Every finding on record at The Blossoms at Conway Rehab & Nursing Center

Based on observation, interview, and facility policy review, the facility failed to ensure 1 of 1 ice machine was maintained in a sanitary condition; dietary staff washed their hands between clean tasks when contaminated; food stored in the freezer was covered; expired food items were promptly removed/discarded on or before the expiration or use by date; food items were free of discoloration, and hot food items were maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service for 1 of the 2 meals observed. The findings are: On [DATE] at10:17 AM, there was a piece of hair inside the lid of the ice machine in the kitchen. The Dietary Manager was asked to describe what was observed inside the lid of the ice machine. She stated it was hair. The left corner of the gasket above the ice machine panel had a sage color residue on it, and there was an orange wet residue below on the right corner of the ice machine panel. The areas were pointed out to the Dietary Manager during an interview, she was asked if the residue buildup could be wiped off and who used the ice from the machine. The Dietary Manager used tissue paper and wiped the wet residue off. The wet sage color and orange color residues easily transferred to the tissue, and she stated the area had dirty rusty color from the water. We use it to fill beverages served to the residents at mealtimes. The ice was also used by the CNAs (Certified Nursing Assistants) to fill water pitchers in the residents' rooms. On [DATE] at 11:59 AM, the Dietary Manager was wearing gloves on her hands when she removed a lettuce head from a bag and placed it on the cutting board, removed one red onion from a box and placed it on the cutting board and without rinsing, sliced and placed them on a plate. She then put new gloves on her hands, picked up a container of shredded cheese, removed the lid, and without changing gloves and washing her hands, she took some shredded cheese and sprinkled them on the lettuce to be served to the resident who requested it. On [DATE] at 10:25 AM, an opened box of sausage links was on a shelf in the freezer. The box was not covered or sealed. During an interview with the Dietary Manager, she stated they would be thrown out due to freezer burn. On [DATE] at 10:33 AM, the following observations were made in the walk-in refrigerator: a. Eight single packs of sour cream were in a box on a shelf with an expiration date of [DATE]. b. There were 24 tomatoes in a box on a shelf in the refrigerator. The tomatoes had sage colors on them. During an interview the Dietary Manager was asked if she could describe the appearance of the tomatoes observed and she stated there were 24 tomatoes with mold. c. A box that contained 38 cups of sweet tea was on a shelf with an expiration date of [DATE]. On [DATE] at 11:34 AM, Dietary Aide (DA) #5 picked up the water hose with his bare hand, used it to spray off leftover food items from the dishes, contaminating his hands. He placed dishes in the dirty racks and pushed them into the dish washing machine to wash. After the dishes stopped washing, DA #5 placed gloves on his hands. He picked up clean plates with his contaminated gloved fingers inside the plates and he was ready to place them in the plate warmer to be used in serving food items to the residents for lunch. DA #5 was asked what he should have done after touching dirty objects and before handling clean equipment and stated he should have washed his hands. On [DATE] at 11:39 AM, DA #6 used his finger to press the tea dispenser to dispense tea the glasses, contaminating his hands. He then picked up the glasses from the trays by their rims and dispensed tea into them to be served to the residents for lunch. On [DATE] at 11:59 AM, the Dietary Manager removed a head of lettuce and a red onion and placed them on the cutting board. She then sliced them and placed them on a plate without rinsing them. On [DATE] at 12:07 PM, the Dietary Manager placed gloves on her hands, removed a lid from the shredded cheese container, contaminating her hands. Without changing gloves and washing her hands, she removed shredded cheese and sprinkled them on the salad to be served to the resident who requested salad. On [DATE] at 12:34 PM, the Dietary Manager moved the blender machine with bare hands towards the edge of the counter. Without washing her hands, she picked up a clean blade and attached it to the blender to be used in pureeing foods for the residents for their lunch. On [DATE] at 12:45 PM, the Dietary Manager was wearing gloves on her hands when she removed the lid from a pan on the steam table that contained plain spaghetti, thereby contaminating the gloves. She then used the same gloved hand to take spaghetti from the pan, transferred them into a 6-ounce ladle spoon, and emptied them into a blender to be pureed for the residents who required pureed diets. On [DATE] at 1:20 PM, the temperature of the food items when checked and read on the steam table by the Dietary Manager were as follows: a. Pureed green beans 116.4 degrees Fahrenheit. b. Pureed bread with milk 126.3 degrees Fahrenheit. c. Fortified potatoes 120 degrees Fahrenheit. d. Regular spaghetti 120 degrees Fahrenheit. The above food items were not reheated before they were served to the residents. The Dietary Manager stated she should have reheated them. On [DATE] at 4:40 PM, the Dietary Manager wore gloves on her hands when she picked up a lid that still had leftover wet food residue on the handle after being washed in the dishwashing machine. After pointing it out to her. She wiped it off with her gloved hand. She also touched the underside of the lid, which had rough areas, further contaminating her gloves. When she attempted to use the same gloves to place slices of turkey into a blender, she was stopped and was asked what she should she have done after touching dirty objects before handling clean equipment and or food. She stated she should have removed her gloves and washed her hands. On [DATE] at 4:41 PM, the Dietary Manager turned on the 3-compartment sink faucet and washed and sanitized the blender bowl, then turned off the faucet with her bare hands. The Dietary Manager did not wash her hands before attaching the blade to the blender to be used in processing meat to be served to the residents who required mechanical soft diets. On [DATE] at 4:42 PM, the Dietary Manager wore gloves on her hands when she opened the bread bag. She then removed a packet of turkey from a box and used a knife to cut it open, further contaminating the gloves. Using the same gloved hands, she took 38 slices of turkey from the packet and placed them into a blender. Then added 9 slices of cheese. She then removed slices of bread and broke them into a blender, with mayo and slices of turkey to be ground and served to the residents who required mechanical soft diets for the supper meal. A review of facility policy titled, Bare hand contact with food and use of plastic gloves indicated, hands should be washed when entering the kitchen and before putting on gloves to work with food and after removing the gloves. A review of the facility policy titled, Hand Washing indicated employees should wash their hands when entering the kitchen at the start of a shift. Before using disposable gloves for working with food, after removing the gloves, and after engaging in other activities that contaminate the hands. A review of the facility policy titled, Food Safety: Ice indicated ice machine and containers should be cleaned and sanitized on a regular basis. A review of the facility policy titled, Food Temperature indicated temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit for hot foods.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a wheelchair was clean and sanitized for one (Resident #6) of one resident and failed to maintain and ensure clean shower rooms for residents in two (200 hall and 100 hall) of three shower rooms in the facility, to maintain a safe, clean, homelike environment. The findings are: 1. During an observation on 05/18/2025 at 1:53 PM, Resident #6 was observed sitting in a wheelchair, eating lunch in the dining area, and the black spokes of the wheelchair were coated in a tan/brown colored substance. Resident #6 described the substance on the wheelchair wheels as dirt or dust. a. During a concurrent interview and observation on 05/21/2025 at 11:35 AM, this surveyor went to Resident #6's room and asked to look at their anti-tippers, equipment designed to keep the wheelchair from turning over. This surveyor observed a visitor bend down, look at the right side of the wheelchair, and commented she knows one thing, it is filthy. The right wheel of Resident #6's wheelchair had a tan/brown substance, with white in the cracks of the spokes, and a tan/brown substance on the left side of the wheelchair, confirmed by the visitor. b. A review of a Medical Diagnosis revealed Resident #6 was admitted to the facility with diagnoses which included right hip bursitis, chronic pain, and epilepsy. c. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/2025 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. The resident could go 150 feet with manual wheelchair. d. During an interview on 05/21/2025 at 11:37 AM, Certified Nursing Assistant (CNA) #15 was asked what the procedure was to maintain clean wheelchairs. CNA #15 stated that it was not in writing, but CNAs on night shift were supposed to wipe down the wheelchairs, because they might start to stink, the wheels can stick to the floor, and I guess it could be an infection control issue if they touch the wheel. e. During an interview on 05/21/2025 at 11:47 AM, the Director of Nursing (DON) was asked if there was a policy or procedure on cleaning resident wheelchairs and the DON stated she did not think so. The Infection Preventionist (IP) Nurse Consultant, revealed there was a procedure for cleaning resident wheelchairs, and wheelchairs should be cleaned on night shift for infection control, cleanliness, and a homelike environment. The DON stated it could also be a dignity issue. The IP Nurse Consultant stated she would provide a copy of the wheelchair cleaning documentation. f. A review of policy titled Infection Prevention and Control Program, revised 11/02/2022, involved all disciplines and provides oversight, policies and procedures, infection prevention, safety, outbreak management and surveillance. Policy did not address cleaning wheelchairs, or the environment specifically. g. A review of Resident Council, notes dated 12/12/2024, and 01/21/2024 under unresolved old business, indicated residents requested their wheelchairs be washed. February Resident Council notes indicated cleaning wheelchairs had been addressed. h. A review of 11-7 Assignment Sheets, for the last two weeks revealed a Wheelchair cleaning schedule: Monday, Wednesday, Fridays, odd numbers rooms are checked to clean wheelchairs, and on Tuesday and Thursdays- even numbers rooms are checked to clean wheelchairs. The Regional Director of Operations (RDO) stated there was no environmental cleaning policy. 2. During an observation on 05/18/2025 at 10:51 AM, Housekeeper #7 opened the shower room on the 200 hall, per request. This surveyor observed a strong musty, mildew type odor immediately. The housekeeper said, it smells like dirty, wet towels. The room was observed to be dimly lit. All light switches were in the ON position. An overhead fluorescent light was observed to be broken and did not work. Two other fluorescent lights were observed to not work. The housekeeper verified that all three lights did not work. The housekeeper indicated it would be hard for a resident to see good with those lights out. Housekeeper #7 described the vents on the ceiling as dirty, with a black substance on the vents, and rusty. An open sharps container was on the floor with two opened, used razors sitting on top. He indicated the used razors should have been inside of the sharps container. Housekeeper #7 said the sharps container should be closed at all times, and out of reach of the residents, because someone could have hurt themselves. a. During an interview on 05/19/2025 at 2:06 PM, Maintenance opened the shower room on the 200 hall. Maintenance described the odor as it smells musty, but not bad musty. He indicated the room was not well lit. He verified there was one broken, non-working fluorescent light, and two non-working fluorescent lights. He reported it was important for the residents and staff to be able to see clearly, to stay safe, and not bump into things. He described the vents on the ceiling as having a little rust, a dark something that appears to be black mold and not in just one spot. He indicated the vents did not look good, they looked unhealthy and unsanitary for the residents. Maintenance went to the nurses' station, on the 100 hall, and was made aware of the Maintenance Logbook. He verified he had not seen the logbook before. b. A review of Maintenance Logs on 05/19/2025 at 1:22 PM, indicated no completed, reported maintenance issues documented, starting 04/29/2025 through 05/19/2025. c. During a concurrent interview and observation on 05/19/2025 at 2:21 PM, the Assistant Director of Nursing (ADON) reported it was not acceptable for an opened sharps container, with two opened razors sitting on top, to be sitting on the floor in the shower room, on the 200 hall. The ADON opened the shower room on the 200 hall, per request. She described vent A as it looked like black mold and rust on the vent, and it needed to be inspected, since it was loose. She described vent B with less black mold, but still evident and some rust. She indicated the intake vent had cobwebs, chipped paint that was falling off, it was not secure, and it was dirty. d. On 05/19/2025 at 3:20 PM, the Administrator opened the shower room on the 200 hall, per request. She described both vents on the ceiling as the same. She indicated the vents on the ceiling in the shower room on the 200 hall were the same as she described in shower room [ROOM NUMBER] hall. When asked if the vent condition adhered to a homelike environment for the residents, the Administrator stated, I will have maintenance look at it. e. During an observation on 05/18/2025 at 11:58 AM, CNA #9 opened the shower room on the 100 hall, per request. A strong musty smell was observed immediately. The CNA reported it smelled musty in the room. The toilet did not have any water in the bowl but had partially dried toilet tissue in the bowl. The CNA reported the toilet should have been able to flush and be in good condition. The trash can, beside the toilet, was observed to have trash and brown liquid at bottom of trash can, without a trash can liner in place. CNA #9 stated the trash can should have had a liner in place, especially since it was a bathroom trash can. The vents on the ceiling were observed to be dirty, with black substances and rust. After she looked at the ceiling vents, the CNA verified the shower room was not conducive to a home-like environment condition for the residents. f. During an observation and interview on 05/19/2025 at 9:56 AM, Housekeeper #8 opened the shower room on the 100 hall, per request. She described the odor in the shower room as musty. The toilet did not have any water in the bowl but had partially dried toilet tissue in the bowl. The housekeeper indicated the toilet needed to be fixed, so the residents could use it, if needed. The trash had been emptied, and the trash can had been moved. The brown liquid at the bottom of the trash can remained, and there was still no liner in the can. She verified the trash can needed to be cleaned, and there should have been a liner in the can. She indicated the ceiling vents were dirty with black substances, and they were rusty. g. During an observation and interview on 05/19/2025 at 2:49 PM, the ADON opened the shower room on the 100 hall, per request. The ADON described the ceiling vents as they have black colored dirt or mold spots, some rust and chipped paint, and definitely dirty. She indicated the toilet needed to be repaired. The ADON then attempted to flush the toilet, without success. h. During a concurrent interview and observation on 05/19/2025 at 1:45 PM, Maintenance reported he was filling in for the usual maintenance person, due to that staff member being out for surgery. Maintenance opened the shower room on the 100 hall, per request. He indicated the toilet did not have water in it, and there was paper in the toilet bowl. He stated, it was possibly plugged up. He attempted to flush the toilet without success, then stated I need to work on that. Maintenance described the ceiling vents as rusty, having a little bit of moisture, something dark on it, it could possibly be mold, and they are just dirty. He reported the trash can should have had a liner, the toilet should have been in working condition, and the ceiling vents needed to be cleaned. Regarding the vents he stated, it is unhealthy, it is not sanitary. i. During a concurrent interview and observation on 05/19/2025 at 2:59 PM, the Administrator confirmed an open sharps container, with two used razors sitting on top, should not have been left out in the shower room. The Administrator opened the shower room on the 100 hall, per request. She described vent B as something black is on the vent, that is all she described vent A as like rust, a little black. When asked if the vent condition adhered to a homelike environment, the Administrator stated, I don't know. She indicated it was important that the toilet should have been in working condition, so that it could flush, and that the trash can should have had a liner in place.

Based on observation, record review, interview, and review of the menu, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure nutritionally balanced meals were provided for the residents for 2 of the 2 meals observed. The findings are: 1. A review of the 5/18/2025 noon meal menu indicated the residents on a pureed diet were to receive a #8 scoop equal to 4 ounces, or 1/2 cup of pureed meat sauce and a #6 scoop, equal to 2/3 cup, of pureed spaghetti noodles. a. On 5/18/25 at 12:45 PM, during the noon meal preparation, the Dietary Manager (DM) used a 6-ounce ladle spoon equal to 3/4 cup to place 3 servings of plain cooked spaghetti into a blender added 2 servings of plain tomato sauce, and pureed. At 12:50 PM, she added 2 more servings of spaghetti into blender to puree. b. At 12:52 PM, she poured pureed spaghetti with plain tomato sauce into a pan, then placed it on the steam table to be served to the residents who required pureed diets. c. On 5/18/2025 at 2:02 PM, during the noon meal service the DM, used #8 scoop, or 1/2 cup, to serve a single serving of spaghetti with plain tomato sauce to the residents on pureed diets. d. During an interview on 5/18/2025 at 2:47 PM, the DM was asked how she prepared the pureed spaghetti, what scoop size was used, and how many servings were given to each resident. The DM stated she just pureed spaghetti with the plain sauce, but she should have used the spaghetti that was already made because there was no meat in the sauce she had used. The DM stated she had used the #8 scoop, and it was only 4 ounces. When asked for the menu, she stated she did not look at the menu because the meal was a resident council request. When she looked at a menu that contained the exact meal for the meal of the month, the DM confirmed she had served it incorrectly. 2. A review of the 5/18/2025 supper meal menu indicated residents on mechanical soft diets were to receive 2 ounces of protein. a. A review of the 5/18/2025 facility recipe for deli sandwich indicated using 2 ounces of lunch meat and one slice of cheese which would be equivalent to a 2-ounce portion. b. During an observation in the kitchen of supper meal preparation on 5/18/2025 at 4:41 PM, the DM placed 38 slices of turkey into a blender, then added 9 slices of cheese and mayo and ground it to be served to the residents who required mechanical soft diets for supper, instead of 16 slices of cheese. c. During an interview, on 5/18/2025 at 1:34 PM, the DM was asked if she could weigh the same amount of deli meat and cheese prepared and served to the residents on mechanical soft diets. She did and stated 2 slices of meat weighed 1 ounce, 4 slices weighed 2 ounces, and 1 cheese slice weighed 1 ounce. d. During an interview on 5/19/2025 at 1:39 PM, the DM was asked how many slices of cheese she had used for mechanical soft diets, and she stated 9 and she should have used 16.

Based on observation, interview, and review of the mealtime schedule, the facility failed to ensure all residents who received meals from the kitchen were consistently being served at regularly scheduled times and failed to provide the residents with a dependable eating schedule for 2 of 2 meal services observed. The findings are: 1. On 05/18/25, a document titled, Meal Times, was provided and revealed mealtimes in the facility were 7:30 AM for breakfast, 12:00 PM for lunch, and 5:00 PM for dinner. 2. On 5/18/2025 at 1:30 PM, the first food cart for Hulan hall was pushed into the dining room by Dietary Aide (DA) #5. At 2:02 PM, the first resident received a meal tray in the dining room. a. During an interview on 5/18/25 at 2:10 PM, Resident #36 stated lunch had not been served on their hall yet, and sometimes it was late. They do not let us know why it is late. b. The last noon tray was served on the 200 Hall at 2:30 PM, 2 hours and 30 minutes after the scheduled mealtime. 3. On 5/18/25 at 6:11 PM, the first supper meal food cart for Hulan hall was pushed into the dining room by DA #5. The last room tray was served on the 200 Hall, at 7:25 PM, 2 hours and 25 minutes late. 4. On 5/18/2025 at 7:32 PM, Resident #18, Resident #31, Resident #42, Resident #43, and Resident #50 were sitting in a common area on the 200 Hall. When asked about the timing of the meals, the residents agreed that meals were frequently delayed at mealtimes and worse on the weekends. 5. On 5/19/25 at 8:22 AM, Resident #17 reported frustration because the pastor who was to provide the Sunday church service in the facility was unable to stay for lunch because the meal was so late. 10. On 05/19/2025 at 11:48 AM, four residents present in the Resident Council meeting were asked if their meal was ever late. One member of the council voiced, It's been about 1 to 2 hours late. Resident #51 reported complaining of hunger around 1:30 PM because they had not had lunch yet. 11. During an interview with the Administrator on 5/19/25 at 12:20 PM, she was asked if she was aware of the food being late and she stated, No, it's not normal and it has never happened before.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure proper hand hygiene was performed during tracheostomy care for one (Resident #29) of 2 residents sampled for infection control. The findings are: A review of the Admission Record, indicated the facility admitted Resident #29 with diagnoses that included aftercare following surgery for tracheostomy and a disorder that makes it difficult to move food from the mouth into the throat and esophagus. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/31/2025, revealed Resident #29 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired, and never/rarely made decisions. A review of Resident #29's Care Plan, initiated on 02/23/2025, revealed the resident required enhance barrier precautions due to have a feeding tube and tracheostomy. Staff were required to wear gloves, gown, and face protection if there is a risk for splash or spray. Resident #29 was at risk for complications related to the tracheostomy. Staff were instructed to provide daily tracheostomy care and as needed. A review of Order Summary, revealed Resident #29 had an order for tracheostomy care, instructing staff to change all tracheostomy related tubing weekly and as needed at bedtime. Suction tracheostomy tube as needed for patency or to keep air way open. Resident #29 had an additional order to change the inner cannula daily and as needed, along with trach care every shift and as needed. During an observation of tracheostomy care for Resident #29 on 05/19/2025 at 11:25 AM, Licensed Practical Nurse (LPN) #3 entered the room and put on a gown and gloves without performing hand hygiene. LPN #3 set up the necessary supplies to provide tracheostomy care, then removed their gloves. Without performing hand hygiene, LPN #3 put on sterile gloves to perform the procedure. LPN #3 proceeded to clean Resident #29 ' s tracheostomy site and apply new dressings. In an interview immediately following the procedure, LPN #3 indicated hand hygiene should have been initiated before trach care began as well as in between changing of gloves. LPN #3 stated that good hand hygiene was important to prevent infection. During an observation of tracheostomy care on 5/21/2025 at 11:20, LPN #4 entered Resident #29 ' s room, performed hand hygiene, and applied personal protective equipment (PPE) in the form of a mask, gloves, and gown. LPN #4 set up the necessary supplies to provide tracheostomy care, then removed their gloves. Without performing hand hygiene, LPN #4 put on sterile gloves to perform the procedure. LPN #4 proceeded to clean Resident #29 ' s tracheostomy site. LPN #4 removed their gloves, put on a new pair without performing hand hygiene, and applied new dressings to the tracheostomy site. In an interview immediately following the procedure, LPN #4 stated, I did not know I was supposed to wash my hands in between glove changes. I thought because I did not touch anything with bare hands it was ok. During an interview on 05/21/2025 at 11:30 AM, the Assistant Director of Nursing (ADON) indicated that staff should wash their hands between glove changes when performing procedures such as tracheostomy care, and the first thing staff should do upon entering a room that is on enhanced barrier precautions is to wash hands and put on personal protective equipment. During an interview on 05/21/2025 at 12:25 PM, the Director of Nursing (DON) indicated that every time gloves were taken off during a procedure, hand washing should occur. A review of a facility policy titled, Tracheostomy Care, dated 01/01/2024, revealed that when staff are performing tracheostomy care and need to remove and replace their gloves, they should wash their hands before putting on fresh gloves. A review of an undated facility policy titled, Hand Washing revealed that when to wash hands as, after handing soiled equipment or utensils. 51885

Based on observation, record review, interview, and facility in-services, the facility failed to ensure privacy for 1 (Resident #4) sampled resident, to promote a dignified existence based on 1 of 1 observation. The findings include: During an observation and interview on 05/18/2025 at 11:41 AM, this surveyor observed a medication cart resting against the wall of 200 hall, with the screen facing out toward anyone who walked at the end of the hallway, for several minutes. This surveyor walked down the hall and noted the computer screen was pulled up with Resident #4's picture, vital signs, medication, date of birth, room number, and allergies facing out toward anyone that was in the hallway. Licensed Practical Nurse (LPN) #18 was found in Resident #4's room, starting an intravenous antibiotic. This surveyor and LPN #18 walked out of the room and saw an unidentified young man in the hallway, facing the medication cart and unlocked computer, turn and walk away. LPN #18 was asked about the normal procedure before leaving a medication cart unattended in the hallway. LPN #18 said we lock the cart and turn the screen off for privacy, especially when other people are around. A review of Medical Diagnosis revealed Resident #4 to have diagnoses which included paraplegia, heart failure, and left knee contracture. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/25 indicated Resident #4 to have a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. During an interview on 05/20/2025 at 8:00 AM, the Administrator was asked what process nursing staff were expected to follow when leaving their medication cart. The Administrator said staff were expected to close the computer screen and lock the medication cart. The Administrator revealed, for privacy reasons, the screen should not have been left open. During an interview on 05/20/2025 3:30 PM, the Director of Nursing (DON) was asked what process nursing staff were expected to follow when leaving the medication cart unattended. The DON stated that the screen and medication cart should be locked. The DON said that staff should close the computer screen on the medication cart to protect residents ' medical information, because it showed the medications they were on and their personal information. The DON revealed this was a HIPPA (Health Insurance Portability and Accountability Act) violation. A review of an in-service titled HIPPA Privacy, dated 10/08/2024, revealed HIPPA Privacy Rules provided standards and protected individuals ' health information and identifying information by limiting or preventing disclosure without authorization. Technology has introduced the risk of sensitive healthcare information being exploited, and any identifiable healthcare information related to medical treatment, physical or mental, past or present is protected by HIPPA. A review of an in-service titled Nursing Home Residents ' Rights, dated 10/08/24, revealed residents have the right to privacy during medical care and treatment, regarding medical affairs, and communication with persons of their choice.

Based on observations, interviews, and record review, the facility failed to ensure adequate and/or increased supervision was provided by staff during periods of increased exit-seeking and aggressive behaviors for 1 (Resident #4) of 3 sampled residents reviewed for elopement. The lack of effective supervision resulted in Resident #4 eloping from the facility and facility staff being unaware of the resident's whereabouts for approximately one hour before the resident walked back into the facility. At the time of the survey, there were nine residents residing in the facility who were identified as at risk for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 08/19/2024 at 6:24 PM, when Resident #4 began to have aggressive behaviors, which included blocking the resident's bedroom door so staff could not enter, throwing furniture and water at staff, refusing medication and dinner, and the resident stated they wanted to fight staff. Resident #4 was last seen at 8:30 PM, and by 9:00 PM, the facility was unable to locate the resident, who had dismantled an exterior window, and eloped from the facility for approximately one hour. The resident ambulated back into the facility at approximately 10:00 PM. The resident had exited the facility without staff knowledge. The Administrator and Director of Nursing were notified of the IJ on 08/21/2024 at 3:31 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 08/22/2024 at 12:11 PM. The IJ was removed on 08/22/2024 at 6:35 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F689 remained at the lower scope and severity of no actual harm with an isolated potential for more than minimal harm that was not immediate jeopardy. The findings are: A review of an Admission Record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of alcohol abuse, altered mental status, encephalopathy, and cognitive communication deficit. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/2024 revealed Resident #4 scored a 02 (indicates cognitively moderately impaired for daily decision making) on a Staff Assessment for Mental Status (SAMS) and was substantial/maximal assistance with mobility and used a wheelchair. Review of the Order Summary Report initiated on 8/2/2024 revealed a physician's order for chlordiazepoxide HCL (a sedative and hypnotic medication) 25 milligrams (mg), to be given every 6 hours as needed for alcohol withdrawal related to alcohol abuse. Another physician's order, with a start date of 08/02/2024, indicated staff should monitor for behaviors including scratching, biting, sexual inappropriate behavior, hitting, attention seeking behaviors, hand wrenching, cussing, elopement attempts, refusal of care, hallucinations, anxiety, depression, change in mood, self-isolation, false accusations, and to include a nurses note for any behavior with added documentation for non-pharmacological interventions. Review of Resident #4's plan of care, initiated on 8/19/2024, revealed the resident was an elopement risk/ wanderer related to disorientation of place, history of attempts to leave facility unattended, and impaired safety awareness. Interventions included to check placement of the electronic wander management device to the left wrist every shift, distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. Staff were to identify patterns of wandering and intervene as appropriate. The plan of care did address the residents' preferences. On 8/20/2024 the plan of care noted Resident #4 required one-on-one care. A review of Progress Notes dated 8/17/2024 at 5:18 PM, revealed Resident #4 was in a wheelchair in the common area under staff supervision due to attempting to enter other resident's rooms. Resident #4 had multiple family members visiting throughout the day. A review of Progress Notes dated 8/18/2024 at 2:05 AM, revealed Resident #4 required frequent redirection, would become angry, would strike out, was an elopement risk and fall risk, and required frequent observation for safety. A review of Progress Notes, dated 8/18/2024 at 6:01 PM, revealed Resident #4 was in the common area watching television. Resident #4 showed signs and symptoms of increased anxiety, which were treated with chlordiazepoxide 25 mg with mild effect. Resident #4 was impulsive, with poor safety awareness, and difficult to redirect at times. Resident #4 wandered and entered other resident rooms, and staff were to keep Resident #4 within sight when not in bed. A review of Medication Administration Record for August 2024 indicated Resident #4 had a physician's order for staff to check placement of the electronic wander management device on the resident's left wrist every shift, with a start date of 08/19/2024 at 3:00 PM. A review of Progress Notes, dated 8/19/2024 at 6:42 PM, revealed Resident #4 began to verbally abuse staff when asked to go to the dining room. Resident #4 closed their bedroom door, blocking the door so staff could not enter and refused all medication and dinner. The Director of Nursing (DON) was present for all events. A review of Progress Notes, dated 8/19/2024 at 7:30 PM, revealed a nurse attempted to give Resident #4 their medication and the resident took the cup of water and threw it in the nurse's face, then proceeded to pick up a chair and tried to hit the nurse with it. Staff attempted to redirect the resident but were unsuccessful. The resident would ball up their fist and state they wanted to fight. A review of a facility incident and accident report, dated 8/19/2024 at 9:00 PM and titled Elopement, revealed at 9:00 PM the staff went to check on Resident #4 and Resident #4 was not in their room. A bedroom window was discovered dismantled with the window removed from the frame. A search was initiated inside and outside of the facility. Family, police, DON, and Administrator were notified of the resident's absence. The resident's mental status was confused and/or disoriented. A review of Progress Notes, dated 08/17/2024 at 5:18 PM through 8/20/2024 at 2:58 AM, did not document facility nursing staff notifying the physician or Advance Practice Nurse (APN) of Resident #4's behaviors, wandering, and exit seeking. A review of Arkansas Incident Report, dated 8/19/2024, indicated the incident was received at 9:24 PM, The report noted the response was in reference to a missing person. Prior to the officer's arrival they were advised Resident #4 had left the facility through a window and was last seen by staff around 7:30 PM. Once the officer arrived, they were directed to the window Resident #4 eloped from. The window screen was sitting against the side of the building and the glass pane of the window was sitting inside the vacant room. It was noted what appeared to be a footprint in the mud just outside of the window. The officer proceeded inside the facility to speak with Licensed Practical Nurse (LPN) #7. LPN #7 advised the officer that around 7:30 or 8:00 staff had noticed Resident #4 was missing. LPN #7 provided medical diagnoses, a description of what the resident was last seen wearing, and a photo of Resident #4. LPN #7 advised the officer that Resident #4 had left the faciity on ce before on 8/17/2024, but the officer was unable to locate a call for that incident. Officer was advised prior to completing the Missing Person Questionnaire with LPN #7 that Resident #4 was located on the property walking back up to the front door. A review of the facility's OLTC Incident and Accident Report, dated 8/19/2024 at 11:56 PM, revealed Resident #4 was found to be missing after staff went to check on the resident and found a window had been dismantled. Previously in the shift, Resident #4 had barricaded the bedroom door to prevent staff from entering. Resident #4 later let staff in the room. Resident #4 was last seen at 8:30 PM by staff. Police, the Administrator, the Director of Nursing (DON), and family were notified at 9:00 PM of Resident #4's absence. At 10:00 PM, Resident #4 walked back to the facility stating the resident had been to Texas. Resident #4 was assessed by ambulance service and sent to the hospital as a precaution. A review of an Elopement Drill Code Silver In-Service with forty-seven out of sixty-eight staff signatures on it dated 8/19/2024 revealed a facility policy titled, Elopements with a reviewed date of 1/2024 that revealed, staff shall investigate and report all cases of missing residents and promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse of Director of Nursing. When the resident returns to the facility the DON or Charge nurse was to examine the resident for injuries, notify the attending physician, notify the resident's legal representative, complete and file Report of Incident/ Accident, and document the event in the resident's medical record. If an employee discovers that a resident is missing from the facility, they should initiate a Code Silver and search the building and premises. When the resident returns to the facility, the DON or charge nurse shall notify all parties involved and document relevant information in the resident's medical record. There was no information regarding how staff should handle a resident with behaviors. A review of Resident #4's hospital visit on 08/19/20245 at 10:38 PM revealed the facility staff last saw Resident #4 at 8:00 PM, the resident was oriented to self only, a records from recent admission indicated the resident likely had dementia and chronic alcohol related encephalopathy A review of Progress Notes, dated 8/20/2024 at 2:58 AM, revealed Resident #4 returned to the facility at 2:30 AM with no new orders. Review of 1:1 Behavior Monitoring Visual Check Sheet revealed Resident #4 was monitored one-on-one starting 8/20/2024 at 2:30 AM through discharge on 8/21/2024 at 12:00 PM. On 8/20/2024 at 9:29 AM, the Surveyor attempted to interview Resident #4 about the elopement on the night of 8/19/2024, but the resident had garbled speech and was unable to be interviewed. During a telephone interview with Certified Nurse Aide (CNA) #1 on 8/20/2024 at 2:15 PM, the CNA stated Resident #4 was exit seeking and wandered and that staff kept the resident in the day area on the weekends so staff could monitor Resident #4. During a telephone interview with LPN #2 on 8/20/2024 at 3:06 PM, the LPN revealed Resident #4 wandered the halls and talked about wanting alcohol and drugs. LPN #2 also indicated the resident wandered into other rooms. LPN #2 stated she redirected Resident #4 when they tried entering other resident rooms. During a telephone interview with LPN #3 on 8/20/2024 at 4:19 PM, the LPN revealed Resident #4 was impulsive, unsteady on their feet when walking around and the facility tried to get the resident to use a wheelchair due to being a fall risk. LPN #3 indicated the resident wandered quite a bit and staff had to keep the resident up at the nurse ' s station because the resident wandered, and the resident was confused. LPN #3 revealed family visited on weekends. During a telephone interview with CNA #4 on 8/20/2024 at 6:01 PM, the CNA revealed Resident #4 liked to roam and would go into wrong rooms and facility staff redirected Resident #4 by keeping the resident by the nurse's station in the day room because the resident wandered. During a telephone interview with CNA #5 on 8/20/2024 at 6:37 PM, the CNA revealed Resident #4 swung a full blown punch at him and that Resident #4 could be aggressive. CNA #5 indicated they redirected the resident by talking with Resident #4 and would give Resident #4 something to do, a snack, or having the resident watch television. During an interview with LPN #6 on 8/20/2024 at 7:19 PM, the LPN revealed Resident #4 wandered and that when she came on shift on 8/19/2024 she was notified Resident #4 had a electronic wander management device in place and that staff were to listen for alarms due to Resident #4's exit seeking behaviors. LPN #6 revealed Resident #4 went into an empty resident room, shut the door, and climbed out the window by taking the window off and climbing out of it. LPN #4 indicated the resident's nurse notified the police, the Administrator, and the DON, who came to the facility. Resident #4 was assessed by paramedics for injuries and upon the resident's return to the facility from the emergency room was placed one-on-one with staff. LPN #6 reported the facility did an in-service on elopement but not on behaviors. During an interview with LPN #7 on 8/20/2024 at 7:24 PM, the LPN revealed Resident #4 was very aggressive toward staff, that on 8/19/2024 Resident #4 threw a glass of water in the LPN's face and then threw a chair at the LPN during medication administration. LPN #7 revealed the DON was trying to talk to the resident, but Resident #4 kept balling up their fists. LPN #7 then revealed CNA #8 assisted her with trying to get the resident to take their medication, but Resident #4 went straight to fighting. LPN #7 indicated that staff kept resident doors closed because Resident #4 kept wandering into other resident rooms. LPN #7 revealed she continued medication pass and when she got to the end of Resident #4's hallway at approximately 8:10 PM, she opened the resident's room door, and the resident was not there. LPN #7 asked staff if anyone had seen Resident #4 and no one had so staff started searching rooms, and closets and then they noticed room [ROOM NUMBER] had the whole window out. LPN #7 indicated Resident #4 lifted the window up and went out. LPN #7 stated Resident #4 came back to the facility and walked up and told the police officer they had to go check on business. Resident #4 was transported to the emergency room and returned at 2:30 AM, was assessed, and a CNA was placed one-on-one with Resident #4. LPN #7 reported she signed an elopement in-service this week, but not one on behaviors. During an interview with CNA #8 on 8/20/2024 at 7:39 PM, the CNA revealed Resident #4 as very aggressive and wandered. CNA #8 revealed that when they do their rounds, the resident would get up out of the wheelchair and wander around and try to get in other rooms. CNA #8 revealed that Resident #4 was redirected by staff telling the resident they can't be in other rooms, and staff take Resident #4 to the resident's room or to the sitting area. CNA #8 revealed she was doing rounds on 08/19/2024 and went down the hallway looking for Resident #4 and could not find the resident in their room. CNA #8 then said she got another CNA to help her look for Resident #4, they let the nurse know and a search was started inside and outside the building. CNA #8 revealed they opened the door to an empty room, room [ROOM NUMBER], and the window was out. CNA #8 took the surveyor to room [ROOM NUMBER] to observe the window which was currently back in place. CNA #8 indicated that one side of the windowpane had been removed and the screen was gone. She revealed that she and another staff member also searched by vehicle and that the resident returned as staff were conducting their last rounds. CNA #8 stated the facility had staff sign an in-service after the resident left for elopement but not behaviors. During an interview with CNA #9 on 8/20/2024 at 7:51 PM, the CNA revealed Resident #4 was aggressive, anxious, confused, always asking for a beer, and very argumentative. CNA #9 indicated the resident wandered and had gone into other rooms like empty ones. CNA #9 indicated he redirected the resident. CNA #9 revealed he was the CNA involved on 8/19/2024 when Resident #4 barricaded themselves in their room using their body up against the door. CNA #9 indicated he went to the resident ' s room and tried to get the resident to come to the dining room for dinner and Resident #4 kept refusing and slammed the door shut. CNA #9 indicated he tried to open the door but could tell the resident was holding it so for resident safety he backed away and notified the DON who was present in the facility. Resident #4 eventually came to the dining room but refused to eat or sit down. CNA #9 said when he came back from his break around 8:20 PM he was alerted by another CNA while outside in his vehicle that Resident #4 eloped. CNA #9 drove around in his vehicle for 30-45 minutes looking for the resident until the police arrived. CNA #9 stated he was told Resident #4 got out through a window. CNA #9 stated he signed the elopement in-service when he came to work. There was not an in-service for behaviors. During an interview with CNA #10 on 8/20/2024 at 8:00 PM, the CNA revealed Resident #4 was terrible, liked to argue, and could not be redirected at all on 8/19/2024. CNA #10 indicated the resident wandered in other rooms. Staff tried redirecting the resident with television, going to the resident ' s room, or just something else away from other resident's rooms. CNA #10 indicated that she and CNA #11, were on the resident ' s hallway on 08/19/2024, going toward the therapy room and that CNA #11 tried to redirect the resident up to the front of the building. CNA #11 finally managed to get Resident #4 to the day room. CNA #10 said the CNAs needed to start their rounds and were on their fifth resident and walked into Resident #4's room and couldn't find the resident. CNA #10 indicated they searched every room, closet and bathroom, looking in the dining room and went back to the resident ' s hallway and saw part of the window sitting on the floor and the screen outside. She stated two CNAs drove around looking, two CNAs were looking around outside of the building, and the nurses looked inside and made telephone calls. CNA #10 said Resident #4 was now one-on-one observation. CNA #10 stated, I think I might need to sign the elopement in-service they have one out for us to sign. During an interview with CNA #11 on 8/20/2024 at 8:13 PM, the CNA stated Resident #4 hit, cussed, slapped, and threw chairs. CNA #11 stated the resident wandered and was usually able to be redirected but not the night of 08/19/2024. CNA #11 sated Resident #4 barricaded the door to their room and would not let CNA #9 in. CNA #11 stated staff kept checking on the resident and that she last saw Resident #4 around the day room at 8:30 PM. She stated the resident took part of the window off in room [ROOM NUMBER] and went out and the resident was now one-on-one with a electronic wander management device. CNA #11 reported having signed an in-service for elopements but nothing for behaviors. During an interview with the DON on 8/21/24 at 9:18 AM, the DON stated she was familiar with Resident #4, and that the resident called staff names in Spanish, was combative at times with staff, and could be difficult to redirect. She stated that on Monday, 8/19/2024, before she left at 7:00 PM, CNA staff came to her because the resident was standing in a corner down on the hallway and was unable to be redirected. She stated the nurse on duty was down on the hall and Resident #4 was talking about fighting and pumping their fists at staff. To decrease agitation, the nurse said she was able to handle the situation and the DON left the facility. The DON said shortly after leaving the facility, she received a call that the resident had thrown water in the LPN's face and thrown a chair at her. The DON stated Resident #4 was really agitated. The DON stated Resident #4 had been roaming around and not exiting seeking until Monday. Once informed the resident had barricaded themselves in their room, the DON instructed staff to leave the resident alone, and the resident then went to the dining room. The DON stated she received a call on Monday night at 9:00 PM that staff could not find the resident after checking all the rooms and walking the perimeter of the facility. The DON said she notified the Administrator and then called the nurse back and told the nurse to call 911 and to conduct a head count of all other residents. The DON indicated when she arrived, emergency medical personnel were already assessing the resident and that she saw the window off the track. The resident went to the hospital to be checked out, the window was replaced, and the resident was one-on-one observation with a electronic wander management device. The DON indicated that Resident #4 was not exiting seeking until 8/19/2024, so the facility placed a electronic wander management device on the resident. The DON stated residents who have been newly admitted to the facility, the resident may be confused, and staff pay more attention to the resident. During an interview with the Administrator on 8/21/2024 at 9:45 AM, the Administrator stated she was familiar with Resident #4 and that when the resident first came to the facility the resident required extensive assistance and then became more alert and wandering all over the building. The Administrator stated on Monday, 08/19/2024, the resident became increasingly agitated and had some behaviors that night and then eloped. The Administrator stated the resident was redirected by staff, reminding the resident where their room was, and directing the resident to the sit-in area. She also stated she heard about the resident not allowing staff in their room and that the resident was agitated. The Administrator stated she was notified by staff they could not locate Resident #4; the building had been searched, and police and family were notified. She revealed she received a call before she got to the facility that the resident was seen walking back toward the building. The Administrator stated Resident #4 went to the emergency room and when they returned, were provided with one-on-one observation with staff and Resident #4 had a electronic wander management device, and all windows are secured. The Administrator indicated that if a resident was exit-seeking they would put a electronic wander management device on the resident with staff doing frequent checks. During an interview with the Maintenance Director on 8/21/2024 at 2:34 PM, the Maintenance Director stated he came to the facility on Monday night, 08/19/2024, and the window was sitting on the floor. He stated he put the top part of the window in the track and was able to push it back over the bottom rail. There was a screw in it so it would move about six inches, but the window was picked up not slid over. On 8/21/2024 at 3:01 PM, with guidance from the State Agency, the facility was provided the IJ Template. At 3:31 PM the IJ Template was signed by the Administrator and Director of Nursing. During an interview with the DON on 8/21/2024 at 3:51 PM, the DON revealed she placed an order for Resident #4 to have a electronic wander management device around 3:00 PM on Monday, 8/19/2024 and that she took a picture of the back of the electronic wander management device, then she placed the device on Resident #4 and took the picture to the Minimum Data Set (MDS) Coordinator to enter in the computer. She said the order was obtained because Resident #4 was going around to the doors holding the handle and trying to get out. During an interview with the MDS Coordinator on 08/21/2024 at 3:55 PM, the MDS Coordinator revealed the resident was exhibiting behaviors and wandering around. A review of a letter from Resident #4's physician, dated 08/22/2024, revealed the physician was not notified of Resident #4's behaviors until 08/19/2024 at 7:20 PM, indicating the physician's order for the electronic wander management device was place prior to the physician being notified. The physician indicated the resident had an as-needed order for a sedative and hypnotic medication and the resident required no further interventions. Removal Plan: 1. On 8/19/24, Resident #4 was placed 1-on-1 immediately upon his return to the facility from the emergency room . Resident #4 remained 1-on-1 until he was transferred to a facility with a secure unit on 8/21/24 at approximately 12:00pm. On 8/19/24 all windows were checked by the Maintenance Director to ensure they were secure with any negative findings corrected. 2. On 8/20/24 Elopement assessments were completed on all residents. The care plan for each resident identified at high risk of elopement was reviewed and updated as necessary. On 8/19/24 during the 11pm - 7am shift, all residents identified with a history of behaviors were assessed for behaviors on their Medication Administration Record, including Resident #4. The care plan for each resident identified at risk of behaviors was reviewed and updated as necessary. 3. On 8/19/24 the administrator/designee initiated an in-service for staff on elopement and/or wandering. All staff have/will be in-serviced prior to working their next shift. The in-service will be completed on 8/22/24. On 8/22/24, the administrator/designee initiated a behavior in-service with staff. All staff have/will be in-serviced prior to working their next shift. The in-service will be completed on 8/22/24. 4. Using a monitoring tool, elopement drills will be conducted 1x weekly on each shift x 8 weeks or until compliance is achieved. Negative findings will be reported to t the administrator immediately. 5. An Ad Hoc QAPI meeting was completed on 8/20/24. All corrections were completed on 8/22/24. Onsite Verification: The IJ was removed on 8/22/2024 at 6:35 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 8/22/2024 at 8:23 AM. Resident #4 was placed 1 on 1 monitoring with staff upon return to the facility from the emergency room and remained 1 on 1 until the resident was transferred to a facility with a secure unit, all windows were checked by the Maintenance Director to ensure they were secure, elopement assessments were completed on all residents, care plans for reach resident identified at high risk for elopement were reviewed and updated, all residents with a history of behaviors were assessed for behaviors on their Medication Administration Record including Resident #4, care plan for each resident identified at risk for behaviors was reviewed and updated, in-service on elopement and/ or wandering initiated 8/19/2024 to be completed by the end of the day on 8/22/2024, on 8/22/2024 Administrator/ designee initiated a behavior in-service with staff with in-service to be completed at the end of the day on 8/22/2024, the facility used a 1 on 1 monitoring tool, and conducted an elopement drill. A total of [16] staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Treatment Nurse, Activity Director, Housekeeping, Dietary staff, Social Director, Business Office Manager, and the Maintenance Director. The staff interviewed verified they had been trained on resident elopement and behaviors. A review of in-service sheets provided indicated [47] of [68] had been provided training. Those staff who were not physically present to receive the in-services were messaged via telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on record review and interview, it was determined the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for resident behaviors for 1 (Resident #4) of 1 sample mixed resident. The findings are: A review of an Admission Record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of alcohol abuse, altered mental status, encephalopathy, and cognitive communication deficit. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/5/2024 revealed Resident #4 scored a 02 (indicates cognitively moderately impaired for daily decision making) on a Staff Assessment for Mental Status (SAMS). A review of the nursing Progress Notes dated 8/17/2024 at 5:18 PM, revealed Resident #4 was in a wheelchair in the common area under staff supervision due to attempting to enter other resident's rooms. Resident #4 had multiple family members visiting throughout the day. A review of nursing Progress Notes dated 8/18/24 at 2:05 AM, revealed Resident #4 requiring frequent redirection and becoming angry and striking out. Resident #4 was assessed as an elopement risk and fall risk and required frequent observation for safety. A review of the nursing Progress Notes dated 8/18/24 at 6:01 PM, revealed Resident #4 was in the common area watching television. Signs and symptoms (S/S) of increased anxiety were observed and treated with Chlordiazepoxide (a medication used to relieve symptoms of anxiety, including nervousness or anxiety and may also be used to treat symptoms of alcohol withdrawal) 25 milligrams (mg) by mouth as needed (PRN) with mild effect. Resident #4 was impulsive with poor safety awareness, difficult to redirect at times, wandered and entered other resident rooms, and staff were to keep the resident within sight when not in bed. A review of a nursing Progress Notes dated 8/19/2024 at 6:42 PM, revealed Resident #4 began to have aggressive behaviors, which included verbally abusing staff when asked to go to the dining room, blocking the resident's bedroom door so staff could not enter, refusing medication and dinner. The Director of Nursing (DON) was present for all events. A review of a nursing Progress Note dated 8/19/2024 at 7:30 PM, revealed Resident #4 was having aggressive behaviors which included refusing medication, throwing furniture and water at staff, balling up fist, and expressing a desire to fight staff. Review of Resident #4's Care Pan, initiated on 8/19/2024, revealed Resident #4's care plan did address the resident's behaviors. Review of a 1:1 Behavior Monitoring Visual Check Sheet revealed Resident #4 was monitored one-on-one starting 8/20/2024 at 2:30 AM, through discharge on 8/21/2024 at 12:00 PM. Review of a facility In-Service Education Report dated 8/22/2024 noted if a resident exhibits a behavior, follow the resident's care plan. If necessary, follow up with the physician. Document the behavior and the notification to the physician if he was notified. During a telephone interview with Licensed Practical Nurse (LPN) #3 on 8/20/2024 at 4:19 PM, LPN #3 revealed Resident #4 was impulsive. During a telephone interview with Certified Nurse's Aide (CNA) #5 on 8/20/2024 at 6:37 PM, CNA #5 revealed Resident #4 swung a full blown punch at him and that Resident #4 could be aggressive. During an interview with LPN #7 on 8/20/2024 at 7:24 PM, the LPN revealed Resident #4 was very aggressive toward staff, that on 8/19/2024 Resident #4 threw a glass of water in the LPN's face and then threw a chair at the LPN during medication administration. LPN #7 revealed the DON was trying to talk to the resident, but Resident #4 kept balling up their fists. LPN #7 then revealed CNA #8 assisted her with trying to get the resident to take their medication, but Resident #4 went straight to fighting. During an interview with CNA #8 on 8/20/2024 at 7:39 PM, CNA #8 revealed Resident #4 was very aggressive and wanders. During an interview with CNA #9 on 8/20/2024 at 7:51 PM, CNA #9 revealed Resident #4 was aggressive, anxious, confused, always asking for a beer, and very argumentative. CNA #9 revealed he was the CNA involved on 8/20/2024 when the residents barricaded themselves in their room using their body up against the door. CNA #9 indicated he went to the resident's room and tried to get the resident to come to the dining room for dinner and Resident #4 kept refusing, slammed the door shut. CNA indicated he tried to open the door but could tell the resident was holding it so for resident safety he backed away and notified the DON who was present in the facility. Resident #4 eventually came to dining room but refused to eat and sit down. During an interview with CNA #10 on 8/20/2024 at 8:00 PM, CNA #10 revealed Resident #4 was terrible, liked to argue, and could not be redirected at all on 8/19/2024. During an interview with CNA #11 on 8/20/2024 at 8:13 PM, CNA #11 revealed Resident #4 hits, curses, slaps, and throws chairs. CNA #11 revealed the resident barricaded the door to Resident #4's room and wouldn't let CNA #9 in. During an interview with the DON on 8/21/2024 at 9:18 AM, the DON said she was familiar with Resident #4, and that the resident calls staff names in Spanish, was combative at times with staff, and could be difficult to redirect. She said that on Monday (8/19/2024) before she left at 7:00 PM, CNA staff came to her because the resident was standing in a corner down on the hallway and not allowing redirection. She said the nurse on duty was down on the hall and Resident #4 was talking about fighting and pumping their fists. To decrease agitation the nurse said she had it and the DON left. The DON said shortly afterward she received a call describing how the resident had thrown water in the LPN's face and thrown a chair at her. She said Resident #4 was really agitated. Once informed the resident had barricaded themselves in their room, she instructed staff to leave the resident alone, and the resident then went to the dining room. During an interview with the Administrator on 8/21/2024 at 9:45 AM, the Administrator said she was familiar with Resident #4. She said on Monday the resident became increasingly agitated and had some behaviors that night. She also said she heard about the Resident #4 not allowing staff in their room and that the resident was agitated. During an interview with the DON on 8/21/2024 at 3:51 PM, the DON confirmed Resident #4 was not care planned for behaviors. During an interview with the Minimum Data Set (MDS) Coordinator on 8/21/2024 at 3:55 PM, the MDS Coordinator confirmed Resident #4 was not care planned for behaviors.

Based on observation and interviews, the facility failed to promote a healthy comfortable environment to support a safe living, healthy homelike and comfortable environment. The findings include: 1. On 07/01/2023, at 2:22 PM, environmental rounds were made in the facility, during which the following were observed: a. Upon entering room [ROOM NUMBER], standing at the entrance, on the left side of the middle to the wall, has 4 pieces of sheetrock two inches by three inches missing from the wall, as well as one gouge measuring six inches. b. Upon entering room [ROOM NUMBER], standing at the entrance, to the far left of the room on the ceiling, are white patches of white, caked in appearance with dark discoloration on a slightly bowed surface. c. Upon entering room [ROOM NUMBER], standing at the front entrance, on the immediate left, past the bathroom, the edge of the left corner wall between the built-in chest of draws, is exposed metal edges mid-way with sheet rock and tape. d. Next to the storage room on the left, (200 hall), there is evidence of side [NAME] at floor level, detached from the wall, six inches in height and one foot in width. e. During an interview with the Administrator on 07/02/2024 at 3:45 PM, the Administrator was asked if they were aware of the needed repairs in rooms 222, 211, 220, and the trim next to the storage room on hall 200, and if the facility had a policy on these issues. The Administrator stated, We do not have a policy for environmental repairs, was not aware, but the Maintenance man will meet you and will correct repair issues. f. During a tour with the Maintenance man on 07/03/2024 at 9:55 AM, in response to the question, Where you aware of the needed repairs in rooms 222, 211, 220, and the trim next to the storage room on hall 200? The Maintenance man stated, I have been working on the bigger jobs and missed the smaller repairs of room [ROOM NUMBER], 220, and the trim issue next to the storage room. I have been working toward repairs of the leaking roof and missed room [ROOM NUMBER].

Based on observation, interview, and record review, the facility failed to ensure that food was utilized prior to the expiration date, that equipment was clean to prevent potential cross contamination, and that hands were washed between clean and dirty tasks. These failed practices had the ability to affect all 47 residents who receive their meals from one of one kitchen according to a list provided by the administrator on 3/7/23 at 9:15 AM. The findings are: On 03/04/2024 at 09:55 AM, the kitchen floor is observed to be worn through revealing the concrete underneath and missing in places. The Dietary Manager (DM) reported being told multiple times that the floor is going to be replaced. The floor is discolored in the corners with debris under several appliances, worktables, and cabinets. On 03/04/2024 at 09:58 AM, a box containing seventeen 4 ounce servings of prune juice was located on the bottom shelf in the dry storage area. The use-by date for the juice was 08/03/2023. Located on the middle shelf in the right rear of the room was a 50 lb. (pound) bag of powdered milk. The date on the bag was 10/04. The DM stated, That has been here since I started. It could be from last year or the year before. I just didn't know what to do with it. There was a bag that had been opened and I threw that out. Located on the middle shelf, on the right side of the room next to the door a container of basil and a container of oregano are observed to have the lid open exposed the contents to air and contaminants. On 03/04/2024 at 10:10 AM, a large box of winter blend vegetables located on the middle shelf of the refrigerator was observed to be open. The bag inside the box was tied on top and was open on two sides leaving the bag open to air and contaminants. Located on the same shelf was a 29.7 lb. box of biscuit dough that was 3/4 full. The bag of dough was not sealed leaving the contents open to air and contaminants. On 03/04/2024 at 10:15 AM, the DM opened the top door of a two door refrigerator. The temperature inside the refrigerator was 48 degrees. DM stated, I have been wanting to move this one out of here. The DM reported that one of the legs is broken. When the door is opened, a plastic bag is observed to contain a variety of items, including a canned drink. The DM removed the bag and stated to Dietary Employee (DE) #1, I think this is yours. A large clear plastic container was also observed in the top section of the refrigerator and contained diced peaches. On 03/04/2024 at 10:18 AM, the metal shelves located in the walk-in refrigerator were covered in rust and the floor was discolored with patches of rust in the corners. On 03/04/2023 at 10:21 AM, the oven had a small puddle of water on the floor just below where the double doors meet. When the oven was opened, it had multiple areas of spilled, cooked on food in the bottom. The areas around the oven controls were coated in crumbs and greasy film. To the right of the range was the deep fryer which was uncovered. The oil had a layer of food particles floating on top. The particles were of various sizes and shades of brown. The inner shelf of the deep fryer was covered in oil with a layer of food particles. The two baskets resting over the top of the oil also had food particles adhered to the sides and bottom. On 03/04/2024 at 11:41 AM, DE #1 performed hand sanitizing. DE #1 then proceeded to use her hands to relocate the food processor and gather the pans and utensils needed to puree items for the lunch meal. DE #1 completed the process of grinding the meat for the residents who receive a mechanical soft diet. Upon completion the mixture was placed into a 1/4 steam table pan and carried to the steam table. DE #1 was then observed pushing a wheeled cart with a pan of gravy. DE #1 then proceeded to place pork into the bowl of the food processor, add gravy and puree. DE #1 did not wash his/her hands between clean and dirty tasks. On 03/04/2024 at 12:15 PM, the red suction device which was used to lift the warm plates and move them to the tray was lying in the floor. The DM picked up the device from the floor and placed it beside the warming plates. At 12:33 AM, DE #1 picked up the suction device and placed the contaminated device on top of the dinner plate to place it onto the tray. The contaminated device was used to place each plate onto the lunch trays of every resident who received a meal from the kitchen. On 03/06/2024 at 09:06 AM, the Administrator provided a policy titled, Food Safety-Infection Control, which documented, .Food Service Workers must wash their hands when: Handling soiled utensils or equipment, switching tasks between raw food and ready-to-eat foods, before and after tasks requiring gloves to work with food, engaging in any activity that may contaminate hands . On 03/07/2024 at 10:30 AM, the DM was asked when hands should be washed in the kitchen. The DM stated, Anytime you touch something that is contaminated, any time you change gloves, anytime you touch a raw food product and before you move on to the next job. The DM was asked how often the oven is cleaned. The DM stated, Every two weeks. The DM was asked how often the deep fryer is cleaned. The DM stated, We clean it and change the oil every time we fry fish. My weekend cook usually does it for me unless we don't have any oil. Sometimes I put it on my order and if I am over my budget, they take it off and don't send it. On 03/07/2023 at 1:30 PM, the Administrator was asked when hands should be washed in the kitchen. The Administrator stated, They should be washed between clean and dirty tasks.

Based on observation, interview, and record review, the facility failed to ensure that a call light was within reach for 1 (Resident #32) of 8 sampled residents who utilize their call light on Hall 100; failed to maintain resident rooms in good condition for 1 (Resident #35) sampled resident; and failed to ensure a sufficient amount of bed linen was available to maintain a homelike environment for all 47 residents who reside in the facility. The findings are: Resident #32 had a diagnosis of Fracture of right acetabulum. On the Quarterly Minimum Data Set, (MDS) with an Assessment Reference Date (ARD) of 1/26/2024, the resident received a score of 13 (13-15 cognition intact) on the Brief Interview for Mental Status (BIMS). a. On 03/04/24 at 11:17 AM, Resident #32 was observed sitting in a wheelchair in their room. The call light was lying on the bed. Resident #32 was asked if he/she could reach the call light if needed. Resident #32 said, The call light is worthless and needs to be thrown away. Resident #32 reported pushing the call light before and nobody ever answered it. The wheelchair was observed to be 3-4 feet from bed. b. On 03/06/24 at 02:36 PM, Resident #32 was observed sitting in a wheelchair in their room. The call light was observed lying on the bed. Resident #32 was asked if he/she could reach the call light if needed. Resident #32 said, It's no use for it to be in reach. When I push it, nobody answers it. The wheelchair was observed 3-4 feet from bed. 2. On 03/04/24 at 10:28 AM, the Surveyor observed the wall behind bed in the room of Resident #35 had gouging scrapes down the wall. a. On 03/06/24 at 08:24 AM, the Surveyor observed gouging scrapes down the resident's wall behind the bed. The Surveyor interviewed Licensed Practical Nurse (LPN) #03 in the resident's room and asked, How long have those gouges been on the resident's wall behind his bed? LPN #3 stated, I'm not sure, but as long as I can remember. When asked, Is that a homelike environment? LPN #3 stated, No, they should be fixed. b. On 03/07/24 at 09:00 AM, the Surveyor took the Maintenance Director to Resident #35's room and the Maintenance Director confirmed the gouges on the resident's wall need repaired and that he was unaware they were on the wall. 3. On 03/05/24 at 09:40 AM, the Resident in room [ROOM NUMBER] B reported that there appears to be a shortage of linen. Resident stated, I am a heavy wetter and more than once when they change me, they don't have any more sheets for this bed. The Resident is observed to require a bariatric bed. Resident describes a flat sheet for a regular size bed may be used to cover the mattress if a bariatric fitted sheet can't be found. Resident states, They just put whatever then can find over it. a. On 03/04/24 at 11:00 AM, the Resident in room [ROOM NUMBER] B describes the linen as being changed about every two weeks. b. On 03/06/24 at 11:18 AM, the Resident in room [ROOM NUMBER] B was observed sitting in a wheelchair beside the bed. Resident is waiting for assistance with making the bed. Observed on top of the bed is a fitted sheet and a flat sheet. There is no pillowcase. At 11:20 AM, CNA #1 entered the resident's room and began to place the sheets on the bed. CNA #1 was asked if there was any shortage of linen. CNA #1 stated, That depends on when they are finished with the laundry. We might have to wait on a load to dry. CNA #1 was asked how long there have been issues with having enough linen and she stated, For as long as I can remember. c. On 03/06/24 at 10:49 AM, the Resident in room [ROOM NUMBER] B is observed to be lying bed with his/her head on a pillow. The pillow is discolored in various shades of yellow/gold. The pillow is observed to be coming unsewn at the seam. There is no pillowcase present. d. On 3/7/24 at 8:40 AM, the Resident in room [ROOM NUMBER] A was observed to be lying in bed with no pillow present. The Resident was asked if they could locate their pillow. The Resident reported having not seen the pillow since last night. The resident raised the head of the bed, and the pillow was observed to be between the mattress frame and the base of the bed. The pillow is the same stained and torn pillow that was observed yesterday. e. On 3/7/24 at 8:55 AM, this surveyor entered the linen room on the 100 Hall. Located on the shelves were a total of 2 pillowcases. At 9:13 AM, this surveyor entered the linen room on the 200 Hall. Located in the closet were 3 pillowcases. f. On 3/7/24 at 9:18 AM, the Laundry/Housekeeping Supervisor (LHS) was asked to accompany this surveyor to the linen closet on the 200 Hall. LHS was asked to address the process for ensuring the linen supply. LHS described laundry aides as coming to the hall at times to assist in moving the dirty laundry which has accumulated during the night so it can be washed as quickly as possible. The LHS confirmed the presence of one washing machine in the facility and when asked when the machine went out, the LHS stated, In May I will have been here one year, and it hasn't worked the entire time I've been here. When the LHS was asked how the linen supply is maintained they reported that when a need is identified that information is relayed to the transport person who is responsible for ordering linen. When asked about pillowcases, the LHS stated, .eww we always seem to be short of those, I have put an order in, but the transport person quit. I know we have a new one but maybe he/she is still training. The LHS described having an additional storage room where linen is stored prior to it being placed on the halls. Surveyor accompanied LHS to this storage room to determine if a supply of pillowcases was available. When asked if pillowcases were available the LHS stated, We don't have any. When asked about the availability of sheets to fit the bariatric beds in the facility the LHS stated, That has always been a problem. We have started keeping them in their rooms.

Based on observation, interview, and record review, the facility failed to ensure residents were showered/bathed as scheduled to promote good personal hygiene for 01 (Resident R #35); ensure residents fingernails were kept clean and free of debris for 01 (Resident #13) sample mix residents who require assistance with showering/bathing. The findings are: 1. On 03/04/24 at 10:27 AM, the Surveyor observed Resident #35 lying in bed with greasy hair. a. On 03/04/24 at 10:28 AM, Resident #35 was asked, How long has it been since you've had a shower/bath? Resident #35 stated, Last shower was last week. b. On 03/06/24 at 08:24 AM, Licensed Practical Nurse (LPN) #03 confirmed the resident's hair was greasy and that he needed a shower. c. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/2023 documented, Self-Care E. Shower/ bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) . Partial/ moderate assistance . d. On 03/06/24 at 09:04 AM, the care plan dated 02/24/2024 documented, . Please ensure my shower/bathing as per my bath schedule. I may need assist with set-up . e. On 03/07/2024 at 10:47 AM, the Nurse Consultant confirmed the residents should be showered per schedule. f. On 03/07/2024 at 10:56 AM, the shower log for the last thirty days for Resident #35 noted the resident had a shower/bath and was independent on 02/26/2024 and 03/04/2024; and on 03/06/2024 required set-up help. It noted the resident refused a shower/bath on 02/12/2024 and 02/28/2024. g. On 03/07/2024 at 10:56 AM, the facility provided a shower refusal sheet that noted Resident #35 refused a shower on 02/12/2024. h. On 03/07/2024 at 10:56 AM, the Administrator confirmed that shower refusal sheets are to be signed by the resident when they refuse, and that Resident #35 had only signed one refusal sheet from 02/12/2024 through 03/06/2024 and only received 03 showers/baths. i. An Inservice Education Report dated 01/17/2023 documented, CNA's [Certified Nursing Assistants] when we have a resident that refuses to take a shower, staff must offer bed bath, and perform bath. If resident does refuse shower, bed bath or both, if resident can sign a refusal sheet, please obtain one and you sign and turn it into your nurse. Your nurse is to go attempt to encourage resident shower or bath as well. All three signatures need to be on refusal sheet. If resident unable to sign, nurse and cna signature must be noted that two attempts made by staff . j. An Inservice Education Report dated 01/30/2023 documented, CNA's Shower Refusals Residents are to have at least two showers a week either. They will be either M/W [Monday /Wednesday] or T/TH [Tuesday/Thursday] Fridays will be make up days for the ones that were missed. When a resident refuses a shower. There are shower refusal sheets that must be signed by the resident and cna. If a resident is unable to sign, then the nurse must go in and attempt to get them to take one. Then if resident still refuses, the nurse needs to sign and place refusal sheet in DON [Director of Nursing] door . k. An Inservice Education Report dated 02/22/2024 documented, .Direct-Care Staff: CNA's and Nurses: As a reminder here is a few things that are in your job description. If a resident misses a shower, they need to have bed bath offer to them. If a resident refuses a shower, they need to have a shower refusal sheet signed . 2. Resident #13's Annual MDS with an ARD of 06/20/2023 documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and required one person's physical help with bathing. a. Resident #13's Care Plan dated 06/19/2019 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] cognitive and motor function deficits . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . b. On 03/04/24 at 10:51 AM, Resident #13 was lying in bed. Residents #13's fingernails were not clean. A dark brown/black substance was observed underneath the fingernails of the left hand. c. On 03/05/24 at 10:24 AM, Residents fingernails appear to have a dark brown/ black substance under the fingernails of the left hand. d. On 03/05/24 at 10:24 AM, the Surveyor accompanied LPN #3 to Resident #13's room. LPN #3 confirmed Resident #13's fingernails were not clean and that they should be kept clean for hygiene purposes. e. On 03/07/2024 at 10:47 AM, the Nurse Consultant confirmed resident's fingernails are to be kept clean. f. An Inservice Education Report dated 01/05/2024 documented, .Staff need to routinely check resident's hands/nails for cleanliness. If they are dirty, please clean their hands/nails. Not only is this a dignity issue it is also infection control. Resident's hands need to be routinely checked for soiling throughout your shift (when getting up for the day, prior to and after meals, after being changed, during showers, prior to going to bed). Failure to check your resident's hands/ nails and overall hygiene routinely during your shift will result in disciplinary action. We need to work as a team to ensure our resident's care and hygiene are met . g. An Inservice Education Report dated 02/13/2024 documented, .Nail Care, nail care is the cnas and nurses' responsibility. Please be performing this during ADL care. This should be done during showers and bed baths. If you notice a residents fingers need to be clean, stop and do it, even if its not their shower day. This is a PRN [as needed] task, mark it in the kiosk and show your performing the tasks. If they are diabetics, you can still clean nails, you just can't cut them . h. An Inservice Education Report dated 02/22/2024 documented, .Direct-Care Staff: CNA'S AND NURSES: As a reminder here is a few things that are in your job description .Doing nail care .

Based on observation, interview, and record review, the facility failed to ensure thickened liquids were within reach and that the cooler was maintained with cold ice packs to promote adequate hydration for 01 (Resident #22) sample mix resident and the facility failed to provide services to maintain acceptable parameters of nutritional status for 01 (Resident #37) of 7 sampled residents who have a physician's order to receive fortified foods. The findings are: On 03/05/24 at 10:09 AM, the Surveyor observed no thickened liquid drinks in Resident #22 room's or the resident's cooler. The ice packs in the cooler were thawed. No fluids were present in the resident's room. On 03/05/24 at 02:30 PM, Licensed Practical Nurse (LPN) #03 confirmed there were no fluids at Resident #22's bedside or in the room. LPN #03 also confirmed the ice packs were thawed and no drinks were in the cooler. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2024 noted in section K- Swallowing/ Nutritional Status the resident is on a mechanically altered diet that required a change in texture of food or liquids such as purred food and thickened liquids. On 03/05/24 at 02:37 PM, the Physician Orders documented, .General diet, Mechanical Soft texture, Nectar consistency . On 03/05/24 at 02:39 PM, the Care Plan for Resident #22 dated 12/20/2019 documented, .Nutrition: Resident has risk for nutritional deficit and/or dehydration related to mechanically altered diet w/thickened liquids and has [history] of aspiration resident receives a mechanical soft diet with nectar thick liquids . On 03/07/2024 at 10:47 AM, the Nurse Consultant confirmed that residents on thickened liquids should have them at the bedside and that ice packs in the cooler should be replaced to keep liquids cold. On 03/07/2024 at 11:10 AM, the Dietary Manager confirmed that the CNA (Certified Nursing Assistant) staff are responsible for bringing the resident ' s cooler to the kitchen to have the ice packs replaced. An In-service Education Report dated 02/22/2024 that documented, As a reminder here is a few things that are in your job description . Offering resident drinks while doing rounds. 2. Resident #37 had diagnoses of Displaced fracture of base of neck of left femur, Dementia, and Alzheimer's. On the Quarterly MDS, with an ARD of 12/26/2023 shows to have received a score of 99 (unable to complete) on a Brief Interview for Mental Status (BIMS), summary of cognitive assessment. a. On 03/06/24 at 12:39 PM, Resident #37's meal ticket called for a magic cup. The Dietary Manager (DM) was asked, What is a magic cup? The DM said, That is a supplement that residents get for weight loss. The DM was asked if Resident #37 was supposed to have one. The DM said, We can't get those right now. The Surveyor asked what was supposed to be given in place of the magic cup. The DM said the resident should have fortified pudding. The DM checked resident's tray and said, [Resident #37] doesn't have one, but I can get him/her one. b. On 03/07/2024 at 8:15 AM, Resident #37 was observed eating breakfast in the dining room. The resident's tray contained pancakes, ground sausage, a bowl of oatmeal which remained covered, 2 packets of artificial sweetener, and coffee. c. On 3/07/2024 at 8:16am, the Cook was asked to identify the fortified food for the breakfast meal. The Cook stated, There is no fortified food for breakfast, but if they put butter and sugar in the oatmeal, it's considered fortified. The Surveyor returned to the resident and observed there to be 2 packets of artificial sweetener and no butter. d. Resident #37's records showed that the Resident's weights from 3/08/2023 until present has decreased from 180lbs to 158lbs, a 12.2% loss. e. On 3/7/2024 at 1:30 PM, the Care Plan dated 12/26/2023 stated, .at risk for weight loss due to diagnosis of dementia . required supervision at mealtime with cues to eat his/her food Resident #37's care plan has orders dated 1/11/2024 for the following interventions: Add fortified foods to all meals. f. On 3/7/2024 at 3:35 PM, the Administrator was asked for what reasons would a resident be prescribed fortified meals. The Administrator said it could be for anemia, vitamin deficiencies, weight loss, etc. The Administrator was asked what could be a possible consequence of the resident not receiving their meals fortified. The Administrator said that it wouldn't be an effective intervention and there wouldn't be an improvement in the residents' nutritional status.

Based on observation, interviews, and record review, the facility failed to assure nursing staff possessed the skill sets necessary to provide nursing services to meet the resident's needs safely and in a manner that promoted each resident's physical well-being, as evidenced by hand hygiene not being performed before putting on gloves during wound care to prevent the spread of infection for 2 (Residents #5, and #18), and the use of a mechanical lift as a care plan documented to prevent accidents for 1 (Resident #22) sampled resident. The findings are: a. On 03/05/2024 at 10:35 AM, Licensed Practical Nurse (LPN) #1, who reported they filled the roles of Treatment Nurse and Infection Preventionist [IP], gathered supplies and placed on bedside table in Resident #5's room. The nurse pulled gloves from uniform pocket, donned (applied) them, and proceeded to clean a pressure ulcer. LPN #1 took a collagen sheet from bedside table, tore it into small pieces placing some inside the wound bed, then laid the remaining collagen sheet back on the bedside table. LPN #1 then touched a different wound with the same gloves on. The nurse then changed gloves without performing hand hygiene. The second wound was cleaned, the remaining collagen picked up from the bedside table and placed in the wound bed before covering with dressing. LPN #1 gathered supplies from the bedside table, placed them in a regular (not biohazard) bag, then doffed (removed) the gloves before pushing the bedside table away from the resident's bed. b. On 03/05/2024 at 11:05 AM, the Surveyor asked LPN #1, Is there anything you would have done different during wound care? LPN #1 said, No. The Surveyor asked, Should hand hygiene be performed before donning gloves, between donning/doffing, and then again after doffing? LPN #1 said, Yes. The Surveyor verbalized their observation including lack of hand hygiene performed before, between, and after donning/doffing, touching a second wound with dirty gloves, then pushing the bedside table away from the resident's bed without performing hand hygiene or disinfecting the bedside table. The LPN was asked, What could the negative outcome be from not performing hand hygiene? LPN #1 said, Spread infection. The nurse was asked, What could the negative outcome be from touching the second wound with dirty gloves from the first wound? LPN #1 said, Spread infection from one wound to the other. c. On 03/05/2024 at 02:15 PM, LPN #1 gathered supplies and took them to Resident #18's room to provide wound care. The nurse donned gloves without performing hand hygiene, cleaned the pressure ulcer, doffed gloves, gathered regular (not biohazard) bags, and threw them away in the trash, then left the resident's room all without performing hand hygiene. The Surveyor asked, Is there anything you would have done different during wound care? LPN #1 said, Probably not. The Surveyor asked if the nurse should have performed hand hygiene between donning/doffing gloves. LPN #1 said, Probably. The Surveyor asked what the negative outcome could be for not performing hand hygiene between donning/doffing. The LPN said, Well, there isn't any hand sanitizer in the rooms, so I didn't know if I could bring some in there or not, but the spread of infection. d. A facility policy in the survey readiness book provided on 03/04/2024 at 10:00 AM titled, Infection Control, documented .7. Prevention of Infection . (3) educating staff and ensuring that they adhere to proper techniques and procedures . e. On 03/05/2024 at 11:42 AM, the facility in-services and competency checkoffs for direct care staff were reviewed. A nursing skill check off for LPN #1 was dated 01/24/24. f. On 03/05/2024 at 03:00 AM, the Nurse Consultant reported the facility did not have a hand hygiene policy. On 03/04/24 02:34 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 and CNA #2 giving Resident #22 the option of standing or using the mechanical lift to transfer from the wheelchair to the bed. Resident #22 chose to stand and was grabbing the grab bar multiple times while rocking in an attempt to get into a standing position. CNA #01 and #02 grasped the back of the resident ' s pants and brief, no gait belt observed, and assisted the resident into bed sitting on the side of bed by swinging them from wheelchair to bed. On 03/04/2024 at 02:39 PM, the Surveyor interviewed CNA #1 and asked, Is the resident to be transferred with a [mechanical lift]? CNA #1 stated, Ya, but they've been allowing [the resident] to do it [themselves]. When asked, Who instructed you that it was okay not to use the [mechanical lift]? CNA #1 stated, I haven't talked to anyone about it or double checked. I actually just came back. On 03/04/2024 at 02:40 PM, the Surveyor interviewed CNA #2 and asked, Is the resident to be transferred with a [mechanical lift]? CNA #2 stated, Yes. When asked, Who instructed you that it was okay to not use the [mechanical lift] to transfer the resident? CNA #2 stated, The resident. On 03/04/2024 at 02:50 PM, the Surveyor interviewed the Director of Nursing (DON) who confirmed that if a resident requires a [mechanical lift] for transfer that is how staff are to transfer them for safety. On 03/04/24 at 03:16 PM, the Surveyor interviewed the Administrator who confirmed that if a resident requires a mechanical lift for transfer that is how staff are to transfer them for safety. The Administrator stated they could not find a lift assessment for Resident #22 and would need to speak to the therapy department. On 03/05/2024 at 10:11 AM, the Surveyor interviewed Resident #22 and asked, Do staff assist you back to bed? Resident #22 stated, They come in here and help me. When asked, Do staff always use the lift to get you up out of bed or put you back in? Resident #22 stated, No they don't. The care plan dated 10/24/2023 noted Resident #22 requires mechanical lift times 1 staff, may use 2 staff when available. On 03/05/2024 at 02:21 PM, the Annual MDS with an ARD of 01/02/2024 documented Resident #22 had a functional limit in range of motion in the lower extremity on one side. On 03/05/2024 at 02:22 PM, the Surveyor could not locate a mechanical lift assessment for Resident #22. The Surveyor requested assessment. On 03/06/2024 at 08:24 AM, the facility had not provided the Surveyor with Resident #22's lift assessment. On 03/07/2024 at 09:59 AM, the Surveyor interviewed the Director of Nursing (DON) confirmed all staff are up to date on the competency skill check-offs. Certified Nursing Assistant Competency Skills Check-Off dated 11/22/2023 for CNA #01 noted the competency was met for fall prevention, transfers, and mechanical lift technique. Certified Nursing Assistant Competency Skill Check-Off dated 03/04/2024 for CNA #02 noted the competency was met for fall prevention, transfers, and mechanical lift technique.

Based on observation, interview, and record review, the facility failed to ensure all pharmaceuticals were available for the residents during medication administration. The findings are: 1. On 03/05/2024 at 08:13 AM, during observation of medication administration for 200 Hall with Licensed Practical Nurse (LPN) #03, Resident #24 did not receive their ordered dose of Lactulose Oral Solution. LPN #3 said she would obtain the lactulose and notify the Surveyor to come back and observe her administer it. a. The Physician Orders dated 03/05/2024 documented, Lactulose Oral Solution 10 GM [gram]/15 ML [milliliter] (Lactulose) 30 ML by mouth every 12 hours as needed for constipation. b. On 03/05/2024 at 11:36 AM, LPN #3 confirmed that the facility does not have Resident #24 ' s Lactulose Oral Solution. c. Resident #24 ' s Nursing Progress note dated 3/5/2024 documented, Medication Administration Note Text: Lactulose Oral Solution 10 GM/15ML Give 30 ml by mouth two times a day related to CONSTIPATION, UNSPECIFIED Give 30ml to =20gm med not available . d. On 03/06/2024 at 12:39 PM, Resident #24 ' s Medication Administration Record (MAR) noted the resident did not receive the 08:00 AM dose of Lactulose Oral Solution on 03/05/2024. 2. On 03/05/2024 at 08:24 AM, during observation of medication administration for 100 Hall/H-Hall with LPN #02, Resident #18 did not receive Folic Acid or [urinary tract infection medication]. a. The physician order dated 09/23/2020 noted [urinary tract infection medication] (Cranberry-Vitamin C-Inulin) Give 30 ml by mouth one time a day for urinary tract health; and on 01/19/2024 noted Folic Acid Oral Capsule 0.8 mg (milligram) (Folic Acid) Give 1 capsule by mouth one time a day for low folate levels. b. On 03/05/2024 at 08:24 AM, LPN #3 confirmed the facility did not have Resident #18's Folic Acid and UTI stat or [urinary tract infection medication]. c. On 03/05/2024 at 09:15 AM, the Surveyor interviewed the Resident #18 and asked, Do you receive your medications daily as ordered? Resident #18 stated, Not lately. I haven't had my [urinary tract infection medication] in a couple of weeks. d. On 03/06/2024 at 12:20 PM, Resident #18 ' s MAR noted resident did not receive the 08:00 AM dose of folic acid capsule 0.8 mg. e. On 03/07/2024 at 09:59 AM, the Director of Nursing (DON) confirmed the facility should have all prescribed medication for the residents at all times. f. On 03/07/2024 at 10:47 AM, the Nurse Consultant confirmed the facility should have all prescribed medications for the residents at all times. g. A facility policy titled Medication Administration, provided by the Administrator on 03/06/2024 at 02:56 PM, documented, Medications shall be administered in a safe and timely manner, and as prescribed . 3. Medications must be administered in accordance with the orders, including any required tie frame . 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation and record review, the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 2 (Residents #18 and #24) of 3 residents observed during medication pass resulting in medication errors. The findings are: 1. On 03/05/2024 at 08:13 AM, during observation of medication administration for the 200 Hall with Licensed Practical Nurse (LPN) #3, Resident #24 did not receive Lactulose (a medication used to treat constipation). LPN #3 said they would obtain the lactulose and notify the Surveyor to come back and observe its administration. a. The Physician Order dated 03/05/2024 documented, Lactulose Oral Solution 10 GM (gram)/15ML (milliliter) (Lactulose) 30 ml by mouth every 12 hours as needed for constipation. b. On 03/05/2024 at 11:36 AM, LPN #3 confirmed that the facility does not have Resident #24's Lactulose. c. A Nursing Progress note dated 03/05/2024 documented, Medication Administration Note Text: Lactulose Oral Solution 10 GM/15ML Give 30 ml by mouth two times a day related to CONSTIPATION, UNSPECIFIED . d. On 03/06/2024 at 12:39 PM, Resident #24's Medication Administration Record (MAR) noted the resident did not receive the 08:00 AM dose of Lactulose on 03/05/2024. 2. On 03/05/2024 at 08:24 AM, during observation of medication administration for 100 Hall/H-Hall with LPN #2, Resident #18 did not receive folic acid or [urinary tract infection medication]. a. The Physician Order dated 09/23/2020 documented, [urinary tract infection medication] Give 30 ml by mouth one time a day for urinary tract health; and on 01/19/2024, Folic Acid Oral Capsule 0.8 mg (Folic Acid) Give 1 capsule by mouth one time a day for low folate levels. b. On 03/05/2024 at 08:24 AM, the Surveyor interviewed LPN #3 who confirmed the facility did not have Resident #18's folic acid and [urinary tract infection medication]. c. On 03/05/2024 at 09:15 AM, Resident #18 asked, Do you receive your medications daily as ordered? Resident #18 stated, Not lately. I haven't had my [urinary tract infection medication] in a couple of weeks. d. On 03/06/2024 at 12:20 PM, Resident #18's MAR documented the resident did not receive the 08:00 AM dose of folic acid [urinary tract infection medication] on 03/05/2024. e. On 03/07/2024 at 09:59 AM, the Director of Nursing (DON) confirmed the facility should have all prescribed medication for the residents at all times. f. On 03/07/2024 at 10:47 AM, the Nurse Consultant confirmed the facility should have all prescribed medications for the residents at all times. g. A facility policy titled, Medication Administration, provided by the Administrator on 03/07/2024 at 10:52 AM documented, Medications shall be administered in a safe and timely manner, and as prescribed to maintain a medication error rate of below 5% . Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation and interview, the facility failed to ensure that garbage receptacles were maintained in a manner to minimize pests. The failed practice had the ability to affect all 47 residents who reside in the facility. The findings are: On 03/04/2024 at 10:27 AM, the dumpster to the left of the back door which was designated for recycling is observed to have the lid open. To the far right, located on the edge of the back parking lot were two trash dumpsters. The lids/doors of each dumpster were open. The Dietary Manager (DM) stated, They must have emptied them this morning because they were overflowing yesterday. There have been some issues with getting someone to pick them up, like maybe we switched companies. On 03/06/2024 at 12:00 PM, the dumpster found to the left after exiting the back kitchen door is observed to have the lid open, exposing the contents and providing an opening for pests. To the right, the two dumpsters at the back of the parking lot are observed to have a lid and a sliding door open. On 03/07/2024 at 12:30 PM, the DM was asked how the dumpsters should be maintained. The DM stated, We are supposed to keep the doors closed and make sure there isn't any trash on the ground. On 03/07/2024 at 01:15 PM, the Administrator was asked how the dumpsters should be maintained. She verbalized that the doors should be closed.

Based on observation, interview, and record review, the facility failed to ensure staff changed gloves/washed hands when contaminated before, during and after wound care in accordance with professional standards of nursing practice, to prevent the potential spread of infection for 3 (Resident #5, #15 and #18) of 4 (Residents #5, #15, #18 and #24) sampled residents who had Physicians Orders for wound dressings changes. This failed practice had the potential to affect 6 residents who received wound care treatment /dressings changes. The findings are: 1. Resident #5 had diagnoses of Paraplegia, Pressure ulcer of right buttock, stage 4 (a stage 4 pressure injury indicates the wound has extended to muscle, tendon, or bone), and Pressure ulcer of left hip, stage 4. An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/23 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognitively intact), and that the resident had pressure injuries to include a stage 4 pressure injury. a. On 03/05/2024 at 10:35 AM, Licensed Practical Nurse (LPN) #1, who was filling the roles of Treatment Nurse and Infection Preventionist, gathered supplies and placed them on bedside table in Resident #5's room. LPN #1 pulled gloves from her pocket and put them on. Using gauze and wound cleanser, the pressure ulcer on resident's left buttock was cleaned. LPN #1 then reached over to the resident's bedside table, grasped a collagen sheet, and tore it into small pieces before placing it inside the wound bed until it was completely covered, before placing the remaining collagen sheet back on the bedside table. LPN #1 touched another wound on the resident's labia with the same gloves on. LPN #1 then changed gloves without performing hand hygiene. The labia wound was cleaned with gauze and wound cleaner, the remaining collagen was picked up off the bedside table and placed in the wound bed, then an antimicrobial foam dressing was placed in the buttock wound and both areas covered with a clean, heart shaped dressing. LPN #1 gathered supplies from the bedside table and placed them in regular (not biohazard) bag, then removed her gloves before pushing the bedside table away from resident's bed, threw away the disposable bag and went outside in the hall. b. On 03/05/2024 at 11:05 AM, LPN #1was asked, Is there anything you would have done different during wound care? LPN #1 said, No. The Surveyor asked, Should you have performed hand hygiene before donning (applying) gloves, between donning/doffing (removing), and then again after doffing? LPN #1 stated Yes. The Surveyor verbalized observation including lack of hand hygiene performed before, between, and after donning/doffing, the second wound being touched with dirty gloves, and the resident's bedside table had been pushed away from bed all without performing hand hygiene. LPN #1 was asked, What could be a negative outcome from not performing hand hygiene? LPN #1 stated, Spread infection. LPN #1 was asked, What could be a negative outcome from touching the second wound with dirty gloves from the first wound? LPN #1 said, Spread infection from one wound to the other. c. A Physician's Order documented, right labia PU [pressure ulcer] clean with wound cleanser, pat dry, apply collagen to wound bed, cover with clean dry dressing every day shift for PU healing AND as needed for as needed for soiling or displacement. d. A Physician's Order documented, Pressure ulcer to left buttock: clean with wound cleanser, pat dry, pack wound with [Named collagen wound dressing], cover with [Named brand] foam, and wound tape. every day shift for wound healing AND as needed for soiled/displacement. e. A care plan saved to the survey folder documented PRESSURE ULCER .Resident was admitted to this facility with a pressure ulcer to left buttock and is at risk for new pressure ulcers related to impaired mobility .Administer treatments as ordered and monitor for effectiveness . Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD . The resident requires: air loss mattress on bed and cushion in wheelchair. 2. Resident #15 had diagnoses of Complete traumatic amputation at knee level, left lower leg and Type II Diabetes Mellitus. The Quarterly MDS with an ARD of 1/04/2024, shows to have a score of 14 (13-15 indicates cognitively intact) on a BIMS. a. On 3/4/2024 at 2:50 PM, LPN #1 came into Resident #15's room to do a dressing change. LPN #1 removed a clean bandage from the packaging and then placed the bandage on the resident's bedside table, which was littered with food crumbs, debris, dried liquid stains, and cluttered. LPN #1 then, with gloved hands, removed the contaminated dressing from Resident #15's left leg. With gauze, LPN #1 cleaned the wound on the left leg, picked up the new bandage with the same gloves and placed the new bandage on the wound on the Resident #15's left leg. b. On 3/7/2024 at 1:30 PM, a review of the medical record reflected Resident #15 was hospitalized from 02/25/2024 through 03/01/2024 due to infection of the left stump from amputation. Resident #15 was discharged back to facility on 3/01/2024 with orders as follows: Resident has orders for wound care as follows: Left BKA (below knee amputation) dehiscence (a partial or total separation of wound edges): Cleanse area with wound cleanser, pat dry, cover with [named a brand of foam dressing]. every day shift AND every 24 hours as needed. 3. Resident #18 had diagnoses of Type 2 diabetes mellitus with diabetic neuropathy, Peripheral vascular disease, Unspecified and morbid (severe) obesity due to excess Calories. An Admission MDS with ARD 11/20/23 documented a BIMS of 14, that the resident has a pressure ulcer/injury. a. On 03/05/2024 at 02:15 PM, LPN #1 was observed gathering supplies and taking them to Resident #18's room. LPN #1 donned gloves without performing hand hygiene, then cleaned a PU on the resident's right buttock with gauze and wound cleanser. The LPN doffed used gloves, donned new gloves without performing hand hygiene, placed collagen to wound bed and covered with dry heart shaped bandage. LPN #1 doffed gloves, gathered up the disposal bag, threw it away, then left the resident's room. The LPN was standing beside treatment cart outside resident's room when the Surveyor asked, Is there anything you would have done different during wound care? LPN #1 stated, Probably not. The Surveyor asked if the nurse should have performed hand hygiene between donning/doffing gloves. The LPN said, Probably. The Surveyor asked what the negative outcome could be for not performing hand hygiene between donning/doffing. LPN #1 stated, Well, there isn't any hand sanitizer in the rooms, so I didn't know if I could bring some in there or not, but the spread of infection. b. A Physician's Order documented, Stage III PU (Indicates full thickness tissue loss, in which subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) right buttock, clean open area with wound cleanser, pat dry, apply collagen to wound bed, cover with dry dressing, every day shift for PU AND as needed for OBSERVE FOR PLACE/SOILING, REPLACE AS NEEDED. c. A care plan saved to the survey folder documented, Resident has potential for pressure ulcer development related to obesity, decreased mobility, diabetes and fragile skin .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . d. A facility policy found in the survey readiness book provided on 03/04/24 at 10:00 am titled, Infection Control documented .7. Prevention of Infection . (3) educating staff and ensuring that they adhere to proper techniques and procedures . e. On 03/05/24 at 03:00 PM, the Surveyor was told by the Nurse Consultant that the facility did not have a hand hygiene policy. 49981

Based on observation, interview, and record review, the facility failed to ensure residents were provided consistent access to personal property for 1 (Resident #46) sampled resident. The findings are: Resident #46 was admitted on [DATE]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2024 documented a score of 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) On 03/05/2024 at 08:43 AM, the Surveyor observed a cell phone in the narcotic box of 100 Hall cart. Complaint stated that Resident #46 had their cellphone taken away by the Director of Nursing (DON) and placed on the med cart. Licensed Practical Nurse (LPN) #2 stated was made aware by other staff that the DON removed the residents cell phone from them and put on the med cart. On 03/05/2024 at 01:30 PM, the DON was asked, On Friday February 23, 2024, did you remove Resident #46's cell phone and lock it up in the 100 hallway medication cart? The DON stated, No. The Surveyor took the DON to the 100 hallway medication cart and had her unlock and open the narcotic drawer. The Surveyor asked the DON whose cellphone is locked up on the med cart? She stated, It's [Resident #46's], but I didn't lock it up. I don't know who put it in there. The weekend crew put it in the drawer left of the computer. When asked, Is this a violation of the resident rights to take their cell phone? the DON stated, Yes. On 03/05/2024 at 01:41 PM, the Administrator confirmed the cell phone was locked up on the medication cart. A facility staff in-service dated 02/26/2024 documented, Residents have the right to their property. Do not take anything from them. An in-service witness statement from the DON dated 02/28/2024 documented, On February 23rd resident came in from smoking, hollering, and stating [the resident] couldn't breathe, and wanted to go to the hospital because [the resident] didn't feel good. This nurse, sat with [the resident], explained to [the resident] we need to put oxygen on, that I knew [the resident] didn't feel good, [the resident] had a yeast infection, a UTI (Urinary tract infection), and we had just started on antibiotics. Going to smoke and not wearing oxygen always makes things worse. Resident yelled If you don't call the ambulance I will. I asked for resident's phone while pushing [the resident] to [the resident's] room. The Resident stated, I just don't feel good. Resident oxygen (saturation) was in the 70's. Arrived at resident's room placed oxygen on resident. Coached resident to breath, resident requested assistance to bed. Assisted resident in bed. Resident stated [the resident] was ok at that time. Wanted [the resident's] phone back. Rechecked resident's oxygen resident oxygen was at 93% with n.c. [nasal cannula]. I told resident I have to go get the paperwork completed and I had to get an order from the MD to send [the resident] to ER (emergency room ). Resident nodded head. I went to computer filled out paperwork. Called MD [Medical Doctor], MD did not answer. APN [Advanced Practice Nurse] did not answer. Went back to check on resident to let [the resident] know MD did not answer, awaiting return call. Resident was laying on . bed eyes closed, appeared to be asleep. Respirations were non-labored. Oxygen was at 93% via n.c. I did not wake resident up. Call light was within reach . A witness statement dated 03/04/2024 from the Regional Director of Operations documented, .When question about her comment regarding the DON taking someone's phone, she stated that she was not present on Friday, but she heard that the DON had placed [Resident #46's] phone on the med cart but that the resident's phone was on the med cart on Saturday and that she returned it to [the resident] . The facility policy titled, 'Resident Rights', provided by the Administrator on 03/07/2024 at 11:38 AM documented, Residents and employees are routinely made aware of rights of this facility. These rights include the resident's right to: f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident of the United States; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility .

Based on observation, record review, and interview, the facility failed to ensure that before a resident was allowed to self-administer nasal spray, the Interdisciplinary Team (IDT) conducted an assessment to determine if this practice was safe, obtain a physician order for self-administration, and develop a care plan to address educating the resident on self-administration, to prevent potential errors in administration for 1 (Resident #35) sampled resident. The findings are: On 03/04/2024 at 10:17 AM, the Surveyor observed a bottle of nasal spray lying in Resident (R) #35's windowsill next to the bed. The Surveyor asked the resident how long he/she had the nasal spray and they stated, Long enough for it to be empty. When asked, Were you assessed to be able to self-administer your own medications? R #35 stated, I don't think so. The physician order dated 11/27/2023 noted saline nasal solution (Saline) 1 spray in both nostrils every 4 hours as needed for dry nares. There was no order related to the self-administration of medication. The care plan date 11/20/2023 does not document that R #35 was assessed to self-administer medications. A facility in-service education report dated 02/04/2024 documented, Direct Care Staff: Nurses: As a reminder, state is writing tags a lot this year for medication carts not being lock, and being unattended, leaving medication at a resident bedside, or not monitoring to ensure a resident takes all their pills. This is a deficiency that is easily preventable with training and monitoring . A facility in-service education report dated 02/13/2024 documented, Direct Care Staff: As a reminder nothing is considered a medication can be stored at bedside. Please pay attention when going in rooms and remove these items as you see them. Anything that says keep out of reach of children should not be in a resident's room per state guidelines . A facility in-service education report dated 02/22/2024 documented, Direct Care Staff: Nurses: Nurses please do not pre-pop your medications. When you initial cups and then leave them in a residents room, it indicates you pre-popped meds. This also may suggest you are leaving your medications at bedside. Please do not do this . R #35's March Medication Administration Record (MAR) does not document self-administration of Nasal Spray. On 03/05/2024 at 08:32 AM, Licensed Practical Nurse (LPN) #03 confirmed the resident does not have a self-administration order to self-administer medication. On 03/05/2024 at 08:54 AM, R #35's Assessments did not document a self-administration assessment for the resident. On 03/07/2024 at 10:57 AM, the Surveyor interviewed the Director of Nursing (DON), who confirmed the resident did not have a self-administration order and medication should not be left at bedside. Facility provided a policy titled, 'Medication Administration' on 03/06/2024 that documented, Medication shall be administered in a safe and timely manner, and as prescribed . 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .

Complaint # (AR 814) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure basic life support measures, including cardiopulmonary resuscitation (CPR), were provided in an effort to prevent death for 1 (Resident #3) of 1 case mix resident who was a full code and experienced cessation of vital signs, and failed to ensure the clinical record was free of discrepancies in code status information, which could have resulted in failure to follow resident wishes in the event of cessation of vital signs for 1 (Resident #3) of 5 (Residents #1, #2, #3, #4, and #5) case mix residents whose code status documentation was reviewed. This failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #3, who was to be a full code per physician's orders [REDACTED]. The failed practice also had the potential to cause more than minimal harm to 38 residents who had physician orders [REDACTED]. 1. Arkansas Act 718 of 2009, [DATE], for withholding cardiopulmonary resuscitation in nursing facilities, documented the act applies to unwitnessed deaths. The Act provides no circumstances under which it is acceptable for a healthcare worker to withhold CPR from a full code resident for a witnessed death. 2. Resident #3 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 11 (,[DATE] indicates moderately cognitively impaired) on a Brief Interview for Mental Status; required extensive two plus persons physical assistance for bed mobility, transfers, toilet use, and personal hygiene; had functional limitation in range of motion on one side of upper and lower extremities; had no shortness of breath; required contact isolation, received Hospice care, and received oxygen therapy. a. An Admission Record form titled Prehospital Consent To Do Not Resuscitate (DNR), dated and signed by the Responsible Party on [DATE], documented, .Pre-hospital Consent . I (Responsible Party) request that 'CPR' be administered to (Resident #3) and request that he / she be stated as 'Full Code' . b. The facility Resident Clinical Profile page with admission date of [DATE] documented, .Code Status: . (Blank) . c. A Hospice Progress Note dated [DATE] documented, .Was the patient / responsible party asked about preference regarding the use of cardiopulmonary resuscitation (CPR) .Yes, and discussion occurred (Specify) . Remains a full code . d. A Baseline Care Plan dated [DATE] documented, .DNR (Do Not Resuscitate) . Hospice . e. The facility Medication Administration Record [REDACTED].CPR . Full Code . f. A physician's orders [REDACTED].CPR (Cardiopulmonary Resuscitation) . Full Code . A Physician's History and Physical dated [DATE] documented, .Code Status . Full Code . g. A Nurses Progress Note dated [DATE] at 11:25 a.m. documented, .Resident arrived by our facility van. Resident came from (Hospital Name). Resident wishes are to be LTC (Long Term Care) and a Full Code . h. A Nurses Progress Note dated [DATE] at 00:00 (12:00 a.m. / midnight), signed by the Assistant Director of Nursing / Licensed Practical Nurse (LPN) #1 and documented as Late Entry, documented, .Resident received resting quietly in bed with family at bedside. She is non-verbal and has a blank stare with glossy eyes. Chest rising and falling at this time with no moaning, groaning or any other audible signs of pain or discomfort noted. She remains under the care of (Name) hospice and MD (Medical Doctor / physician) is aware of current condition. Contact Isolation remains in place [MEDICAL CONDITIONS] . i. A facility Weights and Vitals Summary Sheet dated [DATE] at 1:20 a.m. documented, .Oxygen Saturation - 98% (Room Air) . j. A Nurses Progress Note dated [DATE] at 03:30 (3:30 a.m.), signed by Assistant Director of Nursing / Licensed Practical Nurse (LPN) #1 and documented as Late Entry, documented, .Family remained at bedside throughout the night until approximately 0300 (3:00 a.m.) with no concerns voiced and no issues noted. Resident continues to rest with HOB (head of bed) slightly elevated. Resident turned and repositioned every 2 hours with incontinent care as needed. Will continue to observe and note any changes . k. Three separate Weights and Vitals Summary Sheets dated [DATE] at 3:40 a.m. documented, .Pulse . 76 bpm (beats per minute) (Regular) . .Respirations . 19 breaths/min (per minute) . .Blood Pressure . ,[DATE] . l. A Nurses Progress Note dated [DATE] at 07:30 (7:30 a.m.), signed by Assistant Director of Nursing / Licensed Practical Nurse (LPN) #1 and documented as Late Entry, documented, .CNA (Certified Nursing Assistant) notified this nurse (at) 04:30 (4:30 a.m.) that resident was gurgling and needed suctioning. Upon entering the room, resident had white frothy foam coming from her mouth. This nurse suctioned the excess secretions for better assessment. V/S (vital signs) were unattainable, eyes fixed, extremities cooling, and breath sounds ceased. (Name) Hospice was notified by the other nurse on duty while this nurse attended to resident. Hospice nurse arrived at approx. (approximately) 0500 (5:00 a.m.). She notified family, who pronounced (death) at 0505 (5:05 a.m.) and (Name) Funeral home. Representative of mortuary arrived and family was present in the facility and at bedside. Body was released to funeral home. Personal belongings collected by family and they thanked staff for caring for (Resident #3). All medications were collected and destroyed per policy and procedure . m. An Office of Long Term Care (OLTC) Incident and Accident Next Date Reporting Form, Division of Medical Services (DMS) form 7734, dated [DATE] at 2:15 p.m. and completed by Medical Records documented, .Summary of Incident .Upon request from Hospice of code status and face sheet on (Resident #3) we discovered that her code was actually Full Code. During the morning of (Resident #3) expiring, no CPR (cardiopulmonary resuscitation) was started or attempted by nurse in charge of that hall . Steps Taken to Prevent Continued Abuse or Neglect During the Investigation .(Name) LPN (Licensed Practical Nurse) was the nurse on duty the morning of the occurrence. She was suspended immediately pending the outcome of this investigation . All hospice residents' charts reviewed to verify correct code status being on file . In-service with all nurses started on verifying code status, CPR and proper protocols . n. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Resident in Long Term Care Facilities, DMS form 762, signed by the Administrator on [DATE], documented, .Complete Description of Incident . On the morning of [DATE] (Resident #3) was discovered during rounds at approx. (approximately) 4:00 a.m. to have excessive spittle forming in her mouth. Aide on the hall informed LPN (Licensed Practical Nurse) / ADON (Assistant Director of Nursing) that she was needed to the room. Nurse informed aide to reposition (Resident #3) and she should be ok. Aide returned to room and noticed that more spittle was present. Aide returned to LPN and informed her that she thought that (Resident #3) really needed to be suctioned. Nurse then went to the room to assess resident with suction machine. Hospice notified at 4:35 a.m. by other facility nurse on duty at time at the request of LPN. Hospice nurse arrived at the facility and pronounced resident deceased at 5:09 a.m. Code status was never verified by LPN / ADON. Resident code status was 'Full Code' but no CPR (cardiopulmonary resuscitation) was initiated by (Name) LPN / ADON . Findings and Actions Taken . Resident expired at 5:09 a.m. on [DATE] . (Name) LPN / ADON suspended immediately upon notification of incident . All residents' charts in the facility at the time were reviewed to verify that the correct code status was on file. No discrepancies were found . In-service for all nurses was done to ensure that they knew the process for verification of code status and performance of CPR or not as determined by the resident's wishes and physician's orders [REDACTED]. (Name) LPN / ADON will be terminated for failing to follow 'Full Code' wishes of resident . o. On [DATE] at 9:08 a.m., Certified Nursing Assistant (CNA) #1 was asked if she was working the night (Resident #1) expired. She stated, I worked on the night that (Resident #3) passed away. I was working over on 200 Hall with (Registered Nurse (RN) #1), the nurse, helping with a resident's treatment. (Resident #3) resided on the Rehab (Rehabilitation) Unit. (CNA #2) was coming down the hallway mad because she couldn't find a suction machine, stating that her nurse was taking her time to see (Resident #3), who was foaming at the mouth. I went to the resident's room with (CNA #2). When I entered the room, the nurse, (LPN #1) was in the room with the resident. The resident was dead when I entered the room. I could just tell that she was dead by just looking at her. (CNA #2) had a lid to the suction machine in her hands and (LPN #1) told her it was the wrong one. (LPN #1) was standing in the room with her phone in her hand dialing a number. (CNA #2) asked if resident was gone, and (LPN #1) said, 'Yes'. (CNA #2) left the room to get another lid for the suction machine canister per (LPN #1's) instructions. (RN #1), the other nurse on duty, came to the room and asked (LPN #1) if she had called hospice, and asked if the resident was gone. I left the resident's room, I do not know what (LPN #1) told (RN #1). I went back to my hall. The family had been here most of the night. They had left earlier that morning. p. On [DATE] at 9:39 a.m., RN #1 was asked if she had worked the night (Resident #3) expired. She stated, I was working on the night that (Resident #3) expired. The only thing that I remember from that night, it was early in the morning, I saw (LPN #1) coming up the hall with a suction machine. I asked her where she was going. She said that one of her residents needed to be suctioned. I asked her if she needed any help, and she declined my help. I went back to work on my documentation. About 30 minutes later, I was getting 4:00 a.m. medications out, when (LPN #1) approached me at the nurse's station and asked if I would call hospice for her, that (Resident #3) had passed. I stopped and called hospice for her. The hospice nurse had left the facility about two hours earlier. After calling hospice, I went back to work on my hall. I did not see (Resident #3) that night. I did not go into her room. q. On [DATE] 10:40 a.m., CNA #2 was asked if she was familiar with (Resident #3), and if she had worked the night (Resident #3) had expired. She stated, I am familiar with (Resident #3). On the night that (Resident #3) passed away, I was going into her room every two hours to check on her. I went in at 12:00 a.m., 2:00 a.m., and at 4:00 a.m. At 4:00 a.m., the resident had a lot of saliva in her mouth and was gurgling. When I noticed that, I walked to the 200 Hall Nurse's Station and told (LPN #1) that the resident had a lot of saliva and was gurgling, I told the nurse that the resident needed to be suctioned. (LPN #1) asked when I last turned her, and I told her that I turned her at two (o'clock), and went in now to turn her. (LPN #1) told me to just turn her and she should be okay. I walked back to (Resident #3's) room, and I noticed that there was more saliva and the gurgling sound had gotten worse. I rolled her head all of the way up. I walked back down to 200 Hall Nurses Station where (LPN #1) was, and I told her I cannot turn (Resident #3). She needs to be suctioned. (LPN #1) got up. She went to find a suction machine in the closet. We both went to (Resident #3's) room. (LPN #1) tried to set up the suction machine, but the lid would not fit. I then went to the storage room to get another lid for the suction machine. I took the top back to the room. (LPN #1) set up the suction machine. I looked over to (Resident #3), and noticed that she started foaming at the mouth, I told (LPN #1) that she was foaming at the mouth, and (LPN #1) said it's just her heart giving out on her. I then noticed that the resident was not breathing anymore. (LPN #1) tried to suction the resident. (LPN #1) walked out of the room and told (RN #1) to call hospice. (LPN #1) told me to do oral care on (Resident #3). The resident was not breathing at that time, and (LPN #1) told me she had passed. I laid the resident's head flat, and I left out of the room after doing the oral care. (RN #1) called hospice. Hospice arrived about 35 minutes later. I did not see CPR (cardiopulmonary resuscitation) administered to (Resident #3). There was no conversation about CPR. The resident's daughter left approximately 3:00 a.m. The resident did not respond verbally that night. She just had a blank stare. But she was breathing when I made my rounds. r. On [DATE] at 12:04 p.m., the Director of Nursing (DON) was asked about the night (Resident #3) expired. She stated that after the discovery of CPR (cardiopulmonary resuscitation) not being administered to (Resident #3), they did a 100% chart audit to compare physician's orders [REDACTED]. All nurses were in-serviced on CPR. She stated, There is ongoing monitoring for all new residents admitted to the facility to compare orders against code status and to see if the code status was honored if a resident expired. She stated she did not do any training on suction machines. She did check the suction machine on the crash cart to make sure it was in working order. She stated she did interview the CNA taking care of the resident that night, and the CNA told her the resident's nurse did not respond the first time she was told of the change in resident's condition. s. On [DATE] at 1:04 p.m., the DON was asked when she had discovered the Code Status had not been observed, and CPR had not been administered. She stated she discovered the Code Status and CPR not being administered for (Resident #3) on [DATE] when a Hospice Nurse came to the facility asking for the resident's face sheet and code status. When this information was pulled, they noticed that (Resident #3) was a 'Full Code'. The Director of Nursing stated she started the investigation at that time. t. A facility form titled Termination Form dated [DATE] and provided by the Director of Nursing on [DATE] documented, . (Licensed Practical Nurse) #1 .Resigned from ADON (Assistant Director of Nursing) position . 3. The facility removed the Immediate Jeopardy and reduced the scope / severity to G, on [DATE], as evidenced by the following corrective actions: a. The Findings and Actions Taken portion of the DMS-762 documented, All residents' charts in the facility at the time were reviewed to verify that the correct code status was on file . In-service for all nurses was done to ensure that they knew the process for verification of code status and performance of CPR, or not, as determined by the resident's wishes and physician's orders [REDACTED]. (LPN #1) will be terminated for failing to follow 'Full code' wishes of resident. (Done [DATE]) . b. An in -service record dated [DATE] documented, .Topic CPR . Code status is to be verified in the Electronic Medical Record in (facility computer system). You will find the code status under the documents / misc (miscellaneous) tab (this is normally towards the bottom) . DNR code status is to be signed in order to be an actual DNR (Do Not Resuscitate). The resident is a full code until this is signed . c. A facility monitoring form provided by the Director of Nursing (DON) on [DATE] at 1:06 p.m. documented, .[DATE] . monitoring .' The form contained documentation of monitoring from [DATE] through [DATE]. Each date had a signature, and residents who were newly admitted to the facility were listed as having their code status verified. There had been no resident deaths since the monitoring plan was initiated.

Complaint # (AR 015) and Complaint # (AR 052) were substantiated, all or in part, in these findings. Based on observation, record review, and interview the facility failed to consistently conduct and accurately document pressure ulcer assessments, including measurements, staging, a description of the wound bed and surrounding tissue, and presence or absence of drainage or odor, to allow ongoing, consistent monitoring of healing progress or prompt identification of deterioration that might necessitate a need for a change in treatment; failed to ensure pressure ulcer treatments were provided in accordance with physician orders [REDACTED].#1 and #3) of 5 (Residents #1 -5) case mix residents who required wound care. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who had a Stage III to IV pressure ulcer and a history of pressure ulcers to multiple sites, and Resident #2, who had multiple pressure ulcers and a current [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA) wound infection, and had the potential to cause more than minimal harm to 8 residents who required wound care, according to a list provided by the nurse consultant on 9/19/18 at 2:05 p.m. The Administrator was notified of the Immediate Jeopardy on 9/20/18 at 3:05 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/29/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; was totally dependent on 2-plus people for bed mobility and all other Activities of Daily Living (ADLs) except toilet use, was at risk for developing pressure ulcers, and did not have any existing pressure ulcers. The Care Area Assessment triggered for pressure ulcer risk, with a decision to proceed to care plan. a. The Plan of Care (dated as follows) documented, .The resident has high risk for pressure ulcer development r/t (related to) immobility . 11/22/17 DTI (deep tissue injury) - resolved . 11/22/17 - Stage 2 Right Plantar Foot: reclassified as DTI - resolved . 11/22/17 - Stage 2 Left Ear - resolved . 12/3/17 - Stage 2 Sacrum - resolved . 12/4/17 - DTI Right Heel - resolved . 1/18/18 - Stage 2 Right Heel - resolved . 1/18/18 - Stage 4 Right Buttock - resolved . 6/2/18 Stage 3 to Right Buttocks . Interventions/Tasks . Administer treatments as ordered and monitor for effectiveness . air mattress Date Initiated: 12/04/2017 . Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Monitor dressing to ensure it is intact and adhering. Report loose dressing to Treatment nurse . Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs or symptoms) of infection, wound size (length X (by) width X depth), stage . Neck Pillow Date Initiated: 11/29/2017 . Pro-Stat, Vitamin C, Multivitamin with minerals . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . b. Nurses Notes beginning on 11/22/17 documented as follows: 1) 11/22/2017 (at) 2214 (10:14 p.m.) Admit to facility . There was no documentation a skin audit was completed at the time of admission. 2) 11/29/2017 . 2 DTI to L. (left) plantar foot - Stage 2 to R. (right) plantar foot - Stage 2 to L. ear . 3) 12/5/2018 . sacrum 0.5 cm (centimeters) X 3 cm . Right buttocks 3 cm X 5 cm . 4) 12/13/2017 . current measurements to sacrum are 7 cm X 4 cm X 0.2 cm with wound bed being 100 % [MEDICATION NAME] tissue. Small amount of serous drainage noted. Wound edges are well defined and peri wound tissue is normal. Current treatment is to cleanse with wound wash/NS (normal saline) pat dry, apply zinc cream, cover with dry dressing 3X (times) / (per) week and prn (as needed) . This was the first documentation of a description of the wound tissue and drainage to the sacrum and no further documentation of the wound description and drainage until (MONTH) 2, (YEAR). 5) 12/26/2017 ., sacrum pressure wound 2 cm X 1.5 cm, right buttocks pressure wound 4 cm X 3.5 cm . 6) 1/25/18 . Stage 4 R. buttocks . cleanse (with) wound wash/NS, pat dry, pack (with) alginate rope, cover (with) dry dressing . 7) 1/30/18 ., R. buttocks at 2.5 X 2 X 3.5 tunneling present (with) drainage pinkish red . remains on skilled therapy . 8) 2/13/2018 ., Stage 4 right buttocks 1.2 cm X 1 cm X 0.4 . There were no further assessments documented until 3/1/18. 9) 3/1/2018 . Stage 4 pressure injury to R. buttocks closed . Resident continues to be high risk for skin breakdown so will leave current interventions in place for prevention .Will CP[NAME] (continue with plan of care) . c. The (MONTH) (YEAR) Treatment Administration Record (TAR) documented, .Body Audit every day shift every Wed (Wednesday) open and complete skin observation assessment . The Body Audit was checked and initialed by a licensed nurse as completed on (MONTH) 25th. There were no other body audits documented as being completed for the Month of (MONTH) (YEAR). d. The (MONTH) (YEAR) TAR documented, .Body Audit every day shift every Wed open and complete skin observation assessment . The Body Audit was checked and initialed by a licensed nurse as completed on (MONTH) 2nd, 9th, and the 23rd. There was no documentation of a body audit conducted during the 14-day period between 5/9/18 and 5/23/18 or during the 8 day period between 5/23/18 and 5/31/18. e. Nurses Notes dated 6/2/18 documented, .Resident has 2 cm wide X 4-inch deep Stage 4, pus-like bloody drng (drainage) . Notified Dr (doctor) ordered to pack (with) WTD (wet to dry), NS (normal saline), cover (with) occlusive drsg (dressing) - set up with wound clinic - x-ray of sacrum . f. The Skin Observation Tool dated 6/13/18 documented, .Right buttock . Pressure . Stage 3 . Continue current tx (treatment) order to pressure injury to right buttock. There was no documentation as to why the pressure ulcer was downgraded to a Stage III after being identified at as Stage IV in the Nurses Notes dated 1/25/18. There was no documentation of measurements or description of the wound. g. The Weekly Wound Evaluation and Review dated 6/19/18 documented, .1. Location: right buttock . 2b. Date acquired: 06/02/2018 .4b. Current (stage): 3 . Length in cm 0.7 Width in cm 1 Depth in cm 7 . 7.4 (cm) undermining all the way around . Wound Progress: improving . h. The Weekly Wound Evaluation and Review dated 6/26/18 documented, .1. Location: right buttock .2b. Date acquired: 06/02/2018 .4b. Current: 3 . Length in cm 0.7 Width in cm 0.8 Depth in cm 6.4 . 7.2 undermining from 2 -10 o'clock . Wound Progress: improving, depth and undermining better . i. The Skin Observation Tool dated 6/27/18 documented, .Right buttock . Pressure . 1 X 1.3 X 7 . Stage 3 . Continue current tx to pressure injury. j. The (MONTH) (YEAR) TAR documented, .Body Audit every day shift every Wed open and complete skin observation assessment .Stage 3, Right Buttock: irrigate with wound wash/NS, pat dry, apply [MEDICATION NAME] gel, pack with alginate rope, cover with dry dressing every day shift every Mon (Monday), Wed, Fri (Friday) . Check dressing placement to right buttock and replace PRN every shift . as needed for soiling/saturation . The scheduled wound treatment was not initialed and checked by a licensed nursing staff as being completed on Friday, 7/27/18. k. The Weekly Wound Evaluation and Review dated 7/3/18 documented, .1. Location: right buttock . 2b. Date acquired: 06/02/2018 . 4a Original III 4b. Current: III 5. Visible Tissue 5a Overall Impression b. Improving . 5c Granulation tissue present . 6. Drainage 6a . Serosanguinous . 6b Amount Moderate .Length in cm 0.6 Width in cm 0.5 Depth in cm 6.4 .6.7 undermining from 2 - 10 o'clock .Wound Progress: improving. depth and undermining better . l. The Skin Observation Tool dated 7/4/18 documented, .Right buttock . Pressure . 0.8 X 1.3 X 5.5 . Stage 3 . Continue current tx to right buttock . m. The Weekly Wound Evaluation and Review dated 7/10/18 documented, .1. Location: Right Buttock . 2b. Date acquired: 06/02/2018 . 4a Original III 4b. Current: III 5. Visible Tissue 5a Overall Impression b. Improving . 5c Granulation tissue present . 6. Drainage 6a . Serosanguinous . 6b Amount Moderate .Length in cm 0.6 Width in cm 0.5 Depth in cm 5.4 . 6 undermining from 2 - 10 .Wound Progress: depth and undermining improved . n. The Skin Observation Tool dated 7/11/18 documented, .Right buttock . Pressure . 0.6 X 0.5 X 5.4 . Stage 3 . Continue current tx to pressure injury to right buttock . o. The Weekly Wound Evaluation and Review dated 7/24/18 documented, .B. Observation/Data . 1. Location: right buttock . 2b. Date acquired: 06/02/2018 . 4a Original III 4b. Current: III 5. Visible Tissue 5a Overall Impression b. Improving . 5c Granulation tissue present . 6. Drainage 6a . Serosanguinous . 6b Amount Large .Length in cm 0.6 Width in cm 0.5 Depth in cm 4.8 . 5 cm undermining from 2-10 .Wound Progress: improving, undermining decreased . p. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/4/18 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required extensive assistance of 2 plus persons for bed mobility and total assistance of 2 plus persons for transfers, toilet use, and personal hygiene; was at risk for developing pressure ulcers, had 1 Stage 3 pressure ulcer; required the use of pressure reducing device in chair and bed; and required pressure ulcer care and application of non-surgical dressings. q. A physician order [REDACTED]. Active 8/6/2018 . r. The (MONTH) (YEAR) TAR documented, .Body Audit every day shift every Wed open and complete skin observation assessment . Stage 3, Right Buttock: irrigate with wound wash/NS, pat dry, apply [MEDICATION NAME] gel, pack with [MEDICATION NAME] strip, cover with dry dressing every day shift every Mon, Wed, Fri -Start Date- 08/06/2018 . Check dressing placement to right buttock and replace PRN every shift . as needed for soiling/saturation . The scheduled wound treatment was not initialed and checked by a licensed nurse as being completed on (MONTH) 10 (Friday), 20 (Monday), 22 (Wednesday), 24 (Friday), 27 (Monday), and 31 (Friday). The Body Audit was not initialed and checked by a licensed nursing staff as being completed on Wednesday, [DATE]nd. s. The Skin Observation Tool dated 8/1/18 documented, .Right buttock . Pressure . Stage 3 . continue tx order to right buttock. The Skin Observation Tool dated 8/8/18 documented, .Right buttock . Pressure Stage 3 . continue tx order to right buttock . The Skin Observation Tool dated 8/21/18 documented, .Coccyx . Pressure . 3 X 3 X 0 . Stage 1 . The Skin Observation Tool dated 8/29/18 documented, .Coccyx . Pressure . 3 X 3 X 0 . Stage 1 . dressing in place, continue with tx order. There was no documentation on any of the above of the description of the wound bed, surrounding tissue and presence or absence of drainage or odor t. The (MONTH) (YEAR) TAR documented, .Stage 3, Right Buttock: irrigate with wound wash/NS, pat dry, apply [MEDICATION NAME] gel, pack with [MEDICATION NAME] strip, cover with dry dressing every day shift every Mon, Wed, Fri . Check dressing placement to right buttock and replace PRN . as needed for soiling/saturation . There was no documentation of a Body Audit order on this TAR. The scheduled wound treatment was not initialed and checked by a licensed nursing staff as being completed on (MONTH) 3rd (Monday). u. The Skin Observation Tool dated 9/10/18 documented, .Right buttock . Pressure . No other skin issues noted at this time. v. The Skin Observation Tool dated 9/17/18 documented, .Coccyx . Pressure . 1.2 X 0.8 X 6 . Tx orders remain in place for both areas at this time. No other skin issues noted. Will continue to monitor for changes. w. The Nursing Progress Note dated 9/19/18 at 4:25 p.m. documented, .Type: Skin/Wound Note . Treatment completed as ordered and tolerated well, no s/s (signs or symptoms) of pain or discomfort. Minimal amount of drainage noted, no foul odor, surrounding area to wound is dry and intact. Right buttock wound: 0.6 X 0.5 X 5.0 with 3cm undermining at 10 o'clock . There was no documentation of a description of the wound bed or odor between 9/1/18 and 9/19/18. x. On 9/18/18 at 11:05 a.m., Licensed Practical Nurse (LPN #1) entered Resident #1's room with gloves on. Resident #1 was in a supine position and had a neck cushion. LPN #1 turned Resident #1 onto his right side. The resident had a dressing to his right gluteal fold that was soiled and not dated or initialed. LPN #1 removed the soiled dressing and threw it in a trash can, then, without changing gloves, removed a non-adherent clean wound dressing from a sealed package and placed it on the wound site. The wound was less than dime-size in diameter and had bloody drainage on packing in the wound bed. The LPN did not clean the wound or replace the bloody packing with clean packing prior to applying a clean dressing. LPN #1 cut tape into strips at the bedside with scissors she retrieved from her back pocket, placed the tape on both sides of the dressing and placed the scissors back in her pocket. LPN #1 did not date or initial the clean dressing. y. On 9/19/18 at 1:30 p.m., the Administrator and Nurse Consultant were asked to provide documentation of wound care orientation / training for LPN #1. The Administrator stated, I have not been able to find it. The previous wound care nurse would have done that check off, and she left without notice, and I cannot find her files. She (LPN #1) has been doing treatments for approximately 3 weeks. We have a new wound treatment nurse that started today and who will be doing Infection Control. At 1:40 p.m.; the Administrator and Nurse Consultant were asked if the licensed nursing staff who worked with the resident in June, (MONTH) and (MONTH) (YEAR) were available to confirm whether or not the weekly wound treatments were completed, even though they were not checked and initialed as completed. The Administrator stated, They no longer work here to verify if they did complete those treatments. 2. Resident #3 had [DIAGNOSES REDACTED].#1 through #4), Pressure Ulcer of Unspecified Buttock, and [MEDICAL CONDITION]. The Admission MDS with an ARD of 8/15/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required limited assistance of 2 plus persons for bed mobility and limited assistance of one person for transfers, dressing, and toilet use; was at risk for developing pressure ulcers; and had 2 Stage 2 pressure ulcers with granulation tissue. a. The Admit/Readmit Screener dated 8/8/18 documented, .10. Integrity . Sacrum Pressure 2cm Length 0.5cm Width 2cm Depth Stage 2 . Left gluteal fold Pressure 0.5cm Length 0.5cm Width 4.5cm Stage 2 . Right gluteal fold Pressure 0.5cm Length 0.5cm Width 3cm Depth Stage 2 . b. The Plan of Care dated as initiated 9/11/18 documented, .The resident [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) - wounds . Interventions/Tasks . Open wounds should be kept covered, rather than open to air . The resident has pressure ulcer or potential for pressure ulcer development r/t (related to) Hx (history) of ulcers . Assess/record/monitor wound healing (Specify Freq (frequency)) Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Medical Doctor) . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . c. The (MONTH) (YEAR) physician's orders [REDACTED]. Pressure Ulcer of Sacral Region, Stage 2 . Pressure Ulcer of Contiguous Site of Back, Buttock and Hip, Stage 3 . Order Date 08/09/2018 . Dakin's Solution 0.25 % Apply to sacrum topically every day shift . Pack wounds to bil (bilateral) ischia and sacrum with 1/2 Nugauze daily. Boudreaux's to periwound area with each dressing, cover with 4x4 and tape . Order Date 08/09/2018 . d. The (MONTH) (YEAR) TAR documented, .Dakin's Solution 0.25 % Apply to sacrum topically every day shift . Pack wounds to bil ischia and sacrum with 1/2 Nugauze daily. Boudreaux's to periwound area with each dressing, cover with 4x4 and tape . The TAR was not initialed and checked that the wound care was provided on [DATE], 27, and 31. The (MONTH) (YEAR) TAR documented, .Zinc Oxide Ointment 16 % Apply to sacrum topically two times a day . The TAR was not initialed and checked that the wound care was provided at 5:00 p.m. on 8/10, 8/14, 8/22, and 8/24, at 9:00 a.m. and 5:00 p.m. on 8/27, and at 9:00 a.m. on 8/31. e. The (MONTH) (YEAR) TAR documented, .Dakin's Solution 0.25 % Apply to sacrum topically every day shift Pack wounds to bil ischia and sacrum with 1/2 Nugauze daily. Boudreaux's to periwound area with each dressing, cover with 4x4 and tape . The TAR was not initialed and checked that the wound care was provided from 9/3/18 through 9/11/18. The (MONTH) (YEAR) TAR documented, .Zinc Oxide Ointment 16 % Apply to sacrum topically two times a day . The TAR was not initialed and checked that wound care was provided at 9:00 and 5:00 p.m. from 9/1/18 through 9/11/18 and 5:00 p.m. on 9/13 and 9/14. f. The Progress Note dated 9/18/18 documented, Skin/Wound Note . Wound MD into see resident with no new orders at this time. Wound to Left lower buttocks: 1X 0.5 X 3.5 (cm). Right lower buttock: 1 X 0.5X 2.5. Coccyx: 2 X 0.5X 1.5. Measurements are positional due to the way she may be positioned at time of measurement. No odor or drainage noted to all three wounds at this time. All three wounds have edges that are rolling inward, MD spoke with resident r/t (related to) possible debridement on Monday. Resident agrees to debridement at this time. Oncoming shift made aware of above . g. On 9/19/18 at 8:50 a.m., the Administrator and Nursing Consultant were asked for weekly wound measurements for this resident and were unable to provide any documentation. h. On 9/19/18 at 9:20 a.m., LPN #1 prepared the dressing supplies on a tray in the medication room. During the preparation, she was approached by another nurse who was carrying a cordless phone, and the treatment nurse talked on the phone while using the mouse on the computer to answer questions to whomever was on the phone. Without washing her hands, she took the tray of clean dressing supplies and grabbed a pair of gloves and proceeded to the resident's room. She donned a gown and gloves outside the resident's door. She entered the resident's room and cleared the resident's bedside table of her meal tray and then put her prepared tray of clean supplies on the bedside table. She got Q-tips and a dressing from the bedside dresser and put it beside the tray of wound care supplies. She removed the gown and gloves and left the room, then returned a few seconds later and donned a new gown and gloves and entered the room. She had the resident roll over. There was no dressing in place on any of the wounds. She stated, I am still trying to find out if it was removed previously or what happened with that. The treatment nurse began to clean the wounds of the right buttock, left buttock, and sacral area with Dakin's-soaked 2x2s. She cleaned one wound, then placed the used 2x2 gauze pad back onto the tray with the clean supplies. She did this same procedure with each wound and did not change her gloves between wounds or at any time throughout the entire treatment. After cleaning the wounds, she obtained the jar of [MEDICATION NAME] gauze to pack the wounds. She did not pre-cut the strips prior to packing, and as she was packing the wound to the left buttock, she cut the strip about 3 cm from bottle and the end of it landed on the bed/draw pad. She picked up the bottle of [MEDICATION NAME] gauze from the bed and began to pack the wound to the right buttock without changing gloves. She cut the end of the strip that was protruding from the wound. Without changing gloves, she proceeded to pack the last wound, allowing a strip of approximately 4-5 cm [MEDICATION NAME] gauze to come in contact with the draw pad on the bed. She pushed the contaminated strip of gauze back into the bottle. During the packing of the last wound, the resident began to urinate, and the LPN #1 held the resident's brief, which was pulled down to thigh level, to absorb the urine, then picked up a 2x2 and starting patting the buttock area dry and stated She urinated, so that is why I am doing this. Without changing her gloves, the LPN opened the dressing packages, removed her gloves and put them on the tray of wound dressing supplies, reached into her pocket, got a pen and dated the dressing, then put the same gloves back on and placed the dressing over the wounds. She did not wash her hands at any time before or during the wound care. The wounds measured by the nurse were -Right buttocks - 1.1 cm x 0.5 cm depth 4 cm, Sacrum 2 x 1 cm, and left buttocks 1.5 x 2 cm. i. On 9/20/18 at 1:06 p.m., the Clinical Specialist from the wound clinic was asked about the wound doctor and when he came to the facility. The Clinical Specialist stated, We have several buildings that we go to. He has been coming to this building for at least 2 years. He comes every Monday. I usually make rounds with him and do bedside education. I don't see (Resident #3), because she is Medicare A. He measures, assesses, and debrides wounds if necessary. Any facility that he goes to, they have problems getting his written reports with measurements and treatments. I am not sure why. 3. The facility's Quality Assessment & Performance Improvement (QAPI) plan documented, .Date: [DATE] (YEAR) . Problem Statement: Lack of current comprehensive wound prevention program . Goal: To have 0 (zero) new facility acquired wounds on low risk residents . Potential Root Cause(s): 1. lack of dedicated wound care nurse 2. lack of staff education 3. lack of appropriate pressure relieving devices 4. lack of appropriate use of incontinence supplies . Potential Internal Barrier(s): 1. no internal candidates for wound care position 2. nursing management needs training on skin protocols/wound mgmt. (management) . Tasks Inservice/Implement weekly wound meeting protocol including physician documentation . ongoing (with) hiring process - new nurses starting throughout this month . Inservice/implement facility wide turning schedule (plus) skin interventions . ongoing (with) hiring of new staff throughout this month . Admission Body audit / follow up in 8 hrs (hours) / 72 hrs (with) interventions imp.(implemented) . 4. The facility's Policy and Procedure for Dressing Change - Aseptic, received from the Administrator on 9/20/18, documented, Purpose: 1. To protect the wound 2. To prevent irritation 3. To prevent infection and spread of infection 4. To promote healing .Equipment: Dressings or dressing tray Prescribed cleaning solution(s) Medication, if prescribed Plastic bag for soiled dressings Adhesive remover if necessary to remove tape residual Paper towels or towelette drape Clean gloves (2 pair) .Procedure: 4. Place the plastic bag near the foot of the bed to receive the soiled dressings. 5. Create clean field with paper towels or a towelette drape .8. Put on the first pair of disposable gloves 9. Remove the soiled dressing(s) and discard in the plastic bag. 10. Remove the soiled first pair of gloves and discard in plastic bag. 11. Put on the second pair of disposable gloves . 13. Cleanse the wound(s) with the prescribed solution . 15. Apply the dressing and secure with tape . 16. Remove the second pair of disposable gloves and discard along with all unused supplies in the plastic bag . Documentation Guidelines: Date and time of aseptic dressing change (or shift). Wound measurements (size, depth, tunneling, etc.) Also note any drainage, odor, color, color of drainage, surrounding tissue . Progress (or lack of progress) in healing, per the facility's protocols. Signature and title of nurse performing the dressing change. 5. The Acknowledgment of Receipt and Review for Licensed Practical Nurse (LPN) #1 was reviewed and documented that she was hired on 8/3/18. The Job Description, Dementia Training, Abuse Training, and Handwashing Policy was signed by LPN #1 as being completed prior to working on the floor. There was no documentation of training or check-off on wound care. 6. The Facility's Hand Washing and Hand Hygiene Policy from the Administrator on 9/20/18 documented, .When .1. Before and after contact with a resident (particularly those with high susceptibility to infections) .3. Before and after handling dressings or touching open wounds .5. After taking care of an infected resident, even when gloves are worn . 7. The Immediate Jeopardy was removed and the scope and severity lowered to E on 9/20/18 at 4:17 p.m. when the facility implemented the following Plan of Removal: a. The potentially contaminated wound was cleansed and redressed per wound care orders immediately upon notification of failed practice. b. (Resident #3 and Resident #1), as well as all other residents with potential to be affected were immediately assessed for signs and symptoms of infection with no negative findings. c. All licensed staff will be in-serviced on infection control policies before return to duty to be completed by 9/26/2018. d. All licensed staff will be retrained and checked off on proper wound care technique before return to duty to be completed by 9/26/2018. e. All licensed staff will be in-serviced on accurate wound documentation and TAR (Treatment Administration Record) completion before return to duty to be completed by 9/26/2018. f. All treatment record documentation will be audited daily 5x (times per) week by nursing management for 8 weeks to ensure compliance with the physician orders [REDACTED]. g. Wound care to be monitored by an RN (Registered Nurse) for 5 residents, 3 x per week for 8 weeks to ensure compliance with infection control policies. h. All residents with the potential to be affected will be monitored for signs and symptoms q (every) shift for 2 weeks with any negative findings addressed immediately. i. All negative findings will be corrected immediately. The Plan of Removal was signed by the Administrator.

Complaint # (AR 305) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure that when a resident's transfer needs changed, an assessment was conducted to determine the appropriate mechanical lift and sling size, and failed to ensure both staff members involved in a mechanical lift transfer actively participated in the actual transfer to stabilize the lift sling as it was rolled away from the bed and prevent a fall with injury for 1 (Resident #5) of 6 (Residents #1, #2, #3, #5, #6 and #7) case mix residents who required mechanical lift transfers. The failed practices resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who was transferred via mechanical lift by one staff member and sustained multiple injuries, including a laceration to the head and a fracture to the 5th digit of the right foot, and had the potential to cause more than minimal harm to 32 residents who required mechanical lift transfers, as documented on a list provided by the Director of Nursing (DON) on 7/26/17 at 3:55 p.m. The Administrator was notified of the past immediate jeopardy condition on 7/26/17 at 3:20 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 6/13/17 documented the resident scored 8 (8 - 12 indicates moderately impaired) on a Brief Interview for Mental Status, required extensive assistance of 2 persons with transfers, was not steady, and only able to stabilize with staff assistance with surface to surface transfers. a. The care plan, not dated, documented, Focus The resident has an ADL (activities of daily living) self-care deficient r/t( related to) Activity intolerance/fatigue. Date initiated: 1/17/17 . Interventions/Tasks . Transfer: The resident requires extensive by 2 staff using gait belt to move between surfaces . b. An untitled document dated 7/2/17 documented, Witnessed Fall . Incident Description: Was notified by two aides that this resident fell out of the Hoyer lift onto the floor. Upon inspection resident was found face down on the floor. Had active bleeding from the forehead, nose, and feet. Resident complained that she was hurting all over. Resident Description: 'I don't know, I just fell , I'm not sure what happened!' Immediate Action Taken Description: Called for extra assistance and applied pressure to bleeding sites. Resident alert and orient with slight confusion as normal for resident. Answered questions accordingly. No drowsiness or decline in LOC (Level of Consciousness) noted. Resident was transferred to the hospital ER (emergency room ) due to severity of bleeding and due to current medication list including 4 mg. (milligram) warfarin daily. Injuries Observed at Time of Incident: Injury Type Laceration, Injury Location: Top of Scalp, Injury Type: unable to determine, Injury Location: Left ankle (outer) . Other Info: uses Hoyer lift for transfer, uses a geri chair. c. The ER Physician Documentation dated 7/2/17 documented, ED (Emergency Department) Long H&P (History and Physical) . Triage: Description of Symptoms: . (Ambulance Service) reports Pt (patient) from (name of facility) reports staff was attempting to use Hoyer lift and reports pt. fell from lift approx. (approximately) 3 ft (feet) and hit her face per staff. bleeding noted to left side of head. Pt c/o (complains of) pain to bil (bilateral) ankles, no deformity noted. open fx (fracture) present to right 4th toe. Pt also c/o pain to right upper arm, no deformity noted. LAC (laceration) noted to left and right hands from fall. bruising present to left AC (antecubital) area. Pt also c/o tenderness to left side of face. swelling noted to left side of face and around eyes. Pt. tearful upon exam. 7/2/17 13:36 (1:36 p.m.) Chief Complaint: Fall at nursing home. History of Present Illness: . Patient was apparently being transferred via Hoyer lift to her bed. Report from EMS (Emergency Medical Service) and nursing home staff state that she fell out and struck her head but there was no loss of consciousness. She does have a large head laceration with some bleeding. Dressing was applied prior to arrival. Patient complains of pain to her head, left facial pain, right shoulder pain which is semi-chronic but worse now, right ankle and right foot pain. She has multiple bruising, abrasions, and minor skin tears to the extremities. ED course/Procedures: 7/2/17 16:14 (4:14 p.m.) Patient essentially has suffered a large forehead laceration and open right toe fracture. d. A witness statement dated 7/2/17 by Certified Nursing Assistant (CNA) #1 documented, (CNA #2) and myself were getting R (resident) out of the bed for lunch (at) about 11:35 a.m. We had R hooked up to the lift (Hoyer) and was raising R into the air. We pulled the lift out from under the bed and was getting ready to place her into her chair. As we moved the lift she began to cry and shift in the lift sheet. At that time she fell out and landed on the floor face first and landed half way under the bed . e. A witness statement dated 7/2/17 by CNA #2 documented, As (CNA #1) and I were pulling the lift out with (Resident #5) in a sling for lunch . she began to cry and getting scared as we were lifting her with the Hoyer, we barely got her up and over the floor she began to start shifting her weight and slid out of the sling and fell out onto the floor . f. A witness statement dated 7/2/17 by Licensed Practical Nurse (LPN) #1 documented, Nurse was notified by CNAs that resident fell . When I asked what happened, resident was to be bleeding from a gash on her forehead, from her nose, and from injuries on her foot . CNAs stated that she fell out of the sling. Sling was properly connected at all 4 points . g. A witness statement dated 7/2/17 by LPN #2 documented, .I entered resident's room and observed her on the floor on her back with head below the bed. Resident's nurse and 2 CNAs were standing beside her. Lift was off to far side with sling attached. I observed a large pool of blood on the floor and on resident's head, face, feet and one leg . h. A witness statement dated 7/2/17 by LPN #3 documented, This nurse and CNA walked into resident's room and saw resident on floor face first in a puddle of blood. Resident was spitting from mouth soaking in puddle of blood . i. The Vander-Lift II Operating manual received from the DON on 7/26/17 documented, .Patient Assessment Criteria for Transfers WARNING Before using the Vander-Lift II B450, patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer . which transfer technique to use, which size sling is appropriate, and the number of staff members necessary to transfer each patient. Warning Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. For example, patients with unpredictable behavior due to dementia may require additional help if their behavior poses risk of injury to themselves or to staff members . Sizing and positioning the UNI-FIT Sling . The sling should be long enough to fit from the patient's coccyx to the top of, or a few inches above, the patient's head . j. A Policy and Procedure received from the Nurse Consultant on 7/26/17 at 2:55 p.m. documented, Subject: Lift, transfer and positioning . Policy: All resident care will be provided in a safe, appropriate and timely manner in accordance with individual resident care plan. All residents will be assess by the facility Care Plan Team with regard to the need for assistance with transfer activities, mobility or repositioning in accordance with MDS procedures and requirements . k. On 7/27/17 at 2:21 p.m., a telephone interview was conducted with CNA #2. The CNA was asked where he was and what he was doing at the time the resident fell from the sling on 7/2/17. The CNA stated, I was on the same side as (CNA #1), who was lifting the resident with the lift. I was getting the geri-chair ready. I was 3 or 4 feet away when the resident fell . The CNA was asked how the sling was positioned beneath the resident. CNA #2 stated, The bottom of the sling was past the buttocks close to her knees and the top was at the back of her neck . (Note: the lift sling was not even with or above the top of her head as per the manufacturer's instructions). The CNA stated, The resident was reclining a little bit. The CNA was asked if the resident was moving or demonstrating any behaviors during the transfer. The CNA stated, From my perspective, while I was getting the geri-chair ready, I did not witness her moving. I looked up and saw her falling. CNA #2 was asked if CNA #1 said anything about the resident slipping from the sling during the transfer. CNA #2 stated, (CNA #1) did not say anything. I think we both saw it at the same time. (CNA #1) was pulling the lift from under the bed and just as the resident cleared the bed is when she fell out of the sling. CNA #2 was asked if anyone was stabilizing the sling during the transfer. The CNA stated, No one was holding the sling. l. On 7/27/17 at 12:36 p.m., the Director of Nursing (DON) was asked why the resident was being transferred with the lift. She stated, She was no longer able to stand and bear weight. The DON was asked, Was the resident assessed for transfers after January 2017, prior to using the lift? The DON replied, The last assessment I could find was in January (2017). The DON stated, The CNAs can do more than what the care plan calls for if they deem it necessary for resident safety. The DON was asked, Was the resident assessed for the proper size sling prior to 7/2/17? She replied, Not that I'm aware of. The DON was asked, Prior to the fall, had the staff reported that the resident moved in the sling during transfers? She replied, No one reported to me. m. On 7/27/17 at 2:35 p.m., the DON was asked what the facility's policy was with regard to the number of staff to assist with mechanical lift transfers. The DON replied, They should have 2 people and the appropriate lift. Both people should verify that the lift pad is positioned correctly. 2. The facility removed the immediate jeopardy and corrected the failed practices on 7/2/17, prior to the survey, as evidenced by the following: a. The Facility Investigation Report of Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated 7/10/17 documented CNA #1 and CNA #2 were suspended during the facility's investigation, then terminated. b. An invoice dated 7/5/17 documented the mechanical lift rental company inspected the Vander lift II and the unit was in good working order. c. An in-service dated 7/3/17 documented training was provided to all staff on, Proper use of Hoyer lifts and slings. Demonstrate the head and foot of sling, Demonstrate proper placement of sling on resident and Demonstrate proper use of sling and lift. The inservice documented all CNA's were inserviced and successfully completed a return demonstration. d. A list dated 7/5/17 documented that all residents who were transferred with a lift were assessed for transfers and measured for proper sling size. e. On 7/25/17 at 12:00 p.m., CNAs #3, #4, #5, #6, #7 and #8 were observed conducting mechanical lift transfers. All 6 CNAs demonstrated proper use of the lift to conduct transfers without incident. f. On 7/26/17 CNAs #9, #10 and #11 verbally verified to the surveyor that they had been trained upon hire and again recently on the use of a mechanical lift by the nurse supervisor. Also, they all stated that how a resident was transferred was in the kiosk and on the closet care plans. The CNAs stated that each resident had their own lift sling with their name on it. g. On 7/26/17 at 11:50 a.m. the facility provided documentation of continued monitoring, in the form of a monitoring log of lift transfers conducted on residents from 7/1/17 through 7/25/17 when this survey was initiated. The facility also provided check off lists of employees on the use of a mechanical lift, indicating that all CNAs were checked off on the use of the mechanical lifts since 7/2/17.

Complaint # , (AR 899) was substantiated, all or in part, in this finding. Based on record review and interview, the facility failed to ensure Resident #1 was free from significant medication errors. Facility staff administered [MEDICATION NAME] 4 milligrams (mg) daily from 1/15/15 through 1/29/15 (15 doses) without a physician's order; without an assessment of the resident's baseline coagulation ability; without monitoring the effects of the drug on the resident by performing laboratory tests to measure the resident's [MEDICATION NAME] Time/International Normalization Ratio (PT/INR); and without a review of drug interactions for 1 (Resident #1) of 1 case mix resident who was administered anticoagulant therapy without a physician's order. These failed practices resulted in Immediate Jeopardy which caused or could have caused severe injury, harm or death to Resident #1, who was hospitalized with critical level PT/INR, gastrointestinal (GI) bleeding and a drop in hemoglobin and hematocrit levels which required the administration of multiple doses of Vitamin K and Fresh Frozen Plasma; and had the potential to affect all 86 residents who resided in the facility according to the Resident Census and Conditions of Residents report provided by the Administrator on 2/5/15. The facility removed the Immediate Jeopardy prior to the survey entrance date. However, all of the underlying deficient practices had not been corrected. The facility Administration was informed of the Immediate Jeopardy on 2/5/15 at 10:00 a.m. The findings are: 1. The Nursing 2015 Drug Handbook provided by the Director of Nursing (DON) on 2/5/15 (provided as the drug reference book available to nurses at the facility) documented on page 1275 to 1276, "... [MEDICATION NAME]: ...Interactions: Drug-Drug:..[MEDICATION NAME], or other highly protein-bound drugs: May increase level of [MEDICATION NAME] or other highly protein-bound drug. May increase PT, or INR may increase by 8%. ... ." The Nursing 2015 Drug Handbook documented on pages 1467 to 1470, "... [MEDICATION NAME] sodium ([MEDICATION NAME]). ... Administration: P.O. (by mouth): Draw blood to establish baseline coagulation parameters before therapy. PT and INR determinations are essential for proper control. Recommended INR range is usually 2 to 3. ... Interactions: Drug-Drug: ... anticoagulants (... aspirin) ... [MEDICATION NAME], ... : May increase anticoagulant effect. Monitor patient carefully for bleeding. Reduce anticoagulant dosage as directed. ... Contraindications & Cautions: Contraindicated in patients hypersensitive to drug and in those with bleeding from the GI (Gastrointestinal) ... tract; severe or malignant hypertension ... Use cautiously in patients with ... mild or moderate hypertension... Nursing Considerations: Black Box Warning: [MEDICATION NAME] can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding. Avoid all I.M. (intramuscular) injections. Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, and hematemesis..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Yearly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/15 documented the resident scored 4 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS); required extensive 1 person physical assistance with transfers, dressing, toilet use hygiene and bathing; and received insulin injections, antidepressants, antibiotics but no anticoagulants. a. The January 2015 Physician's Order Sheet documented, "1/8/14: Aspirin 325 mg (milligrams) Tablet - Give one tablet by mouth daily with food... 11/11/14: [MEDICATION NAME] HCL ([MEDICATION NAME]) 50 mg tablet - give one tablet by mouth daily..." b. The January 2015 Medication Treatment and Task Administration Record documented that Aspirin 325 mg was administered daily at 8:00 a.m. from 1/1/15 through 1/29/15, and documented that [MEDICATION NAME] 50 mg was administered at 8:00 a.m. daily from 1/1/15 through 1/29/15. c. The January 2015 Medication Treatment and Task Administration Record documented, "[MEDICATION NAME] ([MEDICATION NAME]) 4 mg tab (tablet). One tab po (by mouth) daily. Doctor: (MD #1). Start: 1/14/2015." The record documented the [MEDICATION NAME] was administered daily at 5:00 p.m. from 1/15/ 15 through 1/29/15, a total of 15 doses. The [MEDICATION NAME] was given in conjunction with [MEDICATION NAME] HCL and Aspirin, which have the side effect of increasing the potential for bleeding and potentiating the effects of [MEDICATION NAME]. d. The January 2015 Physician's Order sheet documented, "1/14/15: New Order: D/C (discontinue) Foley Cath. (catheter)." There was no order in the clinical record that the resident was to be given [MEDICATION NAME] 4 mg daily. This was a significant medication error based on the classification of the drug, the frequency of the error and the condition of the resident. e. The Nurse's Note dated 1/29/15 at 17:00 (5:00 p.m.) documented, "R (resident) bleeding from R (right) upper top molar. Tooth is flat to surface (with) severe carries. Called (Name of Physician) on call. Stated to draw PT/INR STAT (Immediately) in AM (morning). Left note to (Name of facility staff) to set up dentist appt. (appointment) in AM. Called DON (Director of Nursing) to notify of R (Resident's) condition. VS (vital signs) 130/86 (blood pressure), 72 (pulse), 20 (respirations), 97.8 ax (axillary temperature), 96% (pulse oximetry) RA (room air)." The Nurse's Note dated 1/29/15 (no time given) documented, "N.O. (New Order); Send to (Name of Hospital) for eval (evaluation) & tx (treatment). Unable to stop bleeding in R (right) upper top molar. Contact (Name of Ambulance) to transport @ (at) 2130 (9:30 p.m.). Contact DON (Name of DON) @ 1025. Contact family @ 2245 (10:45 p.m.) " The Nurse's Note dated 1/29/15 at 10:50 p.m.) documented, "(Name of Ambulance) to pick up R (resident). Left AA&O x 2 (Alert and Oriented times 2) on stretcher." f. The Hospital Emergency Department (ED) Long H&P History and Physical (H & P) dated 1/29/15 documented, "Chief Complaint: Bleeding. Time Seen by Provider: 01/29/2015 -23:20 (11:20 p.m.). HPI/ROS (History and Physical /Review of Systems) 01/29/15 23:39 (11:39 p.m.). Patient ... was transferred from the nursing home for some bleeding from her right upper tooth. Patient apparently is scheduled to have surgery on this tooth tomorrow. I feel it is likely and extraction. Patient has some dementia. She is a very poor historian and unable to give any additional history. The nursing home was worried because she is on [MEDICATION NAME] that the bleeding might not stop. There is no active bleeding at the time of exam. Review of Systems: ...Gastrointestinal: No vomiting or diarrhea. [MEDICAL CONDITION]: No hematuria. No dysuria urgency or frequency ...Home medications: [REDACTED]. Vital Signs 01/29/15 23:05 (11:05 p.m.) Temp: 98.1 F-Pulse:106 H-Resp:16-BP:137/61. Pulse Ox: 97. Physical Exam: 01/29/15 23:43 (11:43 p.m.). General Appearance: Well developed, well nourished.... in no apparent distress. HEENT (Head, Ears, Eyes, Nose, Throat): ... there is some blood at the edge of the lower lip which is dried. ... Oropharynx: There is no active bleeding noted. There is an area of dried blood around the right upper first molar ....Lab Results: 01/30/15 0015 (12:15 a.m.): WBC (White Blood Count) 18.7 (Reference range 4.1 - 11.3), Red Blood Count (RBC): 3.51 L (low) (Reference Range 3.78 - 5.33), Hemoglobin 10.4 L (Reference Range 11.5 - 16.0), Hematocrit 32.7 L (Reference Range 35.0 - 47.0). ... PT 87.6 (Reference Range 8.9 - 12.6), INR 7.2 ! H (high) (Critical Lab Value) (Reference Range 0.0 - 1.9)." The Hospital Alert and Critical Values Table documented an INR of 5 or above as a Critical Lab Value. The ED Course/Procedures documented, "01/30/2015 00:12 (12:12 a.m.). The patient's PT was 87.6 with an INR 7.9. Patient's CBC revealed slight leukocytosis of 18,000 and hemoglobin 10.2.... Patient at time of exam has no active bleeding and vital signs are normal. We did give the patient a dose of subcutaneous vitamin K. We will instruct the nursing home to hold her [MEDICATION NAME] in the a.m. They will contact her primary care physician in the a.m. for further [MEDICATION NAME] dosage... We will return the patient to the nursing home. Departure: Departure Disposition: D/C (Discharge) to Nursing Home. Clinical Impression: Poisoning by [MEDICATION NAME] sodium. Condition: Stable. Additional Instructions: hold [MEDICATION NAME] in the a.m. Contact the patient's primary care provider in a.m. for further [MEDICATION NAME] dosage orders. 'Would suggest canceling dental procedure in a.m.' Referrals: (Name of Primary Care Physician) - Next available appt (appointment)." g. The Nurse's Note dated 1/30/15 at 2:00 a.m., documented, "R (Resident) returned to facility vie (sic) (Name of Ambulance). New orders; hold [MEDICATION NAME] in a.m. Consider canceling dental procedures in a.m. Contact M.D. (Name of Physician) in a.m. R (Resident) (up) in bed resting (with) HOB (head of bed) (elevated) 20 (degree) angle. R (Resident) denies pain. (No) bleeding at this x (time). Eyes PERL (Pupils Equal and Reactive to Light) R/T (Related To) mouth problems. Afebrile. T (Temperature) 97.1 AX (axillary). Resp.(respirations) unlabored. Cap (capillary) refill less than 3 secs (seconds). POX (Pulse Oximetry) 96% RA. Will monitor." The Nurse's Note dated 1/30/15 at 0200 (2:00 a.m.) documented, "(Name of Hospital) ER (emergency room ) nurse stated R (resident) had 10 mg Vit (Vitamin) K shot SQ (subcutaneous). WBC 18.7/ PT 87.6 / INR 7.2. On call nurse DON (Name of DON) notified." The Nurse's Note dated 1/30/15 at 0300 (3:00 a.m.) documented, "Per on call MD (Name of physician): new order for [MEDICATION NAME] 500 mg po (by mouth) TID (three times a day) x (times) 7 days. Pharmacy notified. (Name of family) notified. DON (Name of DON) notified. Ordered STAT (emergent) from pharmacy. Awaiting delivery." The Nurse's Note dated 1/30/15 at 0300 (3:00 a.m.) documented, "MD (Name of MD #1) called again by this nurse. No answer. Will continue to try to notify." The Nurse's Note dated 1/30/15 at 0300 documented, "R (resident) bleeding large amt (amount) of coagulated blood from mouth. R (Resident) sat (up) (in) Geri-chair to promote (decreased) chances of swallowing blood or aspiration. ADON (Assistant Director of Nursing) notified." The Nurse's Note dated 1/30/15 at 0430 A (4:30 a.m.) documented, "Pharmacy delivered ABT (antibiotic). (One) [MEDICATION NAME] 500 mg given po. R (Resident) tolerated well." The Nurse's Note dated 1/30/15 at 0500 A (5:00 a.m.) documented, "R (resident) projectile vomiting large amounts of coagulated blood. Dark red. R (Resident) sent to (Name of Hospital) ER (emergency room ). Family notified. DON notified." h. The Hospital ED Long H&P documented, "Chief Complaint: Bleeding. Time Seen by Provider: 01/30/15 05:36 (5:36 a.m.) ...has a history of chronic anticoagulation's on [MEDICATION NAME]. She was seen earlier here in the ER with some bleeding from her left upper tooth. The bleeding had pretty much stopped when she was here previously. She was found to have an elevated INR of 7. She was given vitamin K. She was returned to the nursing home in stable condition ...The nursing home has returned her to the ER several hours later because she had some vomiting of dark blood. She had some transient [MEDICAL CONDITION], according to the nursing home history. She has a history of hypertension, dementia, need for anticoagulation which is unclear, history of urinary tract infections. She has a history of insulin-dependent diabetes ...History of [MEDICAL CONDITION]. The patient currently has no complaints. She denies any pain nausea, shortness of breath or other complaints ...Vital Signs: 01/30/15 05:32: Temp: 98.3 F. Pulse: 120 H-Resp.:16 BP: 116/53. Pulse Ox 96. Physical Exam: 01/30/15 -05:45 (5:45 a.m.)... She does appear to be somewhat pale ...HEENT: ...She does have some dried blood about her mouth which is dark red. There is a little bit of blood in her mouth. Do not see any areas of active bleeding in her mouth for (sic) (or) oral cavity at this point. ... Lab Results: WBC: 24.1 H. Red Blood Cells: 3.19 L. Hemoglobin: 9.0 L. Hematocrit: 30.3 L... PT: 83.2 H. INR: 6.9! H (Critical Lab Value) ...Medications Given: Sodium Chloride (NS) 1,000 mls (milliliters) @ 1000 ml/hr (milliliters per hour) IV (intravenous) q 1 H (hour). [MEDICATION NAME] (Vitamin K) 10 mg SQ X (times) 1 ONE ...ED Course/Procedures: This lady's hematocrit has dropped from 33 -30 in the last few hours. Her blood pressure was low. She is a little [MEDICAL CONDITION]. Her blood pressure has improved and her [MEDICAL CONDITION] lessened with some IV fluids. Her INR is still somewhat elevated in the 6 range ...I'm not sure if she has been bleeding from her mouth and swallowed some blood work (sic) (or) she actually has an upper GI (gastrointestinal) bleed. I do not believe however that she could stay here in (Name of city) with the current status of the GI coverage....I've spoken with (Name of Physician) his (sic) (he's) except (sic) (accepted) her at (Name of Hospital).... She will receive fresh frozen plasma and a second dose of vitamin K. I will also give her a dose of [MEDICATION NAME]. Departure: Departure Disposition: ED Admit Inpatient/Observation. Clinical Impression: GI Bleed, Urinary Tract Infection. Condition: Serious ..." i. On 2/4/15 at 2:20 p.m., a list of residents on [MEDICATION NAME] was provided by the Administrator. At the top of the list a handwritten note documented, "PT 87.6. INR 7.2 @ (at) the ER." The Administrator was asked, "Whose lab results are those?" The Administrator stated, "(Resident #1's Name)." The Administrator was asked, "She isn't on the list (of residents on [MEDICATION NAME])." The Administrator stated, "She's in the hospital." j. On 2/4/15 at 3:58 p.m., a copy of the Pharmacy Prescription History from 1/4/15 through 2/4/15 was provided by the Administrator. The Prescription History documented that 5 doses of [MEDICATION NAME] 4 mg were dispensed on 1/15/15, and 31 doses of [MEDICATION NAME] 4 mg were dispensed on 1/20/15 for Resident #1. All of the other residents on the list had physician's orders for [MEDICATION NAME]. There were no physician orders for the [MEDICATION NAME] dispensed on 1/15/15 and 1/20/15 for Resident #1. k. On 2/5/15 at 8:25 a.m., Licensed Practical Nurse (LPN) #2 was asked, "How do you know the medications on the MAR (Medication Administration Record) are ordered by the physician?" LPN #2 stated, "There should be a telephone order." LPN #2 was asked, "If you noticed a resident on [MEDICATION NAME] and Aspirin, would that be a concern for you?" LPN #2 stated, "Yes." LPN #2 was asked, "Do you do periodic chart checks?" LPN #2 stated, "Yes." LPN #2 was asked, "When?" LPN #2 stated, "They do them on 11-7 (night shift) I believe." At 8:30 a.m., LPN #4 was asked, "How do you know the drug listed in the e-MAR (Electronic Medication Administration Record) is actually ordered in the chart?" LPN #4 stated, "You have to check the telephone orders and nurse's notes." LPN #4 was asked, "How often do you check the e-MAR against the orders?" LPN #4 stated, "Only if there is something I haven't been giving (before)." LPN #4 was asked, "If you notice a resident is on [MEDICATION NAME] and Aspirin, what do you do?" LPN #4 stated, "I question the order. Both are blood thinners." LPN #4 was asked, "Do you ever do routine checks to see if the e-MAR drugs are ordered?" LPN #4 stated, "No. I think one of the night nurses may do it." LPN #4 was asked, "How often does that happen?" LPN #4 stated, "Once a week, I think." LPN #4 was asked, "That could mean a resident could get a wrong drug for a week before it is caught. How many doses of a wrong medicine can harm a resident?" LPN #4 stated, "One." LPN #4 was asked, "What can happen if a resident gets Aspirin and [MEDICATION NAME]?" LPN #4 stated, "The resident's blood gets really thin and he or she could bleed out." At 8:35 a.m., LPN #3 was asked, "How do you know the medications on the MAR (Medication Administration Record) are ordered by the physician?" LPN #3 stated, "It should be in the e-MAR, care plan and doctor's orders." LPN #3 was asked, "If you noticed a resident on [MEDICATION NAME] and Aspirin, would that be a concern for you?" LPN #3 stated, "Yes. But I've not administered any lately." LPN #2 was asked, "Do you do periodic chart checks?" LPN #3 stated, "No. I don't know who does it." At 2:05 p.m., Registered Nurse (RN) #1 was asked, "Did you care for (Resident #1)?" RN #1 stated, "Yes." RN #1 was asked, "Did you administer [MEDICATION NAME] to the resident?" RN #1 stated, "Yes." RN #1 was asked, "Why was she getting [MEDICATION NAME]?" RN #1 stated, "I was off 4 days. I came back to work on the 16th. The [MEDICATION NAME] was already ordered on the e-MAR. I gave it." The RN #1 was referred to the e-MAR entries for January 2015. RN #1 stated, "I sent her out that night (1/29/15) because she was bleeding from her gums. I couldn't see where the bleeding was coming from. I kept trying to get it to stop. I checked the lab records. There was no recent PT/INR. I sent her to the ER." RN #1 was asked, "Were you aware the resident was taking Aspirin?" RN #1 stated, "I had worked the 7-3 shift before and administered Aspirin to her." RN #1 was asked, "You knew she was on Aspirin?" RN #1 stated, "Yes. I was not aware she was taking [MEDICATION NAME] when I was on day shift." RN #1 was asked, "You were aware the resident was on Aspirin when you gave the [MEDICATION NAME] on the evening shift?" RN #1 stated, "Yes. I didn't think anything about it." RN #1 was asked, "Did you try to verify the order?" RN #1 stated, "No." l. On 2/5/15 at 9:15 a.m., the Director of Nursing (DON) was asked, "Have you been notified of any abnormal (laboratory results) on (Resident #1)?" The DON stated, "Only the critical lab when she went to the hospital." The DON was asked, "How often was (Resident #1) having a PT/INR (drawn)?" The DON stated, "She wasn't." The DON was asked, "Why?" The DON stated, "We have since discovered it was a transcription error." The DON was asked, "When you discovered the medication error, what happened?" The DON stated, "I notified the MD (Medical Doctor)." The DON was asked, "What did the MD say?" The DON stated, "To check everyone on [MEDICATION NAME] and make sure the PT/INRs were current." The DON was asked, "How did this error happen?" The DON stated, "LPN #1 transcribed the order wrong. There was another resident supposed to be put on [MEDICATION NAME] (1/14/15). The nurse put it into (Resident #1)'s e-MAR. That generated an order to the pharmacy that filled it. The nurses started administering it on 1/15/15." The DON was asked, "You're saying (Resident #1) received 4 mg [MEDICATION NAME] daily from 1/15/15 to 1/29/15?" The DON stated, "Yes." The DON was asked, "Was the MD aware when you started the [MEDICATION NAME]?" The DON stated, "No. Not when we started it." The DON was asked, "When you did notify the MD, what did he say? Did you do anything else?" The DON stated, "We checked everyone in the building for unordered drugs, and checked to see that everyone on [MEDICATION NAME] had a current PT/INR." The DON was asked, "Did you discover anyone else on [MEDICATION NAME] without an order?" The DON stated, "No. We found (Resident #6) had a change in [MEDICATION NAME] to 4 mg on 1/14/15. (Resident #1)'s order was entered on 1/14/15. (Resident #6)'s order was put in (the e-MAR) and she received the ordered dose of [MEDICATION NAME]." The DON was asked, "Aspirin is given on the day shift, and [MEDICATION NAME] is given on the evening shift. Who set that up?" The DON stated, "The previous Clinical Consultant." m. The facility removed the Immediate Jeopardy and reduced the scope/severity to "H" on 2/3/15 (prior to the initiation of the survey) by taking the following corrective actions: 1) Assessment of all residents in the facility for unordered use of [MEDICATION NAME] was completed on 1/30/15. 2) Assessment of all residents on [MEDICATION NAME] for correct dose and current PT/INR was completed on 1/30/15. 3) Investigated the cause of the incident (LPN #1 entered the drug into IMAR on 1/14/15 (completed on 2/4/15); the e-MAR automatically generated a drug order to the pharmacy, the pharmacy filled the order, the drug was administered without ever validating the drug against an actual MD order). 4) The LPN was terminated on 2/3/15. 5) Changed the policy to require faxed orders before the pharmacy will fill medication orders on 2/3/15. 6) Changed the policy on entry of [MEDICATION NAME] to add a vital signs field and require the entry of the current PT/INR prior to administration of any [MEDICATION NAME] in the facility on 2/3/15. 7) In-service to all nurses on the correct use of e-MAR (adding new field for [MEDICATION NAME]) and new policy requiring faxed MD orders to receive meds (medications) from the pharmacy initiated on 2/2/15 and completed on 2/4/15. 8) Monitoring: A report of all meds entered into the e-MAR system will be printed daily and verified against MD orders by the DON and designee, initiated 2/3/15.

Complaint # (AR 899) was substantiated, all or in part, in this finding. Based on record review and interview, the facility failed to provide pharmaceutical services that assured the accurate acquiring and administering of drugs to meet the needs of each resident. The facility failed to ensure medications were ordered, received, and transcribed in a manner that ensured residents were free of significant medication errors. Facility staff administered Coumadin 4 milligrams (mg) daily from 1/15/15 through 1/29/15 (15 doses) without a physician's order; without an assessment of the resident's baseline coagulation ability; without monitoring the effects of the drug on the resident by performing laboratory tests to measure the resident's Prothrombin Time/International Normalization Ratio (PT/INR); and without a review of drug interactions for 1 (Resident #1) of 1 case mix resident who was administered anticoagulant therapy without a physician ' s order These failed practices resulted in Immediate Jeopardy which caused or could have caused severe injury, harm or death to Resident #1, who was hospitalized with critical level PT/INR, gastrointestinal (GI) bleeding and a drop in hemoglobin and hematocrit levels which required the administration of multiple doses of Vitamin K and Fresh Frozen Plasma; and had the potential to affect all 86 residents who resided in the facility according to the Resident Census and Conditions of Residents report provided by the Administrator on 2/5/15. The facility removed the Immediate Jeopardy prior to the survey entrance date. However, all of the underlying deficient practices had not been corrected. The facility Administration was informed of the Immediate Jeopardy on 2/5/15 at 10:00 a.m. The findings are: 1. The Nursing 2015 Drug Handbook provided by the Director of Nursing (DON) on 2/5/15 (provided as the drug reference book available to nurses at the facility) documented on page 1275 to 1276, "... Sertraline Hydrochloride: ...Interactions: Drug-Drug:..Warfarin, or other highly protein-bound drugs: May increase level of sertraline or other highly protein-bound drug. May increase PT, or INR may increase by 8%. ... ." The Nursing 2015 Drug Handbook documented on pages 1467 to 1470, "... Warfarin sodium (Coumadin). ... Administration: P.O. (by mouth): Draw blood to establish baseline coagulation parameters before therapy. PT and INR determinations are essential for proper control. Recommended INR range is usually 2 to 3. ... Interactions: Drug-Drug: ... anticoagulants (... aspirin) ... salicylates, ... : May increase anticoagulant effect. Monitor patient carefully for bleeding. Reduce anticoagulant dosage as directed. ... Contraindications & Cautions: Contraindicated in patients hypersensitive to drug and in those with bleeding from the GI (Gastrointestinal) ... tract; severe or malignant hypertension ... Use cautiously in patients with ... mild or moderate hypertension... Nursing Considerations: Black Box Warning: Warfarin can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding. Avoid all I.M. (intramuscular) injections. Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, and hematemesis..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Yearly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/15 documented the resident scored 4 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS); required extensive 1 person physical assist with transfers, dressing, toilet use hygiene and bathing; and received insulin injections, antidepressants, antibiotics but no anticoagulants. a. The January 2015 Physician's Order Sheet documented, "1/8/14: Aspirin 325 mg (milligrams) Tablet - Give one tablet by mouth daily with food... 11/11/14: Sertraline HCL (Hydrochloride) 50 mg tablet - give one tablet by mouth daily..." b. The January 2015 Medication Treatment and Task Administration Record documented that Aspirin 325 mg was administered daily at 8:00 a.m. from 1/1/15 through 1/29/15, and documented that Sertraline 50 mg was administered at 8:00 a.m. daily from 1/1/15 through 1/29/15. c. The January 2015 Medication Treatment and Task Administration Record documented, "Warfarin (Coumadin) 4 mg tab (tablet). One tab po (by mouth) daily. Doctor: (MD #1). Start: 1/14/2015." The record documented the Coumadin was administered daily at 5:00 p.m. from 1/15/ 15 through 1/29/15, a total of 15 doses. The Coumadin was given in conjunction with Sertraline HCL and Aspirin, which have the side effect of increasing the potential for bleeding and potentiating the effects of Coumadin. d. The January 2015 Physician's Order sheet documented, "1/14/15: New Order: D/C (discontinue) Foley Cath. (catheter)." There was no order in the clinical record that the resident was to be given Coumadin 4 mg daily. This was a significant medication error based on the classification of the drug, the frequency of the error and the condition of the resident. e. The Nurse's Note dated 1/29/15 at 17:00 (5:00 p.m.) documented, "R (resident) bleeding from R (right) upper top molar. Tooth is flat to surface (with) severe carries. Called (Name of Physician) on call. Stated to draw PT/INR STAT (Immediately) in AM (morning). Left note to (Name of facility staff) to set up dentist appt. (appointment) in AM. Called DON (Director of Nursing) to notify of R (Resident's) condition. VS (vital signs) 130/86 (blood pressure), 72 (pulse), 20 (respirations), 97.8 ax (axillary temperature), 96% (pulse oximetry) RA (room air)." The Nurse's Note dated 1/29/15 (no time given) documented, "N.O. (New Order); Send to (Name of Hospital) for eval (evaluation) & tx (treatment). Unable to stop bleeding in R (right) upper top molar. Contact (Name of Ambulance) to transport @ (at) 2130 (9:30 p.m.). Contact DON (Name of DON) @ 1025. Contact family @ 2245 (10:45 p.m.) " The Nurse's Note dated 1/29/15 at (10:50 p.m.) documented, "(Name of Ambulance) to pick up R (resident). Left AA&O x 2 (Alert and Oriented times 2) on stretcher." f. The Hospital Emergency Department (ED) Long H&P History and Physical (H & P) dated 1/29/15 documented, "Chief Complaint: Bleeding. Time Seen by Provider: 01/29/2015 -23:20 (11:20 p.m.). HPI/ROS (History and Physical /Review of Systems) 01/29/15 23:39 (11:39 p.m.). Patient ... was transferred from the nursing home for some bleeding from her right upper tooth. Patient apparently is scheduled to have surgery on this tooth tomorrow. I feel it is likely and extraction. Patient has some dementia. She is a very poor historian and unable to give any additional history. The nursing home was worried because she is on Coumadin that the bleeding might not stop. There is no active bleeding at the time of exam. Review of Systems: ...Gastrointestinal: No vomiting or diarrhea. Genitourinary: No hematuria. No dysuria urgency or frequency ...Home medications: [REDACTED]. Vital Signs 01/29/15 23:05 (11:05 p.m.) Temp: 98.1 F-Pulse:106 H-Resp:16-BP:137/61. Pulse Ox: 97. Physical Exam: 01/29/15 23:43 (11:43 p.m.). General Appearance: Well developed, well nourished.... in no apparent distress. HEENT (Head, Ears, Eyes, Nose, Throat): ... there is some blood at the edge of the lower lip which is dried. ... Oropharynx: There is no active bleeding noted. There is an area of dried blood around the right upper first molar ....Lab Results: 01/30/15 0015 (12:15 a.m.): WBC (White Blood Count) 18.7 (Reference range 4.1 - 11.3), Red Blood Count (RBC): 3.51 L (low) (Reference Range 3.78 - 5.33), Hemoglobin 10.4 L (Reference Range 11.5 - 16.0), Hematocrit 32.7 L (Reference Range 35.0 - 47.0). ... PT 87.6 (Reference Range 8.9 - 12.6), INR 7.2 ! H (high) (Critical Lab Value) (Reference Range 0.0 - 1.9)." The Hospital Alert and Critical Values Table documented an INR of 5 or above as a Critical Lab Value. The ED Course/Procedures documented, "01/30/2015 00:12 (12:12 a.m.). The patient's PT was 87.6 with an INR 7.9. Patient's CBC revealed slight leukocytosis of 18,000 and hemoglobin 10.2.... Patient at time of exam has no active bleeding and vital signs are normal. We did give the patient a dose of subcutaneous vitamin K. We will instruct the nursing home to hold her Coumadin in the a.m. They will contact her primary care physician in the a.m. for further Coumadin dosage... We will return the patient to the nursing home. Departure: Departure Disposition: D/C (Discharge) to Nursing Home. Clinical Impression: Poisoning by warfarin sodium. Condition: Stable. Additional Instructions: hold Coumadin in the a.m. Contact the patient's primary care provider in a.m. for further Coumadin dosage orders. 'Would suggest canceling dental procedure in a.m.' Referrals: (Name of Primary Care Physician) - Next available appt (appointment)." g. The Nurse's Note dated 1/30/15 at 2:00 a.m., documented, "R (Resident) returned to facility vie (sic) (Name of Ambulance). New orders; hold Coumadin in a.m. Consider canceling dental procedures in a.m. Contact M.D. (Name of Physician) in a.m. R (Resident) (up) in bed resting (with) HOB (head of bed) (elevated) 20 (degree) angle. R (Resident) denies pain. (No) bleeding at this x (time). Eyes PERL (Pupils Equal and Reactive to Light) R/T (Related To) mouth problems. Afebrile. T (Temperature) 97.1 AX (axillary). Resp.(respirations) unlabored. Cap (capillary) refill less than 3 secs (seconds). POX (Pulse Oximetry) 96% RA. Will monitor." The Nurse's Note dated 1/30/15 at 0200 (2:00 a.m.) documented, "(Name of Hospital) ER (emergency room ) nurse stated R (resident) had 10 mg Vit (Vitamin) K shot SQ (subcutaneous). WBC 18.7/ PT 87.6 / INR 7.2. On call nurse DON (Name of DON) notified." The Nurse's Note dated 1/30/15 at 0300 (3:00 a.m.) documented, "Per on call MD (Name of physician): new order for Amoxicillin 500 mg po (by mouth) TID (three times a day) x (times) 7 days. Pharmacy notified. (Name of family) notified. DON (Name of DON) notified. Ordered STAT (emergent) from pharmacy. Awaiting delivery." The Nurse's Note dated 1/30/15 at 0300 (3:00 a.m.) documented, "MD (Name of MD #1) called again by this nurse. No answer. Will continue to try to notify." The Nurse's Note dated 1/30/15 at 0300 documented, "R (resident) bleeding large amt (amount) of coagulated blood from mouth. R (Resident) sat (up) (in) Geri-chair to promote (decreased) chances of swallowing blood or aspiration. ADON (Assistant Director of Nursing) notified." The Nurse's Note dated 1/30/15 at 0430 A (4:30 a.m.) documented, "Pharmacy delivered ABT (antibiotic). (One) Amoxicillin 500 mg given po. R (Resident) tolerated well." The Nurse's Note dated 1/30/15 at 0500 A (5:00 a.m.) documented, "R (resident) projectile vomiting large amounts of coagulated blood. Dark red. R (Resident) sent to (Name of Hospital) ER (emergency room ). Family notified. DON notified." h. The Hospital ED Long H&P documented, "Chief Complaint: Bleeding. Time Seen by Provider: 01/30/15 05:36 (5:36 a.m.) ...has a history of chronic anticoagulation's on Coumadin. She was seen earlier here in the ER with some bleeding from her left upper tooth. The bleeding had pretty much stopped when she was here previously. She was found to have an elevated INR of 7. She was given vitamin K. She was returned to the nursing home in stable condition ...The nursing home has returned her to the ER several hours later because she had some vomiting of dark blood. She had some transient hypotension, according to the nursing home history. She has a history of hypertension, dementia, need for anticoagulation which is unclear, history of urinary tract infections. She has a history of insulin-dependent diabetes ...History of remote CVA (Cerebrovascular Accident). The patient currently has no complaints. She denies any pain nausea, shortness of breath or other complaints ...Vital Signs: 01/30/15 05:32: Temp: 98.3 F. Pulse: 120 H-Resp.:16 BP: 116/53. Pulse Ox 96. Physical Exam: 01/30/15 -05:45 (5:45 a.m.)... She does appear to be somewhat pale ...HEENT: ...She does have some dried blood about her mouth which is dark red. There is a little bit of blood in her mouth. Do not see any areas of active bleeding in her mouth for (sic) (or) oral cavity at this point. ... Lab Results: WBC: 24.1 H. Red Blood Cells: 3.19 L. Hemoglobin: 9.0 L. Hematocrit: 30.3 L... PT: 83.2 H. INR: 6.9! H (Critical Lab Value) ...Medications Given: Sodium Chloride (NS) 1,000 mls (milliliters) @ 1000 ml/hr (milliliters per hour) IV (intravenous) q 1 H (hour). Phytonadione (Vitamin K) 10 mg SQ X (times) 1 ONE ...ED Course/Procedures: This lady's hematocrit has dropped from 33 -30 in the last few hours. Her blood pressure was low. She is a little tachycardic. Her blood pressure has improved and her tachycardia has lessened with some IV fluids. Her INR is still somewhat elevated in the 6 range ...I'm not sure if she has been bleeding from her mouth and swallowed some blood work (sic) (or) she actually has an upper GI (gastrointestinal) bleed. I do not believe however that she could stay here in (Name of city) with the current status of the GI coverage....I've spoken with (Name of Physician) his (sic) (he's) except (sic) (accepted) her at (Name of Hospital).... She will receive fresh frozen plasma and a second dose of vitamin K. I will also give her a dose of Protonix. Departure: Departure Disposition: ED Admit Inpatient/Observation. Clinical Impression: GI Bleed, Urinary Tract Infection. Condition: Serious ..." i. On 2/4/15 at 2:20 p.m., a list of residents on Coumadin was provided by the Administrator. At the top of the list a handwritten note documented, "PT 87.6. INR 7.2 @ (at) the ER." The Administrator was asked, "Whose lab results are those?" The Administrator stated, "(Resident #1's Name)." The Administrator was asked, "She isn't on the list (of residents on Coumadin)." The Administrator stated, "She's in the hospital." j. On 2/4/15 at 3:58 p.m., a copy of the Pharmacy Prescription History from 1/4/15 through 2/4/15 was provided by the Administrator. The Prescription History documented that 5 doses of Warfarin 4 mg were dispensed on 1/15/15, and 31 doses of Warfarin 4 mg were dispensed on 1/20/15 for Resident #1. All of the other residents on the list had physician's orders for Coumadin. There were no physician orders for the Coumadin dispensed on 1/15/15 and 1/20/15 for Resident #1. k. On 2/5/15 at 8:25 a.m., Licensed Practical Nurse (LPN) #2 was asked, "How do you know the medications on the MAR (Medication Administration Record) are ordered by the physician?" LPN #2 stated, "There should be a telephone order." LPN #2 was asked, "If you noticed a resident on Coumadin and Aspirin, would that be a concern for you?" LPN #2 stated, "Yes." LPN #2 was asked, "Do you do periodic chart checks?" LPN #2 stated, "Yes." LPN #2 was asked, "When?" LPN #2 stated, "They do them on 11-7 (night shift) I believe." At 8:30 a.m., LPN #4 was asked, "How do you know the drug listed in the e-MAR (Electronic Medication Administration Record) is actually ordered in the chart?" LPN #4 stated, "You have to check the telephone orders and nurse's notes." LPN #4 was asked, "How often do you check the e-MAR against the orders?" LPN #4 stated, "Only if there is something I haven't been giving (before)." LPN #4 was asked, "If you notice a resident is on Coumadin and Aspirin, what do you do?" LPN #4 stated, "I question the order. Both are blood thinners." LPN #4 was asked, "Do you ever do routine checks to see if the e-MAR drugs are ordered?" LPN #4 stated, "No. I think one of the night nurses may do it." LPN #4 was asked, "How often does that happen?" LPN #4 stated, "Once a week, I think." LPN #4 was asked, "That could mean a resident could get a wrong drug for a week before it is caught. How many doses of a wrong medicine can harm a resident?" LPN #4 stated, "One." LPN #4 was asked, "What can happen if a resident gets Aspirin and Coumadin?" LPN #4 stated, "The resident's blood gets really thin and he or she could bleed out." At 8:35 a.m., LPN #3 was asked, "How do you know the medications on the MAR (Medication Administration Record) are ordered by the physician?" LPN #3 stated, "It should be in the e-MAR, care plan and doctor's orders." LPN #3 was asked, "If you noticed a resident on Coumadin and Aspirin, would that be a concern for you?" LPN #3 stated, "Yes. But I've not administered any lately." LPN #2 was asked, "Do you do periodic chart checks?" LPN #3 stated, "No. I don't know who does it." At 2:05 p.m., Registered Nurse (RN) #1 was asked, "Did you care for (Resident #1)?" RN #1 stated, "Yes." RN #1 was asked, "Did you administer Coumadin to the resident?" RN #1 stated, "Yes." RN #1 was asked, "Why was she getting Coumadin?" RN #1 stated, "I was off 4 days. I came back to work on the 16th. The Coumadin was already ordered on the e-MAR. I gave it." The RN #1 was referred to the e-MAR entries for January 2015. RN #1 stated, "I sent her out that night (1/29/15) because she was bleeding from her gums. I couldn't see where the bleeding was coming from. I kept trying to get it to stop. I checked the lab records. There was no recent PT/INR. I sent her to the ER." RN #1 was asked, "Were you aware the resident was taking Aspirin?" RN #1 stated, "I had worked the 7-3 shift before and administered Aspirin to her." RN #1 was asked, "You knew she was on Aspirin?" RN #1 stated, "Yes. I was not aware she was taking Coumadin when I was on day shift." RN #1 was asked, "You were aware the resident was on Aspirin when you gave the Coumadin on the evening shift?" RN #1 stated, "Yes. I didn't think anything about it." RN #1 was asked, "Did you try to verify the order?" RN #1 stated, "No." l. On 2/5/15 at 9:15 a.m., the Director of Nursing (DON) was asked, "Have you been notified of any abnormal (laboratory results) on (Resident #1)?" The DON stated, "Only the critical lab when she went to the hospital." The DON was asked, "How often was (Resident #1) having a PT/INR (drawn)?" The DON stated, "She wasn't." The DON was asked, "Why?" The DON stated, "We have since discovered it was a transcription error." The DON was asked, "When you discovered the medication error, what happened?" The DON stated, "I notified the MD (Medical Doctor)." The DON was asked, "What did the MD say?" The DON stated, "To check everyone on Coumadin and make sure the PT/INRs were current." The DON was asked, "How did this error happen?" The DON stated, "LPN #1 transcribed the order wrong. There was another resident supposed to be put on Coumadin (1/14/15). The nurse put it into (Resident #1)'s e-MAR. That generated an order to the pharmacy that filled it. The nurses started administering it on 1/15/15." The DON was asked, "You're saying (Resident #1) received 4 mg Coumadin daily from 1/15/15 to 1/29/15?" The DON stated, "Yes." The DON was asked, "Was the MD aware when you started the Coumadin?" The DON stated, "No. Not when we started it." The DON was asked, "When you did notify the MD, what did he say? Did you do anything else?" The DON stated, "We checked everyone in the building for unordered drugs, and checked to see that everyone on Coumadin had a current PT/INR." The DON was asked, "Did you discover anyone else on Coumadin without an order?" The DON stated, "No. We found (Resident #6) had a change in Coumadin to 4 mg on 1/14/15. (Resident #1)'s order was entered on 1/14/15. (Resident #6)'s order was put in (the e-MAR) and she received the ordered dose of Coumadin." The DON was asked, "Aspirin is given on the day shift, and Coumadin is given on the evening shift. Who set that up?" The DON stated, "The previous Clinical Consultant." The DON was asked, "Is there any way the nurse on the evening shift sees the 8:00 a.m. drug Aspirin on the e-MAR?" The DON stated, "No." The DON was asked, "How do the nurses know (find out) about drug changes?" The DON stated, "It's supposed to be documented on the 24 hour report. The Nurses should look on the 24 hour report." The DON was asked, "Does that actually happen?" The DON stated, "No." The DON was asked, "Do the nurses check orders in the e-MAR against the orders in the chart? Like a 24 hour chart check?" The DON stated, "They don't do a 24 chart check." At 11:00 a.m., the DON was asked, "The only Medication Error Report I (Surveyor) have is on (LPN #1). Were any other Medication Error Reports completed on the nurses who administered the medication without an order?" The DON stated, "No." The DON was asked, "Would it be an error to administer the Coumadin without an order?" The DON stated, "Yes." The DON was asked, "The Incident and Accident (I&A) log for 3 months (reviewed by the Survey Team); does it contain med (medication) errors?" The DON stated, "No." The DON was asked, "Do you keep a separate log?" The DON did not answer. A copy of any medication error log or review was requested by the survey team, but was not provided by the time of exit on 2/5/15 at 4:15 p.m. m. On 2/5/15 at 9:45 a.m., the Clinical Nurse Consultant stated, "We have changed the policy to require orders to be faxed to the pharmacy before the pharmacy will fill it. We have changed the requirement for entering Coumadin into the system requiring a blank vital sign field that will require the nurse to put the current PT/INR into the e-MAR before they can administer Coumadin. We are printing the new orders entered into the e-MAR daily and checking them against the physician's orders. At 3:10 p.m., the resident's physician, MD #1, was asked, "Were you informed when the resident began taking Coumadin?" MD #1 stated, "No. If I were, I would have stopped it." MD #1 was asked, "Do you have any idea how this could happen?" MD #1 stated, "I have no idea how this could get into the computer without my name on it (written physician order)." n. The facility removed the Immediate Jeopardy and reduced the scope/severity to "H " on 2/3/15 (prior to the initiation of the survey) by taking the following corrective actions: 1) Assessment of all residents in the facility for unordered use of Coumadin was completed on 1/30/15. 2) Assessment of all residents on Coumadin for correct dose and current PT/INR was completed on 1/30/15. 3) Investigated the cause of the incident (LPN #1 entered the drug into e-MAR on 1/14/15 (completed on 2/4/15); the e-MAR automatically generated a drug order to the pharmacy, the pharmacy filled the order, the drug was administered without ever validating the drug against an actual MD order). 4) The LPN was terminated on 2/3/15. 5) Changed the policy to require faxed orders before the pharmacy will fill medication orders on 2/3/15. 6) Changed the policy on entry of Coumadin to add a vital signs field and require the entry of the current PT/INR prior to administration of any Coumadin in the facility on 2/3/15. 7) In-service to all nurses on the correct use of e-MAR (adding new field for Coumadin) and new policy requiring faxed MD orders to receive meds (medications) from the pharmacy initiated on 2/2/15 and completed on 2/4/15. 8) Monitoring: A report of all meds entered into the e-MAR system will be printed daily and verified against MD orders by the DON and designee, initiated 2/3/15.

Complaint # (AR 899) was substantiated, all or in part, in this finding. Based on record review and interview, the Nursing Administration failed to ensure medications were ordered, received, and transcribed in a manner that ensured residents were free of significant medication errors. Facility staff administered [MEDICATION NAME] 4 milligrams (mg) daily from 1/15/15 through 1/29/15 (15 doses) without a physician's order; without an assessment of the resident's baseline coagulation ability; without monitoring the effects of the drug on the resident by performing laboratory tests to measure the resident's [MEDICATION NAME] Time/International Normalization Ratio (PT/INR); and without a review of drug interactions for 1 (Resident #1) of 1 case mix resident who was administered anticoagulant therapy without a physician's order. These failed practices resulted in Immediate Jeopardy which caused or could have caused severe injury, harm or death to Resident #1, who was hospitalized with critical level PT/INR, gastrointestinal (GI) bleeding and a drop in hemoglobin and hematocrit levels which required the administration of multiple doses of Vitamin K and Fresh Frozen Plasma; and had the potential to affect all 86 residents who resided in the facility according to the Resident Census and Conditions of Residents report provided by the Administrator on 2/5/15. The facility removed the Immediate Jeopardy prior to the survey entrance date. However, all of the underlying deficient practices had not been corrected. The facility Administration was informed of the Immediate Jeopardy on 2/5/15 at 10:00 a.m. The findings are: 1. The Director of Nursing Job Description provided by the DON on 2/5/15 at 1:50 p.m. documented, "Purpose of Your Job Description: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times ...Nursing Care Functions... Monitor medication passes and treatment schedules to assure that medications are being administered as ordered and that treatments are provided as scheduled ...Staff Development: Develop and participate in the planning, conducting and scheduling of timely in-service training classes that provides instructions on 'how to do the job', and ensures a well-education (sic) (well-educated) Nursing Services Department. Develop, implement, and maintain an effective orientation program that orients the new employee to the facility, its policies and procedures, and to his/her job position. ... ." 2. The Nursing 2015 Drug Handbook provided by the Director of Nursing (DON) on 2/5/15 (provided as the drug reference book available to nurses at the facility) documented on page 1275 to 1276, "... [MEDICATION NAME]: ...Interactions: Drug-Drug:..[MEDICATION NAME], or other highly protein-bound drugs: May increase level of [MEDICATION NAME] or other highly protein-bound drug. May increase PT, or INR may increase by 8%. ... ." The Nursing 2015 Drug Handbook documented on pages 1467 to 1470, "... [MEDICATION NAME] sodium ([MEDICATION NAME]). ... Administration: P.O. (by mouth): Draw blood to establish baseline coagulation parameters before therapy. PT and INR determinations are essential for proper control. Recommended INR range is usually 2 to 3. ... Interactions: Drug-Drug: ... anticoagulants (... aspirin) ... [MEDICATION NAME], ... : May increase anticoagulant effect. Monitor patient carefully for bleeding. Reduce anticoagulant dosage as directed. ... Contraindications & Cautions: Contraindicated in patients hypersensitive to drug and in those with bleeding from the GI (Gastrointestinal) ... tract; severe or malignant hypertension ... Use cautiously in patients with ... mild or moderate hypertension... Nursing Considerations: Black Box Warning: [MEDICATION NAME] can cause major or fatal bleeding, which is more likely to occur during the starting period and with a higher dose. Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding. Avoid all I.M. (intramuscular) injections. Regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae, nosebleeds, melena, tarry stools, hematuria, and hematemesis..." 3. Resident #1 had [DIAGNOSES REDACTED]. The Yearly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/15 documented the resident scored 4 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS); required extensive 1 person physical assistance with transfers, dressing, toilet use hygiene and bathing; and received insulin injections, antidepressants, antibiotics but no anticoagulants. a. The January 2015 Physician's Order Sheet documented, "1/8/14: Aspirin 325 mg (milligrams) Tablet - Give one tablet by mouth daily with food... 11/11/14: [MEDICATION NAME] HCL ([MEDICATION NAME]) 50 mg tablet - give one tablet by mouth daily..." b. The January 2015 Medication Treatment and Task Administration Record documented that Aspirin 325 mg was administered daily at 8:00 a.m. from 1/1/15 through 1/29/15, and documented that [MEDICATION NAME] 50 mg was administered at 8:00 a.m. daily from 1/1/15 through 1/29/15. c. The January 2015 Medication Treatment and Task Administration Record documented, "[MEDICATION NAME] ([MEDICATION NAME]) 4 mg tab (tablet). One tab po (by mouth) daily. Doctor: (MD #1). Start: 1/14/2015." The record documented the [MEDICATION NAME] was administered daily at 5:00 p.m. from 1/15/ 15 through 1/29/15, a total of 15 doses. The [MEDICATION NAME] was given in conjunction with [MEDICATION NAME] HCL and Aspirin, which have the side effect of increasing the potential for bleeding and potentiating the effects of [MEDICATION NAME]. d. The January 2015 Physician's Order sheet documented, "1/14/15: New Order: D/C (discontinue) Foley Cath. (catheter)." There was no order in the clinical record that the resident was to be given [MEDICATION NAME] 4 mg daily. e. The Nurse's Note dated 1/29/15 at 17:00 (5:00 p.m.) documented, "R (resident) bleeding from R (right) upper top molar. Tooth is flat to surface (with) severe carries. Called (Name of Physician) on call. Stated to draw PT/INR STAT (Immediately) in AM (morning). Left note to (Name of facility staff) to set up dentist appt. (appointment) in AM. Called DON (Director of Nursing) to notify of R (Resident's) condition. VS (vital signs) 130/86 (blood pressure), 72 (pulse), 20 (respirations), 97.8 ax (axillary temperature), 96% (pulse oximetry) RA (room air)." The Nurse's Note dated 1/29/15 (no time given) documented, "N.O. (New Order); Send to (Name of Hospital) for eval (evaluation) & tx (treatment). Unable to stop bleeding in R (right) upper top molar. Contact (Name of Ambulance) to transport @ (at) 2130 (9:30 p.m.). Contact DON (Name of DON) @ 1025. Contact family @ 2245 (10:45 p.m.) " The Nurse's Note dated 1/29/15 at 10:50 p.m.) documented, "(Name of Ambulance) to pick up R (resident). Left AA&O x 2 (Alert and Oriented times 2) on stretcher." f. The Hospital Emergency Department (ED) Long H&P History and Physical (H & P) dated 1/29/15 documented, "Chief Complaint: Bleeding. Time Seen by Provider: 01/29/2015 -23:20 (11:20 p.m.). HPI/ROS (History and Physical /Review of Systems) 01/29/15 23:39 (11:39 p.m.). Patient ... was transferred from the nursing home for some bleeding from her right upper tooth. Patient apparently is scheduled to have surgery on this tooth tomorrow. I feel it is likely and extraction. Patient has some dementia. She is a very poor historian and unable to give any additional history. The nursing home was worried because she is on [MEDICATION NAME] that the bleeding might not stop. There is no active bleeding at the time of exam. Review of Systems: ...Gastrointestinal: No vomiting or diarrhea. [MEDICAL CONDITION]: No hematuria. No dysuria urgency or frequency ...Home medications: [REDACTED]. Vital Signs 01/29/15 23:05 (11:05 p.m.) Temp: 98.1 F-Pulse:106 H-Resp:16-BP:137/61. Pulse Ox: 97. Physical Exam: 01/29/15 23:43 (11:43 p.m.). General Appearance: Well developed, well nourished.... in no apparent distress. HEENT (Head, Ears, Eyes, Nose, Throat): ... there is some blood at the edge of the lower lip which is dried. ... Oropharynx: There is no active bleeding noted. There is an area of dried blood around the right upper first molar ....Lab Results: 01/30/15 0015 (12:15 a.m.): WBC (White Blood Count) 18.7 (Reference range 4.1 - 11.3), Red Blood Count (RBC): 3.51 L (low) (Reference Range 3.78 - 5.33), Hemoglobin 10.4 L (Reference Range 11.5 - 16.0), Hematocrit 32.7 L (Reference Range 35.0 - 47.0). ... PT 87.6 (Reference Range 8.9 - 12.6), INR 7.2 ! H (high) (Critical Lab Value) (Reference Range 0.0 - 1.9)." The Hospital Alert and Critical Values Table documented an INR of 5 or above as a Critical Lab Value. The ED Course/Procedures documented, "01/30/2015 00:12 (12:12 a.m.). The patient's PT was 87.6 with an INR 7.9. Patient's CBC revealed slight leukocytosis of 18,000 and hemoglobin 10.2.... Patient at time of exam has no active bleeding and vital signs are normal. We did give the patient a dose of subcutaneous vitamin K. We will instruct the nursing home to hold her [MEDICATION NAME] in the a.m. They will contact her primary care physician in the a.m. for further [MEDICATION NAME] dosage... We will return the patient to the nursing home. Departure: Departure Disposition: D/C (Discharge) to Nursing Home. Clinical Impression: Poisoning by [MEDICATION NAME] sodium. Condition: Stable. Additional Instructions: hold [MEDICATION NAME] in the a.m. Contact the patient's primary care provider in a.m. for further [MEDICATION NAME] dosage orders. 'Would suggest canceling dental procedure in a.m.' Referrals: (Name of Primary Care Physician) - Next available appt (appointment)." g. The Nurse's Note dated 1/30/15 at 2:00 a.m., documented, "R (Resident) returned to facility vie (sic) (Name of Ambulance). New orders; hold [MEDICATION NAME] in a.m. Consider canceling dental procedures in a.m. Contact M.D. (Name of Physician) in a.m. R (Resident) (up) in bed resting (with) HOB (head of bed) (elevated) 20 (degree) angle. R (Resident) denies pain. (No) bleeding at this x (time). Eyes PERL (Pupils Equal and Reactive to Light) R/T (Related To) mouth problems. Afebrile. T (Temperature) 97.1 AX (axillary). Resp.(respirations) unlabored. Cap (capillary) refill less than 3 secs (seconds). POX (Pulse Oximetry) 96% RA. Will monitor." The Nurse's Note dated 1/30/15 at 0200 (2:00 a.m.) documented, "(Name of Hospital) ER (emergency room ) nurse stated R (resident) had 10 mg Vit (Vitamin) K shot SQ (subcutaneous). WBC 18.7/ PT 87.6 / INR 7.2. On call nurse DON (Name of DON) notified." The Nurse's Note dated 1/30/15 at 0300 (3:00 a.m.) documented, "Per on call MD (Name of physician): new order for [MEDICATION NAME] 500 mg po (by mouth) TID (three times a day) x (times) 7 days. Pharmacy notified. (Name of family) notified. DON (Name of DON) notified. Ordered STAT (emergent) from pharmacy. Awaiting delivery." The Nurse's Note dated 1/30/15 at 0300 (3:00 a.m.) documented, "MD (Name of MD #1) called again by this nurse. No answer. Will continue to try to notify." The Nurse's Note dated 1/30/15 at 0300 documented, "R (resident) bleeding large amt (amount) of coagulated blood from mouth. R (Resident) sat (up) (in) Geri-chair to promote (decreased) chances of swallowing blood or aspiration. ADON (Assistant Director of Nursing) notified." The Nurse's Note dated 1/30/15 at 0430 A (4:30 a.m.) documented, "Pharmacy delivered ABT (antibiotic). (One) [MEDICATION NAME] 500 mg given po. R (Resident) tolerated well." The Nurse's Note dated 1/30/15 at 0500 A (5:00 a.m.) documented, "R (resident) projectile vomiting large amounts of coagulated blood. Dark red. R (Resident) sent to (Name of Hospital) ER (emergency room ). Family notified. DON notified." h. The Hospital ED Long H&P documented, "Chief Complaint: Bleeding. Time Seen by Provider: 01/30/15 05:36 (5:36 a.m.) ...has a history of chronic anticoagulation's on [MEDICATION NAME]. She was seen earlier here in the ER with some bleeding from her left upper tooth. The bleeding had pretty much stopped when she was here previously. She was found to have an elevated INR of 7. She was given vitamin K. She was returned to the nursing home in stable condition ...The nursing home has returned her to the ER several hours later because she had some vomiting of dark blood. She had some transient [MEDICAL CONDITION], according to the nursing home history. She has a history of hypertension, dementia, need for anticoagulation which is unclear, history of urinary tract infections. She has a history of insulin-dependent diabetes ...History of [MEDICAL CONDITION]. The patient currently has no complaints. She denies any pain nausea, shortness of breath or other complaints ...Vital Signs: 01/30/15 05:32: Temp: 98.3 F. Pulse: 120 H-Resp.:16 BP: 116/53. Pulse Ox 96. Physical Exam: 01/30/15 -05:45 (5:45 a.m.)... She does appear to be somewhat pale ...HEENT: ...She does have some dried blood about her mouth which is dark red. There is a little bit of blood in her mouth. Do not see any areas of active bleeding in her mouth for (sic) (or) oral cavity at this point. ... Lab Results: WBC: 24.1 H. Red Blood Cells: 3.19 L. Hemoglobin: 9.0 L. Hematocrit: 30.3 L... PT: 83.2 H. INR: 6.9! H (Critical Lab Value) ...Medications Given: Sodium Chloride (NS) 1,000 mls (milliliters) @ 1000 ml/hr (milliliters per hour) IV (intravenous) q 1 H (hour). [MEDICATION NAME] (Vitamin K) 10 mg SQ X (times) 1 ONE ...ED Course/Procedures: This lady's hematocrit has dropped from 33 -30 in the last few hours. Her blood pressure was low. She is a little [MEDICAL CONDITION]. Her blood pressure has improved and her [MEDICAL CONDITION] lessened with some IV fluids. Her INR is still somewhat elevated in the 6 range ...I'm not sure if she has been bleeding from her mouth and swallowed some blood work (sic) (or) she actually has an upper GI (gastrointestinal) bleed. I do not believe however that she could stay here in (Name of city) with the current status of the GI coverage....I've spoken with (Name of Physician) his (sic) (he's) except (sic) (accepted) her at (Name of Hospital).... She will receive fresh frozen plasma and a second dose of vitamin K. I will also give her a dose of [MEDICATION NAME]. Departure: Departure Disposition: ED Admit Inpatient/Observation. Clinical Impression: GI Bleed, Urinary Tract Infection. Condition: Serious ..." i. On 2/4/15 at 2:20 p.m., a list of residents on [MEDICATION NAME] was provided by the Administrator. At the top of the list a handwritten note documented, "PT 87.6. INR 7.2 @ (at) the ER." The Administrator was asked, "Whose lab results are those?" The Administrator stated, "(Resident #1's Name)." The Administrator was asked, "She isn't on the list (of residents on [MEDICATION NAME])." The Administrator stated, "She's in the hospital." j. On 2/4/15 at 3:58 p.m., a copy of the Pharmacy Prescription History from 1/4/15 through 2/4/15 was provided by the Administrator. The Prescription History documented that 5 doses of [MEDICATION NAME] 4 mg were dispensed on 1/15/15, and 31 doses of [MEDICATION NAME] 4 mg were dispensed on 1/20/15 for Resident #1. All of the other residents on the list had physician's orders for [MEDICATION NAME]. There were no physician orders for the [MEDICATION NAME] dispensed on 1/15/15 and 1/20/15 for Resident #1. k. On 2/5/15 at 8:25 a.m., Licensed Practical Nurse (LPN) #2 was asked, "How do you know the medications on the MAR (Medication Administration Record) are ordered by the physician?" LPN #2 stated, "There should be a telephone order." LPN #2 was asked, "If you noticed a resident on [MEDICATION NAME] and Aspirin, would that be a concern for you?" LPN #2 stated, "Yes." LPN #2 was asked, "Do you do periodic chart checks?" LPN #2 stated, "Yes." LPN #2 was asked, "When?" LPN #2 stated, "They do them on 11-7 (night shift) I believe." At 8:30 a.m., LPN #4 was asked, "How do you know the drug listed in the e-MAR (Electronic Medication Administration Record) is actually ordered in the chart?" LPN #4 stated, "You have to check the telephone orders and nurse's notes." LPN #4 was asked, "How often do you check the e-MAR against the orders?" LPN #4 stated, "Only if there is something I haven't been giving (before)." LPN #4 was asked, "If you notice a resident is on [MEDICATION NAME] and Aspirin, what do you do?" LPN #4 stated, "I question the order. Both are blood thinners." LPN #4 was asked, "Do you ever do routine checks to see if the e-MAR drugs are ordered?" LPN #4 stated, "No. I think one of the night nurses may do it." LPN #4 was asked, "How often does that happen?" LPN #4 stated, "Once a week, I think." LPN #4 was asked, "That could mean a resident could get a wrong drug for a week before it is caught. How many doses of a wrong medicine can harm a resident?" LPN #4 stated, "One." LPN #4 was asked, "What can happen if a resident gets Aspirin and [MEDICATION NAME]?" LPN #4 stated, "The resident's blood gets really thin and he or she could bleed out." At 8:35 a.m., LPN #3 was asked, "How do you know the medications on the MAR (Medication Administration Record) are ordered by the physician?" LPN #3 stated, "It should be in the e-MAR, care plan and doctor's orders." LPN #3 was asked, "If you noticed a resident on [MEDICATION NAME] and Aspirin, would that be a concern for you?" LPN #3 stated, "Yes. But I've not administered any lately." LPN #2 was asked, "Do you do periodic chart checks?" LPN #3 stated, "No. I don't know who does it." At 2:05 p.m., Registered Nurse (RN) #1 was asked, "Did you care for (Resident #1)?" RN #1 stated, "Yes." RN #1 was asked, "Did you administer [MEDICATION NAME] to the resident?" RN #1 stated, "Yes." RN #1 was asked, "Why was she getting [MEDICATION NAME]?" RN #1 stated, "I was off 4 days. I came back to work on the 16th. The [MEDICATION NAME] was already ordered on the e-MAR. I gave it." The RN #1 was referred to the e-MAR entries for January 2015. RN #1 stated, "I sent her out that night (1/29/15) because she was bleeding from her gums. I couldn't see where the bleeding was coming from. I kept trying to get it to stop. I checked the lab records. There was no recent PT/INR. I sent her to the ER." RN #1 was asked, "Were you aware the resident was taking Aspirin?" RN #1 stated, "I had worked the 7-3 shift before and administered Aspirin to her." RN #1 was asked, "You knew she was on Aspirin?" RN #1 stated, "Yes. I was not aware she was taking [MEDICATION NAME] when I was on day shift." RN #1 was asked, "You were aware the resident was on Aspirin when you gave the [MEDICATION NAME] on the evening shift?" RN #1 stated, "Yes. I didn't think anything about it." RN #1 was asked, "Did you try to verify the order?" RN #1 stated, "No." l. On 2/5/15 at 9:15 a.m., the Director of Nursing (DON) was asked, "Have you been notified of any abnormal (laboratory results) on (Resident #1)?" The DON stated, "Only the critical lab when she went to the hospital." The DON was asked, "How often was (Resident #1) having a PT/INR (drawn)?" The DON stated, "She wasn't." The DON was asked, "Why?" The DON stated, "We have since discovered it was a transcription error." The DON was asked, "When you discovered the medication error, what happened?" The DON stated, "I notified the MD (Medical Doctor)." The DON was asked, "What did the MD say?" The DON stated, "To check everyone on [MEDICATION NAME] and make sure the PT/INRs were current." The DON was asked, "How did this error happen?" The DON stated, "LPN #1 transcribed the order wrong. There was another resident supposed to be put on [MEDICATION NAME] (1/14/15). The nurse put it into (Resident #1)'s e-MAR. That generated an order to the pharmacy that filled it. The nurses started administering it on 1/15/15." The DON was asked, "You're saying (Resident #1) received 4 mg [MEDICATION NAME] daily from 1/15/15 to 1/29/15?" The DON stated, "Yes." The DON was asked, "Was the MD aware when you started the [MEDICATION NAME]?" The DON stated, "No. Not when we started it." The DON was asked, "When you did notify the MD, what did he say? Did you do anything else?" The DON stated, "We checked everyone in the building for unordered drugs, and checked to see that everyone on [MEDICATION NAME] had a current PT/INR." The DON was asked, "Did you discover anyone else on [MEDICATION NAME] without an order?" The DON stated, "No. We found (Resident #6) had a change in [MEDICATION NAME] to 4 mg on 1/14/15. (Resident #1)'s order was entered on 1/14/15. (Resident #6)'s order was put in (the e-MAR) and she received the ordered dose of [MEDICATION NAME]." The DON was asked, "Aspirin is given on the day shift, and [MEDICATION NAME] is given on the evening shift. Who set that up?" The DON stated, "The previous Clinical Consultant." The DON was asked, "Is there any way the nurse on the evening shift sees the 8:00 a.m. drug Aspirin on the e-MAR?" The DON stated, "No." The DON was asked, "How do the nurses know (find out) about drug changes?" The DON stated, "It's supposed to be documented on the 24 hour report. The Nurses should look on the 24 hour report." The DON was asked, "Does that actually happen?" The DON stated, "No." The DON was asked, "Do the nurses check orders in the e-MAR against the orders in the chart? Like a 24 hour chart check?" The DON stated, "They don't do a 24 chart check." At 11:00 a.m., the DON was asked, "The only Medication Error Report I (Surveyor) have is on (LPN #1). Were any other Medication Error Reports completed on the nurses who administered the medication without an order?" The DON stated, "No." The DON was asked, "Would it be an error to administer the [MEDICATION NAME] without an order?" The DON stated, "Yes." The DON was asked, "The Incident and Accident (I&A) log for 3 months (reviewed by the Survey Team); does it contain med (medication) errors?" The DON stated, "No." The DON was asked, "Do you keep a separate log?" The DON did not answer. A copy of any medication error log or review was requested by the survey team, but was not provided by the time of exit on 2/5/15 at 4:15 p.m. m. The facility removed the Immediate Jeopardy and reduced the scope/severity to an "H" on 2/3/15 (prior to the initiation of the survey) by taking the following corrective actions: 1) Assessment of all residents in the facility for unordered use of [MEDICATION NAME] was completed on 1/30/15. 2) Assessment of all residents on [MEDICATION NAME] for correct dose and current PT/INR was completed on 1/30/15. 3) Investigated the cause of the incident (LPN #1 entered the drug into IMAR on 1/14/15 (completed on 2/4/15); the e-MAR automatically generated a drug order to the pharmacy, the pharmacy filled the order, the drug was administered without ever validating the drug against an actual MD order). 4) The LPN was terminated on 2/3/15. 5) Changed the policy to require faxed orders before the pharmacy will fill medication orders on 2/3/15. 6) Changed the policy on entry of [MEDICATION NAME] to add a vital signs field and require the entry of the current PT/INR prior to administration of any [MEDICATION NAME] in the facility on 2/3/15. 7) In-service to all nurses on the correct use of e-MAR (adding new field for [MEDICATION NAME]) and new policy requiring faxed MD orders to receive meds (medications) from the pharmacy initiated on 2/2/15 and completed on 2/4/15. 8) Monitoring: A report of all meds entered into the e-MAR system will be printed daily and verified against MD orders by the DON and designee, initiated 2/3/15.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review, and interview the facility failed to ensure wander guard transmitter bracelets were worn by residents who were at risk for elopement as planned in order to reduce the risk of elopement and possible injury for 1 (Resident # 2) of 2 (Residents # 1 and #2) case mix residents who was identified as elopement risk and used wander guard bracelet transmitters. The facility failed to ensure the wander guard alarm system was maintained and functioned correctly in order to alert staff in the event of exit seeking behaviors for 2 (Residents #1 and #2) case mix residents who were identified as elopement risk and used wander guard bracelet transmitters. The facility failed to ensure elopement risk assessments were completed and used upon admission in order to evaluate and implement needed interventions for residents identified as at risk for elopement for 1 of 1 (Resident # 1) case mix resident was admitted to the facility within the last 30 days and was at risk for elopement. The facility failed to ensure staff members monitored residents who were at risk for elopement for placement and functioning of wander guard bracelet transmitters for 2 of 2 (Residents # 1 and #2) case mix residents who were at risk for elopement and used wander guard bracelet transmitters. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury of death to Resident # 2 who eloped from the facility on 4/9/14 and had the potential to affect 2 residents in the facility who were identified a elopement risk with wander guard bracelet transmitters as documented on a list provided by the Assistant Director of Nursing on 4/15/14. The facility was notified of the Immediate Jeopardy condition on 4/16/14 at 1:55 p.m. The findings are: 1. The facility's policy and procedure titled "Elopement Prevention" copied on 4/15/14 at 9:05 a.m. documented, "... Procedure: 1. Each resident's information will be compiled by the admissions coordinator based upon referral source, resident and family information. The admissions coordinator will document any known elopement risk information on the Admission Screening form. 2. The admitting nurse will complete the Elopement Risk Assessment Form. If the score is 10 or greater, a wander guard bracelet will be applied (where available), a care plan will be developed and the Director of Nursing or designee will be notified. ... 4. Admitting nurses or other staff members noting elopement risk and wandering behaviors must notify the charge nurse, Director of Nursing or designee promptly ... 6. The charge nurse, MDS coordinator and/or designee will perform an assessment ... Prevention measure will be coordinated to include: ... e. Implementation of wander prevention technology ... 7. Should technology be required, use of ... Wander guard bracelets (where available) will be utilized. The wander guard bracelet should be obtained from the Director of Nursing or designee. 8. A licensed nurse will place a task in iMar (computerized Medication Administration Record) for the use of the Wander guard bracelet and will document the reason for the application of the bracelet in the resident's clinical record. 9. The process for application and care of the Wander guard bracelet is as follows: ... f. Notify the RNAs (Restorative Nurse's Assistant) that a Wander guard bracelet has been applied ... 10. The Restorative Nursing Assistant will maintain a list of all residents at risk for elopement, including the resident's room numbers ... 11. The Restorative Nursing Assistant will check Wander guard bracelets monthly with documentation of findings (refer to Wander guard/Transmitter testing policy) ..." The manufacturer's 'System Instructions for PatientCARE Wanderer Monitoring System' copied on 4/15/14 at 9:06 a.m. documented, " ...General. The Patient CARE Door Receivers receive signals from short range transmitters that send identification information every 1.5 seconds. When a transmitter passes within the range set on the monitoring device (a range set by staff) and the door is opened (if the contact is installed) the system activates an alarm condition. Upon alarm, the receiver displays the ID (identification) number of the transmitter that has left and sounds an audible alarm ... Receiver Controls: Key Switch (ON) Used to turn ON/OFF unit ... Lock Enable (and) Warn Enable. The next setting in the menu is LOCK ENABLE. The LOCK ENABLE is used when you wish to interface with an electronic locking device. When a patient come close to the door and the system identifies their transmitter, the unit will activate a magnetic lock and prevent the door from opening. Push the UP button to change this setting ON/OFF. The final setting is WARN ENABLE. This setting will activate a warning 'beep' if a patient is within the range of the system. The patient ID number will also be displayed. If you do not wish to have this warning, shut it off by pushing the Down button. Note that ON will change to OFF. ... ATTACHING THE TRANSMITTERS. The transmitters can be attached to the resident using 'Hollister Bands' or standard ID bands. Please note the ID number of the transmitter and the resident name on the list that is included with these instructions ..." 2. Resident # 2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/14 documented the resident scored 2 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, wandered daily and was independent for walking and locomotion on and off the unit. a. A Social Service Progress Note dated 8/20/13 documented, "... No wandering ..." b. The Wander Guard Checklist documented that Wander Guard Number 2634 was assigned to Resident #2 beginning 10/4/13. The Wander Data Collection Tool dated 11/18/13 copied on 4/15/14 at 11:58 a.m. documented, "... Instructions: For each evaluation type (Admission, Annual, etc.) ... Check Yes or No for each evaluation factor. If Yes, summarize on Side Two ... Evaluation Factors: Has the resident wandered? Did the resident wander at home, in previous living setting, family/significant other voiced concerns? No ... Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside facility)? No ... Is the resident cognitively impaired with poor decision-making skills (i.e. (for example) poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes ... Does the resident have any visual, auditory, or communicating deficits? Yes ... Does the resident ambulate independently, with or without the use of assistive devices (including wheelchair)? Yes ... Is this a new behavior or has there been any changes in their functional status (i.e. new medication, pain, acute illness/infection, personal tragedy, new active diagnosis, upsetting information)? No. Is the resident seeking to find spouse/family? No ... (Side Two) Interventions: (Blank) ... Summary of Findings: (Blank) ... BIMS Summary Score (00-15): (Blank) ... Based off Summary of Findings, resident is Not a wander/elopement risk ...". A Social Service Progress Note dated 11/18/13 documented, "... (Resident) does wander ...". c. The Resident Care Plan initiated on 5/22/13 with review dates of 8/20/13, 11/18/13 and 2/16/14 did not identify wandering or the potential for elopement as a Problem/Need. d. There was no documentation the quarterly Wander Data Collection Tool was completed on Resident #2 for the month of February 2014. A Social Service Progress Note dated 2/14/14 documented, "... (Resident) has severe confusion (and) does wander ..." e. Nurse's Notes dated 4/9/14 at 5:45 p.m. and signed by Licensed Practical Nurse (LPN) # 2 documented, "(Resident) returned to facility by pedestrian at this time. (Resident) was walking up the road when pedestrian noticed that (resident) looked confused. (Resident) brought back to facility in good condition ... Wander guard in place to (right) leg ... (Resident) (assisted) to dining room for supper. 1:1 (One to one) monitoring initiated (times) 24 (hours) (with) visual checks (every) 1 (hour) ... (Resident) last seen walking in hallway by dining room (at) 5:26 p.m. per this nurse ..." 1) The Incident and Accident Report dated 4/9/14 documented, "... Date of Occurrence: 4/9/14. Time of Occurrence: 5:45 p.m....Person Involved: (Resident # 2) ...Incident type: Elopement ...Status: Confused ... Describe ...5:45 p.m. "(Resident) returned to facility by pedestrian at this time..." 2) The Witness Statement Form dated 4/9/14 at 5:30 p.m. and signed by CNA #5 documented, "At dinner time I came off Hulan Hall to help with dinner service. Then when (Resident # 2's) tray came out at 5:30 p.m., she was not in dining room. I asked (Certified Nursing Assistant (CNA) # 1) if she would go and get her so that she could eat. (CNA # 1) never came back to the dining area. I then walk the halls, 200 1st then 100. That's when I saw (Resident # 2) with a older lady and daughter with (CNA # 1) walking off Hulan. The lady then said that she needed to speak with someone in charge. I told her that she could speak with her (Resident #2) nurse (LPN # 1) ..." 3) The Witness Statement Form dated 4/9/14 at 5:45 p.m. and signed by CNA #1 documented, "I was on my (hall) looking for (Resident # 2) when I was approached by a random lady telling me there was a older lady standing on the side of the road trying to catch a ride. I ran outside to see if I could see if it was a resident. It was (Resident # 2) starting to get in a silver car. I started running down the road telling the lady I was coming to get (her) and she still took her back to the Hulan hall entrance. I (met) them at the door and walked her to the dining room." On 4/16/14 at 8:55 a.m. CNA # 1 was asked, "Were you working when (Resident # 2) eloped?" CNA # 1 stated "Yes." CNA # 1 was asked, "When did you discover the resident was missing?" CNA # 1 stated, "At dinner time I saw she was not there and I was going to look for her when a visitor told me there was an older lady outside. So I went to check. She had pointed to the front of the building." CNA #1 was asked, "What door did you go out?" CNA # 1 stated, "I tried to go out 200 hall (200 North exit door) and I couldn't get out so I went to Administration (Front Lobby) entrance and left that way." CNA # 1 was asked, "Where was the resident?" CNA # 1 stated, "She was to the right of the door I went out next to the road. She was almost to the first corner and I saw her getting picked up and I was yelling at them that I was coming to get her. She (driver) went ahead and put her in the car and turned around and came back to the Hulan hall entrance and I met her there." CNA # 1 was asked, "Did you help (Resident # 2) back in the building?" CNA # 1 stated, "Yes." CNA # 1 was asked, "Did the alarm sound when (Resident # 2) walked into the building?" CNA # 1 stated, "No, it did not." CNA # 1 was asked, "Do you know what door she went out?" CNA # 1 stated, "I didn't see what door she went out." CNA # 1 was asked, "Was (Resident # 2) acting any different that she normally did?" CNA # 1 stated, "No. She was not trying to get out. She normally gets up from the dining room to go to the bathroom." 5) The Witness Statement Form dated 4/9/14 at 5:45 p.m. and signed by LPN #1 documented, "Summoned to 100 hall per staff. An unfamiliar lady told me that this (resident) was seen walking on side of road and looked confused. She said she picked up (resident) and brought her to facility. (Resident # 2) had wander guard intact to (right) leg ..." On 4/15/14 at 3:35 p.m. LPN # 1 was asked, "Do you know of any residents who have eloped from the facility?" LPN # 1 stated, "(Resident # 2)." LPN # 1 was asked, "Were you working that day?" LPN # 1 stated, "Yes." LPN # 1 was asked, "What happened?" LPN # 1 stated, "I was in the dining room and one of the CNAs, (CNA # 5) told me (Resident # 2) had gotten out and I locked my med (medication) cart and I went around the corner and I was told the lady who brought her back wanted to speak to me." LPN # 1 was asked, "Did you test the wander guard later after supper?" LPN #1 stated, "Yes, the patio door by the 200 hall day room was sounding when she got near it." LPN # 1 was asked, "Did you hear any alarms prior to (CNA # 5) telling you (Resident # 2) was out?" LPN # 1 stated, "No." LPN # 1 was asked, "Did you see (Resident # 2) prior to this elopement?" LPN # 1 stated, "Yes. I had just seen her. She passed me when I was scanning (Resident # 7's) meds (medications). About 5:26 p.m. was when I last saw her. I was at the med cart by the main dining room." f. On 4/16/14 at 3:15 p.m., CNA # 4 was asked, "Were you working the night (Resident # 2) got out?" CNA # 4 stated, "Yes, I was on Hulan hall. (Resident # 6's) wife came to me and said she saw someone who looked like a resident out on the street on the corner. Me and (Maintenance #1) went out and we started looking to where she was pointing and we saw another CNA, (CNA # 1), running toward the facility and she said (Resident # 2) had been picked up and brought back and she running to the facility cause the car had just made it there." CNA # 4 was asked, "Did you hear any exit alarms then or before she told you this?" CNA # 4 stated, "No". CNA # 4 was asked, "What time was this?" CNA # 4 stated, "Right at dinner. I'd just got my trays for Hulan hall. Right around 5:30 p.m. that's usually when the kitchen gives me my trays and then I walk to Hulan hall." CNA # 4 was asked, "When (Resident # 6's family member) stopped you were you back on Hulan hall?" CNA # 4 stated, "Yes. Right when she came in the door she told me she thought she saw one of our residents outside." CNA # 4 was asked, "Did you come in when (Resident # 2) came in?" CNA # 4 stated, "Yes." CNA # 4 was asked, "Did her wander guard set the alarm off?" CNA # 4 stated, "No." g. The Wander Data Collection Tool dated 4/9/14 documented, "... Instructions: Instructions: For each evaluation type (Admission, Annual, etc.) ...Check Yes or No for each evaluation factor. If Yes, summarize on Side Two ...Evaluation Factors: Has the resident wandered? Did the resident wander at home, in previous living setting, family/significant other voiced concerns? No ...Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside facility)? Yes ... Is the resident cognitively impaired with poor decision-making skills (i.e. (for example) poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes ...Does the resident have any visual, auditory, or communicating deficits? Yes ...Does the resident ambulate independently, with or without the use of assistive devices (including wheelchair)? Yes ...Is this a new behavior or has there been any changes in their functional status (i.e. new medication, pain, acute illness/infection, personal tragedy, new active diagnosis, upsetting information)? Yes. Is the resident seeking to find spouse/family? Yes ... (Side Two) Interventions: ... 4. Frequent monitoring ...7. Utilization of check in/out log ...12. Personalization of room with familiar objects and photos ...17. Staff aware of resident's wander risk ...Summary of Findings: Actual elopement 4/9/14 (no) injury ...BIMS Summary Score (00-15): (Blank) ... Based off Summary of Findings, resident is: Is a wander/elopement risk. Intervention numbers utilized: 4, 7, 12, 17. Interventions and Care Plans have been: Implemented ... Updated (date) 4/9/14 ..." The Resident Care Plan updated on 4/9/14 documented, "4/9/14 Elopement, no injury ... 1:1 (One on one) x (times) 24 (hours). Wander guard. Staff awareness of potential for elopement. Frequent visual checks." h. Nurse's Notes dated 4/10/14 at 7:00 a.m. documented, "... Wander guard (changed) working properly at this time ..." i. The "Extra In-service" dated 4/10/14 documented, "Be aware of all wandering residents near exits. Be sure to locate all residents on your hall at least (every) two hours, all residents at risk for elopement will be monitored at more frequent intervals. Listen for all wander guards and check doors when alarm is sounding." Staff signatures were noted on this in-service document. The in-service document was attached to the policy and procedure titled "Elopement Prevention." j. The Medication and Treatment Administration Record Report for April 2014 printed on 4/15/14 at 9:45 a.m., documented, "1:1 monitoring. Place on 1:1 monitoring with visual checks every hour (times) 24 hours. Discontinue (at) 5:45 p.m. 4/10/14." This was initialed as completed on 4/9/14 for the 3:00 p.m. to 11:00 p.m. shift and 11:00 p.m. to 7:00 a.m. shift and on 4/10/14 for the 7:00 a.m. to 3:00 p.m. shift. The Medication and Treatment Administration Record Report for April 2014 printed on 4/15/14 at 9:45 a.m. documented "1:1 monitoring. Place on 1:1 monitoring with visual checks every 15 minutes (times) 24 hours then every hour. Staff must be assigned for this task." This was initialed as completed each shift beginning on 4/10/14 for the 3:00 p.m. to 11:00 p.m. shift through 4/14/14 for the 3:00 p.m. to 11:00 p.m. shift. k. Nurse's Notes dated 4/14/14 at 12:40 p.m. documented, "... wander guard in place and working ...". The Medication and Treatment Administration Record Report for April 2014 printed on 4/15/14 at 9:45 a.m. documented "1:1 monitoring. Visual checks every hour. Staff must be assigned for this task." This was initialed as completed on 4/14/14 for the 11:00 p.m. to 7:00 a.m. shift and on 4/15/14 for the 7:00 a.m. to 3:00 p.m. shift. l. On 4/14/14 at 5:37 p.m., the resident was observed in a chair in the dining room with a wander guard bracelet on the right ankle. m. Nurse's Notes dated 4/15/14 at 6:30 a.m. documented, "(Resident) in her room getting dressed (Wander guard) to right ankle ... wander guard beeping at 6:45 a.m. as (resident) entered 200 hall dayroom. (Every) 30 (minute) checks." There were only 3 entries in the Nurse's Notes regarding verification of the wander guard transmitter/bracelet from 4/9/14 at 5:45 p.m. through 4/15/14 at 6:30 a.m. n. On 4/15/14 at 7:58 a.m., the resident was in the hall by the dining room. The resident then started wandering room to room on the 200 hall. The resident stopped this surveyor and asked to go the bathroom. This surveyor informed the resident's charge nurse, (LPN # 3) who had her medication cart and was passing medications in the dining room that the resident was asking to go the bathroom. LPN # 3 directed CNA # 2, who was in the dining room, to take the resident to the bathroom. CNA # 2 assisted the resident down 200 hall to her room and into the bathroom. After the resident was done and washed her hands, this surveyor asked CNA # 2 to lift the resident's right pant leg up. There was no wander guard bracelet present. The resident left her room. CNA # 3 joined the resident and CNA # 2 in the hallway. This surveyor asked both CNAs to raise the resident's pant legs. There was no wander guard bracelet present on either leg. This surveyor asked the CNAs to move the resident's shirt sleeves up. There was no wander guard bracelet present on either wrist. CNAs # 2 and 3 were asked, "Is she (Resident #2) supposed to have a wander guard?" Both CNAs stated "Yes." CNA # 3 stated, "I'll get her one." At 8:17 a.m., the Assistant Director of Nursing (ADON) approached this surveyor holding a broken wander guard bracelet. The transmitter was still attached to the broken strap/band. The ADON stated, "It was in (Resident # 2's) drawer. At 6:20 a.m., it was there (on Resident #2) when I checked it. She popped it off." The ADON stated the strap/band was flimsy and asked the Director of Nursing (DON) if she could put two straps/bands on the transmitter. o. On 4/15/14 at 8:24 a.m., the surveyor and the DON checked all exit doors. The DON carried a transmitter and approached all exit doors. The wander guard alarms units at each door sounded. The DON was asked, "How long have you had the wander guard system?" The DON stated, "Since I've been here, prior to 2010." The DON was asked, "What is the process to verify door alarms are working?" The DON stated, "Maintenance checks the doors weekly and the RNA (Restorative Nursing Assistant) checks them (transmitter bracelets) monthly by taking (residents) to the exit doors." The DON was asked, "Has any residents at risk of elopement gotten out of the exit doors?" The DON stated, "(Resident # 2)." The DON was asked, "When?" The DON stated, "The evening of 4/9/14." The DON was asked, "Was (Resident # 2) wearing a wander guard at that time?" The DON stated, "Yes." The DON was asked, "Was the alarm going off?" The DON stated, "I did not read that it was going off on the I and A (Incident and Accident report)." The DON was asked, "Does the facility do elopement assessments?" The DON stated, "Yes." The DON was asked, "Was (Resident # 2) at risk for elopement?" The DON stated, "She was at risk but had not tried to exit. She mainly walked around in circles mostly." The DON was asked, "What have you done differently for (Resident # 2) since she eloped 4/9/14?" The DON stated, "For the first night we did one on one till the resident was asleep. Then we did every hour monitoring. Now we are doing every one hour visual checks." The DON was asked, "Is she the only resident who's gotten out of the facility?" The DON stated, "Yes, since I've been here. I started March 2010." The Medication and Treatment Administration Record (MAR) Report for April 2014 printed on 4/15/14 at 9:45 a.m. documented "Wander guard bracelet check for placement and functioning every shift ... Start: 4/15/14 ..." This was initialed as done on 4/15/14 for the 7:00 a.m. to 3:00 p.m. shift. There was no prior documentation of checks for the placement of the wander guard bracelet on the MAR prior to this entry. p. On 4/16/14 at 9:17 a.m., the Maintenance Supervisor stated he had worked in the facility since 3/5/14. The Maintenance Supervisor was shown the form titled "Weekly Exit Door Inspections." The Maintenance Supervisor was asked, "Do you do the weekly exit door inspections?" The Maintenance Supervisor stated, "Yes." The Maintenance Supervisor was asked, "Did you check the exit doors on 4/7/14?" The Maintenance Supervisor stated, "Yes." The Maintenance Supervisor was asked, "Are these all the exit doors in the facility?" The Maintenance Supervisor stated, "No, the main entrance is not on here (Weekly Exit Door Inspection form)." The Maintenance Supervisor was asked, "Have you been checking the main entrance door (Administration/Front lobby door)?" The Maintenance Supervisor stated, "Yes." The Maintenance Supervisor was asked to label the facility map with the names of the exit doors that were on the Weekly Exit Door Inspection form. The Maintenance Supervisor was asked, "What does alarm sound mean on your form?" The Maintenance Supervisor stated, "I take a wander guard (transmitter) with me and it's the wander guard alarm sound I listen for and the check means that it sounded." The Maintenance Supervisor was asked, "What is activation time mean on this form?" The Maintenance Supervisor stated, "That's the time when someone is near the door that it takes to reset itself and start alarming again." The Maintenance Supervisor was asked, "On 4/9/14 were you asked to check the doors after (Resident # 2) eloped?" The Maintenance Supervisor stated, "No and I wasn't even called that night and I should have been. (Administrator) asked me the next day if I had been here that night and I said no." The Maintenance Supervisor was asked, "Did you check all the exits and alarms on 4/10/14?" The Maintenance Supervisor stated, "No. I checked exit north and exit south. I was told she got out of exit north by (Administrator)." The Maintenance Supervisor was asked, "Did it (exit north) function correctly?" The Maintenance Supervisor stated, "No that particular wander guard unit had been turned off and the door closure was defective." The Maintenance Supervisor was asked, "Do you know how long it had been turned off?" The Maintenance Supervisor stated, "No and to my knowledge there is no way to determine that. It does not keep a self-record of when it's off and when it's on." The Maintenance Supervisor was asked, "Have you fixed the door closure?" The Maintenance Supervisor stated, "Yes that next day, 4/10/14, we replaced the entire door closure." The Maintenance Supervisor was asked, "Did you notice any problems with the exit north door on 4/7/14?" The Maintenance Supervisor stated, "No. I replaced exit south because it was defective but I did not know the north exit was defective." The Maintenance Supervisor was asked, "How is the wander guard system turned off?" The Maintenance Supervisor stated, "Manually with a key." The Maintenance Supervisor was asked, "Who all has keys to turn off the wander guard alarm units?" The Maintenance Supervisor stated, "Two maintenance men, myself, the DON and ADON and every nurse's station has a key. Anyone can go to the station and get the key and anything flat and skinny can be inserted into the opening on the lock and into the slot to turn it off." The Maintenance Supervisor was asked to go with this surveyor with a transmitter to the main/administration/front lobby exit door. The Maintenance Supervisor walked to the exit door carrying the transmitter and the alarm did not sound until the transmitter was held to the top of the door facing. The Maintenance Supervisor stated, "Ever since I've been here we've had problems with our alarm system and call our alarm system (name of company) on the second week it was here and they sent a tech (technician) out who said he was not familiar with the wander guard system. He said he's never seen one before and they would do research and get back with me. I called them multiple times over the next 3 weeks reminding them. I sent an email the week before last and last week on Friday (4/11/14) the tech came back with a consultant. The consultant said the problem was the storage of the wander guard bands. They were stored too close to the monitor by exit north. They were in the DON ' s office less than 30 feet from the nearest monitor. We moved them and he said that should correct the problem." At this time the Maintenance Supervisor who was still holding a wander guard transmitter entered the code into the key pad by the door and exited the building with no alarm sounding. The Maintenance Supervisor stated, "That should not have opened. The wander guard is supposed to lock it. There is a second alarm system that is supposed to alarm when the door is opened and that system was not working when I got here." The Maintenance Supervisor was asked, "So what should have just happened?" The Maintenance Supervisor stated, "An alarm should have sounded here and at the nurse's station. It's defective with dead wires and it in the process of being updated. If it had been working it would have let me know the north exit door closure was defective." This surveyor had the Maintenance Supervisor measure the distance from the main/front lobby/administration doors to the road. The distance was 80 feet. This surveyor had the Maintenance Supervisor measure the distance from the north exit (labeled A on the google map) to the road. The distance was 200 feet. This surveyor had the Maintenance Supervisor measure the distance from the road directly in front of the north exit doors to the corner where Resident #2 was found. The distance was 389 feet of which 169 feet were still part of the facility's property. The total distance from north exit to where the resident was found was 589 feet. The Maintenance Supervisor stated, "Last Friday (4/11/14) we moved the wander guards and the system started acting up again and I called (name of alarm system company) and told them it was alarming at the north exit door and it was showing a transmitter code, number on the wander guard that we don't even have. They said they would have to schedule a crew to come out and replace all the wires and fix all of our exit door systems at the same time." The Maintenance Supervisor was asked, "What are you doing in the meantime about your wander guard alarms?" The Maintenance Supervisor stated, "I found if I reset all the alarms every day then it works alright." This surveyor requested invoices, work orders and emails related to the wander guard alarm system. q. The Maintenance Supervisor provided the following documents on 4/16/14 at 10:30 a.m. 1) "(Alarm company name) ...Job #: ... Got (information) on Care Electronics Patient Care Wanderer Monitoring system. Get (with) (name of alarm company employee # 1) about the false alarms possible tuning issue ... Date: 3/20/14." 2) A print out of an email sent by the Maintenance Supervisor to the alarm company documented, "Wander guards; door alarms; ... 4/8/14 at 1:44 p.m. ... Our wander guard system is still malfunctioning and has not been synchronized. Additionally we have a second sensor on each door that is supposed to be a door alarm. It should alert when the door is opened and closed and also if the door is left ajar; this system is not working ..." 3) A print out of an email sent by the alarm company to the Maintenance Supervisor documented, "Service ... 4/8/14 at 3:42 p.m. ... I will have (name) back out there on Friday and he will be accompanied by (name of alarm company employee # 1) from our office. (Name of alarm company employee # 1) had experience with the current system you have and we should be able to get all of this straightened out for you." 4) "(Alarm company name) ...Job #: (Blank) ... Work Performed: Checked 100 hall door alarm, has 2 bad inputs, 1 bad wire to rear door, need to re-pull 4 zone door alarms units. 200 hall has 4 bad input ...units, also 2 bad door connections - trouble shoot ...need to return to trouble shot 4 doors ...wander guard - tentatively corrected - tags (transmitters) may be stored too close to unit ... Date: 4/11/14." r. Interviews were conducted with facility and nursing management regarding the elopement and the alarm systems: 1) On 4/16/14 at 10:30 a.m., the Administrator stated he had worked at this facility since 1/20/14. The Administrator was asked, "Since (Resident # 2) got out what has the facility identified as possible contributing factors?" The Administrator stated, "What we believe is there was a faulty door closure on the door outside (DON's) office." The Administrator was asked, "Is that what's called exit north?" The Administrator stated, "Yes." The Administrator was asked, "Is that the only problem identified?" The Administrator stated, "We had already been working on the wander guard system. They were not sounding properly." The Administrator was asked, "When did you identify that?" The Administrator stated, "It wasn't working when they came out on 3/20/14 and re-synced it and then we found out it wasn't working right again on 4/9/14." The Administrator was shown the email from the Maintenance Supervisor dated 4/8/14. The Administrator was asked, "Did you know about the email dated 4/8/14 regarding the wander guard system malfunctioning?" The Administrator stated, "I saw that about 20 minutes ago." The Administrator was asked, "Did you know about it on 4/8/14?" The Administrator stated, "No." The Administrator was asked, "How do you think (Resident # 2) got out?" The Administrator stated, "It's my guess she went out exit north. I was called Wednesday p.m. (4/9/14) and I did not know how she got out or when. On the morning of 4/10/14 (Maintenance Supervisor) went through all the doors and we found a door closure problem and that's where we were assuming she went out

Complaint # and # were substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to provide adequate supervision to prevent accidents for Resident #1 who required the use of the van lift. The facility failed to train and monitor the competency of the transportation Certified Nursing Assistant (CNA) staff and ensure the performance of preventative maintenance on van-lift equipment to minimize risk of injury during transports for 1 (Resident #1) of 2 (Residents #1 and #6) case mix residents who were transported to appointments outside the facility. These failed practices resulted in Immediate Jeopardy (IJ) which caused or could have caused serious harm, injury or death to Resident #1 who fell in his wheelchair from the facility's van-lift on the rear of the transportation van with resultant fractures of the Cervical-2 and Cervical-3 facets and had the potential to affect 42 residents in the facility who were transported in wheelchairs to and from appointments between 10/1/13 and 12/9/13 and 3 residents who were transported in wheelchairs by the facility's van between 12/23/13 and 12/30/13 according to Daily Transportation Logs provided by the Administrator on 12/31/13 at 10:08 p.m. The facility was notified of the Immediate Jeopardy on 12/30/13 at 8:36 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/13 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required total assistance with 2 persons for transfers, extensive assistance of one person for locomotion on and off corridor, had no limitations of range of motion of upper or lower extremities, used a wheelchair, had no falls prior to or since last assessment and received dialysis. a. The Resident Plan of Care dated 10/23/13 documented," ...Problem Onset: 11/22/13 (Resident) has renal failure and requires hemodialysis ...Problem Onset: 11/22/13 requires assistance of 1-2 people for ADLs (Activities of Daily Living) ...transfers ...Problem: Risk for Injury-potential to fall ...assist as needed with transfers ..." b. The Daily Transportation Logs provided by the Assistant Administrator on 12/31/13 at 10:08 p.m., documented the resident was transported to and from the dialysis center in the facility's transport van on 11/6/13, 11/8/13, 11/18/13, 11/29/13, 12/2/13, 12/3/13, 12/4/13 and 12/9/13. c. A Incident and Accident (I &A) Report dated 12/9/13documented, "Time of occurrence: Unknown before 11:00 at dialysis ...Describe exactly what was observed R (resident) transferred to dialysis transporter, unhooked safety chair, unlocked wheels, pushed w/c (wheelchair) back onto ramp. As the wheels rolled on to the ramp, it just fell . Transporter tried to grab and hold R it pulled her down as well ...Type of Intervention: R transferred to (local hospital) via (ambulance service) from the dialysis center ..." An I&A witness statement form dated 12/10/13 at 10:00 a.m. documented, "I unhooked the safety hooks, unlocked his (Resident #1) wheelchair and backed the wheelchair up on the ramp and as I was holding the wheelchair it felt like we was snatched toward the back and next thing I knew we was on the ground. I raised up and it was a lady and man that helped me back in the van. My legs was bent between the wheel chair and the van. I was helped by this man and lady." This was signed by Transport Certified Nursing Assistant (CNA) #1. d. The (ambulance) run report dated 12/9/13 at 9:43 a.m. documented, " ...found 72 y/o (year old) w/mpt (white male patient) lying supine/part way still in wheelchair. Van driver was unloading pt. with wheelchair lift and lift fell with pt. Pt fell backwards sticking his head on pavement/smamt (small amount) of blood noted ...fall 3 ft (feet) onto concrete. Pt c/o (complaint of) head/neck/upper back pain ..." A (hospital) Radiology report dated 12/9/13 at 12:23 p.m. documented, "...fracture of the C 2-3 (cervical spine at #2 and #3 facet without any subluxation... There is no vertebral body fracture ..." The study was read by the radiologist. e. Nurse's Notes dated 12/13/13 at 2130 (9:30 p.m.) documented, " R arrived (to facility) via (ambulance) transport on stretcher. Dx (diagnosis) (cervical) fracture ..." f. A physician progress notes [REDACTED].He has some neck pain ...He is alert and in no acute distress. He has some mild diffuse tenderness of his cervical spine..." g. A Division of Medical Services (DMS)-7734 and DMS-762 report form dated 12/9/13 documented, " ...on 12/9/13 the transportation van was placed out of service pending service check ..." h. On 12/30/13 at 2:42 p.m., CNA #1 transferred Resident #6 (who was in a wheelchair) from the van. Transport CNA #1 did not instruct the resident to hold to the hand rails and did not have means of centering the wheelchair on the lift pad as documented in the lift Operations Manual due to an absence of yellow lines. On 12/30/13 at 5:41 p.m., Transport CNA #2 demonstrated, with the participation of a member of the survey team, the loading and unloading of a resident in a wheelchair (w/c) into the transportation van. Transport CNA #2 stated, "Explain what you're going to do to the resident the whole time." Transport CNA #2 pushed the wheelchair onto the van lift pad with the back of the wheelchair toward the van and stood behind the w/c on the lift pad and operated the button to raise the lift pad. Transport CNA #2 then pulled the w/c into the van and lifted/jerked the w/c by the handles 3 times in an attempt to turn it around so it would face the front of the van. The surveyor stood at this time to allow CNA #2 to position the wheelchair so it faced toward the front of the van and then resumed her seat in the wheelchair. The hooks and belts to secure the w/c in place were explained to the surveyor before the unloading was demonstrated. The w/c was rolled onto the lift pad. While standing on the lift pad behind the w/c, the surveyor felt the lift pad leaning toward the ground and her torso was reclined at a 75 to 80 degree angle, which caused a "startle," reaction for the surveyor. Transport CNA #2 patted her on the arm and stated, "It's alright" while the lift pad was lowered to the ground. i. On 12/30/13 at 3:50 p.m. Transport CNA #2 was asked if the Operator's Manual for the wheelchair lift was located in the van, she stated, "Probably in my car." A copy of the manual was provided by the Administrator on 12/30/13 at 3:55 p.m. The Administrator was asked at that time where the manual had been located and she stated, "In the Maintenance Department in a binder with the transport schedule." The Administrator was asked where the manual was prior to the incident of 12/9/13 and she stated, "Unsure, it's in there (in van) now." j. On 12/30/13 at 3:55 p.m. the "Operator's Manual" for the wheelchair lift was provided by the Administrator and documented as follows: 1) On page 9 the warning box documented, "If the lift operating instructions and/or lift operation safety precautions are not fully understood, contact the (Manufacture's name) immediately. Failure to do so may result in serious bodily injury and/or property damage ...All transit agency personnel (drivers and wheelchair lift attendants) must read and become familiar with the contents of this manual and supplement(s) before operation." 2) Page 10 of the Operator's Manual documented, "Passenger must be positioned fully inside yellow boundaries. Passenger should grip both handrails (if able)." 3) Page 12 of the Operator's Manual documented, "Maintenance and lubrication procedures must be performed as specified in this manual by a (certified) service personnel ...Keep owner's (operator's) manual in lift-mounted manual storage pouch at all times ... and "Warning: Failure to follow these safety precautions may result in serious bodily injury and/or property damage," 4) The procedures on page 23 of the operation manual documented, "Yellow Boundaries: The passenger must be positioned in the center of the platform to prevent side-to-side load imbalance. The lift attendant (operator) should not ride on the platform with the passenger." 5) Page 26 of the Operator's Manual documented, "Transit agency supervisors should train and educate their lift attendants on the proper use and operation of the wheelchair lift if it is not possible for the attendants to review the safety precautions and operation procedures with the wheelchair lift sales representative. The lift owner's (operator's) manual must be stored in the lift-mounted manual storage pouch at all times ...Maintenance is necessary to ensure safe and trouble free lift operation. General preventive lift maintenance consisting of careful inspections of the lift system and cleaning the lift should be a part of your transit agency's daily lift service program. Simple inspections can detect potential lift operational problems ...Preventive maintenance visual inspections do not take the place of the procedures specified in the Maintenance and Lubrication Schedule provided in the applicable lift installation and service manual. Refer to the Maintenance and Lubrication section in this manual for further details." 6) Page 40 of the Operator's Manual documented, "Lubricate the pivot points specified on page 41 approximately every four weeks (or 100 cycles) with a light penetrating type oil (30 weight or equivalent)." k. On 12/30/13 at 6:00 p.m., the Maintenance Director provided copies of the facility's monthly Vehicle Inspection checklists from January through December 2013. The Maintenance Director stated he had followed the instructions given to him when he began employment 2 months ago. The monthly checklists dated January 2013 through 12/6/13 did not document the required inspections of all pivot points on the lift apparatus, that preventative maintenance had been provided as required to maintain the lift in good working condition or any checks of the van-lift apparatus. l. On 12/31/13 at 10:04 a.m., a copy of the van-lift operating guidelines was provided by the Administrator and the Assistant Administrator. The Administrator stated the Assistant Administrator had read the entire manual the previous night and a new checklist had been developed. m. On 12/31/13 at 11:45 a.m., the Administrator and the Assistant Administrator were asked to provide the "Service Manual (as referred to in the Operations Manual)" for the van's wheelchair lift. The Assistant Administrator stated, "The only one we have is the Operator's Manual. The Installation Manual is listed on the Internet. Maybe that will contain the information related to Maintenance and Service." On 12/31/13 at 12:36 p.m., the Installation/Service Manual was provided by the facility. The Maintenance and Lubrication Schedule was documented on pages 37 through 39. On pages 37 and 38, ten items were listed for inspection and/or oiling every 4 weeks (or 400 cycles). On pages 38 and 39, an additional 19 areas were listed for inspection and/or service every 3 months (or 1200 cycles). On page 39 an additional 15 areas were listed for checks/service every year (or 4800 cycles). On page 40 of the Installation/Service Manual a Warning Box documented "Maintenance and repair procedures must be performed as specified by authorized service personnel only. Failure to do so may result in serious bodily injury and/or property damage." n. On 12/31/13 at 2:51 p.m., the Administrator provided written documentation received at her request from the Service Center Provider who completed the repairs to the transportation van. The correspondence documented the following: "On December 10, 2013 (the nursing home) brought their lift in for an initial inspection and possible repairs. After examining the wheelchair lift for (nursing home) our findings are that when the lift is in the fully stowed position in the van, the outboard barrier latch was depressed by the upper doorplate, releasing the latch, which in turn allowed the outer barrier to unfold completely when lift is operated to floor level. There are several reasons contributing to this condition: Lack of maintenance and inspection of equipment, safety catches were broken on lift, outer barrier latch bent and not working properly and most of all the floor of the van had given away allowing the lift to lean toward the doors. All of this was shown to (the Maintenance Director) with (the nursing home) prior to any work being done on this lift. All of these conditions have been addressed and new inspection prior to release to (the nursing home) on December 23, 2013. According to (van lift manufacturer's) records, the e-mailed manual is the correct operators manual for that lift." o. On 12/31/13 at 12:42 p.m., the Administrator and Assistant Administrator were asked, "To your knowledge was anyone ever instructed to do a pre-trip check off (on the van and the lift)?" The Administrator stated, "No, not to my knowledge." Surveyors requested a policy and procedure related to van/lift usage/training/maintenance from the Administrator. The Installation/Service Manual documented a "Daily Preventive Maintenance Schedule" for "Pre-Trip Inspection: Before each scheduled day of lift service, operate lift minimum one complete cycle and inspect each of the following:" with 20 separate items to inspect prior to use of the lift to transport passengers in the van. The same form documented at the bottom of the page, "Post-Trip Inspection: Operate lift minimum one complete cycle and check each of the above daily pre-trip inspections" with instructions to clean lift surfaces where wheelchairs travel. p. On 12/30/13 at 8:22 p.m., the Administrator was asked how many Transport CNA's were employed by the facility and she stated, "I only know of two (Transport CNA's #1 and #2)." On 12/31/13 at 10:02 a.m., the Administrator provided a listing of seven Transport CNA's (Transport CNA's #1 through #7) that were insured through the facility's carrier to transport passengers in the facility's van. On 12/31/13 at 1:20 p.m., the Administrator and the Assistant Administrator were asked if Transport Aides #3 through #7 were re-trained on the van-lift's use after the 12/9/13 incident, if Transport CNA #1 was re-inserviced on the lift's use and if the Maintenance Director in-serviced was in-serviced. The Assistant Administrator stated, "No. (Transport CNA #2) is the only signed in-service (for retraining after the 12/9/13 incident)." Transport CNA #2's retraining form was dated 12/23/13 (the day the van was returned to the facility as documented on the service provider company's invoice dated 12/23/13). The form documented, "Lift attendant should not ride on platform with passenger." The in-service form documented, "Ensure passenger keeps arms in lap (which differed from the operations manual's instructions to have passengers hold to the hand rails, if able) and did not document the centering of the passenger's wheelchair between yellow marked lines on the lift pad. q. On 12/31/13 at approximately 4:00 p.m., Transport CNA #4 was asked when she had received training for transportation of residents in the facility's van and she stated, "(Director of Nursing (DON)) gave us some stuff yesterday. I was told before that by (DON) or (Transport CNA #2) about the lift." r. On 12/31/13 at 10:02 a.m., documentation of initial training for use of the facility's van-lift was provided for Transport CNA's #1 through #7: 1) Transport CNA #1's training (which was added to a DMS-762 dated 12/9/13) was documented on 3/22/12. On 12/30/13 at 5:07 p.m., Transport CNA #1 was interviewed by telephone and was asked to verbally describe how she loads and unloads residents in wheelchairs into and out of the transportation van. She did cover the basics but failed to mention centering on the lift plate. She did, however, state that she does not ride up and down on the lift with the resident because "That isn't safe." Transport CNA #1 was asked if she had access to the Operator's Manual for the lift. She stated, "I had access to it but I know all I need to know." When asked if she had received any additional training after the incident with Resident #1 she stated, "(Maintenance Director) showed me how after the lift was repaired to make sure the things are flat." 2) Transport CNA's #2's training was dated on 9/7/12. On 12/30/13 at 3:30 p.m., Transport CNA #2 was asked if she had received any training on the use of the wheelchair lift since 12/1/13. Transport CNA #2 stated, "(DON) called me to the office, asked me procedures and watched procedures loading/unloading resident," and when asked to verbally describe how to load and unload passengers in wheelchairs using the van-lift stated, "I'm always on the ramp." 3) Transport CNA's #3 through #7's training dates were documented as follows: CNA #3 - 1/17/12, CNA #4 - 1/13/12, CNA #5 - 2/13/13, CNA #6 - 9/17/12 and CNA #7 - 1/23/12. 2. On 12/30/13 at 8:36 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "E," after the facility began implementation of their Plan of Removal as follows: a. The Facility van was taken out of operation as of 12/30/13 at 2:42 p.m. and is to remain out of commission until proper training is provided by local certified service center to all 7 transport staff with proper check off and return demonstration. This is to be completed by 1/6/14 and any new transportation staff will receive the same training prior to use of van/lift. b. After Resident #1's incident with the lift on 12/9/13, the van went to the service center until 12/23/13 and was not in use. Service by the certified lift center will occur every month for the first 6 months (January through June 2014) to include all required routine checks and preventative maintenance per operations manual and installation/service manual and then every other month thereafter. c. The Pivot points and routine maintenance to the lift will be checked weekly by the Administrator/designee and greased according to the operations manual (every 4 weeks). Starting July 2014 greasing/lubricating the pivot points will be serviced by the Maintenance Director using a light penetrating 30 wt. or equivalent oil. d. Daily check-off's (Pre-Trip Inspections) for van lift use will begin 1/6/14 and will continue each day. These will be completed on day shift and evening shift before their first transportation is made. These will be kept on the van in a binder and signed off by the Administrator/Designee and the transport driver daily times 4 weeks. Then the Administrator/Designee will review the binder and both check-offs weekly thereafter to be documented on the same form, beginning 1/6/14. In-service with the transportation personnel for proper use of daily check off documentation was provided 12/31/13 beginning at 8:30 a.m., to be completed by 1/6/14 at 10:00 a.m. and be ongoing for all new transportation staff. e. Return demonstrations and in-service to be provided monthly with all transportation personnel once a month for 6 months and after initial training provided by the local service center on 1/6/14 and then quarterly thereafter. Training provided on 1/6/14 by the local certified service center will be documented as Assistant Administrator and the same return demonstration will be conducted on facility site every month times 6 and then quarterly. Random observations will be done by Administrator/Designee every week once on each shift times 6 weeks until plan of correction in place. f. A Van/lift Operations manual was placed in the facility van on 12/30/13 and on 12/31/13 a copy of the Installation/Service manual was placed in the facility van. Additional copies of both manuals were also placed in the DON's, Maintenance Director's and Administrator's office.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility Administration failed to provide training and monitor performance of Transport Certified Nursing Assistant (CNA) staff and provide specific information to the Maintenance Director to ensure performance of preventative maintenance on van-lift equipment to minimize risk of injury during transports for 1 (Resident #1) of 2 (Residents #1 and #6) case mix residents who were transported to appointments outside the facility. These failed practices resulted in Immediate Jeopardy (IJ) which caused or could have caused serious harm, injury or death to Resident #1 who fell in his wheelchair from a mechanical lift on the rear of the transportation van with resultant fractures of the Cervical-2 and Cervical-3 facets and had the potential to affect 42 residents in the facility who were transported in wheelchairs to and from appointments between 10/1/13 and 12/9/13 and 3 residents who were transported in wheelchairs by the facility's van between 12/23/13 and 12/30/13 according to Daily Transportation Logs provided by the Administrator on 12/31/13 at 10:08 p.m. The facility was notified of the Immediate Jeopardy on 12/30/13 at 8:36 p.m. The findings are: 1. On 12/31/13 at 9:56 a.m., the Administrator provided a copy of the "Essential Job Functions Nursing Home Administrator " that documented: a. " ... Physical Environment and Atmosphere: Ensure that a system for maintaining and improving buildings, grounds and equipment is planned, implemented, and evaluated..." b. " ...Ensure a comprehensive preventative maintenance program is developed and implemented..." c. " ...Knowledge of: Preventative maintenance systems . . . Equipment needs and management..." On 12/31/13 at 3:51 p.m., the Assistant Administrator provided documentation of the dates of employment for the facility's Administrators since 10/1/13 as follows: Administrator #3 (10/1/13 through 10/23/13), Administrator #2 (10/23/13 through 12/14/13) and the current Administrator 12/14/13 through the current dates. The documentation included the dated of the Assistant Administrator as 9/20/13 through the current dates. 2. On 12/31/13 at 9:56 a.m., the Administrator provided a copy of the "Job Description - Maintenance Director" that documented in the section titled, "Job Responsibilities": "2. Properly maintains the operating condition of various facility equipment. 3. Ensure proper lubrication, condition of parts and wiring, and fluid levels for safe and efficient performance. 4. Keep and maintain maintenance records in accordance with the Preventative Maintenance Program." On 12/31/13 at 4:30 p.m., the Administrator provided documentation of the dates of employment for the current Maintenance Director, that documented he had a date of hire of 10/28/13 and the former Maintenance Director (#2) who was employed for [AGE] years prior to 10/28/13. 3. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/13 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required total assistance with 2 persons for transfers, extensive assistance of one person for locomotion on and off corridor, had no limitations of range of motion of upper or lower extremities, used a wheelchair, had no falls prior to or since last assessment and received [MEDICAL TREATMENT]. a. The Resident Plan of Care dated 10/23/13 documented," ...Problem Onset: 11/22/13 (Resident) has [MEDICAL CONDITION] and requires [MEDICAL TREATMENT] ...Problem Onset: 11/22/13 requires assistance of 1-2 people for ADLs (Activities of Daily Living) ...transfers ...Problem: Risk for Injury-potential to fall ...assist as needed with transfers ..." b. The Daily Transportation Logs provided by the Assistant Administrator on 12/31/13 at 10:08 p.m., documented the resident was transported to and from the [MEDICAL TREATMENT] center in the facility's transport van on 11/6/13, 11/8/13, 11/18/13, 11/29/13, 12/2/13, 12/3/13, 12/4/13 and 12/9/13. c. A Incident and Accident (I &A) Report dated 12/9/13documented, "Time of occurrence: Unknown before 11:00 at [MEDICAL TREATMENT] ...Describe exactly what was observed R (resident) transferred to [MEDICAL TREATMENT] transporter, unhooked safety chair, unlocked wheels, pushed w/c (wheelchair) back onto ramp. As the wheels rolled on to the ramp, it just fell . Transporter tried to grab and hold R it pulled her down as well ...Type of Intervention: R transferred to (local hospital) via (ambulance service) from the [MEDICAL TREATMENT] center ..." An I&A witness statement form dated 12/10/13 at 10:00 a.m. documented, "I unhooked the safety hooks, unlocked his (Resident #1) wheelchair and backed the wheelchair up on the ramp and as I was holding the wheelchair it felt like we was snatched toward the back and next thing I knew we was on the ground. I raised up and it was a lady and man that helped me back in the van. My legs was bent between the wheel chair and the van. I was helped by this man and lady." This was signed by Transport Certified Nursing Assistant (CNA) #1. d. The (ambulance) run report dated 12/9/13 at 9:43 a.m. documented, " ...found 72 y/o (year old) w/mpt (white male patient) lying supine/part way still in wheelchair. Van driver was unloading pt. with wheelchair lift and lift fell with pt. Pt fell backwards sticking his head on pavement/smamt (small amount) of blood noted ...fall 3 ft (feet) onto concrete. Pt c/o (complaint of) head/neck/upper back pain ..." A (hospital) Radiology report dated 12/9/13 at 12:23 p.m. documented, "[MEDICAL CONDITION] 2-3 (cervical spine at #2 and #3) facet without any subluxation... There is no vertebral body fracture ..." The study was read by the radiologist. e. Nurse's Notes dated 12/13/13 at 2130 (9:30 p.m.) documented, " R arrived (to facility) via (ambulance) transport on stretcher. Dx (diagnosis) (cervical) fracture ..." f. A physician progress notes [REDACTED]. He has some mild diffuse tenderness of his cervical spine..." g. A Division of Medical Services (DMS)-7734 and DMS-762 report form dated 12/9/13 documented, " ...on 12/9/13 the transportation van was placed out of service pending service check ..." h. On 12/30/13 at 2:42 p.m., CNA #1 transferred Resident #6 (who was in a wheelchair) from the van. Transport CNA #1 did not instruct the resident to hold to the hand rails and did not have means of centering the wheelchair on the lift pad as documented in the lift Operations Manual due to an absence of yellow lines. On 12/30/13 at 5:41 p.m., Transport CNA #2 demonstrated, with the participation of a member of the survey team, the loading and unloading of a resident in a wheelchair (w/c) into the transportation van. Transport CNA #2 stated, "Explain what you're going to do to the resident the whole time." Transport CNA #2 pushed the wheelchair onto the van lift pad with the back of the wheelchair toward the van and stood behind the w/c on the lift pad and operated the button to raise the lift pad. Transport CNA #2 then pulled the w/c into the van and lifted/jerked the w/c by the handles 3 times in an attempt to turn it around so it would face the front of the van. The surveyor stood at this time to allow CNA #2 to position the wheelchair so it faced toward the front of the van and then resumed her seat in the wheelchair. The hooks and belts to secure the w/c in place were explained to the surveyor before the unloading was demonstrated. The w/c was rolled onto the lift pad. While standing on the lift pad behind the w/c, the surveyor felt the lift pad leaning toward the ground and her torso was reclined at a 75 to 80 degree angle, which caused a "startle," reaction for the surveyor. Transport CNA #2 patted her on the arm and stated, "It's alright" while the lift pad was lowered to the ground. i. On 12/30/13 at 3:50 p.m. Transport CNA #2 was asked if the Operator's Manual for the wheelchair lift was located in the van, she stated, "Probably in my car." A copy of the manual was provided by the Administrator on 12/30/13 at 3:55 p.m. The Administrator was asked at that time where the manual had been located and she stated, "In the Maintenance Department in a binder with the transport schedule." The Administrator was asked where the manual was prior to the incident of 12/9/13 and she stated, "Unsure, it's in there (in van) now." j. On 12/30/13 at 3:55 p.m. the "Operator's Manual" for the wheelchair lift was provided by the Administrator and documented as follows: 1) On page 9 the warning box documented, "If the lift operating instructions and/or lift operation safety precautions are not fully understood, contact the (Manufacture's name) immediately. Failure to do so may result in serious bodily injury and/or property damage ...All transit agency personnel (drivers and wheelchair lift attendants) must read and become familiar with the contents of this manual and supplement(s) before operation." 2) Page 10 of the Operator's Manual documented, "Passenger must be positioned fully inside yellow boundaries. Passenger should grip both handrails (if able)." 3) Page 12 of the Operator's Manual documented, "Maintenance and lubrication procedures must be performed as specified in this manual by a (certified) service personnel ...Keep owner's (operator's) manual in lift-mounted manual storage pouch at all times ... and "Warning: Failure to follow these safety precautions may result in serious bodily injury and/or property damage," 4) The procedures on page 23 of the operation manual documented, "Yellow Boundaries: The passenger must be positioned in the center of the platform to prevent side-to-side load imbalance. The lift attendant (operator) should not ride on the platform with the passenger." 5) Page 26 of the Operator's Manual documented, "Transit agency supervisors should train and educate their lift attendants on the proper use and operation of the wheelchair lift if it is not possible for the attendants to review the safety precautions and operation procedures with the wheelchair lift sales representative. The lift owner's (operator's) manual must be stored in the lift-mounted manual storage pouch at all times ...Maintenance is necessary to ensure safe and trouble free lift operation. General preventive lift maintenance consisting of careful inspections of the lift system and cleaning the lift should be a part of your transit agency's daily lift service program. Simple inspections can detect potential lift operational problems ...Preventive maintenance visual inspections do not take the place of the procedures specified in the Maintenance and Lubrication Schedule provided in the applicable lift installation and service manual. Refer to the Maintenance and Lubrication section in this manual for further details." 6) Page 40 of the Operator's Manual documented, "Lubricate the pivot points specified on page 41 approximately every four weeks (or 100 cycles) with a light penetrating type oil (30 weight or equivalent)." k. On 12/30/13 at 6:00 p.m., the Maintenance Director provided copies of the facility's monthly Vehicle Inspection checklists from January through December 2013. The Maintenance Director stated he had followed the instructions given to him when he began employment 2 months ago. The monthly checklists dated January 2013 through 12/6/13 did not document the required inspections of all pivot points on the lift apparatus, that preventative maintenance had been provided as required to maintain the lift in good working condition or any checks of the van-lift apparatus. l. On 12/31/13 at 10:04 a.m., a copy of the van-lift operating guidelines was provided by the Administrator and the Assistant Administrator. The Administrator stated the Assistant Administrator had read the entire manual the previous night and a new checklist had been developed. m. On 12/31/13 at 11:45 a.m., the Administrator and the Assistant Administrator were asked to provide the "Service Manual (as referred to in the Operations Manual)" for the van's wheelchair lift. The Assistant Administrator stated, "The only one we have is the Operator's Manual. The Installation Manual is listed on the Internet. Maybe that will contain the information related to Maintenance and Service." On 12/31/13 at 12:36 p.m., the Installation/Service Manual was provided by the facility. The Maintenance and Lubrication Schedule was documented on pages 37 through 39. On pages 37 and 38, ten items were listed for inspection and/or oiling every 4 weeks (or 400 cycles). On pages 38 and 39, an additional 19 areas were listed for inspection and/or service every 3 months (or 1200 cycles). On page 39 an additional 15 areas were listed for checks/service every year (or 4800 cycles). On page 40 of the Installation/Service Manual a Warning Box documented "Maintenance and repair procedures must be performed as specified by authorized service personnel only. Failure to do so may result in serious bodily injury and/or property damage." n. On 12/31/13 at 2:51 p.m., the Administrator provided written documentation received at her request from the Service Center Provider who completed the repairs to the transportation van. The correspondence documented the following: "On December 10, 2013 (the nursing home) brought their lift in for an initial inspection and possible repairs. After examining the wheelchair lift for (nursing home) our findings are that when the lift is in the fully stowed position in the van, the outboard barrier latch was depressed by the upper doorplate, releasing the latch, which in turn allowed the outer barrier to unfold completely when lift is operated to floor level. There are several reasons contributing to this condition: Lack of maintenance and inspection of equipment, safety catches were broken on lift, outer barrier latch bent and not working properly and most of all the floor of the van had given away allowing the lift to lean toward the doors. All of this was shown to (the Maintenance Director) with (the nursing home) prior to any work being done on this lift. All of these conditions have been addressed and new inspection prior to release to (the nursing home) on December 23, 2013. According to (van lift manufacturer's) records, the e-mailed manual is the correct operators manual for that lift." o. On 12/31/13 at 12:42 p.m., the Administrator and Assistant Administrator were asked, "To your knowledge was anyone ever instructed to do a pre-trip check off (on the van and the lift)?" The Administrator stated, "No, not to my knowledge." Surveyors requested a policy and procedure related to van/lift usage/training/maintenance from the Administrator. The Installation/Service Manual documented a "Daily Preventive Maintenance Schedule" for "Pre-Trip Inspection: Before each scheduled day of lift service, operate lift minimum one complete cycle and inspect each of the following:" with 20 separate items to inspect prior to use of the lift to transport passengers in the van. The same form documented at the bottom of the page, "Post-Trip Inspection: Operate lift minimum one complete cycle and check each of the above daily pre-trip inspections" with instructions to clean lift surfaces where wheelchairs travel. p. On 12/30/13 at 8:22 p.m., the Administrator was asked how many Transport CNA's were employed by the facility and she stated, "I only know of two (Transport CNA's #1 and #2)." On 12/31/13 at 10:02 a.m., the Administrator provided a listing of seven Transport CNA's (Transport CNA's #1 through #7) that were insured through the facility's carrier to transport passengers in the facility's van. On 12/31/13 at 1:20 p.m., the Administrator and the Assistant Administrator were asked if Transport Aides #3 through #7 were re-trained on the van-lift's use after the 12/9/13 incident, if Transport CNA #1 was re-inserviced on the lift's use and if the Maintenance Director in-serviced was in-serviced. The Assistant Administrator stated, "No. (Transport CNA #2) is the only signed in-service (for retraining after the 12/9/13 incident)." Transport CNA #2's retraining form was dated 12/23/13 (the day the van was returned to the facility as documented on the service provider company's invoice dated 12/23/13). The form documented, "Lift attendant should not ride on platform with passenger." The in-service form documented, "Ensure passenger keeps arms in lap (which differed from the operations manual's instructions to have passengers hold to the hand rails, if able) and did not document the centering of the passenger's wheelchair between yellow marked lines on the lift pad. q. On 12/31/13 at approximately 4:00 p.m., Transport CNA #4 was asked when she had received training for transportation of residents in the facility's van and she stated, "(Director of Nursing (DON)) gave us some stuff yesterday. I was told before that by (DON) or (Transport CNA #2) about the lift." r. On 12/31/13 at 10:02 a.m., documentation of initial training for use of the facility's van-lift was provided for Transport CNA's #1 through #7: 1) Transport CNA #1's training (which was added to a DMS-762 dated 12/9/13) was documented on 3/22/12. On 12/30/13 at 5:07 p.m., Transport CNA #1 was interviewed by telephone and was asked to verbally describe how she loads and unloads residents in wheelchairs into and out of the transportation van. She did cover the basics but failed to mention centering on the lift plate. She did, however, state that she does not ride up and down on the lift with the resident because "That isn't safe." Transport CNA #1 was asked if she had access to the Operator's Manual for the lift. She stated, "I had access to it but I know all I need to know." When asked if she had received any additional training after the incident with Resident #1 she stated, "(Maintenance Director) showed me how after the lift was repaired to make sure the things are flat." 2) Transport CNA's #2's training was dated on 9/7/12. On 12/30/13 at 3:30 p.m., Transport CNA #2 was asked if she had received any training on the use of the wheelchair lift since 12/1/13. Transport CNA #2 stated, "(DON) called me to the office, asked me procedures and watched procedures loading/unloading resident," and when asked to verbally describe how to load and unload passengers in wheelchairs using the van-lift stated, "I'm always on the ramp." 3) Transport CNA's #3 through #7's training dates were documented as follows: CNA #3 - 1/17/12, CNA #4 - 1/13/12, CNA #5 - 2/13/13, CNA #6 - 9/17/12 and CNA #7 - 1/23/12. s. On 12/30/13 at 8:15 p.m., the Assistant Administrator was asked about Transport CNA #2's re-training documented on 12/23/13, if it included a return demonstration. The Assistant Administrator left the room, returned at 8:22 p.m., and stated he had spoken with the Maintenance Director (who had signed with Transport CNA #2 on the in-service for lift use dated 12/23/13) and, "Guidelines/Lift In-Service was a verbalization (no demonstration)." t. On 12/30/13 between 5:40 p.m. and 6:40 p.m., an interview was conducted with the facility's Maintenance Director, who stated the transport aides had "all signed off prior to me coming here." 1) The Maintenance Director was asked if was ever appropriate for the lift attendant to stand on the lift with the resident and he stated, "Absolutely not." 2) The Maintenance Director stated he had received the operations manual for the van-lift on 12/10/13, "Got it from (lift manufacturer)." 3) The Maintenance Director was asked if he had been instructed to perform specific lift apparatus inspections and he stated, "No, just van. It's part of van." He was asked if he had read the lift service manual and stated, "Yes." He was asked if he had read the manual prior to incident and he stated, "No, ma'am." 4) He was asked if the lift pivot points had been lubricated in the last 3 months and he stated, "No, had plenty of grease on them, nothing sticking." 5) He was asked if the lift pad had yellow lines on it (for centering of the wheelchair) and he stated, "No yellow lines." 4. On 12/30/13 at 8:36 p.m., the Immediate Jeopardy was removed and the scope/severity was lowered to an "E," after the facility began implementation of their Plan of Removal as follows: a. The Facility van was taken out of operation as of 12/30/13 at 2:42 p.m. and is to remain out of commission until proper training is provided by local certified service center to all 7 transport staff with proper check off and return demonstration. This is to be completed by 1/6/14 and any new transportation staff will receive the same training prior to use of van/lift. b. After Resident #1's incident with the lift on 12/9/13, van went to service center until 12/23/13 and was not in use. Service by certified lift center will occur every month for the first 6 months (January through June 2014) to include all required routine checks and preventative maintenance per operations manual and installation/service manual and then every other month thereafter. c. The Pivot points and routine maintenance to the lift will be checked weekly by the administrator/designee and greased according to the operations manual (every 4 weeks). Starting July 2014 greasing/lubricating the pivot points will be serviced by the Maintenance Director using a light penetrating 30 wt. or equivalent oil. d. Daily check-off's (Pre-Trip Inspections) for van lift use will begin 1/6/14 and will continue each day. These will be completed on day shift and evening shift before their first transportation is made. These will be kept on the van in a binder and signed off by the Administrator/Designee and the transport driver daily times 4 weeks. Then the Administrator/Designee will review the binder and both check-offs weekly thereafter to be documented on the same form, beginning 1/6/14. In-service with the transportation personnel for proper use of daily check off documentation was provided 12/31/13 beginning at 8:30 a.m., to be completed by 1/6/14 at 10:00 a.m. and be ongoing for all new transportation staff. e. Return demonstrations and in-service to be provided monthly with all transportation personnel once a month for 6 months and after initial training provided by the local service center on 1/6/14 and then quarterly there after. Training provided on 1/6/14 by the local certified service center will be documented as Assistant Administrator and the same return demonstration will be conducted on facility site every month times 6 and then quarterly. Random observations will be done by Adminstrator/Designee every week once on each shift times 6 weeks until plan of correction in place. f. A Van/lift Operations manual was placed in the facility van on 12/30/13 and on 12/31/13 a copy of the Installation/Service manual was placed in the facility van. Additional copies of both manuals were also placed in the DON's, Maintenance Director's and Administrator's office.