Every finding on record at Poplar Springs Nursing CTR, LLC

Based on observation, interview, and record review, the facility failed to respect the resident's right to dignity and privacy by posting personal care instructions on the exterior of a resident's door for one (1) of 21 sampled residents, Resident #54.Findings include:A review of the facility's policy, Resident Rights, dated 4/2012, revealed, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to .d. Privacy and confidentiality . On 7/21/25 at 12:09 PM, during an observation of Resident #54's room, a sign was observed on the exterior of the resident's door and on the wall next to her bed that read, Please get the Resident up three times per week: Monday Wednesday and Friday, prior to her bath please!! per resident and family request. Thank you, Social Services and Unit Manager. On 7/22/25 at 1:14 PM, during an interview with Licensed Practical Nurse (LPN) #1, she acknowledged the sign posted on the exterior of Resident #54's door and stated it was a privacy concern. She reported that the Unit Manager or the Social Services Director placed the sign. On 7/22/25 at 1:33 PM, during an interview with the Social Services Director, she confirmed that she created the sign for Certified Nurse Aides (CNAs) to post. She acknowledged that the sign was a violation of the resident's privacy and stated she had not noticed it before this interview. On 7/22/25 at 1:45 PM, during an interview with the Director of Nursing (DON), she acknowledged the sign posted on the exterior of the resident's door and confirmed it was a violation of the resident's privacy. On 7/24/25 at 11:40 AM, during an interview with the Administrator, he confirmed that he was aware of the sign and acknowledged that it was a privacy issue. A record review of the admission Record revealed the facility admitted Resident #54 on 2/9/22 with current diagnoses including Spastic Quadriplegic Cerebral Palsy. A record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 7/1/25 revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated his cognition was intact. Further review revealed he had bilateral upper and lower extremity impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident received the necessary care and services by not identifying, assessing, or addressing his visual impairment for one (1) of 21 sampled residents, Resident #8.Findings include:A record review of the facility's policy, Hearing and Vision Services, 10/24, revealed, . It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated .Policy Explanation and Compliance Guidelines: 1. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. The process includes .b. MDS (Minimum Data Set) and care area assessments; c. Ongoing monitoring of sensory problems; d. Care plan development .e. Evaluation .On 7/21/25 at 12:37 PM, during an observation and interview with Resident #8's roommate, he stated Resident #8 was blind. An observation revealed Resident #8 leaving his room and asking for assistance to get out the door. Resident #8 bumped into the wall while attempting to leave the room. The roommate provided verbal directions to assist Resident #8 with exiting the room.On 7/22/25 at 11:20 AM, during an interview with the Director of Nursing (DON), she advised that Resident #8 was blind, and the staff provided provide verbal cues regarding what food was on his meal tray and where the food was located on the plate.On 7/23/25 at 2:07 PM, during an interview with Certified Nursing Assistant (CNA) #2, she confirmed Resident #8 was blind.On 7/23/25 at 2:13 PM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that Resident #8 was blind. LPN #1 stated she had witnessed him bump into objects frequently and had placed his hands on the handrail to help guide him when walking in the hallway. She stated she had seen him bump into things numerous times.On 7/23/25 at 2:19 PM, during an observation, CNA #1 was seen leading Resident #8 to a chair by holding his hand.On 7/23/25 at 2:30 PM, during an interview with CNA #1, she confirmed Resident #8 was blind and stated she had seen him walk into walls.On 7/23/25 at 4:25 PM, during a follow up interview with the DON, she stated Resident #8's vision status should have been accurately identified and assessed. The DON stated they had contracted with a company that would come into the facility to address residents' vision, but Resident #8 had refused to be seen. The facility had also offered to set him up and transport him to an outside appointment, but he had refused that as well. A record review of the admission Record revealed the facility admitted Resident #8 on 11/25/09 and he had current diagnoses including Parkinson's Disease and Schizophrenia.A record review of the Quarterly MDS with an Assessment Reference Date of 7/14/25 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of Section B revealed his vision was Adequate.A record review of a Fall Assessment, dated 4/21/25, revealed Resident #8 had an Inadequate vision pattern.A record review of a Progress Notes revealed Resident #8 had a Nurses Note dated 11/1/24 which indicated, .Resident ambulates outside .with guidance .resident has diff (difficulty) seeing when ambulating around facility running into walls .A record review of the medical record for Resident #8 revealed there was no records indicating his visual impairment was identified, assessed, or addressed by the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's vision status for one (1) of 21 sampled residents. Resident #8.Findings include:A review of the facility's policy, MDS Assessments, dated 5/2006, revealed, . It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol . The facility will follow directions per federal and state guidelines for resident assessment protocol and will refer to the MDS RAI manual.During an observation and interview on 7/21/25 at 12:37 PM, Resident #8's roommate stated that Resident #8 was blind. Resident #8 was leaving the room and asked for assistance to get out the door. Resident #8 bumped into the wall while attempting to leave the room. The roommate provided verbal directions to assist Resident #8 with exiting the room.During an interview on 7/22/25 at 11:20 AM, the Director of Nursing (DON) confirmed that Resident #8 was blind.During an interview on 7/23/25 at 2:13 PM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #8 was blind. LPN #1 stated she had witnessed him bump into objects frequently and had placed him on the handrail to help guide him. She stated she had seen him bump into things numerous times.During an interview on 7/23/25 at 4:20 PM, Registered Nurse (RN)/MDS Coordinator #4 confirmed she was aware Resident #8 was blind. She stated his vision status should be reflected on both the MDS and the care plan.During a follow up interview with the DON on 7/23/25 at 4:25 PM, she stated the MDS should be coded correctly for vision for Resident #8. A record review of the admission Record revealed the facility admitted Resident #8 on 11/25/09 and he had current diagnoses including Parkinson's Disease and Schizophrenia.A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 7/14/25 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of Section B indicated his vision was adequate. A record review of a Fall Assessment, dated 4/21/25, revealed Resident #8 had an Inadequate vision pattern.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan that addressed a resident's visual impairment for one (1) of 21 sampled residents. Resident #8.Findings include:A review of the facility's policy, Care Plans-Comprehensive, dated 10/2016, revealed, . An individualized (person-centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident . Policy Interpretation and Implementation .2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set). 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .On 7/21/25 at 12:37 PM, during an observation, Resident #8 was leaving his room and asking for assistance to get out the door. Resident #8 bumped into the wall while attempting to leave the room and his roommate provided verbal directions to assist him with exiting the room.On 7/22/25 at 11:20 AM, during an interview with the Director of Nursing (DON), she confirmed Resident #8 was blind.On 7/23/25 at 2:13 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated she had witnessed Resident #8 bump into objects frequently and assists with placing his hand on the handrail to help guide him in the hallway. She stated she had seen him bump into things numerous times and confirmed that he was blind.On 7/23/25 at 4:05 PM, during an interview with Registered Nurse (RN)/MDS Coordinator #3, she stated she was not aware Resident #8 was blind. She confirmed that the resident's vision status should be included in the care plan and that all staff use the care plan to provide care.On 7/23/25 at 4:20 PM, during an interview with RN/MDS Coordinator #4, she confirmed she was aware Resident #8 was blind. She stated his vision status should be reflected on the care plan, as the care plan is used by all staff to guide care.On 7/23/25 at 4:25 PM, during a follow up interview with the DON, she stated the resident's vision status should be reflected in the care plan.A record review of the admission Record revealed the facility admitted Resident #8 on 11/25/09 and had current diagnoses including Parkinson's Disease and Schizophrenia.A record review of Resident #8's Comprehensive Care Plan revealed no focus area or interventions addressing blindness or visual impairment.A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 7/14/25 revealed Resident #8 had a Brief Interview for Mental Status score of 15, which indicated he was cognitively intact. Review of Section B revealed his vision was Adequate.

Based on record review and staff interview, the facility failed to ensure a resident was free from a significant medication error when a nurse incorrectly transcribed and administered Lasix (a diuretic) at a higher dose than prescribed for one (1) of 21 sampled residents, Resident #2.Findings included: A record review of the admission Record revealed the facility admitted Resident #2 on 10/25/24 with diagnoses including Atherosclerotic Heart Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/10/25 revealed Resident #2 had had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment.A record review of the Adult-Gerontology Nurse Practitioner (AGNP) Subjective, Objective, Assessment, Plan (SOAP) note for Resident #2, dated 11/5/24 revealed Increase Lasix to 40 mg (milligrams) by mouth daily.A record review of the encrypted text message exchange revealed Registered Nurse (RN) #2 received a text message with orders for Resident #2 to Increase lasix to 40 mg PO (by mouth) daily .A record review of the Order Details document revealed Resident #2 had a Physician's order, dated 11/7/24 with the Order Summary to give Lasix 40 mg twice a day, which was not consistent with the nurse practitioner's SOAP note plan. The order was created by RN #2.On 7/23/25 at 3:18 PM, during an interview, the AGNP explained that on 11/5/24, she signed an order to increase Resident #2's Lasix to 40 mg daily and sent the order via encrypted text to RN #2 Charge Nurse. She confirmed that the RN incorrectly entered the order as Lasix 40 mg twice a day. The NP stated she stopped the twice-daily dosage on 7/23/25 when she became aware of the error and confirmed the resident did not require the higher dose.On 7/23/25 at 5:04 PM, during an interview with the Director of Nursing (DON), she acknowledged that the Lasix order was incorrectly entered as twice daily instead of daily. She explained that the facility's current system involves the NP sending encrypted texts to the Charge Nurse, who then inputs the orders, and she does not have oversight of these communications. She stated her expectation is for all medication orders to be entered correctly.On 7/24/25 at 11:21 AM, during an interview with the Administrator, he confirmed that the Lasix order was not transcribed correctly and stated that the facility needs a better system for verifying and communicating orders, which will be addressed in team meetings.

Based on observation and staff interview, the facility failed to store food and maintain food quality in accordance with professional standards for food safety related to overly ripe produce and exposed spice products for one (1) of two (2) kitchen observations.On July 21, 2025, at 10:15 AM, an initial observation and interview with the Kitchen Supervisor revealed refrigerator #1 contained 11 tomatoes exhibiting white biological growth. The spice rack in the food preparation area revealed three bottles of dry seasonings with their lids open, leaving the seasonings exposed. The Kitchen Supervisor acknowledged the presence of overly ripe produce and the opened spice bottles. The Kitchen Supervisor stated that she is responsible for maintaining safety and quality standards in the kitchen and that the staff receive regular in-service training on food safety.On July 24, 2025, at 11:31 AM, during an interview with the Administrator acknowledged the issues with overly ripe foods and the opened spice bottles. He stated that the Kitchen Supervisor is responsible for maintaining food quality and standards and that he expects the Kitchen Supervisor to perform regular checks on the food in the kitchen.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection by not properly covering clean linens during transport and by placing clean linens against worn clothing for one (1) of two (2) laundry observations.A review of the facility's policy, Infection Prevention and Control Program, dated 8/2017, revealed, .It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines.10. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. b. Clean linen shall be delivered to resident care units on covered linen carts with the covers down.A review of the facility's policy, Laundry Handling & Processing Policy, dated 2/1/25, revealed, .(Proper Name of Contract Company) is committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices.Policy.All soiled linens must be covered during transportation and when stored on units.Delivery.Employees should never carry clean linen against their bodies.On 7/23/25 at 7:30 AM, during an observation and interview, Laundry #1 was observed transporting a laundry cart with clean linen down A Hall with the plastic covering flipped over the cart, leaving the clothes and linens exposed. An empty disposable beverage cup was sitting on top of the cart near the linen. Laundry #1 stated he was not aware that the laundry was supposed to be covered.On 7/23/25 at 10:57 AM, during an observation and interview, Laundry #1 was transporting clean linen from one linen cart to another cart on the hall. The laundry worker picked up a blanket, rested it on his upper body, refolded the blanket, and placed it on the clean linen cart. The laundry worker stated he had just started working at this facility and did not know that placing clean linen against his worn clothes could spread infection.On 7/23/25 at 11:32 AM, during an interview with the District Manager of Housekeeping, she acknowledged the linen cart should not be uncovered during transport and confirmed that linen should not be placed against his clothing while refolding. She stated her expectation is that staff maintain infection control standards and that the laundry worker would be retrained on the infection prevention program.On 7/24/25 at 10:42 AM, during an interview with the Infection Preventionist (IP) nurse, she confirmed the laundry worker failed to prevent the possible spread of infection by placing a dirty cup on the clean linen cart, transporting clean laundry uncovered in the hallway, and placing a clean blanket against his clothing.On 7/24/25 at 11:03 AM, during an interview with the Director of Nursing (DON), she confirmed the laundry worker should not place dirty cups on the clean linen cart, transport clean linens uncovered in the hallway, and allow clean linens to come in contact with his clothes. The DON stated she expects all staff to follow the infection control policy.On 7/24/25 at 11:19 AM, during an interview the Administrator, he stated he expects all staff to follow the infection control policy.A record review of Onboarding Documents revealed Laundry #1 received training on Infection Control Overview.

Based on interview and record review, the facility failed to ensure a resident's right to be treated with respect and dignity for one (1) of three (3) residents reviewed for resident rights, Resident #1, when a Certified Nursing Assistant (CNA) used an inappropriate tone and language when responding to the resident's request for care and failed to provide timely assistance, resulting in the resident feeling dismissed and disrespected. Findings included: A review of the facility's document Vulnerable Adult Act, dated 3/21/2022, revealed, .A 'Vulnerable Adult' is any adult person unable to care for his or herself due to a physical or mental decline . Any nursing home resident is considered to be a vulnerable adult . Not respecting the resident's rights or confidentiality . A record review of the facility's investigation, dated 3/17/2025, revealed that on 3/14/2025 at 2:00 PM, the Activities Director found Resident #1 in her room crying. Resident #1 stated that earlier she had returned to her room around 12:30 PM and pressed her call light for assistance transferring to her recliner. CNA #1 entered the room, turned off the call light, and said okay but did not provide assistance. After another 30 minutes, the resident pressed her call light again. According to the resident, it took about two (2) hours for her to receive assistance. When CNA #1 returned, she was rude and stated, Look, we have other things to do, we're short staffed, and I haven't had my break. The Activities Director notified Administration of the resident's allegation. LPN #1 instructed CNA #1 to clock out and report back on 3/17/2025. CNA #1 never returned to provide a written statement. The facility self-reported the incident, suspended CNA #1 pending investigation, and ultimately terminated. The facility then provided in-services to all staff on verbal abuse, neglect, reporting, and the Vulnerable Adult Act. A record review of a witness statement from CNA #2 revealed that she assisted CNA #1 in transferring Resident #1 and observed the resident to be upset, though she did not know why. She confirmed that CNA #1 complained about being short staffed in front of the resident, but she was behind in her workload and left the room to take care of her residents. A record review of the Admission Record revealed the facility admitted Resident #1 on 7/12/2019 with diagnoses including Atrial Fibrillation and Anxiety Disorder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/2025 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. On 4/9/2025 at 1:45 PM, during an interview with the Administrator, he confirmed that on 3/14/2025 at 2:00 PM, Resident #1 alleged verbal abuse and neglect by CNA #1 after being left without assistance and told, We have other stuff to do. CNA #1 was asked to clock out and was later terminated per facility policy. On 4/9/2025 at 3:00 PM, during an interview with Resident #1, she stated that on 3/14/25, CNA #1 turned off her call light and told her she wasn't the only one who needed help, that she hadn't had a break, and would come back when someone could assist her. The resident stated this made her very upset and she cried. On 4/9/2025 at 3:15 PM, during an interview with the Activities Director, she stated that on 3/14/25, she found Resident #1 crying in her room and was told that CNA #1 had spoken rudely and left her waiting for an extended time. She reported the concern to Administration. On 4/9/2025 at 3:30 PM, during an interview with LPN #1, she confirmed that on 3/14/25, she told CNA #1 to clock out after being informed of the incident and instructed her to return on Monday to speak with the DON and Administrator. On 4/9/2025 at 3:45 PM, during an interview with the Business Office Manager, she confirmed that CNA #1 was hired in October 2024 and terminated in March 2025. CNA #1 had completed training on abuse, neglect, and the Vulnerable Adult Act. On 4/9/2025 at 4:00 PM, during an interview with RN #1/Unit Manager, she confirmed that staffing was sufficient on 3/14/225. She observed Resident #1 to be crying and upset following the incident. On 4/10/2025 at 9:00 AM, during an interview with the Director of Nursing (DON), she stated that the facility provides regular in-services on abuse, neglect, and burnout, including one on 1/14/2025. She confirmed that the Social Worker evaluated Resident #1, and the Nurse Practitioner (NP) assessed her on 3/17/2025, and neither found any signs of psychological harm. On 4/10/2025 at 9:20 AM, during an interview with CNA #1, she stated that Resident #1 had asked for help on 3/14/25, and she told the resident she would return with assistance. CNA #1 claimed Resident #1 understood and even told her to help others first. She denied being disrespectful and said she was unaware the resident was upset until later. She stated that she was told to return Monday to speak with the Administrator and DON but was instead terminated. She was never asked to make a statement or give an explanation regarding the event. On 4/10/2025 at 9:45 AM, during an interview with the Administrator, he confirmed that surveillance showed on 3/14/25, Resident #1's call light was on at 12:40 PM, turned off by CNA #1, then again at 1:04 PM, and the lift used at 1:42 PM. On 4/10/2025 at 10:00 AM, during an interview with the DON, she stated that the facility had sufficient staffing on 3/14/25 per the facility assessment. She felt CNA #1 was not experiencing burnout and should have had the capacity to perform her duties without delay or rudeness. On 4/10/2025 at 10:30 AM, during an interview with the Social Services Director, she stated that following her evaluation, Resident #1 did not display signs of psychosocial harm. On 4/10/2025 at 10:45 AM, during an interview with the Nurse Practitioner, she confirmed that she assessed Resident #1 on 3/17/2025 and found no signs of distress. She stated the resident was relieved to hear CNA #1 had been terminated.

Based on interviews, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse for one (1) of three (3) residents reviewed for abuse (Resident #1). Specifically, the facility failed to interview other cognitively intact residents who received care from the alleged perpetrator (CNA #1) to determine whether a pattern of verbal abuse or neglect existed. Findings include: A review of the facility's Abuse Policy and Procedure, dated 3/21/2022, revealed, .Abuse Investigation Process .The investigation will include the following .e. Resident's statements regarding the incident, if appropriate . A record review of the facility's investigation revealed that on 3/14/2025 at 2:00 PM, the Activities Director found Resident #1 in her room crying. Resident #1 alleged verbal abuse and neglect by CNA #1. She stated she had returned to her room at approximately 12:30 PM, pressed her call light for assistance, and CNA #1 turned off the call light but did not assist. The resident alleged CNA #1 returned two (2) hours later and said, We have other things to do, we're short staffed, and I haven't had my break. There were no interviews in the written investigation to determine or identify if other residents were affected by CNA #1's behavior. On 4/10/2025 at 9:45 AM, during an interview with the Administrator, he confirmed that during the investigation, he did not review the surveillance video. He reviewed the video after the State Agency (SA) entrance on 4/9/25, which revealed Resident #1's call light was activated at 12:40 PM and again at 1:04 PM, and the mechanical lift was used at 1:42 PM. He stated the facility conducted a detailed investigation but acknowledged that the facility failed to interview other residents assigned to CNA #1 during the shift. Specifically, those with a Brief Interview for Mental Status (BIMS) score of 13 or higher, who may have provided additional insight into the CNA's behavior. On 4/10/2025 at 10:00 AM, during an interview with the Director of Nursing (DON), she stated that the facility performed a thorough investigation, but they failed to interview other residents with a BIMS score greater than 13, to ascertain if they felt they were abused or neglected by CNA #1. On 4/10/2025 at 10:30 AM, during an interview with the Social Services Director, she stated that following the event with Resident #1, she failed to interview other residents that were assigned to CNA #1 with a BIMS score greater than 13, to determine if others had any issues with the CNA. A record review of the Admission Record revealed the facility admitted Resident #1 on 7/12/2019 with diagnoses including Atrial Fibrillation and Anxiety Disorder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in a manner to prevent the possibility of complications as evidenced by oxygen tubing that was not dated to indicate weekly oxygen tubing/nasal cannula changes for one (1) of one (1) resident reviewed for respiratory care. Resident #18. Findings Include: A review of the facility's Nebulizer and Oxygen Tubing Storage Policy, dated 4/2007, revealed, .It is the policy of the facility to reduce the risk of potential and/or direct exposure to infectious diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respirator equipment. Procedure .The facility will replace all respiratory tubings weekly. These tubings will be dated .Documentation will be placed on the residents treatment record (TAR) of the weekly changing of tubing A record review of the Admission Record revealed that the facility admitted Resident #18 on 2/7/24 with current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A record review of the Order Summary Report revealed Resident #18 had a Physician's Order, dated 7/11/2024, for oxygen therapy at 2 liters per minute (LPM) per nasal cannula as needed. On 08/26/24 at 10:30 AM, during an observation, Resident #18 was in the day room and was wearing a nasal cannula connected to oxygen. The oxygen tubing was not dated to indicate when the nasal cannula and tubing was last changed. On 08/27/24 at 11:10 AM, during an observation, Resident #18 was wearing oxygen per a nasal cannula while in the day room. The tubing of the nasal cannula was not dated to indicate the last tubing change. On 08/27/24 at 11:10 AM, during an interview, Licensed Practical Nurse (LPN) #2, who was responsible for Resident #18's care, confirmed the oxygen tubing was not dated. LPN #2 stated that she was unaware that the oxygen tubing needed to be dated but assured that she would label it moving forward. LPN #2 acknowledged that the facility's policy indicated that oxygen tubing should be dated. On 08/28/24 at 09:10 AM, during an interview with the Director of Nursing (DON), she confirmed that the facility's policy required replacing oxygen tubing weekly and dating the tubing to indicate the date it was last changed. She explained the oxygen tubing is usually changed on Sunday night by the night shift. She stated that the policy was reviewed with all staff during orientation, and she emphasized the importance of adhering to the policy to reduce the risk of infectious diseases and bacterial exposure.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure hands were cleaned with soap or hand sanitizer before, during, and after providing perineal care for one (1) of two (2) residents observed for catheter/perineal care. (Resident #69) Findings Include: A review of the facility's Hand Sanitizing Procedure, revised 4/2015, revealed: .It is the policy of this facility to use hand sanitizer .between handwashing when hands are not visibly soiled or dirty. Procedure .use an alcohol-based hand rub .for all the following situations: 1. Before and after direct contact with residents .10. After removing gloves. A review of the facility's Procedure for Handwashing, revised 4/2015, revealed, .2. Apply one squirt of soap . On 08/28/24 at 10:45 AM, during an observation of perineal care, Certified Nursing Assistant (CNA) #3, assisted by CNA #4, was observed preparing to provide perineal care for Resident #69. CNA #3 turned on the water and attempted to use the soap dispenser but found it empty. CNA #4 suggested using a bottle of soap from the resident's counter, but CNA #3 declined, stating, I cannot use resident soap. CNA #3 and CNA #4 proceeded to wash their hands without soap before starting perineal care. CNA #4 left the room to get Licensed Practical Nurse (LPN) #2 to pause the feeding pump, but did not perform hand hygiene after removing gloves or before applying new gloves. LPN #2 entered the room wearing gloves, paused the feeding pump, and exited the room wearing the same gloves. During perineal care, CNA #3 removed and reapplied her right glove multiple times due to contamination with feces but failed to remove both gloves and perform hand hygiene between glove changes. CNA #3 stated, I should have brought my own hand sanitizer to use. Both CNAs removed their gloves at the end of care and washed their hands without soap. On 08/28/24 at 2:25 PM, during an interview, CNA #4 confirmed that there was no soap in the room and acknowledged that they should not have used the resident's liquid soap. She admitted that not using soap during handwashing could allow bacteria to remain on their hands and pose a risk of infection to the resident. On 08/28/24 at 2:35 PM, CNA #3 admitted that she should have used soap during handwashing, noting that washing hands without soap would not remove germs. She acknowledged that she should have sanitized her hands between glove changes to prevent exposing the resident to bacteria. On 08/28/24 at 2:43 PM, LPN #2 admitted that she should have washed her hands and should have removed her gloves before exiting the room. She stated that failing to do so could spread infection and pose a risk to the resident. On 08/28/24 at 3:07 PM, during an interview, the Infection Preventionist (LPN #1) confirmed that LPN #2 should not have entered the room wearing gloves and should have performed hand hygiene upon entering and exiting the room. She stated that improper hand hygiene and glove changes could increase the resident's risk of infection. On 08/28/24 at 3:32 PM, the Assistant Director of Nursing (ADON) confirmed that LPN #2 should not have entered the room wearing gloves and should have performed hand hygiene. The ADON emphasized that CNA #3 should have removed both gloves, washed her hands, and applied new gloves, as improper glove handling could lead to contamination and infection. On 08/28/24 at 4:15 PM, the Director of Nursing (DON) acknowledged that LPN #2 and CNA #3 failed to follow infection control protocols. She confirmed that their actions could lead to cross-contamination, posing risks of infection and skin breakdown. A record review of the Admission Record revealed the facility admitted Resident #69 on 07/11/24 with current diagnoses including Hemiplegia and Unspecified Hemiparesis following a cerebral infarction. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/24 revealed Resident #69 was severely cognitively impaired, and she was dependent on staff for toileting hygiene.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure perineal care was provided in a manner to prevent complications for one (1) of two (2) residents reviewed for care catheter/bowel and bladder care. (Resident #83) Findings Include: A review of the facility's Perineal Care Policy, revised 1/2010, revealed: .It is the policy of this facility to provide perineal cleanliness and comfort to the resident, to prevent infections and skin irritation, and observe the resident's skin condition .Procedure .For a male resident .b. Wash perineal area starting with urethra and working outward .(3) Continue to wash the perineal area including the penis, scrotum, and inner thighs . On 08/28/24 at 10:05 AM, during an observation of catheter and perineal care, Certified Nursing Assistant (CNA) #1, with the assistance of CNA #2, used pre-moistened disposable wipes to clean Resident #83's penis, catheter tubing, and buttocks. After stating that perineal care was completed, CNA #1 prepared to apply a clean brief to the resident. When asked by the State Agency (SA) to check below the resident's anus for feces, CNA #1 wiped the area a total of nine (9) additional times, each time revealing a moderate amount of feces. The resident was turned over, and when the SA asked CNA #1 to check underneath his scrotum, it was found that feces were present in that area as well. An additional six (6) wipes were used to clean the scrotal area, again revealing a moderate amount of feces. On 08/28/24 at 10:37 AM, during an interview, CNA #1 stated that she should have ensured the resident was completely clean before applying a clean brief. She admitted , I thought he was clean. I did not think to check under his scrotum. She acknowledged that improper cleaning could lead to skin breakdown and infection. On 08/28/24 at 4:04 PM, in an interview, the Director of Nursing (DON) stated that CNA #1 should have ensured the resident was completely clean and emphasized that the CNA's actions could result in infection and cause skin breakdown. A record review of Admission Record revealed that the facility admitted Resident #83 on 2/3/23 with current diagnoses including Pressure Ulcer in the sacral region. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/17/24 revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of nine (9), indicating that the resident was moderately impaired. Section GG indicated that the resident was dependent on staff for toileting care.

Based on staff interview, record review, and facility policy review, the facility failed to develop care plan interventions related to a resident's behaviors for one (1) of 18 care plans reviewed. (Resident #75) Findings included: A review of the facility's policy, Care Plans-Comprehensive, dated 10/2016, revealed, An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team .develops and maintains comprehensive care plan for each resident .2. The comprehensive care plan is based on a thorough assessment that includes .the MDS (Minimum Data Set). 3. Each resident's comprehensive care plan is designed to a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes . A record review of the comprehensive care plan for Resident #75 revealed Focus .potential for behaviors R/T (related to) Mood Disorder . revised on 8/7/2024 . Interventions Administer medications as ordered .Monitor for s/s (signs/symptoms) of behavior changes initiated on 5/3/2022. There were no interventions documented to assist staff in managing Resident #75's behaviors including sexually inappropriate behaviors, verbal aggression, and refusal of care and medications. A record review of the Admission Record revealed the facility admitted Resident #75 on 5/4/22 and he had current diagnoses including Persistent Mood Disorder and Dementia with other Behavioral Disturbance. A record review of the Psych Progress Note, dated 5/30/24, revealed Resident #75 had symptoms including Agitation, Requires frequent redirection, can be difficult to redirect, refuses care refusing meds (medications) at times, and yelling out, refuses care, yelling out, verbally aggressive at times. Current Risk Factors included Aggression: Verbal, episodes of yelling out, verbally aggressive. Case Conceptualization revealed .Staff report resident continues to have episodes of verbally aggressive behaviors, sexually inappropriate speech and behavior at times. Resident refuses care at times . A record review of the Psych Progress Note, dated 6/18/24, revealed Resident #75 had symptoms including Requires frequent redirection, can be difficult to redirect, refuses care refusing meds (medications) at times, and yelling out, verbally aggressive at times. Current Risk Factors included Aggression: Verbal, episodes of yelling out, verbally aggressive. Case Conceptualization revealed .Staff report resident continues to have episodes of verbally aggressive behaviors, sexually inappropriate speech and behavior at times, episodes of agitation, difficult to redirect at times. Resident refuses care at times, refusing to take medications at times . A record review of the Psych Progress Note, dated 7/30/24, revealed Resident #75 had symptoms including Requires frequent redirection, can be difficult to redirect, refuses care refusing meds (medications) at times, and yelling out, verbally aggressive at times. Current Risk Factors included Aggression: Verbal, episodes of yelling out, verbally aggressive. Case Conceptualization revealed .Staff report resident continues to be verbally aggressive, agitated at times, difficult to redirect. Record review of the Discharge Summary from a local geriatric psychiatric facility, dated 5/24/2024, revealed, .(Proper Name of Resident #75) was admitted on [DATE] from a nursing home after making sexual comments to staff. He touched a staff member inappropriately. He also refused care and was combative with staff. He threatened staff and would not allow them to come into his room. During the hospital stay, Patient yelled out obscene and inappropriate comments and made inappropriate advances . A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/2024 revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired. Further review revealed that Resident #75 had verbal behavioral symptoms directed toward others, other behavioral symptoms that were not directed toward others that significantly interfered with the resident's care. The MDS indicated Resident #75 had behaviors that including rejecting care that was necessary to achieve the resident's goals for health and well-being for four (4) to six (6) days of the lookback period. During an interview with Licensed Practical Nurse (LPN) #2 on 08/27/24 at 11:10 AM, she explained she works on the Alzheimer's Unit and is assigned to care for Resident #75. She stated that Resident #75 refused medication and care, and he had inappropriately touched and had swung at her. She confirmed Resident #75 was transferred to a geriatric psychiatric unit in May (2024), but there were no real changes in his behaviors as he continued to refuse care and medications and continued to be verbally aggressive and sexually inappropriate. LPN #2 said there had been no special additions or interventions related to his care and if he had any changes in behavior, she reported it to the provider and to Nursing Services. During an interview with the Director of Nursing (DON) on 08/28/2024 at 12:00 PM, she revealed Resident #75 had shown signs of aggression and sexual inappropriateness and had been transferred to a geriatric psychiatric facility for treatment and evaluation. She confirmed the resident has had encounters with nursing staff with sexual inappropriateness and no special consideration or interventions had been developed. On 08/28/2024 at 12:15 PM, during an interview with the Psychiatric Nurse Practitioner (NP), he stated that Resident #75 was on caseload to manage his medications. The NP confirmed Resident #75 had a history of sexual inappropriateness and aggressive conversation which medication management was currently ineffective. The NP stated he was aware Resident #75 continued to refuse care and medications but deferred to nursing services for behavioral monitoring and documentation related to moods and behaviors exhibited by the resident.

Based on observation, staff interview, and facility policy review, the facility failed to ensure the resident's rights for a safe and homelike environment as evidenced by broken floor tiles in two areas of the hallway for one (1) of eight (8) hallways observed. (Therapy room hallway). Findings Include: A review of the facility policy titled Safe and Homelike Environment, undated, revealed, .In accordance with resident's rights, the facility will provide a safe, clean, comfortable, and homelike environment . This includes ensuring that the resident can receive care and services safely, and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . On 8/27/24 at 9:07 AM, during an observation, there were several broken floor tiles in the hallway in front of an exit door. There was also an area in which the floor tiles were missing in a straight line across the hallway, causing an indention in the hallway which was approximately six inches wide. This hallway led to the Therapy Room. On 8/27/24 at 11:01 AM, during an interview with the Rehabilitation Technician, she stated that she was aware of the broken and missing floor tiles outside of the therapy gym door. She was not aware of any residents who had fallen as a result of the broken and missing floor tiles, but acknowledged it was a hazard and someone could trip if the floors were not repaired. During an interview with the Administrator on 8/27/24 at 10:35 AM, he revealed that the facility had an area near the physical therapy gym, across the hall, with broken tile and cracks in the cement. He acknowledged that the crack was long and deep enough to potentially be a tripping hazard for both residents and staff. On 8/27/24 at 1:58 PM, during an interview with the Maintenance Director, he confirmed that the back hall near the therapy gym had a crack across the hallway in both the cement and tile that could potentially be a tripping hazard for residents going to the therapy gym.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent (5%) as evidenced by four (4) errors were observed out of 39 medication administration opportunities. This affected one (1) of three (3) residents observed during medication pass, resulting in a medication error rate of 10.26%. (Resident #27) Findings Include: A review of the facility's policy, Medication Administration, dated 09/01/2022, revealed: Medications are administered .in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .11 .c. Crush medications as ordered. Do not crush medications with do not crush instructions .Example Guidelines for Medication Administration .Do Not Crush Medications: Slow release, enteric coated . A record review of the Admission Record revealed the facility admitted Resident #27 on 1/25/2023 with current diagnoses including Unspecified Atrial Fibrillation, Acute Systolic Congestive Heart Failure, Bradycardia, and Hypertensive Heart Disease with Heart Failure. A record review of the Order Summary Reportwith active orders as of 8/29/24 revealed Resident #27 had a Physician's Order for Diltiazem Hydrochloride Extended-Release (ER) 24-hour 120 milligram (mg) capsule (Order date: 1/25/2023), Metoprolol Succinate ER 24-hour Sprinkle 100 mg capsule (Order date: 1/25/23), Pantoprazole Sodium Delayed-Release 40 mg tablet (Order date 1/25/23), and Potassium Chloride ER 20 milliequivalent (mEq) tablet (Order date 2/14/23). There were no instructions that indicated the medications should be crushed. On 08/27/24 at 08:42 AM, during an observation and interview, Licensed Practical Nurse (LPN) #2 prepared Resident #27's medications by crushing them together, including Metoprolol ER 24-hour Sprinkle 100 mg, Pantoprazole Delayed-Release 40 mg, Potassium Chloride ER 20 mEq, and Diltiazem Hydrochloride ER 24-hour 120 mg. LPN #2 administered the crushed medications to Resident #27. During an interview, LPN #3 stated that she crushed the medications because she thought Resident #27 had difficulty swallowing. She acknowledged that extended-release and delayed-release medications should not be crushed unless there were specific instructions by a physician indicating the medications could be crushed. There were no instructions on the physician's orders for the ER medications to be crushed before administering to the resident. During an interview with the Director of Nursing (DON) on 08/27/24 at 10:00 AM, she confirmed that extended-release and delayed-release medications should never be crushed unless specified by a physician. She explained that crushing these medications changes the way they are meant to be delivered, potentially compromising the medication's effectiveness.

Based on record review and staff interviews, the facility failed to provide services in an acceptable standard of practice as evidenced by, a resident who went out on therapeutic leave was not provided with all physician prescribed medications for one (1) of four (4) residents sampled. Resident #1. Findings Include: On 7/16/2024 at 9:35 AM, in an interview with Resident #1's daughter, she stated her mother was sent home on therapeutic leave without medications that were needed for the continuation of care. She confirmed the medications the facility failed to send with her mother while she was on leave included Aspirin, Basaglar Kwik Pen (insulin), Fiasp Injection insulin, Miralax Powder, Protonix, Silvadene Cream, and Zyrtec Allergy. Resident #1's daughter stated the therapeutic leave had been planned well in advance and she was taking her mother out of the state for a week. The facility was aware the resident was going with her and should have made sure she had all her medications sent with her. On 7/16/2024 at 9:50 AM, in an interview with the Director of Nursing (DON), she revealed Resident #1 went out with family members on 6/23/24. She confirmed Resident #1 and her daughter were not provided some of the resident's medications when she signed out for therapeutic leave. Those medications included Aspirin, Basaglar Kwik Pen, Fiasp Injection insulin, Miralax Powder, Protonix, Silvadene Cream, and Zyrtec Allergy. The DON stated the procedure for residents who sign out for therapeutic leave is that all active medications should be verified with the provider and sent out with the resident to provide a continuation of care while on leave. On 7/16/2024 at 10:35 AM, interview with Licensed Practical Nurse (LPN) #1, stated she was the nurse who put together medications for Resident #1's leave. She revealed the practice was to send the resident out with all active medications that are on the Medication Administration Record (MAR) after verifying with the provider. She revealed Resident #1's family came on 6/23/24 at night and she had given the resident and her daughter the resident's medications. She confirmed the absence of some active medications that the resident was on at the time of leave, included Aspirin, Basaglar Kwik Pen, Fiasp insulin, Miralax Powder, Protonix, Silvadene Cream, and Zyrtec Allergy. She revealed it was an oversight on her part and it was not intentional. She revealed that this oversight could have caused adverse outcomes if the resident was unable to get her medications. A record review of the Order summary Report with active orders as of 5/31/24 revealed physician's orders for Aspirin dated 9/19/23, Protonix dated 1/31/24, Miralax Powder dated 6/8/22, Basaglar Kwik Pen dated 2/12/24, .Fiasp Injection Solution dated 3/21/24 . Record review of the Order Summary Report with active orders as of 6/30/24 revealed orders for Silvadene External Cream 1% dated 6/4/24 and Zyrtec Allergy dated 6/5/22. A record review of Resident #1's MAR for May 2024 revealed Resident #1 required sliding scale (Flasp Injection insulin) coverage for 72 of 124 accucheck results. A record review of the Transfer/Discharge Report revealed the facility admitted Resident #1 on 5/31/22 and she had diagnoses including Diabetes Mellitus and Atrial Fibrillation.

Based on interviews, record review, and facility policy review, the facility failed to protect a resident from misappropriation of a controlled medication for one (1) of three (3) sampled residents. Findings Include: A review of the facility's policy titled, 7 Types of Abuse, dated 10/2016 revealed, . 7. 'Misappropriation of resident property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent .Taking Their Medications . Record review of the facility investigation Allegations of Abuse/Misappropriation of Pain Medication dated 3/25/24, revealed Resident #1 had been receiving Norco 10-325 milligrams (MG) between two to three times on most days. After the Nurse Practitioner (NP) received a request for Resident #1's Norco to be refilled, the NP requested a urine drug screen to be performed on Resident #1. The drug screen for Resident #1 was negative for opioids. The Director of Nurses (DON) began her investigation and observed the narcotic administration log, in which the Norco had been signed out 21 times between 3/14/24 through 3/25/24. Licensed Practical Nurse (LPN) 1 had signed the medication out 19 times. Both LPN #1 and LPN #2 performed a urine drug screen, in which LPN #1 was positive for opioids and morphine and LPN #2 had a negative urine drug screen. The DON questioned LPN #1 and she revealed she did not have a prescription for her medications, that she had seen pain management in the past, and that she purchased the medication from a friend. LPN #1 was terminated on 3/25/24, for a failed drug test and escorted out of the facility. The Administrator reported the incident to the State Agency (SA), Attorney General Office (AGO), State Board of Nursing, and Board of Pharmacy. On 6/4/24 at 11:00 AM, during an interview with the NP, she confirmed she had taken care of Resident #1 in the past, and he required very little pain medication. The NP explained that when staff requested a refill on for Resident #1's prescription for Norco, she became suspicious and requested a drug urine on the resident. On 6/4/24 at 12:15 PM, during a phone interview with the DON, confirmed that on 3/22/24, the NP received a call from staff requesting Resident #1's Norco be refilled. The NP treated the resident in the past, and he required little to no pain medication, which caused suspicion. The NP ordered a urine drug screen on Resident #1. The results of the urine drug test were received on 3/25/24, and it was negative for opioids for Resident #1. The DON then pulled the narcotic sign-out log on that medication and began testing all nurses who administered the medication. LPN #1 tested positive for opioids and morphine. LPN #1 did not have a prescription for either medication. LPN #1 was then terminated and escorted out of the facility. On 6/4/24 at 12:30 PM, during a phone interview the Administrator confirmed Resident #1 tested negative for opioids, and LPN #1 tested positive for opioids. LPN #1 did not have a prescription for the medication and was unable to produce a prescription. She was terminated, and the facility conducted an investigation, which was reported to SA, AGO, the State Board of Nursing, and the Board of Pharmacy. On 6/4/24 at 1:08 PM, during a phone interview with the Pharmacy Consultant, she confirmed that the facility informed her that Resident #1 was not receiving his prescribed Norco, which was being signed out by LPN #1. LPN #1 tested positive for opioids and morphine, and she was unable to produce a prescription for the medications. On 6/4/24 at 1:30 PM, during an interview with Resident #1, he confirmed that he received only a few pain pills, and they were white. Resident #1 stated that he doesn't usually have pain and does not require pain medications. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/7/24 revealed a Brief Interview for Mental Status (BIMS) score was 14, indicating Resident #1 was cognitively intact. Record review of the Order Summary Report with active orders as of 3/22/24 revealed an order dated 2/1/24 Norco Oral Tablet 10-325 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain . Record review of the Controlled Drug Record revealed Hydrocodone-APAP 10-325 MG (milligrams) (substituted for Norco 10-325 MG), to be given one (1) tablet by mouth every six (6) hours as needed. LPN #1 signed out the medication 19 times, and LPN #2 signed out the medication two (2) times, for a total of 21 times for medication from 3/14/24 to 3/25/24. Record review of the Test Results Record revealed that on 3/25/24, LPN #1 was positive for oxycodone and morphine. On 3/22/24, Resident #1 was negative for opiates in his urine. On 3/25/24, LPN #2 was negative for opiates in the urine. Record review of LPN #1's written statement, undated, revealed, I have been taking pain medication at home that I don't have current prespription (prescription) for. On 6/4/24, the SA validated through interviews, record reviews, facility policy review, and observation with staff, that the facility had begun an immediate investigation when the suspicion of misappropriation of the resident's medication had occurred. The facility completed 100% audit of all medication carts to include a narcotic count verification and review of all controlled substances proof of use forms and narcotic cards records on 3/25/26. The facility had a QAPI (Quality Assurance and Performance Improvement) meeting on 3/26/24, with all required disciplines present. The facility completed in-services and training on controlled drugs and misappropriation. The SA validated that the facility had taken all necessary measures to be at past noncompliance by 3/26/24, with the deficient practice that occurred on 3/22/24.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to provide a privacy cover for a urinary catheter drainage bag for (1) of 20 sampled residents. Resident #80. Findings include: Review of the facility's policy titled, Maintaining Privacy and Dignity for Residents with Foley Catheter Drainage Bags with a revision date of 02/16 revealed, .Procedure .The Drainage bag will be maintained in a storage pouch to hide the contents and prevent embarrassment to the resident . An observation on 3/14/23 at 3:05 PM, revealed Resident #80 lying in bed, with a catheter drainage bag on the side of the bed facing the resident's room door. There was no privacy cover for the urinary catheter drainage bag. During an observation and interview on 3/14/23 at 3:15 PM, with Registered Nurse (RN) #1-Infection Preventionist, she confirmed that Resident #80's catheter drainage bag did not have a privacy cover. She explained that the resident's catheter bag needed to be covered for privacy and dignity. An interview on 3/15//23 at 11:25 AM, with the Director of Nursing (DON), she confirmed that a resident's urine catheter bag would need to be covered for the privacy and dignity of the resident. Record review of the Admission Record revealed Resident #80 was admitted to the facility on [DATE] with medical diagnoses that included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/23 revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 08, which indicated his cognition was moderately impaired. Record review of the Order Summary Report revealed Resident #80 had a Physician's Order, dated 2/22/23, for a Foley (Indwelling) catheter.

Based on observations, staff interviews, record review and facility policy review the facility failed to prevent the possible spread of infection as evidenced by staff not properly wearing face masks, covering the nose and mouth and not performing hand hygiene between each meal tray passed and tray set up for one (1) of four (4) days of survey. Findings Include: Review of the facility's policy, Hand Sanitizing Procedure, revised 06/2018, revealed, .It is the policy of this facility to use hand sanitizer .as a substitute between hand washing when hands are not visibly soiled or dirty. Hand sanitizer will be used between each meal tray passed and tray set up . Review of the facility's policy, Interim COVID-19 Visitation Policy, revised 09/22, revealed, .Policy Explanation and Guidelines .4. The core principles of COVID-19 infection prevention will be adhered to as follows . f. A face covering or mask (covering the mouth and nose) in accordance with Centers for Disease Control (CDC) guidance .i. Staff will adhere to the appropriate use of personal protective equipment (PPE) . An observation and interview on 3/13/23 at 10:05 AM, revealed Licensed Practical Nurse (LPN) #1 was standing at her medication cart in the hallway with her face mask pulled down below her chin, not covering her mouth or nose. During an interview at this time with LPN #1, she revealed she should have had her mask pulled up over her nose and that it was the facility's policy that the staff wear masks properly to prevent the spread of infection. An observation and interview on 3/13/23 at 10:08 AM, revealed Housekeeping Staff #1 in the hallway delivering clean clothes to resident rooms. Her face mask was below her chin and did not cover her mouth and nose. On interview, Housekeeping Staff #1 confirmed that it was the policy of the facility that the staff wear mask appropriately to prevent the spread of infection. She stated, I had a coughing spell and pulled it down. An observation and interview on 3/13/23 at 11:40 AM, revealed Certified Nurse Assistant (CNA) #1 delivered lunch trays to resident rooms and did not perform hand hygiene between each meal tray passed. Her face mask was pulled below her nose and did not cover her mouth and nose. This observation then revealed that CNA #1 entered the dining room on the B hall, set up three residents lunch trays and then sat down and started feeding an Unsampled Resident without performing hand hygiene and her face mask was not covering her nose. An interview at this time with CNA #1 confirmed that she should have her mask pulled up over her nose. She stated, It keeps slipping down. She confirmed that she did not perform hand hygiene before delivering meal trays to residents rooms or before feeding the resident. She revealed it is the policy of the facility that she is to perform hand hygiene before and after delivering meal trays and before feeding a resident. She confirmed it is the policy of the facility that staff are to wear mask. She stated, I'll go wash my hands now. She explained the purpose of wearing the face mask was to prevent the spread of COVID-19 and the purpose of handwashing was to prevent the spread of germs for the residents. In an interview on 3/14/23 at 11:03 AM, with Registered Nurse (RN) #1/Infection Preventionist, she confirmed that all staff and visitors are supposed to wear a face mask over their nose and mouth to prevent the spread of all kinds of things such as COVID-19 and the flu. In an interview on 3/14/23 at 11:15 AM, with RN #3/Staff Development, she confirmed that it is the policy of the facility that staff are to wear their mask and perform hand hygiene when feeding a resident. She confirmed that in-services had been conducted by the facility on handwashing and wearing face masks. In an interview on 3/15/23 at 3:15 PM, with the Director of Nurses (DON), she confirmed that it is the policy of the facility that staff are to wear a face mask over their nose and mouth and hand hygiene should be performed before feeding a resident. She revealed that the purpose of wearing face masks is to prevent the spread of droplets, germs, and bacteria that contain COVID-19, flu, and other things. In an interview on 3/16/23 at 8:30 AM, with the Administrator and the DON, revealed that in-services, such as handwashing and wearing face masks, are mandatory for all staff. The DON stated that some of their staff work at their sister facilities, and they sometimes attend the mandatory in-service at one of those facilities. Record review of the facility's In-Service Training revealed on 7/14/22, the facility provided training on Hand Hygiene, on 8/4/22 the facility provided training on Hand washing and mask, on 11/14/22 the facility provided training on Hand hygiene, on 12/7/22 the facility provided training on Hand Hygiene, and on 1/23/23 the facility provided training on Donning and Doffing PPE and Handwashing.

Based on observation, staff, resident and resident representative interview, record review and facility policy review the facility failed to provide storage bags for oxygen cannulas and nebulizer masks for three (3) of 23 residents receiving respiratory treatment. Resident's #11, #61 and #74 Findings include: Review of the facility's policy, Nebulizer and Oxygen Tubing Storage Policy, dated April 2007, revealed, .It is the policy of this facility to decrease the risk of potential and/or direct exposure to infectious diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment . The facility will replace all respiratory tubing's weekly. These tubings will be dated and stored in a dated plastic bag when not in use . Resident #11 On 03/13/23 at 04:12 PM, during an observation, Resident #11 had an Oxygen (O2) nasal cannula (NC) hanging on the bed's side rail and a nebulizer mask lying on the foot of the bed. The NC and the nebulizer mask were not stored in a storage bag. An interview on 03 /13/ 23 at 4:30 PM with Resident #11 revealed that the staff sometimes in the past had bags for oxygen and nebulizers, but they have not had them in a very long time. Record review of the Order Summary Report for Resident #11 revealed a Physician's Order, dated 12/21/2022, to Change neb (nebulizer) tubing weekly Wednesday .new storage bag when changed . Record review of the Admission Record revealed the facility admitted Resident #11 on 7/28/2021 with diagnoses including Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/23 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. Resident #61 An observation on 03/13/23 at 11:01 AM, revealed Resident #61's oxygen NC and nebulizer mask were not stored in a storage bag. The oxygen NC was draped on the concentrator and the nebulizer mask was laying on top of the nebulizer machine on the bedside table. An observation on 3/14/23 at 2:45 PM, revealed Resident #61 was wearing oxygen, but there was no bag in the room for storage. The Resident Representative (RR) stated that when the resident removes her oxygen, she just puts it on the bed. Resident #61's nebulizer mask was lying on top of the nebulizer machine, not in a storage bag. The RR was in the room and stated that normally there is not a bag in the room, but there was this morning. Record review of the Order Summary Report for Resident #61 revealed a Physician's Order, dated 7/10/20, to Change Neb/O2 tubing weekly on Wednesday .new storage bag when changed . Record review of the Admission Record revealed the facility admitted Resident #61 on 10/04/22 with diagnoses that included Heart Failure and Chronic Obstructive Pulmonary Disease. Record review of the Quarterly MDS with an ARD of 12/26/2022 revealed Resident #61 had a BIMS score of 13 which indicated she was cognitively intact. Resident #74 An observation on 03/13/23 at 10:15 AM, revealed Resident #74's nebulizer mask was lying on top of a nebulizer machine on a bedside table. The nebulizer mask was not stored in a storage bag. Record review of the Order Summary Report for Resident #74 revealed a Physician's Order, dated 3/08/23, to Change Neb/O2 tubing weekly on Wednesday new storage bag when changed . Record review of the Admission Record revealed the facility admitted Resident #74 on 12/01/22 with diagnoses that included Chronic Obstructive Pulmonary Disease, Unspecified Asthma, and Generalized Anxiety Disorder. Record review of the Admission MDS with an ARD of 12/8/2022 revealed Resident #74 had a BIMS score of 07 which indicated she had moderate cognitive impairment. In an interview on 03/14/23 at 3:01 PM, with Licensed Practical Nurse (LPN) #3, she stated that the oxygen cannulas and nebulizer masks should be stored in a zip lock bag, dated, and labeled to prevent them from getting contaminated. An interview on 3/14/23 at 3:10 PM, with Registered Nurse (RN) #2, she confirmed the oxygen cannulas and nebulizer masks were not stored in a zip lock bag yesterday, but they should have been. She stated they put them in bags this morning. She explained that the charge nurse and the cart nurse are responsible for making sure the cannulas and masks are stored properly. The cannulas and masks should be stored in bags because something could get spilled on them, they could get dropped on the floor, or touched by people that could cause contamination. An interview on 3/14/23 at 3:15 PM, with the Director of Nursing (DON), revealed the oxygen cannulas and nebulizer mask should be bagged when not in use due to bacteria and contamination. An interview on 03/16/23 at 09:39 AM, with the Administrator (ADM), confirmed the staff was not following the facility policy if they were not storing oxygen equipment in a plastic bag. An interview on 03/16/23 10:25 AM, with RN #1/Infection Preventionist, revealed the respiratory equipment not being in a bag is an infection control issue and storing it in a bags cuts down on the possibility of bacteria getting on them.

Based on observations, interviews, record reviews, facility investigation and facility policy review, the facility failed to timely assess a resident and obtain an ordered x-ray in a timely manner after complaint of pain of the left arm/shoulder for Resident #4, one (1) of four (4) residents reviewed. Resident #4 complained of pain in her left arm/shoulder and an X-ray was ordered on [DATE]. The X-ray was completed on 1/28/16 with a [DIAGNOSES REDACTED]. The failure to thoroughly assess and get the X-ray timely resulted in a delay of treatment for [REDACTED]. Findings include: The facility's policy entitled Resident Change in Condition, dated 2013, revealed the facility will promptly notify the resident, the attending physician and the resident's responsible party of changes in the resident's condition or status. The Charge Nurse will notify the resident's attending physician when the resident is involved in any incident that results in an injury, including injury of unknown source or significant change in the resident's physical, mental or psychosocial status. Observation and interview with Resident #4 on 2/9/16 at 10:45 AM revealed the resident in bed with her left arm in a sling. Resident #4 stated staff lifted her up and out of her chair in the Beauty Shop and broke her arm. Resident #4 stated after the staff broke her arm they lifted her back to bed with a lift. The facility's investigation report, written by the Director of Nursing (DON), revealed on 1/27/16 at approximately 3:00 PM, Resident #4 had complaints of left shoulder and neck area pain. The assessment by the nurse indicated Resident #4 had swelling and discoloration to the left outer upper arm area. The Hospice Nurse was notified and an order for [REDACTED]. Resident #4 was treated with pain medication and had a routine order for [MEDICATION NAME] 50 milligram (mg) Patch [MEDICATION NAME] every three (3) days and was given as ordered. On 1/28/16 at approximately 9:56 AM the facility received a fax indicating the results of Resident #4's X-Rays, which included an impacted non-displaced surgical neck [MEDICAL CONDITION], and the Nurse Practitioner (NP) was notified. Resident #4 was transferred to the emergency room (ER) related the left arm fracture. Resident #4 returned to the facility on [DATE] with a splint to the left arm and recommendations to follow up with the Orthopedic. This investigation revealed Resident #4 was at the Beauty Shop (on 1/26/16 per record) when she had a watery bowel movement (BM) and was transferred to her room to be changed, started sliding from her wheelchair and staff assisted her to bed to keep her from falling to the floor and was unable to wait and use a lift. The investigation revealed on 1/26/16 at 10:39 PM Resident #4 was administered as needed (PRN) pain medication for complaints of left shoulder/neck discomfort. The investigation concluded this was an unavoidable incident and no abuse occurred. Review of the Activity of Daily Living (ADL) sheet revealed Resident #4 was transferred and toileted on 1/26/16 at 9:35 AM. Review of Resident #4's Electronic Medication Administration Record [REDACTED]. Corresponding progress notes dated at the same times revealed Resident #4 complained of neck pain and left shoulder pain. There was no documented evidence of a physical assessment of Resident #4's neck or shoulder until 1/27/16 at 1:58 PM with a corresponding late entry in the progress notes. A review of the Nursing Assessment from the Hospice Nurse on 1/27/16 at 2:30 PM revealed an assessment of Resident #4 with swelling from her shoulder to her elbow with a purple bruise on her left arm, facial grimacing, and tearful with complaints of pain to her left arm. The Hospice Nurse documented she notified Resident #4's Primary Care Physician (PCP) and an X-Ray and Doppler was ordered of her left arm and the facility nurse was notified. Review of the Progress Notes for Resident #4 revealed a late entry on 1/27/16 at 3:00 PM by Registered Nurse (RN) #1 that Resident #4 had left arm pain. The progress note revealed RN #1 assessed Resident #4 and found swelling and skin discoloration to the left upper arm. Resident #4 complained of inability to move her extremity related to pain. RN #1 documented she notified the Medication Nurse to give Resident #4 PRN (as needed) medication for pain as ordered. RN #1 also documented new orders had been obtained by the Hospice Nurse by Resident #4's PCP for a Left Arm X-Ray and Doppler Study for Resident #4. Review of Physician orders [REDACTED]. Record review revealed an order to transfer Resident #4 to the emergency room (ER) related to (R/T) left arm X-Ray results, written on 1/29/16 at 4:00 PM as a late entry for 1/28/16 at 12:30 PM. Record review of the X-Ray report for Resident #4's left arm (humerus) which was reviewed on 1/28/16 at 9:11 AM, revealed a fracture to the upper left arm near the shoulder (impacted, non-displaced surgical neck [MEDICAL CONDITION]). This report also revealed Resident #4 had bony demineralization and Osteophyte present in the shoulder joint. The X-ray report documented pain and bruising as the reason for the X-ray. Review of the Physician's Progress Notes dated 2/5/16 revealed: patient with [MEDICAL CONDITION] (left upper extremity), fracture stable. Review of the physician consult (Orthopedic) dated 2/4/16 at 11:45 AM revealed a left proximal humerus fracture with a recommendation of a sling. In an interview with the Hospice Nurse on 2/10/16 at 1:50 PM revealed she received a call from the Hospice Health Aide (on 1/27/16) and was told Resident #4's left arm was swollen, tender to touch and a large bruise to her left arm and shoulder. The Hospice Nurse reported this information to the nurses at the Nurses Station and was told she hurts all the time. The Hospice Nurse stated she felt like Resident #4 needed an X-Ray. The Hospice Nurse stated the facility staff did not know Resident #4's arm was swollen and bruised until she notified them. The Hospice Nurse stated Resident #4 told her that she had notified the facility staff of her arm pain last night, all night. The Hospice Nurse then stated she called Resident #4's PCP around 3:10 PM (1/27/16) and obtained an order for [REDACTED]. The Hospice Nurse stated that it was the facility's responsibility to get the X-ray. The Hospice Nurse stated when she called to get the X-ray results the next day she discovered the X-ray had not been obtained. In an interview with Licensed Practical Nurse (LPN) #1 on 2/10/16 at 12:05 PM revealed she was on duty 1/26/16 when Resident #4 had to be brought back from the Beauty Shop because she had a BM (Bowel Movement).LPN #1 stated Resident #4 did not complain of pain to her. LPN #1 stated on 1/27/16 the Hospice CNA called her to Resident #4's room because the Resident complained of pain. LPN #1 stated she gave Resident #4 pain medication and documented in the NP book to be seen by the NP. LPN #1 stated the Hospice Nurse reported ordering an X-ray and Doppler for Resident #4's left arm around 3:00 PM, because she was getting ready to leave her shift. LPN #1 stated she reported this to the nurse coming on duty for the 3 PM to 11 PM shift. LPN #1 stated she did give Resident #4 ordered pain medication for complaints of pain to her left arm (on 1/27/16). In an interview with Registered Nurse (RN) #1 on 2/10/16 at 11:40 AM revealed she also works as the Unit Manager (UM) and stated the ordered X-Ray for Resident #4 should have been done the day it was ordered (1/27/16) and not the next day. RN #1 stated the X-Ray Company comes out when we call them and this was early in the day. RN #1 stated the X-Ray should have been called in sooner. RN #1 stated the RN/LPN is responsible for ensuring the X-ray company is notified of the need for an X-ray and sometimes the Hospice Nurse will call for the X-ray. RN #1 stated when the Hospice Nurse notified them of Resident #4's left arm being swollen, red and bruised, she then assessed Resident #4 and stated this was the first I had seen of it. In a phone interview with Resident #4's Physician on 2/10/16 at 10:45 AM revealed she gave an order for [REDACTED]. The Physician stated if a fracture is suspected the facility should send the resident out to the ER unless the family requests not to, then a mobile X-ray should be done in-house. An interview with Resident #4's Responsible Party (RP) on 2/9/16 at 12:57 PM revealed the facility reported to her the CNAs had to lift Resident #4 out of her wheelchair without using a lift related to her having a large loose bowel movement and slipping out of the wheelchair on 1/26/16. The RP stated the staff broke Resident #4's arm when they lifted her up. Resident #4's RP stated Resident #4 told her the staff was informed about her severe left arm pain when it occurred and reported the pain was so bad she felt like passing out and was nauseated but they did not do anything other than give her medication. Resident #4's RP also stated an X-Ray was ordered by the Hospice Nurse who told her the facility overlooked it. The RP stated Resident #4's incident occurred on 1/26/16 around 10:00 AM-11:30 AM and the X-ray was not obtained until 1/28/16, three day later. The RP stated this is unacceptable to me. I really have a problem with this. The RP stated Resident #4's arm was red, blue and swollen. Resident #4's RP stated Resident #4 no longer felt safe at the facility and requested to be transferred to another facility. Resident #4's RP stated she was being transferred today or tomorrow to another facility. In an interview with the Assistant Director of Nursing (ADON) on 2/10/16 at 1:26 PM revealed she was not aware of the incident with Resident #4 until the day after the injury occurred. She stated the nurse working the hall is responsible for making sure the X-Ray is done and reporting to the next shift for follow-up. The ADON stated if the facility had a Unit Manager (UM) that day they would have been responsible for making sure the X-Ray was done but the UM was not there. In a phone interview with the X-Ray company Office Manager (OM) on 2/10/16 at 12:10 PM revealed all calls were recorded and logged in when the facility calls for services. The OM stated the X-Ray was logged in at 1/27/16 at 10:23 PM and was not ordered stat so the X-Ray was done on 1/28/16 at 9:11 AM with the X-Ray report sent out at 9:52 AM (1/28/16). The OM stated if the facility had called the X-Ray in at 3:00 to 5:00 PM or earlier than 10:00 PM, it would have been done that day and not the next day. In a review of a written statement from Certified Nursing Assistant (CNA) #1, dated 1/28/16 for 1/26/16 at 9:40 AM, revealed Resident #4 was sliding from the wheelchair and was assisted by person assist. Interview with CNA #1 on 2/9/16 at 2:56 PM revealed Resident #4 did not complain of pain nor did she hear a pop when she and another CNA lifted the resident from the chair. In a review of a written statement from CNA #2, dated 1/28/16 , for 1/26/16 at 9:40 AM, revealed Resident #4 was assisted from the wheelchair to the bed by herself and another CNA because Resident #4 was sliding out of the wheelchair. Interview with CNA #2 on 2/9/16 at 2:20 PM revealed she assisted CNA #1 to lift Resident #4 from the chair to the bed on 1/26/15 and did not hear the resident complain of pain nor did she hear a pop. The Face Sheet revealed the facility admitted Resident #4 on 7/18/08 with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 12/21/15, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11 that indicated Resident #4 had moderate cognitive impairment.

Based on observation, interview, and record review the facility failed to obtain an X-ray in a timely manner for one (1) of four (4) residents reviewed, Resident #4, as evidenced by an ordered X-ray on 1/27/16 and not obtained until 1/28/16 with a result of a fractured left Humerus. The failure to obtain the X-ray timely resulted in delayed treatment for [REDACTED]. Findings include: Observation and interview with Resident #4 on 2/9/16 at 10:45 AM revealed the resident in bed with a sling to the left arm. Resident #4 stated staff lifted her out of her chair in the Beauty Shop and broke her arm. A review of the Nursing Assessment from the Hospice Nurse on 1/27/16 at 2:30 PM revealed an assessment of Resident #4. The assessment revealed swelling from the shoulder to the elbow with a purple bruise on her left arm. Resident #4 had facial grimacing, and was tearful with complaints of pain to her left arm. The Hospice Nurse documented she notified Resident #4's Physician and an X-Ray and Doppler was ordered of the left arm and she notified the facility nurse. Review of the Progress Notes for Resident #4 revealed a late entry on 1/27/16 at 3:00 PM by Registered Nurse (RN) #1, for documentation that Resident #4 had left arm pain. The progress note revealed RN #1's assessment of Resident #4 of swelling and skin discoloration to the left upper arm. Resident #4 complained of inability to move her extremity related to pain. RN #1 documented new orders had been obtained by the Hospice Nurse by Resident #4's Physician for a left Arm X-Ray and Doppler Study for Resident #4. Review of Physician orders [REDACTED]. Review of the X-Ray report for Resident #4's left arm (Humerus) which was reviewed on 1/28/16 at 9:11 AM, revealed a fracture to the upper left arm near the shoulder (impacted, non-displaced surgical neck [MEDICAL CONDITION]). Review of the physician's orders [REDACTED].#4 to the emergency room (ER) related to (R/T) left arm X-Ray results, written on 1/29/16 at 4:00 PM as a late entry for 1/28/16 at 12:30 PM. Review of the physician consult (Orthopedic) dated 2/4/16 at 11:45 AM revealed a left proximal Humerus fracture with a recommendation of a sling. An interview with the Hospice Nurse on 2/10/16 at 1:50 PM revealed she received a call from the Hospice Health Aide (on 1/27/16) and was told Resident #4's left arm was swollen, tender to touch and a large bruise to her left arm and shoulder. The Hospice Nurse reported this information to the nurses at the Nurses Station and was told she hurts all the time. The Hospice Nurse stated she felt like Resident #4 needed an X-Ray. The Hospice Nurse stated she called Resident #4's Physician around 3:10 PM (1/27/16) and obtained an order for [REDACTED]. The Hospice Nurse stated that it was the facility's responsibility to get the X-rays once ordered. The Hospice Nurse stated she called to get the X-ray results the next day and the X-ray had not been obtained. In an interview with Licensed Practical Nurse (LPN) #1 on 2/10/16 at 12:05 PM revealed on 1/27/16 the Hospice CNA called her to Resident #4's room because the Resident complained of pain. LPN #1 stated she gave Resident #4 pain medication and documented in the NP (Nurse Practitioner) book to be seen by the NP. LPN #1 stated the Hospice Nurse reported ordering an X-ray and Doppler for Resident #4's left arm around 3:00 PM, because she was getting ready to leave her shift. LPN #1 stated she reported this order to the nurse coming on duty for the 3 PM to 11 PM shift. An interview with Registered Nurse (RN) #1 on 2/10/16 at 11:40 AM revealed the ordered X-Ray for Resident #4 should have been done the day it was ordered (1/27/16) and not the next day. RN #1 stated the X-Ray Company comes out when they are called and this was early in the day. RN #1 stated the X-Ray should have been called in sooner. RN #1 stated the RN/LPN is responsible for calling the X-ray company and sometimes the Hospice Nurse calls. RN #1 stated when the Hospice Nurse notified them of Resident #4's left arm being swollen, red and bruised, she then assessed Resident #4. A phone interview with Resident #4's Physician on 2/10/16 at 10:45 AM revealed she gave an order for [REDACTED]. The Physician stated if a fracture is suspected the facility should send the resident to the ER. An interview with Resident #4's Responsible Party (RP) on 2/9/16 at 12:57 PM revealed she thought the staff broke Resident #4's arm when they lifted her on 1/26/16. Resident #4's RP stated an X-Ray was ordered by the Hospice Nurse who told her the facility overlooked it. The RP stated Resident #4's incident occurred on 1/26/16 around 10:00 AM-11:30 AM and the X-ray was not obtained until 1/28/16. The RP stated Resident #4's arm was red, blue and swollen. In an interview with the Assistant Director of Nursing (ADON) on 2/10/16 at 1:26 PM revealed she was not aware of the incident with Resident #4 until the day after the injury occurred. She stated the nurse working the hall is responsible for making sure the X-Ray is done and reporting to the next shift for follow-up. In a phone interview with the X-Ray company Office Manager (OM) on 2/10/16 at 12:10 PM revealed the X-Ray for Resident #4 was logged in at 1/27/16 at 10:23 PM and was not ordered stat so the X-Ray was done on 1/28/16 at 9:11 AM with the X-Ray report sent out at 9:52 AM (1/28/16). The OM stated if the facility had called the X-Ray in at 3:00 to 5:00 PM or earlier than 10:00 PM, it would have been done that same day and not the next day.

Based on record review, staff interview, and facility policy review, the facility failed to ensure that physician orders regarding the administration of medications were followed for six (6) of 16 sampled residents and two (2) Unsampled Residents. The facility failed to notify the Physician that medications were being held without orders (Resident #1, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9). The facility failed to transcribe and follow the physician's orders as written as related to [MEDICATION NAME] therapy (Unsampled Resident A). In addition, the facility failed to ensure that the physician's orders and pharmacy label matched for Unsampled Resident B. Resident #1 did not receive [MEDICATION NAME] 5 milligrams (mg) as ordered by the Physician on 1/13/12, 1/14/12 and 1/25/12 (used to control blood pressure). Resident #5 did not receive [MEDICATION NAME] 50 milligram tablet as ordered by the Physician on 1/15/12, 1/16/12, 1/22/12, 2/8/12, and 2/14/12 (used to control blood pressure). Resident #5 received [MEDICATION NAME] 40 mg at 5:00 p.m. on 2/23/12. The Physician Order stated for Resident #5 to receive [MEDICATION NAME] 80 mg twice a day for [MEDICAL CONDITION]. Resident #6 did not receive [MEDICATION NAME] 2 mg/ml q (every) HS (hour of sleep) as ordered by the Physician on 1/3/12, 1/4/12, 1/5/12, 1/6/12, 1/7/12, 1/8/12, 1/9/12, 1/13/12, 1/14/12, and 1/21/12 or 2/1/12, 2/2/12, 2/3/12, 2/4/12, 2/5/12, 2/6/12, 2/7/12, 2/9/12, 2/11/12, 2/13/12, 2/14/12, 2/15/12, 2/16/12, 2/17/12, 2/18/12, 2/19/12, 2/20/12 and 2/21/12. Resident #7 did not receive a [MEDICATION NAME] Patch 50 mcg (microgram)/hr (hour) as ordered by the Physician on 2/3/12 to control pain. Resident #8 did not receive a [MEDICATION NAME] 50 mg tablet as ordered by the Physician on 2/4/12. Resident #9 did not receive the [MEDICATION NAME] 0.5 mg treatments as ordered by the Physician q 12 hours at 8:00 a.m. on 1/10/12 and 8:00 p.m. on 2/16/12 and 2/18/12. Unsampled Resident A received [MEDICATION NAME] 4 mg on 2/23/12 (anticoagulant). A Physician's Order was written on 2/22/12 to withhold the [MEDICATION NAME] 4 mg until the INR (International Normalizing Ratio) was less than three (3) and to check the INR daily. Unsampled Resident B received [MEDICATION NAME] 2 mg at 6:20 p.m. on 2/23/12. The Physician's Order stated " [MEDICATION NAME] 2 mg give ? (one half) at HS (hour of sleep). The medication label received from the pharmacy did not match the physician's order. During the investigation, the facility was found not to be in compliance with the requirements for Medicare and Medicaid. A partially extended survey was conducted on 2/20/12 - 2/24/12. An Immediate Jeopardy identified at a "L" scope and severity and substandard quality of care was identified on 2/22/12 at 2:10 p.m. The Administrator and the Director of Nursing (DON) were notified at that time. The facility submitted an Allegation of Compliance (AoC) on 2/23/12 and it was determined not to be acceptable due to the facility having medication errors after the facility alleged that the Allegation of Compliance (AoC) was implemented. The Immediate Jeopardy (IJ) was not removed upon exit from the facility on 2/24/12 and is considered ongoing. Findings Include: Resident #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/12 revealed an Brief Interview for Mental Status (BIMS) score of one (1) which indicated severe cognitive impairment. Observation of Resident #1 was conducted on 2/20/12 at 11:20 a.m. and revealed Resident #1 was in bed eating his lunch meal. Resident #1 was able to state his name. Review of Resident #1's computerized Physician Orders for 1/12 revealed an order on 10/22/10 for [MEDICATION NAME] 5 mg tablet po daily " for Hypertension. Review of Resident #1's Medication Administration Record (MAR) for 1/12 revealed that the [MEDICATION NAME] 5 mg tablet daily for hypertension spaces and initials were circled on the dates of 1/5/12, 1/9/12, 1/13/12, 1/14/12, 1/15/12, 1/21/12 and 1/25/12. Review of Resident #1's " Nurses PRN (as needed) Notes " revealed " 1/5, 1/9, 1/15, 1/21, 1/24 " 2012 " BP (Blood Pressure) meds (medications) held." There was no documentation as to why the medication was held. Resident #1 did not receive [MEDICATION NAME] 5 milligrams (mg) as ordered by the Physician on 1/13/12, 1/14/12, and 1/25/12. (Please note that [MEDICATION NAME] is an antihypertensive medication). The [MEDICATION NAME] 5 mg was a routine scheduled medication and the order did not state to withhold the [MEDICATION NAME] 5 mg. Review of Resident #1's MAR for 2/2012 revealed that the [MEDICATION NAME] 5 mg tablet for hypertension spaces and initials were circled on the dates of 2/1/12, 2/4/12, 2/7/12, 2/9/12, 2/10/12, 2/11/12, 2/12/12, 2/13/12, 2/14/12, 2/15/12 and 2/16/12. There was no indication of why the medication was held. Resident #1 did not receive [MEDICATION NAME] 5 milligrams (mg) as ordered by the Physician on 2/1/12, 2/4/12, 2/7/12, 2/9/12, 2/10/12, 2/11/12, 2/12/12, 2/13/12, 2/14/12, 2/15/12 and 2/16/12. Review of a document titled "Medication Error Report", dated 2/22/12, and revealed that Resident #1 had a Physician order for [REDACTED]. The "Reason for making the error: Nurse held blood pressure medication without ordered parameters from physician" and "Could the error have endangered the life or welfare of the resident" was marked "Yes, adverse effects were possible". The precautions that could be taken to prevent a similar error was "Obtain orders for parameters and in-service staff". That document was signed by Licensed Practical Nurse (LPN) #1, the DON and the attending physician on 2/23/12. Resident #5 Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's quarterly MDS with an ARD of 12/31/11 revealed a BIMS score of 11 which indicated the Resident was cognitively intact. Review of Resident #5's computerized Physician Orders for January 2012 revealed and order for " 10/28/08 [MEDICATION NAME] 50 mg tablet (1) po q day " . Review of Resident #5's 1/2012 MAR revealed that the spaces for the [MEDICATION NAME] 50 mg tablet the MAR contained initials that were circled on 1/15/12, 1/16/12, and 1/18/12 indicating that the [MEDICATION NAME] 50 mg tablet for hypertension was not administered. There was no reason documented as to why the medication was not administered. Review of Resident #5's 2/2012 MAR revealed that the spaces for the [MEDICATION NAME] 50 mg tablet on the MAR had initials that were circled on 2/8/12 and 2/14/12, indicating that the [MEDICATION NAME] 50 mg tablet for hypertension was not administered as ordered by the Physician. Review of Resident # 5's Physician Orders for 1/2012 and 2/2012 revealed no Physician Order to withhold the [MEDICATION NAME] ([MEDICATION NAME]) 50 mg tablet for the dates of 1/15/12, 1/16/12, 1/18/12, 2/8/12 or 2/14/12. Review of a document titled "Medication Error Report" , dated 2/22/12, revealed that Resident #5 had a Physician order for [REDACTED]. Review of the form revealed the following: "Reason for making the error: Nurse held blood pressure medication without ordered parameters from physician " and "Could the error have endangered the life or welfare of the resident" had been marked, with the qualifier of "Yes, adverse effects were possible" indicated. The precautions that could be taken to prevent a similar error were "Obtain orders for parameters and in-service staff". That document was signed by LPN #1, the DON and the attending physician on 2/23/12. Resident #5 Observation of Resident #5 on 2/23/12 at 5:00 p.m. revealed that LPN #1 administered [MEDICATION NAME] 40 mg to Resident #5. Review of Resident #5's computerized Physician Orders dated 2/2012 revealed an order "11/08/11 on [MEDICATION NAME] 80 mg tablet po BID" with a [DIAGNOSES REDACTED]. Review of Resident #5's MAR dated 2/2012 revealed "[MEDICATION NAME] 80 mg tablet po BID" to be administered at 8:00 a.m. and 4:00 p.m. There was no documentation indicating that Resident #5 was to receive [MEDICATION NAME] 40 mg as administered on 2/23/12 at 5:00 p.m. Review of Resident #5's medication package revealed "2/22/12 [MEDICATION NAME] 80 mg substituted for [MEDICATION NAME] 80 mg Take 1 tablet by mouth in the morning and ? tablet (40 mg) in the evening". Further review of the medical record revealed that an order had been written in 9/11 for "[MEDICATION NAME] 80 mg tablet (1) po q a.m.; [MEDICATION NAME] 40 mg tablet (1) po q p.m. @ 5 PM " . That order changed on 11/8/11 by note of a handwritten Physician Order " Increase [MEDICATION NAME] to 80 mg i (one) BID " which was typed on the 12/2011 computerized Physician Orders with "11/8/11" handwritten in as a date change from 11/11/11. (The MAR was correct; however, the medication package label was incorrect). Interview and review of Resident #5's Physician Orders was conducted with LPN #3 on 2/23/12 at 5:55 p.m. It was confirmed that the most current Physician's Order was for Resident #5 to receive [MEDICATION NAME] 80 mg BID, not [MEDICATION NAME] 80 mg in the a.m. and [MEDICATION NAME] 40 mg in the p.m., as was administered. A notation provided by the facility, and confirmed by the Pharmacy, indicated that the Pharmacy was notified on 2/24/12 regarding the medication change. Review of a document titled "Medication Error Report" revealed that the Medication Given" to Resident #5 was " [MEDICATION NAME] 80 mg q a.m. & [MEDICATION NAME] 40 mg q p.m. " The Physicians Orders was " [MEDICATION NAME] 80 mg PO bid " . Review of the docuement "Medication Error Report revealed the following: " Reason for making error: dispense(d) from pharmacy as 80 mg tab alterna(ting) with ? tab 40 mg dose in Bubble pack. Nurse was administer(ing) dose as dispense & documenting [MEDICATION NAME] 80 mg bid." and "What precautions can you take to prevent a similar error? Inservice (inservice) on 5 (five) patient rights & drug administration " were noted/checked. The document was signed by the Assistant Director of Nursing and the Physician. The document was not signed by the nurse who made the medication error on 2/23/12. Review of a document title "Medication Administration TEST" was signed and dated by LPN #3 on 2/22/12. That test included the listing of the five rights of medication administration which were listed as "Right Resident, Right Route, Right Dose, Right Time, Right Medication" . Resident #6 Review of Resident #6's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's computerized Physician Orders for 1/2012 revealed an order "12/22/11 [MEDICATION NAME] 2 mg/ml Oral Concentrate Give 1 ml PO q HS r/t (related to ) restlessness" . Review of Resident #6's MAR for 2/2012 revealed initials with circles, indicating the medication was not administered on the dates of 1/3/12, 1/4/12, 1/5/12, 1/6/12, 1/7/12, 1/8/12, 1/9/12, 1/13/12, 1/14/12, and 1/21/12. (There was no documentation as to why the medication was held). Review of Resident #6's computerized Physician Orders for 2/2012 revealed an order "12/22/11 [MEDICATION NAME] 2 mg/ml Oral Concentrate Give 1 ml PO q HS r/t (related to ) restlessness" . Review of Resident #6's MAR for 2/2012 revealed initials with circles on the dates of 2/1/12, 2/2/12, 2/3/12, 2/4/12, 2/5/12, 2/6/12, 2/7/12, 2/9/12, 2/11/12, 2/13/12, 2/14/12, 2/15/12, 2/16/12, 2/17/12, 2/18/12,2/20/12 and 2/21/12. There was no documentation in the space for 2/19/12. (There was no documentation as to why the medication was held.) Resident #6 did not receive [MEDICATION NAME] 2 mg/ml q (every) HS (hour of sleep) as ordered by the Physician on 1/3/12, 1/4/12, 1/5/12, 1/6/12, 1/7/12, 1/8/12, 1/9/12, 1/13/12, 1/14/12, and 1/21/12 or2/1/12, 2/2/12, 2/3/12, 2/4/12, 2/5/12, 2/6/12, 2/7/12, 2/9/12, 2/11/12, 2/13/12, 2/14/12, 2/15/12, 2/16/12, 2/17/12, 2/18/12, 2/19/12, 2/20/12 and 2/21/12. (There was no documentation as to why the medication was held). Observation of Resident #6 was conducted on 2/22/12 at 3:25 p.m. Resident #6 was sitting on his bed and did not respond to questions. Resident #6's son, who was in the room, reported that Resident #6 was very hard of hearing. Interview with the DON on 2/22/12 at 8:30 a.m. revealed that the family will refuse for Resident #6 to receive the [MEDICATION NAME] at HS (hour of sleep). Resident #7 Review of Resident #7's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #7's computerized Physician Orders dated 2/2012 revealed an order " 6/07/11 [MEDICATION NAME] Patch 50 mcg/hr (1) patch applied topically q 3 days". The patch was ordered for a [DIAGNOSES REDACTED]. Review of Resident #7's 2/2012 MAR revealed no documented evidence that the [MEDICATION NAME] Patch 50 mcg/hr was applied as scheduled on 2/3/12. Review of the "Controlled Drug Record" for Resident #7 revealed no documented evidence that the [MEDICATION NAME] Patch 50 mcg/hr was signed out to be administered on 2/3/12. Review of Resident #7's 2/2012 MAR revealed documentation that the nursing staff had documented initials in the spaces for "Check placement of [MEDICATION NAME] Patch q shift" on the 7 a.m. - 3 p.m. shift on 2/3/12, 2/4/12 and 2/5/12 indicating that the [MEDICATION NAME] was checked for placement every shift on the dates of 2/3/12, 2/4/12 and 2/5/12. The [MEDICATION NAME] was not signed out as being administered but was on the MAR as being checked and in place. Review of the facility policy "Checking Placement of Medication Patches" dated 3/2008 revealed: "POLICY - It is the policy of this facility that medications administered by way of dermal patches, have placement verified q shift. PROCEDURE - The Medication Nurse will administer the medication by Physician's ordered instruction. The patch will be dated and initialed when placed on the resident. The nurse when on medication pass rounds will verify the location of all medication dermal patches on the resident's body. This will be done by the nurse observing the patch and documenting on the MAR the coded location and verification by initial that the patch is indeed in place and in use on the resident's body. " Review of Resident # 7's "Nurse's PRN Notes" revealed no documented evidence of why the [MEDICATION NAME] Patch 50 mcg was not applied to Resident #7 as ordered on [DATE]. Observation of Resident #7 was conducted on 2/20/12 at 3:20 p.m. and revealed the Resident was lying in the bed with the head of bed elevated. A feeding of Glucerna 1.5 was infusing per pump at 50 cc (cubic centimeters) per hour. Resident #7 was able to state her name. Interview with the DON on 2/22/12 at 4:11 p.m. was conducted regarding the [MEDICATION NAME] Patch not being applied. As of 2/24/12 at 11:45 a.m. there was no explanation as to why the [MEDICATION NAME] Patch was not administered as ordered. Resident #7 did not receive a [MEDICATION NAME] Patch 50 mcg (microgram)/hr (hour) which was to be applied on 2/3/12. Please note that the [MEDICATION NAME] Patch is a pain medication and was ordered for " Pressure Ulcer, Buttock " . There was no Physician Order to withhold the [MEDICATION NAME] Patch. Resident #8 Review of Resident #8's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's annual MDS with an ARD of 1/12/12 revealed a BIMS score of zero (0) indicating severe cognitive impairment. Review of Resident #8's computerized Physician Orders for 2/2012 revealed an order "8/24/11 [MEDICATION NAME] 50 mg tablet (1) po BID @ 9 AM & 5 PM ***If pulse < 60 BPM (beats per minute), hold med & call MD" with a [DIAGNOSES REDACTED]. Review of Resident #8's MAR for 2/2012 revealed initials with circles in the spaces on 2/4/12 indicating that Resident #8 did not receive [MEDICATION NAME] 50 mg tablet as ordered by the Physician on 2/4/12 at 9:00 a.m. (The [MEDICATION NAME] was a routine scheduled medication). The Physician's Order stated, " If pulse < (less than) 60 BPM (beats per minute), hold med (medication) & (and) call MD (Medical Doctor) " . Resident #8's pulse on 2/4/12 at 9:00 a.m. was documented as 87 BPM (beats per minute). There was no Physician Order to withhold the [MEDICATION NAME] 50 mg on 2/4/12. Observation of Resident #8 was conducted on 2/20/12 at 3:15 p.m. and revealed the resident was lying on the bed. Resident #8 was awake and alert and could state her name. Interview on 2/22/12 at 4:11 p.m. with the DON was conducted regarding the [MEDICATION NAME] not being administered as ordered. Review of Resident #8's computerized Physician Orders dated 2/2012 revealed an order for [REDACTED]. Review of the Controlled Drug Record revealed no documented evidence that the [MEDICATION NAME] 50 mg was signed out to be administered as ordered at 9:00 a.m. on 2/4/12 and 2/5/12. Documentation on the Medication Administration Record dated 2/2012 revealed that the [MEDICATION NAME] 50 mg was not administered on 2/4/12 at 9:00 a.m. There was no documentation of why it was not administered. The documentation for 2/5/12 indicated the [MEDICATION NAME] 50 mg had been administered at 9:00 a.m. Resident #9 Review of Resident #9's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #9 is currently under hospice care. Review of Resident #9's computerized Physician Orders for 1/2012 and 2/2012 revealed an order "12/21/11 [MEDICATION NAME] 0.5 mg-3 mg/3 ml soln (solution) (1 vial) q 12 hours". Review of Resident #9's MAR for 1/2012 revealed no documented evidence that the [MEDICATION NAME] 0.5 mg treatment was performed on 1/10/12 (at 8:00 a.m. or 8 p.m.), on 2/16/12, or on 2/18/12 (at 8:00 p.m.) as ordered by the Physician. (The [MEDICATION NAME] was a routine scheduled procedure for [MEDICAL CONDITION]). There was no Physician Order to withhold the [MEDICATION NAME] treatment on 1/10/12, 2/16/12 and 2/18/12. Observation of Resident #9 was conducted on 2/22/12 at 5:15 p.m. and revealed the resident was sitting in a chair. Resident #9 was able to state his name. A patch was observed on Resident #9. Upon questionning, Resident #9 reported continued problems with pain management. Resident #9 indicated that his continued pain contributed to problems with eating. Upon futher investigation, it was revealed that Resident #9's pain management regime was changed from pills to patches, as Resident #9 had been observed pocketing pain pills administered to him; therefore, pain patches were ordered, and an order was written to discontinue pain medication on 2/9/12. Unsampled Resident A Review of Unsampled Resident A's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of a Medication Pass for Unsampled Resident A was conducted on 2/23/12 at 5:40 p.m. and revealed LPN #2 administered [MEDICATION NAME] four (4) mg to Unsampled Resident A. Review of Unsampled Resident A's 2/2012 MAR revealed, "[MEDICATION NAME] 4 mg 1 (one) po q day @ PM Start 2-11-12 " . Review of the Physician Orders revealed "2/22/12 (10:00 a.m.) N.O. (New Order) Hold [MEDICATION NAME] until INR is less than 3 (three). Repeat PT ([MEDICATION NAME] Time)/INR q day until INR is less than 3. [MEDICATION NAME] will then be resumed @ (at) a lower dose. " Review of Unsampled Resident A's laboratory results dated "2/21/2012" revealed, "[MEDICATION NAME] 43.2 seconds Normals 9.8-13.2" "INR 4.6 Ratio 0.8 -1.2" and a hand written notation "9/22 hold [MEDICATION NAME] rept (repeat) PT/INR q day. Will resume on (arrow down indicating lower) dose when INR is < 3." (The date should have been 2/22/12). Review of Unsampled Resident A's Nurses Notes dated "2/22/12" revealed "10 A Dr. (doctor) {Medical Director} phoned c (with) PT/INR of 43.2/4.6. N.O. to hold [MEDICATION NAME] & draw daily PT/INRs until INR is <3-then a lower dose [MEDICATION NAME] will be ordered. RP (Responsible Party) notified." Review of Unsampled Resident A's Laboratory results revealed: "2/23/12 [MEDICATION NAME] 36.5 INR 3.8" with a han- written notation "already holding [MEDICATION NAME] & doing q day PT/INR" . Review of the Laboratory test for Unsampled Resident A dated 2/24/12 revealed the [MEDICATION NAME] to be 38.4 seconds and the INR 4.0. Interview conducted with Registered Nurse (RN) #7 and LPN #2 on 2/23/12 at 5:55 p.m. confirmed the Physician's order to hold Unsampled Resident A ' s [MEDICATION NAME] until the INR was <3 had not been written on the MAR to alert LPN #2 not to administer the [MEDICATION NAME] on 2/23/12 at 6:00 p.m. RN #7 reviewed the INR for 2/23/12 and reported it to be 3.8. Review of a document titled "Medication Error Report" dated 2/24/12 revealed that the error related to the administration of the [MEDICATION NAME] 4 mg to Unsampled Resident A on 2/23/12 occurred on 2/22/12 at 6:00 p.m. The Physicians order was "Hold [MEDICATION NAME] until INR is less than 3". The reason for making the error was documented as "Nurse did not transcribe order to MAR". "Could the error have endangered the life or welfare of the resident " was answered "Yes" with the explanation of "Elevated INR level can lead to active bleeding. Type of drug". "What precautions can you take to prevent a similar error?" was answered with "In-service on transcribing orders correctly and following the 5 rights of medication administration." The Medication Error document was signed by the nurse making the error and the ADON on 2/23/12 and the attending physician on 2/24/12. Unsampled Resident B Review of Unsampled Resident B's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of the Medication Pass conducted on 2/23/12 at 6:20 p.m. revealed LPN #3 to administer [MEDICATION NAME] 2 mg to Unsampled Resident B. Review of Unsampled Resident B's computerized Physician Orders dated 2/2012 revealed an order for [REDACTED].? po q hs" for convulsions. Review of Unsampled Resident B's "Controlled Drug Record" revealed the label and instructions to read "[MEDICATION NAME] 2 mg tablet Substituted for [MEDICATION NAME] 2 mg Tablet take 1 Tablet by mouth twice daily " Review of the package of Unsampled Resident B's [MEDICATION NAME] package revealed, "[MEDICATION NAME] 2 mg tablet Substituted for [MEDICATION NAME] 2 mg tablet Take 1 tablet by mouth at bedtime. " The pharmacy label did not match the physician order for [REDACTED]. Unsampled Resident B received [MEDICATION NAME] 2 mg at 6:20 p.m. on 2/23/12. The Physician Order stated "[MEDICATION NAME] 2 mg give ? (one half) at HS (hour of sleep)". There was no Physician order for [REDACTED]. Review of a document title "Medication Administration TEST" was signed and dated by LPN #3 on 2/22/12. That test included the listing of the five rights of medication administration which were listed as "Right Resident, Right Route, Right Dose, Right Time, Right Medication" . Review of the facility policy " ranscribing Physicians Orders" dated "5/2003" revealed: "POLICY - It is the policy of this facility to transcribe and follow the attending physicians orders as written with order clarification obtained when needed. PROCEDURE - Orders will be followed and medications will be administered according to the prescribed physicians instruction and according to state regulation. Orders will be transcribed and noted by a licensed nurse in a timely manner. Transcription will be carried out to appropriate administration records, i.e., MAR and TAR. Medical records nurse will audit daily any orders written for accuracy and correct transcription. Medical records nurse will be responsible for input of all orders appropriately into the computer system. End of month printing will take place and all MARs, TARS, and physicians orders will be reviewed for accuracy. Any new orders written will be put on the 24 hour report that is reviewed by the RN unit manager and/or DON daily." Review of the facility policy "MEDICATION ORDERING AND RECEIVING FROM PHARMACY PROVIDER" , with no date of implementation, revealed on page 43: "b. Receiving Medications from the Pharmacy. *1) A licensed nurse: a) receives medications delivered to the facility and documents delivery on the medication delivery form (Form 13) if one is not provided with the medications delivered. b) verifies medications received and directions for use with the medication order form (Form 11). c) Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor " The facility submitted an Allegation of Compliance (AoC) on 2/23/12 and it was determined during a medication pass for verification of the corrective actions that the AoC was not implemented. The Immediate Jeopardy at an "L" level was not removed upon exit from the facility on 2/24/12 and is considered to be ongoing.

Based on observation, record review, staff interview and policy review the facility failed to consult with residents' physicians prior to withholding blood pressure medications for six(6) of sixteen (16) residents reviewed (Resident #1, Resident #5, Resident #6, Resident # 7, Resident # 8 and Resident #9, as well as failed to notify the physician of a significant medication error regarding a resident on [MEDICATION NAME] therapy (Unsampled Resident A). During the investigation, the facility was found not to be in compliance with the requirements for Medicare and Medicaid. A partially extended survey was conducted on 2/20/12 - 2/24/12. An Immediate Jeopardy identified at a "L" scope and severity and substandard quality of care was identified on 2/22/12 at 2:10 p.m. The Administrator and the Director of Nursing (DON) were notified at that time. The facility submitted an Allegation of Compliance (AoC) on 2/23/12 and it was determined not to be acceptable due to the facility having medication errors after the facility alleged that the Allegation of Compliance (AoC) was implemented. The Immediate Jeopardy (IJ) was not removed upon exit from the facility on 2/24/12 and is considered ongoing. Findings Include: Cross-refer to F281 for findings related to medications being held without physician notification, as well as the occurrence of a significant medication error without physician notification. Review of the facility policy "A Matter of Rights: A Guide to Your Rights and Responsibilities as a Resident" revealed on page seven, "To have your physician and legal representative or interested family member notified if: there is significant change in your condition; your treatment needs to be changed significantly".

Based on observation, record review, staff interview and facility policy review the facility failed to ensure that a medication error rate of 5% or less was maintained. This was evidenced by the medication pass conducted on 2/23/12 revealing three (3) medication errors out of 40 opportunities resulting in a 7.5% medication error rate. This was for Resident #5, Unsampled Resident A and Unsampled Resident B. An Immediate Jeopardy at a scope and severity of a "L" and substandard quality of care was identified on 2/22/12 at 2:10 p.m. in regards to physician's orders not being followed for the administration of medications. The Administrator and the Director of Nursing (DON) were notified at that time. The facility submitted an Allegation of Compliance (AoC) on 2/23/12. During the verification of the implementation of corrective actions, a medication pass observation was conducted. It was determined that the Immediate Jeopardy at a "L" scope and severity could not be removed due to continued non-compliance regarding administering medications as ordered by the physician. On 2/24/12, the Immediate Jeopardy at a "L" level was considered to be on going. Findings Include: Resident #5 Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 ' s quarterly MDS with an ARD of 12/31/11 revealed a BIMS score of "11" which indicated the Resident was cognitively intact. Observation of Resident #5 on 2/23/12 at 5:00 p.m. revealed that Licensed Practical Nurse (LPN) #3 administered [MEDICATION NAME] 40 mg to the Resident. Review of Resident #5 ' s computerized Physician Orders dated 2/2012 revealed an order " 11/08/11 [MEDICATION NAME] 80 mg tablet po BID " with a [DIAGNOSES REDACTED]. Review of Resident #5 ' s MAR dated 2/2012 revealed " [MEDICATION NAME] 80 mg tablet po BID " to be administered at 8:00 a.m. and 4:00 p.m. There was no documentation indicating that Resident #5 was to receive [MEDICATION NAME] 40 mg as administered on 2/23/12 at 5:00 p.m. Review of Resident #5 ' s medication package revealed " 2/22/12 [MEDICATION NAME] 80 mg substituted for [MEDICATION NAME] 80 mg Take 1 tablet by mouth in the morning and ? tablet (40 mg) in the evening " . Further review of the medical record revealed that an order had been written in 9/11 for " [MEDICATION NAME] 80 mg tablet (1) po q AM; [MEDICATION NAME] 40 mg tablet (1) po q pm @ 5 PM " . That order changed on 11/8/11 by note of a handwritten Physician Order " Increase [MEDICATION NAME] to 80 mg i (one) BID " which was typed on the 12/2011 computerized Physician Orders with " 11/8/11 " handwritten in as a date change from 11/11/11. Interview and review of Resident #5 ' s Physician Orders was conducted with LPN #3 on 2/23/12 at 5:55 p.m. and there was confirmation that the most current Physician's Order was for Resident #5 to receive [MEDICATION NAME] 80 mg BID, not [MEDICATION NAME] 80 mg in the a.m. and [MEDICATION NAME] 40 mg in the p.m. as was administered. Review of a document titled " Medication Error Report " revealed that the " Medication Given " to Resident #5 was " [MEDICATION NAME] 80 mg q am & [MEDICATION NAME] 40 mg q pm " The Physicians Orders was " [MEDICATION NAME] 80 mg PO bid " . The " Reason for making error: dispense(d) from pharmacy as 80 mg tab alterna(ting) with ? tab 40 mg dose in Bubble pack. Nurse was administer(ing) dose as dispense & documenting [MEDICATION NAME] 80 mg bid. " " What precautions can you take to prevent a similar error? Inserve (inservice) on 5 (five) patient rights & drug administration " . That document was signed by the Assistant Director of Nursing and the Physician. The document was not signed by the nurse who made the medication error on 2/23/12. Review of a document title " Medication Administration TEST " was signed and dated by LPN #3 on 2/22/12. That test included the listing of the five rights of medication administration which were listed as " Right Resident, Right Route, Right Dose, Right Time, Right Medication " . Unsampled Resident A Review of Unsampled Resident A ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of a Medication Pass for Unsampled Resident A was conducted on 2/23/12 at 5:40 p.m. and revealed LPN #2 to administer [MEDICATION NAME] four (4) mg to Unsampled Resident A. Review of Unsampled Resident A ' s 2/2012 MAR revealed, " [MEDICATION NAME] 4 mg i (one) po q day @ 6pm Start 2-11-12 " . Review of the Physician Orders revealed " 2/22/12 10 A (10:00 a.m.) N. O. (New Order) Hold [MEDICATION NAME] until INR is less than 3 (three). Repeat PT ([MEDICATION NAME] Time)/INR q day until INR is less than 3. [MEDICATION NAME] will then be resumed @ (at) a lower dose. " Review of Unsampled Resident A ' s laboratory results dated " 2/21/2012 " revealed, " [MEDICATION NAME] 43.2 seconds Normals 9.8-13.2 " " INR 4.6 Ratio 0.8 -1.2 " and a hand written notation " 9/22 hold [MEDICATION NAME] rept (repeat) PT/INR q day. Will resume on (arrow down indicating lower) dose when INR is < 3. " Review of Unsampled Resident A ' s Nurses Notes dated " 2/22/12 " revealed " 10 A Dr. (doctor) {Medical Director} phoned c (with) PT/INR of 43.2/4.6. N.O. to hold [MEDICATION NAME] & draw daily PT/INRs until INR is <3-then a lower dose [MEDICATION NAME] will be ordered. RP (Responsible Party) notified. " Review of Unsampled Resident A ' s Laboratory results revealed: " 2/23/2012 [MEDICATION NAME] 36.5 INR 3.8 " with a hand written notation " already holding [MEDICATION NAME] & doing q day PT/INR " . Review of the Laboratory test for Unsampled Resident A dated 2/24/12 revealed the [MEDICATION NAME] to be 38.4 and the INR 4.0. Interview conducted with Registered Nurse (RN) #7 and LPN #2 on 2/23/12 at 5:55 p.m. confirmed that the order to hold Unsampled Resident A ' s [MEDICATION NAME] until the INR was <3 had not been written on the MAR to alert LPN #2 not to administer the [MEDICATION NAME] on 2/23/12 at 6 p.m. RN #7 reviewed the INR for 2/23/12 and reported it to be 3.8. Review of a document titled " Medication Error Report " dated 2/24/12 revealed that the error related to the administration of the [MEDICATION NAME] 4 mg to Unsampled Resident A on 2/23/12 occurred on 2/22/12 at 6:00 p.m. The Physicians order was " Hold [MEDICATION NAME] until INR is less than 3 " . The reason for making the error was documented as " Nurse did not transcribe order to MAR " . " Could the error have endangered the life or welfare of the resident " was answered " Yes " with the explanation of " Elevated INR level can lead to active bleeding. Type of drug " . " What precautions can you take to prevent a similar error? " was answered with " In-service on transcribing orders correctly and following the 5 rights of medication administration. " The Medication Error document was signed by the nurse making the error and the ADON on 2/23/12 and the attending physician on 2/24/12. Unsampled Resident B Review of Unsampled Resident B's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of the Medication Pass conducted on 2/23/12 at 6:20 p.m. revealed LPN #3 to administer [MEDICATION NAME] 2 mg to Unsampled Resident B. Review of Unsampled Resident B's computerized Physician Orders dated 2/2012 revealed an order for [REDACTED].? po q hs" for convulsions. Review of Unsampled Resident B's "Controlled Drug Record" revealed the label and instructions to read "[MEDICATION NAME] 2 mg tablet Substituted for [MEDICATION NAME] 2 mg Tablet take 1 Tablet by mouth twice daily" . Review of the package of Unsampled Resident B's [MEDICATION NAME] package revealed, "[MEDICATION NAME] 2 mg tablet Substituted for [MEDICATION NAME] 2 mg tablet Take 1 tablet by mouth at bedtime " The pharmacy label did not match the physician order for [REDACTED]. Review of the facility policy "Transcribing Physicians Orders" dated "5/2003" revealed: "POLICY - It is the policy of this facility to transcribe and follow the attending physicians orders as written with order clarification obtained when needed. PROCEDURE - Orders will be followed and medications will be administered according to the prescribed physicians instruction and according to state regulation. Orders will be transcribed and noted by a licensed nurse in a timely manner. Transcription will be carried out to appropriate administration records. ie MAR and TAR. Medical records nurse will audit daily any orders written for accuracy and correct transcription. Medical records nurse will be responsible for input of all orders appropriately into the computer system. End of month printing will take place and all MARs, TARS, and physicians orders will be reviewed for accuracy. Any new orders written will be put on the 24 hour report that is reviewed by the RN unit manager and/or DON daily " Review of the facility policy "MEDICATION ORDERING AND RECEIVING FROM PHARMACY PROVIDER" , with no date of implementation, revealed on page 43: "b. Receiving Medications from the Pharmacy. *1) A licensed nurse: a) receives medications delivered to the facility and documents delivery on the medication delivery form (Form 13) if one is not provided with the medications delivered. b) verifies medications received and directions for use with the medication order form (Form 11). c) Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor."

Based on observation, record review, staff interview and policy review the facility to ensure that there were no significant medication errors. This was for one (1) out of 40 medications observed during the medication pass. This was for Unsampled Resident A. Unsampled Resident A received [MEDICATION NAME] 4 mg on 2/23/2012 at 5:40 p.m. The [MEDICATION NAME] was supposed to be held and not administered until the INR was 3 or less. An Immediate Jeopardy at a scope and severity of an "L" and substandard quaility of care was identified on 2/22/12 at 2:10 p.m. in regards to physician's orders not being followed for the administration of medications.The Administrator and the Director of Nursing (DON) were notified at that time. The facility submitted an Allegation of Compliance (AoC) on 2/23/12. During the verification of the implementation of corrective actions, a medication pass observation was conducted. It was determined that the Immediate Jeopardy at a "L" scope and severity could not be removed due to the medication errors. On 2/24/12, the Immediate Jeopardy at a "L" level was considered to be on going. Findings Include: Unsampled Resident A Review of Unsampled Resident A's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of a Medication Pass for Unsampled Resident A was conducted on 2/23/12 at 5:40 p.m. and revealed that LPN #2 administered [MEDICATION NAME] four (4) mg to Unsampled Resident A. Review of Unsampled Resident A's 2/2012 MAR revealed, " [MEDICATION NAME] 4 mg 1 (one) po q day at 6:00 p.m. Start 2-11-12". Review of the Physician Orders revealed "2/22/12 10 A (10:00 a.m.) N. O. (New Order) Hold [MEDICATION NAME] until INR is less than 3 (three). Repeat PT ([MEDICATION NAME] Time)/INR q day until INR is less than 3. [MEDICATION NAME] will then be resumed @ (at) a lower dose." Review of Unsampled Resident A ' s laboratory results dated "2/21/12" revealed, "[MEDICATION NAME] 43.2 seconds Normals 9.8-13.2 " "INR 4.6 Ratio 0.8 -1.2" and a hand written notation "9/22 hold [MEDICATION NAME] rept (repeat) PT/INR q day. Will resume on (arrow down indicating lower) dose when INR is < 3". Review of Unsampled Resident A's Nurses Notes dated "2/22/12" revealed "10 A Dr. (doctor) {Medical Director} phoned c (with) PT/INR of 43.2/4.6. N.O. to hold [MEDICATION NAME] & draw daily PT/INRs until INR is <3--then a lower dose [MEDICATION NAME] will be ordered. RP (Responsible Party) notified". Review of Unsampled Resident A's Laboratory results revealed: "2/23/12 [MEDICATION NAME] 36.5 INR 3.8" with a hand-written notation "already holding [MEDICATION NAME] & doing q day PT/INR" . Review of the Laboratory test for Unsampled Resident A dated 2/24/12 revealed the [MEDICATION NAME] to be 38.4 and the INR 4.0. Interview conducted with Registered Nurse (RN) #7 and LPN #2 on 2/23/12 at 5:55 p.m. confirmed that the order to hold Unsampled Resident A's [MEDICATION NAME] until the INR was less than 3 had not been written on the MAR; therefore, LPN #2 was not alerted regarding the change in administration of [MEDICATION NAME] (for the 2/23/12 6:00 p.m. medication pass). RN #7 reviewed the INR for 2/23/12 and reported it to be 3.8. Review of a document titled "Medication Error Report" dated 2/24/12 revealed that the error related to the administration of the [MEDICATION NAME] 4 mg to Unsampled Resident A on 2/23/12 occurred on 2/22/12 at 6:00 p.m. The Physician's order was written: " Hold [MEDICATION NAME] until INR is less than 3 " . The reason for making the medication error was documented as " Nurse did not transcribe order to MAR" . "Could the error have endangered the life or welfare of the resident " was answered " Yes " with the explanation of " Elevated INR level can lead to active bleeding. Type of drug " . " What precautions can you take to prevent a similar error " was answered with " In-service on transcribing orders correctly and following the 5 rights of medication administration. " The Medication Error document was signed by the nurse making the error and the ADON on 2/23/12 and the attending physician on 2/24/12. Review of the facility policy " Transcribing Physicians Orders " dated " 5/2003 " revealed: " POLICY - It is the policy of this facility to transcribe and follow the attending physicians orders as written with order clarification obtained when needed. PROCEDURE - Orders will be followed and medications will be administered according to the prescribed physicians instruction and according to state regulation. Orders will be transcribed and noted by a licensed nurse in a timely manner. Transcription will be carried out to appropriate administration records. ie MAR and TAR. Medical records nurse will audit daily any orders written for accuracy and correct transcription. Medical records nurse will be responsible for input of all orders appropriately into the computer system. End of month printing will take place and all MARs, TARS, and physicians orders will be reviewed for accuracy. Any new orders written will be put on the 24 hour report that is reviewed by the RN unit manager and/or DON daily. " Review of the facility policy " MEDICATION ORDERING AND RECEIVING FROM PHARMACY PROVIDER " , with no date of implementation, revealed on page 43: " b. Receiving Medications from the Pharmacy. *1) A licensed nurse: a) receives medications delivered to the facility and documents delivery on the medication delivery form (Form 13) if one is not provided with the medications delivered. b) verifies medications received and directions for use with the medication order form (Form 11). c) Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. "

Based on observation, record review, staff interview and policy review, the facility failed to ensure that the process of acquiring, receiving, storing, controlling and reconciling of medications was followed. This was evidenced by the following: inconsistencies in documentation of narcotic count reconciliation; failure to ensure that all medications were accounted for (Resident #4 Lidoderm Patches); the Controlled Drug Record did not match the amount of narcotic in the bottle (Resident #6, Resident #7, Resident #8, Unsampled C Ativan and Morphine Sulfate); and opening of the back of the bubble packs of medications as if administered (Resident #12, Resident #13, Resident #14, Resident #15, and Resident #16). These issues were noted as related to two (2) of four (4) medication carts, on three (3) nursing units, and ten (10) of sixteen (16) residents reviewed (Resident #4, Resident #6, Resident #7, Resident #8, Resident #9, Resident #12, Resident #13, Resident #14, Resident #15 and Resident #16 ) and two (2) of sixteen (16) Unsampled Residents reviewed (Unsampled Resident C and Unsampled Resident P). The facility failed to ensure that a process of identifying, evaluating and addressing medication issues related to the prevention and reporting of medication inconsistencies was followed. This was confirmed by the review of Controlled Drug Records for Medication Carts on the B and C Hall and observation of the remaining narcotics. There was inconsistent documentation of the reconciliation of liquid narcotic medications at the shift change, incorrect narcotic counts, and bottles containing medications that were not accurate, Fentanyl Patches not being documented as administered to Resident #7, and medications (Lidoderm 5% Patches) that were delivered to the facility with no record of the disposition of those medications. An Immediate Jeopardy at a scope and severity of an "L" was identified on 2/22/12 at 2:10 p.m. regarding physician's orders not being followed for the administration of medications.The Administrator and the Director of Nursing (DON) were notified at that time. The facility submitted an Allegation of Compliance (AoC) on 2/23/12. During the verification of the implementation of corrective actions, a medication pass observation was conducted. It was determined that the Immediate Jeopardy at a "L" scope and severity could not be removed due to the continued medication errors. On 2/24/12, the Immediate Jeopardy at a "L" level was considered to be on going Findings Include: B Hall Medication Room Observation conducted in the B Hall Medication Room on 2/20/12 at 1:10 p.m. with Registered Nurse (RN) # 2 in attendance revealed: Resident #12 Atarax 25 mg filled 9/21/11, bubble pack had three (3) tears on the foil on the back of the bubble pack at the location of pills #5, #15 and #23. There was a pill remaining in the #15 bubble but no pill in the #5 or #23 bubbles. Resident #13 Theo 24 caps filled on 2/13/12, bubble pack had one (1) tear on the foil on the back of the bubble pack at the location of pill #9. The pill remained in the packet. Resident #14 Renagel 800 mg filled on 1/27/12, bubble pack had one (1) tear on the foil on the back of the bubble pack at the location of pill #31. The pill remained in the packet. Resident #15 Synthroid 150 micrograms (mcg) filled on 2/17/12, bubble pack had eight (8) tears on the foil on the back of the bubble pack at the location of pills # seven (7) through #14. The tears were uniform in appearance from pill #8 to pill #14. Resident #16 Zestoretic 20/12.5 mg filled 2/17/12 bubble pack had three (3) tears on the foil on the back of the bubble pack at the location of pills #29, #30 and #31. The tears were uniform in appearance. Observation of the packages containing medications and torn foil and interview with the Pharmacy Consultant was conducted on 2/21/12 at 2:10 p.m. and confirmed the torn areas on the back of the bubble packs for Resident #12, Resident #13, Resident #14 and Resident #16. There was no explanation to determine how the foil on the bubble packs had been damaged. Review of the facility policy "Medication Packaging" revealed (on page 57) "c. Any problems noted with packaging of a medication are reported immediately to the provided pharmacy." Resident #4 Review of Resident #4's medical record revealed an admission date of [DATE] and a readmission date of [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/7/12 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that Resident #4 was cognitively intact. Observation of Resident #4 was conducted on 2/20/12 at 11:20 a.m. and revealed the resident was sitting in the bedroom, in a chair, eating the lunch meal. Resident #4 was able to state her name. Review of Resident #4's Physician Orders from 10/11 thru 2/12 revealed an order dated 10/4/11 for a Lidoderm 5% (five percent) Patch to be applied topically to the back and right shoulder every day as needed. Review of Resident #4's MAR for 10/11 revealed that a patch was applied on 10/12/11 and 10/31/11. The MAR for 11/11 revealed that a patch was applied on 11/8/11, 11/14/11, 11/16/11, 11/18/11, 11/19/11, and 11/21/11. The MAR for 12/11 revealed that a patch was applied on 12/14/11 and 12/30/11. The MAR for 1/12 revealed that a patch was applied 1/26/12 and 1/29/12.There was no documentation that any patches were applied in 2/2012. Resident #4 had a total of 12 patches applied to the Resident in five (5) months. Review of the Delivery Manifest (from the Pharmacy) revealed that Resident #4 had a delivery of 30 Lidoderm Patches on 10/5/11, 11/9/11, 11/21/11,12/30/11, to total 120 Lidoderm Patches delivered to the facility. Twelve (12) Lidoderm Patches were documented to have been applied to Resident #4 for the time period 10/11 through 2/12. A total of 108 Lidoderm Patches were not accounted for by the facility. Observation of Resident #4's medications in the medication cart on B Hall was conducted on 2/20/12 at 12:55 p.m. with LPN #5 in attendance. There were no Lidoderm Patches on the Medication Cart. By the end of survey on 2/24/12, there was no accounting of the missing 108 Lidoderm 5% patches. Review of Resident #4's 10/4/11 admission orders [REDACTED]. Review of Resident #4's Respiratory Treatment Record for 10/2011 revealed that one (1) Albuterol Sulfate treatment was performed on 10/11/11; the 1120/11 Respiratory Treatment Record revealed no treatments were performed; one (1) treatment was indicatede on 12/1/11; zero (0) treatments were indicated for 1/2012; zero (0) treatments in 2/2012. Therefore, two (2) Respiratory Treatments were indicated to have been performed from 10/2011 to 2/2012. Review of the Drug Manifest revealed that on 10/5/11, 180 ml Albuterol Sulfate pouches were delivered to the facility. The 180 ml pouches were delivered in 1 ml packets of 30 packets per pouch. Observations of the medications on the medication cart for Resident #4 on 2/12/12 at 12:55 p.m. revealed that there were no Albuterol Sulfate pouches on the cart to administer to Resident #4. Interview with and documentation provided by the Administrator on 2/23/12 at 9:14 a.m. revealed that there was documentation from the pharmacy that two (2) sixty-count boxes of Albuterol Sulfate had been delivered, but cthat the Albuterol Sulfate could not be accounted for. Resident #6 Review of Resident #6's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #6 was conducted on 2/22/12 at 3:25 p.m. Resident #6 was sitting on his bed and did not respond to surveyor's questions. Resident #6's son, who was in the room, reported that Resident #6 was very hard of hearing. Review of Resident #6's computerized Physician Orders for 2/2012 revealed an order dated 12/29/11 for Morphine Sulfate 100 mg (milligrams)/ 5 ml (milliliter) solution to be given two (2) ml every 2 hours as needed. The order changed to one (1) ml to be administered q 2 hours as needed on 1/27/12. Observation of the bottle containing the Morphine Sulfate on 2/21/12 at 4:25 p.m. revealed that 32 doses remained in the bottle. Review of the Controlled Drug Record revealed that on 1/17/12 40 doses remained to be administered. That left eight (8) doses unaccounted for. The last dose of Morphine medication was documented as being administered on 1/17/12. Review of Resident #6's computerized Physician Orders for 2/2012 revealed an order for [REDACTED]. Review of the Controlled Drug Record revealed a documented total of 40 doses remaining to be administered. That left a total of 20 doses of Lorazepam (Ativan) unaccounted for. Resident #7 Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #7 was conducted on 2/20/12 at 3:20 p.m. and revealed the Resident was lying in the bed with the head of the bed elevated. A feeding of Glucerna 1.5 was infusing per pump at 50 cc (cubic centimeters) per hour. Resident #7 was able to state her name. Observation of the Medication Cart on the C Hall on 2/21/12 at 4:25 p.m. with Licensed Practical Nurse (LPN) #4 revealed that Resident #7 had a bottle of Morphine Sulfate liquid. The amount remaining on the Controlled Drug Record revealed that 59 doses of Morphine Sulfate remained to be administered. Observation of the bottle that contained the Morphine Sulfate revealed that 13 milliliters (ml) remained in the bottle.which equaled to 52 doses remaining in the bottle which meant that seven (7) doses of the medication were unaccounted for. The dosage was documented on the Controlled Drug Record to administer 0.25 ml of Morphine Sulfate. There was no documented physician order on the 2/2012 computerized Physician Orders. The last date that the medication was administered was 1/18 (no year was documented). Review of Resident #7's computerized Physician Orders dated 2/2012 revealed an order "6/07/11 Duragesic Patch 50 mcg/hr (1) patch applied topically q 3 days". The patch was ordered for a [DIAGNOSES REDACTED]. Review of Resident #7's 2/2012 MAR indicated [REDACTED]. Review of the "Controlled Drug Record" for Resident #7 revealed no documented evidence that the Duragesic Patch 50 mcg/hr was signed out to be administered on 2/3/12. Review of Resident #7's 2/2012 MAR indicated Check placement of Duragesic Patch q shift" on the 7 a.m.-3 p.m. shift on 2/3/12, 2/4/12 and 2/5/12 indicating that the Duragesic patch was checked for placement every shift on the dates of 2/3/12, 2/4/12 and 2/5/12. Interview was conducted with the Director of Nursing on 2/23/12 beginning at 8:00 a.m. related to the Duragesic Patch not being documented as signed out or administered to Resident #7 on 2/3/12. By the end of survey on 2/24/12, no explanation had been provided to the surveyor. Resident #8 Review of Resident #8's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's annual MDS with an ARD of 1/12/12 revealed a BIMS score of zero (0) indicated severe cognitive impairment. Observation of Resident #8 was conducted on 2/20/12 at 3:15 p.m. and revealed the resident to be lying on the bed. Resident #8 was awake and alert and could state her name. Review of Resident #8's computerized Physician Orders for 2/2012 revealed an order for [REDACTED]. Observation of the Controlled Drug Record revealed that there were 109 doses (22 ml) remaining in the bottle to be administered. Observation of the bottle of Morphine Sulfate revealed that there were 22 ml in the bottle which would equal to 88 doses of Morphine Sulfate remaining to be administered. That left 21 doses unaccounted for. The last dose was administered on 12/20/11. The bottles of medication and reviews of the Controlled Drug Record of Resident #6 Morphine Sulfate and Ativan, Resident #7's Morphine Sulfate and Resident #8 Morphine Sulfate was conducted with the Consultant Pharmacist and Licensed Practical Nurse (LPN) #4 in attendance on 2/21/12 at 4:25 p.m. The Consultant Pharmacist verified the amounts of medication remaining in the bottles and the amount of doses remaining on the Controlled Drug Record to be administered to Residens #6, Resident #7 and Resident #8. Resident #9 Observation of the Controlled Drug Destruction conducted by the Consultant Pharmacist and the DON on 2/22/12 at 11:00 a.m. revealed that Resident #9 had a Controlled Drug Record for Morphine Sulfate ER (Extended Release) 30 mg to be administered with one (1) 15 mg Morphine Sulfate ER tablet. The documentation on the Controlled Drug Record revealed that 17 Morphine Sulfate ER 30 mg tablets should remain instead of the 16 that were in the bottle for destruction. Resident #9 had Controlled Drug Record for Morphine Sulfate ER 15 mg to be administered with one (1) 30 mg Morphine Sulfate ER. The documentation on the Controlled Drug Record revealed that 17 Morphine Sulfate ER 15 mg tablets should remain instead of the 16 that were in the bottle for destruction. Interview with the DON and the Pharmacy Consultant on 2/22/12 at 12:30 p.m. confirmed that a dose was not accounted for in each bottle. Review of the MAR for Resident #9 revealed that the medication (Morphine Sulfate ER x 1 30 mg tablet and 15 mg tablet x 1) had been documented as administered on 2/9/12 but not signed out on the Controlled Drug Destruction record. Unsampled Resident C Review of Unsampled Resident C's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Unsampled Resident C's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation pm 2/23/12 at 2:58 p.m. with LPN #5 and LPN #6 of Unsampled Resident C ' s bottle of Morphine Sulfate revealed that there was five (5) ml, which would equal to 20 doses remaining in the bottle. The documentation on the Controlled Drug Record revealed that six (6) doses remained in the bottle. Interview with LPN #5 and LPN #6 on 2/23/12 at 2:28 p.m. revealed that the nursing staff look at the book (Control Drug Record) to see how many doses remain documented and then look at the bottle. LPN #5 and LPN #6 confirmed that the facility has no way to count the medication accurately because the calculations performed were for doses not milliliter. LPN #5 and LPN #6 confirmed that the bottle contained 20 doses of Morphine Sulfate and the Controlled Drug Record had documented 6 doses remaining to be administered leaving a total remaining in the bottle of 14 additional doses with no explanation of why there was more in the bottle than on the Controlled Drug Record. Unsampled Resident P Review of Unsampled Resident P's medical record revealed an admission date of [DATE], with a readmission date of [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Unsampled Resident P's PRN MAR indicated give 0.5 ml q one (1) hour as needed" beginning 2/6/12. Review of the Controlled Drug Record for Roxinal 20 mg/ml revealed that 30 does had been delivered to the facility on [DATE], with one (1) dose administered on 2/16/12. The order was changed on 2/21/12, to give 0.25 ml every one (1) hour as needed. the controlled Drug Record (page 2) showed that 59 doses were carried over to that form. Interview with LPN #7 on 2/23/12 at 3:05 p.m. confirmed that the order for Unsampled Resident P ' s Roxinal (Morphine) 20 mg/ml had changed from0.5 ml to be administered prn to 0.25 ml to be administered prn on 2/21/12. LPN #7 stated that a scored syringe was sent with the medication for administration. Interview with the ADON and the Consultant Pharmacist on 2/23/12 at 3:10 p.m. confirmed that the dosage amounts on the Controlled Drug Record were incorrect. It should have been noted on Page 1 when the amount to be administered was 0.5 ml per dose that 60 doses were in the bottle and on Page 2 when the dose changed to 0.25 ml per dose that 120 doses should have been documented. The staff did not know how to calculate the amount of doses to compare to the amount of medication remaining in the bottle. The bottle of Roxinal (Morphine) that was delivered to the facility contained 30 ml. The staff filled out a new Controlled Drug Record on 2/23/12 and documented that 120 doses remained in the bottle.

Based on record review, staff interview, consultant pharmacist interview, and policy review, the facility failed to ensure that the process of acquiring, receiving, storing, controlling and reconciling of medications was followed. This was evidenced by inconsistencies in documentation of narcotic count reconciliation, and failure to ensure that the medications were administered to Residents as ordered by the Physician, failure to account for all medications as evidenced by 108 missing Lidoderm 5% Patches, and inaccurate medication labels from the pharmacy. The facility also failed to ensure that a process of identifying, evaluating and addressing medication related issues related to the prevention and reporting of medication inconsistencies. This was evidenced by inconsistent documentation by nursing staff (Medication Nurses) for the reconciliation of narcotic medication at the shift change resulting in incorrect narcotic counts. An Immediate Jeopardy at a scope and severity of an "L" was identified on 2/22/12 at 2:10 p.m. in regards to the physician's orders [REDACTED].The Administrator and the Director of Nursing (DON) were notified at that time. The facility submitted an Allegation of Compliance (AoC) on 2/23/12. During the verification of the implementation of corrective actions, a medication pass observation was conducted. It was determined that the Immediate Jeopardy at a "L" scope and severity could not be removed due to continued medication errors. On 2/24/12, the Immediate Jeopardy at a "L" level was considered to be on going. Findings Include: Cross refer to F-425 for additional information related to the facilities failure to monitor the process of acquiring, receiving, storing, controlling and reconciling the medications.

Based on observation, record review, staff interview, medication pass observation and facility policy review the facility failed to be administered in a manner that enabled resident's to attain or maintain the highest practicable physical well being of residents residing in the facility. The facility failed to ensure that physician's orders [REDACTED]. that a process of identifying, evaluating and addressing medication issues related to the prevention and reporting of medication inconsistencies. This was evidenced by inconsistent documentation by nursing staff (Medication Nurses) for the reconciliation of narcotic medication at the shift change resulting in incorrect narcotic counts. This practice had the potential to affect all resident's residing in the facility. An Immediate Jeopardy at a scope and severity of an "L" and substandard quality of care was identified on 2/22/12 at 2:10 p.m. in regards to physician's orders [REDACTED].The Administrator and the Director of Nursing (DON) were notified at that time. The facility submitted an Allegation of Compliance (AoC) on 2/23/12. During the verification of the implementation of corrective actions, a medication pass observation was conducted. It was determined that the Immediate Jeopardy at a "L" scope and severity could not be removed due to continued non-compliance regarding administering medications as ordered by the physician. On 2/24/12, the Immediate Jeopardy at a "L" level was considered to be on going. Findings Include: Cross refer findings to F281 for the facility's failure to ensure that the physician's orders [REDACTED]. Cross refer findings to F332 for the facility's failure to ensure that medication errors were equal to or less than 5%. Cross refer findings to F333 for the facility's failure to ensure that a significant medication error did not occur with the administration of [MEDICATION NAME]. Cross refer findings to F425 for the facility's failed to ensure that a process of identifying, evaluating and addressing medication issues related to the prevention and reporting of medication inconsistencies was followed. This was confirmed by the review of Controlled Drug Records for Medication Carts on the B and C Hall and observation of the remaining narcotics. There were inconsistent documentation of the reconciliation of liquid narcotic medications at the shift change, incorrect narcotic counts, and bottles containing medications that were not accurate, [MEDICATION NAME] Patches not being documented as administered to Resident #7, and medications ([MEDICATION NAME] 5% Patches) that were delivered to the facility and no record of the disposition of those medications. Cross refer findings to F431 for the facility's failure to ensure that the process of acquiring, receiving, storing, controlling and reconciling of medications was followed. This was evidenced by inconsistencies in documentation of narcotic count reconciliation, and failure to ensure that the medications were administered to Residents as ordered by the Physician, failure to account for all medications as evidenced by 108 missing [MEDICATION NAME] 5% Patches, and inaccurate medication labels from the pharmacy.

Based on observation, record review, staff interview and policy review, the facility failed to implement measures and to promote healing to prevent three (3) of five (5) residents reviewed from acquiring avoidable pressure areas (Resident #1, # 4 and #5). Resident #1 had no documentation of an unstageable pressure area to the sacral area when he was transferred to the hospital on [DATE]. Resident #4 had a redevelopment of a pressure ulcer to the foot. CNA's removed the dressing to the foot and failed to notify the nursing staff. Resident #5 had a history of [REDACTED]. Resident #5 continued to scoot in the wheelchair and developed a pressure area to the coccyx. There were no additional implementations in place to prevent the resident from scooting in the wheelchair. Findings Include: RESIDENT #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. Review of the Admission Assessment Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was assessed to be severely impaired in cognitive skills for daily decision making. Resident #1's bed mobility was coded as requiring extensive assistance of two (2) persons to physically assist the resident in turning. Resident #1 was identified to be incontinent of bowel and bladder. The MDS indicated that Resident #1 had not pressure ulcers at the time of the assessment. Resident #1 was identified to be at risk for the development of pressure ulcers. Review of the "Section M1200 - Skin and Ulcer Treatments" revealed that none of the following interventions were in place to prevent pressure ulcer development: "Pressure reducing device for chair/bed; Turning/repositioning program; or Nutrition or hydration intervention to manage skin problems." Review of the complaint, received by the State Licensing Agency from the facility, revealed a letter dated January 21, 2011 that stated: "(Resident #1) also has a substantial bed sore on his rear end. The sore is so bad that the doctor at the hospital recommended surgery to remove dead tissue deep inside the sore. My father is too frail for surgery so the hospital staff was and the hospice staff are now caring for the sore the best they can." Review of the Nurses Progress Notes on 12/01/10 at 12:00 revealed that Resident #1 was in the hospital from 11/04/10 through 11/17/10. On 11/30/10 " a coccyx crease tear was noted measuring 3 cm by 2 cm by .1 cm. An order was received for a [MEDICATION NAME] dressing to be changed every three (3) days. There was documentation in the Nurses Progress Notes on 12/09/10 at 4:05 p.m. that the coccyx skin tear measured 2.4 cm by .1 cm by .1 cm. with a light pink wound bed noted. On 12/17/10 it was documented in the Nurses Progress Notes that the coccyx crease skin tear was closed. Review of the Care Plan for Resident #1 revealed: "11/23/10 - Problem: Incontinent of bowel and bladder." Interventions included: "Perform body audit weekly." "Monitor skin condition daily and report any problems to nurse." "11/30/10 - Problem: Resident is at risk for pressure ulcer formation." Interventions stated: "Assist to turn & (and) reposition q (every) 2 (hours) & prn (as needed)." "Incont (Incontinent) care q 2 & prn. Moisture barrier Q shift." "Maintain pressure reducing mattress." "Assess for & report all red areas." "Ensure adequate nutrition & hydration." "Weekly skin & body audit per assigned nurses c (with) +/- (positive/negative) impairments documented." Review of a "Temporary Care Plan Problem List" revealed on 11/30/10 "coccyx tear in crease (buttock)." It was noted on 12/17/10 as being resolved. Review of the Nurses Notes on 01/09/11 at 09:35 a.m. for Resident #1 revealed: "Physician returned the call and ordered the resident to be sent to the ER (emergency room ) r/t (related to ) (arrow down indicating decreased) LOC (level of consciousness) and (arrow up indicating an elevation) temp (temperature)." "1025 - Resident transferred from bed to stretcher per (company name) paramedics. Left facility to ER". Review of the emergency room Initial Assessment Form for Resident #1 revealed an admission date of [DATE] at 10:46 a.m. and was subsequently transferred to the Nursing Unit at 02:05 p.m. Review of the Admission History & Physical by the hospital dated 01/09/11 revealed: "He has a severe ulcer with some red discoloration central eschar in his sacral iliac area bilaterally. He has a rash on his buttocks and posterior upper thighs." The IMPRESSION was documented as "Multiple [MEDICAL CONDITION] including decubitus ulcer tears and a number of purpura." Review of a CONSULTATION dated 01/09/11 for Resident #1 revealed: "BRIEF SUMMARY: This is an [AGE] year-old bedridden white male who has been a couple of days positive for fever of unknown etiology, possible [MEDICAL CONDITION] in nature. We are asked to see him because of wounds under the arms, on the legs, and on the sacral area." "PHYSICAL EXAMINATION: The sacral area though has a linear dark ulcer and a very grove between the buttocks at this time with a second dark area on the left gluteal region. There is a dark skin that has not broken down completely that extends over the right gluteal area for very broad area of almost 15 cm in size (NOTE: 1 inch= 2.5 cm). The is no deep induration or drainage at this time." "IMPRESSION: Unstageable sacral decubitus ulcer." "RECOMMENDATIONS: (3). The sacral area is unstageable at this time, may require eventual deep debridement but at this time with no sign of infection, we will go ahead and just start [MEDICATION NAME] and safe gel only account of keep it clean and moist and I will try get the sacral Alvin pad to the area and attempt to try to offload and protect this area as best we can." The INITIAL ASSESSMENT documented by hospital Nursing Staff for Resident #1 dated 01/09/11 revealed the following documentation: " PRESSURE AREA #1 Location: Buttocks." "Stage: III (3)" (Note Stage III was described as Subcutaneous tissue exposed)." "Size in Cms: 6 x 8 cms." "Appearance: Dark Purple & red." "1530 Lg (large) purplish decubitus to buttocks." Review of a PROGRESS NOTE dated 01/10/11 (from hospital) revealed "He has some sacral decubitus abnormalities which are fairly severe. See photographs in chart". There was no documented evidence of the unstageable sacral decubitus in the nursing facility's documentation. An interview with the facility Director of Nursing (DON) on 02/25/11 at 08:55 a.m. revealed when asked if Resident #1 had any skin breakdown: "Only excoriation I know about was December 17 (2010)". The DON stated that the son of Resident #1 had visited the facility and showed her the pictures of Resident #1's skin breakdown that had been taken by the hospital when Resident #1 was admitted on [DATE]. She stated that she was "unaware of that." Interview with the attending Physician at the hospital on [DATE] at 01:10 p.m. confirmed that the decubitus was present upon admission to the hospital and "did not get on the ambulance." "What is indisputable is the ulcers- that is a definite--should have been documented". The Physician stated that he had cared for Resident #1 for [AGE] years and that he had a lot of problems. Interview with the facility Administrator on 02/25/11 at 03:00 p.m. revealed that the son of Resident #1 had brought black and white pictures from the hospital for the Director of Nursing to review and "we had difficulty seeing the black and white pictures and what he wanted - he was more concerned about making sure we follow up for other residents." The color pictures provided by the hospital were shared with the Director of Nursing, the Administrator and two (2) nursing consultants of the facility on 02/25/11 at 03:45 p.m. The pictures showed the aforementioned areas that were present on Resident #1's coccyx upon admission to the hospital. The last documented skin assessment for Resident #1 was performed on 01/03/11 and no additional areas of concern were noted on that assessment. There was no documented assessment from 01/03/11 thru 01/09/11 that confirmed that Resident #1 did not have the above stated pressure ulcer at the facility. Review of a document completed by RN #2 on 02/25/11 revealed: "Resident was transferred to (Name of Hospital) ER at 10 am on 01/09/11 due to respiratory complications, [MEDICAL CONDITION], and decreased LOC. I did not complete a body audit or remove his ace wraps on his legs before he left because I was more concerned with his respiratory complications. The wraps were removed on the 11-7 shift as ordered. No new skin abnormalities noted when 11-7 shift removed wraps. Due to his acute status, I focused more on getting him sent to the hospital." A bath list was provided which listed the day of the week and the shift that residents were to receive their bath. Resident #1 was on the list for a bath on Saturday prior to the transfer to the hospital on Sunday. There was no documented evidence that the bath was provided. RESIDENT #4 Record Review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/10 revealed that Resident #4 Brief Interview for Mental Status (BIMS) score of "12" which indicated that Resident was moderately impaired in cognitive skills for daily decision making. On 02/17/11 Resident #4 was noted to have a Stage III pressure area noted on his left foot, third toe. A pressure area was noted to that same area that had healed on 09/21/10. This was categorized as a facility acquired pressure area and felt it was due to the residents shoes, of which he would not accept a change. Review of the physician's orders [REDACTED]." Interview with Resident #4 on 02/25/11 at 11:55 a.m. revealed that he had lost a toenail on the left foot and the toenail grew back. Then it swelled up and got discolored on the middle toe. He stated that the CNA took the bandage off his left foot when he got his shower about 09:30 a.m. and the CNA had placed a clean sock on the foot with no dressing in place. Observation of the wound on the 3rd toe of the left foot was conducted on 02/25/11 at 02:30 p.m. LPN #1 removed the shoe and the sock from the left foot and there was no dressing in place. LPN # 1 asked the attending RN if the CNA's had reported to anyone that the dressing was removed during the bath earlier in the day. The RN stated that it was a common problem at the facility (that CNA's did not report the removal of a dressing). RESIDENT #5 Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/10 revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicates the resident was severely impaired in cognitive skills for daily decision making. Transfer skills were identified to required extensive assistance of one (1) person. Walking did not occur. In Section M the resident was scored as at risk for pressure ulcers with no pressure ulcers present noted on the assessment date. Resident #5 was identified to require the use of a trunk restraint. Review of Resident #5's Care Plan revealed a problem on 08/06/10 stating: "Need for Pelvic Restraint while in wheelchair to prevent unassisted rising and possible injury." Interventions included: "Apply Pelvic Restraint while in w/c (wheelchair); Release q (every) 2 (two) hours; Check placement q 30 minutes visual check; Release et monitor if resident becomes agitated; Monitor for less restrictive measures." Review of Resident #5's Care Plan revealed a problem on 01/24/11 stating: "Has pressure ulcer to coccyx." Interventions included: "Wound tx (treatment) as ordered. Reevaluate q 14 days for effectiveness. Notify MD (Medical Doctor) if tx ineffective; Practice good infection control; Keep clean & (and) dry; Assist to turn & reposition q 2 (hours) & prn (as needed); Maintain pressure reducing matress (mattress); Ensure adequate nutrition & hydration. Have dietary to assess for nutritional needs; Obtain labs as ordered & report abnormals to MD". Review of the "RESTRAINT DECISION FORM" for Resident #5 dated 08/06/10 revealed: "Pelvic Restraint in use due to Resident scooting out of w/c c soft belt on - Pelvic Restraint will prevent injury." Review of the Physician order [REDACTED]." Review of the "FIRST REPORT OF WOUND" dated "01/24/11" revealed that Resident #5 had a wound reported on 01/24/11 at a Stage III (three) wound on the coccyx with the length being noted at 0.4 cm (centimeters), width at 0.4 cm and depth 0.3 cm. . (NOTE: 1 inch = 2.5 centimeters) The treatment ordered was to "Clean coccyx P.U. (pressure ulcer) c (with) NS (normal saline) Apply Santyl oint (ointment)-cover c most 4 x 4 gauze et cover c bandage daily et prn; Alternating air mattress; [MEDICATION NAME] et [MEDICATION NAME] now then [MEDICATION NAME] q month until healed." Interview with Licensed Practical Nurse (LPN) #1 on 02/24/11 at 08:40 a.m. confirmed that Resident #5 had a facility acquired Stage III pressure ulcer on the coccyx because she "has a cushion and pelvic restraint and scoots and goes back and forth". Observation on 02/24/11 at 10:30 a.m. revealed that Resident #5 was seated in a wheelchair in the Day Room of the Alzheimer's Unit. Resident #5 was noted to be leaning over, a cushion was noted in the chair. Interview on 02/25/11 at 11:00 a.m. with Registered Nurse (RN) # 1 revealed: "(Resident #5) has a pelvic restraint. Pressure Ulcer at top of coccyx due to her slouching down so much- constant have to try to keep up in chair. Restraint is due to sliding down in chair." "She slides to try to get her feet on the floor." Interview with the Certified Occupational Therapy Assistant (COTA) #1 on 02/25/11 at 11:05 a.m. confirmed that the pelvic restraint was used due to "battle sliding/getting up." COTA #1 stated: "We need to get leg rests (for wheelchair)". Observation on 02/25/11 at 12:30 p.m. revealed that Resident #5 was seated in a wheelchair with no foot rests in place. A pelvic restraint and a cushion were noted. Resident #5 was observed scooting in the wheelchair and attempted to propel self with the aide of her feet. Observation on 02/25/11 at 12:50 p.m. of the wound was made. The Treatment Nurse measured the wound as 0.7 cm in length, 0.5 cm in width and 0.5 cm in depth which was larger than when the initial report was made on 01/24/11. Interview with Certified Nursing Assistant (CNA) #4 on 02/25/11 at 01:00 p.m. confirmed that Resident #5 "scoots in chair a lot". There were no documented interventions to prevent Resident #5 from acquiring a pressure ulcer from sliding, slouching in the chair. Review of the "Skin Care Policy and Procedure" (with no implementation date) revealed: "It is the policy of this facility that skin problems will be minimized to the greatest extend possible through aggressive approach and the following components: I. Prevention, Evaluation, and Screening. II. Ongoing Surveillance. III. Treatment orders. IV. Treatment Regimen." "The Nursing Department pocedures will be such that the staff is alerted immediately if the resident either has the problem of skin breakdown or is at risk for the development of skin breakdown. The Nursing Department will maintain the capability to respond to residents needs (in the are of skin integrity) by the following means..." "With an array of preventative measures practiced on the residents behalf when the resident is identified as being at risk."