview with EI #2. EI #2 was asked what was the facility policy on food on the outside of a container after being opened. EI #2 replied, all containers needed to be cleaned on the outside. EI #2 was asked what was the potential harm when peanut butter was on the outside of a container at the lid, side and at the bottom of the container. EI #2 replied, it could cause rodents to come, and the potential to get in food. On 10/5/2017 at 11:15 a.m., the surveyor conducted an interview with EI #4, evening cook. EI #4 was asked what was on the outside of the peanut butter container. EI #4 replied, peanut butter. EI #4 was asked why was it there. EI #4 replied, some one did not wipe it down after use. EI #4 was asked how much of peanut butter was on the outside of the container. EI #4 replied, a medium amount all at the top and outside of the container. EI #4 was asked what was the facility policy on food on the outside of a container after being opened. EI# 4 replied, it should be thrown away or washed off. EI #4 was asked where was the peanut butter located. EI #4 replied, on a shelf in storage. EI #4 was asked what was the potential harm when peanut butter was on the outside of a container at the top of the lid, side of the container and at the bottom of the container. EI #4 replied, it could attract insects.

Based on observations, medical record review and interview, the facility failed to ensure RI (Resident Identifier) #17's call light was within reach. This was observed on two of three days of the survey and affected one of 15 residents whose call lights were observed. Findings Include: RI #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #17's most recent Quarterly MDS(Minimum Data Set) with an ARD (Assessment Reference Date) of 09/15/2017 revealed RI #17 had a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident was severely impaired for daily decision making. RI #17's MDS revealed the resident sometimes was able to make him/her self understood and could sometimes understand others. On 10/03/2017 at 6:46 p.m. Eastern Standard Time (EST), RI #17 was observed laying in bed with the call light not within reach. The call light was hanging low to the floor. On 10/04/2017 at 4:54 p.m. EST, an observation was made of RI #17's call light under the bed hanging to the floor on the right side. RI # 17 was laying in bed on his/her right side. On 10/04/2017 at 4:55 p.m. EST, the surveyor asked RI #17 if he/she was able to use the call light. RI #17 replied, I can't reach it. On 10/04/2017 at 5:00 p.m., EST, the surveyor interviewed EI (Employee Identifier) #6, the CNA (Certified Nursing Assistant) assigned to work with RI #17. EI #6 was asked if she was assigned to RI #17 that day. EI #6 said yes. EI #6 was asked if RI #17 was able to make his/her needs known to her. EI #6 explained sometimes RI #17 could tell her if he/she needed to be changed and if he/she wanted something to drink or eat. EI #6 was asked to look under RI #17's bed. EI #6 was asked where was RI #17's call light located. EI #6 said almost on the floor. During the surveyor's interview with EI #6, RI #17 said, I need to be cleaned. EI #6 was asked was RI #17's call light within reach. EI #6 said not then, it was not. EI #6 was asked why should RI #17's call light be within reach. EI #6 said because if RI #17 needed something, he/she could call. EI #6 was asked who was responsible for ensuring RI #17's call light was within reach. EI #6 said the CNAs and nurses. EI #6 was asked how did she think it made RI #17 feel not being able to reach his/her call light. EI #6 explained it may make him/her feel bad. EI #6 was asked what was the potential harm in not having RI #17's call light within reach. EI #6 said, they would not know if he/she was in need of something.

Based on observations and interview, the facility failed to ensure RL (Room Locator) #1 and the East Hall were free of strong urine odors. This was observed on three of three days of the survey and affected one of four halls and one of 74 resident rooms located in the facility. Findings Include: On 10/03/2017 at 6:12 p.m. EST (Eastern Standard Time), an observation was made of the East Hall and a strong urine smell was present. On 10/04/2017 at 8:03 a.m. EST, an observation was made of the East Hall and a strong urine smell was present. On 10/04/2017 at 10:15 a.m. CST (Central Standard Time), an observation was made of RL #1 and the East hall and a urine smell was present. On 10/05/2017 at 9:29 a.m., EST, an observation was made of the East Hall and a strong urine smell was present. On 10/05/2017 at 12:31 p.m., EST, an interview was conducted with EI (Employee Identifier)#7, Environmental Manager. EI #7 was asked how often resident rooms and lobbies/halls were cleaned by housekeeping. EI #7 said daily. EI #7 was asked why should resident rooms and halls be free of odors. EI #7 explained because you would want to keep a clean environment for the residents and visitors and you would want the residents to feel at home because the facility was their home. EI #7 was asked who was responsible for ensuring residents' rooms and halls were clean. EI #7 said, I am. EI #7 was asked how often did she make environmental rounds. EI #7 said all day through out the day. EI #7 was asked what was the potential harm for residents' rooms and halls to have strong odors. EI #7 explained if residents refused to bathe and change their clothes, it could cause body odors or urine odors. This deficiency was cited as a result of the investigation of complaint/report #AL 351.

Based on a review of a facility policy titled, Care Planning Policy and Procedure, medical record review, review of RI (Resident Identifier) #1's Activity Care Plan and Activities Rosters and interviews, the facility failed to implement RI #1's Care Plan by not providing RI #1 with a radio to listen to music, which was identified as an interest and an approach on RI #1's Activities Roster. The facility also failed to ensure RI #1's Activity Care Plan reflected an interest of TV (Television) which was present on RI #1's Activities Roster. This affected one of 15 residents whose Care Plans were reviewed. Findings Include: A review of a facility policy titled, Care Planning Policy and Procedure with a revised date of 07/2011 revealed: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being. RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/01/2017, revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated RI #1 was cognitively intact. A review of RI #1's Care Plan revealed the following: Care Plan .Goal .resident will confirm contentment with current program schedule during one-to-one visits wkly (weekly) .Approaches .Check-in with resident weekly to ensure resident is satisfied with current Independent activity pattern .Periodically inform resident of .music . A review of RI #1's Activities Roster, dated from 08/01/2017 through 09/30/2017, revealed RI #1 received one on one activities which included TV(Television)/Radio. RI #1's Activities Roster also revealed a one on one activity of Sensory-Smells/Taste/Textures/Bright Objects/Sounds. The documented one on one activities provided were not listed as approaches on RI #1's Activity Care Plan. A hand written one on one activity schedule, with no date, was provided to the surveyor by EI (Employee Identifier) #8, Activity Director, which revealed RI #1's scheduled one on one activities were scheduled for Wednesdays and Thursdays. On 10/04/2017 at 5:13 p.m., EST (Eastern Standard Time), the surveyor interviewed RI #1. RI #1 was asked when was the last time the Director of Activity, EI #8, spoke with him/her about his/her Care Plan for activities. RI #1 said he/she could not remember but it had been months. RI #1 was asked did he/she let the Activity Director know he/she did not watch TV. RI #1 replied, Yes I told them to many bad things going on so I don't watch it. RI #1 was asked who he/she told in the Activity department regarding not wanting to watch TV. RI #1 said he/she could not remember. RI #1 was asked did he/she have a radio. RI #1 said, no, he/she did not have a radio. On 10/04/2017 at 5:27 p.m., an interview was conducted with EI #8. EI #8 was asked how she determined what RI #1 enjoyed. EI #8 said RI #1 was alert and could answer all of her questions and could tell what he/she enjoyed. EI #8 was asked did RI #1 have a radio in his/her room. EI #8 said he/she had one. EI #8 was asked should an Activity Care Plan be resident centered. EI #8 said yes. EI #8 was asked why. EI #8 explained because the Care Plan showed what the resident liked. EI #8 was asked did the Activity Care Plans reflect one on one activity. EI #8 said yes because they offered one on one. EI #8 was informed, on RI #1's Activities Roster, radio and TV was offered. EI #8 was asked was that a reflection of RI #1's preferred activities. EI #8 said no. EI #8 explained the approaches documented on RI #1's Activity Care Plan were group and not one on one activity. EI #8 was asked should RI #1's Activity Care Plan approaches reflect what was done in RI #1's one on one activity. EI #8 said yes it needed to be added. EI #8 was asked why should RI #1's Activity Care Plan be reflective of RI #1's one on one activities that were offered and documented on RI #1's Activities Roster. EI #8 explained so it would be person centered for RI #1's one on one activities. On 10/05/2017 at 9:01 a.m., EST, an interview was conducted with EI #10, Activity Assistant. EI #10 was asked how she knew what activity approaches the residents that received one on one activities were to receive. EI #10 explained because the Care Plans and the Activity Director let the Activity staff know what the resident liked. EI #10 was informed on RI #1's one of one Activities Roster it was charted RI #1 received Sensory-Smells/Taste/Textures/Bright Objects/Sounds. EI #1 was asked was that an approach identified on RI #1's Activity Care Plan. EI #10 said no. EI #10 was asked why she would chart that activity on RI #1's Activities Roster. EI #10 explained because that was what she did with RI #1. EI #10 was asked did she follow RI #1's Activity Care Plan. EI #10 said no. On 10/05/2017 at 12:03 p.m., EST, a second interview was conducted with EI #8. EI #8 was asked what weekly meant on the Activity Care Plans. EI #8 explained it meant three times a week or whatever was on the one on one schedule. EI #8 was asked why Care Plan approaches should be followed by the Activity staff. EI #8 explained so staff would know what the resident liked and disliked. EI #8 was asked why Care Plans were developed. EI #8 explained so they could know what to offer the resident. EI #8 was asked who was responsible for ensuring Care Plan approaches for activities were followed. EI #8 said, I am. EI #8 was asked were the activities identified as one on one activities for RI #1 regarding Sensory-Smells/Taste/Textures/Bright Objects/Sounds an approach identified on RI #1's Activity Care Plan. EI #8 replied, No it's not on there. EI #8 was asked should it be an approach on RI #1's Activity Care Plan if it was provided to RI #1. EI #8 said yes. On 10/05/2017 at 1:30 p.m., EST, an interview was conducted with EI #9, CNA (Certified Nursing Assistant). EI #9 was asked if she was familiar with RI #1. EI #9 said yes. EI #9 was asked what RI #1 enjoyed doing. EI #9 stated RI #1 loved music and further explained she was going to let the facility know how much RI #1 enjoyed music. EI #9 stated she was going to see if the facility could get RI #1 a radio or if she could get RI #1 a radio. EI #9 was asked if RI #1 watched TV. EI #9 said no, RI #1 enjoyed music and would sleep. EI #9 was asked did RI #1 have a CD player or radio. EI #1 stated no, she had never seen one in RI #1's room.

Based on interviews, medical record review and review of Activity Assessments and Activities Rosters, the facility failed to individualize RI (Resident Identifier) #1's activities to reflect his/her interests. This affected one of 15 residents whose Activities were reviewed. Findings Include: RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/01/2017 revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated RI #1 was cognitively intact. A review of RI #1's ACTIVITY assessment dated [DATE] revealed the following: .Type of Assessment Reason for Assessment Admission . Speech Clear . Activity History/Preference .Establishes own goals .Preferred Activity Location Own Room . Lifelong/Potential Interests: CURRENT . News .TV/Radio . A review of RI #1's Activities Roster dated 07/01/2017 through 09/30/2017 revealed the following: .7/1/17 .One on One TV/Radio . .8/1/17 . Fun/Relaxation/Socialization TV/Radio .8/2/17 .Education/Cognitive Learning .Newspaper . .9/1/17 . One on One TV/Radio .9/7/17 .One on One .Sensory-Smells/Tastes/Textures/Bright Object/Sounds . The review of RI #1's Activities Rosters dated 07/01/2017 through 09/30/2017 revealed RI #1 was offered and provided TV/radio, newspaper and sensory activities, which were not reflective of RI #1's interests. RI #1 stated he/she did not watch TV nor had a radio. RI #1 stated he/she did not watch TV due to bad things going on. The newspaper was not reflective of RI #1's interest due to him/her stating too many bad things going on. On 10/04/2017 at 10:13 a.m., EST (Eastern Standard Time) an interview was conducted with RI #1 regarding activities. RI #1 was asked what types of activities had the facility provided him/her with. RI #1 explained activity staff used to ask him/her what he/she liked but activity staff did not come every week, but came to his/her room every now and then. RI #1 explained he/she enjoyed music and voiced the different types of music he/she enjoyed. RI #1 further stated he/she did not watch TV(Television). On the same date during the interview with RI #1, at 10:30 a.m, EST, the surveyor observed RI #1's television off and did not observe a radio in the room. RI #1 explained he/she had a CD player, however, the surveyor did not observe a CD player in the resident's room. On 10/04/2017 at 5:13 p.m., EST, a second interview was conducted with RI#1. RI #1 was asked if he/she told the Activity Department he/she did not watch TV. RI #1 replied, Yes, I told them too many bad things going on, so I don't watch it. RI #1 was asked who did he/she tell in the Activity Department about not watching television. RI #1 said he/she could not remember. The surveyor asked RI #1 if someone from the Activity Department were to ask what he/she enjoyed, would he/she tell them. RI #1 said, Yes. RI #1 was asked had activity staff offered him/her any CD's with music she enjoyed. RI #1 said, No. RI #1 was asked if he/she had a radio. RI #1 said no, he/she did not have a radio but had a CD player with earplugs. The surveyor did not observe a CD player. On 10/04/2017 at 5:27 p.m., EST, an interview was conducted with EI (Employee Identifier) #8, Activity Director. EI #8 was asked when completing a resident's Activity Assessment, how did she determine what the resident enjoyed. EI #8 explained when she interviewed the resident, she went over their likes and that was how she determined what they liked to do. EI #8 further explained she also conducted an interview with the family and asked them what the resident liked to do. EI #8 was asked how she determined RI #1 enjoyed watching TV and listening to the radio. EI #8 explained RI #1 was alert and could answer all of her questions and RI #1 could tell her what he/she enjoyed. EI #8 further explained RI #1 enjoyed staying in his/her room. EI #8 was asked if RI #1 told her he/she enjoyed watching TV and listening to the radio. EI #8 said yes. EI #8 was asked did RI #1 have a radio in his/her room. EI #8 said he/she had one. EI #8 was asked if RI #1 was alert enough to tell her what he/she enjoyed. EI #8 said yes. The surveyor informed EI #8 that RI #1 did not watch TV nor did RI #1 have a radio. EI #8 was asked was she aware of this. EI #8 said no. EI #8 was asked what did resident centered mean regarding activities. EI #8 explained it should be their interest so activity staff would know what to offer. EI #8 was asked if RI #1's Activities Roster which stated radio/TV was an activity, a true reflection of RI #1's preferred likes. EI #8 said, no. EI #8 was asked if the Activities Roster which indicated TV as a provided activity a reflection of RI #1's likes. EI #8 said no, it should not have been on RI #1's Activities Roster. On 10/05/2017 at 1:30 p.m., EST, an interview was conducted with EI #9, CNA (Certified Nursing Assistant). EI #9 was asked if she was familiar with RI #1. EI #9 said yes. EI #9 was asked what did RI #1 enjoy doing. EI #9 stated RI #1 loved music and further explained she was going to let the facility know how much RI #1 enjoyed music. EI #9 stated she was going to see if the facility could get RI #1 a radio or if she could get RI #1 a radio. EI #9 was asked if RI #1 watched TV. EI #9 said no, RI #1 enjoyed music and would sleep. EI #9 was asked did RI #1 have a CD player or radio. EI #9 stated no, she had never seen one in RI #1's room.

Based on an interview and review of Resident Identifier (RI) #s ,[DATE]'s trust fund accounts, the facility failed to ensure the remaining balances in the residents' trust fund accounts were returned to the appropriate agency or sponsor within the thirty days following the residents' deaths. This affected four of eight expired residents whose trust funds were reviewed. Three expired residents had funds which should have been returned to the Social Security Administration, and one expired resident had funds which should have been returned to the sponsor. Findings include: On [DATE] a review was conducted of the resident's trust fund accounts managed by the facility. There were four resident accounts whose balances had not been cleared within the thirty mandated disbursement requirement after discharge or death. Resident Identifier (RI) #20 was discharged from the facility to the hospital on [DATE], and the final check was written to clear RI #20's account on [DATE], four days after the thirty day deadline. RI #21 expired on [DATE], but RI #21's account was not cleared until [DATE], 54 days after the thirty day deadline. RI #22 expired on [DATE], but the final disbursement was not made until [DATE], 117 days after the thirty day deadline. RI #23 expired on [DATE], and the clearing of the account was pending as of [DATE]. On [DATE] at 11:10 a.m. (Eastern Daylight Savings Time), an interview was conducted with Employee Identifier (EI) #1 the Administrative Assistant. EI #1 was asked if the trust fund accounts had been cleared for RI #20, 21, 22, and 23. EI #1 stated RI #s 20, 21 and 22's accounts have been cleared but more than thirty days after their death and RI #23's account was still waiting to be cleared. EI #1 was asked if the agency/sponsor should have been paid within the thirty day deadline. EI #1 said Corporate did not want a check sent because the Social Security Administration would take the money out of the accounts electronically and make a negative balance. EI #1 was asked when the accounts should have been cleared, EI #1 replied, Thirty days or less.

Based on record review and interview, the facility failed to ensure two licensed staff members did not administer the blood pressure medication, [MEDICATION NAME], in the cheek of Resident Identifier (RI) #1, when the resident was unresponsive and difficult to arouse. This route, used to administer this medication, increased the likelihood of Resident Identifier (RI) #1 swallowing the medication in an unsafe manner. According to the facility in-service for administering medications by mouth, oral medications should only be administered to residents who are alert and have the ability to swallow. On 09/29/2016, at 5:10 a.m., RI #1 was found in bed by EI #3, the Registered Nurse (RN), assigned to care for RI #1 during the 11 p.m. to 7 a.m. shift. EI #4 stated the resident was heard snoring in bed, difficult to arouse, with a frothy white substance draining from the mouth. RI #1's blood pressure was elevated to 188/110, higher than normal parameters. At 8:20 a.m., RI #1 was sent to the hospital by Emergency Medical Services. (EMS refers to the treatment and transport of people in crisis health situations that may be life threatening.) According to facility staff, RI #1 was admitted to the Intensive Care Unit. This deficient practice affected RI #1, one sampled resident, but had the potential to affect all residents who reside at the facility. On 10/06/2016 at 8:00 a.m., the Administrator and the DON (Director of Nursing) were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Care. The Immediate Jeopardy began 09/29/2016, until the facility implemented corrective actions. The Immediate Jeopardy was relieved on 10/07/2016, onsite at 7:00 p.m. Findings Include: According to FUNDAMENTAL OF NURSING, 8th edition of Potter and Perry, under ADMINISTERING ORAL MEDICATIONS, page 612, ASSESSMENT 1 Check accuracy and completeness of each Medication Administration Record [REDACTED]. 3 Assess for contraindications to patient receiving oral medication, including . inability to swallow . and decreased level of consciousness . CLINICAL DECISION: If there are any contraindications to the patient receiving oral medications or if in doubt of the patient's ability to swallow oral medications, . inform Prescriber (doctor) . On 10/03/2016, the Department of Public Health received an anonymous complaint. The anonymous caller alleged on 09/28/2016, during the 11 p.m. to 7 a.m. shift, the nurse assigned to care for (Name of RI #1) did nothing for the resident when the resident was found unresponsive and with a frothy mouth. The caller stated the third shift nurse documented she found the resident unresponsive with a frothy mouth at 5:00 a.m., last Wednesday (09/28/2016). The resident's vitals were blood pressure of 160 or 170 over 100 something and blood sugar was 64. The caller alleged that the resident's blood sugar should be maintained over 100 because anything less than 100 would cause the resident to become diaphoretic (cause sweating) and unresponsive. It was not until the 1st shift nurse came in, made rounds and found the resident unresponsive, that something was done for the resident. The first shift nurse sent the resident out to the hospital. The resident is currently at the hospital in ICU (Intensive Care Unit) and is not expected to live. RI #1 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2016, revealed the resident had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. A review of RI #1's Physician Orders for the month of September 2016 revealed: .[MEDICATION NAME] HCL ([MEDICATION NAME]) 0.1 MG (MILLIGRAM) TABLET PO (BY MOUTH) Q (EVERY) 8H (HOURS) PRN **B/P (BLOOD PRESSURE) >(GREATER THAN) 170 SYSTOLIC OR 100 DIASTOLIC** . A review of RI #1's Departmental Notes revealed: . 09/29/2016 6:50 AM . At 5:10 a.m. Resident was noted laying supine crossways of his/her bed snoring loudly and white frothy substance draining from (his/her mouth), hard to arouse, . will monitor closely as (he/she) is sleeping at this time. Signed by: EI #3 . 09/29/2016 8:20 AM .Writer entered res (resident) room. Res. noted to be unresponsive. BS 32 . BP 191/118, HR (Heart Rate) 109, 24 RR (Respirations) . Signed by: EI #4, LPN (Licensed Practical Nurse) . The Departmental Notes for 09/29/2016 at 8:40 am, documented, Res. (resident) still unresponsive. PRN (as needed) [MEDICATION NAME] 01. (0.1) mg (milligram) given for BP (blood pressure) 191/118 . This entry was signed by EI #4, LPN. On 10/4/2016, at 1:49 p.m., an interview was conducted with EI #4. EI #4 said she went in the resident's room around 8:00 a.m. and the resident was on her/his back with white froth coming from the mouth. EI #4 said RI #1 was snoring and breathing, but not alert. EI #4 said RI #1's BP was really high and she went and got [MEDICATION NAME], crushed it and tucked it in RI #1's cheek. On 10/05/2016, at 7:53 a.m., an interview was conducted with EI #3. EI #3 was asked what she did for RI #1 when she found the resident in that state (frothy mouth, hard to arouse, elevated BP (188/110), snoring and BS of 64. EI #3 was asked if she gave [MEDICATION NAME]. EI #3 said she did. EI #3 was asked how she gave the [MEDICATION NAME] to RI #1 since the resident was not responsive. EI #3 said she put the pill on the edge of the resident's tongue next to her gum and cheek. EI #3 was asked if she rechecked RI #1's BP. EI #3 said no. EI #3 was asked why she did not recheck the BP. EI #3 said she got lost in the midst of going back and forth. On 10/05/2016, at 10:05 a.m., a telephone interview was conducted with EI #12, the Medical Director. EI #12 was asked if crushing [MEDICATION NAME] and placing it inside of the resident's cheek was an appropriate way to administer a medication to an unresponsive resident. EI #12 said [MEDICATION NAME] under the tongue, yes, but in the cheek, he did not know. On 10/05/2016, at 10:50 a.m., an interview was conducted with EI #2. EI #2 was asked if it was an appropriate decision to give oral medication to an unresponsive resident. EI #2 said she would not do it. When asked why she would not administer oral medications to an unresponsive resident, EI #2 stated she would be worried about the resident choking. A review of a facility in-service titled, Indications for administering medications by mouth with a date of 10/07/2016 revealed: Oral medications should only be administered to residents who are alert and have the ability to swallow. If the resident is unresponsive or has decreased or no ability to swallow, medications should be administered by alternate route. Alternate routes include rectally, intramuscular, subcutaneous, [MEDICATION NAME], intravenous and sublingual for certain medications. Notify the physician if a resident is unresponsive or has decreased ability to swallow for orders on alternate routes or alternate medications to administer . This tag was cited as a result of the investigation of complaint/report number AL 725. ******************************************************** On 10/07/2016 at 7:00 p.m., the facility submitted an Acceptable Allegation of Credible Compliance, which documented: RI #1 was found on 09/29/16 at 5:10 AM by charge nurse laying supine crossways of her bed snoring loudly and white frothy substance draining from her mouth, hard to arouse. RI #1 ' s BP was 188/110 and blood sugar was 64. On 09/29/16 at 8:20 AM RI #1 was found by charge nurse resident was unresponsive. Abdomen was distended. Blood sugar was 32. BP was 191/118, HR 109, RR 24. Blood sugar recheck was 57. On 09/29/16 at 8:40 AM RI #1 was reassessed by charge nurse and was unresponsive. Resident sent to St Francis for evaluation. All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Administration of PO medication and when not to administer PO medication. This has the potential to affect all residents in the facility. Immediate Jeopardy can be removed 10/07/2016. Facility Administrator or designee monitoring and will continue to monitor to ensure implementation of AOCC by monitoring 24-hour book daily. 6-Quality of Care: RI #1 was found on 09/29/16 at 5:10 AM by charge nurse laying supine crossways of her bed snoring loudly and white frothy substance draining from her mouth, hard to arouse. RI #1 ' s BP was 188/110 and blood sugar was 64. On 09/29/16 at 8:20 AM RI #1 was found by charge nurse resident was unresponsive. Abdomen was distended. Blood sugar was 32. BP was 191/118, HR 109, RR 24. Blood sugar recheck was 57. On 09/29/16 at 8:40 AM RI #1 was reassessed by charge nurse and was unresponsive. Resident sent to St Francis for evaluation. All staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other employees will be in-serviced prior to starting their shift until 100% of staff receives the in-service training. In-service includes the following information: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - decreased responsiveness or unresponsiveness, frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). This has the potential to affect all residents in the facility. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received disciplinary action by the DON on 10/3/2016 which included the nurse did not reassess resident ' s BP after medication was administered. BP was 188/110, medication was given but no documentation was completed. Blood Sugar was 64 and no intervention was put in place to increase Blood Sugar. Nurse did not reassess resident ' s vitals prior to end of shift. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Head to toe assessment, MD notification, how to check blood sugar, normal range of blood sugar, following MD orders for blood sugars, how to obtain blood pressures, normal range of blood pressure, following MD orders for PRN medication for BP, shift report, following the plan of care, administration of PO medication, and when not to administer PO medication All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: physician's order [REDACTED]. If the resident has a low blood sugar and no orders to treat, refer to standing order for treatment based on resident ' s responsiveness. All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: Each licensed nurse scheduled to work a medication cart will use the 24-hour report book to communicate any changes from shift to shift. Both the oncoming licensed nurse and the outgoing licensed nurse will review the 24-hour report book together and initial that this has been completed. Each license nurse will document any change in condition including but not limited to abnormal blood sugars, abnormal blood pressure, change in responsive level, and frothy substance from the mouth. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents MD orders from 09/01/16-10/07/16 to ensure all orders related to their diabetes have been followed. All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: All resident care plans must be followed for treatment of [REDACTED]. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents careplans to ensure all interventions related to diabetes are being followed from 09/01/16-10/07/16. The administrator provided one-on-one in-service education to the DON on 10/6/2016 on the 7PM-11PM shift. In-service included the following all the areas of: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - Decreased responsiveness or unresponsiveness, Frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). physician's order [REDACTED]. If the resident has a low blood sugar and no orders to treat, refer to standing order for treatment based on resident ' s responsiveness. All resident care plans must be followed for treatment of [REDACTED]. Resident ' s with low blood sugars should be treated as a medical emergency. Treatment should be initiated immediately to include following physicians orders for treatment of [REDACTED]. in condition for further orders, activate 911 if necessary. DON received one-on-one in-service training from the RN Supervisor on 10/7/16 on the 3pm-11pm shift including return demonstration. In-service included the following: Head to toe assessment, MD notification, how to check blood sugar, normal range of blood sugar, following MD orders for blood sugars, how to obtain blood pressures, normal range of blood pressure, following MD orders for PRN medication for BP, shift report, following the plan of care, administration of PO medication, and when not to administer PO medication All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Administration of PO medication and when not to administer PO medication When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. This has the potential to affect all residents in the facility. Immediate Jeopardy can be removed 10/07/2016. ****************************************************************************** The team monitored the implementation of the AOCC (Allegation of Credible Compliance) by verifying the following: staff members were interviewed and confirmed that they received in-service training on reporting changes in resident condition. The disciplinary action for the charge nurse assigned to RI #1 on 09/29/2016 at 5:10 a.m. was reviewed and the nurse was interviewed to confirm her knowledge of the training in the areas of blood sugar monitoring, blood pressure monitoring, following the care plan and following physician's orders [REDACTED].

Based on record review and interview, the facility failed to ensure the Medical Director was notified when Resident Identifier (RI) #1 had a change in condition. On 09/29/2016, at 5:10 a.m., RI #1 was found in bed by EI #3, the Registered Nurse (RN), assigned to care for RI #1 during the 11 p.m. to 7 a.m. shift. EI #4 stated the resident was heard snoring in bed, difficult to arouse, with a frothy white substance draining from the mouth. RI #1's blood pressure was elevated to 188/110, higher than normal parameters, and his/her blood sugar was 64, lower than the normal parameters established by RI #1's doctor. RI #1's care plan directed the staff to notify the physician if the blood sugar was below 70, however, the physician was not contacted. According to the American Heart Association guidelines normal blood pressure is Systolic (Upper) mm Hg (millimeters of mercury) is Less than 120 and normal Diastolic (Lower) mm HG is Less than 80. The American Diabetes Association suggests the following target for most non-pregnant adults with diabetes, before a meal 80-130 mg/dl (milligrams per deciliter). EI #4, the oncoming nurse, stated when she entered the resident's room, around 8:00 a.m., she found RI #1 unresponsive, with a distended abdomen and the resident's blood sugar had further dropped to 32. At 8:20 a.m., RI #1 was sent to the hospital by Emergency Medical Services, EMS refers to the treatment and transport of people in crisis health situations that may be life threatening. According to facility staff, RI #1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. This deficient practice affected RI #1, one sampled resident, but had the potential to affect all residents who resided at the facility. On 10/06/2016, at 8:00 a.m., the Administrator and the DON (Director of Nursing) were notified of the findings of Immediate Jeopardy level of J in the area of Resident Rights. The Immediate Jeopardy began on 09/29/2016, until the facility implemented corrective actions on 10/07/2016 at 7:00 p.m. Findings Include: On 10/03/2016, the Department of Public Health received an anonymous complaint. The anonymous caller alleged on 09/28/2016, during the 11 p.m. to 7 a.m. shift, the nurse assigned to care for (Name of RI #1) did nothing for the resident when the resident was found unresponsive and with a frothy mouth. The caller stated the third shift nurse documented she found the resident unresponsive with a frothy mouth at 5:00 a.m., last Wednesday (09/28/2016). The resident's vitals were blood pressure of 160 or 170 over 100 something and blood sugar was 64. The caller alleged that the resident's blood sugar should be maintained over 100 because anything less than 100 would cause the resident to become diaphoretic (cause sweating) and unresponsive. It was not until the 1st shift nurse came in, made rounds and found the resident unresponsive, that something was done for the resident. The first shift nurse sent the resident out to the hospital. The resident is currently at the hospital in ICU (Intensive Care Unit) and is not expected to live. A review of a facility policy titled, Notification of Change of Condition of a Resident with a revised date of 09/2011 revealed: Purpose: To ensure resident's rights and continuity of care by identifying and reporting a Significant Change in Physical .well being. Procedure: Notify the Physician of status change. Document the notification in the medical record. A review of a facility document titled, REGISTERED NURSE JOB DESCRIPTION revealed: . B. Nursing Care Functions Duties: . notify physicians of resident accidents, incidents and changes in condition . RI #1 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's most recent Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 09/06/2016, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13, which indicated RI #1 was cognitively intact. A review of RI #1's Diabetes Mellitus Care Plan revealed: . Problem/Need . Problem Onset: 01/30/2012 I have insulin dependent,, adult onset Diabetes. I am at risk for low and high blood sugars. Approaches . (c) If blood sugar is below 70 notify the physician . A review of RI #1's Departmental Notes dated and timed 09/29/2016 6:50 a.m. revealed: . At 5:10 a.m. Resident was noted laying supine crossways of (his/her) bed snoring loudly and white frothy substance draining from (his/her) mouth, hard to arouse, assisted to lay correct way in the bed by two staff members, skin is cool and dry Bp (blood pressure) is 188/110 and blood sugar is 64. No [MEDICAL CONDITION] activity noted at this time, we will provide safety, moved table away from side of bed. Staff provided a.m. care and we will monitor closely as (he/she) is sleeping at this time. I will report to oncoming nurse. This entry was signed by EI #3, the RN who cared for RI #1 during the 11 p.m. to 7:00 a.m. shift on 09/29/2016. The next entry revealed, 09/29/2016 8:20 AM .Writer entered res (resident) room. Res. noted to be unresponsive. Abdomen distended. BP 191/118, HR (Heart Rate)109, 24 RR (Respirations). BS recheck 57. The entry was signed by EI #4, LPN (Licensed Practical Nurse), the oncoming nurse who relieved EI #3. On 10/04/2016, at 1:49 p.m., an interview was conducted with EI #4, the oncoming nurse. EI #4 was asked about the nursing report she received from EI #3, the 11 p.m. to 7 a.m. nurse, on 09/29/2016 concerning RI #1. EI #4 said EI #3 told her RI #1 had a [MEDICAL CONDITION] during the night and was resting. EI #4 was asked how she found the resident. EI #4 said when she went into RI #1's room around 8:00 a.m., the resident was on her/his back with white froth coming from the mouth. RI #1 was snoring, breathing, but not alert and RI #1's abdomen was very distended (swollen). EI #4 said she had never seen the resident's abdomen like that before and stated it looked like Ascites (abdominal swelling caused by an accumulation of fluid) and it was firm. EI #4 further described the size of RI #1's abdomen as looking like the resident was nine months pregnant. EI #4 stated when EI #3 came back to the facility and relieved her later at 7 p.m. that night, EI #3 stated she had also noticed RI #1's distended abdomen. On 10/05/2016, at 7:53 a.m., an interview was conducted with EI #3, the RN who found RI #1 in an unresponsive state with and elevated blood pressure and low blood sugar during the 11 p.m. to 7 a.m. shift. EI #3 was asked about RI #1's condition when she assessed RI #1 on 09/29/2016, at 5:10 a.m. EI #3 stated RI #1 was laying with her/his head toward the side of the bed, with buttocks on the mattress and feet on the floor and arms out to the side. EI #3 stated RI #1 had frothy looking sputum on the left jaw and was snoring deeply. According to EI #3, as she touched RI #1, the resident's eyes would flutter. EI #1 stated RI #1 looked like she/he had a [MEDICAL CONDITION]. EI #3 remembered that the resident's blood pressure was in the 180's, over 108 or 110 and the blood sugar was 64. When asked if RI #1 had a history of [REDACTED]. EI #3 said she reported to the oncoming nurse (EI #4) her assessment of RI #1 at 5:50 a.m. including that RI #1 looked like he/she had a [MEDICAL CONDITION]. EI #3 also informed EI #4 of RI #1's blood sugar reading and that she did not treat the blood sugar reading of 64. EI #3 was asked if she notified the doctor about RI #1's low blood sugar reading. EI #3 said no. EI #3 was asked if she notified the doctor concerning RI #1's elevated blood pressure reading. EI #3 said no. When asked if RI #1 had a distended abdomen, EI #3 recalled that RI #1's abdomen did seem as if it was distended. EI #3 described RI #1's distended abdomen as looking like the resident was six months pregnant. EI #3 was asked if she reported the distended abdomen. EI #3 said no, she did not think so. When asked why she did not report the distended abdomen, EI #3 did not know. On 10/05/2016, at 10:05 a.m., a telephone interview was conducted with EI #12, the Medical Director. EI #12 was asked if he would expect the nurse to notify him when a resident is found snoring, with a white frothy substance draining from the mouth, not able to arouse, blood sugar of 64 and a blood pressure of 188 over 110. EI #12 stated yes. EI #12 was asked if the nurse notified him on 09/29/2016, of those findings concerning RI #1. EI #12 confirmed the staff did not contact him. This tag was cited as a result of the investigation of complaint/report number AL 725. ******************************************************** On 10/07/2016 at 7:00 PM, the facility submitted an Acceptable Allegation of Credible Compliance, which documented: All staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other employees will be in-serviced prior to starting their shift until 100% of staff receives the in-service training. In-service includes the following information: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - decreased responsiveness or unresponsiveness, frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). This has the potential to affect all residents in the facility. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received disciplinary action by the DON on 10/3/2016 which included the nurse did not reassess resident ' s BP after medication was administered. BP was 188/110, medication was given but no documentation was completed. Blood Sugar was 64 and no intervention was put in place to increase Blood Sugar. Nurse did not reassess resident ' s vitals prior to end of shift. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service includes the following information: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - Decreased responsiveness or unresponsiveness, Frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). ******************************************************** The team monitored the implementation of the AOCC (Allegation of Credible Compliance) by verifying the following: staff members were interviewed and confirmed that they received in-service training on reporting changes in resident condition. The disciplinary action for the charge nurse assigned to RI #1 on 09/29/2016 at 5:10 a.m. was reviewed and the nurse was interviewed to confirm her knowledge of the training in the areas of blood sugar and blood pressure monitoring. The Team determined the facility had implemented their AOCC and the Immediate Jeopardy was relieved onsite on 10/07/2016 at 7:00 p.m.

Based on record review, observation and interview, the facility failed to ensure: 1a) A licensed nurse followed the physician's orders to treat RI (Resident Identifier) #1's low BS (Blood Sugar) of 64 on 09/29/2016 at 5:10 a.m. On 09/29/2016, at 5:10 a.m., RI #1 was found in bed by EI #3, the Registered Nurse (RN), assigned to care for RI #1 during the 11 p.m. to 7 a.m. shift. EI #3 stated the resident was found snoring in bed, difficult to arouse, with a frothy white substance draining from the mouth. RI #1's blood pressure was elevated to 188/110, higher than normal parameters, and his/her blood sugar was 64, lower than the normal parameters established by RI #1's doctor. RI #1's careplan directed the staff to notify the physician if the blood sugar was below 70, however, the physician was not called. EI #4, the oncoming nurse, stated when she entered the resident's room, around 8:00 a.m., she found RI #1 unresponsive, with a distended (swollen) abdomen and the resident's blood sugar had dropped further to 32. At 8:20 a.m., RI #1 was sent to the hospital by Emergency Medical Services, EMS refers to the treatment and transport of people in crisis health situations that may be life threatening. According to facility staff, RI #1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. This deficient practice affected RI #1, but had the potential to affect all 25 diabetic residents who reside in the facility. 1b) Also, the facility further failed to ensure the physician's orders were followed for RI #1, #3, #17, #18 and #19, five diabetic residents, to perform blood sugar checks or treat the blood sugars with insulin coverage. This deficient practice affected five of the 25 diabetic residents who resided in the facility but had the potential to affect all 25 diabetic residents. On 10/06/2016 at 8:00 a.m., the Administrator and the DON (Director of Nursing) were notified of the findings of Immediate Jeopardy level of J in the area of Resident Assessments. The Immediate Jeopardy began on 09/29/2016, until the facility implemented corrective actions. The Immediate Jeopardy was relieved on 10/07/2016, at 7:00 p.m. 2) The facility further failed to ensure a licensed staff members did not sign the MAR (Medication Administration Record) to indicate a medication was administered before administering medication to the resident. 3) The facility failed to ensure the Narcotic Record was not signed before the narcotic medication was removed from the locked box and administered to the resident. These deficient practice affected three of five nurses observed during medication administration. Findings Include: 1a) On 10/03/2016, the Department of Public Health received an anonymous complaint. The anonymous caller alleged on 09/28/2016, during the 11 p.m. to 7 a.m. shift, the nurse assigned to care for (Name of RI #1) did nothing for the resident when the resident was found unresponsive and with a frothy mouth. The caller stated the third shift nurse documented she found the resident unresponsive with a frothy mouth at 5:00 a.m., last Wednesday (09/28/2016). The resident's vitals were blood pressure of 160 or 170 over 100 something and blood sugar was 64. The caller alleged that the resident's blood sugar should be maintained over 100 because anything less than 100 would cause the resident to become diaphoretic (cause sweating) and unresponsive. It was not until the 1st shift nurse came in, made rounds and found the resident unresponsive, that something was done for the resident. The first shift nurse sent the resident out to the hospital. The resident is currently at the hospital in ICU (Intensive Care Unit) and is not expected to live. A review of the Alabama Board of Nursing, Alabama Administrative Code, Chapter 610-X-6 Standards of Nursing Practice revealed: . 610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice) . (1)The practice of professional nursing includes, but is not limited to: . (c) Exercise of appropriate nursing judgment. (g) Executing medical regimens including administering medications and treatments prescribed by a licensed or otherwise legally authorized Prescriber. (2) Competence in the practice of nursing by a registered nurse shall include, but is not limited to: (a) Knowledge and compliance with: (ii) Standards of nursing practice. A review of the facility policy titled, Medication Administration-General Guidelines dated 01/12, revealed: . Procedures . 2. Medications are administered in accordance with written orders of the attending physician. RI #1 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/06/2016, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. A review of RI #1's Departmental Notes dated and timed 09/29/2016 6:50 a.m. revealed: . At 5:10 a.m. Resident was noted laying supine crossways of (his/her) bed snoring loudly and white frothy substance draining from (his/her) mouth, hard to arouse, assisted to lay correct way in the bed by two staff members, skin is cool and dry Bp (blood pressure) is 188/110 and blood sugar is 64. No [MEDICAL CONDITION] activity noted at this time, we will provide safety, moved table away from side of bed. Staff provided a.m. care and we will monitor closely as (he/she) is sleeping at this time. I will report to oncoming nurse. This entry was signed by EI #3, the RN who cared for RI #1 during the 11 p.m. to 7:00 a.m. shift on 09/29/2016. On 10/14/2016, at 10:04 a.m., an interview was conducted with EI #4, who received nursing report from EI #3 on 09/29/2016. EI #4 was asked if EI #3 told her what RI #1's blood sugar was on the night shift. EI #4 said no. EI #4 was asked if EI #3 told her about the elevated blood pressure. EI #4 said no. EI #4 was asked if EI #3 reported RI #1's distended abdomen to her. EI #4 said no, not in report but EI #3 came back and relieved her at 7 p.m. that night and asked how RI #1 was. EI #4 said she told EI #3 about the resident's distended abdomen and EI #3 said she noticed it, but thought that it was normal for RI #1. EI #4 said she felt like EI #3 left it up to her to provide treatment. EI #4 said she read EI #3's nurse's notes and it said she would report to the oncoming nurse. EI #4 said that was wrong because EI #3 did not report what was in the nurse's note to her. A review of RI #1's Physician Orders for September 2016 revealed: .[MEDICATION NAME] 1 MG (MILLIGRAM) VIAL IM (INTRAMUSCULAR) PRN (AS NEEDED) FOR BLOODSUGAR (BLOOD SUGAR) LESS THAN 70 MG/DL (MILLIGRAMS PER DECILITER) .GLUCOSE GEL ONE TUBE PO (BY MOUTH) FOR REDUCED FSBS (FINGER STICK BLOOD SUGAR)-GIVE AFTER GLUCAGAN ([MEDICATION NAME]) . A review of RI #1's September 2016 MAR (Medication Administration Record) revealed: .[MEDICATION NAME] 1 MG VIAL IM PRN FOR BLOODSUGAR (blood sugar)LESS THAN 70 MG/DL .GLUCOSE GEL ONE TUBE PO FOR REDUCED FSBS-GIVE AFTER [MEDICATION NAME] . During an interview on 10/05/2016, at 7:53 a.m., EI #3, RN assigned to care for RI #1 on the 11 p.m. to 7 a.m. shift, was asked to look at RI #1's September 2016 MAR (Medication Administration Record) and tell what parameters were ordered to treat RI #1's blood sugar. EI #3 said [MEDICATION NAME] 1 mg IM or subq (subcutaneous) for blood sugar less than 70. EI #3 was asked if she treated RI #1's blood sugar of 64. EI #3 admitted she did not treat RI #1's blood sugar. EI #3 was asked if she followed physician's orders when she did not treat the blood sugar of 64. EI #3 said no. When asked if she checked physician's orders, EI #3 said she did not remember checking the orders. EI #3 was asked what the potential harm was if RI #1 did not receive treatment for [REDACTED]. EI #3 said lots of things could happen. RI #1 was just treated for [REDACTED]. EI #3 added that the resident could further decline. On 10/05/2016, at 10:05 a.m., a telephone interview was conducted with EI #12, the Medical Director. EI #12 was asked if he would expect the nurse to follow physician's orders to treat the resident when found snoring, with a white frothy substance draining from the mouth, not able to arouse, blood sugar of 64 and blood pressure of 188/110. EI #12 said yes, the nurses could give RI #1 PRN blood sugar medication and things to make the blood sugar increase. EI #12 was asked what the potential harm was if the resident was in that condition and did not receive treatment for 3 hours and ten minutes. EI #12 said more significant [DIAGNOSES REDACTED], [MEDICAL CONDITION], aspiration and all kinds of severe things. A review of RI #1's September 2016 MAR revealed omissions for FSBS (fasting blood sugar) BEFORE MEALS, SS (sliding scale) USING [MEDICATION NAME] (insulin) 10 UNITS on the 14th at 7:00 AM, 20th at 7:00 AM and the 24th at 7:00 AM. On 10/06/2016, at 4:59 p.m., an interview was conducted with EI #16, and RN. EI #16 was asked if RI #1's 7:00 a.m. blood sugar was taken or insulin coverage given on September 20th. EI #16 said no, not at 7:00 a.m. EI #16 was asked if it should have been done. EI #16 said yes, it should have been checked. EI #16 was asked if physician's orders were followed. On 10/07/2016, at 10:20 a.m., an interview was conducted with EI #3. EI #3 was asked if RI #1's 7:00 a.m. blood sugar was taken or insulin coverage addressed on September 24th. EI #3 said by looking at the MAR, no. EI #3 was asked if it should have been done. EI #3 said yes. EI #3 was asked who would have been responsible for doing it. EI #3 said she was. EI #3 was asked if physician's orders were followed since there was no proof the blood sugar was taken or insulin coverage given. EI #3 said no. EI #3 was asked what was the potential harm in not following physician's orders. EI #3 said the blood sugar could have been too high or too low and RI #1 may have needed treatment. On 10/07/2016, at 12:42 p.m., an interview was conducted with EI #2, the DON. EI #2 was asked if there was any proof that insulin coverage was given to RI #1 on September 14th. EI #2 said no. EI #2 was asked should insulin coverage have been given. EI #2 said yes. EI #2 was asked if physician's orders were followed since there was no proof that insulin coverage was given. EI #2 said no. EI #2 was asked what the potential harm was in not following physician's orders. EI #2 said an elevated blood sugar. 1b) RI #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #3's Physician Orders for September 2016 documented: .Order Date 7/21/16, Start Date 7/21/16, Order Type FSS (Finger Stick Sugar) . Orders FSBS (Finger Stick Blood Sugar) AC (before meals & (and) HS (hour of sleep) (DX) (Diagnosis) DM (Diabetes Mellitus). A review of RI #3's September 2016 MAR revealed omissions on the 15th at 11:30 a.m., 20th 8:00 p.m., 24th at 7:00 a.m. and the 27th at 7:00 a.m. On 10/07/2016, at 12:42 p.m., an interview was conducted with EI #2. EI #2 was asked if there was any proof that [MEDICATION NAME] (insulin) was given to RI #3 on September 20th. EI #2 said no. EI #2 was asked if there was any proof the blood sugar check was done on September 15th, 24th or the 27th. EI #2 said no. 1c) RI #17 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #17's MAR revealed: FSBS (fasting blood sugar) AC (before meals) & HS (hour of sleep) (DX) DM (Diabetes Mellitus) GIVE [MEDICATION NAME] R INSULIN SS (sliding scale) COVERAGE SQ . A review of RI #17's September 2016 MAR revealed omissions on the 17th at 6:30 a.m., 20th at 6:30 a.m. and 9:00 p.m., 21st at 6:30 a.m., 24th at 6:30 a.m. and the 29th at 6:30 a.m. On 10/07/2016, at 10:34 a.m., an interview was conducted with EI #3. EI #3 was asked if RI #17's blood sugar was taken or insulin coverage given on September 24th and 29th. EI #3 said no. EI #3 was asked if it should have been done. EI #3 said yes, to determine if RI #17 needed treatment. EI #3 was asked who was responsible for doing it. EI #3 said on those two days, she was. EI #3 was asked if physician's orders were followed since there was no proof that blood sugar was taken or insulin coverage was given. EI #3 said no. EI #3 was asked what the potential harm was in not following physician's orders. EI #3 said the blood sugar could go untreated, whether low or high. On 10/07/2016, at 12:42 p.m., an interview was conducted with EI #2. EI #2 was asked if there was any proof RI #17's blood sugar was taken or insulin coverage given on September 17th, 20th and 21st. EI #2 said no. EI #2 was asked if there should be proof it was done. EI #2 said yes. EI #2 was asked if physician's orders were followed since there was no proof that blood sugar was taken or insulin coverage was given. EI #2 said no. 1d) RI #18 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #18's MAR revealed: FSBS BID (twice a day) @6AM and 4:30PM (DX) DM .revealed an omission on the 24th at 6:00 a.m. On 10/07/2016, at 10:22 a.m., an interview was conducted with EI #3. EI #3 was asked if RI #18's blood sugar was taken on September 24th. EI #3 said by the MAR, it was not. EI #3 was asked who was responsible for doing it. EI #3 said she was. EI #3 was asked if physician's orders were followed since there was no proof that blood sugar was taken. EI #3 said no. EI #3 was asked what the potential harm was in not following physician's orders. EI #3 said the blood sugar could be too high or too low and go untreated. 1e) RI #19 was admitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #19's MAR revealed: FSBS (finger stick blood sugar) AC&HS (before meals and hour of sleep) (DX) DM . with omissions on the 15th at 11:30 a.m., 18th at 9:00 p.m., 24th at 7:00 a.m. and the 27th at 7:00 a.m. On 10/07/2016 at 10:38 a.m., an interview was conducted with EI #3. EI #3 was asked if RI #19's blood sugar was taken on September 24th and 27th. EI #3 said no. EI #3 was asked if it should have been done. EI #3 said yes. EI #3 was asked who was responsible for doing it. EI #3 said she was responsible. EI #3 was asked if physician's orders were followed. EI #3 said no. EI #3 was asked what the potential harm was in not following physician's orders. EI #3 said failure to treat the blood sugar, whether high or low. On 10/07/2016, at 12:42 p.m., an interview was conducted with EI #2. EI #2 was asked if there was any proof RI #19's blood sugar was obtained on September 15th at 11:30 a.m. EI #2 said no. EI #2 was asked if it should have been done. EI #2 said yes. EI #2 was asked who was responsible for doing it. EI #2 said the nurse on that shift. EI #2 was asked if physician's orders were followed. EI #2 said no. 2. A review of the facility's policy titled, Medication Administration - General Guidelines, dated 01/12 documented: . Procedures . 22. After administration, return to the cart and document administration on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). On 10/4/16 at 9:14 a.m., during the medication administration observation, EI #6, a Licensed Practical Nurse (LPN), was observed signing off the MAR after punching each medication in a medicine cup and before administering the medication to the resident. On 10/7/16 at 9:36 a.m., the surveyor conducted a brief interview with EI #6. When asked when she signed for the medication during the 10/4/16 observation, EI #6 replied, as she pulled the medications. EI #6 was asked why she signed the MAR before administering the medications. EI #6 explained that she always initialed, but if the resident did not take the medication she would circle it and put the reason on back of the MAR. EI #6 was asked when she should have signed the MAR during medication administration. EI #6 replied as she pulled them. EI #6 informed the Surveyor that she did not know the facility's policy on signing the MAR during medication administration. EI #6 was asked if it was an acceptable practice of the facility for a licensed nurse to sign off the MAR before administering the medication. EI #6 stated this was what she did. On 10/6/16 at 12:16 p.m., during the medication administration observation, EI #8 was observed signing off the MAR after calling out each medication she was going to administer to a resident, then placed each medication into a medicine cup. On 10/6/16 at 12:22 p.m., during the medication administration observation, EI #8, a LPN, was observed signing off the MAR for a medication, then informed the surveyor she had to go get the medication from the medication room and check backup (resident extra medication) for the medication. After returning to the cart with the backup medication, EI #8 placed three [MEDICATION NAME] 25 mg (milligram) (75 mg) tablets into a medicine cup. On 10/6/16 at 5:05 p.m., the Surveyor conducted an interview with EI #8. EI #8 was asked when she signed for the medication she administered on 10/6/16. EI #8 explained she generally would give the medication then sign the MAR, but on today she signed the MAR before giving the medication. EI #8 was asked why she signed the MAR before administering the medications. EI #8 replied to make sure the resident was getting all that was due at that time. EI #8 was asked when she should have signed the MAR during medication administration. EI #8 explained, get the pills, give the pills to the resident, then she would come sign them out. EI #8 was asked about the facility's policy on signing the MAR during medication administration. EI #8 answered, to pull the medication, give it then come back and sign the MAR. EI #8 was ask if it was an acceptable practice of the facility for a licensed nurse to sign off the MAR before administering the medication. EI #8 stated, no she was quite sure it was not acceptable. EI #8 was asked what potential harm could occur if the MAR was signed before the medication was administered. EI #8 replied something could happen and the resident did not get it. On 10/7/19 at 10:09 a.m., EI #2, the DON/Infection Control Coordinator was interviewed and asked when should the MAR be signed off or initialed during medication administration. EI #2 replied after the medication is administered. EI #2 was asked if it was an acceptable practice of the facility for a licensed nurse to sign off the MAR before the medication is administered. EI #2 replied no it was not what the facility trained on. EI #2 was asked what was the facility's policy on signing the MAR during medication administration. EI #2 explained to sign the MAR after the medication is administered. EI #2 was asked what potential harm could occur if the MAR is signed before the medication was administered. EI #2 stated she did not see a potential issue. 3. A review of the facility's policy titled, Controlled Medication Administration, dated 04/2013 documented: 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 . 3. When a controlled medication is to be administered, the licensed nurse removing the medication immediately enters the following information on the controlled drug record . A. Date and time of removal. B. Amount removed. C. Signature. On 10/05/2016, at 11:17 a.m., during the medication administration observation, EI #7, an LPN, was observed signing off the narcotic record before pulling the narcotic medication from the locked box to administer to a resident. On 10/05/2016, at 11:49 a.m., during the medication administration observation, EI #7 was observed again signing off the narcotic record before pulling the narcotic medication from the locked box. On 10/06/2016, at 5:20 p.m., the Surveyor conducted a telephone interview with EI #7. EI #7 verified she signed the narcotic sheet before pulling the medication out the locked box. On 10/06/2016, at 12:05 p.m., during the medication administration observation, EI #8, an LPN was observed signing off the narcotic record before pulling the narcotic medication from the locked box, after she informed the Surveyor what medication she was about to prepare for administration. On 10/06/2016, at 4:58 p.m., the Surveyor conducted an interview with EI #8. EI #8 was asked during medication administration on 10/06/2016, when did she sign off the narcotic record. EI #8 replied before she gave it. EI #8 was asked when she should have signed off the narcotic record. EI #8 stated, In hind sight I should have signed off after it was given. On 10/07/2016, at 10:19 a.m., the Surveyor conducted an interview with EI #2, the DON/Infection Control Coordinator. EI #2 was asked during medication administration when should the narcotic record be signed. EI #2 replied when the narcotic is pulled. EI #2 was asked should the narcotic record be signed before the controlled medication is pulled from the locked box. EI #2 replied it should be done simultaneously. Pull the card, pop the pill sign the sheet. EI #2 was asked what the facility's policy was on signing the narcotic record when administering a controlled medication. EI #2 replied to sign the Narcotic Drug Control Record when you pull the narcotic. EI #2 was asked what potential issue could occur if the narcotic record sheet is signed before removing the controlled medication from the locked box. EI #2 replied the pill can be forgotten to be popped. This tag was cited as a result of the investigation of complaint/report number AL 725. ********************************************************* On 10/07/2016 at 7:00 p.m., the facility submitted an Acceptable Allegation of Credible Compliance, which documented: RI #1 was found on 09/29/16 at 5:10 AM by charge nurse laying supine crossways of her bed snoring loudly and white frothy substance draining from her mouth, hard to arouse. RI #1 ' s BP was 188/110 and blood sugar was 64. On 09/29/16 at 8:20 AM RI #1 was found by charge nurse resident was unresponsive. Abdomen was distended. Blood sugar was 32. BP was 191/118, HR 109, RR 24. Blood sugar recheck was 57. On 09/29/16 at 8:40 AM RI #1 was reassessed by charge nurse and was unresponsive. Resident sent to St Francis for evaluation. All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: Physician ' s orders must be followed at all times for treatment of [REDACTED]. If the resident has a low blood sugar and no orders to treat, refer to standing order for treatment based on resident ' s responsiveness. All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: Each licensed nurse scheduled to work a medication cart will use the 24-hour report book to communicate any changes from shift to shift. Both the oncoming licensed nurse and the outgoing licensed nurse will review the 24-hour report book together and initial that this has been completed. Each license nurse will document any change in condition including but not limited to abnormal blood sugars, abnormal blood pressure, change in responsive level, and frothy substance from the mouth. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents MD orders from 09/01/16-10/07/16 to ensure all orders related to their diabetes have been followed. This has the potential to affect all diabetic residents in the facility. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received disciplinary action by the DON on 10/3/2016 which included the nurse did not reassess resident ' s BP after medication was administered. BP was 188/110, medication was given but no documentation was completed. Blood Sugar was 64 and no intervention was put in place to increase Blood Sugar. Nurse did not reassess resident ' s vitals prior to end of shift. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Head to toe assessment, MD notification, how to check blood sugar, normal range of blood sugar, following MD orders for blood sugars, how to obtain blood pressures, normal range of blood pressure, following MD orders for PRN medication for BP, shift report, following the plan of care, administration of PO medication, and when not to administer PO medication Immediate Jeopardy can be removed 10/07/2016. Facility Administrator or designee monitoring and will continue to monitor to ensure implementation of AOCC by monitoring 24-hour book daily ******************************************************* The team monitored the implementation of the AOCC (Allegation of Credible Compliance) by verifying the following: staff members were interviewed and confirmed that they received in-service training. Nurses were interviewed to confirm her knowledge of the training in the areas of following physician's orders and blood sugar management. The Team determined the facility had implemented their AOCC and the Immediate Jeopardy was relieved onsite on 10/07/2016 at 7:00 p.m.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #1's care plan was followed in order to treat a low blood sugar of 64 and notify the physician. On 09/29/2016, at 5:10 a.m., RI #1 was found in bed by Employee Identifier (EI) #3, the Registered Nurse (RN), assigned to care for RI #1 during the 11 p.m. to 7 a.m. shift. EI #4 stated the resident was heard snoring in bed, difficult to arouse, with a frothy white substance draining from the mouth. RI #1's blood pressure was elevated to 188/110, higher than normal parameters, and his/her blood sugar was 64, lower than the normal parameters, established by RI #1's doctor. RI #1's care plan directed the staff to notify the physician if the blood sugar was below 70, however, the physician was not contacted. According to the American Heart Association guidelines normal blood pressure is Systolic (Upper) mm Hg (millimeters of mercury) is Less than 120 and normal Diastolic (Lower) mm HG is Less than 80. The American Diabetes Association suggests the following target for most non-pregnant adults with diabetes, before a meal 80-130 mg/dl (milligrams per deciliter). EI #4, the oncoming Licensed Practical Nurse (LPN), stated when she entered the resident's room, around 8:00 a.m., she found RI #1 unresponsive, with a distended (swollen) abdomen and the resident's blood sugar had further dropped to 32. At 8:20 a.m., RI #1 was sent to the hospital by Emergency Medical Services, EMS refers to the treatment and transport of people in crisis health situations that may be life threatening. According to facility staff, RI #1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. This deficient practice affected RI #1, one sampled resident, but had the potential to affect all residents who resided at the facility. On 10/06/2016, at 8:00 a.m., the Administrator and the Director of Nursing (DON) were notified of the findings of Immediate Jeopardy level of J in the area of Resident Assessment. The Immediate Jeopardy began on 09/29/2016, until the facility implemented corrective actions. The Immediate Jeopardy was relieved 10/07/2016, at 7:00 p.m. Findings Include: On 10/03/2016, the Department of Public Health received an anonymous complaint. The anonymous caller alleged on 09/28/2016, during the 11 p.m. to 7 a.m. shift, the nurse assigned to care for (Name of RI #1) did nothing for the resident when the resident was found unresponsive and with a frothy mouth. The caller stated the third shift nurse documented she found the resident unresponsive with a frothy mouth at 5:00 a.m., last Wednesday (09/28/2016). The resident's vitals were blood pressure of 160 or 170 over 100 something and blood sugar was 64. The caller alleged that the resident's blood sugar should be maintained over 100 because anything less than 100 would cause the resident to become diaphoretic (cause sweating) and unresponsive. It was not until the 1st shift nurse came in, made rounds and found the resident unresponsive, that something was done for the resident. The first shift nurse sent the resident out to the hospital. The resident is currently at the hospital in ICU (Intensive Care Unit) and is not expected to live. A review of a facility policy titled, Care Planning Policy and Procedure with a revised date of 07/2011, revealed: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable well being. RI #1 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's most recent Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2016, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A review of RI #1's Departmental Notes revealed: .09/29/2016 6:50 AM .At 5:10 a.m. Resident was noted laying supine crossways of (his/her) bed snoring loudly and white frothy substance draining from his/her mouth, hard to arouse, assisted to lay correct way in the bed by two staff members, skin is cool and dry BP (blood pressure) 188/110 and blood sugar is 64. No [MEDICAL CONDITION] activity noted at this time, we will provide safety, moved table away from side of bed. Staff provided a.m. care and we will monitor closely as (he/she) is sleeping at this time. I will report to oncoming nurse . Signed by: EI #3 . A review of RI #1's Care Plan revealed: .Problem/Need . Problem Onset: 01/30/2012 I have insulin dependent,, adult onset Diabetes. I am at risk for low and high blood sugars. Approaches . *GLYCOGEN I MG (MILLIGRAM) IM (INTRAMUSCULAR) SQ (SUBCUTANEOUS) PRN (AS NEEDED) (DX) (DIAGNOSIS) [DIAGNOSES REDACTED] . *Observe for signs and symptoms of hypo/[MEDICAL CONDITION]. Report to charge nurse if noted. *HYPOGLYCEMIC REACTION: Observe for . lethargy. Report to charge nurse. *IF HYPOGLYCEMIC REACTION NOTED . (b) Give milk or juice (c) If blood sugar is below 70 notify the physician . On 10/05/2016, at 7:53 a.m., an interview was conducted with EI #3. EI #3 was asked if she treated RI #1's blood sugar of 64. EI #3 said she did not. EI #3 was asked if she notified the physician of the blood sugar. EI #3 said no. EI #3 was asked what were signs and symptoms of [DIAGNOSES REDACTED]. EI #3 said lethargy and slow to respond. EI #3 was asked if RI #1 had any of those symptoms. EI #3 said yes. EI #3 was asked if the physician should have been notified, according to the care plan. EI #3 said yes. EI #3 was asked if RI#1's care plan was followed. EI #3 said no. This tag was cited as a result of the investigation of complaint/report number AL 725. ******************************************************** On 10/07/2016 at 7:00 p.m., the facility submitted an Acceptable Allegation of Credible Compliance, which documented: RI #1 was found on 09/29/16 at 5:10 AM by charge nurse laying supine crossways of her bed snoring loudly and white frothy substance draining from her mouth, hard to arouse. RI #1 ' s BP was 188/110 and blood sugar was 64. On 09/29/16 at 8:20 AM RI #1 was found by charge nurse resident was unresponsive. Abdomen was distended. Blood sugar was 32. BP was 191/118, HR 109, RR 24. Blood sugar recheck was 57. On 09/29/16 at 8:40 AM RI #1 was reassessed by charge nurse and was unresponsive. Resident sent to St Francis for evaluation. All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: All resident care plans must be followed for treatment of [REDACTED]. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents careplans to ensure all interventions related to diabetes are being followed from 09/01/16-10/07/16. This has the potential to affect all residents in the facility. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received disciplinary action by the DON on 10/3/2016 which included the nurse did not reassess resident ' s BP after medication was administered. BP was 188/110, medication was given but no documentation was completed. Blood Sugar was 64 and no intervention was put in place to increase Blood Sugar. Nurse did not reassess resident ' s vitals prior to end of shift. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service includes the following information: All resident care plans must be followed for treatment of [REDACTED]. Immediate Jeopardy can be removed 10/07/2016. Facility Administrator or designee monitoring and will continue to monitor to ensure implementation of AOCC by monitoring 24-hour book daily. ******************************************************** The team monitored the implementation of the AOCC (Allegation of Credible Compliance) by verifying the following: staff members were interviewed and confirmed that they received in-service training on reporting changes in resident condition. The disciplinary action for the charge nurse assigned to RI #1 on 09/29/2016, at 5:10 a.m. was reviewed and the nurse was interviewed to confirm her knowledge of the training in the areas of blood sugar monitoring, blood pressure monitoring and following the care plan. The team determined the facility had implemented their AOCC and the Immediate Jeopardy was relieved onsite on 10/07/2016, at 7:00 p.m.

Based on record review and interview, the facility to failed ensure licensed nursing staff administered RI #1's ordered treatment when the resident was difficult to arouse and experienced a hypoglycemic episode with a blood sugar of less than 70 mg/dl (milligrams per deciliters) and a hypertensive episode with an elevated blood pressure above 180/110. On 09/29/2016, at 5:10 a.m., Resident Identifier (RI) #1 was found in bed by Employee Identifier (EI) #3, the Registered Nurse (RN), assigned to care for RI #1 during the 11 p.m. to 7 a.m. shift. EI #3 stated the resident was heard snoring in bed, difficult to arouse, with a frothy white substance draining from the mouth. RI #1's blood pressure was elevated to 188/110, higher than normal parameters, and his/her blood sugar was 64, lower than the normal parameters, established by RI #1's doctor. RI #1's care plan directed the staff to notify the physician if the blood sugar was below 70, however, the physician was not contacted and RI #1 was not treated for [REDACTED]. According to the American Heart Association guidelines normal blood pressure is Systolic (Upper) mm Hg (millimeters of mercury) is Less than 120 and normal Diastolic (Lower) mm HG is Less than 80. The American Diabetes Association suggests the following target for most non-pregnant adults with diabetes, before a meal 80-130 mg/dl (milligrams per deciliter). The night shift RN informed the oncoming nurse, for the 7:00 a.m. to 3:00 p.m. shift (day shift), that the resident had suffered a [MEDICAL CONDITION] on the night shift but was resting well. However, according to RI #1's medical record, the resident did not have a history of [MEDICAL CONDITION] nor was the resident on [MEDICAL CONDITION] medication. At 8:20 a.m., three hours and ten minutes after the night shift nurse's assessment of RI #1's condition, the oncoming shift nurse assessed RI #1 to be unresponsive, with frothy sputum coming from the mouth, distended (swollen) stomach, and the blood sugar had fallen to a level of 32. At 8:20 a.m., RI #1 was sent to the hospital by Emergency Medical Services, EMS refers to the treatment and transport of people in crisis health situations that may be life threatening. According to facility staff, RI #1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. This deficient practice affected RI #1, but had the potential to affect all residents who reside in the facility. On 10/06/2016 at 8:00 a.m., the Administrator and the Director of Nursing (DON) were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Care. The Immediate Jeopardy began on 09/29/2016, until the facility implemented corrective actions. The Immediate Jeopardy was relieved on 10/07/2016, at 7:00 p.m. Findings Include: On 10/03/2016, the Department of Public Health received an anonymous complaint. The anonymous caller alleged on 09/28/2016, during the 11 p.m. to 7 a.m. shift, the nurse assigned to care for (Name of RI #1) did nothing for the resident when the resident was found unresponsive and with a frothy mouth. The caller stated the third shift nurse documented she found the resident unresponsive with a frothy mouth at 5:00 a.m., last Wednesday (09/28/2016). The resident's vitals were blood pressure of 160 or 170 over 100 something and blood sugar was 64. The caller alleged that the resident's blood sugar should be maintained over 100 because anything less than 100 would cause the resident to become diaphoretic (cause sweating) and unresponsive. It was not until the 1st shift nurse came in, made rounds and found the resident unresponsive, that something was done for the resident. The first shift nurse sent the resident out to the hospital. The resident is currently at the hospital in ICU (Intensive Care Unit) and is not expected to live. A review of a facility document titled, REGISTERED NURSE JOB DESCRIPTION revealed: . B. Nursing Care Functions Duties: . monitor residents' treatment and medications and make independent decisions regarding care to ensure residents are receiving proper care . consult with physicians in providing care, treatment . and notify physicians of resident accidents, incidents and changes in condition . and provide direct nursing care as necessary . RI #1 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's most recent Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2016, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A review of RI #1's Departmental Notes revealed: . 09/29/2016 6:50 AM . At 5:10 a.m. Resident was noted laying supine crossways of (his/her) bed snoring loudly and white frothy substance draining from his/her mouth, hard to arouse, assisted to lay correct way in the bed by two staff members, skin is cool and dry Bp is 188/110 and blood sugar is 64. No [MEDICAL CONDITION] activity noted at this time, we will provide safety, moved table away from side of bed. Staff provided a.m. care and we will monitor closely as (he/she) is sleeping at this time. I will report to oncoming nurse. The entry was signed by EI #3. The next note documented: 09/29/2016, 8:20 AM .Writer entered res (resident) room. Res. noted to be unresponsive. Abdomen distended (swollen). BS 32. [MEDICATION NAME] IM (Intramuscular) administered x 2, followed by glucose oral gel. BP (blood pressure)191/118, HR (Heart Rate) 109, 24 RR (Respirations). BS (blood sugar) recheck 57. Signed by: EI #4, LPN (Licensed Practical Nurse) . A review of RI #1's Care Plan revealed: .Problem/Need . Problem Onset: 01/30/2012 I have insulin dependent,, adult onset Diabetes. I am at risk for low and high blood sugars. Approaches . (c) If blood sugar is below 70 notify the physician . A review of RI #1's Physician Orders for September 2016 revealed: .[MEDICATION NAME] 1 MG (MILLIGRAM) VIAL IM PRN (AS NEEDED) FOR BLOODSUGAR (BLOOD SUGAR) LESS THAN 70 MG/DL (MILLIGRAMS PER DECILITER) .GLUCOSE GEL ONE TUBE PO (BY MOUTH) FOR REDUCED FSBS (FINGER STICK BLOOD SUGAR)-GIVE AFTER GLUCOGAN ([MEDICATION NAME]) . A review of RI #1's September 2016 MAR (Medication Administration Record) revealed an entry for . [MEDICATION NAME] 1 MG VIAL IM PRN FOR BLOODSUGAR LESS THAN 70 MG/DL .GLUCOSE GEL ONE TUBE PO FOR REDUCED FSBS-GIVE AFTER GLUCOGAN . Further review of the MAR indicated [REDACTED]. A review of the EMS run sheet revealed: .Type of Service Requested 911 Response .Dispatch Complaint Unconscious .Disp (Dispatch) Notified 09/29/16 07:36:28 .Response Mode Lights and Sirens Transport Mode Lights and Sirens . Chief Complaint: Unresponsive .Secondary Impression .Diabetic Symptoms ([DIAGNOSES REDACTED]) . ASSESSMENTS 09/29/2016 07:51:27 Left Eye: Non-Reactive. Right Eye: Non-Reactive.VITAL SIGNS 09/29/2016 07:58:59 211/137 . RESPONDED EMERGENCY TO UNRESPONSIVE PT (PATIENT) AT (NAME OF FACILITY) . STAFF STATES THAT THE PT WAS LAST SEEN NORMAL LAST NIGHT . THIS MORNING (HE/SHE) WAS FOUND WITH AN EXTREMELY DISTENDED ABDOMEN AND UNRESPONSIVE. STAFF CHECKED (HIS/HER) SUGAR AND FOUND IT WAS 32. THEY ADMINISTERED 2 SHOTS OF [MEDICATION NAME] AND 1 ORAL GLUCOSE. (HIS/HER) SUGAR CAME UP TO 57 JUST BEFORE EMS ARRIVAL. PUPILS EQUAL, ROUND, BUT NOT REACTIVE TO LIGHT . H (HEAD) TO T (TOE) ASSESSMENT UNREMARKABLE EXCEPT FOR PT BEING A COMPLETE ASSIST AT THIS TIME . GAVE REPORT AND TRANSFERRED PT CARE TO NURSE . ONCE IN ER (emergency room ) BED . On 10/04/2016, at 12:58 p.m., an interview was conducted with EI #15, RN/ADON (Registered Nurse/Assistant Director of Nursing). EI #15 was asked why RI #1 was sent to the hospital on [DATE]. EI #15 said unresponsiveness. EI #15 said RI #1's primary nurse, EI #4, asked for help and she went to the resident's room and the first thing she saw was RI #1's huge belly and white, frothy saliva coming out of the resident's mouth. EI #15 said she could not get RI #1 to arouse or anything. EI #15 was asked what time she saw RI #1 in that condition. EI #15 said it was 8:00 a.m. or 8:30 a.m. EI #15 said the night nurse said she checked the resident's blood sugar and it was 64. EI #15 said EI #4 checked the resident's blood sugar about 8:00 a.m. and it was 32 and she came to get assistance from her at that time. EI #15 was asked if there was an order for [REDACTED].#15 said yes, if the blood sugar was below 70 give one tube of oral glucose and if unresponsive, give [MEDICATION NAME] IM 1mg. EI #15 was asked if the blood sugar was 64 on the night shift, should the night shift nurse have given treatment. EI #15 said yes. EI #15 was asked if the resident was unresponsive on the night shift. EI #15 said according to the nurse's notes, RI #1 was not responding well. EI #15 was asked what the harm was if the blood sugar was 64 on night shift and RI #1 did not receive any treatment from 5:10 a.m. to 8:20 a.m. EI #15 said diabetic coma and if a person did not get treatment, they could die. On 10/14/2016, at 10:04 a.m., an interview was conducted with EI #4, who received nursing report from EI #3 on 09/29/2016. EI #4 was asked what was reported to her concerning RI #1. EI #4 said EI #3 reported RI #1 had a [MEDICAL CONDITION] during the night and was resting. EI #4 was asked how she found the resident. EI #4 said she went in the resident's room around 8:00 a.m. and the resident was on her/his back with white froth coming from the mouth. EI #4 said RI #1 was snoring, breathing, but not alert and the abdomen was very distended (swollen). EI #4 said she had never seen the resident's abdomen like that before. EI #4 said the first thing she did was check the blood sugar because the resident was a brittle diabetic and the blood sugar was 32. EI #4 said she ran and got help from another nurse and they gave two [MEDICATION NAME] injections IM and a tube of oral Glucose gel. EI #4 said RI #1's blood pressure was really high and she went and got [MEDICATION NAME] (blood pressure medication), crushed it and tucked it in RI #1's cheek. EI #4 said she rechecked the blood sugar and she thought it was 57 and for RI #1 that was too low, so she talked to EI #15 (ADON) and they made the decision to send RI #1 out. EI #4 was asked if the resident's blood sugar was 64 on the night shift, should the night shift nurse have given treatment. EI #4 said yes. EI #4 was asked what should have been done. EI #4 said the same thing she did; injections and oral glucose gel. EI #4 was asked to the describe RI #1's abdomen. EI #4 said it looked like Ascites (abdominal swelling caused by an accumulation of fluid) and it was firm. EI #4 said it looked like the resident was nine months pregnant. EI #4 was asked if EI #3 told her what RI #1's blood sugar was on the night shift. EI #4 said no. EI #4 was asked if EI #3 told her about the elevated blood pressure. EI #4 said no. EI #4 was asked if EI #3 reported RI #1's distended abdomen to her. EI #4 said no, not in report but EI #3 came back and relieved her at 7 p.m. that night and asked how RI #1 was. EI #4 said she told EI #3 about the resident's distended abdomen and EI #3 said she noticed it, but thought that it was normal for RI #1. EI #4 said she felt like EI #3 left it up to her to provide treatment. EI #4 said she read EI #3's nurse's notes and it said she would report to the oncoming nurse. EI #4 said that was wrong because EI #3 did not report what was in the nurse's note to her. EI #4 was asked what the harm was if the blood sugar of 64 went untreated from 5:10 a.m. to 8:20 a.m. EI #4 said RI #1 could die and from what she heard, RI #1 probably would die. EI #4 said she asked the DON about RI #1 and the DON said the resident was still in ICU on the vent and not breathing on her/his own. On 10/05/2016, at 7:53 a.m., an interview was conducted with EI #3. EI #3 was asked what condition RI #1 was in when she saw her on 09/29/2016 at 5:10 a.m. EI #3 said RI #1 was laying with her/his head toward the side of the bed with buttocks on the mattress and feet on the floor with arms out to the side. EI #3 said RI #1 had frothy looking sputum on the left jaw and was snoring deeply. EI #3 said when she touched RI #1, the resident's eyes would flutter. EI #1 said RI #1 looked like she/he had a [MEDICAL CONDITION] to her. EI #3 said she thought she had given RI #1 some [MEDICAL CONDITION] medication. EI #3 said the resident's blood pressure was 180's over 108 or 110 and the blood sugar was 64. EI #3 was asked if the resident had a history of [REDACTED].#3 said not to her knowledge, but the resident looked postictal (the altered state of consciousness after a [MEDICAL CONDITION], characterized by drowsiness, confusion and other disorienting symptoms). EI #3 was asked what she reported to the oncoming nurse, EI #4, concerning RI #1 on 09/29/2016, at the change of the shift. EI #3 said she let the nurse know she saw RI #1 at 5:50 a.m. and the resident looked like she had a [MEDICAL CONDITION]. EI #3 said she told EI #4 what the blood sugar was but she did not treat the blood sugar of 64. EI #3 said she could tell EI #4 looked concerned and would get with the doctor and go and see RI #1. EI #3 was asked if she notified the doctor of RI #1's blood sugar. EI #3 said no. EI #3 was asked if she notified the doctor of RI #1's blood pressure. EI #3 said no. EI #3 was asked if RI #1 had a distended (swollen) abdomen. EI #3 said it did seem as if the resident did have a distended abdomen. EI #3 was asked to describe the distended abdomen. EI #3 said it looked like the resident was probably six months pregnant. EI #3 was asked if she reported the distended abdomen to the oncoming nurse. EI #3 said no, she did not think so. EI #3 was asked why she did not report the distended abdomen. EI #3 said she did not know. EI #3 said another patient was trying to pull dressings off and that distracted her. EI #3 said the CNAs (Certified Nursing Assistants) told her as soon as she finished with RI #1, to come to that resident's room. EI #3 was asked if RI #1's medical condition was more critical than a resident pulling dressings off. EI #3 said yes. EI #3 was asked why her attention went to the resident pulling dressings off. EI #3 said she was not looking for a way to defend it (decision) and she was trying to take care of both residents. EI #3 said she heard someone in the hall ask if RI #1 was still alive and someone said yes. EI #3 said she knew the resident was on the ventilator and was not doing well. EI #3 was asked what she did for RI #1 when she found the resident in that state (frothy mouth, hard to arouse, elevated blood pressure, snoring and blood sugar of 64). EI #3 said she and two CNAs turned the resident in bed, checked the blood sugar, checked the blood pressure and treated the blood pressure. EI #3 was asked if she gave [MEDICATION NAME]. EI #3 said she did. EI #3 was asked how she gave the [MEDICATION NAME] to RI #1 since the resident was not responding. EI #3 said she put the pill on the edge of the resident's tongue next to his/her gum and next to his/her cheek. EI #3 was asked if she rechecked RI #1's blood pressure. EI #3 said no. EI #3 was asked why she did not recheck the blood pressure. EI #3 said she got lost in the midst of going back and forth. EI #3 was asked what the harm was if RI #1 did not receive treatment for [REDACTED]. EI #3 said the resident could further decline. On 10/05/2016, at 10:05 a.m., a telephone interview was conducted with EI #12, the Medical Director. EI #12 was asked if he would expect the nurse to notify him of the resident being found snoring, with a white frothy substance draining from the mouth, not able to arouse, blood sugar of 64 and blood pressure of 188/110. EI #12 said yes. EI #12 was asked if he would expect the nurse to treat the resident. EI #12 said yes, the nurses could give RI #1 PRN blood pressure medication and things to make the blood sugar increase. EI #12 was asked if the nurse notified him on 09/29/2016, of those findings (white frothy substance draining from the mouth, not able to arouse, blood sugar of 64 and blood pressure of 188/110). EI #12 said they did not call him. EI #12 was asked if crushing [MEDICATION NAME] and placing it inside of the resident's cheek was an appropriate thing to do with an unresponsive resident. EI #12 said [MEDICATION NAME] under the tongue, yes, but in the cheek, he did not know. EI #12 was asked what the harm was if the resident was in that condition and did not receive treatment for 3 hours and ten minutes. EI #12 said more significant [DIAGNOSES REDACTED], [MEDICAL CONDITION], aspiration and all kinds of severe things. This tag was cited as a result of the investigation of complaint/report number AL 725. ******************************************************** On 10/07/2016 at 7:00 PM, the facility submitted an Acceptable Allegation of Credible Compliance, which documented: RI #1 was found on 09/29/16 at 5:10 AM by charge nurse laying supine crossways of her bed snoring loudly and white frothy substance draining from her mouth, hard to arouse. RI #1 ' s BP was 188/110 and blood sugar was 64. On 09/29/16 at 8:20 AM RI #1 was found by charge nurse resident was unresponsive. Abdomen was distended. Blood sugar was 32. BP was 191/118, HR 109, RR 24. Blood sugar recheck was 57. On 09/29/16 at 8:40 AM RI #1 was reassessed by charge nurse and was unresponsive. Resident sent to St Francis for evaluation. All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Administration of PO medication and when not to administer PO medication. This has the potential to affect all residents in the facility. Immediate Jeopardy can be removed 10/07/2016. Facility Administrator or designee monitoring and will continue to monitor to ensure implementation of AOCC by monitoring 24-hour book daily. 6-Quality of Care: RI #1 was found on 09/29/16 at 5:10 AM by charge nurse laying supine crossways of her bed snoring loudly and white frothy substance draining from her mouth, hard to arouse. RI #1 ' s BP was 188/110 and blood sugar was 64. On 09/29/16 at 8:20 AM RI #1 was found by charge nurse resident was unresponsive. Abdomen was distended. Blood sugar was 32. BP was 191/118, HR 109, RR 24. Blood sugar recheck was 57. On 09/29/16 at 8:40 AM RI #1 was reassessed by charge nurse and was unresponsive. Resident sent to St Francis for evaluation. All staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other employees will be in-serviced prior to starting their shift until 100% of staff receives the in-service training. In-service includes the following information: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - decreased responsiveness or unresponsiveness, frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). This has the potential to affect all residents in the facility. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received disciplinary action by the DON on 10/3/2016 which included the nurse did not reassess resident ' s BP after medication was administered. BP was 188/110, medication was given but no documentation was completed. Blood Sugar was 64 and no intervention was put in place to increase Blood Sugar. Nurse did not reassess resident ' s vitals prior to end of shift. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Head to toe assessment, MD notification, how to check blood sugar, normal range of blood sugar, following MD orders for blood sugars, how to obtain blood pressures, normal range of blood pressure, following MD orders for PRN medication for BP, shift report, following the plan of care, administration of PO medication, and when not to administer PO medication All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: physician's order [REDACTED]. If the resident has a low blood sugar and no orders to treat, refer to standing order for treatment based on resident ' s responsiveness. All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: Each licensed nurse scheduled to work a medication cart will use the 24-hour report book to communicate any changes from shift to shift. Both the oncoming licensed nurse and the outgoing licensed nurse will review the 24-hour report book together and initial that this has been completed. Each license nurse will document any change in condition including but not limited to abnormal blood sugars, abnormal blood pressure, change in responsive level, and frothy substance from the mouth. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents MD orders from 09/01/16-10/07/16 to ensure all orders related to their diabetes have been followed. All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: All resident care plans must be followed for treatment of [REDACTED]. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents careplans to ensure all interventions related to diabetes are being followed from 09/01/16-10/07/16. The administrator provided one-on-one in-service education to the DON on 10/6/2016 on the 7PM-11PM shift. In-service included the following all the areas of: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - Decreased responsiveness or unresponsiveness, Frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). physician's order [REDACTED]. If the resident has a low blood sugar and no orders to treat, refer to standing order for treatment based on resident ' s responsiveness. All resident care plans must be followed for treatment of [REDACTED]. Resident ' s with low blood sugars should be treated as a medical emergency. Treatment should be initiated immediately to include following physicians orders for treatment of [REDACTED]. in condition for further orders, activate 911 if necessary. DON received one-on-one in-service training from the RN Supervisor on 10/7/16 on the 3pm-11pm shift including return demonstration. In-service included the following: Head to toe assessment, MD notification, how to check blood sugar, normal range of blood sugar, following MD orders for blood sugars, how to obtain blood pressures, normal range of blood pressure, following MD orders for PRN medication for BP, shift report, following the plan of care, administration of PO medication, and when not to administer PO medication All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Administration of PO medication and when not to administer PO medication When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. This has the potential to affect all residents in the facility. Immediate Jeopardy can be removed 10/07/2016. Facility Administrator or designee monitoring and will continue to monitor to ensure implementation of AOCC by monitoring 24-hour book daily. ******************************************************** The team monitored the implementation of the AOCC (Allegation of Credible Compliance) by verifying the following: staff members were interviewed and confirmed that they received in-service training on reporting changes in resident condition. The disciplinary action for the charge nurse assigned to RI #1 on 09/29/2016 at 5:10 a.m. was reviewed and the nurse was interviewed to confirm her knowledge of the training in the areas of blood sugar monitoring, blood pressure monitoring, following the care plan and following physician's orders [REDACTED].

Based on record review and interview, the facility failed to ensure the QA (Quality Assurance) Committee developed and implemented an action plan after RI (Resident Identifier) #1 did not receive an ordered treatment when the resident was difficult to arouse and experienced a hypoglycemic episode with a blood sugar of less than 70 mg/dl (milligrams per deciliters) and a hypertensive episode with an elevated blood pressure above 180/110. On 09/29/2016, at 5:10 a.m., RI #1 was found in bed by Employee Identifier (EI) #3, the Registered Nurse (RN), assigned to care for RI #1 during the 11 p.m. to 7 a.m. shift. EI #3 stated the resident was heard snoring in bed, difficult to arouse, with a frothy white substance draining from the mouth. RI #1's blood pressure was elevated to 188/110, higher than normal parameters, and his/her blood sugar was 64, lower than the normal parameters, established by RI #1's doctor. RI #1's care plan directed the staff to notify the physician if the blood sugar was below 70, however, the physician was not contacted and RI #1 was not treated for [REDACTED]. According to the American Heart Association guidelines normal blood pressure is Systolic (Upper) mm Hg (millimeters of mercury) is Less than 120 and normal Diastolic (Lower) mm HG is Less than 80. The American Diabetes Association suggests the following target for most non-pregnant adults with diabetes, before a meal 80-130 mg/dl (milligrams per deciliter). The night shift (11 p.m. - 7 a.m.) RN (Registered Nurse) informed the oncoming nurse, for the 7:00 a.m. to 3:00 p.m. shift (day shift), that the resident had suffered a [MEDICAL CONDITION] on the night shift, but was resting well. However, according to RI #1's medical record, the resident did not have a history of [MEDICAL CONDITION] nor was the resident on [MEDICAL CONDITION] medication. At 8:20 a.m., three hours and ten minutes after the night shift nurse's assessment of RI #1's condition, the oncoming shift nurse assessed RI #1 to be unresponsive, with frothy sputum coming from the mouth, distended (swollen) stomach, and the blood sugar had fallen to a level of 32. At 8:20 a.m., RI #1 was sent to the hospital by Emergency Medical Services, EMS refers to the treatment and transport of people in crisis health situations that may be life threatening. According to facility staff, RI #1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. During an interview with EI #12, the Medical Director, who is a member of the QA Committee, stated he would expect the facility to follow the established policy and procedures when the resident was found to be unresponsive, with frothy sputum coming from the mouth, distended stomach, and the blood sugar had fallen to a level of 32. This deficient practice affected RI #1, but had the potential to affect all residents who resided in the facility. On 10/31/2016, at 1:10 p.m., the Administrator was notified of the findings of Immediate Jeopardy level of J in the area of Quality Assurance. The Immediate Jeopardy began on 09/29/2016, until the facility implemented corrective actions. The Immediate Jeopardy was relieved on 10/31/2016, at 3:00 p.m. Findings Include: Cross reference F 281, F 282, F 309 and F 333. On 10/03/2016, the Department of Public Health received an anonymous complaint. The anonymous caller alleged on 09/28/2016, during the 11 p.m. to 7 a.m. shift, the nurse assigned to care for (Name of RI #1) did nothing for the resident when the resident was found unresponsive and with a frothy mouth. The caller stated the third shift nurse documented she found the resident unresponsive with a frothy mouth at 5:00 a.m., last Wednesday (09/28/2016). The resident's vitals were blood pressure of 160 or 170 over 100 something and blood sugar was 64. The caller alleged that the resident's blood sugar should be maintained over 100 because anything less than 100 would cause the resident to become diaphoretic (cause sweating) and unresponsive. It was not until the 1st shift nurse came in, made rounds and found the resident unresponsive, that something was done for the resident. The first shift nurse sent the resident out to the hospital. The resident is currently at the hospital in ICU (Intensive Care Unit) and is not expected to live. On 10/04/2016, at 1:46 p.m., an interview was conducted with EI #2, the DON. EI #2 said she did an investigation of the situation with RI #1. EI #2 was asked what her conclusion of the investigation was. EI #1 said EI #3 did assess the resident at 5:10 a.m., but did not go back after administering a prn (as needed) medication and recheck the blood sugar. EI #2 said she wrote EI #3 up for that. EI #2 said she wrote EI #3 up for failure to document because there was no documentation on the MAR (Medication Administration Record) or in the nurse ' s notes that she administered [MEDICATION NAME] (blood pressure medication). EI #2 said if it was not documented, technically it was not done. EI #2 was asked what could be proven that EI #3 did for RI #1 in those three hours and ten minutes (from 5:10 a.m. to 8:20 a.m.) EI #2 said all she could prove was that the resident was assessed. EI #2 was asked what the harm was to the resident if he/she was left without medical treatment for [REDACTED]. EI #2 said the blood sugar could continue to decrease and the blood pressure could continue to increase. On 10/05/2016, at 10:05 a.m., a telephone interview was conducted with EI #12, the Medical Director. EI #12 was asked if he would expect the nurse to notify him of the resident being found snoring, with a white frothy substance draining from the mouth, not able to arouse, blood sugar of 64 and blood pressure of 188/110. EI #12 said yes. EI #12 was asked if he would expect the nurse to follow physician's order [REDACTED]. EI #12 said yes, the nurses could give RI #1 PRN blood pressure medication and things to make the blood sugar increase. EI #12 was asked what the harm was if the resident was in that condition and did not receive treatment for 3 hours and ten minutes. EI #12 said more significant [DIAGNOSES REDACTED], [MEDICAL CONDITION], aspiration and all kinds of severe things. On 10/07/2016 at 1:00 p.m., an interview was conducted with EI #1, the Administrator. EI #1 was asked if the facility had a Quality Assurance (QA) Committee. EI #1 said yes. EI #1 was asked who was on the committee. EI #1 explained that all department heads, any member of the IDT (Interdisciplinary Team) the Administrator, DON and the Medical Director were members of the QA Committee. When asked how often the committee met, EI #1 stated every week and a formal meeting every quarter with the Medical Director. EI #1 was asked if the facility had identified any quality deficiencies. EI #1 said no, not right now today. EI #1 was asked to describe a sample of the types of quality deficiencies the facility had identified and how the facility addressed the concern. EI #1 explained how the QA pain subcommittee noted resident was not marked properly on the facility matrix (802). EI #1 said the MDS (Minimum Data Set) staff was in-serviced and made sure pain was marked correctly on the facility matrix and they made sure the resident was marked correctly on the MDS for pain. This tag was cited as a result of the investigation of complaint/report number AL 725. ********************************************************************* This Parkwood Healthcare's allegation of credible compliance for QA (F520) Facility held an emergency QA meeting on 10/31/16 to review F520 quality assessments and assurance regulations. An in-service was held on the 3-11 shift with committee. The in-service included the responsibility of the committee to identify whether quality deficiencies are present (potential or actual deviations from appropriate care processes or facility procedures) that require action. If there are quality deficiencies, the committee is responsible to develop and implement plans of action based on root cause to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans. Action plans may include but are not limited to the development or revision of clinical protocols based on standards of practice, revision of policy and procedures, training for staff concerning changes, plans to purchase or repair equipment and/or improve the physical plant and standards for evaluating staff performance. The in-service also included that quality deficiencies are potential markers of quality that the facility considers to be in the need of investigating and after investigation may or may not represent a deviation from quality that results in a potential or actual undesirable outcome. The DON or designee will review 24 hour report for all shifts since he/she last worked or since another designee has reviewed the 24 hour report. The DON or designee will sign the 24 hour report that is checked that is proof monitoring. The DON or designee will take the 24 hour repot to each stand up meeting to determine any potential or actual deviation from appropriate care processes or facility procedures that will require immediate action. If immediate action is required the medical director will be notified to provide input and an emergency QA meeting will be called and held to develop an appropriate plan of action and begin the investigation process to determine the root cause analysis. If needed the action plan the will be revised based on root. Facility began reviewing items on the 24 hour report shift on 10/10/16 in the stand up meeting. All items which required additional follow up where addressed accordingly. Facility began all staff training on the 3-11 shift on 10/31/16 and will continue training until 100% of all staff are trained. Staff will not be able to work until training is received. Training includes the following: All staff member are required to report any potential or actual deviations from appropriate care processes or facility procedures. Facility held an emergency QA meeting on 10/31/16 to review F520 quality assessments and assurance regulations. An in-service was held on the 3-11 shift with committee. The in-service included the responsibility of the committee to identify whether quality deficiencies are present (potential or actual deviations from appropriate care processes or facility procedures) that require action. If there are quality deficiencies, the committee is responsible to develop and implement plans of action based on root because to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans. Action plans may include but are not limited to the development or revision of clinical protocols based on standards of practice, revision of policy and procedures, training for staff concerning changes, plans to purchase or repair equipment and/or improve the physical plant and standards for evaluating staff performance. The in-service also included that quality deficiencies are potential markers of quality that the facility considers to be in the need of investigating and after investigation may or may not represent a deviation from quality that results in a potential or actual undesirable outcome. The DON or designee will review 24 hour report for all shifts since he/she last worked or since another designee has reviewed the 24 hour report. The DON or designee will sign the 24 hour report that is checked that is proof monitoring. The DON or designee will take the 24 hour repot to each stand up meeting to determine any potential or actual deviation from appropriate care processes or facility procedures that will require immediate action. If immediate action is required the medical director will be notified to provide input and an emergency QA meeting will be called and held to develop an appropriate plan of action and begin the investigation process to determine the root cause analysis. If needed the action plan the will be revised based on root. The information below are the steps the facility have already taken which started 10/06/16 as part of the allegation of credible compliance: RI #1 was found on 09/29/16 at 5:10 AM by charge nurse laying supine crossways of her bed snoring loudly and white frothy substance draining from her mouth, hard to arouse. RI #1 ' s BP was 188/110 and blood sugar was 64. On 09/29/16 at 8:20 AM RI #1 was found by charge nurse resident was unresponsive. Abdomen was distended. Blood sugar was 32. BP was 191/118, HR 109, RR 24. Blood sugar recheck was 57. On 09/29/16 at 8:40 AM RI #1 was reassessed by charge nurse and was unresponsive. Resident sent to St Francis for evaluation. All staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other employees will be in-serviced prior to starting their shift until 100% of staff receives the in-service training. In-service includes the following information: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - decreased responsiveness or unresponsiveness, frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). This has the potential to affect all residents in the facility. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received disciplinary action by the DON on 10/3/2016 which included the nurse did not reassess resident ' s BP after medication was administered. BP was 188/110, medication was given but no documentation was completed. Blood Sugar was 64 and no intervention was put in place to increase Blood Sugar. Nurse did not reassess resident ' s vitals prior to end of shift. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Head to toe assessment, MD notification, how to check blood sugar, normal range of blood sugar, following MD orders for blood sugars, how to obtain blood pressures, normal range of blood pressure, following MD orders for PRN medication for BP, shift report, following the plan of care, administration of PO medication, and when not to administer PO medication EI #3 is no longer an employee at the facility All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: physician's order [REDACTED]. If the resident has a low blood sugar and no orders to treat, refer to standing order for treatment based on resident ' s responsiveness. All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: Each licensed nurse scheduled to work a medication cart will use the 24-hour report book to communicate any changes from shift to shift. Both the oncoming licensed nurse and the outgoing licensed nurse will review the 24-hour report book together and initial that this has been completed. Each license nurse will document any change in condition including but not limited to abnormal blood sugars, abnormal blood pressure, change in responsive level, and frothy substance from the mouth. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents MD orders from 09/01/16-10/07/16 to ensure all orders related to their diabetes have been followed. All licensed nursing staff in-service started on 3-11 shift on 10/6/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: All resident care plans must be followed for treatment of [REDACTED]. Facility conducted a 100% audit on 10/7/16 which started on 7-3 shift and completed on 3-11 shift of all diabetic residents careplans to ensure all interventions related to diabetes are being followed from 09/01/16-10/07/16. The administrator provided one-on-one in-service education to the DON on 10/6/2016 on the 7PM-11PM shift. In-service included the following all the areas of: Nurses are to report all changes in resident condition to the resident ' s physician. Certified Nurses Assistants are to report all changes in resident condition to the charge nurse. All staff are to report all changes in resident condition to the charge nurse. CNA - Any change in resident ' s status observed must be reported to the charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, high blood pressure, unusual positioning (lying crossways in bed, leaning to one side). Nurses - Any change in resident ' s status observed must be reported to resident ' s physician - Decreased responsiveness or unresponsiveness, Frothy substance in mouth, elevated blood pressure or decreased blood sugar. All staff - Any change in resident ' s status observed must be reported to resident ' s charge nurse - decreased responsiveness or unresponsiveness, frothy substance in mouth, unusual positioning (lying crossways in bed, leaning to one side). physician's order [REDACTED]. If the resident has a low blood sugar and no orders to treat, refer to standing order for treatment based on resident ' s responsiveness. All resident care plans must be followed for treatment of [REDACTED]. Resident ' s with low blood sugars should be treated as a medical emergency. Treatment should be initiated immediately to include following physicians orders for treatment of [REDACTED]. in condition for further orders, activate 911 if necessary. DON received one-on-one in-service training from the RN Supervisor on 10/7/16 on the 3pm-11pm shift including return demonstration. In-service included the following: Head to toe assessment, MD notification, how to check blood sugar, normal range of blood sugar, following MD orders for blood sugars, how to obtain blood pressures, normal range of blood pressure, following MD orders for PRN medication for BP, shift report, following the plan of care, administration of PO medication, and when not to administer PO medication Facility has replaced the DON All licensed nursing staff in-service started on 3-11 shift on 10/7/16 by RN Supervisor. All other licensed nursing staff will be in-serviced prior to starting their shift until 100% of licensed nursing staff receives the in-service training. In-service includes the following information: When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. Charge Nurse assigned to RI # 1 on 09/29/16 at 5:10 AM received one-on-one in-service training by the RN Supervisor on 10/7/2016 on 7-3 shift. In-service included the above information. The same charge nurse also received one-on-one training including return demonstration on 10/7/2016 on 7-3 shift. In-service include the following: Administration of PO medication and when not to administer PO medication When not to administer PO medications to a resident to include but not limited to when a resident is found unresponsive. All licensed nursing staff are to follow MD orders regarding any type of medication given routine or PRN and how to properly administer the medications including route of administration. This has the potential to affect all residents in the facility. Facility Administrator or designee monitoring and will continue to monitor to ensure implementation of AOCC by monitoring 24-hour book daily. ************************************************************************ The Immediate Jeopardy was relieved on 10/31/2016, at 3:00 p.m.