Every finding on record at The Blossoms at North Little Rock Rehab & Nursing

Number of residents sampled: Number of residents cited: Based on observation and interview, the facility failed to ensure that waste was properly contained in the dumpster, and the area was free from debris, in one of one dumpster area. The findings include: During an observation and concurrent interview on 08/24/2026 at 10:32 AM, the dumpster area behind the building was littered with plastic cup lids, peach slices, gloves and plastic bags. The Dietary Manager stated, I have not cleaned up around the dumpster in a few weeks, it is my responsibility to pick up around it as needed. It is to be kept clean to prevent rodents. During an interview on 08/27/2026 at 10:00 AM, the Administrator indicated it was their expectation that kitchen staff followed safe sanitation standards to prevent cross contamination and pest infestation.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, the facility failed to ensure two (Resident #122 and Resident #20) who received enteral feedings received appropriate care and services to prevent complications. Specifically, the facility failed to provide enteral nutrition per the Physician's Order for Resident #122 and failed to follow manufacturers' guidelines on tubing replacement for Resident #20. The findings include:Resident #122 Review of an admission Record revealed Resident #122 was admitted on [DATE] with diagnoses that included malignant neoplasm of the tongue and pharynx, chronic obstructive pulmonary disease and emphysema. MDS Review Review of the Care Plan initiated on 08/24/2026, revealed Resident #122 may be at risk for weight loss related to cancer of the throat and tongue, and tube feeding. Interventions included prepare/serve the residents' nutritional diet as ordered. Review of Resident #122's Order Summary Report revealed an order dated 08/24/2026 for an enteral feed order to be administered continuously every shift at49 milliliters (ml) per hour via Percutaneous Endoscopic Gastrostomy (PEG) tube related to malignant neoplasm of base of tongue. During an observation on 08/24/2026 at 1:40 PM, this surveyor observed that the feeding pump was set at a continuous rate of 46 ml per hour for Resident #122. During an observation on 08/26/2026 at 2:26 PM, this surveyor observed that the feeding pump was set at a continuous rate of 46 ml per hour. During an interview on 08/26/2026 at 2:33 PM, Registered Nurse (RN) #5 stated that Resident #122's tube feeding should be set at a continuous rate of 49 ml per hour. RN #5 stated, I noticed this morning it was at 46 ml per hour, and I changed it to the correct level of 49 ml per hour after I checked the orders. RN #5 stated that she was not sure why it was on the lower rate of 46 ml per hour now and that it would not necessarily cause the resident any harm. During an interview on 08/27/2026 at 8:44 AM, Licensed Practical Nurse (LPN) #6 stated she worked on 08/23/206 on the hall that Resident #122 resided. LPN #6 stated she does check the rate of tube feedings before leaving work and that she did not adjust the rate for Resident #122's tube feeding on 08/23/2026. LPN #6 stated she checks the tube feeding rate every time she enters the resident's room. During an interview on 08/27/2026 at 3:10 PM, the Medical Director stated that if a tube feeding was running too slowly the resident may not get enough calories. During an interview on 08/27/2026 at 10:00 AM, the Director of Nursing (DON) stated that she expected staff to review the order for the feeding to ensure the rate was correct along with the correct formula. After review of Resident #122's Physician Orders, the DON stated that it appeared that Resident #122's feeding rate was incorrectly set to 46 ml per hour, instead of 49 ml per hour as ordered. Resident #20Review of an admission Record revealed the facility admitted Resident #20 on 07/06/2026 with diagnoses that included metabolic encephalopathy, neurosyphilis and dysphagia. Review of an annual Minimum Data Set (MDS) with an admission Reference Date of 07/09/2026, revealed a Brief Interview for Mental Status of a 00 which indicated the resident had severe cognitive impairment. The MDS also revealed that Resident #20 was dependent on staff for self-care and mobility. Review of Resident #20's Care Plan initiated on 07/09/2026, revealed that the resident required tube feedings related to dysphagia. Interventions included to administer medications as ordered. Review of Resident #20's Order Summary Report revealed an order dated 07/06/2026 enteral feedings every shift. During an observation on 08/24/2026 at 11:30 AM, this surveyor observed a bag of enteral feeding hanging for Resident #20 dated 08/22/2026. During an observation on 08/25/2026 at 8:22 AM, this surveyor observed the bag of enteral feeding that was hanging for Resident #20 was dated 08/22/2026.During an interview on 08/26/2026 at 2:28 PM, RN #5 stated that the bag looked like it was hung on 08/22/2026 and not changed and that staff probably added formula to the bag instead of changing the whole system to start a new set up. RN #5 stated she believed best practice was to change the set up every 24 hours to prevent the sugar in the formal from breeding bacteria. During an interview on 08/26/2026 at 10:00 AM, the DON stated she expected staff to review the Physicians Order for the feeding to ensure the rate was correct and the formula was correct. The DON stated that the feeding set was to be changed per manufacturer's guidelines. During an interview on 08/27/2026 at 8:44 AM, LPN # 6 stated she did notice the date 08/22/2026 on the feeding set for Resident #20. LPN #6 stated, I am not sure how long the bag hangs for. I was not told how often they are to be changed. Review of the [name brand]feeding set insert with an expiration date of 01/31/2031, revealed due to the risk of bacterial contamination and overall system accuracy, do not use feeding sets for greater than 24 hours.Review of an undated facility policy titled Enteral Tube Medication Administration Policy, revealed that the manufacturer's written recommendations regarding suggested time for hanging of the product are consulted when determining the schedule for enteral feeding administration. The policy also revealed that the caloric content per milliliter is verified before administration to ensure the correct dosage is given to achieve caloric objectives.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to ensure biologicals and medications were not stored past the use by/discard date, for two (D- Front Hall and B- Short Hall) of four medication carts reviewed. The findings include: B-Short Hall Medication Cart: During an observation on 08/27/2026 at 11:42 AM, Licensed Practical Nurse (LPN) #13 unlocked the medication cart for B-Short Hall. The following were observed:-Resident #97's Torsemide 20 mg (milligrams) medication card indicated a use by date of 02/18/2026. -Resident #97's Cyclobenzapril 10 mg card indicated a use by date of 05/15/2026.-Resident #78 's Cyclobenzapril 5 mg card indicated a use by date of 08/23/2025. During an interview on 08/27/2026 at 11:53 AM, LPN #13 stated she was an agency nurse, and this was her first time to have worked in the facility. She stated she did not know how the facility disposed of expired medications because she had not received any education by the facility. She stated she did not know who was responsible for checking the medication cart for expired medications. She was asked to review Resident #97's electronic medication administration record (eMAR) and stated there was an active order for Torsemide but she did not see an active order for Cyclobenzapril. She checked Resident 78's eMAR and stated there was no active order for Cyclobenzapril. D-Front Hall Medication Cart: During an observation on 08/27/2026 at 12:13 PM, Unit Manager (UM) #14 unlocked the medication cart for D-Front Hall. The following were observed: -Resident #7's Hydroxyzine 25 mg medication card indicated a use by date of 07/08/2026.-Resident #3's Ondansetron 4 mg medication card indicated a use by date of 07/10/2026.-Resident #10's Hydroxyzine 25 mg medication card indicated a use by date of 07/09/2026.-Resident #25's Donepezil 10 mg medication card indicated a use by date of 02/27/2026. During an interview on 08/27/2026 at 12:25 PM, UM #14 stated she matched the medication to the MAR (Medication Administration Record) before starting her medication rounds. She stated she checked for expiration dates on the medication card when she checked the medication. She stated the Pharmacist was responsible for checking the medication cart for expired medications and came to the facility once a month, usually on the third Thursday. She stated as the nurse, she checked the medication cart for expired medications when I get free time. She stated several things could happen if a resident received a dose of an expired medication, with one example given that the medication may not work and whatever the medication is supposed to do, it is not doing. This surveyor did not speak with the Pharmacist during this survey. During an interview on 08/27/2026 at 3:15 PM, the Medical Director stated an expired medication slowed the efficiency of the medication, and the medication could gradually lose effectiveness. During an interview on 08/27/2026 at 5:15 PM, the Director of Nursing (DON) stated the nurses were responsible for checking the medication carts for expired medications and the medication carts should be checked every day. She stated when a medication had expired, ideally it should be removed from the medication cart. She stated if a resident received a dose of an expired medication, the efficiency of the medication might not be appropriate. She stated she expected the nurses on the floor to check the medication cards for expired dates. A review of an undated facility policy titled Expired Medications and Medications with Shortened Expiration Dates revealed that the DON or other authorized personnel will delegate to appropriate personnel the task of ensuring all outdated or expired medications (with the exception of controlled substances, refer to controlled substances policy) are removed from medication cart or other area that medication may be stored in. This policy also revealed that in the event that a medication has a shortened expiration date once opened the medication (open-date) will be labeled with the date opened and the initials of the nurse.

Number of residents sampled: Number of residents cited: Based on observations, interviews and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed. The findings include: During an observation and concurrent interview on 08/24/2026 at 10:25 AM, this surveyor observed Dietary Aide (DA) #7 with a gloved right hand, turn over raw chicken breast, contaminating the hand. With a gloved left hand, DA #7 picked up the salt container and poured salt into their right gloved hand that was previously contaminated by the raw chicken breast. DA #7 sprinkled the salt from the right gloved hand onto the chicken breast and then put the salt back in the salt container. DA #7 stated he should not have poured the salt back into the salt container after contaminating the glove by touching the raw chicken breast. DA #7 stated, this can cause sickness and is not sanitary. During an observation and concurrent interview on 08/24/2026 at 10:27 AM, this surveyor observed a container of mashed potatoes, a container of gravy and a container of ham, that were covered with aluminum foil and dated 08/24/2026, in the walk-in refrigerator. All three containers had holes in them, exposing the food inside to contamination. The Dietary Manager (DM) stated that all food stored in the walk-in refrigerator should be completely covered to prevent cross contamination. During an observation and concurrent interview on 08/24/2026 at 10:30 AM, the drip pan on the stove was covered with a grayish brown substance. The DM stated, that it is grease and filthy. The DM also stated the dirty drip pan could cause a fire or cause illness to the residents. During an observation and concurrent interview on 08/24/2026 at 12:31 PM, this surveyor observed CNA #11 hold a plate of food with their thumb on the top surface of the plate two times. During this time, they did not sanitize between two trays. CNA #11 stated that putting fingers on a plate and not sanitizing hands between trays could cause an infection. During an observation and concurrent interview on 08/26/2026 at 11:48 PM, the DM washed their hands with soap and water, then picked up the paper towels by putting their fingers in the middle of the un-sanitized spindle, re-contaminating their hands. The DM stated that putting their fingers in the paper towel holder could cause contamination. The DM stated, the paper towel holder is not pulling the paper out properly, so we have not been using it. During an observation and concurrent interview on 08/26/2026 at 11:51 AM, the Dietary Consultant washed her hands with soap and water, then picked up the paper towels by putting her fingers in the middle of the un-sanitized spindle, re-contaminating their hands. The Dietary Consultant stated, my hands were clean when I picked up the paper towels. During an observation and concurrent interview on 08/26/2026 at 12:16 PM, [NAME] #8 checked the broccoli temperature, and started to clean the thermometer with an alcohol pad, [NAME] #8 dropped the alcohol pad into the pan of broccoli, contaminating it. [NAME] #8 used a bare hand to retrieve the alcohol pad out of the broccoli further contaminating it. DA # 7 then stirred the contaminated broccoli and [NAME] #8 plated three residents' plates and placed them on the tray for service. When asked if it was safe to serve the plates to the residents, [NAME] #8 stated no, it was contaminated. The broccoli was pulled from the serving line, and the three plates were discarded. During an interview on 08/27/2026 at 9:21 AM, the DM stated that serving food that had an alcohol pad in it and was touched with bare hands could cause sickness to residents from contaminated foods. During an observation and concurrent interview on 08/24/2026 at 11:10 AM, CNA #9 inserted a paper towel into the ice chute from which ice was dispensed on B Hall, wiped, and revealed a black residue that had transferred to the paper towel. CNA #9 stated it looks like dirt and can cause illness. During an interview on 08/27/2026 at 8:30 AM, Maintenance # 10 stated the ice chute was cleaned weekly to prevent mold and mildew and the facility did not keep a log of the cleanings. During an interview on 08/27/2026 10:20 AM, the Director of Nursing (DON) stated she expected the kitchen staff to follow all hygiene guidelines to prevent food borne illness. During an interview on 08/27/2026 10:00 AM, the Administrator stated I expect the kitchen staff to follow the policy and procedures. Review of a signed statement dated 08/27/2026, revealed the alcohol pad did fall in the pan of broccoli and that the three plates of food were not served to the residents, and the remaining pan of food was thrown away. Review of a signed ice machine cleaning statement dated 08/25/2026, revealed the general cleaning of the spout, trays and drains are completed monthly for A hall, B Hall and D Hall. Review of a facility in-service titled Grease Fire Procedures dated 06/10/2026, revealed to prevent grease fires, empty grease traps/stove top drip trays frequently and do not allow them to overflow- must be checked daily. Review of an undated facility policy titled Food Storage, revealed that food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Refrigerated food storage: All foods should be covered, labeled and dated. All foods will be checked to ensure that foods (including leftover) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Frozen Foods: All foods should be covered, labeled and dated. All foods will be checked to ensure that foods will be consumed by their safe use by dates or discarded.

Based on observations, interviews, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were completed for one resident (Resident #27) out of 4 residents reviewed for ADL care (Resident #6, #7, and #115). Specifically, incomplete documentation was noted in Resident #27's electronic health record (EHR) regarding Resident #27 received bath/showers, as appropriate. Based on observations, interviews, record review and facility policy review, the facility failed to ensure Activities of Daily Living (ADLs) related to hygiene/bathing were completed for one resident (Resident #27) out of four residents reviewed. The findings include: Review of Resident #27's admission Record revealed the facility admitted Resident #27 on 05/30/2023 with diagnoses that included quadriplegia, hemiplegia and hemiparesis affecting Resident #27's right dominant side and an expressive language disorder. Review of Resident #27's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/2026, revealed Resident #27 had a Brief Interview of Mental Status (BIMS) score of 9 which indicated Resident #27 had moderate cognitive impairment. The MDS also revealed Resident #27 required substantial/maximal assistance with self-care including personal hygiene, and the ability to shower/bathe self and was dependent with tub/shower transfer. Review of Resident #27's Care Plan initiated 06/13/2026 revealed Resident #27 required substantial assist of 1-2 staff members with bed mobility, dressing, toileting, transfers, personal hygiene, bathing and locomotion. The care plan also indicated that Resident #27 chose to be bedfast most of the time. Interventions included to give shower/bath as per by bath schedule and if needed give a sponge bath on non-shower days. During an interview on 08/26/2026 at 1:31 PM, Certified Nursing Assistant (CNA) #4 stated that Resident #27 frequently spilled food and drink while in bed. CNA #4 also stated Resident #27 was expected to get a bath per Resident #27's shower schedule every Monday, Wednesday, and Friday and as needed. During an interview on 08/27/2026 at 2:53 PM, CNA #3 stated that Resident #27 got a bath every Monday, Wednesday, and Friday, and as needed. Review of Resident #27's ADL log from April, May and June 2026 revealed no documentation that the resident received a bath/shower on the following dates: -04/03/2026 (Friday)-04/08/2026 (Wednesday)-04/10/2026 (Friday)-04/15/2026 (Wednesday)-04/17/2026 (Friday)-04/29/2026 (Wednesday)-05/01/2026 (Friday)-05/08/2026 (Friday) -06/17/2026 (Wednesday)-06/19/2026 (Monday)-06/26/2026 (Friday) During an interview on 08/27/2026 at 4:52 PM, the Director of Nursing (DON) stated that Resident #27 liked to eat with Resident #27's hands, so keeping Resident #27's gown and linen clean was a challenge. The DON also stated that CNAs were expected to document if a resident received a bath/shower by the end of their shift but could document up to 24 hours later. The DON also stated that she had no way to determine if the missing documentation was because Resident #27 refused, or if a bath/shower was not completed. During an interview on 08/27/2026 at 5:25 PM, the Administrator stated that she could not determine if Resident #27 did not receive a bath/shower, or if the bath/shower was refused. The Administrator also stated that Resident #27 was known to refuse a lot of treatments and had Care Plan interventions for that. A review of Resident #27's Care Plan did not reveal interventions related to Resident #27 having behaviors related to refusal of care. During a follow-up interview on 08/27/2026 at 6:00 PM, the Administrator stated the facility did not have an ADL or bath/shower policy.

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure respiratory care for one (Resident #73) of one resident reviewed was provided according to the resident's care plan, and professional standards of practice.The findings include:Review of Resident #73's admission Record revealed the facility admitted Resident #73 on 09/25/2025 with diagnoses that included cerebral palsy, traumatic brain injury, epilepsy, and tracheostomy status.Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/2026, revealed Resident #73 had a Staff Assessment for Mental Status (SAMS) score of 3 which indicated Resident #73 was severely impaired for daily decision making. The MDS also revealed Resident #73 was dependent on functional abilities and had respiratory failure.Review of Resident #73's Order Summary dated 04/22/2025 revealed an order for Change oxygen tubing and humidifier bottle once weekly on Thursday during the 11-7 shift and as needed.Review of Resident #73's Care Plan initiated 09/26/2025, revealed interventions for trach care per Medical Doctor (MD) order and facility protocol.During an observation on 08/24/2026 at 11:43 AM, this surveyor observed that Resident #73 had an oxygen concentrator and a humidifier. The humidifier bottle had a handwritten date of 08/14/2026 on the bottle.During an observation on 08/25/2026 at 11:23 AM, this surveyor observed that Resident #73's humidifier bottle still had the same date as 08/14/2026 on the bottle.During an observation and concurrent interview on 08/26/2026 at 1:43 PM, Licensed Practical Nurse (LPN) #1 confirmed the date on the humidifier bottle to be 08/14/2026, which indicated when it was last changed. LPN #1 also indicated that the humidifier bottles should be changed every week, on Thursdays, on the night shift, and that it should have been changed, to reflect a date of 08/21/2026 if it had been changed then. LPN #1 also stated that a result of humidifier bottles not being changed timely could be a risk of infection to the resident.During an observation and concurrent interview on 08/26/2026 at 3:38 PM, this surveyor observed LPN #2 complete tracheostomy care for Resident #73. After LPN #2 removed the old dressing, trach collar, and disposable inner cannula, LPN #2 removed dirty gloves and immediately put on sterile gloves, without performing hand hygiene, to suction the trachea and complete the trach care. For Resident #73, LPN #2 observed that the humidity bottle was dated 08/14/2026 which indicated the last time it was changed and stated that it should have been changed last Thursday on the night shift (08/21/2026), but apparently it had not been changed. LPN #2 stated she had been educated on tracheostomy care sometime last year by a vendor that came to the facility. LPN #2 also stated that hand hygiene should be performed prior to putting on clean gloves, and the risk of not performing hand hygiene and changing gloves when appropriate, during trach care, could result in cross-contamination.During an interview on 08/27/2026 at 9:39 AM, the Infection Preventionist (IP) stated that a nurse should perform hand hygiene when changing gloves, especially going from dirty to clean [tasks]. The IP also stated that a result of a nurse not performing hand hygiene and changing gloves when appropriate, during trach care, could result in cross-contamination. In addition, the IP stated that the risk of Resident #73's humidifier bottles not being changed timely could result in bacterial growth.During an interview on 08/27/2026 at 11:35 AM, the Director of Nursing (DON) stated that hand hygiene should be performed prior to applying gloves to perform tracheostomy care, and the risk of hand hygiene not being performed prior to putting on gloves appropriately was cross-contamination. The DON also stated that humidifier bottles should be changed every seven days and dated with the date changed. The DON indicated that there was an infection risk if humidifier bottles were not changed timely.Review of the facility policy titled Tracheostomy Care last reviewed 01/2024, revealed the following:After old dressings are removed, soiled gloves are to be discarded and hand hygiene performed.After suctioning a trach, soiled gloves are to be discarded, hand hygiene is to be performed and fresh gloves donned before replacing the inner cannula.Prior to performing site and stoma care, clean gloves are to be applied.Review of a facility in-service regarding trach care dated 03/19/2026, revealed that high output compressor bottle[s] were to be changed weekly.A review of a professional standards article titled Tracheostomy: A Guide to Nursing Care, indicated tracheostomy dressing and tie changes should be performed aseptically. The article also indicated that humidification is necessary to replace the function of the nose to warm and moisten the inhaled air via tracheostomy.

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors related to omitted antiseizure medication administration for one (Resident #2) of three residents reviewed for medication administration. The findings include: Review of Resident #2's admission Record revealed the facility admitted Resident #2 on 10/05/2025 with diagnoses that included epilepsy intractable with status epilepticus, acute respiratory failure with hypoxia, cognitive communication deficit, cerebral aneurysm, dementia, Alzheimer's disease, dysphagia, depression and anxiety. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date of 10/10/2025, revealed Resident #2 had a Brief Interview for Mental Status score of 7, which indicated the resident had severe cognitive impairment. The MDS also revealed the resident was being administered anti-seizure medications. Review of Resident #2's Care Plan, initiated on 10/08/2025, revealed the resident had a seizure disorder. Interventions included administering seizure medications as ordered by doctor. Review of an After Visit Summary revealed Resident #2 was to be discharged from the hospital to the facility on [DATE]. Resident #2's medication list in the After Visit Summary indicated the resident needed to take antiseizure medication, 25mg (milligrams), once daily for 180 days. Review of the Medical Director's History and Physical (H&P) visit note dated 10/08/2025, revealed Resident #2 had an active medical problem of status epilepticus. The assessment and plan of the H&P revealed Resident #2 would continue antiseizure medication for epilepsy. Review of Resident #2's Order Summary Report revealed an active order with a start date of 10/07/2025 for an antiseizure medication to be administered one tablet by mouth one time a day related to epilepsy, intractable with status epilepticus for 180 days. Review of Resident #2's Medication Administration Record (MAR) for October 2025 revealed the antiseizure medication was coded as the following per the chart codes list: -10/15/2025 coded 5 (Hold/See Nurse Notes) by Registered Nurse (RN) #6. -10/16/2025, 10/17/2025 and 10/18/2025 coded 9 (other/see nurse notes) by Licensed Practical Nurse (LPN) #3.-10/19/2025 coded 5 by the Assistant Director of Nursing (ADON). -10/20/205,10/21/2025, and 10/22/2025 coded 5 by RN #6. -10/23/2025 and 10/24/2025 coded 9 by LPN #3. -10/25/2025 coded as administered by LPN #3. -10/26/2025 coded 9 by LPN #7.-10/27/2025 coded 5 by RN #6. -The resident was discharged from the facility on 10/27/2025. Review of Resident #2's Progress Notes revealed that on 10/15/2025 there was no note that indicated the antiseizure medication was on hold. On 10/16/2025, 10/17/2025, and 10/18/2025 LPN #3 noted the antiseizure medication order and included that the medication was on order. On 10/19/2025, 10/20/2025, 10/21/2025, and 10/22/2025 there were no notes regarding the antiseizure medication. On 10/23/2025 and 10/24/2025 LPN #3 noted the antiseizure medication order with no further details. On 10/26/2025 LPN #7 indicated medication not available regarding the antiseizure medication. On 10/27/2025, RN #6 noted the antiseizure medication order with no further details. During a telephone interview on 05/14/2026 at 9:40 AM, the Pharmacist indicated seven tablets of the antiseizure medication were sent to the facility on [DATE] for Resident #2 with permission from the Director of Nursing (DON) to bill the facility for the medication. On 10/13/2025 the Pharmacist reported the pharmacy had a memo from the DON not to bill the facility. The Pharmacist reported she did not have any more processing request for the antiseizure medication and no additional doses of Resident #2's antiseizure medication had been provided to the facility following the initial seven doses. She reported the prescription for the antiseizure medication was not exhausted, and additional doses were available for the facility to request. The Pharmacist indicated if a resident suddenly stopped taking antiseizure medication the resident would be at an increased risk of seizures. She explained that a resident may take more than one antiseizure medication as different medications work in different ways. She reported it was not unusual for a resident to be prescribed more than one antiseizure medication because the medication's mechanism of action was usually different. During an interview on 05/12/2026 at 2:04 PM, LPN #4 indicated if a medication was not available for administration to the resident, the nurse should inform the provider that the medication was not available and an order to hold the medication should be obtained. She reported that the nurse should contact the pharmacy to inquire of the reason the medication was not available in the facility. During an interview on 05/13/2026 at 1:40 PM, LPN #5 indicated if a medication was not available for administration to the resident, the nurse should inform the pharmacy, the provider and the resident's family that the medication was not available to be administered. She reported that once a medication was ordered from the pharmacy, the pharmacy would have the medication delivered to the facility within two hours if it was ordered stat. She reported it was important for a resident to receive their medication because it was ordered for a reason, they need their medication and it could have a bad effect on the resident if medications were missed. During an interview on 05/13/2026 at 2:17 PM, the ADON indicated if a 5 or a 9 was in the date box of the MAR, a progress note should be present to explain the reason the medication was not administered. He reported that if a medication was not available for a resident, the nurse should call the pharmacy and inquire about the missing medication and make sure the medication had been ordered and that the pharmacy did have the order. He indicated that it was important that a resident received their prescribed medications because they have been diagnosed by a provider, so they need to take the medications. During an interview on 05/13/2026 at 3:02 PM, LPN #4 indicated if a medication was not available to administer to the resident, the nurse should call the provider to hold the medication, notify the pharmacy so we can get the medication and notify the family of the resident. She stated, we must have an order to hold the medication. During an interview on 05/13/2026 at 3:59 PM, the Director of Nursing (DON) reported the floor nurses were responsible for administering medications. She reported a provider order was required for a medication to be held. She indicated if a medication was not available for administration the doctor should be notified and the pharmacy needed to be contacted. She stated, the floor nurse that cannot find the medication, should be trying to find out where it [the medication] is. She indicated it was important for a resident to receive their prescribed medication because that was the plan of care the provider made for them. During an interview on 05/13/2026 at 5:12 PM, LPN #3 indicated if a medication was not available for administration, she will usually find out if the pharmacy had received the order. She reported that when a medication was not available, the nurse should contact the provider and the family. She indicated she did not recall if she notified the provider or family. She reported that she went to the DON about the medication not being available. She verified in a Progress Note dated 10/16/2025 she indicated the medication was on order. She indicated it was important for a resident to receive prescribed medication to keep the resident from having problems that the medication was treating. When asked about the 10/25/2025 entry in Resident #2's MAR, LPN #3 stated the medication was not available on that date, but verified she had indicated the medication was administered. During an interview on 05/14/2026 at 9:00 AM, Medication Assistant Certified (MAC) #2 reported if a medication was not available for administration, she would tell the charge nurse and place a stat order on the pharmacy website. She indicated that if she noticed a medication was not being administered to a resident, she would notify the charge nurse. During an interview on 05/14/2026 at 9:10 AM, LPN #1 reported if a medication was not available for administration, she would contact the pharmacy to ensure the medication had been ordered. She indicated she would also notify the resident or the resident's representative and let the provider know about it. During a telephone interview on 05/14/2026 at 10:09 AM, Advanced Practice Registered Nurse (APRN) reported she expected if a medication was not available the nurse would let her know and the nurse would reach out to the pharmacy. She reported it was important that a resident's prescribed medication was administered as ordered because they needed the medication. She indicated she could not recall being notified of Resident #2 not receiving the antiseizure medication. During a telephone interview on 05/14/2026 at 10:24 AM, Medical Director reported that if medication was not available, he would expect the nurse to contact him and the pharmacy. He reported he could not recall if he was notified of Resident #2 not receiving medication. During an interview on 05/14/2026 at 11:45 AM, Administrator reported she was told by the DON on 10/28/2025 that the family had made an allegation of the resident not receiving one dose of seizure medication. She reported that the pharmacy had not notified the facility that they had not sent the medication yet. She indicated cost was not an issue with the medication being filled, not on the facility side. She reported it was important that a resident received prescribed medication as ordered for their health and safety.

Based on observation, interview and facility policy review, the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items and clean equipment; the ice machine was maintained in clean and sanitary conditions; walls were free of accumulations of dust to ensure meals were prepared in clean, sanitary conditions for two of two meals observed. The findings are: 1. On 04/21/25 at 11:10 AM, during the initial kitchen tour with Dietary [NAME] (DC) #1, the ice machine, in a room on the hallway leading to the kitchen, had a pink discoloration/substance to the inside of the plastic panel dispenser. 2. On 04/22/25 at 02:57 PM, the following observations were made in the kitchen: a. There was a puddle of grayish water over the concrete. During an interview with the Dietary Manager (DM), she stated that the water may have been coming from the concrete and was gray in color. a. The wall behind the oven had an accumulation of dust on it, near food being prepared for the residents. b. The floor tile on the right side of the juice machine, in the food preparation room, was missing. The area where the tile was missing had puddles of discolored liquid settled on it. The DM stated the area needed to be fixed and cleaned. 3. On 04/22/25 at 3:30 PM, the inside right corner of the ice machine, close to the area where ice forms before dropping down into the collector, had wet black residue on it. This surveyor asked the Dietary Manager to wipe the wet black residue. She did so, and the wet black residue easily transferred to the tissue. The DM was asked to describe what was observed around the right corner of the ice machine, how often they cleaned the ice machine, and who used the ice from the ice machine. The Dietary Manager stated it was black residue. The staff cleaned it once a week, and the Maintenance Supervisor cleaned the upper part where the ice forms. The Certified Nursing Assistants (CNAs) use it for the water pitchers in the residents' rooms, for beverages served to the residents, and the kitchen staff use it to fill beverages served to the residents at mealtimes. The DM was asked what the concerns about the ice machine not been cleaned were, and she stated cross contamination. 4. On 4/22/25 at 3:39 PM, during an interview with the Maintenance Supervisor, he was asked how often he cleaned the area in the ice machine where ice formed. He stated he cleaned it once a month. 5. On 04/22/25 at 3:53 PM, this surveyor observed Dietary [NAME] (DC) #1 push the blender motor towards the edge of the counter. Without washing his hands, he picked up a clean blade with his contaminated bare hand and attached it to the base of the blender to be used in pureeing foods to be served to the residents who required pureed diets. DC #1 was asked what he should have done after touching dirty objects and before handling clean equipment. He stated he should have washed his hands. 6. On 04/22/25 at 4:25 PM, this surveyor observed Dietary Aide (DA) #2 wearing gloves on her hands, when she picked up a box of plastic food wrap from the counter and placed it in another location. Without changing gloves and washing her hands, she picked up cornbread with her contaminated gloved hand and placed the cornbread in an individual bag to be served to the residents for supper. 7. On 04/22/25 at 5:18 PM, during an interview with DA #2, she was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have removed her gloves, washed her hands, and then put new gloves on. 8. On 04/22/25 at 4:32 PM, this surveyor observed DA #3 wearing gloves when he picked up a pan of cornbread located on top of the oven and sat it on the counter. He then picked up a box of plastic food wrap and placed it on the counter, contaminating his gloved hands. He then picked up cornbread with his contaminated gloved hands and placed it individually in a bag to be served to the residents for supper meal. DA #3 was asked what he should have done after touching dirty objects and before handling clean equipment. He stated he should have washed his hands and changed his gloves. 9. On 04/23/25 at 10:40 AM, DC #4, removed cartons of whole milk and placed them on the counter. Without washing her hands, she picked up the blender blade and attached it to the base of the blender, to be used in pureeing food items to be served to the residents who received pureed diets for the lunch meal. 10. On 04/23/25 at 11:05 AM, this surveyor observed DC #4 turn on the three (3)-compartment sink faucet with her bare hand as she obtained water in a pitcher. After obtaining water, she used her bare hand to turn off the faucet. Without washing her hands, she picked up the blender blade and attached it to the base of the blender to be used in grounding food items to be served to the residents who received mechanically soft diets for the lunch meal. DC #4 was asked what she should have done after touching dirty objects and before handling clean equipment. She stated she should have washed her hands. 11. A review of a facility policy titled, Handwashing indicated hands should be washed before entering the kitchen at the start of a shift, during food preparation, as often as possible to prevent cross contamination when changing tasks, and after engaging in other activities that contaminate the hands. 12. A review of a facility policy titled, Food Storage indicated food should be stored by methods prepared, to prevent contamination or cross contamination.

Based on observation, interview, facility document review, and policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were utilized for two (Resident #1 and Resident #202) of two residents reviewed for Enhanced Barrier Precautions. The findings include: 1. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2025 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #1 had diagnoses which included: spina bifida, quadriplegia, neurogenic bladder, and a colostomy. a. Provider notes, dated 04/21/2025, and the Weekly Wound Evaluation, dated 04/21/2025, indicated the resident had a stage 4 ulcer to the right buttock area. b. On 04/21/25 at 2:25 PM, the Treatment Nurse (TN) was observed performing a dressing change to the right buttock for Resident #1. EBP signage was on the door of Resident #1's room, indicating the need for staff to wear both a gown and gloves when care was provided for Resident #1. The TN performed hand hygiene, put on gloves but no gown, and positioned the resident. The TN took off the old dressing with visible drainage, cleaned the wound, and completed the dressing change. During the procedure, the TN's clothing touched the bed linens and mattress, while the TN's bare forearm propped Resident #1's right hip, making skin-on-skin contact with the resident, in close proximity of the wound. c. Resident #1's Care Plan , revised 04/21/2025, had EBP listed as an intervention with wounds, with an initiation date of 04/04/2024. The Care Plan stated, gloves and gown required prior to the high-contact care. High-contact care activities listed included, but not limited to, wound care: any skin opening requiring a dressing. d. During an interview with the TN on 04/24/25 at 10:43 AM, the TN indicated that a gown should have been put on for the dressing change to prevent cross-contamination. e. During an interview 04/24/25 at 12:25 PM, the Medical Director (MD) indicated wearing a gown would be appropriate during wound care. 2. The MDS with an ARD of 04/11/2025 indicated Resident #202 had a BIMS score of 4 (which indicated the resident was severely cognitively impaired). The MDS also indicated Resident #202 had diagnoses, which included: a urinary tract infection (last 30 days), dementia, sepsis, and osteomyelitis of the vertebra, sacral and sacrococcygeal region. a. On 04/23/25 at 7:25 AM, Licensed Practical Nurse (LPN) #5 was observed administering an intravenous (IV) antibiotic medication, to Resident #202. EBP signage was on the door of Resident #202's room, which indicated the need for staff to wear both a gown and gloves when care was provided for the resident. The nurse donned gloves, dated and timed the IV tubing, primed the line, entered the room, and began to manipulate the resident's arm, gown, and Peripherally Inserted Central Catheter (PICC), without putting on a gown. b. On 04/23/2025, immediately following the antibiotic administration observation described above, LPN #5 was interviewed and indicated a gown should have been put on for the encounter. LPN #5 indicated EBP should be followed anytime staff does personal care for the resident, because a PICC line goes straight into the bloodstream and to the heart, and a gown would help protect the resident. c. Resident #202's Care Plan , revised on 04/16/2025, indicated that EBP was required for high-contact care. The list of high-contact care included: the use of a central line. 3. During an interview with the Director of Nursing (DON) on 04/24/2025 at 10:30 AM, the DON indicated a gown should have been put on during the dressing change for Resident #1. 4. During an interview with the Administrator on 04/25/2025 at 3:03 PM, the Administrator indicated a gown should have been worn during the dressing change for Resident #1. 5. A review of the policy titled Medication Administration, revised 11/25/2022, stated Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of the medications, as applicable. 6. A review of the posted EBP signage on both the doors of Resident #1 and Resident #202 revealed that providers and staff must wear gloves and gown for central line and wound care dressings.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator was covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods were dated the day received or opened to assure first in, first out usage to prevent potential for food bone illness, and dietary staff washed their hands before handling clean. equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 96 residents who received. meals from the kitchen. The findings are: 1. On [DATE] at 08:19 AM, two opened plastic lock bags that contained cheese slices were on a shelf in the walk-in refrigerator. The bags were not sealed. 2. On [DATE] at 08:33 AM, an opened bag of coffee was on the counter. The bag was not sealed, exposing it to cross contamination. 3. On [DATE] at 08:39 AM, the following observations were made on a shelf in the refrigerator at the nurse's station on the D-hall. a. Two cartons of 2% milk with expiration date of [DATE]. b. Three unopened cups of nectar thickener water with an expiration date of [DATE]. c. An opened bag of Mexican style cheese with no received or opened date. d. A bowl of chocolate and a bowl of apple sauce covered with saran wrap. There was no date as of when they were stored. 4. On [DATE] at 11:05 AM, Dietary Employee (DE) #1 peeled cooked sweet potatoes skins off. She pushed the food cart towards the counter. Without washing her hands, she attached a clean blade at the base of the blender to be used in pureeing food items to be served to the residents for lunch meal. 5. On [DATE] at 11:13 AM, DE #1 pushed a cart that contained baked chicken towards the food preparation counter and without washing her hands, she attached a clean blade to the base of the blender, placed 10 servings of baked chicken breast into a blender, ground and poured into a pan. 6. On [DATE] at 11:18 AM, DE #1 picked up a pan of baked chicken from the stove and placed it on the counter. Without washing her hands, she attached a clean blade at the base of the blender with her bare hand to be used in pureeing food items to be served to the residents who required pureed diets. At 01:10 PM, the Surveyor asked the DE #1 what should have been done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 7. A Facility policy titled, hand washing/When to wash hand, provided by the Dietary Supervisor on [DATE] at 09:33 AM documented, .When entering the kitchen at the start of a shift and after engaging in other activities that contaminate the hands .

Based on observation and interview, the facility failed to ensure residents had a clean and homelike environment. The findings are: 1. On 03/28/2024 at 09:44 AM, the Surveyor observed a wall on D-Hall with large sections of chipped and missing paint with black rub marks along the wall. The bathroom on D-Hall had missing floor tiles and thick, black matter under the shower seat on the floor, along the baseboards, in the corners, and around the commode. The Secure Unit on D-Hall had a cobweb in the corner behind the entrance door. The wall above the rail behind the entrance door had brown matter. A bag with dry, pink matter and an empty medicine cup was tucked behind the handrail. The fire extinguisher cover had small rust spots along the bottom of the door. In room D29 the heating and air conditioning wall unit had dark matter with loose particles inside the vent and one of the vent's slats was broken. The horizontal blinds covering the window had a broken string, would not go up and down, or close. The bathroom between rooms D27 and D29 had black, crusty matter around the commode and in the corners. The commode was twisted 5-6 inches to the right. 1a. On 03/28/2024 at 09:57 AM, the Surveyor asked the Housekeeper (HSKP), Can you describe the walls behind the entrance doors? The HSKP said there is a cobweb in the corner and that could be coffee or spit on the wall. The Surveyor asked, Can you describe what is behind the handrail? The HSKP said trash. The Surveyor asked, Can you describe the bathroom between Rooms D27 and D29? The HSKP said it looked like it could be feces or rust around the toilet and in the corner. The Surveyor asked, How often do you clean the handrails, rooms, and bathrooms? The HSKP said I clean the handrails, rooms, and bathrooms once a day and whenever it is needed. 1b. On 03/28/2024 at 10:09 AM, the Administrator confirmed the following on D-Hall; chipped paint on the wall of the hallway, trash behind the handrail, rust spots on the fire extinguisher door, a cobweb in the corner behind the door, and the dirty wall above the handrail; the shower room with missing tiles, and the dirt under the shower seat, and the corners. The broken blinds in Room D29 the dirty air conditioning unit, the bathrooms between Rooms D27 and D29 and the loose commode. 1c. On 03/28/2024 at 10:27 PM, the Surveyor asked the Director of Nursing (DON) who was responsible for reporting maintenance concerns. The DON said everyone is. If housekeeping, nursing, or dietary notices anything that needs to be fixed they should report it immediately. 1d. On 03/28/2024 at 11:05 AM, the Surveyor asked Maintenance, How are you made aware of problems in the facility that need to be fixed? Maintenance said we have a text system and a maintenance request book at the front desk. I wasn't made aware of the toilet on D-Hall until this morning. The Surveyor asked, Can you describe what is wrong with the commode? Maintenance said it look like loose bolts. 1e. Review of the Maintenance Request Book showed no requests related to the above issues. 2.On 03/25/2024 at 10:57 AM, in room B8 scrapped paint was observed on the walls. a. On 03/25/2024 at 10:58 AM, in room B10 scrapped paint was observed on the walls. b. On 03/25/2024 at 11:16 AM, in room B12 scrapped paint was observed on the walls. c. On 03/25/2024 at 11:39 AM, in room B1 scrapped paint was observed on the walls. d. On 03/28/2024 at 09:15 AM, the Maintenance Supervisor was asked, Can you tell me why the walls are scrapped in rooms B8, B10, B12, and B1? He stated, We're working on them. 3. On 03/26/2024 at 07:45 AM a form titled Policies and Procedures: Resident Rights Effective Date 4/2021 Review Date 1/2024 was received from the administrator. It documented, .federal and state laws guarantee certain basic rights to all residents of this facility . include the right to . a safe, clean, homelike environment . 4. On 03/25/2024 at 10:57 AM, in room B8 scrapped paint was observed on the walls. a. On 03/25/2024 at 10:58 AM, in room B10 scrapped paint was observed on the walls. b. On 03/25/2024 at 11:16 AM, in room B12 scrapped paint was observed on the walls. c. On 03/25/2024 at 11:39 AM, in room B1 scrapped paint was observed on the walls. d. On 03/28/2024 at 09:15 AM, the Maintenance Supervisor was asked, Can you tell me why the walls are scrapped in rooms B8, B10, B12, and B1? He stated, We're working on them. 3. On 03/26/2024 at 07:45 AM, a form titled Policies and Procedures: Resident Rights Effective Date 04/2021 Review Date 01/2024 was received from the administrator. It documented, .federal and state laws guarantee certain basic rights to all residents of this facility .include the right to .a safe, clean, homelike environment . 48483

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 03/27/2024 at 12:09 PM, Dietary Employee (DE) #1 poured the pureed cauliflower into a pan and placed it in a pan of hot water on the stove. The consistency of the pureed cauliflower was not formed, water was separated from the vegetable. At 01:16 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed cauliflower served to the residents on pureed diets. She stated, They should have added a little thickener. 2. On 03/28/2024 at 08:14 AM, the residents on pureed diets were served the following food items. a. Pureed sausage served to the residents on pureed diets was gritty with sausage skin in it and not smooth. b. The pureed bread served to the residents on pureed diets was thick, had lumps in it and was not smooth. 3. On 03/28/2024 at 10:40 AM, the surveyor asked Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets, she stated, Pureed sausage had sausage skin still in it. We will remove the skin next time we use it. Pureed bread had little lumps in it.

Based on observations, interviews and policy review, the facility failed to ensure Resident or Resident representative was invited to a comprehensive care plan meeting for 1 (Resident #45) of 98 residents who receive a care plan. The findings are: 1. On 03/26/2024 at 07:45 AM, the Administrator provided Resident Rights which indicate a Resident, Be informed of, and participate in his or her care planning and treatment. 2. On 03/26/2024 at 09:37 AM, by phone Surveyor spoke with Resident #45's Representative [RR]. RR #45 indicated that it had been two years since she had received notification or a call regarding a care plan meeting. 3. On 03/27/2024 at 10:10 AM, interviewed Social Services Director [SSD] regarding when the last time Resident #45's family was invited to a care plan meeting. SSD indicated it was about two years ago. SSD was specifically asked what was the last date Resident #45's family was invited to a care plan meeting? SSD stated, It had been about two years ago. 4. On 03/28/2024 at 11:50 AM, the Administrator reported that the facility does not have a policy for care plans.

Based on observation, record review and interview, the facility failed to ensure kitchen equipment was clean and in good condition, dietary staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and opened containers of food were refrigerated after opening when required. The failed practices had the ability to effect 96 residents who received their meals from 1 of 1 kitchen as documented on a list provided by the Dietary Consultant on 02/23/23 at 3:02 PM. The findings are: 1. On 02/21/23 at 10:55 AM, the Dry Storage Room had paper and other debris on the floor, under the storage racks. Rusted areas were noted on multiple shelves on each rack. 2. On 02/21/23 at 10:58 AM, on the top shelf of a rack in the Dry Storage Room was a gallon, plastic container of picante sauce. Approximately 1 cup of the picante Sauce had been removed from the container. The label on the container stated, Refrigerate after opening. 3. On 02/21/23 at 11:05 AM, in the walk-in refrigerator three quarters of the wire shelves were covered in rust. 4. On 02/21/23 at 11:20 AM, Dietary Aide (DA) #1 assembled the items necessary to puree the lunch meal. DA #1 placed a bowl on the Robo-coupe and attached the blade. DA #1 gathered a plastic pitcher of chicken broth. He applied a hot mitt to his hand, opened the steamer and obtained a steam table pan. DA #1 picked up a box of plastic wrap and placed it on the worktable. He picked up the steamtable pan and covered it with plastic wrap and placed it in the steamer. The bowl, blade, and lid were taken to the 3-compartment sink, rinsed, and returned to the work area. He placed his hand inside a hot mitt, opened the door to the steamer and brought out a steam table pan of Sausage and Chicken Jambalaya. Upon completion of the blending process, the food was returned to the steamtable pan and the pan was carried to the worktable which housed the plastic wrap. The pan was covered and returned to the steamer. The Robo-coup was returned to the 3-compartment sink for cleaning. Each time DA #1 moved from a clean task to a dirty task he did not wash his hands. 5. On 02/21/23 at 11:35 AM, DA #2 was rolling flatware in napkins for lunch. A resident knocked on the kitchen door and requested that someone prepare her (Brand) noodles. The resident presented with a red plastic bowl containing a packet of noodles. DA #2 took the bowl and placed it on the counter in front of the microwave oven. DA #2 obtained gloves and without washing her hands put the glove on. DA #2 emptied the noodles into the bowl, added water and placed them in the microwave. She them took off her gloves and washed her hands and returned to roll flatware. DA #2 left the station and rolled a 3-tiered cart to the preparation room. Without washing her hands, she returned to the microwave, removed the bowl, carried it to the sink, and poured the excess water into the sink. She returned the bowl to the microwave for additional time. Without washing her hands, DA #2 retrieved the bowl from the microwave a second time, poured off the excess water and placed the noodles into the red bowl. Without washing her hands, she applied gloves, obtained plastic wrap, covered the red bowl, placed it on a tray and delivered it to the resident. 6. On 2/22/23 at 11:55 AM, insulated carts were brought into the kitchen for lunch. Pieces of what appeared to be dried food was littering the bottom of two carts. The outside ledge of the carts just over the wheels were littered with debris of various colors, shapes, and sizes. 7. On 02/22/23 at 12:00 PM, DA #1 obtained the temperatures of the food items for lunch. Prior to completing his tasks DA #1 left the tray line, donned a heat mitt, opened the door to the steamer and removed a steamtable pan containing baked fish. Without washing his hands, he returned to assessing food temperatures. 8. On 02/22/23 at 8:45 AM, the shelving units in the walk-in refrigerator contained multiple areas of rust. The middle shelf was covered with a white powdery substance. The Surveyor asked the Dietary Consultant to identify the white substance. He stated, .It almost feels like powdered sugar . 9. On 02/22/23 at 8:48 AM, two racks designed to hold the insulated dome cover and/or base that surrounds the plates were standing in the kitchen. The inner portion of each tier on the rack was covered in a layer of brownish, black buildup in various depths. The substance had food particles of various shapes and sizes adhered to it and a French Fry of indeterminate age on the bottom tier. 10. On 02/23/23 at 10:15 AM, the Surveyor asked the Dietary Manager when hand should be washed when working in the kitchen. The Dietary Manager stated, .Whenever you have been outside. When you have gone to the restroom. When you have touched yourself or your clothes. When you have been working with something that isn't cooked . 11. On 02/24/23 at 8:40 AM, the Surveyor asked DA #1 when hands should be washed while working in the kitchen. DA #1 stated, .When I prepare a ready to eat food such as lettuce or tomato or right before I serve. I wash my hands a lot . 12. On 02/24/23 at 8:43 AM, , the Surveyor asked DA #3 when should hands be washed while working in the kitchen. DA #3 stated, .Any time you change stations or touch something dirty . 13. The facility policy and procedure titled, Hand Washing, provided by the Dietary Consultant on 02/23/23 at 3:02 PM documented, .Procedure: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands: .f. After handling soiled equipment or utensils. g. During food preparations, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks . i. Before donning disposable gloves for working with food and after gloves are removed. j. After engaging in other activities that contaminate the hands .

Based on observation, record review, and interview the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for 2 (Residents #16 and #23) of 17 [Residents #11, #13, #16, #21, #23, #29, #33, #34, #35, #38, #55, #56, #59, #62, #78, #82 and #142) sampled residents reviewed. The findings are: 1. Resident #16 had diagnoses of Depression, Cerebral Infarction, Hemiplegia and Hemiparesis - Right Side Effected, and Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. On 02/21/23 at 12:08 PM, Resident #16's bathroom had multiple brownish spots, and a half inch sized ball of hair on the floor. The metal trim around the inner bathroom door was rusted with jagged edges and parts were missing at the bottom where the frame meets the tile floor. Three wall tiles were missing on the wall directly above the floor trim with black and brown stains visible on the wall where the tile was missing. There were multiple tan and brown spots on the floor around the toilet. 2. On 02/23/23 at 2:00 PM, the Surveyor accompanied the Maintenance Director to Resident #16's bathroom. There continued be multiple brownish spots, a half inch sized ball of hair, and rusted, jagged edges of the metal door frame, multiple areas of brown and black discoloration with 3 missing tiles on the wall and multiple tan and brown areas around the toilet. The Surveyor asked the Maintenance Director if he knew how long the bathroom had been in this condition. The Maintenance Director answered, No, but it couldn't have been long since the tiles are stacked up here behind the toilet. The Surveyor asked if it had been reported to him. The Maintenance Director answered, No. The Surveyor and the Maintenance Director walked to two additional resident rooms that had discolored areas on multiple ceiling tiles. The Surveyor asked the Maintenance Director how long the ceiling tiles had been discolored. The Maintenance Director answered, I had someone repair the roof on one of the wings and replaced the roof on that wing within the last 3 to 4 years. The Surveyor asked the Maintenance Director if there was a record of repairs. The Maintenance Director answered, No, that would be something to talk to the Administrator about. a. On 02/23/23 at 2:27 PM, the Surveyor requested all roof/ceiling repair invoices from the Administrator. b. On 02/23/23 at 3:30 PM, the Nurse Consultant stated, There are no repair invoices . It's an old building and leaks are not uncommon in an old building. 3. Resident #23 had diagnoses of Paraplegia, and Pressure Ulcer of Sacral Region, Stage 4. The 5 Day Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) had one Stage 3 and one Stage 4 pressure ulcers present on admission and used a wheelchair. a. On 02/21/23 at 12:38 PM, Resident #23 was lying in bed, an electric power chair was across from the bed with a pressure relief cushion in the seat. There were multiple white colored dried spots on the cushion. The Surveyor asked Resident #23 how often the wheelchair and cushion were cleaned and if the spots bothered him. He stated, Yes, it bothers me. Can you take care of that for me? b. On 02/22/23 at 8:30 AM, LPN #1 performed wound care on Resident #23 in bed. There were white spill stains on the cushion in the seat of Resident #23's wheelchair. c. On 02/23/23 at 8:50 AM, the Surveyor asked the Director of Nursing (DON) for the policy and procedure and process for cleaning wheelchairs and wheelchair pressure relief cushions. The DON stated, They are cleaned on Monday and Thursday. If they are soiled or not cleanable, we replace them. We do not have a policy and procedure for cleaning the resident cushions and wheelchairs. d. On 02/23/22 at 3:15 PM, the Surveyor asked Licensed Practical Nurse (LPN) #4 how often the wheelchair and pressure relief cushions were cleaned, who was responsible, and what if there were spill spots and stains on them. LPN # 4 stated, The 11-7 [11:00 PM to 7:00 AM] shift. Certified Nursing Assistants [CNA's] rotates the odd and even rooms for cleaning of the wheelchairs and pressure relief cushions. We should clean any spills immediately. The Surveyor asked if it was acceptable for Resident #23's pressure relief cushion in his wheelchair to have the white spots and spill stains visible for two days in a row. LPN # 4 stated, No, it's not. e. On 02/23/22 at 3:15 PM, the Surveyor asked CNA #4 how often the wheelchair and pressure relief cushions were cleaned, who was responsible, and what if there were spill spots and stains on them. CNA #4 stated, We clean them two times a week, Monday, and Thursday. We are supposed to clean spills as they occur. The Surveyor asked if it was acceptable for Resident #23's pressure relief cushion in his wheelchair to have the white spots and spill stains visible for two days in a row. CNA #4 stated, No, it's not. f. On 02/23/22 at 4:00 PM, the DON stated the facility did not have a policy on the cleaning of wheelchairs and pressure relief devices. 47912

Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided to maintain good hygiene for 2 (Resident #66 and #78) of sampled residents who were dependent on staff for bathing and failed to ensure fingernails were cleaned and groomed to promote good personal hygiene and grooming for 1 (Resident #16) of 23 (Residents #1, #2, #11, #16, #23, #25, #29, #33, #34, #38, #39, #45, #48, #50, #55, #56, #59, #62, #65, #78, #80, #82 and #85) sampled residents who were dependent on staff for fingernail care. This failed practice had the potential to affect 29 residents who were dependent on staff for bathing/showers and 93 residents' who were dependent on staff for nail care as documented on list provided by the Director of Nursing (DON) on 02/23/23 at 3:45 pm. The findings are: 1. Resident #66 had diagnoses of Multiple Sclerosis, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Paraplegia. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Data (ARD) dated 02/04/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of one person with personal hygiene and was totally dependent on one person for bathing. a. The Care Plan with a revision date of 12/23/19 documented, . I'm at risk for an ADL [activities of daily living] self-care performance deficit r/t [related to] External devices, Hemiplegia, Impaired balance, Limited Mobility . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . The resident requires extensive assist by (X1) [times one] staff with showering . PERSONAL HYGIENE: The resident requires extensive assist by (X1) staff with personal hygiene and oral care . b. The Resident Grievance Reports for the last 3 months documented on 11/02/22 Resident #66's complaint, Did not get a bath on Monday . Resolution: Received bed bath same day. On 01/16/23 Resident #66's complaint, Didn't receive bath on previous Friday . Resolution: R [Resident] A&O [Alert and oriented] x [times] 4 and able to communicate needs. Bath was given after grievance. c. On 02/22/23 at 7:51 AM, Resident #66 was in his room, seated in his wheelchair. He stated, Something I forgot to tell you yesterday is. I'm not getting bed baths like scheduled. I'm supposed to get one on Mondays, Wednesdays, and Fridays. I got one last Friday and today is Wednesday, so I didn't get one on Monday. They may say that I refuse, but I never refuse. The Surveyor asked if the staff is responsible for shaving him also. He stated, No. I have a homeboy that comes in and shaves me. d. On 02/24/23 at 9:54 AM, the Surveyor asked Certified Nursing Assistant (CNA) #5, Who is responsible for giving residents showers? She stated, The aide for that hall. The Surveyor asked, How does the CNAs know which resident gets showers on which day? CNA #5 stated, It's in [Facility Computer Software]. The Surveyor asked, If a resident refuses a shower, what do the CNAs do? She stated, We will try multiple times to get them to take a shower. Then we will tell the nurse. e. On 02/24/23 at 10:03 AM, the Surveyor asked the DON, Who is responsible for giving residents showers? She stated, The CNAs. The Surveyor asked, If a resident refuses a shower, what do the CNAs do? She stated, They will document refusal in [Facility Computer Software], try multiple attempts and then notify the nurse so they can intervene. 37145 2.Resident #78 had diagnoses of Cognitive Communication Disorder, Anxiety, and Cerebral Infarction without Residual Deficits. The Quarterly MDS with an ARD of 01/19/23 documented the resident scored 10 (8-12 indicates moderately cognitively impaired) on a BIMS and required extensive one person physical assistance with personal hygiene and one person physical assistant with bathing activity. a. The Care Plan with a revision date of 05/015/22 documented, .BATHING/SHOWERING: The resident is totally dependent on (X1) staff to provide bathing . b. The February 2023 ADL Survey Report for bathing provided by the DON on 02/23/22 at 9:45 AM documented Resident #78 was scheduled to receive showers/bathing 3 times per week on Tuesdays, Thursdays, and Saturdays. On 02/04/23, 02/11/23 and 02/14/23 documented code 98. The Surveyor asked the DON what code 98 meant. She said it is for refused. The key at the bottom of the document documented, .98-Resident Refused . c. On 02/21/23 at 1:51 PM, Resident #78 was in her room. She stated I haven't had a bath in a week. Resident #78's hair was oily and matted. d. On 02/22/23 at 8:50 AM, Resident #78 was in bed. The Surveyor asked if she had received a shower since yesterday. She stated No. Her hair continued to be oily and matted. e. On 02/24/23 at 8:45 AM, the Surveyor asked CNA #2 how often Resident #78 received a shower and shampoo. CNA #2 stated, Three times a week, but sometimes she refuses. The Surveyor asked him to look at the survey report provided by the DON and asked him, Has the resident received a shower or shampoo since 02/09/23? He stated, I give my showers when they are scheduled but I am not always good at getting them documented. The Surveyor asked what no documentation of the bathing being complete meant. He stated, If it isn't documented it isn't done. f. On 02/24/23 at 9:00 AM, the Surveyor asked the DON to look at Resident #78's ADL Survey Report for bathing and asked if Resident #78 had had a shower and shampoo since 02/09/23. The DON stated, I can tell you it was completed on 02/09/23 and refused on 02/11/23 and 02/14/22. The showers may not have been documented since then and we have to look at resident right to refuse. 3. Resident #16 had diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis - Right Side Effected, Alzheimer's Dementia and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required set up assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. a. The Care Plan with a revision date of 11/27/18 documented, .I'm at risk for an ADL [activities of daily living] self-care performance deficit r/t [related to] HIV, neuropathy, major depression and noncompliance with care . Nail Care was not addressed on the Care Plan. b. On 02/23/23 at 8:50 AM, the Surveyor asked the DON where nailcare was documented. The DON replied, Nailcare is not documented on the ADL sheets, it's not documented anywhere. The Surveyor asked when nailcare was done. The DON replied, On Sundays. The Surveyor asked the DON for policy and procedures for nailcare and ADLs. The DON replied, There is no policy and procedure for ADLs or nailcare . They train their staff on nailcare . The Resident is often resistive to care. c. On 02/23/23 at 1:42 PM, Resident #16 was sitting in his wheelchair outside of his room in the hallway. The fingernails on both hands extended approximately 1/4 inch beyond the fingertips. The Surveyor asked Resident #16 if he liked his fingernails that long. Resident #16 replied, No. The Surveyor asked if he would like to have them trimmed. Resident #16 replied, Yes. d. On 02/23/23 at 3:45 PM, the Surveyor requested the Bathing and/or Activities of Daily Living policy and procedure from the Administrator. At 4:40 PM, the Nurse Consultant entered the Conference Room and stated, We do not have a policy on bathing or ADLs. 47912

Based on observation, and interview, the facility failed to ensure all mechanical and electrical equipment in the kitchen was maintained in safe operating condition. The failed practice had the ability to affect 92 residents who receive their meals from the kitchen according to a list provided by the Administrator on 02/24/23 at 9:00 AM. The findings are: 1. On 02/21/23 at 10:50 AM, during a tour of the kitchen, there was frozen water on the floor of the walk-in freezer. The water came from the motor/condenser located on the top of the unit. The water had traveled down the wall and accumulated on the top of a case of previously opened hamburger buns. 2. On 02/22/23 at 8:40 AM, the floor of the walk-in freezer continued to have water frozen on the floor. The water on the floor was located directly beneath the motor/condenser attached to the top of the freezer. An area directly under one leak extended from the floor of the freezer up approximately 6 inches. The water had run down the wall, freezing on the wall and on top of an opened box of hamburger buns. The ice on top of the box had accumulated and formed an area of ice approximately 1/4 inch to 1 and 1/2 inches thick. The running water had also frozen on the front of the box. The Surveyor asked the Dietary Manager if she had reported the issue of the water to the Maintenance Department. She stated, .No, it ' s been doing that since I got here so I really didn't think anything about it . The Dietary Consultant stated that the issue with the water dripping will be reported on this date. 3. On 02/22/23 at 1:45 PM, the Dietary Manager and Dietary Consultant approached this Surveyor. The Dietary Consultant reported that the Dietary Manager misspoke on 02/21/23 when she stated that she had not spoken to the Maintenance Department about the water in the freezer. The Dietary Consultant described that the Dietary Manager was simply unaware that action had been taken previously. The Dietary Consultant described that the administration had written a Performance Improvement Plan (PIP). Review of the plan revealed that the plan was written in August 2021. The August 2021 PIP provided by the Dietary Consultant on 02/22/23 documented, Observation during routine inspection there was ice buildup noted in different areas of the freezer. A handwritten note in the observation section documented, Can't come due to COVID. Notation was not signed or dated. Action the unit has been looked at for repair at different times. Supply chain issues as well as labor issues have prevented timely repair. Will continue to discuss repair time with vendor. Maintenance immediately removed built up ice. Dietary staff will keep the ice chipped away as needed until vendor can make repairs. Dietary personnel will contact maintenance if there are any issues noted to temperatures. A handwritten note in this section documented, Oct. [October] 2022 Maint. [Maintenance] repaired. Person Responsible Dietary, Maintenance. Evaluation Method Observations. Multiple hand written notations made in this section documented, Holding temp-no negative outcomes; dietary keeps ice chipped-temps [temperatures] good. Notations were not dated. On 12/22 a handwritten notation documented, Some buildup, temps good. Goal or Measure of Success and Date No ice buildup in unit. Evaluation Date/Results On-going. An Invoice dated 08/25/2021 provided by the Dietary Consultant documented service had been provided to the freezer on 8/02/21. 4. On 02/23/23 at 8:30 AM, the Surveyor asked the Administrator to review the PIP that was provided on 02/22/23 and to address the Goal or Measure of Success and Date. The Surveyor asked, for the date of the PIP completion, as one was not listed. The Administrator stated, With COVID and everything, I couldn't put in a date. Because of COVID and staffing and not knowing when I could get someone in here, I couldn't put down a date. Do you want me to make one up? The Surveyor asked the Administrator for a policy concerning the QA [Quality Assurance]/QAPI [Quality Assurance and Performance Improvement] program including the completion of the PIP. Administrator stated, Let me look. At 9:40 AM, the Nurse Consultant reported that there was no policy for the PIP process. 5. On 02/23/23 at 3:55 PM, the Surveyor asked the Maintenance Director if he was aware of the problem with dripping water in the freezer. The Maintenance Director stated, .I didn't really know that it was happening all the time . I know we have had people out here before . The Surveyor asked when was the last time he worked on the freezer. The Maintenance Director stated, .A month or two ago I was called because I think the temperature was dropping a little bit . I defrosted the coil . The Surveyor asked if there was a maintenance log which would provide a record of reported issues and when they were addressed. The Maintenance Director stated, They just started that log system again about a month ago. So, before that I wouldn't be able to tell you . The Maintenance Director stated that he was out during November and December of 2022 and thought that an outside repair service had been called in to fix a problem during this time. However, he was uncertain of the exact nature of the problem. The Surveyor asked the Maintenance Director to provide an invoice of this service call. 6. An Invoice dated 02/24/23 provided by the Administrator documented service had been provided to the freezer on 02/23/23.

Based on observation, record review, and interview, the facility failed to consider the residents' food preferences and serve items listed on the meal ticket for 1 (Resident #66) of 1 sampled resident. This failed practice had the potential to affect 92 residents who received a meal tray from the kitchen as documented on a list provided by the Administrator on 02/24/23 at 9:00 AM. The findings are: Resident #66 had diagnoses of Multiple Sclerosis (MS), Personal History of Transient Ischemic Attack, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Paraplegia, Unspecified. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision after set up for eating. a. The Physicians Order dated 01/26/20 documented, .General diet, Regular texture, Thin Liquids consistency. b. The Care Plan with revision date of 03/03/20 documented, .The resident is presently within his/her ideal body weight (IBW) range . Present weight is 162lbs [pounds] . 9/1/20 Magic cup with dinner . Determine food preferences through one-to-one interview &/or family interview . Offer between meal snacks & meal substitutions, as appropriate. Offer the resident a bedtime snack . c. The Dietary Progress Note dated 07/05/22 at 16:51 (4:51 PM) documented, RD [Registered Dietician] / Wt [weight] Change Review: .Wt indicating significant wt loss of -12.21% x [times] 180 days. Wt change of -0.98% x 30 days . Resident is a very picky eater, but the kitchen is working w/ [with] him to meet his needs. Met with him today and he spoke about specific requests for a particular fruit at each meal. He was educated that fruit wouldn't necessary encourage weight gain, however, he was adamant that that's all he desired at this time. Tray card updated and communicated to DM [Dietary Manager] onsite. Staff reports that health decline and wt loss may also be r/t [related to] MS dx [diagnosis] and food prefs [preferences] he made are in order to slow the progression of the dz [disease]. The MS diet guidelines encourage consuming more plant based foods and grains. RD to f/u [follow-up] at next visit to see how things are going and be available prn [as needed] . d. The Grievance dated 02/08/23 documented Resident #66 filed the following complaint, .For breakfast, tired of getting same fruit and oatmeal . Resolution: Resident receives other fruits and alternates . e. On 02/21/23 at 12:03 PM, Resident #66 was in his room, seated in his wheelchair (w/c). The Surveyor asked if he had lost any weight since living at facility. He stated, Yes, I've lost some. I don't know how much but I've gained some back. I don't like beef or pork, so they used to send me junk food to replace them, but I wouldn't eat it. I started asking for fruit. I like grapes, oranges and bananas. The Surveyor asked if he received fruit for breakfast this morning. He stated, Yes, I got oranges for breakfast, and I get orange slices every meal. It's usually the only fruit I get. f. On 02/21/23 at 1:01 PM, Resident #66 was in his room, seated in his w/c when his lunch tray was set up in front of him on the bedside table by Certified Nursing Assistant (CNA) #1. His lunch consisted of 2 bowls of orange slices, 2 bowls of green beans and 2 slices of whitish colored fileted meat. The Surveyor asked Resident #66 if the meat on his plate was chicken or fish. He stated, It's fish. I can eat fish, but I don't want it on Monday, Wednesday, and Friday. I get the same thing all the time. The Surveyor asked if she could see his meal ticket that was on his tray. He stated, Yes. The meal ticket stated, Chicken tenders and oranges. At 1:04 PM, the Surveyor asked CNA #1 if the meat on his plate was chicken or fish. She stated, I don't know but it looks like fish. CNA #1 looked at the meal ticket, then asked Resident #66 if he wanted chicken tenders instead of fish. He stated, Sure, I could eat some chicken. CNA #1 told Resident #66 that she would go to the kitchen to get him some. CNA #1 returned to resident's room after approximately 5 minutes and told Resident #66 that someone from the kitchen would be bringing his chicken. g. On 02/22/23 at 8:00 AM, Resident #66 was eating breakfast in his room. Orange slices were in a bowl on breakfast tray. h. On 02/22/23 at 1:00 PM, Resident #66 was finishing up lunch in his room. A banana peeling was on his lunch tray. The Surveyor asked if he got a different fruit for lunch. He stated, Yes, I had a banana. i. The Nutritional assessment dated [DATE] documented, .Significant Change . 11. A. Food Preferences . 6. List any Food/Beverage DISLIKES NO FRIED FOODS, NO PORK, NO RICE. Serve only one sweet potato when on menu, NO GRAVY, NO DAIRY, BEEF, BREAD, CUCUMBERS, EGGS 7. Additional Comments Related to Food Preferences DM is working with resident to accommodate food preferences . j. On 02/23/23, Resident #66's Care Plan was revised with the following information, .The resident is presently within his/her ideal body weight (IBW) range .9/1/20 Magic cup with dinner . Resident prefers a variety of fruits with meals where fruits are served. Doesn't like to receive same fruit repeatedly . k. On 02/24/23 at 10:16 AM, the Surveyor asked the Dietary Manager, How often are residents assessed for likes and dislikes? She stated, Quarterly. The Surveyor asked, Are you familiar with [Resident #66]? She stated, Yes. The Surveyor asked, On 02/21/23 [Resident #66's] lunch meal ticket stated, Chicken and oranges, but was served fish. Was fish his alternative? She stated, No. The Surveyor asked, How did you know to put fish on his plate and not chicken? She stated, He tells us that he gets tired of the same old thing all the time, so I've bought turkey and fish to try to please him. The Surveyor asked, Are there set alternatives or is it a choice? The Dietary Manager stated, There is always a choice, even if the resident doesn't want either they can suggest something they want. l. The facility policy and procedure titled Meal Identification and Preference Cards/Tickets, provided by the Dietary Consultant on 02/24/23 at 11:00 AM documented, .Policy: A meal identification and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preferences . 4. Meal ID cards/tickets will be used during meal service to assure the correct diet is being served and food preferences are honored .

Based on record review, and interview, the facility failed to ensure a Baseline Care Plan was developed within 48 hours of admission to include the minimum healthcare information necessary to provide for the resident's care needs to promote continuity of care and minimize the potential for adverse events after admission for 1 (Resident #142) of the 4 (Residents #21, #69, #71 and #302) sampled residents who were admitted to the facility in the past 30 days as documented on the MDS (Minimum Data Set) Resident Matrix provided by the MDS Coordinator on 02/22/23 at 10:43 AM. The findings are: Resident #142 was admitted to the facility on [DATE] and had a diagnoses of Other Lack of Coordination, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus with Diabetic Neuropathy. The Medicare 5 Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/16/23 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons with transfers and dressing, extensive physical assistance of one person with bed mobility, locomotion on and off the unit, toilet use and personal hygiene, and limited physical assistance of one person with eating, had an indwelling catheter and had frequent bowel incontinence. The Baseline Care Plan with an initiated date 02/14/23 was not completed and contained no documentation related to the resident's Activities of Daily Living until a revision of the Care Plan on 02/21/23. On 2/24/23 at 9:35 AM, the Surveyor asked the MDS Coordinator, When should the Baseline Care Plan be initiated for a resident? The MDS Coordinator stated, On admission and completed within 48 hours. The Surveyor asked, Why is the Baseline Care Plan important? The MDS Coordinator stated, It establishes the specialized needs for those particular residents care. The Surveyor asked, What could the potential outcome be if the Baseline Care Plan is not completed in a timely manner? The MDS Coordinator stated, It could delay the proper care a resident needs. The Surveyor asked, Would you consider a resident who was admitted on [DATE] and the Baseline Care Plan initiated on 02/13/23 timely? The MDS Coordinator stated, No, that's 72 hours. On 02/24/23 at 10:12 AM, the Surveyor asked the Director of Nursing (DON), When should the Baseline Care Plan be initiated for a resident? The DON stated, It should be done upon admission by the admitting nurse. The Surveyor asked, Why is the Baseline Care Plan important? The DON stated, So all staff members involved in caring for that particular resident knows what care needs to be provided. The Surveyor asked, What could the potential outcome be if the Baseline Care Plan is not completed in a timely manner? The DON stated, The appropriate care may not be provided for that particular resident. The Surveyor asked, Would you consider a resident who was admitted on [DATE] and the Baseline Care Plan initiated on 02/13/23 timely? The DON stated, It is not. On 2/24/23 at 10:45 AM the Surveyor asked Licensed Practical Nurse (LPN) #2, When should the Baseline Care Plan be initiated for a resident? LPN #2 stated, It should be done upon admission by the nurse doing the admission and completed in 24 hours. The Surveyor asked, Why is the Baseline Care Plan important? LPN #2 stated, So all staff members involved can care for the resident's individualized needs. The Surveyor asked, What could the potential outcome be if the Baseline Care Plan is not completed in a timely manner? LPN #2 stated, The individualized care needs for a resident may not be provided. The Surveyor asked, Would you consider a resident who was admitted on [DATE] and the Baseline Care Plan initiated on 02/13/23 timely? LPN #2 stated, No sir. The facility policy and procedure titled, Baseline Care Plans, provided by the DON on 02/24/23 at 9:11 AM stated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . 1. To ensure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission . 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan .

Based on observation, record review, and interview, the facility failed to ensure nursing staff assessed and obtained treatment orders for a laceration with sutures to promote healing and prevent potential infection for one (Resident #59) of 1 sampled resident who had sutures and required suture care and removal. The findings are: Resident #59 had diagnoses of Dementia and Repeated Falls. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required one person extensive physical assistance with personal hygiene and bathing. a. The February 2023 Physician Orders did not contain orders for treatment to suture line or suture removal. b. The Care Plan with a revision date of 02/08/23 did not address an injury to Resident #59's forehead. c. On 02/21/23 at 11:54 AM, Resident #59 was sitting up in bed, the right side of her forehead had a dry scab with several sutures visible. d. On 02/22/23 at 10:31 AM, Resident #59 was in her room. She had a dry scab with sutures on the right side of her forehead. e. On 02/23/23 at 10:15 AM, the Surveyor asked the Wound Nurse/Licensed Practical Nurse (LPN) #1, How long should sutures stay in? LPN #1 stated, Usually they are removed between 7 to 21 days. The Surveyor asked, Who is responsible for suture removal? LPN #1 stated, It depends on the order, usually I remove them with an order. If there is no order for treatment or removal, I contact the physician or Advanced Practice Nurse [APN] to get an order for treatment and removal, if appropriate. The Surveyor asked, When should [Resident #59] have the sutures on her forehead removed? The LPN #1 stated, I didn't know she had sutures. f. On 02/23/23 at 10:25 AM, the Surveyor asked LPN #2/Unit Manager, Who is responsible for obtaining orders for wounds, suture removal and such when someone returns from the hospital, doctors or ER [emergency room ]? LPN # 2 stated, The Wound Nurse. If someone returns on evening or night shift, then the floor nurse receiving them is responsible for informing the other shifts and getting orders. g. On 02/23/23 at 10:29 AM, the Surveyor asked the Director of Nursing (DON), Who is responsible for continuity of care and orders when someone is sent out to the emergency room and returns? The DON stated, The floor nurse, if it's the middle of night they write the orders, then the administrative staff follows up on it the next day. h. On 02/24/23 at 11:55 AM, the Surveyor asked the Nurse Consultant for the policy and procedure on suture care. The Nurse Consultant stated, We don't have one.

Complaint # (AR 379) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure the facility abuse prohibition policies and procedures were implemented, as evidenced by: failure to ensure an allegation of staff-to-resident abuse and neglect was immediately reported to the facility Administrator within 2 hours of discovery, which resulted in a delay in initiating an investigation and protective measures to prevent further potential abuse for 2 (Residents #2 and #3) of 8 (Residents #1, #2, #3, #4, #5, #6, #7, and #8) case mix residents who resided on A Hall and B Hall, and received care from Licensed Practical Nurse (LPN) #1. The failure to report the allegation of abuse / neglect, resulted in LPN #1 being allowed to work the rest of his 11:00 p.m. to 7:00 a.m. shift, as well as the 3:00 p.m. to 11:00 p.m. shift on 12/18/18, and the 11:00 p.m. to 7:00 a.m. shift, until 7:14 a.m., on 12/19/18. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Residents #2 and #3, who were the alleged victims of verbal and emotional abuse, and had the potential to cause more than minimal harm to 57 residents in the facility who received care from LPN #1, according to a list provided by the Administrator on 1/8/19 at 8:40 a.m. The facility removed the Immediate Jeopardy condition on 12/21/18, prior to the survey entrance date, when LPN #1 was terminated; however, a current deficient practice existed at the time of the survey, due to the facility's failure to report alleged violations of abuse to the State Survey Agency and other officials within 2 hours for 5 (Residents #3, #4, #5, #6 and #8) of 8 (see identifiers above) case mix residents who received care from LPN #1. The Administrator was informed of the removed Immediate Jeopardy condition on 1/7/19 at 1:15 p.m. The findings are: 1. The facility's policy titled Abuse, Neglect and Exploitation dated 11/2017, and provided by the Administrator on 1/7/18 documented, .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents . cause physical harm, pain or mental anguish .Verbal Abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Mental (Emotional) Abuse includes .humiliation, harassment, threats of punishment or deprivation . Mistreatment means inappropriate treatment or exploitation of a resident . Response and Reporting of Abuse, Neglect and Exploitation . In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . to the Administrator of the facility and to other officials (including the State Survey Agency .) in accordance with State law . Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in process . Resident protection after an alleged abuse, neglect . Reassignment of nursing staff duties . Time off for nursing staff . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and exhibited no behaviors. a. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, dated 12/19/18 documented, .(Resident #1) reported that she had turned her call light on and because (LPN #1) and (Certified Nursing Assistant (CNA) #1) were arguing loudly and cursing at each other in the hallway, she didn't get her call light answered timely and her needs taken care of. During the interview, (Resident #1) stated that (LPN #1) called her (name, indicating a wealthy or privileged person) and was rude with her. She also stated that (LPN #1) has cursed her on several occasions and is very mean. When asked about (CNA #1), she stated that (CNA #1) answers her call light with 'what do you need' in a snappy way. (Resident #1) stated (CNA #1) is a mean person. She will stand in her doorway and spray bleach on the floor knowing that bleach makes it hard for (Resident #1) to breathe. During the investigation, 4 other residents indicated that (LPN #1) was rude and hateful when talking to them, and 1 staff stated (LPN #1) was rude and hateful when talking to her and had her in tears on one occasion when she asked (LPN #1) to suction a resident . (LPN #1) and (CNA #1) suspended pending investigation . Abuse and neglect in-service done with all staff . Due to the additional resident complaints in reference to (LPN #1) being rude and mean, and the additional staff that have indicated that (LPN #1) speaks mean to them as well, (LPN #1) is terminated effective 12/21/18. Due to other residents indicating that (CNA #1) is mean and curses a lot, she is terminated effective 12/21/18 . b. A Witness Statement dated 12/19/18 for Resident #1 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (LPN #1) called her '(name, indicating a wealthy or privileged person)' He's very rude with her. She states that (LPN #1) has cursed her several times. (Resident #1) states he (LPN #1) is very mean. She says she has never seen anything like this. (Resident #1) states (LPN #1) is certifiable . c. On 1/4/19 at 9:25 a.m., Resident #1 was lying in bed. The resident was asked if she had had any problems with staff members in the facility. She stated, Any problems? Well yes, I have. Did you want to ask me about anyone in particular? The resident was asked about LPN #1. She stated, I have reported him to State before. And I have tried to report him here. I've tried and tried to talk to (DON). (LPN #1) and (CNA #1) had a bad argument the other night. It was terrible. All the cussing and such they did. She (CNA #1) was telling him (LPN #1) she had taped him on her phone (telephone) taking medications out of the medication cart. He's got bad diabetes. The resident was asked if the LPN had ever been inappropriate with her. She stated, (LPN #1) calls me (name, indicating a wealthy or privileged person)'. And he has cussed me. He is very mean. She was asked why he called her (name, indicating a wealthy or privileged person)'. She stated, I don't know. It's like he's saying I'm too good or something. I've been poor my whole life! He's just mean. He says that to hurt my feelings. (CNA #1), she was also so mean. She didn't want to be here and didn't want to help you. Do these people think we want to be here? No one wakes up and thinks they will wind up in a nursing home, but some of us do. We don't deserve to be treated like we get treated here. She was asked if she felt what she had experienced was abuse. She stated, Abuse? Well of course it is. Anytime someone says something to you to intentionally belittle you and hurt your feelings, it is abuse. I pray he and (CNA #1) have been fired. If they have, thank you Jesus . 3. A handwritten statement signed by CNA #1 and dated 12/20/18 documented, .To whom it may concern, I (CNA #1) is (sic) bringing an incident to the forefront that occurred on 12/17/18 (Monday) night on 11/7 shift. I am an aid (CNA) on B wing and (LPN #1) is the nurse. A resident (Resident #3 per the Administrator) fell on the floor and I was the only aid on the hall at the time. The other aid was on her break. The emergency light came on in this patient's room and I went (and) answered it and the resident was on the floor in the bathroom. When I walked in and saw her on the floor, I asked her 'was she ok' and told her to 'hold on until I go get some help to help me get her up.' Me being an aid for over [AGE] years, I know the proper protocol is to not move her or anything until the nurse checks her. Didn't know where (LPN #1) was, so I went to D wing to get (CNA #2) and (CNA #3) to help me. Looking around for (LPN #1), the nurse, finds him in the Conference Room asleep on the bench that's in there. Told him (LPN #1) the resident was on the floor. His remark was '(Expletive - GD), I'm not for this (expletive, indicating feces) tonight.' He comes down to the room, walks in, and instead of checking her, he says 'I'm not touching you because you got (expletive indicating feces) on you. When are you leaving, don't you supposed to be leaving?' I go get the Hoyer lift and (CNA #2) and I get her (Resident #3) up. Meanwhile, he's sitting on the other bed in her room talking about she did this on purpose. So I said, are you going to help us, because the lift just went so far down for us to hook it up. We got her on the lift and I said 'man this is pitiful.' He yells out and say '(Expletive - FY) while still sitting on the bed watching us struggle trying to get the resident secured back in her chair. I said, 'really (LPN #1), (expletive - F) me?' He said '(CNA #1) you just being a (expletive - B) tonight' and left out the room. So when we got her up he went back and laid down in the Conference Room. After this happened, I went on my break but really didn't get a break because I went to another hall to find something to help clean up the poop that was on the floor in her (the resident's) room. As I'm coming back down the hall from D wing, I see him going in another resident's room with the lift, so I put down the supplies and went to the room, and (Resident #2) was on the floor with a split forehead. Again, instead of helping, he's telling the resident, which is a white male, 'oh you on the floor, huh.' The resident responded, 'yes I fell out of my wheelchair.' (LPN #1) replied, 'yeah I know you want to work the black man that makes all the money to take care of the poor! Yeah I know you want to blame it on the black man like it's my fault you fell .' We got the resident up with the lift, got him in the bed while (LPN #1) is sitting on the bed again saying, 'my (expletive - D) feet hurt.' So (Resident #2) said, 'don't do all that hollering at me now because you was rude to me when you first came in here.' He had this resident so afraid that the resident said, 'what's your name.' I told him that my name is (CNA #1) and (CNA #2) told him her name. The resident then said, 'please don't leave me. Stay in here with me because I don't want him back in here. Do ya'll have anybody else that can take care of me?' Then, when the ambulance came and got him as he was going down the hall and (LPN #1) was walking with them, the resident said, 'stop, stop,' and asked (LPN #1) 'where you going, because I don't want you to go nowhere with me.' As the night went on, (LPN #1) knew that I was going to go to my DON (Director of Nursing) the next morning about how he was talking to, not only me, but to the residents! So he came to me talking about 'can we please talk about this.' I said 'no leave me alone. I'm going to tell how you was talking to these patients.' . When the DON got there that morning I went to her about it, and she called (LPN #1) to the office. I tell her what happened and what he said to me and the resident, and while I'm in the office she said to him, '(LPN #1) I know (CNA #1's) not lying because you get complaints about how you talk to people and these patients and family members.' She went on to tell him that she knows he's loud, rude and belligerent and that she know he says things to offend people. He need to tone it down. Then she told us that if we don't leave it alone and get along it's going to be our job. So he said, 'I don't have to say anything else to her. I don't have to like her.' Which he don't have to like me, but he do have to do right by them patients on B wing and on the A wing! So I leave out of the office. Ok, the next night, 12/18/18 (Tuesday), it was another fall. Same thing takes place again! He sends the resident out again! I'm sitting on the hall and I hear him on the phone telling somebody what happened. So, I call my boss, my DON, and asked her 'can I go home' because at this point I can't work with him steadily talking as if he trying to say that I'm not a good aid. Mind you, I've worked on this same hall forever without any problems, been at this facility for 3 years, hard 3 years ok! She told me not to go home, so I didn't. After I get through doing a round, I go to the desk where the sink is to wash my hands, and hear him on the phone with (DON), so he says 'hold up' and 'let me go in the shower room because you know (CNA #1) is taking note of everything I say and do.' He's in the shower room talking to my boss, my DON, on the phone, and I hear him talking about the previous nurse that quit, the aid on the hall with me, and me! He's saying that the nurse that quit used to leave and go (expletive indicating perform oral sex) and come back, that she was getting beat up by her boyfriend, these (expletive - B) that work here are broke and poor . He went on to say that I'm [MEDICAL CONDITION] and my boyfriend must be done mad and I'm taking it out on him, that I'm acting like a (expletive - B), I must be on my period this week. Now mind you, he's talking to the DON and she is carrying on this conversation with him, and the other aid on the hall said I can't believe he's indulging in this conversation like this with the boss lady. So I said, 'she knows how he talks to people and that's why, because she indulges in it and obviously condones it' . Then he goes back outside and calls the DON back on the phone. When he comes back in the side door he says, 'Oh, I'm not worried about anything. (DON) is my friend and she knows! Ha, ha, ha, your word against mine.' Mind you, about a week or so ago, a new aid came to the hall and asked him to go suction a resident out, and he told her, 'you better leave me the (expletive - F) alone because I'm not going to keep coming down there to suction her.' Had the aid crying, and she called (DON) and told on him. A couple minutes later, he's sitting at the desk with his phone playing Monopoly on the computer, busted out laughing, and says, 'look, look, look at this text.' Showed us the text with (DON) saying, '(LPN #1), you got that girl crying, and she still crying. Don't talk to her like that. She seems like she cares about her resident. By the way, you missed the crab boil we had today.' It's being swept under the rug how he talk and do people! It's sad and ridiculous. I know by me speaking up I will not have a job, because our jobs are threatened all the time. I just feel like somebody needs to say something because the residents are in danger really with him as a nurse, because he does not care at all! If others would have the courage to say something, they will say the same thing, but they know that it would probably be their job like it's going to be mine . Based on the date of the written statement (11/20/18), the statement was written 2 days after the initial incident occurred. The CNA's statement also indicated that after the incidents occurred, she waited until the following morning to report the incidents to the Director of Nursing (DON). 4. Resident #2 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 12/21/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and exhibited no behaviors. a. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, dated 12/21/18 documented, .When investigating another resident report of abuse, (Resident #2) commented that (LPN #1) hollered at him when he came into (Resident #2's) room and found him on the floor. (Resident #2) stated that (LPN #1), instead of helping him up, (LPN #2) laughed at him and left him in urine. On a second incident after falling, (Resident #2) stated that (LPN #1) told him to get off the phone when he was talking to his wife. (Resident #2) stated that (LPN #1) just sat on the bed while the 2 CNAs got him (the resident) up off the floor, not offering to help at all. (Resident #2) stated he felt belittled and shamed. (Resident #2's) wife stated when she was on the phone with her husband, (LPN #1) was heard scolding (Resident #2) for talking to her. She heard (LPN #1), in a hateful, rude way, tell (Resident #2) to get off the phone . He expressed that he was glad (LPN #1) was no longer at facility . Witness statements obtained from alert residents and staff. 5 additional residents expressed that (LPN #1) was sarcastic, mean, and rude when talking to them. Due to additional resident complaints in reference to (LPN #1) being rude, sarcastic, and mean, and (Resident #2's) wife hearing (LPN #1) as well, (LPN #1) has been terminated effective 12/21/18 . b. A Nurse's Note dated 12/18/18 at 4:05 a.m. and signed by LPN #1 documented, .Resident was found on floor with laceration to forehead. Resident had a substantial amount of blood on floor and clothing . Resident was Hoyer lifted from floor and complaining. Vitals were taken. 128/54 b/p (blood pressure), 64 pulse, 18 resp (respirations) 86% pulse ox (oxygen saturation) on room air. Resident informed his wife of transport to (hospital). Resident took bandages off head at this time. (Ambulance service) transport came and resident was taken to hospital. Report given to Charge Nurse at ER (emergency room ) dept (department) . c. A Nurse's Note dated 12/19/18 at 3:14 a.m. and signed by LPN #1 documented, .Resident fell on floor as he was trying to get to bathroom. Call light within reach. Resident got out of bed unassisted. Resident did not use call light or call for help. Resident called for help after the fact. Resident sent to (hospital) for observation. Resident transported by (ambulance service) . d. A Witness Statement dated 12/19/18 for Resident #2 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (LPN #1) hollered at (Resident #2). He (LPN #1) asked, how did you get over there to that bed. (Resident #2) explained to him that he slipped in his urine and slid over to the other bed. (Resident #2) asked (LPN #1) to help him out of the urine. (LPN #1) laughed and threw his hands up and walked out of his room. (LPN #1), per (Resident #2), told him to get off the phone. First fall . He wouldn't help him up and let (Resident #2) remain in urine uncovered. (Resident #2's) gown came off. (LPN #1) yanked on (Resident #2's) arm and told him to get up. Second fall . Fall and busted head. He (Resident #2) was on the phone with wife. (LPN #1) entered his room hollering at (Resident #2) 'get off the phone'. He told him he was calling his wife. He told him not to call, and (Resident #2) told (LPN #1) it was ok to call, and gave (LPN #1) her telephone number. The two ladies helped him with the (one lady just started) lift as (LPN #1) sat on the bed talking loudly to (Resident #1), stating he didn't understand how he made it to the other side of bed . Afterwards he (Resident #2) called son and informed son that he was scared. He felt scared because he (LPN #1) had acted unprofessional and rude to (Resident #2). (Resident #2) felt belittled and shamed. (Resident #2) had never experienced anything like that. He stated (LPN #1) has been the only rude one to him. He prefers him not to come around him . e. On 1/9/19 at 9:20 a.m., the resident was contacted via telephone and asked about his experience at the facility with LPN #1. He stated, Well, I got up out of bed and I couldn't make it to the bathroom. I peed and slipped in it and fell . He came in my room hollering at me and laughed at me, 'What are you doing over there?' He let me lay in it. I was so embarrassed and felt shamed. The next night, I fell and hit my head. Knocked a little hole in it. He wouldn't clean me up! I was on the phone with my wife, and he hollered at me to get off the phone with her. He was asked if he asked a CNA to stay with him due to being afraid of LPN #1. He stated, Yes, I did. He was asked why he was afraid. He stated, I don't know. I don't get scared like that too often. He was asked about the part of CNA #1's statement that documented he was being rolled out by the ambulance crew and he told LPN #1 that he didn't want him going anywhere with him. He stated, That's right. I told him that as they were taking me out. He was asked if he felt his treatment by LPN #1 was abuse. He stated, Yes. Wouldn't you? 5. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), and exhibited no behaviors. a. A Nurse's Note dated 12/18/18 at 7:38 a.m., and signed by LPN #1, documented, .Resident is unharmed r/t (related to) fall. Resident had no injuries. Resident was Hoyer lifted off of floor. Resident was placed back in wheelchair. No s/sx (signs / symptoms) of pain and / or distress of note. Will cont (continue) to observe . b. Resident #3 was referenced in CNA #1's witness statement (see paragraph 3), but was discharged from the facility on 12/18/18 (see paragraph 14). There was no witness statement from this resident, and the resident could not be reached for interview during the survey. 6. Resident #8 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/19/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required extensive assistance with activities of daily living. a. The Care Plan dated 10/25/18 documented, .I have been known to have a behavior problem of refusal of care, manipulative behaviors, false accusations and verbal abuse r/t (related to) poor impulse control, major [MEDICAL CONDITION] . b. A Witness Statement dated 12/19/18 for Resident #8 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? . 'Yes' (Resident #8) stated (LPN #1) has been very sarcastic to her while bringing her meds to her. The way he addressed her and his mannerism was not nice. (Resident #8) stated in the past he has given her OTC (over the counter) sleeping meds (medications) when she was taking prescribed pain pills. He stated to her, nobody stays awake on his shift . c. On 1/8/19 at 9:30 a.m., the resident was lying in bed. She was asked if she had ever had any issues with LPN #1. She stated, Oh! Oh my God! He should be in jail for some of the things he's done. He does not need to be a nurse. She was asked to explain. She stated, My niece came up here one day and as she was walking down the hall, she saw a resident on the floor. She went to find the nurse to report it, and (LPN #1) and a CNA came out of an empty room. I think we know what they were doing, but anyway, she reported to him there was a resident on the floor, and he yelled at her, and said, 'no there wasn't.' My niece got so upset. So, when she walked back by the room, they had put him (the resident) in bed and put the bed in the highest position it would go! She told them the bed should be in the lowest position with a mat on the floor. The next thing I know, (LPN #1) comes in here, grabs my gown up close to my neck, and tells me I'd better keep my mouth shut because me and my niece are going to get him fired. He needs to be in jail. There are so many things he has done. A resident who used to be here, she had Dementia. She would walk up and down the hall. One night I heard a CNA yelling at her to get in bed. Another CNA started yelling at that CNA that the resident would go to bed when she got ready. Then, (LPN #1) showed up and told them to leave the room. The next thing I hear is him yelling at that resident to stay in bed. The next day, I saw the resident. She was walking up the hall mumbling and crying, and she was black and blue all around her neck and upper chest area. I believe that was investigated. But they get together and get their stories straight before they talk to anyone. I'm so glad he isn't here anymore. She was asked if she felt the treatment she had received from the LPN was abuse, and she stated, Oh God, yes! I'm telling you, he should be in jail because he will wind up killing someone. She was asked if she reported this to anyone. She stated, Of course not. Are you serious? They already hate me here because I can talk and say what is going on . 7. Resident #4 had [DIAGNOSES REDACTED]. The 14 Day Medicare MDS with an ARD of 11/8/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required limited assistance with activities of daily living. a. The Care Plan dated 11/8/18 documented, I have a potential psychosocial well-being problem r/t (related to) depression . I am known to make false accusations towards staff when things don't go my way . b. A Witness Statement dated 12/19/18 for Resident #4 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (Resident #4) dreads to see him come to work because he has told (Resident #4) that he knows (Resident #4) does not like him. (LPN #1) has been over 2 hours late administering (Resident #4) pain meds. (LPN #1) stated he had just finished dealing with a dead body and slammed his door. (Resident #4) states (LPN #1) placed his hand in his face and stated is he asking for a pill. (Resident #4) states (LPN #1) is the only nurse that treats him this way. On 12/18/18, (Resident #4) went to go smoke. (Resident #4) asked for pain meds (medications) because he was in pain. (LPN #1) stated to him he 'ain't going to get it' . (Resident #4) has overheard (LPN #1) fussing with other residents. The other day (Resident #4) observed (LPN #1) push an aide into a room . c. On 1/4/19 at 10:15 a.m., the resident was in his room watching television. He was asked about how LPN #1 had treated him. He stated, (LPN #1) treated me like (expletive, indicating feces). One example was, I was getting ready to go out and smoke, and I told (LPN #1) I was ready for my pain pill whenever. (LPN #1) said 'you ain't gonna get it.' He stuck his hand in my face. And I didn't get the pill until the next nurse came on. The resident was asked if he reported this to anyone and stated, There were several people around when he did that. And I reported it when they asked me. He was asked if he felt his treatment from the LPN was abuse. He stated, Yeah. He definitely should not be a nurse. It made me cry. The resident began sobbing. 8. Resident #5 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 12/11/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and had a [MEDICAL CONDITION]. a. A Witness Statement dated 12/19/18 for Resident #5 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (LPN #1) accused him of playing with his [MEDICAL CONDITION] bag. (Resident #5) stated to (LPN #1) that he didn't play with his bag. (Resident #5) stated (LPN #1) told him he was going to make (Resident #5) pay for playing with his bag. He left (Resident #5) in his chair with BM (bowel movement) running down his leg and chair for 30 minutes per (Resident #5). (Resident #5) would like another nurse. He stated (LPN #1) is very unprofessional and rude . b. On 1/7/19 at 9:30 a.m., the resident was lying in bed. He was asked if he had had any problems with LPN #1. He stated, Yes. He's awful. He was asked what he meant. He stated, I remember exactly what he said to me. The evening before, he had to change my [MEDICAL CONDITION] bag. And he didn't do it right, so it started leaking again. I was outside smoking, and I could hear it and smell it. So I came in and told him it needed to be changed. He said, 'You're going to pay for playing with that bag.' And then he let me sit in (expletive, indicating feces) for 30 minutes. It was running down my leg and chair. He was asked if he felt the treatment he received from the LPN was abuse. He stated, Yes. And I guarantee that's not the first time he's done something like that to someone. He's in the wrong line of work. He needs to be working on cars in a garage somewhere. But I wouldn't want him working on my car either . 9. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/19/18 documented the resident scored 12 (8-12 indicates moderate cognitive impairment) on a BIMS, required extensive assistance with activities of daily living, and had an indwelling urinary catheter. a. A Witness Statement dated 12/19/18 for Resident #6 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (Resident #6) stated (LPN #1) speaks to him sarcastically. (Resident #6) stated he has heard (LPN #1) talk to women and make the women cry. (Resident #6) stated that hearing (LPN #1) talk to people like that makes him upset . b. On 1/7/19 at 10:00 a.m., the resident was lying in bed. He was asked if he had ever had any problems with LPN #1. He stated, (LPN #1) . I don't much cotton to him. I don't like him. I don't even want him in my room. He was supposed to be tending to my catheter one time. I had on a pair of overalls. I may be blind, but I know when he went to empty the bag, he poured the urine on my overalls. This is all the resident would say about LPN #1. 10. On 1/3/19 at 4:25 p.m., the Administrator was asked if any staff had reported anything to her about LPN #1. She stated, No. The Administrator then provided copies of the 2 reports/investigations involving Resident #1 and Resident #2. After reviewing the documentation and seeing that other residents had made allegations against LPN #1, the Administrator was asked if she had reported these allegations to the Office of Long Term Care and other officials such as the Arkansas State Board of Nursing. She stated, No, I haven't. 11. On 1/3/19 at 4:56 p.m., the Director of Nursing (DON) was asked what CNA #1 had reported to her and stated, (CNA #1) has never reported anything to me about (LPN #1). (CNA #1) thought she was going to lose her job that night, because the nurse has to call me after every fall. That fall was on her hall. She called me saying she was going to go home because (LPN #1) was trying to blame her for the fall. I told her, no he wasn't. Then, she went to saying she heard his conversation with me. She had no idea what my part of the conversation was because she couldn't hear me. It wasn't even about her! At this time, part of CNA #1's witness statement that referred to the meeting she allegedly had with LPN #1 and CNA #1 that morning, was read to the DON. The DON stated, I got onto them two because they got into it. The reason she even came to me is because she thought (LPN #1) was going to come to me about her, so she wanted to get to me first. No resident name came up at all during our conversation. She was asked if any resident had complained to her about LPN #1. She stated, No. 12. On 1/4/19 at 9:45 a.m., LPN #2 was asked if she was involved with Resident #1 initially reporting the altercation between LPN #1 and CNA #1. She stated, Yes. I was here. (Resident #1) was calling me and calling me, so I was getting ready to go see her, and

Complaint # (AR 379) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure allegations of staff-to-resident verbal and emotional abuse were immediately reported to the facility Administrator within 2 hours of discovery, which resulted in a delay in initiating an investigation and protective measures to prevent further potential abuse for 2 (Residents #2 and #3) of 8 (Residents #1, #2, #3, #4, #5, #6, #7 and #8) case mix residents who resided on A Hall and B Hall, and received care from Licensed Practical Nurse (LPN) #1. The failure to report the allegation of abuse / neglect, resulted in LPN #1 being allowed to work the rest of his 11:00 p.m. to 7:00 a.m. shift, as well as the 3:00 p.m. to 11:00 p.m. shift on 12/18/18, and the 11:00 p.m. to 7:00 a.m. shift, until 7:14 a.m., on 12/19/18. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Residents #2 and #3, who were the alleged victims of verbal and emotional abuse, and had the potential to cause more than minimal harm to 57 residents in the facility who received care from LPN #1, according to a list provided by the Administrator on 1/8/19 at 8:40 a.m. The facility removed the Immediate Jeopardy condition on 12/21/18, prior to the survey entrance date, when LPN #1 was terminated; however, a current deficient practice existed at the time of the survey, due to the facility's failure to report alleged violations of abuse to the State Survey Agency and other officials within 2 hours for 5 (Residents #3, #4, #5, #6 and #8) of 8 (see identifiers above) case mix residents who received care from LPN #1. The Administrator was informed of the removed Immediate Jeopardy condition on 1/7/19 at 1:15 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and exhibited no behaviors. a. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, dated 12/19/18 documented, .Date Incident Reported to OLTC . 12/19/18 . Date and Time of Incident . (Blank) . Date and Time of Discovery . 12/19/18 . (Resident #1) reported that she had turned her call light on and because (LPN #1) and (Certified Nursing Assistant (CNA) #1) were arguing loudly and cursing at each other in the hallway, she didn't get her call light answered timely and her needs taken care of. During the interview, (Resident #1) stated that (LPN #1) called her (name, indicating a wealthy or privileged person) and was rude with her. She also stated that (LPN #1) has cursed her on several occasions and is very mean. When asked about (CNA #1), she stated that (CNA #1) answers her call light with 'what do you need' in a snappy way. (Resident #1) stated (CNA #1) is a mean person. She will stand in her doorway and spray bleach on the floor knowing that bleach makes it hard for (Resident #1) to breathe. During the investigation, 4 other residents indicated that (LPN #1) was rude and hateful when talking to them, and 1 staff stated (LPN #1) was rude and hateful when talking to her and had her in tears on one occasion when she asked (LPN #1) to suction a resident . (LPN #1) and (CNA #1) suspended pending investigation . Abuse and neglect in-service done with all staff . Due to the additional resident complaints in reference to (LPN #1) being rude and mean, and the additional staff that have indicated that (LPN #1) speaks mean to them as well, (LPN #1) is terminated effective 12/21/18. Due to other residents indicating that (CNA #1) is mean and curses a lot, she is terminated effective 12/21/18 . b. A Witness Statement dated 12/19/18 for Resident #1 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (LPN #1) called her '(name, indicating a wealthy or privileged person)' He's very rude with her. She states that (LPN #1) has cursed her several times. (Resident #1) states he (LPN #1) is very mean. She says she has never seen anything like this. (Resident #1) states (LPN #1) is certifiable . c. On 1/4/19 at 9:25 a.m., Resident #1 was lying in bed. The resident was asked if she had had any problems with staff members in the facility. She stated, Any problems? Well yes, I have. Did you want to ask me about anyone in particular? The resident was asked about LPN #1. She stated, I have reported him to State before. And I have tried to report him here. I've tried and tried to talk to (DON). (LPN #1) and (CNA #1) had a bad argument the other night. It was terrible. All the cussing and such they did. She (CNA #1) was telling him (LPN #1) she had taped him on her phone (telephone) taking medications out of the medication cart. He's got bad diabetes. The resident was asked if the LPN had ever been inappropriate with her. She stated, (LPN #1) calls me (name, indicating a wealthy or privileged person)'. And he has cussed me. He is very mean. She was asked why he called her (name, indicating a wealthy or privileged person)'. She stated, I don't know. It's like he's saying I'm too good or something. I've been poor my whole life! He's just mean. He says that to hurt my feelings. (CNA #1), she was also so mean. She didn't want to be here and didn't want to help you. Do these people think we want to be here? No one wakes up and thinks they will wind up in a nursing home, but some of us do. We don't deserve to be treated like we get treated here. She was asked if she felt what she had experienced was abuse. She stated, Abuse? Well of course it is. Anytime someone says something to you to intentionally belittle you and hurt your feelings, it is abuse. I pray he and (CNA #1) have been fired. If they have, thank you Jesus . 2. A handwritten statement signed by CNA #1 and dated 12/20/18 documented, .To whom it may concern, I (CNA #1) is (sic) bringing an incident to the forefront that occurred on 12/17/18 (Monday) night on 11/7 shift. I am an aid (CNA) on B wing and (LPN #1) is the nurse. A resident (Resident #3 per the Administrator) fell on the floor and I was the only aid on the hall at the time. The other aid was on her break. The emergency light came on in this patient's room and I went (and) answered it and the resident was on the floor in the bathroom. When I walked in and saw her on the floor, I asked her 'was she ok' and told her to 'hold on until I go get some help to help me get her up.' Me being an aid for over [AGE] years, I know the proper protocol is to not move her or anything until the nurse checks her. Didn't know where (LPN #1) was, so I went to D wing to get (CNA #2) and (CNA #3) to help me. Looking around for (LPN #1), the nurse, finds him in the Conference Room asleep on the bench that's in there. Told him (LPN #1) the resident was on the floor. His remark was '(Expletive - GD), I'm not for this (expletive, indicating feces) tonight.' He comes down to the room, walks in, and instead of checking her, he says 'I'm not touching you because you got (expletive indicating feces) on you. When are you leaving, don't you supposed to be leaving?' I go get the Hoyer lift and (CNA #2) and I get her (Resident #3) up. Meanwhile, he's sitting on the other bed in her room talking about she did this on purpose. So I said, are you going to help us, because the lift just went so far down for us to hook it up. We got her on the lift and I said 'man this is pitiful.' He yells out and say '(Expletive - FY) while still sitting on the bed watching us struggle trying to get the resident secured back in her chair. I said, 'really (LPN #1), (expletive - F) me?' He said '(CNA #1) you just being a (expletive - B) tonight' and left out the room. So when we got her up he went back and laid down in the Conference Room. After this happened, I went on my break but really didn't get a break because I went to another hall to find something to help clean up the poop that was on the floor in her (the resident's) room. As I'm coming back down the hall from D wing, I see him going in another resident's room with the lift, so I put down the supplies and went to the room, and (Resident #2) was on the floor with a split forehead. Again, instead of helping, he's telling the resident, which is a white male, 'oh you on the floor, huh.' The resident responded, 'yes I fell out of my wheelchair.' (LPN #1) replied, 'yeah I know you want to work the black man that makes all the money to take care of the poor! Yeah I know you want to blame it on the black man like it's my fault you fell .' We got the resident up with the lift, got him in the bed while (LPN #1) is sitting on the bed again saying, 'my (expletive - D) feet hurt.' So (Resident #2) said, 'don't do all that hollering at me now because you was rude to me when you first came in here.' He had this resident so afraid that the resident said, 'what's your name.' I told him that my name is (CNA #1) and (CNA #2) told him her name. The resident then said, 'please don't leave me. Stay in here with me because I don't want him back in here. Do ya'll have anybody else that can take care of me?' Then, when the ambulance came and got him as he was going down the hall and (LPN #1) was walking with them, the resident said, 'stop, stop,' and asked (LPN #1) 'where you going, because I don't want you to go nowhere with me.' As the night went on, (LPN #1) knew that I was going to go to my DON (Director of Nursing) the next morning about how he was talking to, not only me, but to the residents! So he came to me talking about 'can we please talk about this.' I said 'no leave me alone. I'm going to tell how you was talking to these patients.' . When the DON got there that morning I went to her about it, and she called (LPN #1) to the office. I tell her what happened and what he said to me and the resident, and while I'm in the office she said to him, '(LPN #1) I know (CNA #1's) not lying because you get complaints about how you talk to people and these patients and family members.' She went on to tell him that she knows he's loud, rude and belligerent and that she know he says things to offend people. He need to tone it down. Then she told us that if we don't leave it alone and get along it's going to be our job. So he said, 'I don't have to say anything else to her. I don't have to like her.' Which he don't have to like me, but he do have to do right by them patients on B wing and on the A wing! So I leave out of the office. Ok, the next night, 12/18/18 (Tuesday), it was another fall. Same thing takes place again! He sends the resident out again! I'm sitting on the hall and I hear him on the phone telling somebody what happened. So, I call my boss, my DON, and asked her 'can I go home' because at this point I can't work with him steadily talking as if he trying to say that I'm not a good aid. Mind you, I've worked on this same hall forever without any problems, been at this facility for 3 years, hard 3 years ok! She told me not to go home, so I didn't. After I get through doing a round, I go to the desk where the sink is to wash my hands, and hear him on the phone with (DON), so he says 'hold up' and 'let me go in the shower room because you know (CNA #1) is taking note of everything I say and do.' He's in the shower room talking to my boss, my DON, on the phone, and I hear him talking about the previous nurse that quit, the aid on the hall with me, and me! He's saying that the nurse that quit used to leave and go (expletive indicating perform oral sex) and come back, that she was getting beat up by her boyfriend, these (expletive - B) that work here are broke and poor . He went on to say that I'm [MEDICAL CONDITION] and my boyfriend must be done mad and I'm taking it out on him, that I'm acting like a (expletive - B), I must be on my period this week. Now mind you, he's talking to the DON and she is carrying on this conversation with him, and the other aid on the hall said I can't believe he's indulging in this conversation like this with the boss lady. So I said, 'she knows how he talks to people and that's why, because she indulges in it and obviously condones it' . Then he goes back outside and calls the DON back on the phone. When he comes back in the side door he says, 'Oh, I'm not worried about anything. (DON) is my friend and she knows! Ha, ha, ha, your word against mine.' Mind you, about a week or so ago, a new aid came to the hall and asked him to go suction a resident out, and he told her, 'you better leave me the (expletive - F) alone because I'm not going to keep coming down there to suction her.' Had the aid crying, and she called (DON) and told on him. A couple minutes later, he's sitting at the desk with his phone playing Monopoly on the computer, busted out laughing, and says, 'look, look, look at this text.' Showed us the text with (DON) saying, '(LPN #1), you got that girl crying, and she still crying. Don't talk to her like that. She seems like she cares about her resident. By the way, you missed the crab boil we had today.' It's being swept under the rug how he talk and do people! It's sad and ridiculous. I know by me speaking up I will not have a job, because our jobs are threatened all the time. I just feel like somebody needs to say something because the residents are in danger really with him as a nurse, because he does not care at all! If others would have the courage to say something, they will say the same thing, but they know that it would probably be their job like it's going to be mine . Based on the date of the written statement (11/20/18), the statement was written 2 days after the initial incident occurred. The CNA's statement also indicated that after the incidents occurred, she waited until the following morning to report the incidents to the Director of Nursing (DON). 3. Resident #2 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 12/21/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and exhibited no behaviors. a. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, dated 12/21/18 documented, .Date Incident Reported to OLTC . 12/21/18 . Date and Time of Incident . (Blank) . Date and Time of Discovery . 12/21/18 .When investigating another resident report of abuse, (Resident #2) commented that (LPN #1) hollered at him when he came into (Resident #2's) room and found him on the floor. (Resident #2) stated that (LPN #1), instead of helping him up, (LPN #2) laughed at him and left him in urine. On a second incident after falling, (Resident #2) stated that (LPN #1) told him to get off the phone when he was talking to his wife. (Resident #2) stated that (LPN #1) just sat on the bed while the 2 CNAs got him (the resident) up off the floor, not offering to help at all. (Resident #2) stated he felt belittled and shamed. (Resident #2's) wife stated when she was on the phone with her husband, (LPN #1) was heard scolding (Resident #2) for talking to her. She heard (LPN #1), in a hateful, rude way, tell (Resident #2) to get off the phone . He expressed that he was glad (LPN #1) was no longer at facility . Witness statements obtained from alert residents and staff. 5 additional residents expressed that (LPN #1) was sarcastic, mean, and rude when talking to them. Due to additional resident complaints in reference to (LPN #1) being rude, sarcastic, and mean, and (Resident #2's) wife hearing (LPN #1) as well, (LPN #1) has been terminated effective 12/21/18 . b. A Nurse's Note dated 12/18/18 at 4:05 a.m. and signed by LPN #1 documented, .Resident was found on floor with laceration to forehead. Resident had a substantial amount of blood on floor and clothing . Resident was Hoyer lifted from floor and complaining. Vitals were taken. 128/54 b/p (blood pressure), 64 pulse, 18 resp (respirations) 86% pulse ox (oxygen saturation) on room air. Resident informed his wife of transport to (hospital). Resident took bandages off head at this time. (Ambulance service) transport came and resident was taken to hospital. Report given to Charge Nurse at ER (emergency room ) dept (department) . c. A Nurse's Note dated 12/19/18 at 3:14 a.m. and signed by LPN #1 documented, .Resident fell on floor as he was trying to get to bathroom. Call light within reach. Resident got out of bed unassisted. Resident did not use call light or call for help. Resident called for help after the fact. Resident sent to (hospital) for observation. Resident transported by (ambulance service) . d. A Witness Statement dated 12/19/18 for Resident #2 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (LPN #1) hollered at (Resident #2). He (LPN #1) asked, how did you get over there to that bed. (Resident #2) explained to him that he slipped in his urine and slid over to the other bed. (Resident #2) asked (LPN #1) to help him out of the urine. (LPN #1) laughed and threw his hands up and walked out of his room. (LPN #1), per (Resident #2), told him to get off the phone. First fall . He wouldn't help him up and let (Resident #2) remain in urine uncovered. (Resident #2's) gown came off. (LPN #1) yanked on (Resident #2's) arm and told him to get up. Second fall . Fall and busted head. He (Resident #2) was on the phone with wife. (LPN #1) entered his room hollering at (Resident #2) 'get off the phone'. He told him he was calling his wife. He told him not to call, and (Resident #2) told (LPN #1) it was ok to call, and gave (LPN #1) her telephone number. The two ladies helped him with the (one lady just started) lift as (LPN #1) sat on the bed talking loudly to (Resident #1), stating he didn't understand how he made it to the other side of bed . Afterwards he (Resident #2) called son and informed son that he was scared. He felt scared because he (LPN #1) had acted unprofessional and rude to (Resident #2). (Resident #2) felt belittled and shamed. (Resident #2) had never experienced anything like that. He stated (LPN #1) has been the only rude one to him. He prefers him not to come around him . e. On 1/9/19 at 9:20 a.m., the resident was contacted via telephone and asked about his experience at the facility with LPN #1. He stated, Well, I got up out of bed and I couldn't make it to the bathroom. I peed and slipped in it and fell . He came in my room hollering at me and laughed at me, 'What are you doing over there?' He let me lay in it. I was so embarrassed and felt shamed. The next night, I fell and hit my head. Knocked a little hole in it. He wouldn't clean me up! I was on the phone with my wife, and he hollered at me to get off the phone with her. He was asked if he asked a CNA to stay with him due to being afraid of LPN #1. He stated, Yes, I did. He was asked why he was afraid. He stated, I don't know. I don't get scared like that too often. He was asked about the part of CNA #1's statement that documented he was being rolled out by the ambulance crew and he told LPN #1 that he didn't want him going anywhere with him. He stated, That's right. I told him that as they were taking me out. He was asked if he felt his treatment by LPN #1 was abuse. He stated, Yes. Wouldn't you? 4. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), and exhibited no behaviors. a. A Nurse's Note dated 12/18/18 at 7:38 a.m., and signed by LPN #1, documented, .Resident is unharmed r/t (related to) fall. Resident had no injuries. Resident was Hoyer lifted off of floor. Resident was placed back in wheelchair. No s/sx (signs / symptoms) of pain and / or distress of note. Will cont (continue) to observe . b. Resident #3 was referenced in CNA #1's witness statement (see paragraph 3), but was discharged from the facility on 12/18/18 (see paragraph 14). There was no witness statement from this resident, and the resident could not be reached for interview during the survey. 5. Resident #8 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/19/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required extensive assistance with activities of daily living. a. The Care Plan dated 10/25/18 documented, .I have been known to have a behavior problem of refusal of care, manipulative behaviors, false accusations and verbal abuse r/t (related to) poor impulse control, major [MEDICAL CONDITION] . b. A Witness Statement dated 12/19/18 for Resident #8 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? . 'Yes' (Resident #8) stated (LPN #1) has been very sarcastic to her while bringing her meds to her. The way he addressed her and his mannerism was not nice. (Resident #8) stated in the past he has given her OTC (over the counter) sleeping meds (medications) when she was taking prescribed pain pills. He stated to her, nobody stays awake on his shift . c. On 1/8/19 at 9:30 a.m., the resident was lying in bed. She was asked if she had ever had any issues with LPN #1. She stated, Oh! Oh my God! He should be in jail for some of the things he's done. He does not need to be a nurse. She was asked to explain. She stated, My niece came up here one day and as she was walking down the hall, she saw a resident on the floor. She went to find the nurse to report it, and (LPN #1) and a CNA came out of an empty room. I think we know what they were doing, but anyway, she reported to him there was a resident on the floor, and he yelled at her, and said, 'no there wasn't.' My niece got so upset. So, when she walked back by the room, they had put him (the resident) in bed and put the bed in the highest position it would go! She told them the bed should be in the lowest position with a mat on the floor. The next thing I know, (LPN #1) comes in here, grabs my gown up close to my neck, and tells me I'd better keep my mouth shut because me and my niece are going to get him fired. He needs to be in jail. There are so many things he has done. A resident who used to be here, she had Dementia. She would walk up and down the hall. One night I heard a CNA yelling at her to get in bed. Another CNA started yelling at that CNA that the resident would go to bed when she got ready. Then, (LPN #1) showed up and told them to leave the room. The next thing I hear is him yelling at that resident to stay in bed. The next day, I saw the resident. She was walking up the hall mumbling and crying, and she was black and blue all around her neck and upper chest area. I believe that was investigated. But they get together and get their stories straight before they talk to anyone. I'm so glad he isn't here anymore. She was asked if she felt the treatment she had received from the LPN was abuse, and she stated, Oh God, yes! I'm telling you, he should be in jail because he will wind up killing someone. She was asked if she reported this to anyone. She stated, Of course not. Are you serious? They already hate me here because I can talk and say what is going on . 6. Resident #4 had [DIAGNOSES REDACTED]. The 14 Day Medicare MDS with an ARD of 11/8/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required limited assistance with activities of daily living. a. The Care Plan dated 11/8/18 documented, .I have a potential psychosocial well-being problem r/t (related to) depression . I am known to make false accusations towards staff when things don't go my way . b. A Witness Statement dated 12/19/18 for Resident #4 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (Resident #4) dreads to see him come to work because he has told (Resident #4) that he knows (Resident #4) does not like him. (LPN #1) has been over 2 hours late administering (Resident #4) pain meds. (LPN #1) stated he had just finished dealing with a dead body and slammed his door. (Resident #4) states (LPN #1) placed his hand in his face and stated is he asking for a pill. (Resident #4) states (LPN #1) is the only nurse that treats him this way. On 12/18/18, (Resident #4) went to go smoke. (Resident #4) asked for pain meds (medications) because he was in pain. (LPN #1) stated to him he 'ain't going to get it' . (Resident #4) has overheard (LPN #1) fussing with other residents. The other day (Resident #4) observed (LPN #1) push an aide into a room . c. On 1/4/19 at 10:15 a.m., the resident was in his room watching television. He was asked about how LPN #1 had treated him. He stated, (LPN #1) treated me like (expletive, indicating feces). One example was, I was getting ready to go out and smoke, and I told (LPN #1) I was ready for my pain pill whenever. (LPN #1) said 'you ain't gonna get it.' He stuck his hand in my face. And I didn't get the pill until the next nurse came on. The resident was asked if he reported this to anyone and stated, There were several people around when he did that. And I reported it when they asked me. He was asked if he felt his treatment from the LPN was abuse. He stated, Yeah. He definitely should not be a nurse. It made me cry. The resident began sobbing. 7. Resident #5 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 12/11/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and had a [MEDICAL CONDITION]. a. A Witness Statement dated 12/19/18 for Resident #5 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (LPN #1) accused him of playing with his [MEDICAL CONDITION] bag. (Resident #5) stated to (LPN #1) that he didn't play with his bag. (Resident #5) stated (LPN #1) told him he was going to make (Resident #5) pay for playing with his bag. He left (Resident #5) in his chair with BM (bowel movement) running down his leg and chair for 30 minutes per (Resident #5). (Resident #5) would like another nurse. He stated (LPN #1) is very unprofessional and rude . b. On 1/7/19 at 9:30 a.m., the resident was lying in bed. He was asked if he had had any problems with LPN #1. He stated, Yes. He's awful. He was asked what he meant. He stated, I remember exactly what he said to me. The evening before, he had to change my [MEDICAL CONDITION] bag. And he didn't do it right, so it started leaking again. I was outside smoking, and I could hear it and smell it. So I came in and told him it needed to be changed. He said, 'You're going to pay for playing with that bag.' And then he let me sit in (expletive, indicating feces) for 30 minutes. It was running down my leg and chair. He was asked if he felt the treatment he received from the LPN was abuse. He stated, Yes. And I guarantee that's not the first time he's done something like that to someone. He's in the wrong line of work. He needs to be working on cars in a garage somewhere. But I wouldn't want him working on my car either . 8. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/19/18 documented the resident scored 12 (8-12 indicates moderate cognitive impairment) on a BIMS, required extensive assistance with activities of daily living, and had an indwelling urinary catheter. a. A Witness Statement dated 12/19/18 for Resident #6 documented, .Have you ever seen or heard (LPN #1) be verbally inappropriate to residents or other staff? 'Yes' . (Resident #6) stated (LPN #1) speaks to him sarcastically. (Resident #6) stated he has heard (LPN #1) talk to women and make the women cry. (Resident #6) stated that hearing (LPN #1) talk to people like that makes him upset . b. On 1/7/19 at 10:00 a.m., the resident was lying in bed. He was asked if he had ever had any problems with LPN #1. He stated, (LPN #1) . I don't much cotton to him. I don't like him. I don't even want him in my room. He was supposed to be tending to my catheter one time. I had on a pair of overalls. I may be blind, but I know when he went to empty the bag, he poured the urine on my overalls. This is all the resident would say about LPN #1. 9. On 1/3/19 at 4:25 p.m., the Administrator was asked if any staff had reported anything to her about LPN #1. She stated, No. The Administrator then provided copies of the 2 reports/investigations involving Resident #1 and Resident #2. After reviewing the documentation and seeing that other residents had made allegations against LPN #1, the Administrator was asked if she had reported these allegations to the Office of Long Term Care and other officials such as the Arkansas State Board of Nursing. She stated, No, I haven't. 10. On 1/3/19 at 4:56 p.m., the Director of Nursing (DON) was asked what CNA #1 had reported to her and stated, (CNA #1) has never reported anything to me about (LPN #1). (CNA #1) thought she was going to lose her job that night, because the nurse has to call me after every fall. That fall was on her hall. She called me saying she was going to go home because (LPN #1) was trying to blame her for the fall. I told her, no he wasn't. Then, she went to saying she heard his conversation with me. She had no idea what my part of the conversation was because she couldn't hear me. It wasn't even about her! At this time, part of CNA #1's witness statement that referred to the meeting she allegedly had with LPN #1 and CNA #1 that morning, was read to the DON. The DON stated, I got onto them two because they got into it. The reason she even came to me is because she thought (LPN #1) was going to come to me about her, so she wanted to get to me first. No resident name came up at all during our conversation. She was asked if any resident had complained to her about LPN #1. She stated, No. 11. On 1/4/19 at 9:45 a.m., LPN #2 was asked if she was involved with Resident #1 initially reporting the altercation between LPN #1 and CNA #1. She stated, Yes. I was here. (Resident #1) was calling me and calling me, so I was getting ready to go see her, and I am telling you, it wasn't nothing but the Lord. (Administrator) just happened to be on the hall that morning, and I asked her to go down to (Resident #1's) room with me. I didn't know what she wanted. She told (Administrator) about a big altercation between (LPN #1) and (CNA #1). (Administrator) asked her at any time during that altercation, were you not cared for, and she said, 'yes'. She said no one answered my light for a long time. She was asked if she had ever observed LPN #1 be inappropriate with any resident. She stated, I've never seen him be inappropriate with a resident, but he's made comments about residents to me. And comments to other people. The pharmacy lady would always bring me the meds (medications) because she said she couldn't deal with (LPN #1) because he would tell her 'for an older lady she's got a nice (expletive, indicating buttocks)'. 12. The time card and the Daily Assignments form for LPN #1, provided by the Administrator on 1/8/19 at 9:30 a.m., documented LPN #1 finished his 11:00 p.m. to 7:00 a.m. shift on 12/18/18, returned to work the 3:00 p.m. to 11:00 p.m. shift on 12/18/18 and was assigned the A Wing, and worked the 11:00 p.m. to 7:00 a.m. shift on 12/19/18 and was assigned the B Wing, clocking out at 7:14 a.m. He did not return to work after 12/19/18 at 7:14 a.m. There was no documentation in any of the facility's investigation reports or documented corrective actions to indicate residents were protected from further potential abuse by LPN #1 on the above 3 shifts. <br

Complaint # (AR 065) was substantiated, with these findings: Based on observation, record review and interview, the facility failed to ensure a mechanical lift and 2-staff assistance was provided during a transfer, as per the resident's assessed and care planned need, to prevent injury for 1 (Resident #3) of 3 (Residents #3, #4 and #5) case mix residents who required mechanical lift transfers. 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 manually transferred by one staff member and sustained a fracture to the right ankle, and had the potential to cause more than minimal harm to 2 residents who required mechanical lift transfers, as documented on a list provided by the Director of Nursing (DON) on 6/8/17 at 12:20 p.m. The Administrator was notified of the Past Immediate Jeopardy on 6/8/17 at 3:30 p.m. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/20/17 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS), was totally dependent on the assistance of 2 plus people with transfers, and had functional limitation in range of motion in the upper extremity on one side and the lower extremities on both sides. a. The Care Plan dated 7/22/16 documented, .At risk for injury (related to) falls related to gait / balance problems . Unaware of safety needs, dependent on staff for transfers x (times) 2 staff. Approaches: .Mechanical lift x 2 staff for transfers. b. Nurse's Notes dated 4/28/17 at 9:20 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, This nurse was summoned to resident room at approximately 3 p.m. to look at resident's foot. CNA (Certified Nursing Assistant #1) reports that something doesn't look right . Resident's RLE (right lower extremity) appeared swollen compared to the LLE (left lower extremity) . Entire foot from great toe to directly above the ankle is swollen. Upon further examination RLE foot noticeably drooping . Notified on call APN (Advanced Practice Nurse), received order at 3:15 p.m. for x-ray of foot and ankle. Mobile x-ray present at 5:45 p.m. Results obtained at 6:30 p.m. Notified APN, order received to send resident to emergency room for evaluation . Ambulance arrived at 7 p.m. c. An x-ray report dated 4/28/17 documented, (Resident #3) is a 81 (year old) female . presents to ED (Emergency Department) with c/o (complaints of) cold rt (right) foot with no pulse. She is bedridden and nonverbal and ED MD (Medical Doctor) noted pt (patient) to have Rt tib(tibia)/fib (fibula) fx (fracture) of X-ray. There was also a small abrasion to the right ankle and there appeared to be deformity to just above the right ankle. Further HPI (History of Present Illness) is limited at this point . Final Diagnoses: [REDACTED]. It is my medical opinion that this patient will require an acute care hospital stay for at least 2 mid-nights for treatment of [REDACTED]. d. An Office of Long Term Care (OLTC) Witness Statement form dated 4/28/17 at 2:35 p.m. and signed by CNA #4 documented, I .saw (CNA #1) lift (Resident #3) from wheelchair to bed. e. An OLTC Witness Statement form dated 4/29/17 at 7:45 a.m. and signed by CNA #2 documented, Resident was transferred by (CNA #1) without lift . I didn't assist with the transfer . other CNAs that was present didn't assist either. f. An OLTC Witness Statement form dated 4/29/17 at 8:02 a.m. and signed by CNA #1 documented, Went to use lift on resident and lift was not working so I transferred resident to bed with two other aids (CNAs) on the side of me . and noticed resident ankle swol (swollen) when I elevated her feet. Notified the nurse immediately. g. An OLTC Witness Statement form dated 4/29/17 at 8:23 a.m. and signed by CNA #3 documented, During the transfer, I was told the lift didn't work so after that I walked away from the wheelchair and the resident towards the other side of resident's bed. That's when (CNA #1) body lifted her from wheelchair to bed alone . h. The facility removed the immediate jeopardy and corrected the failed practices on 4/29/17, prior to the survey, as evidenced by the following: i.) A Quality Assurance Performance Improvement (QAPI) form documented CNA #1 was suspended on 4/28/17 during the facility's investigation, then terminated for gross misconduct on 5/3/17. ii.) A document dated 4/28/17 documented the DON checked the mechanical lift on A Hall on 4/28/17, which was reported as not working by CNA #1. The DON found no problems with the lift. The DON also interviewed multiple staff who stated they were not aware of any issues with the lift. iii.) A QAPI dated April 2017 documented CNAs #2, #3 and #4 were disciplined and re-educated on the facility's transfer policy. iv.) In-service documentation dated 4/29/17 documented multiple in-services were provided to staff through 5/5/17 on, .Residents must be transferred per their Care Plan. Residents are not to be body lifted . Use appropriate lift device on residents . Residents are not to be body lifted to wheelchair, bed, shower chair, etc (et cetera) . If lift is not working, go to another hall and get another lift. Make sure and charge batteries on lift after use. Refer to maintenance if unable to get to work at all . If you witness anyone not adhering to lift procedure please notify DON immediately . v.) A document dated 4/29/17 documented a list of all residents who were reassessed for proper transfer method on that date, as well as a review of their Care Plans to ensure their transfer method and level of assistance required were up to date. A document was also provided to indicate the residents' Closet Care Plans (utilized by CNAs to determine the care required for each resident) were updated on 4/29/17. vi.) A document dated 5/1/17 documented the Maintenance Director inspected the lift on A Hall again on 5/1/17 found no issues with the lift. vii.) On 6/7/17 at 4:20 p.m., and 6/8/17 at 12:00 p.m., the survey team conducted observations of staff utilizing the mechanical lift for transfers on Resident #7 and a non-case mix resident. The mechanical lift was in safe, proper working order and CNAs #10, #11, #14 and #15 all demonstrated proper use of the lift to conduct transfers without incident. All 4 CNAs were interviewed and stated they had received training on proper transfer techniques. viii.) On 6/9/17 at 10:45 p.m., the Human Resource Director provided documentation to demonstrate that all new hires employed by the facility had received transfer and mechanical lift training.

Complaint # (AR 958) was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to immediately report to the administrator a suspicious injury of unknown origin, failed to thoroughly investigate the suspicious injury of unknown origin and failed to report the suspicious injury to the Office of Long Term Care and the local police authorities in accordance with state law for one (Resident #1) case mix resident who was found with bruising around both eyes. The failed practices resulted in Immediate Jeopardy which could have resulted in serious harm or death for Resident #1 and had the potential to cause more than minimal harm for 33 residents residing on the C - Hall per the Census by Hall provided by the Director of Nursing (DON) on 2/23/15. The facility was notified of the Immediate Jeopardy on 2/26/15 at 2:30 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/15 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required no assistance with bed mobility, transfers and walking in her room and required supervision only for walking in corridor and locomotion on and off unit; and had no falls prior to assessment. a. On 2/24/15 at 1:00 p.m., Resident #1 had skin discoloration around both eyes. The resident was asked if she could tell the surveyor when and what had happened to cause the now fading bruises around her eyes. The resident was unable recall any event that caused her bruises at that time. b. Nurses Notes dated 2/14/15 (not time) and signed by Licensed Practical Nurse (LPN) #1 documented, " ...It was reported to this nurse that the resident had a blackened eye. Upon inspection, the (resident) was noted to have a bruised forehead and (right) periorbital areas. (Resident) stated that she wasn't in pain. Her vision is intact. At this time the (Resident) is ambulating throughout the unit (without) incident. (Resident) is unable to remember how her injuries occurred. DON (Director of Nursing), POA (Power of Attorney) and APN (Advanced Practice Nurse) on call notified of incident. 136/82, 72, 20, 98.4 (vital signs)..." 1) The facility's 'Bruise Investigation' report completed by LPN #1 documented, "(Page 1)...Resident Name: (Resident #1) ...Describe the Bruise: (Right) peri-orbital region and forehead; purplish in color ...Date Reported: 2/14/15 ...Time Reported 14:30 (2:30 p.m.) Resident Condition: Demented ...Does resident ambulate on own? (Yes) ...Review of medications (anticoagulants): ASA 81 mg (milligram) (one) po (by mouth) QD (everyday) ...Care Plan Reviewed/Revised as needed: (Yes) ...Nurses Notes Documented: (Yes) ... Administrator Notified: (not marked) ...Director of Nurses Notified: (Yes) ...Date: 2/14/15 Time: 14:30 (2:30 p.m.) ..." (Page 2) of the facility's 'Bruise Investigation' report was completed by the DON documented, " ...Caregiver/Employee Name: (CNA #7) ...Date: 2/15/15 Shift: 11-7 (11:00 p.m.-7:00 a.m.)...Response: ' (Resident #1) said she bumped her head on the wall when she was sitting down. ' (No) marks or bruises noted. (Resident) unreliable... Phone interview ...Caregiver/Employee Name: (CNA #6) Date: 2/15/15 Shift: 11 - 7 ...Response: ' (Resident #1) tripped and fell back in her chair and bumped her head on the wall. She did not have any bumps on her head. I didn't realize she hit her head hard. ' Caregiver/Employee Name: (LPN #1) Date: 2/15/15 Shift: 11 - 7 Response: ' I checked (Resident #1) she did not have any red marks or bumps on her head. Neuro's and vitals checked were done. On call MD (Medical Doctor) was notified. No other orders were written. ' Bruises to peri orbital area; Phone interview ... In my professional opinion, no abuse, neglect or mistreatment occurred. (Signed by DON) ... Further Investigation required: (Signed by DON) dated: 2/15/15 ...Details of investigation and resolution: (Resident) was observed ambulating in her room and as the staff passed the door. (Resident) was attempting to sit in chair - feet hit chair leg and (resident) fell backwards onto chair and (her) head hit wall - No immediate injury noted. Then later her eyes started bruising - checked again per MD after being notified by LPN #1 notified MD on call - checked by MD #1 (no) new orders noted ...(signed by DON dated: 2/16/15). " c. On 2/25/15 at 9:50 a.m., the Administrator (DOH 2/9/15) was asked if a reportable had been done for (Resident #1) on 2/14/15 when it was first documented the resident had bilateral bruising of both eyes with injury of unknown origin. The Administrator stated the DON was taking care of 'that situation' because she (Administrator) was not aware that she (Resident #1) had injuries of unknown origin. d. On 2/26/15 at 10:00 a.m., the DON was asked if the incident was reported to the Office of Long Term Care for Resident #1 on 2/14/15. She stated, " The Administrator usually initiates a reportable, but we did not do a reportable because I had received a verbal statement from (CNA #6) via a phone interview the following day informing me that she had witnessed (Resident #1) tripping on her chair and falling down in her chair and bumping the back of her head on the wall early (between 5:00 a.m. and 6:00 a.m.) that morning." The DON was asked if (CNA #6) had reported that incident to anyone prior to telling her (DON) a day later. The DON stated, "No, but she no longer works here. She was a no call no show a couple days after that incident during the ice storm." e. On 2/25/15 at 10:40 a.m., the DON reported that MD #1 was currently in the building and that she had spoken with her in regards to the incident with (Resident #1) on 2/14/15. The DON stated, "(MD #1) said she was not notified (of the incident) and that she had not assessed (Resident #1) after the incident because she had not been on call that weekend; and added they must have called the APN. The DON stated, "That is not what LPN #1 told me when I was investigating the next day. I understood that she had called MD #1 and that she (MD #1) was either here at that time or came in immediately to assess (Resident #1) after being informed of incident. I did not look for physician progress notes [REDACTED]." f. On 2/25/15 at 10:45 a.m., MD #1 was asked if she had been notified of the incident on 2/14/15 involving (Resident #1) and if so did she (MD #1) come in and assess her (Resident #1). MD #1 stated, "No, I was not aware of it until now. I was not on call that weekend. They must have called my APN. I'm going to see her today because her injuries are not consistent with the witness statement from one of the CNAs that they witnessed her tripping and falling back in her chair and hitting the back of her head." g. On 2/25/15 at 11:00 a.m., the DON was asked if she believed the injuries to (Resident #1) were consistent with the witness statement from (CNA #6). She said, "No." The DON was asked if she thought that she should have initiated a more thorough investigation immediately since no one was able to give a valid explanation of how (Resident #1) could have sustained such injuries? She stated, "Yes." The DON was asked if she thought based on current information, a reportable should have been initiated? The DON stated, "Yes" h. On 2/26/15 at 10:35 a.m., CNA #1 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I do not know what happened. I noticed her black eyes around lunch time (2/14/15). I was in her room that morning but she was in bed curled up and asleep. I did not notice her eyes at that time. I did not work the day before but I do know she did not have those black eyes the last time I worked with her. I reported her black eyes to (LPN #1) as soon as I noticed (the bruises). " i. On 2/26/15 at 10:45 a.m., CNA #2 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I have no idea how she got her black eyes. The last day I saw her she wasn't like that. The first time I noticed was when I was getting her up for lunch on (2/14/15). She sleeps all day if you let her; she's asleep right now. I don't remember seeing her eyes before then (lunch) that morning." j. On 2/26/15 at 11:00 a.m., LPN #1 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know how it happened. One of the CNA's came and told me about it around noon. I had been in her room that morning to give mid-morning medications and did not notice her eyes but she was lying down at the foot of her bed, half on her belly and half on her left side facing the wall. She only leaned up on her left elbow and only partly looked back over her right shoulder. The room was dark and I did not notice her eyes. When I assessed her it was slightly red and yellowish only around her right eye and up that side of her forehead. At that time I wondered how this could have happened but she does have [MEDICAL CONDITION] and it could have occurred by falling. I initiated neuro checks immediately and they remained normal throughout my shift. I notified the on call doctor, POA and DON. I did not tell anyone that she was seen by the doctor. I did tell the POA I was sure they would check it out to see what happened but that she was okay." k. On 2/26/15 at 11:40 a.m., CNA #5 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I saw her at breakfast that morning. They were black then. (CNA #1) brought it to my attention. She told the nurse about it. We did not know how it happened." l. On 2/26/15 at 11:42 a.m., CNA #3 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know; I worked the 11-7 shift on (2/13/15) and there wasn't nothing wrong with her eyes when I left work at 7:00 a.m. the next morning. I didn't work the next night but I was called by a co-worker (name not given) and told that night she had two black eyes." m. On 2/26/15 at 11:45 a.m., CNA #4 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know what happened. I worked the 3 -11 and the 11-7 shifts on (2/13/15). When I left at 7:00 a.m. the next morning her eyes were not like that. All we had to do with her the night before was to keep her clothes on her. When I came in at 3:00 p.m. on (2/14/15) she had the black eyes and no one could tell me how it happened." 2. On 2/26/15 at 3:15 p.m., the facility removed the Immediate Jeopardy and reduced the scope/severity to " G " implementing the following plan of removal: a. Upon discovery of the incident all residents on C-Hall were given body audits on 2/25/15 by nursing staff to ensure no injuries of unknown origin went unreported with no negative findings. All staff was in serviced on reporting witnessed and unwitnessed events immediately to charge nurse, DON and Administrator by Nurse Consultant on 2/26/15 to ensure all injuries are reported and investigated in a timely manner. b. Nurse consultant reviewed I & A (Incident and Accident) log for past six months on 2/26/15 to ensure no injuries of unknown origins went unreported with no negative findings. c. All residents on C-Hall with the BIMS level above 10 were interviewed on 2/26/15 by Social Services Director and asked if anyone ever hit, pushed, talked badly to you or hurt you in anyway with no negative findings. d. All staff will be in serviced by DON starting on 2/26/15 and prior to next scheduled work shift, as well as all new hires and staff returning from leave, on reporting immediately any suspected abuse, injuries of unknown origins or neglect to supervisor, DON and Administrator to ensure all events are reported and investigated in a timely manner. e. DON/Designee will review all I & A's daily for the next two weeks and three times a week thereafter to ensure injuries of unknown origins are reported and investigated in a timely manner and upon discovery any negative findings will be corrected immediately and DON/Designee will report findings to the monthly QA&A (Quality Assurance and Accountability) Committee for follow-up and recommendations.

Complaint # (AR 958) was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure established policy and procedures to prevent abuse were implemented for 1 of 1 (Resident #1) case mix residents who had a suspicious injury of unknown origin. The failed practice resulted in Immediate Jeopardy which could have resulted in serious harm or death for Resident #1 and had the potential to cause more than minimal harm for 33 residents residing on the C - Hall per the Census by Hall provided by the Director of Nursing (DON) on 2/23/15. The facility was notified of the Immediate Jeopardy on 2/26/15 at 2:30 p.m. The findings are: 1. The facility's policy and procedure titled 'Resident Abuse' provided by the Administrator on 2/26/15 at 10:25 a.m. documented, "...Subject: Resident Abuse - Injuries of Unknown Origin...Procedures: 3. The Administrator and Director of Nursing are to be notified immediately....4. Notification MUST be made to the following: a. Resident's responsible party...b. Physician... 5. The Administrator, Director of Nursing or their designee, must begin a documented investigation include interviews with the resident of the cause of the injury....6. The investigation will include interviews with the resident, all staff involved, any family, visitors, or volunteers which may have had contact with the resident and may help with the investigation. Obtain written statements as deemed necessary...7. The Director of Nursing and/or Administrator must notify the Regional Clinical Director (RCD)...8. All injuries of unknown origin must be reported to the appropriate agencies per state specific protocols. " 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/15 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required no assistance with bed mobility, transfers and walking in her room and required supervision only for walking in corridor and locomotion on and off unit; and had no falls prior to assessment. a. On 2/24/15 at 1:00 p.m., Resident #1 had skin discoloration around both eyes. The resident was asked if she could tell the surveyor when and what had happened to cause the now fading bruises around her eyes. The resident was unable recall any event that caused her bruises at that time. b. Nurses Notes dated 2/14/15 (not time) and signed by Licensed Practical Nurse (LPN) #1 documented, " ...It was reported to this nurse that the resident had a blackened eye. Upon inspection, the (resident) was noted to have a bruised forehead and (right) periorbital areas. (Resident) stated that she wasn't in pain. Her vision is intact. At this time the (Resident) is ambulating throughout the unit (without) incident. (Resident) is unable to remember how her injuries occurred. DON (Director of Nursing), POA (Power of Attorney) and APN (Advanced Practice Nurse) on call notified of incident. 136/82, 72, 20, 98.4 (vital signs)..." 1) The facility's 'Bruise Investigation' report completed by LPN #1 documented, "(Page 1)...Resident Name: (Resident #1) ...Describe the Bruise: (Right) peri-orbital region and forehead; purplish in color ...Date Reported: 2/14/15 ...Time Reported 14:30 (2:30 p.m.) Resident Condition: Demented ...Does resident ambulate on own? (Yes) ...Review of medications (anticoagulants): ASA 81 mg (milligram) (one) po (by mouth) QD (everyday) ...Care Plan Reviewed/Revised as needed: (Yes) ...Nurses Notes Documented: (Yes) ... Administrator Notified: (not marked) ...Director of Nurses Notified: (Yes) ...Date: 2/14/15 Time: 14:30 (2:30 p.m.) ..." (Page 2) of the facility's 'Bruise Investigation' report was completed by the DON documented, " ...Caregiver/Employee Name: (CNA #7) ...Date: 2/15/15 Shift: 11-7 (11:00 p.m.-7:00 a.m.)...Response: ' (Resident #1) said she bumped her head on the wall when she was sitting down. ' (No) marks or bruises noted. (Resident) unreliable... Phone interview ...Caregiver/Employee Name: (CNA #6) Date: 2/15/15 Shift: 11 - 7 ...Response: ' (Resident #1) tripped and fell back in her chair and bumped her head on the wall. She did not have any bumps on her head. I didn't realize she hit her head hard. ' Caregiver/Employee Name: (LPN #1) Date: 2/15/15 Shift: 11 - 7 Response: ' I checked (Resident #1) she did not have any red marks or bumps on her head. Neuro's and vitals checked were done. On call MD (Medical Doctor) was notified. No other orders were written. ' Bruises to peri orbital area; Phone interview ... In my professional opinion, no abuse, neglect or mistreatment occurred. (Signed by DON) ... Further Investigation required: (Signed by DON) dated: 2/15/15 ...Details of investigation and resolution: (Resident) was observed ambulating in her room and as the staff passed the door. (Resident) was attempting to sit in chair - feet hit chair leg and (resident) fell backwards onto chair and (her) head hit wall - No immediate injury noted. Then later her eyes started bruising - checked again per MD after being notified by LPN #1 notified MD on call - checked by MD #1 (no) new orders noted ...(signed by DON dated: 2/16/15). " c. On 2/25/15 at 9:50 a.m., the Administrator (DOH 2/9/15) was asked if a reportable had been done for (Resident #1) on 2/14/15 when it was first documented the resident had bilateral bruising of both eyes with injury of unknown origin. The Administrator stated the DON was taking care of 'that situation' because she (Administrator) was not aware that she (Resident #1) had injuries of unknown origin. d. On 2/26/15 at 10:00 a.m., the DON was asked if the incident was reported to the Office of Long Term Care for Resident #1 on 2/14/15. She stated, " The Administrator usually initiates a reportable, but we did not do a reportable because I had received a verbal statement from (CNA #6) via a phone interview the following day informing me that she had witnessed (Resident #1) tripping on her chair and falling down in her chair and bumping the back of her head on the wall early (between 5:00 a.m. and 6:00 a.m.) that morning." The DON was asked if (CNA #6) had reported that incident to anyone prior to telling her (DON) a day later. The DON stated, "No, but she no longer works here. She was a no call no show a couple days after that incident during the ice storm." e. On 2/25/15 at 10:40 a.m., the DON reported that MD #1 was currently in the building and that she had spoken with her in regards to the incident with (Resident #1) on 2/14/15. The DON stated, "(MD #1) said she was not notified (of the incident) and that she had not assessed (Resident #1) after the incident because she had not been on call that weekend; and added they must have called the APN. The DON stated, "That is not what LPN #1 told me when I was investigating the next day. I understood that she had called MD #1 and that she (MD #1) was either here at that time or came in immediately to assess (Resident #1) after being informed of incident. I did not look for physician progress notes [REDACTED]." f. On 2/25/15 at 10:45 a.m., MD #1 was asked if she had been notified of the incident on 2/14/15 involving (Resident #1) and if so did she (MD #1) come in and assess her (Resident #1). MD #1 stated, "No, I was not aware of it until now. I was not on call that weekend. They must have called my APN. I'm going to see her today because her injuries are not consistent with the witness statement from one of the CNAs that they witnessed her tripping and falling back in her chair and hitting the back of her head." g. On 2/25/15 at 11:00 a.m., the DON was asked if she believed the injuries to (Resident #1) were consistent with the witness statement from (CNA #6). She said, "No." The DON was asked if she thought that she should have initiated a more thorough investigation immediately since no one was able to give a valid explanation of how (Resident #1) could have sustained such injuries? She stated, "Yes." The DON was asked if she thought based on current information, a reportable should have been initiated? The DON stated, "Yes" h. On 2/26/15 at 10:35 a.m., CNA #1 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I do not know what happened. I noticed her black eyes around lunch time (2/14/15). I was in her room that morning but she was in bed curled up and asleep. I did not notice her eyes at that time. I did not work the day before but I do know she did not have those black eyes the last time I worked with her. I reported her black eyes to (LPN #1) as soon as I noticed (the bruises). " i. On 2/26/15 at 10:45 a.m., CNA #2 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I have no idea how she got her black eyes. The last day I saw her she wasn't like that. The first time I noticed was when I was getting her up for lunch on (2/14/15). She sleeps all day if you let her; she's asleep right now. I don't remember seeing her eyes before then (lunch) that morning." j. On 2/26/15 at 11:00 a.m., LPN #1 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know how it happened. One of the CNA's came and told me about it around noon. I had been in her room that morning to give mid-morning medications and did not notice her eyes but she was lying down at the foot of her bed, half on her belly and half on her left side facing the wall. She only leaned up on her left elbow and only partly looked back over her right shoulder. The room was dark and I did not notice her eyes. When I assessed her it was slightly red and yellowish only around her right eye and up that side of her forehead. At that time I wondered how this could have happened but she does have [MEDICAL CONDITION] and it could have occurred by falling. I initiated neuro checks immediately and they remained normal throughout my shift. I notified the on call doctor, POA and DON. I did not tell anyone that she was seen by the doctor. I did tell the POA I was sure they would check it out to see what happened but that she was okay." k. On 2/26/15 at 11:40 a.m., CNA #5 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I saw her at breakfast that morning. They were black then. (CNA #1) brought it to my attention. She told the nurse about it. We did not know how it happened." l. On 2/26/15 at 11:42 a.m., CNA #3 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know; I worked the 11-7 shift on (2/13/15) and there wasn't nothing wrong with her eyes when I left work at 7:00 a.m. the next morning. I didn't work the next night but I was called by a co-worker (name not given) and told that night she had two black eyes." m. On 2/26/15 at 11:45 a.m., CNA #4 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know what happened. I worked the 3 -11 and the 11-7 shifts on (2/13/15). When I left at 7:00 a.m. the next morning her eyes were not like that. All we had to do with her the night before was to keep her clothes on her. When I came in at 3:00 p.m. on (2/14/15) she had the black eyes and no one could tell me how it happened." 3. On 2/26/15 at 3:15 p.m., the facility removed the Immediate Jeopardy and reduced the scope/severity to "G" by implementing the following plan of removal: a. Upon discovery of the incident all residents on C-Hall were given body audits on 2/25/15 by nursing staff to ensure no injuries of unknown origin went unreported with no negative findings. All staff was in serviced on reporting witnessed and unwitnessed events immediately to charge nurse, DON and Administrator by Nurse Consultant on 2/26/15 to ensure all injuries are reported and investigated in a timely manner. b. Nurse consultant reviewed I & A (Incident and Accident) log for past six months on 2/26/15 to ensure no injuries of unknown origins went unreported with no negative findings. c. All residents on C-Hall with the BIMS level above 10 were interviewed on 2/26/15 by Social Services Director and asked if anyone ever hit, pushed, talked badly to you or hurt you in anyway with no negative findings. d. All staff will be in serviced by DON starting on 2/26/15 and prior to next scheduled work shift, as well as all new hires and staff returning from leave, on reporting immediately any suspected abuse, injuries of unknown origins or neglect to supervisor, DON and Administrator to ensure all events are reported and investigated in a timely manner. e. DON/Designee will review all I & A's daily for the next two weeks and three times a week thereafter to ensure injuries of unknown origins are reported and investigated in a timely manner and upon discovery any negative findings will be corrected immediately and DON/Designee will report findings to the monthly QA&A (Quality Assurance and Accountability) Committee for follow-up and recommendations.

Complaint # (AR 958) was substantiated (all or in part) with these findings. Based on observation, record review and interview, Nursing Administration failed to ensure established policy and procedures to prevent abuse were implemented for 1 of 1 (Resident #1) case mix residents who had a suspicious injury of unknown origin. The failed practice resulted in Immediate Jeopardy which could have resulted in serious harm or death for Resident #1 and had the potential to cause more than minimal harm for 33 residents residing on the C - Hall per the Census by Hall provided by the Director of Nursing (DON) on 2/23/15. The facility was notified of the Immediate Jeopardy on 2/26/15 at 2:30 p.m. The findings are: 1. The facility's job description titled 'Director of Nursing' provided by the Administrator on 2/26/15 at 2:10 p.m. documented, "...Summary: Responsible for organizing, planning, directing, and evaluating nursing and other resident care services...Essential Duties and Responsibilities: ...Manages State survey process and complaint survey investigations...Oversees State Incident reporting to assure complete investigation and intervention. " 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/15 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required no assistance with bed mobility, transfers and walking in her room and required supervision only for walking in corridor and locomotion on and off unit; and had no falls prior to assessment. a. On 2/24/15 at 1:00 p.m., Resident #1 had skin discoloration around both eyes. The resident was asked if she could tell the surveyor when and what had happened to cause the now fading bruises around her eyes. The resident was unable recall any event that caused her bruises at that time. b. Nurses Notes dated 2/14/15 (not time) and signed by Licensed Practical Nurse (LPN) #1 documented, " ...It was reported to this nurse that the resident had a blackened eye. Upon inspection, the (resident) was noted to have a bruised forehead and (right) periorbital areas. (Resident) stated that she wasn't in pain. Her vision is intact. At this time the (Resident) is ambulating throughout the unit (without) incident. (Resident) is unable to remember how her injuries occurred. DON (Director of Nursing), POA (Power of Attorney) and APN (Advanced Practice Nurse) on call notified of incident. 136/82, 72, 20, 98.4 (vital signs)..." 1) The facility's 'Bruise Investigation' report completed by LPN #1 documented, "(Page 1)...Resident Name: (Resident #1) ...Describe the Bruise: (Right) peri-orbital region and forehead; purplish in color ...Date Reported: 2/14/15 ...Time Reported 14:30 (2:30 p.m.) Resident Condition: Demented ...Does resident ambulate on own? (Yes) ...Review of medications (anticoagulants): ASA 81 mg (milligram) (one) po (by mouth) QD (everyday) ...Care Plan Reviewed/Revised as needed: (Yes) ...Nurses Notes Documented: (Yes) ... Administrator Notified: (not marked) ...Director of Nurses Notified: (Yes) ...Date: 2/14/15 Time: 14:30 (2:30 p.m.) ..." (Page 2) of the facility's 'Bruise Investigation' report was completed by the DON documented, " ...Caregiver/Employee Name: (CNA #7) ...Date: 2/15/15 Shift: 11-7 (11:00 p.m.-7:00 a.m.)...Response: ' (Resident #1) said she bumped her head on the wall when she was sitting down. ' (No) marks or bruises noted. (Resident) unreliable... Phone interview ...Caregiver/Employee Name: (CNA #6) Date: 2/15/15 Shift: 11 - 7 ...Response: ' (Resident #1) tripped and fell back in her chair and bumped her head on the wall. She did not have any bumps on her head. I didn't realize she hit her head hard. ' Caregiver/Employee Name: (LPN #1) Date: 2/15/15 Shift: 11 - 7 Response: ' I checked (Resident #1) she did not have any red marks or bumps on her head. Neuro's and vitals checked were done. On call MD (Medical Doctor) was notified. No other orders were written. ' Bruises to peri orbital area; Phone interview ... In my professional opinion, no abuse, neglect or mistreatment occurred. (Signed by DON) ... Further Investigation required: (Signed by DON) dated: 2/15/15 ...Details of investigation and resolution: (Resident) was observed ambulating in her room and as the staff passed the door. (Resident) was attempting to sit in chair - feet hit chair leg and (resident) fell backwards onto chair and (her) head hit wall - No immediate injury noted. Then later her eyes started bruising - checked again per MD after being notified by LPN #1 notified MD on call - checked by MD #1 (no) new orders noted ...(signed by DON dated: 2/16/15). " c. On 2/25/15 at 9:50 a.m., the Administrator (DOH 2/9/15) was asked if a reportable had been done for (Resident #1) on 2/14/15 when it was first documented the resident had bilateral bruising of both eyes with injury of unknown origin. The Administrator stated the DON was taking care of 'that situation' because she (Administrator) was not aware that she (Resident #1) had injuries of unknown origin. d. On 2/26/15 at 10:00 a.m., the DON was asked if the incident was reported to the Office of Long Term Care for Resident #1 on 2/14/15. She stated, " The Administrator usually initiates a reportable, but we did not do a reportable because I had received a verbal statement from (CNA #6) via a phone interview the following day informing me that she had witnessed (Resident #1) tripping on her chair and falling down in her chair and bumping the back of her head on the wall early (between 5:00 a.m. and 6:00 a.m.) that morning." The DON was asked if (CNA #6) had reported that incident to anyone prior to telling her (DON) a day later. The DON stated, "No, but she no longer works here. She was a no call no show a couple days after that incident during the ice storm." e. On 2/25/15 at 10:40 a.m., the DON reported that MD #1 was currently in the building and that she had spoken with her in regards to the incident with (Resident #1) on 2/14/15. The DON stated, "(MD #1) said she was not notified (of the incident) and that she had not assessed (Resident #1) after the incident because she had not been on call that weekend; and added they must have called the APN. The DON stated, "That is not what LPN #1 told me when I was investigating the next day. I understood that she had called MD #1 and that she (MD #1) was either here at that time or came in immediately to assess (Resident #1) after being informed of incident. I did not look for physician progress notes [REDACTED]." f. On 2/25/15 at 10:45 a.m., MD #1 was asked if she had been notified of the incident on 2/14/15 involving (Resident #1) and if so did she (MD #1) come in and assess her (Resident #1). MD #1 stated, "No, I was not aware of it until now. I was not on call that weekend. They must have called my APN. I'm going to see her today because her injuries are not consistent with the witness statement from one of the CNAs that they witnessed her tripping and falling back in her chair and hitting the back of her head." g. On 2/25/15 at 11:00 a.m., the DON was asked if she believed the injuries to (Resident #1) were consistent with the witness statement from (CNA #6). She said, "No." The DON was asked if she thought that she should have initiated a more thorough investigation immediately since no one was able to give a valid explanation of how (Resident #1) could have sustained such injuries? She stated, "Yes." The DON was asked if she thought based on current information, a reportable should have been initiated? The DON stated, "Yes" h. On 2/26/15 at 10:35 a.m., CNA #1 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I do not know what happened. I noticed her black eyes around lunch time (2/14/15). I was in her room that morning but she was in bed curled up and asleep. I did not notice her eyes at that time. I did not work the day before but I do know she did not have those black eyes the last time I worked with her. I reported her black eyes to (LPN #1) as soon as I noticed (the bruises). " i. On 2/26/15 at 10:45 a.m., CNA #2 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I have no idea how she got her black eyes. The last day I saw her she wasn't like that. The first time I noticed was when I was getting her up for lunch on (2/14/15). She sleeps all day if you let her; she's asleep right now. I don't remember seeing her eyes before then (lunch) that morning." j. On 2/26/15 at 11:00 a.m., LPN #1 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know how it happened. One of the CNA's came and told me about it around noon. I had been in her room that morning to give mid-morning medications and did not notice her eyes but she was lying down at the foot of her bed, half on her belly and half on her left side facing the wall. She only leaned up on her left elbow and only partly looked back over her right shoulder. The room was dark and I did not notice her eyes. When I assessed her it was slightly red and yellowish only around her right eye and up that side of her forehead. At that time I wondered how this could have happened but she does have [MEDICAL CONDITION] and it could have occurred by falling. I initiated neuro checks immediately and they remained normal throughout my shift. I notified the on call doctor, POA and DON. I did not tell anyone that she was seen by the doctor. I did tell the POA I was sure they would check it out to see what happened but that she was okay." k. On 2/26/15 at 11:40 a.m., CNA #5 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I saw her at breakfast that morning. They were black then. (CNA #1) brought it to my attention. She told the nurse about it. We did not know how it happened." l. On 2/26/15 at 11:42 a.m., CNA #3 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know; I worked the 11-7 shift on (2/13/15) and there wasn't nothing wrong with her eyes when I left work at 7:00 a.m. the next morning. I didn't work the next night but I was called by a co-worker (name not given) and told that night she had two black eyes." m. On 2/26/15 at 11:45 a.m., CNA #4 was asked if she knew how (Resident #1) had sustained two black eyes? She stated, "I don't know what happened. I worked the 3 -11 and the 11-7 shifts on (2/13/15). When I left at 7:00 a.m. the next morning her eyes were not like that. All we had to do with her the night before was to keep her clothes on her. When I came in at 3:00 p.m. on (2/14/15) she had the black eyes and no one could tell me how it happened." 3. On 2/26/15 at 3:15 p.m., the facility removed the Immediate Jeopardy and reduced the scope/severity to "G" by implementing the following plan of removal: a. Upon discovery of the incident all residents on C-Hall were given body audits on 2/25/15 by nursing staff to ensure no injuries of unknown origin went unreported with no negative findings. All staff was in serviced on reporting witnessed and unwitnessed events immediately to charge nurse, DON and Administrator by Nurse Consultant on 2/26/15 to ensure all injuries are reported and investigated in a timely manner. b. Nurse consultant reviewed I & A (Incident and Accident) log for past six months on 2/26/15 to ensure no injuries of unknown origins went unreported with no negative findings. c. All residents on C-Hall with the BIMS level above 10 were interviewed on 2/26/15 by Social Services Director and asked if anyone ever hit, pushed, talked badly to you or hurt you in anyway with no negative findings. d. All staff will be in serviced by DON starting on 2/26/15 and prior to next scheduled work shift, as well as all new hires and staff returning from leave, on reporting immediately any suspected abuse, injuries of unknown origins or neglect to supervisor, DON and Administrator to ensure all events are reported and investigated in a timely manner. e. DON/Designee will review all I & A's daily for the next two weeks and three times a week thereafter to ensure injuries of unknown origins are reported and investigated in a timely manner and upon discovery any negative findings will be corrected immediately and DON/Designee will report findings to the monthly QA&A (Quality Assurance and Accountability) Committee for follow-up and recommendations.

Complaint # and was substantiated (all or in part) with these findings: A. Based on observation, record review and interview, the facility failed to ensure that Resident #1 received the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure laboratory orders for [MEDICATION NAME]/International Normalized Ratio (PT/INR) was drawn as ordered to promptly identify indicators of unsafe level of anticoagulant therapy, to monitor the therapeutic effectiveness, and to aid the physician in the management of the dosage for 1 (Resident #1) of 3 (Resident's #1, 5 and 6) case mix residents who had orders for anticoagulant therapy. These failed practices resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was admitted to the hospital with [REDACTED].#1on 9/25/12 at 12:00 p.m. The facility Administration was informed of the Immediate Jeopardy on 9/28/12 at 3:07 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 8/15/12 documented, the resident scored 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, required extensive assistance of one staff member for most Activities of Daily Living (ADL's) and received anticoagulant therapy in the last 7 days. a. The August 2012 Physician order [REDACTED]. " b. A lab report dated 7/9/12 documented the following results: PT ([MEDICATION NAME]) 23.2 H (High) reference range seconds 9.4 -12.5 INR(international normalized ratio) 2.30 H reference range ratio 0.8 - 1.2. " The July 2012 Physician order [REDACTED]. c. The August 2012 Physicians Order sheet documented, " ...PTI ([MEDICATION NAME]/International Normalized Ratio) every Mondays - Complex ...Start Date 7/13/12. " As of 9/24/12, there were no lab results in the clinical record for the weekly PTI for 7/16/12, 7/23/12, 7/30/12 or 8/6/12. d. On 9/25/12 at 2:45 p.m., the Interim Director of Nursing (DON) was informed that surveyor could not find any nurses notes after 7/4/12 until 8/7/12 in the resident's clinical record. As of 9/26/12 at 10:45 a.m., no nurses notes were found after 7/4/12 until 8/7/12. A Nurses Note dated 8/7/12 documented, "...Physician #1 here N.O. (New Order) noted pharmacy aware. Lab notified of lab draw for 8/13/12." A telephone order dated 8/7/12 documented, " ...Check INR (check) BMP (basic metabolic panel) on Monday." e. A lab report dated 8/13/12 documented the following results: PT ([MEDICATION NAME]) 36.9 H (High) (reference range) 12.5-15.9 seconds INR(international normalized ratio) 2.7 (reference range) 2.0-3.5. " The August 2012 Physician order [REDACTED]. f. As of 9/24/12, there were no lab results in the clinical record for the weekly PTI for 8/20/12, 8/27/12, or 9/3/12. 1) On 9/25/12 at 2:45 p.m., the Interim Director of Nursing (DON) was asked to find the most recent PT/INR report prior to resident's transfer to the hospital on [DATE]. She confirmed 8/13/12 as the most recent PT/INR prior to hospitalization . The Interim DON was asked if she had been able to find a physician order [REDACTED]. The Interim DON was informed that the August 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. As of 9/27/12 at 10:00 a.m., the August 2012 MAR indicated [REDACTED] 2) On 9/28/12 at 11:22 a.m., the Medical Director (Physician #1) was interviewed and stated, " ... I haven't been getting my labs on time. If I ask the facility, I get the lab results ...I keep every Monday a standing order for PT/INRs. When I become more comfortable, then change to every 2 weeks but with (Resident #1) that has not been the case. I have told the Administrator my problems and had recently tried to get through to Corporate since I was getting nowhere with the previous Administrator." g. The Resident ' s Care Plan documented, "...Focus: Resident is at risk for bleeding r/t (related to) usage of [MEDICATION NAME] Date initiated 8/28/2012....Goal PT/INR results will be within therapeutic ranges and will be maintained for resident..." h. Nurses Note dated 9/10/12 at 0330 (3:30 a.m.) documented, "...CNA (Certified Nurse Assistant) reported bleeding from rectum area, resident c/o (complained of) stomach ache, abdomen felt tender to touch, toilet where resident used bathroom filled with brisket red blood - MD (Medical Doctor) paged - N.O. Send to ER (emergency room ). i. The Hospital Discharge Note dated 9/17/12 documented, " HPI (History and Physical Information): admitted from NH (Nursing Home) with LGIB (Lower [MEDICAL CONDITION]). Pt (Patient) had grossly bloody stools x 3 and some cramping in LLQ (left lower quadrant) abdominal pain...She is on [MEDICATION NAME] daily...At 9/10/12 at 0540 (5:40 a.m.) RBC (red blood cells) 3.64 L (low) (normals 4.10 - 5.0), Hgb (Hemoglobin) 8.6 L (normals 12.0 - 16.0), Hct (Hematocrit) 27.5 L (normals 36.0 - 48.0), PTS ([MEDICATION NAME]) 34.2 H (normals 8.8-12.0), INR (International Normalized Ratio) = 3.2 (Low intensity range 2.0-3.0. High intensity range 2.5 - 3.5), APTTS (Activated Partial [MEDICAL CONDITION] Time)= 34.4 sec (H) (normals 20.0 - 31.0), Occult Blood = Positive...9/10/12 at 1126 (11:26 a.m.) received 2 units PRBC (Packed Red Blood Cells) and 2 units PRBC at 1417 (2:17 p.m.)." g. Nurses Notes dated 9/15/12 at 12:30 p.m., documented the resident was readmitted to the facility. The admission orders ...Diagnosis: [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 5mg tablet po i (one) daily...Labs: (was blank, no labs were ordered)..." The September 2012 MAR indicated [REDACTED]. h. A physician progress notes [REDACTED]. She was anemic from GI bleed with H/H (Hemoglobin /Hematocrit) down to Hgb 8/Hct 27.2. She received blood [MEDICAL CONDITION]. She was complaining of [MEDICAL CONDITION] pain during hospital stay. She is still reporting LLQ pain to a lesser extent. Pain is exacerbated with deep breathing, not modified by meals or position. She denies any trauma. She has no bleed since return...Assessment and Plan: Hematochezia ? (questionable) Diverticular disease. She is at risk for GI bleed from [MEDICATION NAME] but she needs to be anticoagulated for cardio embolic [MEDICAL CONDITION]; will have to keep INR goal between 2 - 2.5. A-Fib not controlled - monitor INR every Monday. Will decrease to 31.5 mg/wk (milligrams per week). LUQ pain ? Gastritis vs Ischemic bowel? [MEDICATION NAME] S/P (status [REDACTED]. 1) Nurses Note dated 9/18/12 at 2000 (8:00 p.m.) and signed by (Physician #1) documented, "... Stat INR then q Monday. (Decrease) [MEDICATION NAME] to 4.5 po (at) 1700 (5:00 p.m.). DC (discontinue) [MEDICATION NAME] 5 mg..." 2) A Physician order [REDACTED]. 2. The Immediate jeopardy was removed on 9/29/12 and the scope and severity was reduced to an "H" when the facility initiated the following plan of removal: 1) Medication Administration Lab 9/29/12. Licensed Staff Education was begun on 9/28/12 by RN/Designee to include accurate transcription of [MEDICATION NAME] orders onto the physician's orders [REDACTED]. 2) A complete medication matchback was initiated immediately on 9/28/12 by RN/Designee for residents with [MEDICATION NAME] orders to ensure accurate orders in relation to resident INRs. These orders will be verified with the Physician to ensure accurate dosages are delivered on 9/29/12. The INR value will be added to the MAR for Physician Review during their rounds. Physician will be notified of INR lab values upon receipt to determine accurate dosage. 3) The DON/RN/Designee will monitor orders for [MEDICATION NAME] 5 days/week for 4 weeks, then 3 days/week for 2 weeks, then weekly for four weeks, or until substantial compliance is obtained. Negative findings will be addressed with corrective measures immediately. Results will be reported to the QA Committee by the DON/RN/Designee monthly. B. Based on observations, record reviews, and interviews, the facility failed to ensure Resident #7, #10, #2 received the necessary care and services to ensure the residents attained the highest practicable physical and mental well being in accordance with the comprehensive assessment and plan of care. The facility failed to ensure that medications to relieve pain were administered according the physicians plan of care for 2 (Residents #7 and #10) of 5 (Residents #6, 7, 8, 10 and 12) case mix residents who were identified to need pain management and resided on the A Hall. The facility failed to ensure treatments were performed according to the physician's plan of care for 1 of (Resident #7) of 5 (Residents #2, 3, 5, 6 and 7) case mix residents who required dressing changes. The facility failed to ensure the full amount of Intravenous (IV) Antibiotic was infused for 1 (Resident #2) of 1case mix who were ordered to receive IV antibiotics and resided on the B Hall. The facility failed to ensure newly admitted residents had Physician order [REDACTED].#2 and 11) case mix residents who were newly admitted to the facility in the last 30 days. The failed practices had the potential to cause more than minimal harm for 18 residents who received pain medication and resided on the A Hall as identified by a list provided by the Registered Nurse #1 on 9/29/12, 30 residents who required dressing changes as identified by a list provided by Licensed Practical Nurse #11 on 9/25/12, 1 resident who received IV antibiotics and resided on the B Hall according to a list provided by RN #1 on 9/29/12 and 23 residents who was admitted to the facility within the last 30 days as identified by a list provided by the Administrator on 10/12/12. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/19/12 documented the resident scored 15 on the Brief Interview for Mental Status (BIMS) and had severe pain almost constantly. a. A physician order [REDACTED]." A physician order [REDACTED]." b. The Care Plan dated 8/29/12 documented: "I am at risk for pain r/t (related to) recent surgery (aka (Above knee amputation)). Other (infected aka). Goals: Resident will state a reduction in pain after receiving interventions... My goal is to be free from pain with use of pain medication and comfort measures over the next 90 days... Interventions: ... Administer, monitor effectiveness, and monitor for adverse side effects of PRN (as needed) pain management medication. Administer, monitor effectiveness, and monitor for adverse side effects of routine pain management medication. Assess pain on an ongoing basis using the appropriate number scale or facial expression scale. Assess/record signs and symptoms of pain and worsening pain. Report significant changes in pain status to physician... Assess and record changes in skin status. Report pertinent changes to physician..." c. A physician order [REDACTED]. DC (discontinue) all previous tx (treatments). 2. (Right and left) stumpwounds. Clean (with) NS (normal saline), apply [MEDICATION NAME] topically to wound bed. Pack (with) gauze moistened (with) chlorpactin. Cover (with) dry dressing Q day. 3. Use 1/4 strength Dakins if chlorpactin not available. 4. Zinc oxide to buttox BID (twice a day) until resolved." d. On 9/25/12 at 12:25 p.m., Resident #7 was in the bed and had put the call light on. The resident asked a Certified Nurse Assistant (CNA) to tell the nurse she needed a pain pill. The CNA went to tell the nurse. The resident stated that she had not had her medications yet. Also the resident stated that she did not get her dressings changed last Thursday and Friday. The Resident was a double [MEDICAL CONDITION] with dressings to both stumps dated 9/24/12. The resident complained that the dressings were not changed regularly and since there was an infection in the wounds, the resident stated she thinks it very important that the dressings are changed timely. At 12:35 p.m., Licensed Practical Nurse (LPN) #12 came into the resident's room and gave the resident the following medications: [REDACTED].), Phentoxaphene, [MEDICATION NAME]. The LPN was asked which medications were the ones given. The LPN stated, "Morning Medications." The Surveyor asked why the medications were given so late, since these were the 9 a.m. medications. The LPN stated, "Because I'm new and although I started giving the meds (medications) at 8 a.m., there is a lot of meds and I am the only nurse on this hall. At 3:39 p.m. LPN #12 was asked if 9 a.m. [MEDICATION NAME] was given to the resident at 12:40 p.m., when was the 1300 (1:00 p.m.) [MEDICATION NAME] given. The LPN stated, "Approximately 2 p.m." LPN #12 and LPN #1 were in the process of changing out the medications, which LPN #1 stated should have been done by the nurse on the 11-7 shift. e. On 9/26/12 at 3:31 p.m., the Treatment Nurse LPN # 8 was preparing to do the treatments on the resident. The LPN was asked if he had ever missed a treatment on the resident. The LPN stated, "Possibly, if they pull me to the floor, I can't do both jobs." LPN #8 was asked if any treatments were missed last week on the resident. The LPN looked at the Treatment Administration Record (TAR) and there was only 1 space, the 18th of September (a Tuesday), where the TAR was not initialed to indicate the treatment was not done. He stated, "Possibly, that's the day I was on the floor. I guess they did not call anyone else in to do the treatments." When the treatment was completed, the resident stated, "When (LPN #8) is not here, the dressings do not get done." f. The September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] "[MEDICATION NAME] 10/325 mg, 2 tabs PO q 6 (hours)." There were initials missing on the 0900 (9 a.m.) dose on 9/9/12, on the 1500 (3 p.m.) dose on 9/9/12 and 9/25/12, on the 2100 (9 p.m.) dose on 9/25/12, and on the 0300 (3 a.m.) dose on 9/1/12, 9/4/12, 9/6/12, and 9/18/12, to indicate the medication was not given at these times. "[MEDICATION NAME] ... 300 mg ... three times daily..." There were initials missing on the 0900 dose on 9/9/12, on the 1300 (1 p.m.) dose on 9/9/12 and 9/21/12, on the 1700 (5 p.m.) dose on 9/9/12, to indicate the medication was not given at these times. g. The Narcotic Sign Out Book, Page 40, was provided by Registered Nurse (RN) #1 on 9/27/12 at 4:00 p.m. Documentation was as follows: "... (Resident #7) ... Oxy-APAP ([MEDICATION NAME]-Acetaminaphen/[MEDICATION NAME]) ... 2 tabs po q 6 (hours)." [MEDICATION NAME] had been signed out on 9/25/12 at 0300, on 9/25/12 at 0900, although the surveyor observed the 0900 medications being given at 12:35 p.m. Page 99 and 114 of the [MEDICATION NAME] Sign Out Book for September were reviewed, there were 5 doses given on 9/21/12, instead of 4, 2 doses missed on 9/4/12, 2 doses missed on 9/2/12, and 1 dose missed on 9/1/12. On 9/28/12 at 11 a.m., RN #1 reviewed the Narcotic Sign Out Sheets for Resident #7 and the MAR. She agreed that the medications had not been administered accurately and treatments possibly missed. 2. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/10/12 documented the resident scored 11 (7-12 indicates moderately impaired) on the BIMS, had frequent pain, rated 4 on a 1-10 scale. a. A physician order [REDACTED]." Page 1393 of the Nursing 2010 Drug handbook documented: "... Pregabalin ... [MEDICATION NAME] ... Indications & Dosages: [MEDICAL CONDITION]: Adults: 75 mg P.O. b.i.d. (150 mg/day). May increase to 150 mg b.i.d. ... If pain relief insufficient with 300 mg/day ... Patient teaching: ... Warn patient not to stop drug abruptly..." A physician order [REDACTED]." b. The Care Plan dated 8/24/12 documented: "I am at risk for pain r/t (related to) Hx (history) chronic pain complaints. Goals: Resident will state a reduction in pain after receiving interventions... My goal is to be free from pain with use of pain medication and comfort measures over the next 90 days.. Interventions: Description: Administer, monitor effectiveness, and monitor for adverse side effects of PRN (as needed) pain management medication... Assess pain on an ongoing basis using the appropriate 1-10 number scale or facial expression scale... Assess/record signs and symptoms of pain and worsening pain... Report significant changes in pain status to physician..." c. On 9/26/12 at 11:30 a.m., Resident #10 complained that she did not get her medications last night until 10:00 p.m. The Resident also stated that she had not had her morning medications yet. The resident was in a wheelchair with hands deformed with arthritis, and shaking slightly. d. The September 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME] was to be given at 0900 (9 a.m.) and at 1700 (5 p.m.) There were no initials at 0900 on the MAR indicated [REDACTED]. 1) The Narcotic Sign Out Book, Page 39, was provided by Registered Nurse (RN) #1 on 9/27/12 at 3:50 p.m. Documentation was as follows: "... (Resident #10) ... Take tab 1 po bid. [MEDICATION NAME] 75 mg ..." The [MEDICATION NAME] had been signed out on 9/24/12 at 0900, on 9/25/12 at 0900 and 1900 (7:00 p.m.), and on 9/26/12 at 1730 (5:30 p.m.). This would indicate that the 1700 dose on 9/24/12 was not administered, the 1700 dose on 9/25/12 was given 2 hours late, and the 0900 dose on 9/26/12 was not administered. 2) On 9/28/12 at 6:10 p.m., RN #1 reviewed the Narcotic Sign Out Sheet for Resident #10's [MEDICATION NAME] and agreed that the medication had not been administered accurately. e. The September 2012 MAR indicated [REDACTED]. [MEDICATION NAME] was to be given at 2100 (9:00 p.m.). There was initials everyday in September at 2100 on the MAR indicated [REDACTED]. 1) The Narcotic Sign Out Book, Page 35, was provided by Registered Nurse (RN) #1 on 9/28/12 at 4:20 p.m. Documentation was as follows: "... (Resident #10) ... [MEDICATION NAME] 2 mg ... take 1/4 tab = 0.25 mg QHS ..." The [MEDICATION NAME] had been signed out on 9/23/12 at 2100, on 9/24/12 at 2100 and on 9/26/12 at 2200 (10:00 p.m.) 28 were signed in. Nothing was signed out on 9/25/12, 9/26/12 or on 9/27/12. This would confirm that the medication was not given on 9/25/12, 9/26/12, or on 9/27/12. 2) A copy of the Bubble pack for [MEDICATION NAME] 2 mg was received from RN #1 on 9/28/12 at 4:20 p.m. Documentation was as follows: "(Resident #10) Take 1/4 tablet (0.5 mg) by mouth at bedtime." The medication was received on 9/26/12 with 28 doses in the pak. No doses had been popped out of the pack. On 9/28/12 at 6:10 p.m., RN #1 reviewed the bubble packs and the Narcotic Sign Out Book and agreed that [MEDICATION NAME] was not given accurately. f. On 9/29/12 at 12:30 p.m., Resident #10 was asked if pain was experienced when there were late or missed doses of [MEDICATION NAME]. The Resident stated, "Sometimes I do, and sometimes I don't." 3. Resident #2 had [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) available for review. The resident was admitted to the facility on [DATE]. a. On 9/24/12 at 11:26 p.m. during initial rounds with Licensed Practical Nurse (LPN) #7, there was an IV (intravenous) pump in the resident's room. The pump was off. A 250 ml (milliter) bag was still connected with a label that documented, " [MEDICATION NAME] 1 GM (gram) 250 ml." There was approximately 50 ml in the bag. LPN #7 was asked how much was in the bag and she stated, "It looks like about 50cc's (cubic centimeters)." The LPN stated that the resident was on contact isolation due [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphylacoccus Aureus) of a sacral wound. On 9/24/12 at 11:52 p.m. LPN #13 was asked about the amount of [MEDICATION NAME] left in the bag and she stated, "I don't know why there is 50cc's left in the bag." b. As of 9/25/12 at 12:44 p.m., there were no Admission Physician order [REDACTED]. The Administrator was asked for MEDICATION ORDERS FOR [REDACTED] At 2:05 p.m. all telephone orders were reviewed and copied that were available in the resident's record: A Telephone Order dated 9/14/12 documented, " ... APAP ([MEDICATION NAME]) 2 g (gram) po (by mouth) q (every) 6 hrs (hours) x (times) 7 days then prn (as needed) pain. ... " Another Telephone Order dated 9/14/12 documented, " ... Humalog Insulin Sliding Scale If FS (fasting sugar) 200-250 give 2 units SC (subcutaneous) 252-300 (give) 4 units SC, 300-350 give 6 units SC, 351-400 give 8 units SC, (greater than) 400 give 10 units call MD (Medical Doctor). There were no other medication orders but there were medications present on the Medication Administration Record. f. On 9/25/12 at 4:45 p.m. the Administrator stated, "I'm still looking for a list of her medications." When asked how they knew what medications to place on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurse who wrote those no longer works here." On 9/26/12 at 10:40 a.m., RN #1 was asked about the admission medications for the resident. She stated, "I cannot find the admission paper work. I have no explanation for the meds (medications) on the MAR (medication administration record) that weren't even on the hospital med list. The nurse who did this no longer works here. She worked last Tuesday and has been a no call no show after that." On 9/27/12 at 8:30 a.m. RN #1 stated, "We never did find any physician orders [REDACTED]. We did have the hospital fax over a list yesterday and now have clarified with the physician."

Complaint # and was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure residents were free of significant medication errors to reduce the potential for adverse side affects for 2 (Resident #1 and #5) of 3 (Resident #s 1, 5 and 6) case mix residents on anticoagulant therapy and for 1of 1 (Resident #2) case mix resident who received Intravenous (IV) antibiotics on the B Hall, 1 of 1 (Resident # 5) case mix residents who received Atrixia and 2 (Residents #1 and 2) of 5 (Residents #1, 2, 3, 9 and 11) case mix residents who resided on the B hall and received oral medications, 1 (Resident #8) of 2 (Residents #2 and 8) case mix residents who received Novalog insulin and 1 (Resident #13) of 1 case mix resident who received [MEDICATION NAME] 70.30 insulin. The facility failures to ensure anticoagulant therapy was administered as directed by the physician resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was admitted to the hospital with [REDACTED].#1on 9/25/12 at 12:00 p.m. This failed practice also had the potential to affect 15 residents on [MEDICATION NAME] Insulin and 1 residents on [MEDICATION NAME] 70/30 according to the Inter-Director of Nursing, RN #1 on 9/29/12 at 5:00 p.m., 1 resident who received IV antibiotics, 2 residents who received Atrixia and 29 residents who received oral medication and resided on the B hall according to a list provided by Registered Nurse #1 on 9/29/12. The facility Administration was informed of the Immediate Jeopardy on 9/28/12 at 3:07 p.m. The findings are: 1. Resident #1 had a [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 8/15/12 documented, the resident scored 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, required extensive assistance of one staff member for most Activities of Daily Living (ADL's) and received Anticoagulant therapy in the last 7 days. a. The Hospital Discharge Note dated 9/17/12 documented, " HPI (History and Physical Information): admitted from NH (Nursing Home) with LGIB (Lower [MEDICAL CONDITION]). Pt (Patient) had grossly bloody stools x 3 and some cramping in LLQ (left lower quadrant) abdominal pain...She is on [MEDICATION NAME] daily...At 9/10/12 at 0540 (5:40 a.m.) RBC (red blood cells) 3.64 L (low) (normals 4.10 - 5.0), Hgb (Hemoglobin) 8.6 L (normals 12.0 - 16.0), Hct (Hematocrit) 27.5 L (normals 36.0 - 48.0), PTS ([MEDICATION NAME]) 34.2 H (normals 8.8-12.0), INR (International Normalized Ratio) = 3.2 (Low intensity range 2.0-3.0. High intensity range 2.5 - 3.5), APTTS (Activated Partial [MEDICAL CONDITION] Time)= 34.4 sec (H) (normals 20.0 - 31.0), Occult Blood = Positive...9/10/12 at 1126 (11:26 a.m.) received 2 units PRBC (Packed Red Blood Cells) and 2 units PRBC at 1417 (2:17 p.m.)." b. A physician progress notes [REDACTED]. She was anemic from GI bleed with H/H (Hemoglobin /Hematocrit) down to Hgb 8/Hct 27.2. She received blood [MEDICAL CONDITION]. She was complaining of [MEDICAL CONDITION] pain during hospital stay. She is still reporting LLQ pain to a lesser extent. Pain is exacerbated with deep breathing, not modified by meals or position. She denies any trauma. She has no bleed since return...Assessment and Plan: Hematochezia, ? (questionable) Diverticular disease. She is at risk for GI bleed from [MEDICATION NAME] but she needs to be anticoagulated for cardio [MEDICAL CONDITION](cardiovascular accident); will have to keep INR goal between 2 - 2.5. A-Fib ([MEDICAL CONDITION]) not controlled - monitor INR every Monday. Will decrease to 31.5 mg/wk (milligrams pe r week). LUQ pain ? Gastritis vs Ischemic bowel? [MEDICATION NAME] S/P (status [REDACTED]. 1) Nurses Note dated 9/18/12 at 2000 (8:00 p.m.) and signed by (Physician #1) documented, "... [MEDICATION NAME] 1 g (gram) tab po (per mouth) QID (four times a day) Dx (diagnosis):[MEDICAL CONDITION](Gastrointestinal Regurgitation Disease) ...Stat INR then q Monday. (Decrease) [MEDICATION NAME] to 4.5 po (at) 1700 (5:00 p.m.). DC (discontinue) [MEDICATION NAME] 5 mg..." 2) A Physician order [REDACTED]. 3) Lab results dated 9/18/12 at 3:10 p.m. for PT/ INR documented, "...PT = 14.3 H/INR 1.3...with handwritten documentation, NO (new order) rec'd (received) (and) noted. Med (Medication) ordered..." Nurses Note dated 9/18/12 at 2000 (8:00 p.m.) completed by weekend Registered Nurse (RN) #2 documented, "...(Increase) [MEDICATION NAME] to 6 mg. and repeat I & R (INR) on Monday... T/O (Telephone Order) Physician #2/RN #2..." There was no documented telephone order for the increase in the [MEDICATION NAME] in the Clinical record. 4) On 9/28/12 at 11:22 a.m. the Medical Director (Physician #1) stated, " ... (Physician #2) is my Associate and he saw the results of her PT/INR and called to increase her (Resident #1) [MEDICATION NAME] to 6 mg due to her low INR. On the 18th her [MEDICATION NAME] ([MEDICATION NAME]) was ordered due to her abdominal problems and continued symptoms. She was still having abdominal pain, they could not find the active source. ... " c. The September 2012 Medication Administration Record (MAR) copied on 9/27/12 at 10:00 a.m. documented, "...9/18/12 [MEDICATION NAME] 1 g tab po QID (four times a day) Dx:[MEDICAL CONDITION](Gastrointestinal Regurgitation Disease)." The MAR documented the medication was not administered on the following dates and times as indicated by a circled initial on the date and time scheduled for administration or no initial as being given: 9/19/12 at 0900 (9:00 a.m.), 1300 (1:00 p.m.) and 1700 (5:00 p.m.-LPN#4) initials circled; no initials at 2100 (9:00 p.m.); 9/20/12 no initials at 0900 and 1300; 9/21/12 at 0900 and 1300 initials circled (LPN #4); and 9/22/12 at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. initials circled. d. On 9/27/12 at 4:25 p.m., the Interim DON provided copies of the bubble packs for the [MEDICATION NAME] 1 g. 0900 and 1300 doses filled 9/19/12, there were no bubble packs available for review for the 1700 and 2100 doses filled 9/19/12. The bubble packets documented: Filled by pharmacy 9/19/12 ...Quantity 20 (5 each for the 4 bubble packs). The medication packets for 0900 and 1300 doses were punched out each day 9/20/12 - 9/22/12, there were 2 pills remaining in each of the packets (9/23/12 and 9/24/12). On 9/27/12 at 4:10 p.m., Licensed Practical Nurse (LPN) #4 was asked what it meant when she initialed the MAR and circled it? She stated, "When I do that the medication wasn't available to give." When asked if she documented that the medication wasn't available to administer? She stated, "No, not here because we're told that would make the facility look bad because they didn't make sure it was here to give." e. The September 2012 MAR copied 9/27/12 at 10:50 a.m. documented: "9/18/12 [MEDICATION NAME] 4.5 mg 1 po daily (scheduled 1700 hours)." The MAR documented the medication ([MEDICATION NAME] 4.5 mg) was not administered on 9/19/12 (LPN #4's initials circled), 9/21/12 (not initialed) and 9/25/12 (initials circled). The MAR documented [MEDICATION NAME] 4.5 mg was administered on 9/20/12, 9/22-24/12, and 9/26/12 at 1700. The September 2012 MAR did not document the increase in the [MEDICATION NAME] from 4.5 mg to 6 mg on 9/18/12. On 9/28/12 at 6:00 p.m., RN #1 stated, "I called the Pharmacy Provider and they told me that they had never received an order for [REDACTED]. ..." 2. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/2/12 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on one to two staff members for all Activities of Daily Living (ADL ' s), had functional limitation with impairment on both sides of the upper/lower extremities, received tube feedings while a resident and received Anticoagulants 7 times during the last 7 days. a. The September 2012 Physician order [REDACTED]. 1) A Physician's telephone order dated 9/11/12 documented, "[MEDICATION NAME] 5 mg PT (per tube) (at)1700 x 2 days then 3 mg PT (at) 1700 daily, INR on Mondays- Notify MD of results..." 2) A Physician's telephone order 9/18/12 at 0900 documented, "[MEDICATION NAME] 2.5 mg q day, [MEDICATION NAME] 5 mg q day. STAT INR on Friday." b. The September 2012 Medication Administration Record (MAR) copied 9/28/12 at 10:15 a.m. documented, "...9/11/12 [MEDICATION NAME] 5 mg PT @ 1700 x 2 days then, [MEDICATION NAME] 3mg PT (at) 1700 (5:00 p.m.) daily. [MEDICATION NAME] 5 mg was initialed as administered on 9/11/12 and 9/12/12 on the MAR. [MEDICATION NAME] 3 mg was not initialed as administered on the MAR for 9/13/12, 9/14/12, 9/17/12, and 9/18/12. The MAR documented, "9/18/12 [MEDICATION NAME] 5 mg 1 tab po qd (everyday) at 1700." There were no initials on the MAR to indicate the resident received [MEDICATION NAME] 5 mg on 9/18/12 as ordered. The MAR documented the resident received [MEDICATION NAME] 5 mg on 9/19/12 thru 9/27/12. The September 2012 Medication Administration Record (MAR) copied 9/28/12 at 10:15 a.m., did not document the order for the [MEDICATION NAME] 2.5 mg q day received per telephone order dated 9/18/12. There was no record of administration from 9/18/12 - 9/27/12. c. On 9/29/12 at 4:00 p.m. the Interim Director of Nursing (DON) was asked if (Resident #5) received her [MEDICATION NAME] and [MEDICATION NAME] as ordered. She stated ( after reviewing the MARS, Bubble Packs and Pharmacy Printout), "It doesn't look like it. 3. Resident #2 had [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) available for review. The resident was admitted to the facility on [DATE]. a. On 9/24/12 at 11:26 p.m. during initial rounds with Licensed Practical Nurse (LPN) #7, there was an IV (intravenous) pump in the resident's room. The pump was off. A 250 ml (milliliter) bag was still connected with a label that documented, " [MEDICATION NAME] 1 GM (gram) 250 ml." There was approximately 50 ml in the bag. LPN #7 was asked how much was in the bag and she stated, "It looks like about 50cc's (cubic centimeters)." The LPN stated that the resident was on contact isolation due [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphylacoccus Aureus) of a sacral wound. On 9/24/12 at 11:52 p.m. LPN #13 was asked about the amount of [MEDICATION NAME] left in the bag and she stated, "I don't know why there is 50cc's left in the bag." b. During a review of the resident's September 2012 MAR on 9/28/12 at 6:35 p.m. and after comparing with the bubble packs and the pharmacy order forms the following discrepancies were identified: Potassium CHL ER 20 meq (milliequivalent) Take 1 tablet by mouth 3 times a day ... 21 were received on 9/17/12. There had been 45 opportunities for the medication to be administered, 9 were circled and 6 were blank. 1 tablet was left in the 1 pm card and 2 were left in the 5 pm card. [MEDICATION NAME] 20 mg Take 1 tablet by mouth twice a day, 28 tablets were received on 9/20/12. The MAR documented 28 tablets were administered per nurses initials however, 7 tablets were left in the bubble packet. [MEDICATION NAME] 500 mg/100ml (milliters) Q 8 hours times 20 days, 6 doses were received on 9/14/12 at 1:28 pm, 15 doses were received 9/14/12 at 8:47 p.m., 7 doses were received on 9/21/12 and 7 doses were received on 9/26/12 for a total of 35 doses . There were 45 opportunities for the medication to be administered per the MAR. There were 7 blanks on the MAR for 9/14, 17, 23 or 24 at 12:30 a.m., 9/17/12 and 9/24/12 at 4:30 p.m. and 9/28/12 at 8:30 a.m. [MEDICATION NAME] 500 mg IV (Intravenous) Q 12 hours, 14 doses were received on 9/14/12, 5 doses were received on 9/21/12 and 7 doses were received on 9/26/12 for a total of 26 doses. There were 29 opportunities for the medication to be administered per the MAR. The MAR had a blank space on 9/14/12 and 9/20/12 for the 9:00 p.m. dose indicating the medication was not administered. Cefepine 1 g (gram) in Sodium Chloride 100 ml Q 12 hours, 14 doses were received on 9/14/12, 5 doses were received on 9/21/12 and 5 doses were received on 9/26/12 for a total of 24 doses . There were 29 opportunities for the medication to be administered per the MAR. There were 3 blanks . There was no documentation on the MAR to indicate the medication was given on 9/14/12 at 10:00 p.m. and 10/23/12, and 9/24/12 at 10:00 p.m. c. On 9/28/12 at 7:00 p.m., Registered Nurse (RN) #1 was asked why there were so many missed doses and doses documented as given when there was no medication available to give. She stated, "I can't answer that, there's a problem here as you can tell." 4. Resident #8 had a [DIAGNOSES REDACTED]. The resident had a blood glucose test ac and hs (bedtime) everyday and was to receive sliding scale insulin ([MEDICATION NAME]) per the results as follows: 200 - 250 = 2 units. a. On 9/27/12 at 4:25 p.m., during the 4:30 p.m. medication pass, LPN #1 took a blood glucose test with a reading of 213 milligrams per deciliter (mg/dl). LPN #1 stated, "The resident is to receive [MEDICATION NAME] 10 units." The LPN #1 did not prime the [MEDICATION NAME] before administering the [MEDICATION NAME] to the resident. The LPN #1 did not leave the [MEDICATION NAME] needle in the injection site after administering the injection for the recommended 6 seconds. b. According to the manufacture's "Patient instructions for use [MEDICATION NAME]": "Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E: Turn the dose selector to select 2 units. F: Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0.".... "Giving the injection" ..."J. Keep the needle in the skin for at least 6 seconds, and keep the push button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given." c. According to the manufacture's package insert: "Give 5 to 10 minutes before meal" The Facility's Employee List received from the Administrator on 9/25/12 documented the facility meal times were 7:30 a.m., 12:30 p.m. and 5:30 p.m. d. This was a significant error due to the classification of medication, Anti-diabetic Insulin. 5. Resident #13 had a [DIAGNOSES REDACTED]. a. On 9/27/12 at 5:23 p.m., during the 5:00 p.m. medication pass, LPN #2 did not prime the [MEDICATION NAME] 70/30 Pen before administering the [MEDICATION NAME] 70/30 58 units sq. b. According to the manufacture's "Instructions for Insulin Pen Use" "Is important to read, understand, and follow the instructions in the Insulin Delivery Device User Manuel before using. Failure to follow instructions may result in getting too much or too little insulin. The needle must be changed and the Pen must be primed to a stream of Insulin (not just a few drops) before each injection to make sure the Pen is ready to dose. You may need to prime a new Pen up to six times before a stream of Insulin appears. Performing these steps before each injection is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. This was a significant error due to the classification of medication, Anti-diabetic Insulin. c. This was a significant error due to the classification of medication, Anti-diabetic Insulin. 6. The Immediate jeopardy was removed on 9/29/12 and the scope and severity was reduced to an "H" when the facility initiated the following plan of removal: 1) Medication Administration Lab 9/29/12. Licensed Staff Education was begun on 9/28/12 by RN/Designee to include accurate transcription of [MEDICATION NAME] orders onto the physician's orders [REDACTED]. 2) A complete medication matchback was initiated immediately on 9/28/12 by RN/Designee for residents with [MEDICATION NAME] orders to ensure accurate orders in relation to resident INRs. These orders will be verified with the Physician to ensure accurate dosages are delivered on 9/29/12. The INR value will be added to the MAR for Physician Review during their rounds. Physician will be notified of INR lab values upon receipt to determine accurate dosage. 3) The DON/RN/Designee will monitor orders for [MEDICATION NAME] 5 days/week for 4 weeks, then 3 days/week for 2 weeks, then weekly for four weeks, or until substantial compliance is obtained. Negative findings will be addressed with corrective measures immediately. Results will be reported to the QA Committee by the DON/RN/Designee monthly.

Complaint # and was substantiated (all or in part) with these findings: Based on observations, record reviews, and interviews, the Facility Administration and Nursing Administration failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care as evidenced by: The facility's failure to ensure laboratory orders for [MEDICATION NAME]/International Normalized Ratio (PT/INR) was drawn as ordered to promptly identify indicators of unsafe level of anticoagulant therapy, to monitor the therapeutic effectiveness, and to aid the physician the management of the dosage for 1 (Resident #1) of 3 (Resident's #1, 5 and 6) case mix residents who had orders for anticoagulant therapy. These failed practices resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was admitted to the hospital with [REDACTED].#1on 9/25/12 at 12:00 p.m. The facility Administration was informed of the Immediate Jeopardy on 9/28/12 at 3:07 p.m. The facility's failure to ensure residents were free of significant medication errors to reduce the potential for adverse side affects for 2 (Resident #1 and #5) of 3 (Resident #s 1, 5 and 6) case mix residents on anticoagulant therapy and for 5 (Resident #s 1, 2, 5, 8 and 13) of 14 (Residents #1-3 and 5-14) case-mix residents who received medications. The facility failures to ensure anticoagulant therapy was administered as directed by the physician resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was admitted to the hospital with [REDACTED].#1on 9/25/12 at 12:00 p.m., 1 resident who received Inravenous antibiotics as identified by Registered Nurse #1 on 9/29/12 and 115 residents who received oral medications and resided at the facility according to a list provided by the Administrator on 10/12/12. This failed practice also had the potential to affect 15 residents on [MEDICATION NAME] Insulin and 13 residents on [MEDICATION NAME] 70/30 according to the Inter-Director of Nursing, RN #1 on 9/29/12 at 5:00 p.m. The findings are: 1. The facility job descriptions for the Administrator and Director of Nursing was received from Registered Nurse #1 on 9/29/12. a. The Job Description titled "Administrator" documented: "Summary ...Responsible for the overall direction, coordination and evaluation of all facility operating activities ...Responsible for monitoring regulatory compliance to assure high quality of resident care." b. The Job Description titled "Director of Nursing" documented: " Summary ...Responsible for organizing, planning, directing, and evaluating nursing and other resident care services ..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 8/15/12 documented, the resident scored 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, required extensive assistance of one staff member for most Activities of Daily Living (ADL's) and received anticoagulant therapy in the last 7 days. a. The August 2012 Physician order [REDACTED]. " b. A lab report dated 7/9/12 documented the following results: PT ([MEDICATION NAME]) 23.2 H (High) reference range seconds 9.4 -12.5 INR(international normalized ratio) 2.30 H reference range ratio 0.8 - 1.2. " The July 2012 Physician order [REDACTED]. c. The August 2012 Physicians Order sheet documented, " ...PTI ([MEDICATION NAME]/International Normalized Ratio) every Mondays - Complex ...Start Date 7/13/12. " As of 9/24/12, there were no lab results in the clinical record for the weekly PTI for 7/16/12, 7/23/12, 7/30/12 or 8/6/12. d. On 9/25/12 at 2:45 p.m., the Interim Director of Nursing (DON) was informed that surveyor could not find any nurses notes after 7/4/12 until 8/7/12 in the resident's clinical record. As of 9/26/12 at 10:45 a.m., no nurses notes were found after 7/4/12 until 8/7/12. A Nurses Note dated 8/7/12 documented, "...Physician #1 here N.O. (New Order) noted pharmacy aware. Lab notified of lab draw for 8/13/12." A telephone order dated 8/7/12 documented, " ...Check INR (check) BMP (basic metabolic panel) on Monday." e. A lab report dated 8/13/12 documented the following results: PT ([MEDICATION NAME]) 36.9 H (High) (reference range) 12.5-15.9 seconds INR(international normalized ratio) 2.7 (reference range) 2.0-3.5. " The August 2012 Physician order [REDACTED]. f. As of 9/24/12, there were no lab results in the clinical record for the weekly PTI for 8/20/12, 8/27/12, or 9/3/12. 1) On 9/25/12 at 2:45 p.m., the Interim Director of Nursing (DON) was asked to find the most recent PT/INR report prior to resident's transfer to the hospital on [DATE]. She confirmed 8/13/12 as the most recent PT/INR prior to hospitalization . The Interim DON was asked if she had been able to find a physician order [REDACTED]. The Interim DON was informed that the August 2012 Medication Administration Record was not found in the clinical record. As of 9/27/12 at 10:00 a.m., the August 2012 MAR was not available for review. g. The Resident ' s Care Plan documented, "...Focus: Resident is at risk for bleeding r/t (related to) usage of [MEDICATION NAME] Date initiated 8/28/2012....Goal PT/INR results will be within therapeutic ranges and will be maintained for resident..." h. Nurses Note dated 9/10/12 at 0330 (3:30 a.m.) documented, "...CNA (Certified Nurse Assistant) reported bleeding from rectum area, resident c/o (complained of) stomach ache, abdomen felt tender to touch, toilet where resident used bathroom filled with brisket red blood - MD (Medical Doctor) paged - N.O. Send to ER (emergency room ). i. The Hospital Discharge Note dated 9/17/12 documented, " HPI (History and Physical Information): admitted from NH (Nursing Home) with LGIB (Lower [MEDICAL CONDITION]). Pt (Patient) had grossly bloody stools x 3 and some cramping in LLQ (left lower quadrant) abdominal pain...She is on [MEDICATION NAME] daily...At 9/10/12 at 0540 (5:40 a.m.) RBC (red blood cells) 3.64 L (low) (normals 4.10 - 5.0), Hgb (Hemoglobin) 8.6 L (normals 12.0 - 16.0), Hct (Hematocrit) 27.5 L (normals 36.0 - 48.0), PTS ([MEDICATION NAME]) 34.2 H (normals 8.8-12.0), INR (International Normalized Ratio) = 3.2 (Low intensity range 2.0-3.0. High intensity range 2.5 - 3.5), APTTS (Activated Partial [MEDICAL CONDITION] Time)= 34.4 sec (H) (normals 20.0 - 31.0), Occult Blood = Positive...9/10/12 at 1126 (11:26 a.m.) received 2 units PRBC (Packed Red Blood Cells) and 2 units PRBC at 1417 (2:17 p.m.)." j. Nurses Notes dated 9/15/12 at 12:30 p.m., documented the resident was readmitted to the facility. The admission orders ...Diagnosis: [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 5mg tablet po i (one) daily...Labs: (was blank, no labs were ordered)..." The September 2012 MAR documented the resident received 5 mg of [MEDICATION NAME] 9/15/12 - 9/18/12. k. A physician progress notes [REDACTED]. She was anemic from GI bleed with H/H (Hemoglobin /Hematocrit) down to Hgb 8/Hct 27.2. She received blood [MEDICAL CONDITION]. She was complaining of [MEDICAL CONDITION] pain during hospital stay. She is still reporting LLQ pain to a lesser extent. Pain is exacerbated with deep breathing, not modified by meals or position. She denies any trauma. She has no bleed since return...Assessment and Plan: Hematochezia ? (questionable) Diverticular disease. She is at risk for GI bleed from [MEDICATION NAME] but she needs to be anticoagulated for cardio embolic [MEDICAL CONDITION]; will have to keep INR goal between 2 - 2.5. A-Fib not controlled - monitor INR every Monday. Will decrease to 31.5 mg/wk (milligrams per week). LUQ pain ? Gastritis vs Ischemic bowel? [MEDICATION NAME] S/P (status [REDACTED]. 1) Nurses Note dated 9/18/12 at 2000 (8:00 p.m.) and signed by (Physician #1) documented, "... Stat INR then q Monday. (Decrease) [MEDICATION NAME] to 4.5 po (at) 1700 (5:00 p.m.). DC (discontinue) [MEDICATION NAME] 5 mg..." 2) A Physician order [REDACTED]. 3) Lab results dated 9/18/12 at 3:10 p.m. for PT/ INR documented, "...PT = 14.3 H/INR 1.3...with handwritten documentation, NO (new order) rec'd (received) (and) noted. Med (Medication) ordered..." Nurses Note dated 9/18/12 at 2000 (8:00 p.m.) completed by weekend Registered Nurse (RN) #2 documented, "...(Increase) [MEDICATION NAME] to 6 mg. and repeat I & R (INR) on Monday... T/O (Telephone Order) Physician #2/RN #2..." There was no documented telephone order for the increase in the [MEDICATION NAME] in the Clinical record. 4) On 9/28/12 at 11:22 a.m. the Medical Director (Physician #1) stated, " ... (Physician #2) is my Associate and he saw the results of her PT/INR and called to increase her (Resident #1) [MEDICATION NAME] to 6 mg due to her low INR. On the 18th her [MEDICATION NAME] ([MEDICATION NAME]) was ordered due to her abdominal problems and continued symptoms. She was still having abdominal pain, they could not find the active source. ... " l. The September 2012 Medication Administration Record (MAR) copied on 9/27/12 at 10:00 a.m. documented, "...9/18/12 [MEDICATION NAME] 1 g tab po QID (four times a day) Dx:[MEDICAL CONDITION](Gastrointestinal Regurgitation Disease)." The MAR documented the medication was not administered on the following dates and times as indicated by a circled initial on the date and time scheduled for administration or no initial as being given: 9/19/12 at 0900 (9:00 a.m.), 1300 (1:00 p.m.) and 1700 (5:00 p.m.-LPN#4) initials circled; no initials at 2100 (9:00 p.m.); 9/20/12 no initials at 0900 and 1300; 9/21/12 at 0900 and 1300 initials circled (LPN #4); and 9/22/12 at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. initials circled. m. On 9/27/12 at 4:25 p.m., the Interim DON provided copies of the bubble packs for the [MEDICATION NAME] 1 g. 0900 and 1300 doses filled 9/19/12, there were no bubble packs available for review for the 1700 and 2100 doses filled 9/19/12. The bubble packets documented: Filled by pharmacy 9/19/12 ...Quantity 20 (5 each for the 4 bubble packs). The medication packets for 0900 and 1300 doses were punched out each day 9/20/12 - 9/22/12, there were 2 pills remaining in each of the packets (9/23/12 and 9/24/12). On 9/27/12 at 4:10 p.m., Licensed Practical Nurse (LPN) #4 was asked what it meant when she initialed the MAR and circled it? She stated, "When I do that the medication wasn't available to give." When asked if she documented that the medication wasn't available to administer? She stated, "No, not here because we're told that would make the facility look bad because they didn't make sure it was here to give." n. The September 2012 MAR copied 9/27/12 at 10:50 a.m. documented: "9/18/12 [MEDICATION NAME] 4.5 mg 1 po daily (scheduled 1700 hours)." The MAR documented the medication ([MEDICATION NAME] 4.5 mg) was not administered on 9/19/12 (LPN #4's initials circled), 9/21/12 (not initialed) and 9/25/12 (initials circled). The MAR documented [MEDICATION NAME] 4.5 mg was administered on 9/20/12, 9/22-24/12, and 9/26/12 at 1700. The September 2012 MAR did not document the increase in the [MEDICATION NAME] from 4.5 mg to 6 mg on 9/18/12. On 9/28/12 at 6:00 p.m., RN #1 stated, "I called the Pharmacy Provider and they told me that they had never received an order for [REDACTED]. ..." 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/2/12 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on one to two staff members for all Activities of Daily Living (ADL ' s), had functional limitation with impairment on both sides of the upper/lower extremities, received tube feedings while a resident and received Anticoagulants 7 times during the last 7 days. a. The September 2012 Physician order [REDACTED]. 1) A Physician's telephone order dated 9/11/12 documented, "[MEDICATION NAME] 5 mg PT (per tube) (at)1700 x 2 days then 3 mg PT (at) 1700 daily, INR on Mondays- Notify MD of results..." 2) A Physician's telephone order 9/18/12 at 0900 documented, "[MEDICATION NAME] 2.5 mg q day, [MEDICATION NAME] 5 mg q day. STAT INR on Friday." b. The September 2012 Medication Administration Record (MAR) copied 9/28/12 at 10:15 a.m. documented, "...9/11/12 [MEDICATION NAME] 5 mg PT @ 1700 x 2 days then, [MEDICATION NAME] 3mg PT (at) 1700 (5:00 p.m.) daily. [MEDICATION NAME] 5 mg was initialed as administered on 9/11/12 and 9/12/12 on the MAR. [MEDICATION NAME] 3 mg was not initialed as administered on the MAR for 9/13/12, 9/14/12, 9/17/12, and 9/18/12. The MAR documented, "9/18/12 [MEDICATION NAME] 5 mg 1 tab po qd (everyday) at 1700." There were no initials on the MAR to indicate the resident received [MEDICATION NAME] 5 mg on 9/18/12 as ordered. The MAR documented the resident received [MEDICATION NAME] 5 mg on 9/19/12 thru 9/27/12. The September 2012 Medication Administration Record (MAR) copied 9/28/12 at 10:15 a.m., did not document the order for the [MEDICATION NAME] 2.5 mg q day received per telephone order dated 9/18/12. There was no record of administration from 9/18/12 - 9/27/12. c. On 9/29/12 at 4:00 p.m. the Interim Director of Nursing (DON) was asked if (Resident #5) received her [MEDICATION NAME] and [MEDICATION NAME] as ordered. She stated ( after reviewing the MARS, Bubble Packs and Pharmacy Printout), "It doesn't look like it. 4. Resident #2 had [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) available for review. The resident was admitted to the facility on [DATE]. a. On 9/24/12 at 11:26 p.m. during initial rounds with Licensed Practical Nurse (LPN) #7, there was an IV (intravenous) pump in the resident's room. The pump was off. A 250 ml (milliner) bag was still connected with a label that documented, " [MEDICATION NAME] 1 GM (gram) 250 ml." There was approximately 50 ml in the bag. LPN #7 was asked how much was in the bag and she stated, "It looks like about 50cc's (cubic centimeters)." The LPN stated that the resident was on contact isolation due [MEDICAL CONDITIONS] of a sacral wound. On 9/24/12 at 11:52 p.m., LPN #13 was asked about the amount of [MEDICATION NAME] left in the bag and she stated, "I don't know why there is 50cc's left in the bag." b. During a review of the resident's September 2012 MAR on 9/28/12 at 6:35 p.m. and after comparing with the bubble packs and the pharmacy order forms the following discrepancies were identified: Potassium CHL (Chloride) ER (Extended Release) 20 meq (milliequivalent) Take 1 tablet by mouth 3 times a day ... 21 were received on 9/17/12. There had been 45 opportunities for the medication to be administered, 9 were circled and 6 were blank. 1 tablet was left in the 1 pm card and 2 were left in the 5 pm card. [MEDICATION NAME] ([MEDICATION NAME]) 20 mg to take 1 tablet by mouth twice a day with the initial dose given on 9/14/12 at 9:00 p.m. The record documented the medications were administered as ordered as indicated by a Nurse initial for each date administered. Since admission there were 28 tablets received, 14 tablets delivered on 9/14/12 and 14 tablets delivered on 9/20/12 according to the Delivery Manifest dated 9/14/12 and 9/20/12. The bubble pack had 7 tablets left. [MEDICATION NAME] 500 mg/100 milliliters (ml) Intravenous Q 8 hours times 20 days with the initial dose given on 9/14/12 at 8:30 a.m. The medication was scheduled to be administered at 8:30 a.m., 4:30 p.m. and 12:30 a.m. The Delivery Manifests documented 6 doses of the medication were received at 1:28 p.m. and 15 at 8:47 p.m. on 9/14/12, 7 received on 9/21/12 and 7 received on 9/26/12, a total of 35 doses. There was no documentation on the MAR to indicate the medication was administered on 9/14, 17, 23 or 24 at 12:30 a.m., 9/17/12 and 9/24/12 at 4:30 p.m. and 9/28/12 at 8:30 a.m. [MEDICATION NAME] 500 mg Intravenous Q 12 hours with the initial dose given on 9/14/12 at 9:00 a.m. The medication was scheduled to be administered at 9:30 a.m. and 9:00 p.m. The Delivery Manifests documented 14 doses were received on 9/14/12, 5 doses were received on 9/21/12, 5 doses were received on 9/26/12 at 12:40 p.m. and 5 doses were received on 9/26/12 at 1:07 p.m. The Medication had 29 opportunities for administration. The MAR had a blank space on 9/14/12 and 9/20/12 for the 9:00 p.m. dose indicating the medication was not administered. Cefepine 1 gram in Sodium Chloride 100 ml Q 12 hours with the initial dose given on 9/14/12 at 10:00 a.m. The medication was scheduled to be administered at 10:00 a.m., and 10:00 p.m. The Delivery Manifests documented 14 doses of the medication were received on 9/14/12, 5 were received on 9/21/12 and 5 were received on 9/26/12. There were 29 opportunities for the medication to be administered. The facility received a total of 24 doses of the medication. There was no documentation on the MAR to indicate the medication was given on 9/14/12 at 10:00 p.m. and 9/23/12, and 9/24/12 at 10:00 p.m. The MAR documented a total of 26 doses administered. c. On 9/28/12 at 7:00 p.m., Registered Nurse (RN) #1 was asked why there were so many missed doses and doses documented as given when there was no medication available to give. She stated, "I can't answer that, there's a problem here as you can tell." 5. Resident #8 had a [DIAGNOSES REDACTED]. The resident had a blood glucose test ac and hs (bedtime) everyday and was to receive sliding scale insulin ([MEDICATION NAME]) per the results as follows: 200 - 250 = 2 units. a. On 9/27/12 at 4:25 p.m., during the 4:30 p.m. medication pass, LPN #1 took a blood glucose test with a reading of 213 milligrams per deciliter (mg/dl). LPN #1 stated, "The resident is to receive [MEDICATION NAME] 10 units." The LPN #1 did not prime the [MEDICATION NAME] before administering the [MEDICATION NAME] to the resident. The LPN #1 did not leave the [MEDICATION NAME] needle in the injection site after administering the injection for the recommended 6 seconds. b. According to the manufacture's "Patient instructions for use [MEDICATION NAME]": "Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E: Turn the dose selector to select 2 units. F: Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0.".... "Giving the injection" ..."J. Keep the needle in the skin for at least 6 seconds, and keep the push button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given." c. According to the manufacture's package insert: "Give 5 to 10 minutes before meal" The Facility's Employee List received from the Administrator on 9/25/12 documented the facility meal times were 7:30 a.m., 12:30 p.m. and 5:30 p.m. d. This was a significant error due to the classification of medication, Anti-diabetic Insulin. 6. Resident #13 had a [DIAGNOSES REDACTED]. a. On 9/27/12 at 5:23 p.m., during the 5:00 p.m. medication pass, LPN #2 did not prime the [MEDICATION NAME] 70/30 Pen before administering the [MEDICATION NAME] 70/30 58 units sq. b. According to the manufacture's "Instructions for Insulin Pen Use" "Is important to read, understand, and follow the instructions in the Insulin Delivery Device User Manuel before using. Failure to follow instructions may result in getting too much or too little insulin. The needle must be changed and the Pen must be primed to a stream of Insulin (not just a few drops) before each injection to make sure the Pen is ready to dose. You may need to prime a new Pen up to six times before a stream of Insulin appears. Performing these steps before each injection is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. This was a significant error due to the classification of medication, Anti-diabetic Insulin. c. This was a significant error due to the classification of medication, Anti-diabetic Insulin. 7. The Immediate jeopardy was removed on 9/29/12 and the scope and severity was reduced to an "H" when the facility initiated the following plan of removal: 1) Medication Administration Lab 9/29/12. Licensed Staff Education was begun on 9/28/12 by RN/Designee to include accurate transcription of [MEDICATION NAME] orders onto the physician's orders [REDACTED]. 2) A complete medication match back was initiated immediately on 9/28/12 by RN/Designee for residents with [MEDICATION NAME] orders to ensure accurate orders in relation to resident INRs. These orders will be verified with the Physician to ensure accurate dosages are delivered on 9/29/12. The INR value will be added to the MAR for Physician Review during their rounds. Physician will be notified of INR lab values upon receipt to determine accurate dosage. 3) The DON/RN/Designee will monitor orders for [MEDICATION NAME] 5 days/week for 4 weeks, then 3 days/week for 2 weeks, then weekly for four weeks, or until substantial compliance is obtained. Negative findings will be addressed with corrective measures immediately. Results will be reported to the QA Committee by the DON/RN/Designee monthly.

Complaint # and was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility's Quality Assessment and Assurance Committee (QA&A) failed to identify quality deficiencies and to develop appropriate plans of action to correct identified quality deficiencies as evidenced by: The facility's failure to ensure laboratory orders for [MEDICATION NAME]/International Normalized Ratio (PT/INR) was drawn as ordered to promptly identify indicators of unsafe level of anticoagulant therapy, to monitor the therapeutic effectiveness, and to aid the physician the management of the dosage for 1 (Resident #1) of 3 (Resident's #1, 5 and 6) case mix residents who had orders for anticoagulant therapy. These failed practices resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was admitted to the hospital with [REDACTED].#1on 9/25/12 at 12:00 p.m. The facility Administration was informed of the Immediate Jeopardy on 9/28/12 at 3:07 p.m. The facility's failure to ensure residents were free of significant medication errors to reduce the potential for adverse side affects for 2 (Resident #1 and #5) of 3 (Resident #s 1, 5 and 6) case mix residents on anticoagulant therapy and for 5 (Resident #s 1, 2, 5, 8 and 13) of 14 (Residents #1-3 and 5-14) case-mix residents who received medications. The facility failures to ensure anticoagulant therapy was administered as directed by the physician resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was admitted to the hospital with [REDACTED].#1on 9/25/12 at 12:00 p.m. and 1 resident who received Inravenous antibiotics as identified by Registered Nurse #1 on 9/29/12 and 115 residents who received oral medications and resided at the facility according to a list provided by the Administrator on 10/12/12. This failed practice also had the potential to affect 15 residents on [MEDICATION NAME] Insulin and 13 residents on [MEDICATION NAME] 70/30 according to the Inter-Director of Nursing, RN #1 on 9/29/12 at 5:00 p.m. The findings are: 1. The facility job descriptions for the Administrator and Director of Nursing was received from Registered Nurse #1 on 9/29/12. a. The Job Description titled "Administrator" documented: "Summary ...Responsible for the overall direction, coordination and evaluation of all facility operating activities ...Responsible for monitoring regulatory compliance to assure high quality of resident care." b. The Job Description titled "Director of Nursing" documented: " Summary ...Responsible for organizing, planning, directing, and evaluating nursing and other resident care services ..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 8/15/12 documented, the resident scored 15 (13 - 15 indicates cognitively intact) on the Brief Interview for Mental Status, required extensive assistance of one staff member for most Activities of Daily Living (ADL's) and received anticoagulant therapy in the last 7 days. a. The August 2012 Physician order [REDACTED]. " b. A lab report dated 7/9/12 documented the following results: PT ([MEDICATION NAME]) 23.2 H (High) reference range seconds 9.4 -12.5 INR(international normalized ratio) 2.30 H reference range ratio 0.8 - 1.2. " The July 2012 Physician order [REDACTED]. c. The August 2012 Physicians Order sheet documented, " ...PTI ([MEDICATION NAME]/International Normalized Ratio) every Mondays - Complex ...Start Date 7/13/12. " As of 9/24/12, there were no lab results in the clinical record for the weekly PTI for 7/16/12, 7/23/12, 7/30/12 or 8/6/12. d. On 9/25/12 at 2:45 p.m., the Interim Director of Nursing (DON) was informed that surveyor could not find any nurses notes after 7/4/12 until 8/7/12 in the resident's clinical record. As of 9/26/12 at 10:45 a.m., no nurses notes were found after 7/4/12 until 8/7/12. A Nurses Note dated 8/7/12 documented, "...Physician #1 here N.O. (New Order) noted pharmacy aware. Lab notified of lab draw for 8/13/12." A telephone order dated 8/7/12 documented, " ...Check INR (check) BMP (basic metabolic panel) on Monday." e. A lab report dated 8/13/12 documented the following results: PT ([MEDICATION NAME]) 36.9 H (High) (reference range) 12.5-15.9 seconds INR(international normalized ratio) 2.7 (reference range) 2.0-3.5. " The August 2012 Physician order [REDACTED]. f. As of 9/24/12, there were no lab results in the clinical record for the weekly PTI for 8/20/12, 8/27/12, or 9/3/12. 1) On 9/25/12 at 2:45 p.m., the Interim Director of Nursing (DON) was asked to find the most recent PT/INR report prior to resident's transfer to the hospital on [DATE]. She confirmed 8/13/12 as the most recent PT/INR prior to hospitalization . The Interim DON was asked if she had been able to find a physician order [REDACTED]. The Interim DON was informed that the August 2012 Medication Administration Record was not found in the clinical record. As of 9/27/12 at 10:00 a.m., the August 2012 MAR was not available for review. g. The Resident ' s Care Plan documented, "...Focus: Resident is at risk for bleeding r/t (related to) usage of [MEDICATION NAME] Date initiated 8/28/2012....Goal PT/INR results will be within therapeutic ranges and will be maintained for resident..." h. Nurses Note dated 9/10/12 at 0330 (3:30 a.m.) documented, "...CNA (Certified Nurse Assistant) reported bleeding from rectum area, resident c/o (complained of) stomach ache, abdomen felt tender to touch, toilet where resident used bathroom filled with brisket red blood - MD (Medical Doctor) paged - N.O. Send to ER (emergency room ). i. The Hospital Discharge Note dated 9/17/12 documented, " HPI (History and Physical Information): admitted from NH (Nursing Home) with LGIB (Lower [MEDICAL CONDITION]). Pt (Patient) had grossly bloody stools x 3 and some cramping in LLQ (left lower quadrant) abdominal pain...She is on [MEDICATION NAME] daily...At 9/10/12 at 0540 (5:40 a.m.) RBC (red blood cells) 3.64 L (low) (normals 4.10 - 5.0), Hgb (Hemoglobin) 8.6 L (normals 12.0 - 16.0), Hct (Hematocrit) 27.5 L (normals 36.0 - 48.0), PTS ([MEDICATION NAME]) 34.2 H (normals 8.8-12.0), INR (International Normalized Ratio) = 3.2 (Low intensity range 2.0-3.0. High intensity range 2.5 - 3.5), APTTS (Activated Partial [MEDICAL CONDITION] Time)= 34.4 sec (H) (normals 20.0 - 31.0), Occult Blood = Positive...9/10/12 at 1126 (11:26 a.m.) received 2 units PRBC (Packed Red Blood Cells) and 2 units PRBC at 1417 (2:17 p.m.)." j. Nurses Notes dated 9/15/12 at 12:30 p.m., documented the resident was readmitted to the facility. The admission orders ...Diagnosis: [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 5mg tablet po i (one) daily...Labs: (was blank, no labs were ordered)..." The September 2012 MAR documented the resident received 5 mg of [MEDICATION NAME] 9/15/12 - 9/18/12. k. A physician progress notes [REDACTED]. She was anemic from GI bleed with H/H (Hemoglobin /Hematocrit) down to Hgb 8/Hct 27.2. She received blood [MEDICAL CONDITION]. She was complaining of [MEDICAL CONDITION] pain during hospital stay. She is still reporting LLQ pain to a lesser extent. Pain is exacerbated with deep breathing, not modified by meals or position. She denies any trauma. She has no bleed since return...Assessment and Plan: Hematochezia ? (questionable) Diverticular disease. She is at risk for GI bleed from [MEDICATION NAME] but she needs to be anticoagulated for cardio embolic [MEDICAL CONDITION]; will have to keep INR goal between 2 - 2.5. A-Fib not controlled - monitor INR every Monday. Will decrease to 31.5 mg/wk (milligrams per week). LUQ pain ? Gastritis vs Ischemic bowel? [MEDICATION NAME] S/P (status [REDACTED]. 1) Nurses Note dated 9/18/12 at 2000 (8:00 p.m.) and signed by (Physician #1) documented, "... Stat INR then q Monday. (Decrease) [MEDICATION NAME] to 4.5 po (at) 1700 (5:00 p.m.). DC (discontinue) [MEDICATION NAME] 5 mg..." 2) A Physician order [REDACTED]. 3) Lab results dated 9/18/12 at 3:10 p.m. for PT/ INR documented, "...PT = 14.3 H/INR 1.3...with handwritten documentation, NO (new order) rec'd (received) (and) noted. Med (Medication) ordered..." Nurses Note dated 9/18/12 at 2000 (8:00 p.m.) completed by weekend Registered Nurse (RN) #2 documented, "...(Increase) [MEDICATION NAME] to 6 mg. and repeat I & R (INR) on Monday... T/O (Telephone Order) Physician #2/RN #2..." There was no documented telephone order for the increase in the [MEDICATION NAME] in the Clinical record. 4) On 9/28/12 at 11:22 a.m. the Medical Director (Physician #1) stated, " ... (Physician #2) is my Associate and he saw the results of her PT/INR and called to increase her (Resident #1) [MEDICATION NAME] to 6 mg due to her low INR. On the 18th her [MEDICATION NAME] ([MEDICATION NAME]) was ordered due to her abdominal problems and continued symptoms. She was still having abdominal pain, they could not find the active source. ... " l. The September 2012 Medication Administration Record (MAR) copied on 9/27/12 at 10:00 a.m. documented, "...9/18/12 [MEDICATION NAME] 1 g tab po QID (four times a day) Dx:[MEDICAL CONDITION](Gastrointestinal Regurgitation Disease)." The MAR documented the medication was not administered on the following dates and times as indicated by a circled initial on the date and time scheduled for administration or no initial as being given: 9/19/12 at 0900 (9:00 a.m.), 1300 (1:00 p.m.) and 1700 (5:00 p.m.-LPN#4) initials circled; no initials at 2100 (9:00 p.m.); 9/20/12 no initials at 0900 and 1300; 9/21/12 at 0900 and 1300 initials circled (LPN #4); and 9/22/12 at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. initials circled. m. On 9/27/12 at 4:25 p.m., the Interim DON provided copies of the bubble packs for the [MEDICATION NAME] 1 g. 0900 and 1300 doses filled 9/19/12, there were no bubble packs available for review for the 1700 and 2100 doses filled 9/19/12. The bubble packets documented: Filled by pharmacy 9/19/12 ...Quantity 20 (5 each for the 4 bubble packs). The medication packets for 0900 and 1300 doses were punched out each day 9/20/12 - 9/22/12, there were 2 pills remaining in each of the packets (9/23/12 and 9/24/12). On 9/27/12 at 4:10 p.m., Licensed Practical Nurse (LPN) #4 was asked what it meant when she initialed the MAR and circled it? She stated, "When I do that the medication wasn't available to give." When asked if she documented that the medication wasn't available to administer? She stated, "No, not here because we're told that would make the facility look bad because they didn't make sure it was here to give." n. The September 2012 MAR copied 9/27/12 at 10:50 a.m. documented: "9/18/12 [MEDICATION NAME] 4.5 mg 1 po daily (scheduled 1700 hours)." The MAR documented the medication ([MEDICATION NAME] 4.5 mg) was not administered on 9/19/12 (LPN #4's initials circled), 9/21/12 (not initialed) and 9/25/12 (initials circled). The MAR documented [MEDICATION NAME] 4.5 mg was administered on 9/20/12, 9/22-24/12, and 9/26/12 at 1700. The September 2012 MAR did not document the increase in the [MEDICATION NAME] from 4.5 mg to 6 mg on 9/18/12. On 9/28/12 at 6:00 p.m., RN #1 stated, "I called the Pharmacy Provider and they told me that they had never received an order for [REDACTED]. ..." 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/2/12 documented the resident had severely impaired cognitive skills for daily decision making per a staff assessment for mental status, was totally dependent on one to two staff members for all Activities of Daily Living (ADL ' s), had functional limitation with impairment on both sides of the upper/lower extremities, received tube feedings while a resident and received Anticoagulants 7 times during the last 7 days. a. The September 2012 Physician order [REDACTED]. 1) A Physician's telephone order dated 9/11/12 documented, "[MEDICATION NAME] 5 mg PT (per tube) (at)1700 x 2 days then 3 mg PT (at) 1700 daily, INR on Mondays- Notify MD of results..." 2) A Physician's telephone order 9/18/12 at 0900 documented, "[MEDICATION NAME] 2.5 mg q day, [MEDICATION NAME] 5 mg q day. STAT INR on Friday." b. The September 2012 Medication Administration Record (MAR) copied 9/28/12 at 10:15 a.m. documented, "...9/11/12 [MEDICATION NAME] 5 mg PT @ 1700 x 2 days then, [MEDICATION NAME] 3mg PT (at) 1700 (5:00 p.m.) daily. [MEDICATION NAME] 5 mg was initialed as administered on 9/11/12 and 9/12/12 on the MAR. [MEDICATION NAME] 3 mg was not initialed as administered on the MAR for 9/13/12, 9/14/12, 9/17/12, and 9/18/12. The MAR documented, "9/18/12 [MEDICATION NAME] 5 mg 1 tab po qd (everyday) at 1700." There were no initials on the MAR to indicate the resident received [MEDICATION NAME] 5 mg on 9/18/12 as ordered. The MAR documented the resident received [MEDICATION NAME] 5 mg on 9/19/12 thru 9/27/12. The September 2012 Medication Administration Record (MAR) copied 9/28/12 at 10:15 a.m., did not document the order for the [MEDICATION NAME] 2.5 mg q day received per telephone order dated 9/18/12. There was no record of administration from 9/18/12 - 9/27/12. c. On 9/29/12 at 4:00 p.m. the Interim Director of Nursing (DON) was asked if (Resident #5) received her [MEDICATION NAME] and [MEDICATION NAME] as ordered. She stated ( after reviewing the MARS, Bubble Packs and Pharmacy Printout), "It doesn't look like it. 4. Resident #2 had [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS) available for review. The resident was admitted to the facility on [DATE]. a. On 9/24/12 at 11:26 p.m. during initial rounds with Licensed Practical Nurse (LPN) #7, there was an IV (intravenous) pump in the resident's room. The pump was off. A 250 ml (milliner) bag was still connected with a label that documented, " [MEDICATION NAME] 1 GM (gram) 250 ml." There was approximately 50 ml in the bag. LPN #7 was asked how much was in the bag and she stated, "It looks like about 50cc's (cubic centimeters)." The LPN stated that the resident was on contact isolation due [MEDICAL CONDITIONS] of a sacral wound. On 9/24/12 at 11:52 p.m. LPN #13 was asked about the amount of [MEDICATION NAME] left in the bag and she stated, "I don't know why there is 50cc's left in the bag." b. During a review of the resident's September 2012 MAR on 9/28/12 at 6:35 p.m. and after comparing with the bubble packs and the pharmacy order forms the following discrepancies were identified: Potassium CHL(Chloride) ER (Extended Release) 20 meq (milliequivalent) Take 1 tablet by mouth 3 times a day ... 21 were received on 9/17/12. There had been 45 opportunities for the medication to be administered, 9 were circled and 6 were blank. 1 tablet was left in the 1 pm card and 2 were left in the 5 pm card. [MEDICATION NAME] ([MEDICATION NAME]) 20 mg to take 1 tablet by mouth twice a day with the initial dose given on 9/14/12 at 9:00 p.m. The record documented the medications were administered as ordered as indicated by a Nurse initial for each date administered. Since admission there were 28 tablets received, 14 tablets delivered on 9/14/12 and 14 tablets delivered on 9/20/12 according to the Delivery Manifest dated 9/14/12 and 9/20/12. The bubble pack had 7 tablets left. [MEDICATION NAME] 500 mg/100 milliliters (ml) Intravenous Q 8 hours times 20 days with the initial dose given on 9/14/12 at 8:30 a.m. The medication was scheduled to be administered at 8:30 a.m., 4:30 p.m. and 12:30 a.m. The Delivery Manifests documented 6 doses of the medication were received at 1:28 p.m. and 15 at 8:47 p.m. on 9/14/12, 7 received on 9/21/12 and 7 received on 9/26/12, a total of 35 doses. There was no documentation on the MAR to indicate the medication was administered on 9/14, 17, 23 or 24 at 12:30 a.m., 9/17/12 and 9/24/12 at 4:30 p.m. and 9/28/12 at 8:30 a.m. [MEDICATION NAME] 500 mg Intravenous Q 12 hours with the initial dose given on 9/14/12 at 9:00 a.m. The medication was scheduled to be administered at 9:30 a.m. and 9:00 p.m. The Delivery Manifests documented 14 doses were received on 9/14/12, 5 doses were received on 9/21/12, 5 doses were received on 9/26/12 at 12:40 p.m. and 5 doses were received on 9/26/12 at 1:07 p.m. The Medication had 29 opportunities for administration. The MAR had a blank space on 9/14/12 and 9/20/12 for the 9:00 p.m. dose indicating the medication was not administered. Cefepine 1 gram in Sodium Chloride 100 ml Q 12 hours with the initial dose given on 9/14/12 at 10:00 a.m. The medication was scheduled to be administered at 10:00 a.m., and 10:00 p.m. The Delivery Manifests documented 14 doses of the medication were received on 9/14/12, 5 were received on 9/21/12 and 5 were received on 9/26/12. There were 29 opportunities for the medication to be administered. The facility received a total of 24 doses of the medication. There was no documentation on the MAR to indicate the medication was given on 9/14/12 at 10:00 p.m. and 9/23/12, and 9/24/12 at 10:00 p.m. The MAR documented a total of 26 doses administered. c. On 9/28/12 at 7:00 p.m., Registered Nurse (RN) #1 was asked why there were so many missed doses and doses documented as given when there was no medication available to give. She stated, "I can't answer that, there's a problem here as you can tell." 5. Resident #8 had a [DIAGNOSES REDACTED]. The resident had a blood glucose test ac and hs (bedtime) everyday and was to receive sliding scale insulin ([MEDICATION NAME]) per the results as follows: 200 - 250 = 2 units. a. On 9/27/12 at 4:25 p.m., during the 4:30 p.m. medication pass, LPN #1 took a blood glucose test with a reading of 213 milligrams per deciliter (mg/dl). LPN #1 stated, "The resident is to receive [MEDICATION NAME] 10 units." The LPN #1 did not prime the [MEDICATION NAME] before administering the [MEDICATION NAME] to the resident. The LPN #1 did not leave the [MEDICATION NAME] needle in the injection site after administering the injection for the recommended 6 seconds. b. According to the manufacture's "Patient instructions for use [MEDICATION NAME]": "Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E: Turn the dose selector to select 2 units. F: Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0.".... "Giving the injection" ..."J. Keep the needle in the skin for at least 6 seconds, and keep the push button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given." c. According to the manufacture's package insert: "Give 5 to 10 minutes before meal" The Facility's Employee List received from the Administrator on 9/25/12 documented the facility meal times were 7:30 a.m., 12:30 p.m. and 5:30 p.m. d. This was a significant error due to the classification of medication, Anti-diabetic Insulin. 6. Resident #13 had a [DIAGNOSES REDACTED]. a. On 9/27/12 at 5:23 p.m., during the 5:00 p.m. medication pass, LPN #2 did not prime the [MEDICATION NAME] 70/30 Pen before administering the [MEDICATION NAME] 70/30 58 units sq. b. According to the manufacture's "Instructions for Insulin Pen Use" "Is important to read, understand, and follow the instructions in the Insulin Delivery Device User Manuel before using. Failure to follow instructions may result in getting too much or too little insulin. The needle must be changed and the Pen must be primed to a stream of Insulin (not just a few drops) before each injection to make sure the Pen is ready to dose. You may need to prime a new Pen up to six times before a stream of Insulin appears. Performing these steps before each injection is important to confirm that insulin comes out when you push the injection button, and to remove air that may collect in the insulin cartridge during normal use. This was a significant error due to the classification of medication, Anti-diabetic Insulin. c. This was a significant error due to the classification of medication, Anti-diabetic Insulin. 7. The Immediate jeopardy was removed on 9/29/12 and the scope and severity was reduced to an "H" when the facility initiated the following plan of removal: 1) Medication Administration Lab 9/29/12. Licensed Staff Education was begun on 9/28/12 by RN/Designee to include accurate transcription of [MEDICATION NAME] orders onto the physician's orders [REDACTED]. 2) A complete medication matchback was initiated immediately on 9/28/12 by RN/Designee for residents with [MEDICATION NAME] orders to ensure accurate orders in relation to resident INRs. These orders will be verified with the Physician to ensure accurate dosages are delivered on 9/29/12. The INR value will be added to the MAR for Physician Review during their rounds. Physician will be notified of INR lab values upon receipt to determine accurate dosage. 3) The DON/RN/Designee will monitor orders for [MEDICATION NAME] 5 days/week for 4 weeks, then 3 days/week for 2 weeks, then weekly for four weeks, or until substantial compliance is obtained. Negative findings will be addressed with corrective measures immediately. Results will be reported to the QA Committee by the DON/RN/Designee monthly.

Complaint # was substantiated, all or in part, with these findings. Based on observation and record review, the facility failed to ensure supervision was provided to prevent accidents for a resident with altered mental status and hallucinations by leaving her alone on a bedside commode and failed to follow the facility's policy and procedures to ensure the resident was assessed after falls, causative factors were investigated and interventions were identified and implemented to prevent falls for 1 (Resident #4) of 5 (Residents #1-#5) case mix residents with a history of falls. This failed practice resulted in actual harm to Resident #4, who sustained bilateral tibial fractures, and was likely to affect 80 residents who were at high risk for falls, according to a list received from the Director of Nursing (DON) on 12/15/11 at 4:50 p.m. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set with an assessment reference date of 11/5/11 documented the resident scored 12 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status, required the extensive physical assistance of 2+ persons for toilet use and the total assistance of 2+ persons for transfers. a. The Resident Plan of Care dated 11/9/11 documented " ... falls ... Assist me with all transfers and ambulation." b. An Event Reporting form dated 11/15/11 documented, "Resident observed on floor on her knees. R (resident) stated she saw a snake on top of refrigerator so was attempting to get out of bed away from snake c/o (complained of) pain to knees & (and) leg assessed pt (patient) knees were red. R was transferred to bedside commode & call light was put in reach to notify staff when done on commode. R stated she tried to get up again and get in bed and R fell again on the floor L (left) leg swollen near knee... transported resident to (hospital)." There was no other documentation in the Nurse's Notes or elsewhere in the chart for each separate fall with immediate assessment of the resident's range of motion of all extremities, all locations of pain and severity, a complete set of vital signs or a body audit to identify abrasion, lacerations, hematomas and all swelling. The Plan of Care was not updated to address the resident's altered mental status with hallucinations after her return from the hospital on [DATE]. c. The hospital Discharge Summary dated 11/17/11 documented, "Final diagnosis - Bilateral proximal tibia fractures..." d. An In-service Education Report dated 12/2/11 documented a written in-service was provided to staff. The in-service documented, "Always ensure residents' call lights are within reach. Always monitor residents closely. If a resident is using a bedside commode, ensure that he or she has the call light within reach and monitor unless asked to leave the room for privacy -AND- if safe per the resident's care plan..." The in-service did not address what to do if a resident was confused, had just fallen or had a history of [REDACTED]. It did not instruct staff not to move the resident until an assessment was completed, and it was deemed safe to move the resident, including range of motion, pain, swelling (where on the body with severity), a complete set of vital signs, a neurological assessment and a complete body audit. It did not instruct staff regarding investigating the causative factors related to the fall The facility's Fall Prevention Program was not included in the in-service. e. On 12/13/11 at 2:45 p.m., the surveyor asked Resident #4 if she had an accident. She stated, "I'll say I did, I stepped in a hole and broke both ankles." The surveyor asked the resident where she was at the time of the accident and the resident stated, "I was outside. My cousin was with me but they weren't no help." f. As of 12/13/11 at 4:48 p.m., there was no documentation in the Nurses' Notes of the resident's mental confusion on 11/15/11. The Nurses' Notes had an entry dated 11/9/11 and the next entry was dated 11/17/11, when the resident returned from the hospital. A Resident Transfer Form dated 11/15/11 documented, "Possible fracture." No other information except the resident's name was on the Resident Transfer Form. g. On 12/14/11 at 2:22 p.m., the DON was asked for the Incident and Accident report for each of the resident's falls. She stated, "This (Event Reporting form dated 11/15/11) is the resident's first and second fall combined." The DON was asked if the resident was assessed after the first fall. She stated, "Yes, the nurse was in there. It says she was assessed." The DON was asked for the documentation of the assessment and she left the room to find it. She returned and stated, "I don't see anything and the nurse is no longer here..." She was asked who investigated the resident's 2 falls on 11/15/11. She stated the Assistant DON, the Administrator and herself. She was asked if anyone investigated why the resident was hallucinating. She stated, "It happened so fast and she was sent out right away." The DON was asked about the Certified Nursing Assistant (CNA) leaving the resident alone after the first fall when she was seeing snakes. The DON stated, "Do I think the CNA should have left her alone? No..." h. On 12/14/11 at 3:12 p.m., Licensed Practical Nurse (LPN) #1 stated, "I was told by the nurse that was taking care of her (Resident #4) that night (LPN #2) that she had fallen... (Resident #4) told them that she saw a snake on top of her refrigerator." LPN #1 was asked if that was the first she had heard of a snake. She stated, "Earlier that day, she said she was in the woods. She didn't say anything about a snake" LPN #1 was asked why there was not an assessment of the resident after her falls. She stated, "I figured (LPN #2) did all that because I wasn't her nurse that night." LPN #1 was asked if it is normal procedure to do an assessment after a resident falls with vital signs and range of motion. She stated, "Yes ma'am..." The LPN also stated, "I did not know she was left on the bedside commode alone until after the fact." i. On 12/14/11 at 4:41 p.m., CNA #1 stated, "I can't tell you about the first fall because I was at lunch. I was called off lunch on her second fall." CNA #1 was asked if Resident #4 was assigned as her resident that day. She stated, "She was." CNA #1 was asked if the resident had been confused that day. She stated, "Yes, I know. I believe they called me down that afternoon because she had called her daughter and said she was in the woods and had to use the bathroom and was on her light for a couple of hours and no one would help her. I had been in and out of her room that day probably 3 times before dinner. She never stated that she needed to use the restroom, nor was she on her light at all and it was on the side of her." The CNA was asked if the resident should have been left alone on the bedside commode in her confused state. She stated, "No, another CNA (CNA #2) did that. (CNA #2) was watching my residents while I was on lunch." She was asked if vital signs were done after she was called in. She stated, "She (CNA #2) did get the equipment for vital signs. I don't know if she got them or not... I wouldn't have left out of the room." j. On 12/15/11 at 11:28 a.m., CNA #3 was asked if she had an in-service about leaving a confused resident alone on the bedside commode. She stated, "No, I haven't been in-serviced. I work PRN (as needed). That's how I end up missing an in-service." k. On 12/15/11 at 11:37 a.m., CNA #4 was asked if she had an in-service about leaving a confused resident alone on the bedside commode. She stated, "I have not been in-serviced on this. No, I don't remember an in-service." l. The Fall Prevention Program provided by the Administrator on 12/15/11 at 3:46 p.m., documented, "... In the event of a fall, the nurse will: A. Immediately assess the resident and document findings in the medical record. The resident should not be moved until an assessment is completed and it is deemed appropriate to move the resident. The assessment may include (but not limited to) the following: a. Assess range of motion of all extremities for changes in functional range of motion, swelling, pain, etc (etcetera). b. Assess for verbal/non-verbal sign or symptoms of pain. Any complaints of pain will require additional assessments as to location, severity and so forth. Complaints or symptoms of pain must be identified and addressed. This may include administering pain medications, positioning, notifying physician or orders - possible x-rays, etc. c. Obtain a complete set of vital signs including temperature. This may also include lying to sitting and sitting to lying blood pressure to rule out orthostatic hypotension. The nurse may also wish to obtain pulse ox as assessment data. d. Obtain a fingerstick blood sugar if deemed appropriate for hypo/hyperglycemic residents. e. Conduct a body audit to identify any injuries such as abrasions, lacerations, hematomas, swelling, etc. C. Investigate to determine possible causative and/or contributing factors related to the fall...D. Initiate any necessary interventions to provide safety and minimize additional fall...G. Complete the Event Report and place in the resident's medical record...H. Complete the Alleged Fall Report...J. Initiate Neurological Assessment if indicated...K. Provide any necessary staff training...Be sure to include the topic of training and date training initiated..."