Every finding on record at The Waters of Union City , LLC

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 4 staff (Registered Nurse (RN) A) failed to use appropriate Personal Protective Equipment (PPE) during medication administration through a Peripherally Inserted Central Catheter (PICC) for 1 of 8 (Residents #66) sampled residents reviewed for medication administration. The findings include: 1. Review of the facility policy titled, Guidelines for Enhanced Barrier Precautions-(EBP) AN Extension of Personal Protective Equipment---(PPE), dated December 2022, revealed .It is the policy of the facility to ensure that additional and appropriate PPE (Personal Protective Equipment) is utilized, when indicated.Enhanced Barrier Precautions are defined as the use of PPE (gown and gloves) during high contact resident care activities.Who is at High Risk.Resident(s) with an indwelling medical device including.Central Venous Catheters.Feeding Tubes (any type).Examples of High Contact Resident Care Activities at which time EBP is to be practiced are.Device Care or Use to include.Central Lines.Feeding Tubes. 2. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including with diagnoses Osteomyelitis (Bone infection) of the right ankle and foot, Heart Failure, and Sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed it was still in progress at the time of the survey. Review of the Physician's Order dated 3/12/2026, revealed .Normal Saline Flush Use 10 ml [milliliters] intravenously as needed for PICC line Maintenance.Daptomycin [antibiotic] Intravenous Solution Reconstituted 500 MG [milligram] Use 500 mg intravenously [medical technique that delivers medication directly into a vein for immediate absorption] one time a day for osteomyelitis. Review of the Physician's Orders dated 3/16/26, revealed .Enhanced Barrier Precautions every shift for osteomyelitis/IV [intravenously] PICC. Observation during medication administration on 3/16/2026 at 1:32 PM, revealed RN A gathered supplies to administer IV medications to Resident #66. RN A entered Resident #66's room, there was no EBP signage on the door or in the room to indicate that Resident #66 was on EBP. RN A placed a barrier on the table and placed supplies on top of the table. RN A washed her hands and donned (put on) gloves, cleaned the top of the medication bottle, cleaned the stopper to the 500 ml bag of fluids, mixed medication, removed gloves and performed hand hygiene. RN A donned gloves, attached the tubing to the bag of fluids/medication, removed gloves, and performed hand hygiene. RN A donned gloves, primed the tubing line, removed gloves, performed hand hygiene, donned gloves, cleaned top of port for 15 seconds with alcohol wipe, flushed PICC line with 10 ml of Normal Saline, cleaned the port for 15 seconds with alcohol wipe, cleaned the end of tubing connector for 15 seconds, and connected the tubing to the PICC line. RN A set the rate at 100 ml with a volume of 50 ml to run over 30 minutes. RN A removed gloves, threw away her supplies, washed her hands, and exited the room. RN A failed to wear a gown when administering the IV antibiotic through the PICC line. During an interview on 3/16/2026 at 1:50PM, RN A was asked should Resident #66 have been in Enhanced Barrier Precautions due to his PICC line. RN A stated, Yes, he should be. RN A was asked if PPE should have been worn during IV medication administration. RN A stated, Yes, it should. RN A was asked if she should have worn PPE when administering IV medication to Resident #66. RN A stated, Yes I should have. During an interview on 3/16/2026 at 2:24 PM, the Director of Nursing (DON) was asked if Enhanced Barrier Precautions should have been used during medication administration via a PICC line. The DON stated, Yes.

Based on facility policy review, medical record review, and interview, the facility failed to assure residents received care and services for the provision of parenteral fluids for 1 of 1 sampled resident (Resident #66) reviewed for a peripheral inserted central catheter (PICC) line. The findings include: Review of a facility policy titled, .Maintenance Flushing.Peripherally Inserted Central Catheters (PICC), dated 6/2025, revealed .The SASH method will be used when administering intermittent medications or fluids through an open-ended PICC. SASH [an intravenous normal saline and heparin combination to keep access open] = Saline>Administer Medicine>Saline>Heparin.In 10 cc [cubic centimeter] syringe, draw up 5 cc normal saline.In second syringe draw up 3 cc or prescribed amount of Heparin solution.Insert.saline syringe.and inject saline.Insert Heparin syringe.and inject. Review of the medical record review revealed Resident #66 was admitted to the facility on [DATE], with diagnosis of Orthopedic Aftercare, Osteomyelitis (an infection in a bone), Sepsis (a life-threatening condition caused by the body's extreme response to an infection), Diabetes, and Heart Failure. Review of the Medication Administration Record (MAR) dated 3/1/2026 - 3/31/2026, revealed Resident #66 from 3/12/2026 - 3/16/2026 had blank/unsigned documentation for the administration of Normal Saline and Heparin flushes, indicating the medication had not been administered. Review of the Physician Orders dated 3/12/2026, revealed .ceftriaxone [an antibiotic].intravenously [fluids administered by vein].DAPTOmycin [an antibiotic] intravenously one time a day.Heparin Flush Solution.intravenously as needed for PICC maintenance.Normal Saline Flush.intravenously as needed for PICC line Maintenance. Review of the Care Plan dated 3/15/2026, revealed I have a PICC line.right upper arm.Flush PICC with Normal Saline per MD [medical doctor] orders.I am receiving IV [intravenous] medications related to .osteomyelitis (a serious infection of the bone marrow and tissue caused by bacteria or fungi) .Flush IV tubing and port per facility protocol. During an interview on 3/16/2026 at 2:30 PM, the Director of Nursing (DON) was asked do you follow the SASH protocol when flushing a PICC line. The DON stated, Yes. The DON was asked what the policy for SASH is. The DON stated, You give saline, medication, saline and heparin when you are using the line [PICC line]. The DON was asked to look at the Normal Saline and Heparin as needed orders on the MAR. The DON was asked should Normal Saline and Heparin have times to administer according to the meds given. The DON stated, Yes, it should not be PRN [as needed]. The DON was asked to look at the empty blanks on the MAR and confirmed she could not provide any additional information verifying that the flushes of Normal Saline and Heparin were given. During an interview on 3/16/2026 at 2:48 PM, Registered Nurse (RN) A was asked how do you normally flush a PICC line after a medication is administered. RN A stated, With 10 cc of normal saline and 5 cc heparin . RN A was asked how do you know what to use to flush a PICC line. RN A stated, I flush per PICC protocol. RN A was asked should the flush times have been on the MAR scheduled with the medication. RN A stated, Yes it should have been, but it is listed as PRN.

Based on the facility policy review, medical record review, observations, and interview, the facility failed to minimize the potential for foodborne illness transmission by not properly monitoring temperatures for 2 of 46 (Resident #10 and Resident #27) personal refrigerators located in resident rooms. The findings included: 1. Review of the undated facility policy titled, Refrigerator/Freezer Temperatures, revealed .in order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators .Each refrigerator .located outside of the main kitchen (i.e .personal) is checked daily and recorded on Refrigerator .Temperature log by the appropriate department .If the temperature on the internal thermometer is outside of the acceptable range .personal refrigerators are permitted to be kept in a resident's room .Each refrigerator shall have a temperature log with daily entry .Each refrigerator will have an inside thermometer .will be maintained at or below 41 degrees Fahrenheit [F] . 2. Review of the medical records revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Atrial and Chronic Kidney Disease. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Idiopathic Peripheral Neuropathy, Peripheral Vascular Disease and Anorexia. During observation on 1/28/2025 at 10:05 AM and on 1/29/2025 at 12:50 PM, revealed Resident #10's refrigerator was full of food items and no thermometer was visible. During observation on 1/29/2025 at 12:45 PM, revealed Resident #27's refrigerator temperature was 60 degrees. No food items were present. Observation and interview on 1/30/2025 at 1:28 PM, Certified Nursing Assistant (CNA) A was asked to verify Resident #10's refrigerator temperature. CNA A stated, to be honest, there is not even a thermometer in her refrigerator. CNA A was asked if there should be a thermometer in the refrigerator and she responded yes. Observation and interview on 1/30/2025 at 1:34 PM, CNA A was asked to verify Resident #27's refrigerator temperature. CNA A stated the temperature was 45 degrees F. CNA A was asked what the temperature should be, and she stated, the temperature should be less than 41 degrees F. CNA A was then asked what should be done next and she confirmed the temperature should be adjusted and the temperature rechecked. CNA A did not discard the food items in the refrigerator. 3. During an interview on 1/30/2025 at 5:15 PM, the Director of Nursing (DON) was asked what staff was responsible for checking the refrigerator temperatures. The DON stated that nursing staff checks the temperatures. The DON was asked what the temperature should the refrigerator temps be and she stated between 35-41 degrees F. The DON was then asked what should be done if the refrigerator temperature was out of range. The DON stated they are to adjust the temperature and recheck the temperature. If there are food items in the refrigerator, they should be thrown away.

Based on policy review, record review, and interview the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 8 of 24 (Resident #1, #2, #4, #11, #13, #20, #22, and #47) residents reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled, Guidelines for Resident Rights-Advanced Directive(s), dated 6/4/2024, revealed Residents have specific rights related to advance directives .The facility must ensure that these rights are explained, documented . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Chronic Atrial Fibrillation and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #1 was moderately cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 3/30/2023, revealed the document was not filled out completely or correctly. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Aphasia, Tracheostomy, Cerebral Infarction, Atrial Fibrillation, Diabetes, and Anxiety. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 2, which indicated Resident #2 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 10/1/2024, revealed the document was not filled out completely or correctly. 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, Heart Failure, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #4 was moderately cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 10/3/2024, revealed the document was not filled out completely or correctly. 5. Review of medical record revealed Resident #11 was admitted on [DATE], with diagnoses that included Diabetes, Paranoid Schizophrenia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #11 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 9/19/2024, revealed the document was not filled out completely or correctly. 6. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Hypertension, Heart Failure, Chronic Kidney Disease, and Atrial Fibrillation. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #13 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 9/24/2024, revealed the document was not filled out completely or correctly. 7. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Schizophrenia, and Cardiomyopathy. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #20 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 10/22/2024, revealed the document was not filled out completely or correctly. 8. Review of medical record revealed Resident #22 was admitted on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Hypertensive Chronic Kidney Disease, Dementia, and End Stage Renal Disease. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 3, which indicated Resident #22 was severely cognitively impaired. Review of the facility document, Acknowledgement of Advanced Directive Discussion, dated 11/19/2024, revealed the document was not filled out completely or correctly. 9. Review of medical record revealed Resident #47 was admitted on [DATE], with diagnoses including Anxiety, Depression, and Rheumatoid Arthritis. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #47 was cognitively intact. Review of the facility document titled, Acknowledgement of Advance Directive Discussion, dated 9/5/2024, revealed the document was not filled out completely or correctly. 10. During an interview on 1/29/2025 at 10:57 AM, the Admissions Director confirmed that the facility Acknowledgement of Advance Directive Discussion form was not filled out correctly on admissions. The Admissions Director confirmed that if a resident had a cognitive deficit, she was not aware the responsible party should have filled out the advance directive form. During an interview on 1/29/2025 at 11:08 AM, the Director of Social Services confirmed that the facility Acknowledgement of Advance Directive Discussion form was not correctly filled out. She confirmed that the Responsible Party should have been notified to fill out the form if resident was unable due to cognitive deficits. 47127 49311 50408

Based on policy review, medical record review, and interview, the facility failed to ensure behavior monitoring and side effects of psychoactive medications were monitored for 1 of 5 sampled residents (Resident #256) reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, .Psychotropic Medication . dated 8/18/2023, revealed .Psychoactive medications include .anti-psychotic and anti-depressants .Monitors psychotropic drug use daily noting any adverse side effects .Monitors for presence of target behaviors on a daily basis . 2. Review of the medical record review revealed Resident #256 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Psychosis, Dementia, and Diabetes. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #256 received an anti-psychotic and anti-depressant medication 7 days of the review period. Review of the Order Summary Report dated 1/16/2025, revealed SEROquel (an anti-psychotic medication) oral tab .12.5mg (milligram) .one time a day . Review of the Order Summary Report dated 1/16/2025, revealed SEROquel .oral tab .12.5 mg . in the afternoon . Review of the Order Summary Report dated 1/16/2025, revealed SEROquel .oral tab .25mg .at bedtime . Review of the Order Summary Report dated 1/23/2025, revealed Lexapro (an anti-depressant) .5 mg .one time a day . Review of the medical record revealed the anti-psychotic and the anti-depressant medications were not monitored for behaviors or side effects. During an interview on 1/30/2025 at 1:05 PM, The Director of Nurses (DON) confirmed there were no orders for behavior or side effect monitoring for the antipsychotic and psychotropic medications that Resident #256 was receiving. The DON confirmed the facility should be monitoring these medications daily.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained for 1 of 2 (Resident #48) sampled residents observed during a dressing change. The findings include: 1. The Lippincott Manual of Nursing Practice, 10th EDITION documented, .Keep the drainage bag in a dependent position, below the level of the bladder . 2. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 3. A physician's orders [REDACTED].Cleanse wound to sacral area with Dakins, pat dry, Apply Calcium Alginate and Collogen dressing to wound bed, cover with ABD (abdominal) pad, secure with border dressing daily every day shift . A physician's orders [REDACTED].May change indwelling silicone silver tip catheter number 18 Fr (french) 30 cc (cubic centimeters) bulb as needed for [MEDICAL CONDITION] . 4. Observations in Resident #48's room on 9/24/19 at 2:20 PM, revealed Registered Nurse (RN) #1 performed dressing changes with the assistance of Certified Nursing Assistant (CNA) #1 and CNA #2. CNA #1 placed Resident #48's indwelling urinary catheter tubing and bag on the foot of the bed during the dressing change. CNA #1 and #2 changed a blue pad saturated with bloody drainage from the resident's sacral wound by rolling the resident, and placed a clean, dry blue pad under the resident on top of a bed sheet that was saturated with wound drainage. After the dressing change, Resident #48 was positioned in the bed and the bedside drainage bag was positioned back under the bed at 3:03 PM, 35 minutes later. Interview with CNA #1 on 9/24/19 at 3:05 PM, in Resident #48's room, CNA #1 was asked if it was appropriate to leave the catheter bag on the bed during the dressing change. CNA #1 stated, no . Interview with CNA #2 on 9/24/19 at 3:07 PM, in Resident #48's room, CNA #2 was asked if it was appropriate to cover the saturated bed linen with a clean blue pad. CNA #2 stated, .no .we did not have the supplies in the room . Interview with the Director of Nursing (DON) on 9/25/19 at 11:25 AM, in the DON Office, the DON was asked if it was appropriate to place a bedside drainage bag in the bed with a resident during a dressing change. The DON stated, .no ma'am . The DON was asked it was appropriate to replace blue pads over bed linen that was saturated with drainage from a wound. The DON stated, .all of the linens should have been changed .

Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications free of significant medication errors. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . [MEDICATION NAME] .Insulin .[MEDICATION NAME] .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].=5 (units) .300-349 =10 (units) .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered [MEDICATION NAME] 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered until a meal tray was delivered to Resident #18 at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in a significant medication error. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in a significant medication error. 3. Medical record review revealed Resident # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered until a meal tray was delivered to Resident #24 at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in a significant medication error. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving [MEDICATION NAME] insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.

Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH Edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 29 opportunities, resulting in an error rate of 10XXX 759% The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . [MEDICATION NAME] .Insulin . [MEDICATION NAME] . Rapid-Acting Insulin .ONSET .15 min . ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].= 5 (units) .300-349 = 10 (units) .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered [MEDICATION NAME] 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered to Resident #18 until a meal tray was delivered at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in medication administration error #1. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered to Resident #18 until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the [MEDICATION NAME] resulted in medication administration error #2. 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered [MEDICATION NAME] 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered to Resident #24 until a meal tray was delivered at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in medication administration error #3. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving [MEDICATION NAME] insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.

Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a quarterly assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 2 of 19 (Resident #2 and #5) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 (MONTH) 1, (YEAR) page 2-33 documented, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act) assessment of any type .The ARD (Assessment Reference Date) (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 7/3/19 revealed Item Z0500B was not completed. The MDS should have been completed by 7/17/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 7/3/19 MDS for Resident #2 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If it is from July, then yes. 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD date of 8/2/19 revealed Item Z0500B was not completed. The MDS should have been completed by 8/16/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 8/2/19 MDS for Resident #5 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If that was the ARD date, then, yes it should have.

Based on medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized and develop an appropriate plan to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. The QA program failed to ensure all beds/side rails were safe for residents. The facility failed to ensure the QA program ensured medications and biologicals were properly stored and secure. The QA failed to ensure residents' rights to have personal items in their room, keep residents' electronic records confidential, and promote resident dignity and respect. The facility failed to have a QA program that ensured physician's orders were followed, care plans implemented, infection control maintained and pain monitored. The QA program failed to ensure communication between the facility and the [MEDICAL TREATMENT] clinic for [MEDICAL TREATMENT] residents. The facility failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections from previous surveys. The failure to ensure vulnerable residents' environment was free from the accidents and hazards of chemicals, medications, sharps, and biohazardous material placed sampled Residents #2, 20, 21, 26, 41, 46, 53, 62, 82 and 96 in IMMEDIATE JEOPARDY. The failure to ensure Resident's #20 and 53 were free of accident and hazards from improper functioning bed/side rails placed them at risk for entrapment. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the IMMEDIATE JEOPARDY on 9/18/16 at 10:14 PM, in the Conference Room. An extended survey was conducted from 9/28/16 - 9/29/16. The IMMEDIATE JEOPARDY is effective 9/18/16, and is ongoing. The findings included: 1. Interview with the Administrator on 9/28/16 at 7:20 PM, in the Administrator's office, the Administrator was asked how the QA Committee identified issues. The Administrator stated, .It depends on the scope and severity of the issue identified .Most of our PIPS (Performance Improvement Plan) last 9-12 months .there are action items for issues of a small magnitude . The Administrator was asked how does the QA Committee identify issues. The Administrator stated, .We use a variety of tools being Point Right (computer software) .Casper Reports .real time data .the Minimum Data Set Coordinator loads the Point Right Data .We have weekly risk meetings that covers weights, any skin issues .and have a weekly DQI (Daily Quality Instrument) that covers any incidents that were addressed throughout the week .we have daily clinical start up meetings where we review incidents, no BM's (bowel movements), input/output, admissions from the previous day, doctor's visits that are due that day, all skilled documentation, progress notes and any late medications . Stand up takes place daily here, we review current census, any admissions, planned discharges, meals for the day, activities for the day, any grievances, compliments, maintenance issues, and each discipline's focus for the day . The Administrator stated, .Non clinical rounds or Angel rounds are done weekly by every department head and are due to me by Friday . The Administrator was ask to describe his tracking methods. The Administrator stated, .Month over month we monitor performance, PIPS, Quality Indicator Data .Point Right is our main tracking tool for quality measure data . The Administrator was asked how did he evaluate the effectiveness of the implementation of the solution to an issue. The Administrator stated, .Hard data is the most objective . The Administrator was asked what are some of the problems the QA Committee has identified. The Administrator stated, .Late medications, antipsychotic medication reduction, getting in front of infection control. and rehospitalization s .This survey identified all new issues for us . 2. The QA program failed to failed to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. The failure to protect vulnerable residents from accident hazards and in a safe environment placed residents in Immediate Jeopardy. Refer to F 323 and F 465. 3. The QA program failed to ensure the facility honored resident's rights to have personal items in their room. Refer to F 151. 4. The QA program failed to ensure residents' electronic records were kept private and confidential. Refer to F 164 and 516. 5. The QA program failed to promote care that maintained residents' dignity, respect, and quality of care. Refer to F241. 6. The QA program failed to follow the resident's care plan interventions related to accidents, unnecessary medications, oxygen, foley catheter care, labs, and pain monitoring. Refer to F 282. 7. The QA program failed to ensure physician's orders were followed laboratory, medication administration and pain assessment; failed to ensure communication between facility and [MEDICAL TREATMENT] clinic. Refer to F 309. 8. The QA program failed to ensure Foley catheter bags and tubing did not touch the floor. Refer to F 315. 9. The QA program failed to ensure oxygen was administered according to the physician's orders. Refer to F 328. 10. The QA program failed to ensure residents were monitored for side effects and adverse drug reactions. Refer to F 329. 11. The QA program failed to ensure accurate nurse staffing information was posted at the beginning of each shift. Refer to F 356. 12. The QA program failed to to ensure practices to prevent the potential spread of infection were maintained as evidenced of meal plates not covered, ,staff members handling food with their bare hands, staff did not perform hand hygiene during meal service, Dietary staff's hair not restrained, Dietary Staff failed to perform hand hygiene in the kitchen, and unlabeled and undated food. Refer to F 371 13. Administration failed to ensure medications and biologicals were properly stored and supplies were not stored past the expiration date. Refer to F 431 14. The QA program failed to failed to ensure practices to prevent the potential spread of infection. Refer to F 441 15. The QA program failed to ensure there was an operational call light system in 4 of 52 resident bathrooms. Refer to F 463. 16. The QA program failed to ensure the Medical Director assisted the facility with identifying evaluating, and addressing clinical concerns, coordinated the medical care and provided clinical guidance and oversight regarding the implementation of resident care policies and procedures for prevention of accident hazards. Refer to F 501 17. The QA program failed to promptly notify the physician of resident lab results. Refer to F 505 18. The QA program failed to ensure the quality assurance program was effective in maintaining long term compliance with the previous deficient practices for dignity and respect of individuality, following care plan, kitchen sanitation, drug / biological storage and infection control. Refer to F 164, F282, F371, F431, F441. A revisit survey #1 for the Allegation of Compliance (AOC) was conducted on 10/4/16 through 10/5/16. The facility remains out of compliance with Immediate Jeopardy at F-520 ongoing. Based on review of the Allegation of Compliance (AOC), policy review, review of side rail assessments, record review, observation and interview the facility failed to ensure a quality assurance program that identified and developed an effective plan of action to correct immediate jeopardy deficient practices that affect the residents residing in the facility. The findings included: Review of the AOC submitted by the facility on September 29, 2016 revealed, a Quality Assurance Performance Improvement (QAPI) committee meeting was conducted on 9/20/16 .to discuss the immediacy of the cited deficiencies, the implemented interventions and on-going action plans .Specific interventions included: daily safety rounds conducted .to ensure safety for all Residents (daily safety that consist of ensuring that all doors/locks operate properly, unsafe areas are secure, hazardous items are properly secured, biohazardous items are properly contained/secured, .Resident care supplies are secured in personal lock boxes/cabinets or drawers, .Administrator reviewing daily safety rounds daily, Administrator conducting random audit rounds .All of these interventions will be reviewed by the QAPI committee weekly .and as needed . In an interview conducted in the conference room on 10/4/16 at 4:30PM the DON brought in the requested designation policy and stated, l guess I am in charge . The Administrator left on Saturday, flew out to(NAME)for the week. The DON was asked who was completing the Administrator's audits and oversite duties according to the AOC and stated, I guess that would be me. The DON was shown a Non Clinical Rounds report dated 9/30/16 that revealed, .S19 perineal cleaner in Btrm(bathroom) cabinet, sewing needles, mouthwash & denture cleaner overbed t(table) . The DON was asked to explain this report and stated, That is our Guarding Angel IDT rounds. The DON was asked to provide the follow-up to this IDT form dated 9/30/16 and for all documentation of the audits and oversite duties by the Administrator. In an interview conducted in the conference room on 10/5/16 at 12:00 Noon, the DON brought in a typed statement and stated, Here is a statement the Administrator sent to me about his oversite. Review of this statement revealed no signature or date, the statement read in part, .To whom it may concern: I, (Named Administrator), oversaw and directed the actions taken during the Allegation of Compliance process . There was no documentation provided to the survey team of the Administrators oversite activites or audits per AOC. The DON stated, As a result of our daily IDT round and the IDT round report on 9/30/16 we have increased to hourly rounds starting today . There was no documentation the items documented as found in resident room S19 on the 9/30/16 ( the next day after alleged compliance) IDT round report had been identified and addressed until 10/5/16 after being brought to the facilities attention by the survey team. The facility failed to follow their AOC, failed to have an Administrator/Acting Administrator present, in charge and aware they were in charge on 10/5/16 and failed to ensure an effective QA program that identified and addressed issues timely. Refer to F323, F431, F465, F490, F493, F501

Based on medical record review, observation and interview, the Administration failed to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents by failing to ensure an effective Quality Assurance (QA) program that recognized and develop an appropriate plan to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. Administration failed to ensure all beds/side rails were safe for residents, and medications and biologicals were properly stored and secured from vulnerable residents. Administration failed to ensure residents' rights to have personal items in their room was honored, residents' electronic records were kept confidential, and failed to promote resident dignity and respect. Administration failed to ensure staff followed physician's orders [REDACTED]. Administration failed to ensure communication between the facility and the [MEDICAL TREATMENT] clinic for [MEDICAL TREATMENT] residents, and failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections from previous surveys. The failure to ensure vulnerable residents' environment was free from the accidents and hazards of chemicals, medications, sharps, and biohazardous material placed sampled Residents #2, 20, 21, 26, 41, 46, 53, 62, 82 and 96 in IMMEDIATE JEOPARDY. The failure to ensure Resident's #20 and 53 were free of accident and hazards from improper functioning bed/side rails placed them at risk for entrapment. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the IMMEDIATE JEOPARDY on 9/18/16 at 10:14 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F323, which is Substandard Quality of Care. An extended survey was conducted from 9/28/16 - 9/29/16. The IMMEDIATE JEOPARDY is effective 9/18/16, and is ongoing. The findings included: 1. Administration failed to ensure the facility honored resident's rights to have personal items in their room for Refer to F 151. 2. Administration failed to ensure the facility maintained the privacy and confidentiality of residents' electronic records. Refer to F 164 and 516. 3. Administration failed to ensure staff promoted care that maintained residents' dignity, respect, and quality of care. Refer to F241. 4. Administration failed to ensure staff followed the resident's care plan interventions related to accidents, unnecessary medications, oxygen, foley catheter care, labs, and pain monitoring. Refer to F 282. 5. Administration failed to ensure the staff followed physician's orders [REDACTED]. Refer to F 309. 6. Administration failed to ensure the staff followed infection control policies and did not allow Foley catheter bags and tubing did not touch the floor. Refer to F 315. 7. Administration failed to ensure the staff maintained the residents' environment free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. The facility's failure to protect vulnerable residents from accident hazards and in a safe environment placed residents in Immediate Jeopardy; Refer to F 323 and F 465. 8. Administration failed to ensure staff followed physician's orders [REDACTED].#49. Refer to F 328. 9. Administration failed to ensure staff monitored residents for medication side effects and adverse drug reactions for Resident #20. Refer to F 329. 10. Administration facility failed to ensure staff posted current and accurate nurse staffing information at the beginning of each shift during 3 of 3 (days 9/18/19, 9/19/16 and 9/23/16) days of observing the posting for nursing staff. Refer to F 356. 11. Administration failed to to ensure staff practiced infection control techniques to prevent the potential spread of infection were maintained as evidenced of meal plates not covered ,staff members handling food with their bare hands, staff did not perform hand hygiene during meal service, Dietary staff's hair not restrained, Dietary Staff failed to perform hand hygiene in the kitchen, and unlabeled and undated food. Refer to F 371 12. Administration failed to ensure the staff stored medications and biologicals securely and supplies were not stored past the expiration date; Refer to F 431 13. Administration failed to ensure staff practiced infection control to prevent the potential spread of infection. Refer to F 441 14. Administration failed to ensure there was an operational call light system in 4 of 52 (Resident # 113, 22, 11, and 96) resident bathrooms; Refer to F 463. 15. Administration failed to ensure staff promptly notified physician of resident lab results for Residents #18 and 46. Refer to F 505 16. Administration failed to ensure the quality assurance program was effective in identifying issues and concerns and maintaining previous interventions related to dignity and respect of individuality, following care plan, kitchen sanitation, drug / biological storage, infection control. Refer to F 164, F282, F371, F431, F441. A revisit survey #1 for the Allegation of Compliance (AOC) was conducted on 10/4/16 through 10/5/16. The facility remains out of compliance with Immediate Jeopardy at F-490 ongoing. Based on review of the Credible Allegation of Compliance, review of Non Clinical Rounds report, review of policy, review of statement, and interview, the facility failed to follow their AOC, failed to be administered in a manner that used its resources effectively and efficiently to ensure the residents' environment was free from the accident hazards of medications and items labeled Keep out of reach from Children. The Administration failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections from previous surveys. The findings included: Review of the AOC submitted by the Administrator on September 29,2016 revealed, .All audits will be overseen by the Administrator and presented to the to the IDT (interdisciplinary team), and during QAPI (quality assurance performance improvement) weekly . and as needed . Structured Dailey safety rounds have been established by the Administrator .Administrator will be responsible for reviewing completed rounds to ensure they are conducted and conducted correctly .Administrator is responsible for ensuring that all audits are conducted correctly and appropriately. The status of all education and audits will be reviewed daily by the Administrator. Any concerns or issues will be brought immediately to QAPI . Administrator conducting random audit rounds to validate the submitted date, weekly Guarding Angel Rounds completed by IDT . In an interview conducted in the conference room on 10/4/16 at 9:45 AM the Regional Nurse Consultant #2 was asked the whereabouts of the Administrator and stated, The Administrator is in(NAME)Florida. In an interview conducted in the conference room on 10/4/16 at 1:30 PM the Director of Nursing (DON) was asked who was in charge of the facility during the Administrator's absence and stated, .I guess (Named Regional Nurse Consultant #2) is in charge, he is over me, he has an Administrator's license. The DON informed the survey team he was leaving to attend to some business and would return later in the day. The surveyor asked the DON to have the Regional Nurse Consultant #2 to provide the survey team a copy of his Administrator's license. In an interview conducted in the conference room on 10/4/16 at 1:45 PM the Regional Nurse Consultant #2 asked Why do you need my Administrator's license, I am not in charge, (Named DON) is. The Regional Nurse Consultant #2 failed to provide a copy of his Administrator's license to the survey team. The survey team asked for a copy of the designation policy. In an interview conducted in the conference room on 10/4/16 at 4:30PM the DON brought in the requested designation policy and stated, l guess I am in charge . The Administrator left on Saturday, flew out to(NAME)for the week. The DON was asked who was completing the Administrator's audits and oversite duties according to the AOC and stated, I guess that would be me. The DON was shown a Non Clinical Rounds report dated 9/30/16 that revealed, .S19 perineal cleaner in Btrm(bathroom) cabinet, sewing needles, mouthwash & denture cleaner overbed t(table) . The DON was asked to explain this report and stated, That is our Guarding Angel IDT rounds. The DON was asked to provide the follow-up to this IDT form dated 9/30/16 and for all documentation of the audits and oversite duties by the Administrator. In an interview conducted in the conference room on 10/5/16 at 12:00 Noon, the DON brought in a typed statement and stated, Here is a statement the Administrator sent to me about his oversite. Review of this statement revealed no signature or date, the statement read in part, .To whom it may concern: I, (Named Administrator), oversaw and directed the actions taken during the Allegation of Compliance process . There was no documentation provided to the survey team of the Administrators oversite activites or audits per AOC. The DON stated, As a result of our daily IDT round and the IDT round report on 9/30/16 we have increased to hourly rounds starting today . There was no documentation the items documented as found in resident room S19 on the 9/30/16 ( the next day after alleged compliance) IDT round report had been identified and addressed until 10/5/16 after being brought to the facilities attention by the survey team. The facility failed to follow their AOC, failed to have an Administrator/Acting Administrator present, in charge and aware they were in charge on 10/4/16. The Administrator failed to follow the AOC, failed to provide oversight, failed to ensure quality issues were identified and a plan of action was developed and implemented timely. Refer to F-323, F- 431, F- 465, F-520

Based on review of facility policy, review of facility documents, medical record review, observation, and interview, the facility failed to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners, equipment hazards and bed/side rail entrapment. The facility's failure to protect vulnerable residents from accident hazards and in a safe environment placed 10 of 55 (Residents' #2, 20, 21, 26, 41, 46, 53, 62, 82 and 96) sampled residents in IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/18/16 at 10:14 PM, in the Conference Room. The facility was cited an Immediate Jeopardy at F323, which is Substandard Quality of Care. An extended survey was completed on 9/29/16. The Immediate Jeopardy is effective 9/18/16, and is ongoing. The findings included: 1. The facility's Safety and Disaster Management policy documented, .Label chemicals not stored in original containers. Use manufacturer's label information for strength and safety guidelines . The facility's Medication Storage policy documented, .Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: secured (locked) locations, accessible only to designated staff .Are all medications and biologicals stored and labeled properly . The facility's Janitor Closets/Mop Fill Areas Cleaning policy documented, .This is a routine procedure that is used to maintain our janitor's closets in a clean, neat, orderly, and secure manner . The facility's Medical Waste Storage policy documented, .Containers .used to store medical wastes and sharps .will be locked at all times to prevent unauthorized access . The facility's Hazard Communication Written Program policy documented, .The Executive Director of (name of facility) has the ultimate responsibility for overall administration and maintenance of the program .Employees should: Be alert to the potential hazards of materials in their work area . The facility's Emergency Crash Cart policy documented, .Emergency cart will be secured at the nurse's station . 2. Observations outside the North Hall Biohazard Room on 9/18/16 at 2:45 PM, revealed the door of the Biohazard room to be unlocked and accessible. The Biohazard room contained a barrel of biohazardous material. The Biohazard barrel was overflowing with biohazardous material and the lid was not secure due to the overflow. Interview with LPN #1 on 9/18/16 at 2:53 PM, outside of the North Hall Biohazard Room, LPN #1 was asked what was disposed of in the Biohazard room. LPN #1 stated, .contaminated with body fluids, visible blood .door should be locked . Observations outside the North Hall Clean Utility room on 9/18/16 at 6:10, 6:43 PM and 7:50 PM, revealed a crash cart sitting outside the Clean Utility room that was unlocked. The unlocked and unattended crash cart contained (1) open box of 25 g hypodermic needles, (20) safety lancets, 1000 ml 0.9% sodium chloride, (3) 3 ml 22 1 ½ needles, (1) 22 g angiocath, (2) 1 cc insulin syringes, (1) 5 ml Heplock 100u/ml, (3) tuberculin syringes, (1) 3 cc syringe. Interview with RN #4 on 9/19/19 at 10:22 AM, in the North Hall Clean Utility room, RN #4 was asked if it was appropriate for the crash carts to be unlocked. RN #4 stated, .I don't know if it's ever been locked . Interview with the Director of Nursing (DON) on 9/18/16 at 10:20 PM, in the Conference room, the DON was asked if it was appropriate for the crash cart to be unlocked. The DON stated, No. Observations in the North Hall Clean Utility Room on 9/18/16 at 7:50 PM, revealed (6) cans of shaving cream with Butane and Propane listed as ingredients with instructions to Keep Out of Reach of Children, (8) packets of denture cleaner with instructions to Keep Out of Reach of Children, (17) nail clippers, (6) mouth washes with instructions to Keep Out of Reach of Children, (1) shampoo and body wash with instructions to Keep Out of Reach of Children, (6) Peri washes with instructions to Keep Out of Reach of Children, and (8) 1.69 ounce bottles of Liquid Treatment System with instructions to Keep Out of Reach of Children. The North Hall Clean Utility Room was located behind the North Hall nursing station and was accessible to any residents, family, and visitors by way of entrances from the Central Hall and the North Hall. 3. Observations in Resident #41's bathroom on 9/18/16 at 2:55 PM, revealed a (1) 10 ounce aerosol can of hairspray on the counter. Interview with LPN #1 on 9/18/16 at 3:02 PM, LPN #1 was asked if it was acceptable to have chemicals in resident's rooms. LPN #1 stated, .No .supposed to be bagged .I take them out . 4. Observations in the Director of Activities room on 9/18/16 at 3:25 PM, revealed the Director of Activities door to be unlocked. Inside the room revealed an open door to the immediate left, revealing another room with multiple wires and cables, a pair of scissors sitting on a ledge, and a one (1) 2.5 ounce can of aerosol smoke detector tester. Interview with the Director of Nursing (DON) on 9/18/16 at 3:30 PM, in the Director of Activities room, the DON was asked what the room inside the Director of Activities room was. The DON stated, .not sure .Electrical room . The DON was asked if residents should be able to walk into the Electrical room. The DON stated, .Absolutely not . Interview with the Administrator on 9/18/16 at 11:45 PM, in the Conference room, the Administrator was asked if he knew why the Electrical room closet inside the Director of Activities room was unlocked. The Administrator stated, .I can't say 100% why it was unlocked . 5. Observations in the Oxygen Storage/Central Supply room on 9/18/16 at 5:07 PM, 9:26 PM through 9:58 PM, and 9/19/16 at 10:07 AM, revealed the door to ajar, leaving the room unlocked, unsecured and unattended. The Oxygen/Central Supply room contained: (6) bottles of Centravites multivitamin/mineral - 60 tablets (tabs)/ bottle (5) bottles of Eyevits - 60 tabs/bottle (3) bottles of Vitamin B1 100 milligrams (mgs) - 100 tabs/bottle (12) bottles of Vitamin B 12 500 mcg (micrograms) - 100 tabs/bottle (2) bottles Iron extended release - 60 tabs/bottle (3) bottles of B complex with C - 130 caplets/bottle (5) bottles of Vitamin D 300 international units (IUs) - 100 tab/bottle (4) bottles of Vitamin D 1000 IU - 100 tabs/bottle (9) bottles of Melatonin 3 mg - 60 tab/bottle (11) bottles of Multivitamin - 100 tab/bottle (4) bottles of Mutivitamin with iron - 100 tabs/bottle (7) bottles of Multivitamin with minerals -100 tabs/bottle (2) bottles of Calcium Citrate + Vit D3 - 100 tabs/bottle (3) bottles of Calcium 600 mg + D 400 IU - 60 tabs/bottle (7) bottles of Oyster shell Calcium 500 mg - 100 tabs/bottle (1) bottle of Oyster shell calcium 250 mg with Vitamin D - 100 tabs/bottle (5) bottles of Magnesium oxide 400 mg - 120 tabs/bottle (4) bottles of Fish oil 500 mg - 130 Soft gels/bottle (1) bottle of Florastor 250 mg - 50 caplets/bottle (1) bottle of Zinc 50 mg - 100 tabs/bottle (4) bottles of Ferrous sulfate 325mg - 100 tabs/bottle (4) bottles of Coenzyme Q-10 50 mg - 30 Soft gels/bottle (2) bottles of Renavite - 100 tabs/bottle (3) bottles of Cranberry juice extract 425 mg - 60 caps/bottle (3) bottles of Niacin 250 mg - 100 tabs/bottle (8) bottles of Enteric coated Aspirin 81 mg - 120 tabs/bottle (4) bottles of Aspirin 325 mg - 100 tabs/bottle (3) bottles of Enteric coated Aspirin 325 mg - 100 tabs/bottle (3) bottles of Ibuprofen 200 mg -100 tabs/bottle (3) bottles of Non Aspirin PM 500 mg and Diphenhydramine 25 mg - 50 tablets/bottle (13) bottles of Acetaminophen 325 mg -100 tabs/bottle (4) bottles of Acetaminophen 500 mg- 100 tab/bottle (15) boxes of Gas relief Simethicone 125 mg - 10 Soft gels/box (8) boxes of Loperamide 2 mg - 12 caps/box (5) 4 ounce bottles of Loperamide 1 mg/ 7.5 ml (milliliter) (5) bottles of Docusate Calcium 100 Soft gels - 250 mg/bottle (8) bottles of Docusate sodium 100 mg - 100 tabs/bottle (5) bottles of Sennosides 8.6 mg - 100 tabs/bottle (6) bottles of Biscodyl 5 mg - 100 tabs/ bottle (6) bottles of Natural vegetable lax with stool softener docusate 50 mmg (micromilligram) (6) bottles Sennqwide 8.6 mg - 60 tabs/bottle (17) bottles of Omeprazole 20 mg 14 tabs/bottle (12) bottles of Diphenhydramine 25mg - 100 tabs/bottle (6) boxes of Mucinex 600 mg - 40 tabs/box (4) bottles of Mucus relief expectorant 400 mg - 100 tabs/ bottle (1) bottle of Loratadine 10 mg - 90 tabs/bottle (14) 6 fluid ounce bottles of Loratadine (1) bottle of Cetirizine 10 mg - 90 tabs/bottle (11) bottles of Rantidine 75 mg- 30 tab/bottle (30) 1.5 ounce bottles of Biotene Mouth spray (2) boxes Denture cleanser tabs- 90 tabs/box (6) bottles of Melatonin 5mg- 90 tabs/bottle (1) 0.33 ounce box of Benzocaine 20 percent (%) (1) 16 fluid ounce bottle of Eldertonic (1) 13 ounce bottle of Natural Psyllium Fiber Powder (8) 12 ounce bottles of Geri Mox antacid (7) 16 fluid ounce bottle of MOM (2) bottle of Calcium carbonate 500mg - 150 tabs/bottle (1) 8.3 ounce bottle of Polyethylene Glycol 3350 (1) 16 fluid ounce bottle of Acetaminophen liquid 160 mg/ 5ml (2) 16 ounce bottles of Mineral oil (8) 16 fluid ounce bottles of Ultrtuss DM (7) 1.59 ounce boxes of Miconazole Nitrate 2% (16) 1 ounce tubes of 1 % Hydrocortisone cream (5) 2 ounce tubes of Zinc oxide (15) boxes of Alcohol pad - 200 pads/box (32) Xeroform gauze dressings (74) bottles of Solyzer liquid treatment system (24) D batteries (29) C batteries (30) AAA batteries (28) AA batteries (17) 9- volt batteries (2) boxes of 3 milliliters (ml) 22g 1 1/2 syringes -100/box (1) box of 3 ml 25 gauge (g) 3 inch () syringes 100/box (3) boxes of 1 ml 25g 5/8 tuberculin syringes 100/box (2) boxes of 3 ml 25 g 5/8 syringes 100/box (2) boxes of 1 ml 25g 1 syringes 100/box (3) Emergency Response Safety Kit contains spill kit, sanizide germicidal solution 2 ounces (oz), (2) packages saniwipes (3) boxes of Angiocath 20 g - 50/box (1) box of Angiocath 24g - 50/box (1) Opened box of 25g 1 1/2 hypodermic needles (49 count) (1) box of 7mg Nicotine Patches - 14 patches/box (57) packets of Vitamin A & D ointment skin protectant (11) Staple remover kits (3) bottles of Lubricating Eye Drops (4) bottles of Systane Eye Lubricant (3) bottles of Nasal Decongestant Spray (4) bottles of Saline Nasal Spray (5) bottles of Eye Wax Removal Aide (6) boxes safety lancet -200/box (3 ½) boxes Microkill Bleach Germicidal Wipes 1000/box (20) Glucose Gel Packets (5) boxes of Latex Free Insulin Syringes - 100/box (2) bottles of 10gm Sodium Bicarbonate -1000 tablets/bottle. The Oxygen/Central Supply Room was located on the Central Hall between the North and South Hall in the facility and was accessible to all residents, family and visitors. Interview with the DON outside the Oxygen Storage/Central Supply room on 9/18/16 at 10:01 PM, the DON was asked what his expectations for the staff were when entering and leaving the Oxygen Storage/Central Supply room. The DON stated, .to shut the door . ensuring the door was locked and secure. 6. Observations in the South Hall Clean Utility room on 9/18/16 at 6:05 PM, 8:15 PM, and 9:27 PM, revealed the door to be opened with (5) shaving cream containing Stearic Acid, Trithanolamineisobutane, Sodium Laurtl, Sulfate Laureth 23, and Propane, Butane Fragrance, and BHT as ingredients, (7) unopened packages of razors - 10 razors/package and (1) opened package of razors containing 6 razors, (10) mouth washes with instructions to Keep Out of Reach of Children, 5 packages of denture cleaning tablets, (6) shampoo and body washes with instructions to Keep Out of Reach of Children, 5 perineal washes with instructions for External Use Only, (10) Nourishing skin cream with instructions for External Use Only, (8) roll on deodorants with instructions for External Use Only, (1) spray bottle of germicidal cleaner, and a purse that was opened with a package of cigarettes. ¿@ Observations in the South Hall nurse's bathroom on 9/18/16 at 5:49 PM, 6:19 PM, 7:47 PM, and 10:08 PM, and 9/20/16 at 8:22 PM, revealed (2) periwash and (1) mouth wash with instructions to Keep out of Reach of Children. There was a sign posted, on the inside door of this nurse's South Hall bathroom, to leave the door unlocked with arrows showing how the lock was to be turned to ensure it was not locked. The bathroom was behind the nurse's station, but accessible to residents when there were no staff at the nursing station. Observations in the South Hall on 9/18/16 beginning at 5:49 PM, revealed LPN #2 left the nursing station unattended for 4 minutes. LPN #2 returned to the nurses station briefly and left the station unattended for 5 minutes. Observations on the South Hall nurse's station on 9/18/16 at 5:50 PM and 6:22 PM, revealed a hand washing sink with a cabinet that contained (3) shampoo and body washes, (1) baby powder, (1) periwash, (1) nourishing skin cream. All of these personal care items were labeled with instructions to Keep Out of the Reach of Children. The sink was just inside the nurse's station, but accessible to residents when there were no staff at the nursing station. Observations on the South Hall on 9/18/16 at 7:46 PM, revealed the South Hall Janitor's closet unlocked, unattended and contained: (1) 64 ounce All Purpose Citrus Cleaner Odor Eliminator (1) partial gallon of Carpet and Upholstery Extraction Liquid (1) partial 2.5 gallon of Gloss Restorer (1) 2.5 gallon unknown white substance lying in the floor. Interview with LPN #2 on 9/18/16 at 8:00 PM, at the South Hall nurse's station, LPN #2 was asked if she had any wanderers on the South Hall. LPN #2 stated, Yes, ma'am, (Resident #21) .she has a wanderguard . LPN #2 stated, Yes. It is for her safety. ¿@ Interview with the Administrator on 9/18/16 at 10:14 PM, in the conference room, the Administrator was asked if it was appropriate for the identified doors to be unlocked, opened and unattended. The Administrator stated, .it is clear there are hazardous materials available to residents . Interview with the Pharmacy Technician, on 9/19/16 at 10:40 AM, at the South Nurse's Station, the Pharmacy Tech was asked if she expected the storage areas with over the counter medications and dressings to be locked. The Pharmacy Tech stated, Yes. Interview with the Administrator on 9/19/16 at 12:09 PM, in the Conference room, the Administrator stated, .the clean utility doors have never had locks on them as long as I have been here and the Maintenance Director told me he has never known there to be locks on those doors since the building was built. The Administrator's date of employment at the facility was April 13, 2015. Interview with Regional Nurse Consultant (RNC), on 9/19/18 at 12:28 PM, in the Conference room, the RNC was asked if the facility had wanderers. The RNC stated, . (Resident #21) has a BIMS (Brief Interview for Mental Status) of 99 (severe cognitive deficits) and self- propels self in her wheelchair and has wander-guard . (Resident #54) has a BIMS of 99 and self- propels herself in her wheelchair and has a wander-guard . (Resident #46) has a BIMS of 7 (severe cognitive deficit) and self-propels herself and is confused off and on . Interview with CNA #7 on 9/20/16 at 8:36 AM, in Break room, CNA #7 was asked what were her responsibilities for the day. CNA #7 stated, (Administrator) wants me to sign off the doors every 15 minutes that they are locked .we have 11 doors to check .the bathroom on the South station was unlocked, someone forgot to lock it . Interview with LPN #2 on 9/27/16 at 7:41 AM, in the Conference room, LPN #2 was asked what doors are supposed to be locked. LPN #2 stated, .the Biohazard Room, the Clean Utility Rooms, the Janitor's Closets, the Central Supply Closet .I forgot to say bathrooms (nursing stations) .they have never been locked . 7. On 9/19/16 at 9:30 PM the facility was asked to provide a list of residents that have the behaviors of wandering. The facility's Regional Nurse Consultant provided a list of 7 residents with wander guards for the behavior of wandering. The list included Residents # 2, 21, 26, 46, 62, 82 and 96. (a). Medical record review for Resident #2 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Set (MDS) date 5/19/16 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 7, indicating the resident was severely cognitively impaired. The Resident Mood Interview revealed the resident answered Yes, to feeling down, depressed or hopeless Record review of the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 4, indicating the resident was severely cognitively impaired. The Resident Mood Interview revealed the resident answered Yes to feeling down, depressed or hopeless The MDS revealed the resident had the behaviors of wandering that occurred 1 to 3 days during this assessment period. Review of Resident #2's plan of care revised on 8/10/16 revealed, .At risk for elopement related to: hx (history) of wandering .Will remain safe during placement at Living Center .Assess for risk of elopement per living center policy .Educate family/responsible party on talking positively about Living Center Placement .Encourage family to bring in personal possessions .Evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings .Involve patient in preferred activities .Involve the patient in decision making regarding daily choices .Redirect patient from doors .Wanderguard. Check wanderguard and replace per MD orders . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . (b). Medical record review for Resident #21 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Aricept Tablet 10 milligrams (mg) by mouth at bedtime. Namenda XR 28 mg by mouth daily. Seroquel 100 mg by mouth at bedtime. Xanax 0.5 mg as needed for anxiety. Record review of the Quarterly MDS dated [DATE] revealed Resident #21 had a BIMS of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making. Record review of Resident #21's plan of care revised on 7/18/16 revealed, .At risk for elopement related to hx (history) of Attempts to leave .Will remain safe during placement at Living Center .Resident checks PRN (as needed) for increased monitoring of wandering .Wanderguard bracelet per orders . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . (c). Medical record review for Resident #26 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS dated [DATE] revealed Resident #26 had a BIMS of 6, indicating the resident was severely cognitively impaired. Record review of the Quarterly MDS dated [DATE] revealed Resident #26 had a BIMS of 8, indicating the resident was moderately cognitively impaired. The Resident Mood Interview revealed the resident answered Yes to feeling down, depressed or hopeless. Record review of Resident #26's plan of care revised on 7/19/16 revealed, .I sometimes have delusional behaviors and making statements like 'I'll throw myself on the floor' . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . There was no documentation the facility included the behavior of wandering in resident's plan of care. Review of the physician's orders [REDACTED]. (d). Record review revealed Resident # 46 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician order [REDACTED]. The mental health provider's psychiatric note dated 9/12/16 documented .Staff note that she continues to pick up things that do not belong to her .this can be attributed to memory loss and confusion associated. Review of the last Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8. Review of the Abnormal Involuntary Movement (AIMS) assessment dated [DATE] documented a score of 0 (zero). Review of Care Plan initiated 7/29/16 and revised 9/13/16 documented .sometimes have behaviors .taking objects which do not belong to me .will be safe in the environment . Review of Progress Notes dated 4/2/16 at 10:47 AM documented Notable behaviors frequently taking items from other resident's, and also noted taking items off the walls in the hallway and transporting them to her room. Takes pictures of other residents and states they represent people in her family. Store food in room, milk container by the window and crackers on the lampshades. Hoarding discouraged and spoiled items thrown away. Encouraging resident to eat meals in day room with supervision because she has been observed putting her meals in potted plants and mixing coffee, tea, milk, soup into her water pitcher. Poor safety awareness, attempted to use fingernail polish as lipstick before nursing intervention . Review of Progress Notes dated 4/17/16 at 11:00 PM documented .She can be resistant and combative with care at times . She is a fall risk due to her cognition and poor safety awareness . Review of Progress Notes dated 8/19/16 at 11:47 AM documented Resident was observed to have pink coloring in her hair from pink lipstick . Observations on 9/18/16 at 4:55 PM revealed Resident #46 up in room in wheel chair (w/c). Stated I'm fixing to call my son to get something to color. Has red paint on her fingers. Dressing to right wrist, stated my watch rubbed it, no watch on during observation. Observations on 9/20/16 at 8:28 AM revealed Resident #46 self propelling around room in w/c, cushion in w/c and towel on cushion. Observations on 9/21/16 at 9:53 AM revealed Resident #46 self propelling in w/c from room to corridor into dining room stopping to look into other rooms along the way. Observations on 9/22/16 at 8:34 AM revealed Resident #46 self propelling around room in w/c looking through drawers, talking to herself. Observations on 9/23/16 at 10:28 AM, revealed Resident #46 self propelling in w/c around the central hallway area by the oxygen room. Resident #46 was asked how she was doing and what was she up to today, Resident # 46 responded I don't know, I'm not here today. Resident #46 continued self propelling herself down the hallway. Observations on 9/24/16 at 8:23 AM revealed Resident #46 self propelling around in room and hall in w/c, going back and forth from room to hall, through drawers, pulling out pictures, stated I have to put these (pictures in hand) on the wall before it (wall) collapse. Observations on 9/25/16 at 9:55 AM revealed Resident #46 in her w/c in the south hall outside her room. Resident #46 was taping her meal card to the wall. When Resident # 46 asked what she was doing, Resident #46 stated I'm putting my name up. Interview with LPN #6 on 9/20/16 at 8:31 AM on the south hall at the medication cart, LPN #6 was asked why Resident #46 had a towel in her wheelchair. LPN #6 replied I don't know but if you take it away from her she will go and get another one and put it back in there. She is independent and self propels herself around the unit. She will find a towel if you take it. She finds things and put them behind her. LPN stated that's like a behavior she has. (e). Medical record review for Resident #62 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS dated [DATE] revealed Resident #62 had a BIMS score of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making. Record review of the Quarterly MDS dated [DATE] revealed Resident #62 had a BIMS score of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making and had Disorganized thinking . Record review of Resident #62's plan of care revised on 8/9/16 revealed, .I am at risk for elopement Not being able to make good safety decisions .I will remain safe within the facility .Find something on the unit I would like to do to divert my attention .Test my Wanderguard alarm to make sure it's working properly .At risk for elopement related to: Attempts to leave .Wandering . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . (f). Medical record review for Resident #82 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Annual MDS dated [DATE] revealed Resident #82 had a BIMS score of 2, indicating the resident was severely cognitively impaired. Record review of the Quarterly MDS dated [DATE] revealed Resident #82 had a BIMS score of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making. Record review of Resident #82's plan of care revised on 8/17/16 revealed, .At risk for elopement related to: Resident states 'I am leaving, going home', wandering .Will remain safe during placement at Living Center .check Wanderguard and replace per MD orders . Review of the physician's orders [REDACTED].Wanderguard bracelet to alert staff to attempts to leave facility unaccompanied .Change wanderguard 2 weeks prior to exp date . Interview with CNA #5 on 9/18/16 at 9:33 PM, at the South Hall nurses station, CNA #5 was asked if she was aware of any wanderers. CNA #5 stated, . (Resident #62) comes inside the nurse's station and sneaks up on us, we don't even know she's there . (g). Medical record review of the Significant Change MDS dated [DATE] for Resident #96 revealed a BIMS score of 2, indicating the resident was severely cognitively impaired. Observations on the North Hall on 9/19/16 at 5:22 PM, revealed Resident #96 mobilizing himself in his wheelchair and states to himself, .when can you get me out of here .did my wife go home . Observations at the North Hall nurse's station on 9/20/16 at 9:15 AM, revealed Resident #96 sitting in his wheelchair behind the desk and stated, .I want to go home if you don't get me a job to do . 8. Medical record review for Resident #41 revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a BIMS score of 10, indicating the resident was moderately cognitively impaired. Resident #41 resided on the North Hall. 9. The facility's Bed Rail Guideline policy documented .Assessment is completed to identify potential benefits from utilizing bed rails and minimize risks. If bed rails are being considered assessment is completed before use, with ongoing reassessment (at least quarterly) Care plan interventions are implemented when bed rails are utilized and reviewed at least quarterly. The assessment and documentation also includes: measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress. A visual review is performed to assess that the mattress does not shift/slide allowing for an increased gap between the bed and the bed rail .Residents with bed rails have appropriate assessments completed There is evidence of multidisciplinary approach to bed rail utilization There is evidence that risk and benefits were explained to resident and that the 'Guidance on Bed Rails' brochure was given to and discussed with the resident . Review of the Guidance for Industry and FDA (Food and Drug Administration) Staff- Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment revealed, .Given the adult population at risk for wedging entrapments . the following is recommended: To reduce the risk of Head entrapment, there should be no more than 4 3/4 inches between the mattress and the rail. To reduce the risk of Neck entrapment, there should be no more than 2 3/8 inches from the mattress to the rail. (a) Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) for Resident #20 dated 8/28/16 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident needed extensive assistance with one person for bed mobility and limited assistance by one person for transfer, to walk in the room or corridor, dressing, toilet use, and personal hygiene. The MDS documented that he received scheduled pain medication and had a history of [REDACTED]. The resident received antidepressants, anticoagulants, diuretics, oxygen and Continuous Positive Airway Pressure (CPAP) use while a resident at the facility. The care plan for Resident #20, dated 8/24/16 documented the following for the resident: At risk for falls related to use of medication, a history of falls, and his impaired balance/mobility. Physical functioning deficit. Pain management and medication administration. At risk for sleep pattern disturbance with a use of sl

Based on review of facility policy, review of facility documents, medical record review, observation, and interview, the facility failed to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards for 10 of 55 (Residents #41, 2, 21, 26, 46, 62, 82, 96, 20 and 53) sampled residents. The facility's failure to protect vulnerable residents from accident hazards and in a safe environment placed residents in IMMEDIATE JEOPARDY. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the IMMEDIATE JEOPARDY 9/18/16 at 10:14 PM, in the Conference Room. An extended survey was completed on 9/28/16. The IMMEDIATE JEOPARDY is effective 9/18/16, and is ongoing. The findings included: 1. The facility's Safety and Disaster Management policy documented, .Label chemicals not stored in original containers. Use manufacturer's label information for strength and safety guidelines . The facility's Medication Storage policy documented, .Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: secured (locked) locations, accessible only to designated staff .Are all medications and biologicals stored and labeled properly . The facility's Janitor Closets/Mop Fill Areas Cleaning policy documented, .This is a routine procedure that is used to maintain our janitor's closets in a clean, neat, orderly, and secure manner . The facility's Medical Waste Storage policy documented, .Containers .used to store medical wastes and sharps .will be locked at all times to prevent unauthorized access . The facility's Hazard Communication Written Program policy documented, .The Executive Director of (name of facility) has the ultimate responsibility for overall administration and maintenance of the program .Employees should: Be alert to the potential hazards of materials in their work area . The facility's Emergency Crash Cart policy documented, .Emergency cart will be secured at the nurse's station . 2. Observations outside the North Hall Biohazard Room on 9/18/16 at 2:45 PM, revealed the door of the Biohazard room to be unlocked and accessible. The Biohazard room contained a barrel of biohazardous material. The Biohazard barrel was overflowing with biohazardous material and the lid was not secure due to the overflow. Interview with Licensed Practical Nurse (LPN) #1 on 9/18/16 at 2:53 PM, outside of the North Hall Biohazard Room, LPN #1 was asked what was disposed of in the Biohazard room. LPN #1 stated, .contaminated with body fluids, visible blood .door should be locked . Observations outside the North Hall Clean Utility room on 9/18/16 at 6:10, 6:43 PM and 7:50 PM, revealed a crash cart sitting outside the Clean Utility room that was unlocked. The unlocked and unattended crash cart contained (1) open box of 25 gauge (g) [MEDICATION NAME] needles, (20) safety lancets, 1000 ml (milliliters) 0.9% (percent) sodium chloride, (3) 3 ml 22 1 ½ needles, (1) 22 g angiocath, (2) 1 cc (cubic centimeters) insulin syringes, (1) 5 ml Heplock 100u (units)/ml, (3) [MEDICATION NAME] syringes, (1) 3 cc syringe. Interview with RN #4 on 9/19/19 at 10:22 AM, in the North Hall Clean Utility room, RN #4 was asked if it was appropriate for the crash carts to be unlocked. RN #4 stated, .I don't know if it's ever been locked . Interview with the Director of Nursing (DON) on 9/18/16 at 10:20 PM, in the Conference room, the DON was asked if it was appropriate for the crash cart to be unlocked. The DON stated, No. Observations in the North Hall Clean Utility Room on 9/18/16 at 7:50 PM, revealed (6) cans of shaving cream with Butane and Propane listed as ingredients with instructions to Keep Out of Reach of Children, (8) packets of denture cleaner with instructions to Keep Out of Reach of Children, (17) nail clippers, (6) mouth washes with instructions to Keep Out of Reach of Children, (1) shampoo and body wash with instructions to Keep Out of Reach of Children, (6) Peri washes with instructions to Keep Out of Reach of Children, and (8) 1.69 ounce bottles of Liquid Treatment System with instructions to Keep Out of Reach of Children. The North Hall Clean Utility Room was located behind the North Hall nursing station and was accessible to any residents, family, and visitors by way of entrances from the Central Hall and the North Hall. 3. Medical record review for Resident #41 revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a BIMS score of 10, indicating the resident was moderately cognitively impaired. Resident #41 resided on the North Hall. Observations in Resident #41's bathroom on 9/18/16 at 2:55 PM, revealed a (1) 10 ounce aerosol can of hairspray on the counter. Interview with LPN #1 on 9/18/16 at 3:02 PM, LPN #1 was asked if it was acceptable to have chemicals in resident's rooms. LPN #1 stated, .No .supposed to be bagged .I take them out . 4. Observations in the Director of Activities room on 9/18/16 at 3:25 PM, revealed the Director of Activities door to be unlocked. Inside the room revealed an open door to the immediate left, revealing another room with multiple wires and cables, a pair of scissors sitting on a ledge, and a one (1) 2.5 ounce can of aerosol smoke detector tester. Interview with the Director of Nursing (DON) on 9/18/16 at 3:30 PM, in the Director of Activities room, the DON was asked what the room inside the Director of Activities room was. The DON stated, .not sure .Electrical room . The DON was asked if residents should be able to walk into the Electrical room. The DON stated, .Absolutely not . Interview with the Administrator on 9/18/16 at 11:45 PM, in the Conference room, the Administrator was asked if he knew why the Electrical room closet inside the Director of Activities room was unlocked. The Administrator stated, .I can't say 100% why it was unlocked . 5. Observations in the Oxygen Storage/Central Supply room on 9/18/16 at 5:07 PM, 9:26 PM through 9:58 PM, and 9/19/16 at 10:07 AM, revealed the door to ajar, leaving the room unlocked, unsecured and unattended. The Oxygen/Central Supply room contained: (6) bottles of Centravites multivitamin/mineral - 60 tablets (tabs)/ bottle (5) bottles of Eyevits - 60 tabs/bottle (3) bottles of Vitamin B1 100 milligrams (mgs) - 100 tabs/bottle (12) bottles of Vitamin B 12 500 mcg (micrograms) - 100 tabs/bottle (2) bottles Iron extended release - 60 tabs/bottle (3) bottles of B complex with C - 130 caplets/bottle (5) bottles of Vitamin D 300 international units (IUs) - 100 tab/bottle (4) bottles of Vitamin D 1000 IU - 100 tabs/bottle (9) bottles of [MEDICATION NAME] 3 mg - 60 tab/bottle (11) bottles of Multivitamin - 100 tab/bottle (4) bottles of Mutivitamin with iron - 100 tabs/bottle (7) bottles of Multivitamin with minerals -100 tabs/bottle (2) bottles of Calcium [MEDICATION NAME] + Vit D3 - 100 tabs/bottle (3) bottles of Calcium 600 mg + D 400 IU - 60 tabs/bottle (7) bottles of Oyster shell Calcium 500 mg - 100 tabs/bottle (1) bottle of Oyster shell calcium 250 mg with Vitamin D - 100 tabs/bottle (5) bottles of Magnesium oxide 400 mg - 120 tabs/bottle (4) bottles of Fish oil 500 mg - 130 Soft gels/bottle (1) bottle of [MEDICATION NAME] 250 mg - 50 caplets/bottle (1) bottle of Zinc 50 mg - 100 tabs/bottle (4) bottles of [MEDICATION NAME] sulfate 325mg - 100 tabs/bottle (4) bottles of [MEDICATION NAME] Q-10 50 mg - 30 Soft gels/bottle (2) bottles of Renavite - 100 tabs/bottle (3) bottles of Cranberry juice extract 425 mg - 60 caps/bottle (3) bottles of [MEDICATION NAME] 250 mg - 100 tabs/bottle (8) bottles of [MEDICATION NAME] coated Aspirin 81 mg - 120 tabs/bottle (4) bottles of Aspirin 325 mg - 100 tabs/bottle (3) bottles of [MEDICATION NAME] coated Aspirin 325 mg - 100 tabs/bottle (3) bottles of [MEDICATION NAME] 200 mg -100 tabs/bottle (3) bottles of Non Aspirin PM 500 mg and [MEDICATION NAME][MEDICATION NAME] 25 mg - 50 tablets/bottle (13) bottles of [MEDICATION NAME] 325 mg -100 tabs/bottle (4) bottles of [MEDICATION NAME] 500 mg- 100 tab/bottle (15) boxes of Gas relief [MEDICATION NAME] 125 mg - 10 Soft gels/box (8) boxes of [MEDICATION NAME] 2 mg - 12 caps/box (5) 4 ounce bottles of [MEDICATION NAME] 1 mg/ 7.5 ml (milliliter) (5) bottles of [MEDICATION NAME] Calcium 100 Soft gels - 250 mg/bottle (8) bottles of [MEDICATION NAME] sodium 100 mg - 100 tabs/bottle (5) bottles of Sennosides 8.6 mg - 100 tabs/bottle (6) bottles of [MEDICATION NAME] 5 mg - 100 tabs/ bottle (6) bottles of Natural vegetable lax with stool softener [MEDICATION NAME] 50 mmg (micromilligram) (6) bottles Sennqwide 8.6 mg - 60 tabs/bottle (17) bottles of [MEDICATION NAME] 20 mg 14 tabs/bottle (12) bottles of [MEDICATION NAME][MEDICATION NAME] 25mg - 100 tabs/bottle (6) boxes of [MEDICATION NAME] 600 mg - 40 tabs/box (4) bottles of Mucus relief [MEDICATION NAME] 400 mg - 100 tabs/ bottle (1) bottle of [MEDICATION NAME] 10 mg - 90 tabs/bottle (14) 6 fluid ounce bottles of [MEDICATION NAME] (1) bottle of [MEDICATION NAME] 10 mg - 90 tabs/bottle (11) bottles of Rantidine 75 mg- 30 tab/bottle (30) 1.5 ounce bottles of [MEDICATION NAME] Mouth spray (2) boxes Denture cleanser tabs- 90 tabs/box (6) bottles of [MEDICATION NAME] 5mg- 90 tabs/bottle (1) 0.33 ounce box of [MEDICATION NAME] 20 percent (%) (1) 16 fluid ounce bottle of [MEDICATION NAME] (1) 13 ounce bottle of Natural [MEDICATION NAME] Fiber Powder (8) 12 ounce bottles of Geri Mox antacid (7) 16 fluid ounce bottle of MOM (2) bottle of Calcium [MEDICATION NAME] 500mg - 150 tabs/bottle (1) 8.3 ounce bottle of Polyethylene [MEDICATION NAME] 3350 (1) 16 fluid ounce bottle of [MEDICATION NAME] liquid 160 mg/ 5ml (2) 16 ounce bottles of Mineral oil (8) 16 fluid ounce bottles of Ultrtuss DM (7) 1.59 ounce boxes of [MEDICATION NAME] 2% (16) 1 ounce tubes of 1 % [MEDICATION NAME] cream (5) 2 ounce tubes of Zinc oxide (15) boxes of Alcohol pad - 200 pads/box (32) Xeroform gauze dressings (74) bottles of Solyzer liquid treatment system (24) D batteries (29) C batteries (30) AAA batteries (28) AA batteries (17) 9- volt batteries (2) boxes of 3 milliliters (ml) 22g 1 1/2 syringes -100/box (1) box of 3 ml 25 gauge (g) 3 inch () syringes 100/box (3) boxes of 1 ml 25g 5/8 [MEDICATION NAME] syringes 100/box (2) boxes of 3 ml 25 g 5/8 syringes 100/box (2) boxes of 1 ml 25g 1 syringes 100/box (3) Emergency Response Safety Kit contains spill kit, sanizide germicidal solution 2 ounces (oz), (2) packages saniwipes (3) boxes of Angiocath 20 g - 50/box (1) box of Angiocath 24g - 50/box (1) Opened box of 25g 1 1/2 [MEDICATION NAME] needles (49 count) (1) box of 7mg Nicotine Patches - 14 patches/box (57) packets of Vitamin A & D ointment skin protectant (11) Staple remover kits (3) bottles of Lubricating Eye Drops (4) bottles of [MEDICATION NAME] Eye Lubricant (3) bottles of Nasal Decongestant Spray (4) bottles of Saline Nasal Spray (5) bottles of Eye Wax Removal Aide (6) boxes safety lancet -200/box (3 ½) boxes Microkill Bleach Germicidal Wipes 1000/box (20) Glucose Gel Packets (5) boxes of Latex Free Insulin Syringes - 100/box (2) bottles of 10gm Sodium [MEDICATION NAME] -1000 tablets/bottle. The Oxygen/Central Supply Room was located on the Central Hall between the North and South Halls in the facility and was accessible to all residents, family and visitors. Interview with the DON outside the Oxygen Storage/Central Supply room on 9/18/16 at 10:01 PM, the DON was asked what his expectations for the staff were when entering and leaving the Oxygen Storage/Central Supply room. The DON stated, .to shut the door . ensuring the door was locked and secure. 6. Observations in the South Hall Clean Utility room on 9/18/16 at 6:05 PM, 8:15 PM, and 9:27 PM, revealed the door to be opened with (5) shaving cream containing Stearic Acid, Trithanolamineisobutane, Sodium Laurtl, Sulfate Laureth 23, and Propane, Butane Fragrance, and BHT as ingredients, (7) unopened packages of razors - 10 razors/package and (1) opened package of razors containing 6 razors, (10) mouth washes with instructions to Keep Out of Reach of Children, 5 packages of denture cleaning tablets, (6) shampoo and body washes with instructions to Keep Out of Reach of Children, 5 perineal washes with instructions for External Use Only, (10) Nourishing skin cream with instructions for External Use Only, (8) roll on deodorants with instructions for External Use Only, (1) spray bottle of germicidal cleaner, and a purse that was opened with a package of cigarettes. ¿@ Observations in the South Hall nurse's bathroom on 9/18/16 at 5:49 PM, 6:19 PM, 7:47 PM, and 10:08 PM, and 9/20/16 at 8:22 PM, revealed (2) periwash and (1) mouth wash with instructions to Keep out of Reach of Children. There was a sign posted, on the inside door of this nurse's South Hall bathroom, to leave the door unlocked with arrows showing how the lock was to be turned to ensure it was not locked. The bathroom was behind the nurse's station, but accessible to residents when there were no staff at the nursing station. Observations in the South Hall on 9/18/16 beginning at 5:49 PM, revealed LPN #2 left the nursing station unattended for 4 minutes. LPN #2 returned to the nurses station briefly and left the station unattended for 5 minutes. Observations on the South Hall nurse's station on 9/18/16 at 5:50 PM and 6:22 PM, revealed a hand washing sink with a cabinet that contained (3) shampoo and body washes, (1) baby powder, (1) periwash, (1) nourishing skin cream. All of these personal care items were labeled with instructions to Keep Out of the Reach of Children. The sink was just inside the nurse's station, but accessible to residents when there were no staff at the nursing station. Observations on the South Hall on 9/18/16 at 7:46 PM, revealed the South Hall Janitor's closet unlocked, unattended and contained: (1) 64 ounce All Purpose Citrus Cleaner Odor Eliminator (1) partial gallon of Carpet and Upholstery Extraction Liquid (1) partial 2.5 gallon of Gloss Restorer (1) 2.5 gallon unknown white substance lying in the floor. Interview with LPN #2 on 9/18/16 at 8:00 PM, at the South Hall nurse's station, LPN #2 was asked if she had any wanderers on the South Hall. LPN #2 stated, Yes, ma'am, (Resident #21) .she has a wanderguard . LPN #2 stated, Yes. It is for her safety. ¿@ Interview with the Administrator on 9/18/16 at 10:14 PM, in the conference room, the Administrator was asked if it was appropriate for all the doors to be unlocked, opened and unattended. The Administrator stated, .it is clear there are hazardous materials available to residents . Interview with the Pharmacy Technician, on 9/19/16 at 10:40 AM, at the South Nurse's Station, the Pharmacy Tech was asked if she expected the storage areas with over the counter medications and dressings to be locked. The Pharmacy Tech stated, Yes. Interview with the Administrator on 9/19/16 at 12:09 PM, in the Conference room, the Administrator stated, .the clean utility doors have never had locks on them as long as I have been here and the Maintenance Director told me he has never known there to be locks on those doors since the building was built. The Administrator's date of employment at the facility was April 13, 2015. Interview with Regional Nurse Consultant (RNC), on 9/19/18 at 12:28 PM, in the Conference room, the RNC was asked if the facility had wanderers. The RNC stated, . (Resident #21) has a BIMS (Brief Interview for Mental Status) of 99 (severe cognitive deficits) and self- propels self in her wheelchair and has wander-guard . (Resident #54) has a BIMS of 99 and self- propels herself in her wheelchair and has a wander-guard . (Resident #46) has a BIMS of 7 (severe cognitive deficit) and self-propels herself and is confused off and on . Interview with the RNC on 9/19/16 at 1:14 PM, in the Conference room stated, .(Resident #82) with a BIMS of 99 also wears a wander-guard and uses a wheelchair to mobilize self .(Resident #99) mobilizes himself in his wheelchair and has a wander guard . Interview with CNA #7 on 9/20/16 at 8:36 AM, in the Break room, CNA #7 was asked what were her responsibilities for the day. CNA #7 stated, (Administrator) wants me to sign off the doors every 15 minutes that they are locked .we have 11 doors to check .the bathroom on the South station was unlocked, someone forgot to lock it . Interview with LPN #2 on 9/27/16 at 7:41 AM, in the Conference room, LPN #2 was asked what doors are supposed to be locked. LPN #2 stated, .the Biohazard Room, the Clean Utility Rooms, the Janitor's Closets, the Central Supply Closet .I forgot to say bathrooms (nursing stations) .they have never been locked . 7. On 9/19/16 at 9:30 PM the facility was asked to provide a list of residents that have the behaviors of wandering. The facility's Regional Nurse Consultant provided a list of 7 residents with wander guards for the behavior of wandering. The list included Residents # 2, 21, 26, 46, 62, 82 and 96. (a). Medical record review for Resident #2 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Set (MDS) date 5/19/16 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 7, indicating the resident was severely cognitively impaired. The Resident Mood Interview revealed the resident answered Yes to feeling down, depressed or hopeless. Record review of the Quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 4, indicating the resident was severely cognitively impaired. The Resident Mood Interview revealed the resident answered Yes: to feeling down, depressed or hopeless The MDS revealed the resident had the behaviors of wandering that occurred 1 to 3 days during this assessment period. Review of Resident #2's plan of care revised on 8/10/16 revealed, .At risk for elopement related to: hx (history) of wandering .Will remain safe during placement at Living Center .Assess for risk of elopement per living center policy .Educate family/responsible party on talking positively about Living Center Placement .Encourage family to bring in personal possessions .Evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings .Involve patient in preferred activities .Involve the patient in decision making regarding daily choices .Redirect patient from doors .Wanderguard. Check wanderguard and replace per MD orders . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . (b). Medical record review for Resident #21 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] Tablet 10 milligrams (mg) by mouth at bedtime. [MEDICATION NAME] XR 28 mg by mouth daily. [MEDICATION NAME] 100 mg by mouth at bedtime. [MEDICATION NAME] 0.5 mg as needed for anxiety. Record review of the Quarterly MDS dated [DATE] revealed Resident #21 had a BIMS of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making. Record review of Resident #21's plan of care revised on 7/18/16 revealed, .At risk for elopement related to hx (history) of Attempts to leave .Will remain safe during placement at Living Center .Resident checks PRN (as needed) for increased monitoring of wandering .Wanderguard bracelet per orders . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . (c). Medical record review for Resident #26 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS dated [DATE] revealed Resident #26 had a BIMS of 6, indicating the resident was severely cognitively impaired. Record review of the Quarterly MDS dated [DATE] revealed Resident #26 had a BIMS of 8, indicating the resident was moderately cognitively impaired. The Resident Mood Interview revealed the resident answered Yes to feeling down, depressed or hopeless. Record review of Resident #26's plan of care revised on 7/19/16 revealed, .I sometimes have delusional behaviors and making statements like 'I'll throw myself on the floor' . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . There was no documentation the facility included the behavior of wandering in resident's plan of care. Review of the physician's orders [REDACTED]. (d). Record review revealed Resident # 46 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Progress Notes dated 4/2/16 at 10:47 AM documented Notable behaviors frequently taking items from other resident's, and also noted taking items off the walls in the hallway and transporting them to her room. Takes pictures of other residents and states they represent people in her family. Store food in room, milk container by the window and crackers on the lampshades. Hoarding discouraged and spoiled items thrown away. Encouraging resident to eat meals in day room with supervision because she has been observed putting her meals in potted plants and mixing coffee, tea, milk, soup into her water pitcher. Poor safety awareness, attempted to use fingernail polish as lipstick before nursing intervention . Review of Progress Notes dated 4/17/16 at 2300 (11:00PM) documented .She can be resistant and combative with care at times . She is a fall risk due to her cognition and poor safety awareness . Review of the Abnormal Involuntary Movement (AIMS) assessment dated [DATE] documented a score of 0 (zero). Review of Care Plan initiated 7/29/16 and revised 9/13/16 documented .sometimes have behaviors .taking objects which do not belong to me .will be safe in the environment . Review of Progress Notes dated 8/19/16 at 1:47AM documented Resident was observed to have pink coloring in her hair from pink lipstick. Review of the last Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8. Review of physician order [REDACTED]. PHS Psych note dated 9/12/16 documented .Staff note that she continues to pick up things that do not belong to her .this can be attributed to memory loss and confusion associated. Observations on 9/18/16 at 4:55 PM revealed Resident #46 up in room in wheel chair (w/c). Stated I'm fixing to call my son to get something to color. Has red paint on her fingers. Dressing to right wrist, stated my watch rubbed it, no watch on during observation. Observations on 9/20/16 at 8:28 AM revealed Resident #46 self propelling around room in w/c, cushion in w/c and towel on cushion. Observations on 9/21/16 at 9:53 AM revealed Resident #46 self propelling in w/c from room to corridor into dining room stopping to look into other rooms along the way. Observations on 9/22/16 at 8:34 AM revealed Resident #46 self propelling around room in w/c looking through drawers, talking to herself. Observations on 9/23/16 at 10:28 AM, revealed Resident #46 self propelling in w/c around the central hallway area by the oxygen room. Resident #46 was asked how she was doing and what was she up to today, Resident # 46 responded I don't know, I'm not here today. Resident #46 continued self propelling herself down the hallway. Observations on 9/24/16 at 8:23 AM revealed Resident #46 self propelling around in room and hall in w/c, going back and forth from room to hall, through drawers, pulling out pictures, stated I have to put these (pictures in hand) on the wall before it (wall) collapse. Observations on 9/25/16 at 9:55 AM revealed Resident #46 in her w/c in the south hall outside her room. Resident #46 was taping her meal card to the wall. When Resident # 46 asked what she was doing, Resident #46 stated I'm putting my name up. Interview with LPN #6 on 9/20/16 at 8:31 AM on the south hall at the medication cart, LPN #6 was asked why Resident #46 had a towel in her wheelchair. LPN #6 replied I don't know but if you take it away from her she will go and get another one and put it back in there. She is independent and self propels herself around the unit. She will find a towel if you take it. She finds things and put them behind her. LPN stated that's like a behavior she has. (e). Medical record review for Resident #62 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Quarterly MDS dated [DATE] revealed Resident #62 had a BIMS score of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making. Record review of the Quarterly MDS dated [DATE] revealed Resident #62 had a BIMS score of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making and had Disorganized thinking . Record review of Resident #62 plan of care revised on 8/9/16 revealed, .I am at risk for elopement Not being able to make good safety decisions .I will remain safe within the facility .Find something on the unit I would like to do to divert my attention .Test my Wanderguard alarm to make sure it's working properly .At risk for elopement related to: Attempts to leave .Wandering . Review of the physician's orders [REDACTED].Change wanderguard 2 weeks prior to exp (expiration) date .Check placement of wanderguard every shift . (f). Medical record review for Resident #82 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Annual MDS dated [DATE] revealed Resident #82 had a BIMS score of 2, indicating the resident was severely cognitively impaired. Record review of the Quarterly MDS dated [DATE] revealed Resident #82 had a BIMS score of 99, indicating the resident was unable to complete the interview. The assessment revealed the resident was Moderately impaired for daily decision making. Record review of Resident #82 plan of care revised on 8/17/16 revealed, .At risk for elopement related to: Resident states 'I am leaving, going home', wandering .Will remain safe during placement at Living Center .check Wanderguard and replace per MD orders . Review of the physician's orders [REDACTED].Wanderguard bracelet to alert staff to attempts to leave facility unaccompanied .Change wanderguard 2 weeks prior to exp date . Interview with CNA #5 on 9/18/16 at 9:33 PM, at the South Hall nurses station, CNA #5 was asked if she was aware of any wanderers. CNA #5 stated, . (Resident #62) comes inside the nurse's station and sneaks up on us, we don't even know she's there . (g). Medical record review of the Significant Change MDS dated [DATE] for Resident #96 revealed a BIMS score of 2, indicating the resident was severely cognitively impaired. Observations on the North Hall on 9/19/16 at 5:22 PM, revealed Resident #96 mobilizing himself in his wheelchair and states to himself, .when can you get me out of here .did my wife go home . Observations at the North Hall nurse's station on 9/20/16 at 9:15 AM, revealed Resident #96 sitting in his wheelchair behind the desk and stated, .I want to go home if you don't get me a job to do . 8. The facility's Bed Rail Guideline policy documented .Assessment is completed to identify potential benefits from utilizing bed rails and minimize risks. If bed rails are being considered assessment is completed before use, with ongoing reassessment (at least quarterly) Care plan interventions are implemented when bed rails are utilized and reviewed at least quarterly. The assessment and documentation also includes: measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress. A visual review is performed to assess that the mattress does not shift/slide allowing for an increased gap between the bed and the bed rail .Residents with bed rails have appropriate assessments completed There is evidence of multidisciplinary approach to bed rail utilization There is evidence that risk and benefits were explained to resident and that the 'Guidance on Bed Rails' brochure was given to and discussed with the resident . Review of the Guidance for Industry and FDA (Food and Drug Administration) Staff- Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment revealed, .Given the adult population at risk for wedging entrapments . the following is recommended: To reduce the risk of Head entrapment, there should be no more than 4 3/4 inches between the mattress and the rail. To reduce the risk of Neck entrapment, there should be no more than 2 3/8 inches from the mattress to the rail. (a) Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) for Resident #20 dated 8/28/16 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident needed extensive assistance with one person for bed mobility and limited assistance by one person for transfer, to walk in the room or corridor, dressing, toilet use, and personal hygiene. The MDS documented that he received scheduled pain medication and had a history of [REDACTED]. The resident received antidepressants, anticoagulants, diuretics, oxygen and Continuous Positive Airway Pressure ([MEDICAL CONDITION]) use while a resident. The care plan for Resident #20, dated 8/24/16 documented the following for the resident: At risk for falls related to use of medication, a history of falls, and his impa

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications and biologicals were properly stored, secured and not unattended in 5 of 10 (Oxygen Storage/Central Supply, North Hall Crash Cart, South Hall Treatment Cart, North Hall Medication Cart, and North Hall Treatment Cart) medication storage areas accessible to residents with cognitive deficits and wandering behaviors. The facility also failed to ensure bleach wipes were not stored past their expiration date 2 of 2 (North and South halls) halls observed during there survey. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 10:14 PM, in the Conference Room. The facility was cited an Immediate Jeopardy at F323, which is Substandard Quality of Care. An extended survey was conducted [DATE] - [DATE]. The Immediate Jeopardy is effective [DATE], and is ongoing. The findings included: 1. The facility's Medication Storage policy documented, .Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: secured (locked) locations, accessible only to designated staff . The facility's Emergency Crash Cart policy documented, .Emergency cart will be secured at the nurses station . 2. Observations in the Oxygen Storage/Central Supply room on [DATE] at 5:07 PM, 9:26 PM through 9:58 PM, and [DATE] at 10:07 AM, revealed the door to be unlocked, unsecured and unattended. The Oxygen Storage/Central Supply room contained the following: (6) bottles of Centravites multivitamin/mineral - 60 tablets (tabs)/ bottle (5) bottles of Eyevits - 60 tabs/bottle (3) bottles of Vitamin B1 100 milligrams (mgs) - 100 tabs/bottle (12) bottles of Vitamin B 12 500 micrograms (mcgs) - 100 tabs/bottle (2) bottles Iron extended release - 60 tabs/bottle (3) bottles of B complex with C - 130 caplets/bottle (5) bottles of Vitamin D 3 00 international units (IUs) - 100 tab/bottle (4) bottles of Vitamin D 1000 IU - 100 tabs/bottle (9) bottles of Melatonin 3 mg - 60 tab/bottle (11) bottles of Multivitamin - 100 tab/bottle (4) bottles of Mutivitamin with iron - 100 tabs/bottle (7) bottles of Multivitamin with minerals -100 tabs/bottle (2) bottles of Calcium Citrate plus (+) Vit D3 - 100 tabs/bottle (3) bottles of Calcium 600 mg + D 400 IU - 60 tabs/bottle (7) bottles of Oyster shell Calcium 500 mg - 100 tabs/bottle (1) bottle of Oyster shell calcium 250 mg with Vitamin D - 100 tabs/bottle (5) bottles of Magnesium oxide 400 mg - 120 tabs/bottle (4) bottles of Fish oil 500 mg - 130 Soft gels/bottle (1) bottle of Florastor 250 mg - 50 caplets/bottle (1) bottle of Zinc 50 mg - 100 tabs/bottle (4) bottles of Ferrous sulfate 325mg - 100 tabs/bottle (4) bottles of Coenzyme Q-10 50 mg - 30 Soft gels/bottle (2) bottles of Renavite - 100 tabs/bottle (3) bottles of Cranberry juice extract 425 mg - 60 caps/bottle (3) bottles of Niacin 250 mg - 100 tabs/bottle (8) bottles of Enteric coated Aspirin 81 mg - 120 tabs/bottle (4) bottles of Aspirin 325 mg - 100 tabs/bottle (3) bottles of Enteric coated Aspirin 325 mg - 100 tabs/bottle (3) bottles of Ibuprofen 200 mg -100 tabs/bottle (3) bottles of Non Aspirin PM 500 mg and Diphenhydramine 25 mg - 50 tablets/bottle (13) bottles of Acetaminophen 325 mg -100 tabs/bottle (4) bottles of Acetaminophen 500 mg- 100 tab/bottle (15) boxes of Gas relief Simethicone 125 mg - 10 Soft gels/box (8) boxes of Loperamide 2 mg - 12 caps/box (5) 4 ounce bottles of Loperamide 1 mg/ 7.5 ml (milliliter) (5) bottles of Docusate Calcium 100 Soft gels - 250 mg/bottle (8) bottles of Docusate sodium 100 mg - 100 tabs/bottle (5) bottles of Sennosides 8.6 mg - 100 tabs/bottle (6) bottles of Biscodyl 5 mg - 100 tabs/ bottle (6) bottles of Natural vegetable lax with stool softener docusate 50 mmg (micromilligram) (6) bottles Sennqwide 8.6 mg - 60 tabs/bottle (17) bottles of Omeprazole 20 mg 14 tabs/bottle (12) bottles of Diphenhydramine 25mg - 100 tabs/bottle (6) boxes of Mucinex 600 mg - 40 tabs/box (4) bottles of Mucus relief expectorant 400 mg - 100 tabs/ bottle (1) bottle of Loratadine 10 mg - 90 tabs/bottle (14) 6 fluid ounce bottles of Loratadine (1) bottle of Cetirizine 10 mg - 90 tabs/bottle (11) bottles of Rantidine 75 mg- 30 tab/bottle (30) 1.5 ounce bottles of Biotene Mouth spray (2) boxes Denture cleanser tabs- 90 tabs/box (6) bottles of Melatonin 5mg- 90 tabs/bottle (1) .33 ounce box of Benzocaine 20% (1) 16 fluid ounce bottle of Eldertonic (1) 13 ounce bottle of Natural Psyllium Fiber Powder (8) 12 ounce bottles of Geri Mox antacid (7) 16 fluid ounce bottle of MOM (2) bottle of Calcium carbonate 500mg - 150 tabs/bottle (1) 8.3 ounce bottle of Polyethylene Glycol 3350 (1) 16 fluid ounce bottle of Acetaminophen liquid 160 mg/ 5ml (2) 16 ounce bottles of Mineral oil (8) 16 fluid ounce bottles of Ultrtuss DM (7) 1.59 ounce boxes of Miconazole Nitrate 2% (16) 1 ounce tubes of 1 % Hydrocortisone cream (5) 2 ounce tubes of Zinc oxide (15) boxes of Alcohol pad - 200 pads/box (32) Xeroform gauze dressings (74) bottles of Solyzer liquid treatment system (24) D batteries (29) C batteries (30) AAA batteries (28) AA batteries (17) 9- volt batteries (2) boxes of 3 milliliter (ml) 22 gauge (g) 1 ,[DATE] inch () syringes -100/box (1) box of 3 ml 25g 3 syringes 100/box (3) boxes of 1 ml 25g ,[DATE] tuberculin syringes 100/box (2) boxes of 3 ml 25 g ,[DATE] syringes 100/box (2) boxes of 1 ml 25g 1 syringes 100/box (3) Emergency Response Safety Kit contains spill kit, sanizide germicidal solution (2oz), (2) packages saniwipes (3) boxes of Angiocath 20 g - 50/box (1) box of Angiocath 24g - 50/box (1) Opened box of 25g 1 ,[DATE] hypodermic needles (49 count) 1 box of 7mg Nicotine Patches - 14 patches/box (57) packets of Vitamin A & D ointment skin protectant (11) Staple remover kits (3) bottles of Lubricating Eye Drops (4) bottles of Systane Eye Lubricant (3) bottles of Nasal Decongestant Spray (4) bottles of Saline Nasal Spray (5) bottles of Eye Wax Removal Aide (6) boxes safety lancet -200/box (3 ½) boxes Microkill Bleach Germicidal Wipes 1000/box (20) Glucose Gel Packets (5) boxes of Latex Free Insulin Syringes - 100/box (2) bottles of 10gm Sodium Bicarbonate -1000 tablets/bottle Interview with the Director of Nursing (DON) outside the Oxygen Storage/Central Supply room on [DATE] at 10:01 PM, the DON was asked what the expectations for the staff were when entering and leaving the Oxygen Storage/Central Supply room were. The DON stated, .to shut the door . 2. Observations outside the North Hall Clean Utility room on [DATE] at 6:10, 6:43 PM and 7:50 PM, revealed a crash cart sitting outside the Clean Utility room that was unsecured. The unlocked and unattended crash cart contained (1) open box of 25 gauge (g) hypodermic needles, (20) safety lancets, 1000 milliliter (ml) 0.9 percent (%) sodium chloride, (3) 3 ml 22 1 ½ needles, (1) 22 g angiocath, (2) 1 cubic centimeter (cc) insulin syringes, (1) 5 ml heplock 100 units (u)/ml, (3) tuberculin syringes, (1) 3 cc syringe. Interview with Registered Nurse (RN) #4 on [DATE] at 10:22 AM, in the North Hall Clean Utility room, RN #4 was asked if it was appropriate for the crash carts to be unlocked. RN #4 stated, .I don't know if it's ever been locked . Interview with the DON on [DATE] at 10:20 PM, in the Conference room, the DON was asked if it was appropriate for the crash cart to be unlocked. The DON stated, No. ¿@ Interview with the Administrator on [DATE] at 10:14 PM, the Administrator was asked if it was appropriate for all the above doors to be unlocked, opened and unattended. The Administrator stated, .it is clear there are hazardous materials available to residents . Interview with LPN #2 on [DATE] at 8:00 PM, at the South Hall nurse's station, LPN #2 was asked if she had any wanderers on the South Hall. LPN #2 stated, Yes, ma'am, (Resident #21) .she has a wanderguard . LPN #2 was asked if the wanderguard was to prevent the resident from leaving the building. LPN #2 stated, Yes. It is for her safety. Interview with CNA #5 on [DATE] at 9:33 PM, at the South Hall nurses station, CNA #5 was asked if she was aware of any wanderers. CNA #5 stated, . (Resident #54) comes inside the nurse's station and sneaks up on us, we don't even know she's there . Interview with (Named Pharmacy Technician) on [DATE] at 10:40 AM, the Pharmacy Tech was asked if she expected the storage areas with over the counter medications and dressings to be locked. The Pharmacy Tech stated, Yes. (The Pharmacist was unavailable for interview.) Interview with Regional Nurse Consultant (RNC), on [DATE] at 12:28 PM, in the Conference room, the RNC was asked if the facility had wanderers. The RNC stated, . (Resident #21) has a BIMS (Brief Interview for Mental Status) of 99 (severe cognitive deficits) and self- propels self in her wheelchair and has wander-guard . (Resident #54) has a BIMS of 99 and self- propels herself in her wheelchair and has a wander-guard . (Resident #46) has a BIMS of 7 (severe cognitive deficit) and self-propels herself and is confused off and on . 7. On [DATE] at 9:30 PM the facility was asked to provide a list of residents that have the behaviors of wandering. The facility's Regional Nurse Consultant provided a list of 7 residents with wander guards for the behavior of wandering. The failure of the facility to ensure medications and biologicals were properly stored, secured and not unattended placed the 7 residents in a situation where the potential for harm or injury was very high. The 7 residents identified as having wandering behaviors had [DIAGNOSES REDACTED]. The 7 identified residents' Brief Interview for Mental Status (BIMS) score indicated cognitive deficits. 8. Observations on [DATE] at 4:55 PM revealed Resident #46 up in room in wheel chair (w/c). Stated I'm fixing to call my son to get something to color. Has red paint on her fingers. Dressing to right wrist, stated my watch rubbed it, no watch on during observation. Observations on [DATE] at 8:28 AM revealed Resident #46 self propelling around room in w/c, cushion in w/c and towel on cushion. Observations on [DATE] at 9:53 AM revealed Resident #46 self propelling in w/c from room to corridor into dining room stopping to look into other rooms along the way. Observations on [DATE] at 8:34 AM revealed Resident #46 self propelling around room in w/c looking through drawers, talking to herself. Observations on [DATE] at 10:28 AM, revealed Resident #46 self propelling in w/c around the central hallway area by the oxygen room. Resident #46 was asked how she was doing and what was she up to today, Resident # 46 responded I don't know, I'm not here today. Resident #46 continued self propelling herself down the hallway. Observations on [DATE] at 8:23 AM revealed Resident #46 self propelling around in room and hall in w/c, going back and forth from room to hall, through drawers, pulling out pictures, stated I have to put these (pictures in hand) on the wall before it (wall) collapses. Observations on [DATE] at 9:55 AM revealed Resident #46 in her w/c in the south hall outside her room. Resident #46 was taping her meal card to the wall. When Resident # 46 asked what she was doing, Resident #46 stated I'm putting my name up. Interview with LPN #6 on [DATE] at 8:31 AM on the south hall at the medication cart, LPN #6 was asked why resident #46 had a towel in her wheelchair. LPN #6 replied I don't know but if you take it away from her she will go and get another one and put it back in there. She is independent and self propels herself around the unit. She will find a towel if you take it. She finds things and put them behind her. LPN stated that's like a behavior she has. Interview with CNA #5 on [DATE] at 9:33 PM, at the South Hall nurses station, CNA #5 was asked if she was aware of any wanderers. CNA #5 stated, . (Resident #62) comes inside the nurse's station and sneaks up on us, we don't even know she's there . Observations on the North Hall on [DATE] at 5:22 PM, revealed Resident #96 mobilizing himself in his wheelchair and states to himself, .when can you get me out of here .did my wife go home . Observations at the North Hall nurse's station on [DATE] at 9:15 AM, revealed Resident #96 sitting in his wheelchair behind the desk and stated, .I want to go home if you don't get me a job to do . 9. Observations on the South Hall on [DATE] at 5:12 PM, revealed a tub of Clorox wipes on the treatment cart with an expiration date of [DATE]. Interview with LPN #6 on [DATE] at 5:15 PM, at the South Hall Treatment cart confirmed the bleach wipes on the South Hall treatment cart to be expired and stated, .Oh, I need to remove those . Observations on the North Hall on [DATE] at 5:00 PM, revealed 16 packs of germicidal bleach wipes with an expiration date of ,[DATE] on the North Hall medication cart. Interview with LPN #1 on [DATE] at 5:05 PM, at the North Hall medication cart stated, Those are no good. Observations on the North Hall at [DATE] at 5:15 PM, revealed 37 packs of germicidal bleach wipes with the expiration date ,[DATE] on the North Hall Treatment cart. Interview with the DON on [DATE] at 5:21 PM at the North nurses station, the DON was asked if it was acceptable to have expired bleach wipes on the carts. The DON stated, No. The DON was asked who was responsible for monitoring for expired items on the carts, the DON stated, .the nurses who use the cart and (name of pharmacy staff) with pharmacy comes in and checks the carts. It's everybody's responsibility. Refer to F 323.

Based on medical record review, observation and interview, the facility failed to ensure there was an effective Governing Body (GB) responsible for the overall operation and management of the facility and to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents. The facility failed to ensure the GB managed an effective Quality Assurance (QA) program that recognized and developed an appropriate plan to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. The facility failed to ensure the GB provided management of safe practices by failing to ensure all beds/side rails were safe for residents, and medications and biologicals were properly stored and secured from vulnerable residents. The facility failed to ensure the GB provided oversight to ensure residents' rights to have personal items in their room was honored, residents' electronic records were kept confidential, and failed to promote resident dignity and respect. The facility failed to ensure the GB implemented infection control techniques, and promoted staff to follow physician's orders [REDACTED]. The facility failed to ensure the GB promoted communication between the facility and the [MEDICAL TREATMENT] clinic for [MEDICAL TREATMENT] residents, and failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections from previous surveys. The failure to ensure vulnerable residents' environment was free from the accidents and hazards of chemicals, medications, sharps, and biohazardous material placed sampled Residents #2, 20, 21, 26, 41, 46, 53, 62, 82 and 96 in IMMEDIATE JEOPARDY. The failure to ensure Resident's #20 and 53 were free of accident and hazards from improper functioning bed/side rails placed them at risk for entrapment. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the IMMEDIATE JEOPARDY on 9/18/16 at 10:14 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F323, which is Substandard Quality of Care. An extended survey was from 9/28/16 - 9/29/16. The findings included: 1. The Governing Body failed ensure the resident's rights were honored to have personal items in their room for Refer to F 151. 2. The Governing Body failed to ensure the facility maintained the privacy and confidentiality of residents' electronic records. Refer to F 164 and 516. 3. The Governing Body failed to ensure the facility promoted care that maintained residents' dignity, respect, and quality of care. Refer to F241. 4. The Governing Body failed to ensure the facility followed the resident's care plan interventions related to accidents, unnecessary medications, oxygen, foley catheter care, labs, and pain monitoring. Refer to F 282. 5. The Governing Body failed to ensure the facility followed physician's orders [REDACTED]. Refer to F 309. 6. The Governing Body failed to ensure the facility practiced good infection control techniques. Refer to F 315. 7. The Governing Body failed to failed to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. The facility's failure to protect vulnerable residents from accident hazards and in a safe environment placed residents in Immediate Jeopardy; Refer to F 323 and F 465. 8. The Governing Body failed to ensure the facility followed physician orders [REDACTED]. Refer to F 328. 9. The Governing Body failed to ensure nursing monitored residents for side effects and adverse drug reactions. Refer to F 329. 10. The Governing Body failed to ensure the facility posted accurate nursing staff information. Refer to F 356. 11. The Governing Body failed to to ensure practices to prevent the potential spread of infection were maintained as evidenced of meal plates not covered, ,staff members handling food with their bare hands, staff did not perform hand hygiene during meal service, Dietary staff's hair not restrained, Dietary Staff failed to perform hand hygiene in the kitchen, and unlabeled and undated food. Refer to F 371 12. The Governing Body failed to ensure the facility stored medications and biologicals securely and supplies were not stored past the expiration date; Refer to F 431 13. The Governing Body failed to ensure the facility practiced infection control in order to prevent the potential spread of infection. Refer to F 441 14. The Governing Body failed to ensure there was an operational call light system in 4 of 52 (Resident # 113, 22, 11, and 96) resident bathrooms; Refer to F 463. 15. The Governing Body failed to ensure staff promptly notified physicians of resident laboratory results for Residents #18 and 46. Refer to F 505 16. The Governing Body failed to ensure the quality assurance program was effective in identifying issues and concerns and maintaining previous interventions related to dignity and respect of individuality, following care plan, kitchen sanitation, drug / biological storage, infection control. Refer to F 164, F282, F371, F431, F441. 17. Interview with the Administrator on 9/29/16 at 8:55 AM, the Administrator was asked about the governing body of the facility. The Administrator stated there was not a governing body. There were owners of the facility and a Chief Operating Officer (CEO). A revisit survey #1 for the Allegation of Compliance (AOC) was conducted on 10/4/16 through 10/5/16. The facility remains out of compliance with Immediate Jeopardy at F-493 ongoing. Based on review of the Allegation of Compliance and interview, the governing board failed to follow the AOC and failed to monitor the oversight of corrective actions for the Immediate Jeopardy deficient practices that effected the residents residing in the facility. The findings included: Review of the AOC submitted September 29,2016 revealed, .The Regional Director of Operations and the Regional Nurse will monitor the Administrators oversight of corrective action regarding cited deficiencies until in complete compliance including the removal of the immediate jeopardy . In an interview conducted in the conference room on 10/4/16 at 9:45 AM the Regional Nurse Consultant #2 was asked the whereabouts of the Administrator and stated, The Administrator is in(NAME)Florida. In an interview conducted in the conference room on 10/4/16 at 1:30 PM the Director of Nursing (DON) was asked who was in charge of the facility during the Administrator's absence and stated, .I guess (Named Regional Nurse Consultant #2) is in charge, he is over me, he has an Administrator's license. The DON informed the survey team he was leaving to attend to some business and would return later in the day. The surveyor asked the DON to have the Regional Nurse Consultant #2 to provide the survey team a copy of his Administrator's license. In an interview conducted in the conference room on 10/4/16 at 1:45 PM the Regional Nurse Consultant #2 asked Why do you need my Administrator's license, I am not in charge, (Named DON) is. The Regional Nurse Consultant #2 failed to provide a copy of his Administrator's license to the survey team. The survey team asked for a copy of the designation policy. In an interview conducted in the conference room on 10/4/16 at 4:30PM the DON brought in the requested designation policy and stated, l guess I am in charge . The Administrator left on Saturday, flew out to(NAME)for the week. The DON was asked who was completing the Administrator's audits and oversite duties according to the AOC and stated, I guess that would be me. The DON was shown a Non Clinical Rounds report dated 9/30/16 that revealed, .S19 perineal cleaner in Btrm(bathroom) cabinet, sewing needles, mouthwash & denture cleaner overbed t(table) . The DON was asked to explain this report and stated, That is our Guarding Angel IDT rounds. The DON was asked to provide the follow-up to this IDT form dated 9/30/16 and for all documentation of the audits and oversite duties by the Administrator. In an interview conducted in the conference room on 10/5/16 at 12:00 Noon, the DON brought in a typed statement and stated, Here is a statement the Administrator sent to me about his oversite. Review of this statement revealed no signature or date, the statement read in part, .To whom it may concern: I, (Named Administrator), oversaw and directed the actions taken during the Allegation of Compliance process . There was no documentation provided to the survey team of the Administrators oversite activites or audits per AOC. The DON stated, As a result of our daily IDT round and the IDT round report on 9/30/16 we have increased to hourly rounds starting today . There was no documentation the items documented as found in resident room S19 on the 9/30/16 ( the next day after alleged compliance) IDT round report had been identified and addressed until 10/5/16 after being brought to the facilities attention by the survey team. The governing body failed to ensure there was an Administrator/Acting Administrator present, in charge and aware they were in charge in the facility on 10/4/16 and failed to follow the AOC and provide oversight. Refer to F-323, F-431, F- 465, F-520

Based on medical record review, observation and interview, the Medical Director failed to use resources effectively and efficiently to attain and maintain the highest practicable functioning of all residents by failing to ensure an effective Quality Assurance (QA) program that recognized and develop an appropriate plan to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. The Medical Director failed to ensure all beds/side rails were safe for residents, and medications and biological's were properly stored and secured from vulnerable residents. The Medical Director failed to ensure residents' rights to have personal items in their room was honored, residents' electronic records were kept confidential, and failed to promote resident dignity and respect. The Medical Director failed to ensure staff followed physician's orders [REDACTED]. The Medical Director failed to ensure communication between the facility and the [MEDICAL TREATMENT] clinic for [MEDICAL TREATMENT] residents, and failed to ensure the QA program was effective in identifying issues and concerns within the facility and maintaining plans of corrections from previous surveys. The failure to ensure vulnerable residents' environment was free from the accidents and hazards of chemicals, medications, sharps, and biohazardous material placed sampled Residents #2, 20, 21, 26, 41, 46, 53, 62, 82 and 96 in IMMEDIATE JEOPARDY. The failure to ensure Resident's #20 and 53 were free of accident and hazards from improper functioning bed/side rails placed them at risk for entrapment. IMMEDIATE JEOPARDY is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were informed of the IMMEDIATE JEOPARDY on 9/18/16 at 10:14 PM, in the Conference Room. The facility was cited an IMMEDIATE JEOPARDY at F323, which is Substandard Quality of Care. An extended survey was from 9/28/16 - 9/29/16. The findings included: 1. The Medical Director failed to ensure staff honored resident's rights to have personal items in their room for Refer to F 151. 2. The Medical Director failed to ensure the staff protected residents' electronic records and kept them private and confidential. Refer to F 164 and 516. 3. The Medical Director failed to ensure staff promoted care that maintained residents' dignity, respect, and quality of care. Refer to F241. 4. The Medical Director failed to ensure staff followed the resident's care plan interventions related to accidents, unnecessary medications, oxygen, foley catheter care, labs, and pain monitoring. Refer to F 282. 5. The Medical Director failed to ensure the staff followed physician's orders [REDACTED]. Refer to F 309. 6. The Medical Director failed to ensure staff followed facility policies for Foley catheter bags and tubing not touching the floor. Refer to F 315. 7. The Medical Director failed to failed to ensure residents' environment was free from the accident hazards of biohazard materials, aerosol sprays, scissors, medications, bleach wipes, items labeled Keep out of reach from Children, floor cleaners and equipment hazards. The facility's failure to protect vulnerable residents from accident hazards and in a safe environment placed residents in IMMEDIATE JEOPARDY. Refer to F 323 and F 465. 8. The Medical Director failed to ensure staff administered oxygen according to the physician's orders [REDACTED]. Refer to F 328. 9. The Medical Director failed to ensure the staff monitored residents for medication side effects and adverse drug reactions for Resident #20. Refer to F 329. 10. The Medical Director facility failed to ensure staff posted current and accurate nurse staffing information was posted at the beginning of each shift during 3 of 3 (days 9/18/19, 9/19/16 and 9/23/16) days of observing the posting for nursing staff. Refer to F 356. 11. The Medical Director failed to ensure staff practices to prevent the potential spread of infection were maintained as evidenced of meal plates not covered,staff members handling food with their bare hands, staff did not perform hand hygiene during meal service, Dietary staff's hair not restrained, Dietary Staff failed to perform hand hygiene in the kitchen, and unlabeled and undated food. Refer to F 371 12. The Medical Director failed to ensure medications and biologicals were properly stored and supplies were not stored past the expiration date; Refer to F 431 13. The Medical Director failed to failed to ensure practices to prevent the potential spread of infection. Refer to F 441 14. The Medical Director failed to ensure there was an operational call light system in 4 of 52 (Resident # 113, 22, 11, and 96) resident bathrooms; Refer to F 463. 15. The Medical Director failed to ensure staff promptly notified physician of resident lab results for Residents #18 and 46. Refer to F 505 16. The Medical Director failed to ensure the quality assurance program was effective in identifying issues and concerns and maintaining previous interventions related to dignity and respect of individuality, following care plan, kitchen sanitation, drug / biological storage, infection control. Refer to F 164, F282, F371, F431, F441. 17. Telephone interview with the Medical Director (MD) on 9/28/16 at 6:30 PM, in the Conference room, the MD was asked what his responsibility regarding facility policies. The MD stated, .review all policies annually .they revise until we can agree . The MD was asked if he attended the Quality Assurance (QA) meetings, the MD stated, Yes .monthly. The MD was asked if he was aware of issues with laboratory (lab) orders not being carried through and results not being placed on residents' charts, the MD stated, I was not aware of any of that .I don't hunt for stuff or go through every record checking for labs. The MD was asked if he did oversight on attending physicians. The MD stated, .I have a professional relationship with them and I will address any issues I am aware of with them. The MD was asked if he was made aware of residents receiving medications late and their physician not being notified. The MD stated, No, I am not aware of that. The MD was asked if he was aware of entrapment issues with bed rails, call lights disabled in residents' bathrooms and oxygen therapy delivered at a lower rate than ordered. The MD confirmed that he had no prior knowledge of these issues. The MD was asked if he was aware of unsecured doors throughout the facility that contained hazardous chemicals and medications. The MD stated, I became aware when you all informed the facility, Yes, I agree it could be a safety issue. The MD was asked what his responsibility would be to ensure corrective action. The MD stated, Ensure all deficiencies are corrected timely . A revisit survey #1 for the Allegation of Compliance (AOC) was conducted on 10/4/16 through 10/5/16. The facility remains out of compliance with Immediate Jeopardy at F-501 ongoing. Based on review of the Allegation of Compliance and interview, the Medical Director failed to assist the facility to identify, evaluate, and address/resolve medical and clinical concerns that affected the residents residing in the facility. The findings included: Review of the Allegation of Compliance (AOC) submitted by the facility on September 29, 2016 revealed, .The Medical Director has been actively involved with the AOC process thus far and will continue to be involved in the AOC plan . In an interview in the conference room on 10/5/16 at 1:00 PM the DON was asked about the Medical Director's involvement to resolve the Immediate Jeopardy deficiencies and stated, He was at the 9/20/16 QAPI(Quality Assurance and Performance Improvement) meeting and suggested new doors. He has not been present at any other meetings. Don't think we have any new policies. The surveyor asked for any documentation the Administrator might have of the Medical Directors involvement and the facility was unable to provide any to the survey team. In a phone interview on 10/7/16 at 8:30 AM the Medical Director was asked if he was the Medical Director and stated, I am the Medical Director for The Waters of Union City previously Golden Living Center. The Medical Director was asked about his awareness of the survey teams findings, his input provided to the facility to address the concerns, if he had been onsite recently and if he had participated in any Quality Assurance meetings to address the concerns and stated, Yes, they made me aware of the situation, yes, correction is in process, yes, I was out there yesterday, yes, I am aware of the revisit, I am regularly attending QA, monthly, there has not been a QA meeting since exit. Refer to F-323, F-431, F- 465, F-490, F-520

Based on policy review, medical record review, observation, and interview the facility failed to ensure the resident's indwelling urinary catheter bag did not touch the floor for 5 of 5 (Resident #96, 11, 49, 91 and 75) sampled residents reviewed with an indwelling urinary catheter. The findings included: 1. The facility's Catheter (Indwelling), Insertion and Removal of (Female and Male) policy documented, .PROCEDURES DETAILS .14. Secure urinary drainage bag .KEEP OFF THE FLOOR AT ALL TIMES . 2. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented .H0100. Appliances .Indwelling catheter .(check mark) . Observations in Resident #11's room on 9/20/16 at 7:56 AM, revealed resident's urinary drainage bag hanging from the side of the bed and touching the floor. 2. Medical record review revealed Resident #91 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Quarterly MDS dated [DATE] documented, .H0100. Appliances .Indwelling catheter .(check mark) . Observations in Resident #91's room on 9/20/16 at 8:08 AM and 1:27 PM, revealed resident's urinary drainage bag hanging from the side of the bed and touching the floor. 3. Medical record review revealed Resident # 96 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented, .H0100. Appliances .Indwelling catheter .(check mark) Observations at the north nurses station on 9/21/16 at 11:30 revealed Resident #96 sitting in a wheelchair with his urinary drainage bag in a privacy bag on the back of the wheelchair with the tubing laying in the floor. Observations at the north nurses station on 9/21/16 at 11:58 AM, revealed Certified Nursing Assistant (CNA) #6 pushing Resident #96 into the north hall day room for lunch with the foley catheter tubing dragging on the floor. Observations on North hall by room [ROOM NUMBER] on 9/21/16 at 4:55 PM, revealed CNA #7 placed Resident #96's foley drainage bag into a privacy bag on the back of his wheelchair, dragging the catheter tubing on the floor. Observations on North hall at Resident #96's room on 9/28/16 at 8:12 AM, revealed resident sitting in the doorway of his room with his foley catheter tubing laying on the floor. 4. Medical record review revealed Resident #49 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14 Day MDS dated [DATE] documented, .H0100. Appliances .Indwelling catheter .(check mark) .Ostomy .(check mark) . Observations in Resident #49's room on 9/20/16 at 4:55 PM, revealed that his urinary drainage bag was hanging from the side of the bed and touching the floor. 5. Medical record review revealed Resident #75 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30 Day MDS dated [DATE] documented, .H0100. Appliances .Indwelling catheter .(check mark) . Observation in Resident #75's room on 9/24/16 at 4:43 PM, revealed that his urinary drainage bag hanging from the side of the bed and touching the floor. 6. Interview with Licensed Practical Nurse (LPN) #1 on 9/21/2016 at 3:55 PM, at the North hall nurses station the LPN was asked how would you monitor foley catheter positioning. The LPN stated, By observing, it should never be on floor. Nurses check when giving meds, CNA's check during rounds and in between . Interview with the Director of Nursing (DON) on 9/24/16 at 1:17 PM, in the conference room, the DON was asked if it was acceptable for a foley bag to be on the floor. The DON stated, No. Interview with CNA #2 on 9/28/16 at 11:36 AM, at the North hall nurses station the CNA was asked if it was good infection control practice to raise the foley catheter above the bladder or allow the tubing to touch the floor. The CNA stated, No.

Based on medical record review, observation, and interview the facility failed to follow the care plan interventions related to [MEDICAL TREATMENT] communication, monitoring for pain, laboratory (lab) results, medication side effects, administration of oxygen, keeping Foley catheter tubing off the floor and assisting with bed mobility for 8 of 16 (Resident #12, 18, 20, 46, 49, 53, 64 and 96) sampled residents reviewed for care plans of the 54 residents included in the Stage 2 review. The findings include: 1. Medical Record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission pain evaluation documented, Pain Evaluation .Description: Admission .Date: 6/23/2016 13:15 .Resident and daughter state she is in constant pain with [MEDICAL CONDITION], unable to take medicine for [MEDICAL CONDITION] because it made her swell. Which made legs hurt worse, usually pain is a 6-7 but at night it gets to a 10 has to have her pain medicine then will be a 4 . Review of the Care Plan dated 6/23/16 documented, .Needs Pain management and monitoring related to: [MEDICAL CONDITION], Peripheral [MEDICAL CONDITION], Chronic Pain .Will maintain adequate level of comfort as evidenced by no s/sx (signs or symptoms) of unrelieved pain or distress, or verbalizing satisfaction with level of comfort .Administer Pain medication as ordered .Evaluate and Establish level of pain on numeric scale/evaluation tool .Evaluate need to provide medications prior to treatment or therapy .Utilize pain monitoring tool to evaluate effectiveness of interventions .Observe for potential medication side effects . Review of the Medication Administration Record for Resident #12 for August and September 2016 revealed Resident #12 received [MEDICATION NAME]-[MEDICATION NAME] Tablet 10-325 mg (milligrams) every 6 hours. Review of the Order Summary Report for Resident #12 dated 8/25/16 documented, .Assess for pain Q (every) shift . Interview with Licensed Practical Nurse (LPN) #6 on 9/28/16 at 1:25 PM, at the South Hall nurse's station, the LPN was asked if there was any documentation on Resident #12 regarding her pain assessment. LPN #6 stated, .not on scheduled pain pills, only on the PRN (as needed) . The LPN was asked what the checkmarks on the Medication Administration Record (MAR) meant. The LPN stated, .just where she is asked how she is feeling . Interview with the Director of Nursing (DON) on 9/28/2016 at 2:30 PM, in the DON office, the DON was asked how Resident #12's pain was being monitored. The DON stated, .should entered a numeric value to rate her pain .the computer should have prompted them to put a number in .they should all have a numeric value every shift .someone just didn't activate that tab that would prompt them to put a number in . The facility failed to follow care plan interventions to assess Resident #12 for pain every shift. 2. Medical Record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. HgbA1C (glycosylated hemoglobin-referring to an elevation of a person's blood sugar) Q (every) 4 months (Dec/Apr/Aug). Review of the Care Plan for Resident #18 initiated 4/26/16 and revised 7/20/16 documented .Labs (laboratory) per Physician order [REDACTED].lab work or X-rays as ordered by physician . Notify/report to physician . Review of the Pharmacy Recommendation for Resident #18 dated 9/7/16 documented, Please file to chart Lab results of labs due in August for the following labs HgBA1c. There was no documentation in the medical record the HgbA1C had been drawn for August 2016. Interview with the DON on 9/2716 at 3:15 PM, in the conference room, the DON was asked to review Resident #18's chart for the August lab results. The DON stated, I don't see the results but I can get it for you. On 9/27/16 at 4:25 PM, the DON returned with Resident #18's HgBA1C results collected on 8/18/16 at 4:06 PM. The DON was then asked if the results were reported to the physician, and the DON stated it was not in any of the notes. The DON was asked to review the physician progress notes [REDACTED]. The DON stated, No, I don't see where he addressed the lab. The DON was asked if staff followed Resident #18's care plan and physician orders, the DON stated No. Interview with the DON on 9/2816 at 4:10 PM, on the North Hall, the DON was asked if it was acceptable for staff to not follow physician orders [REDACTED]. The DON stated, No. The DON was asked if he expected staff to obtain and report lab results to the physician. The DON stated, Yes, results should be reported to the physician timely. The facility failed to follow care plan interventions for Resident #18 for reporting/notifying the physician of lab results. 3. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Section J documented the resident received scheduled pain medication. Section N documented 1 injection given, 3 days of antidepressants, 4 days of anticoagulant, and 4 days of diuretics during the 7 day look back period. Review of the care plan dated 8/24/16 revealed Resident #20 was at risk for falls related to the use of medication. The care plan documented a potential problem with pain management, and interventions included administering pain medications as ordered and observe for side effects. The care plan documented a potential for drug-related complications with use of antidepressants, anticoagulant medications, diuretic medications and the usage of over 9 medications with intervention of monitoring for side effects and adverse reactions. Review of physician's orders [REDACTED]. 9/7/16 - [MEDICATION NAME]-[MEDICATION NAME] Solution 5-4 milligrams (mgs)/milliliter (ml), Give 1 teaspoon two times a day for cough. The order end date was 9/19/16. 8/24/16 - [MEDICATION NAME] Extended Release Tablet extended release (ER), 12 Hour Abuse-Deterrent Give 10 mg by mouth two times a day for chronic pain. 8/24/16 - [MEDICATION NAME] 25 mg 1 tablet daily. 8/24/16 - [MEDICATION NAME] 20 mg one time a day on even days. 8/27/16 - [MEDICATION NAME] 50 mg at bedtime for difficulty sleeping. 9/1/16 - [MEDICATION NAME] Sodium 4 mg daily. Review of the MAR and nurse's notes for August and September revealed there was no regular monitoring for side effects or adverse drug reactions. Interview with LPN #6 on 9/21/16 at 5:05 PM, in the front hallway by the medication cart, LPN #6 was asked where side effects were charted for Resident #20. LPN #6 stated, I don't think they are. I've never seen them in this system. LPN #6 was asked where adverse drug reactions were documented. LPN #6 stated, As far as I know they are not in the system. Interview with the DON on 9/24/16 at 1:17 PM, in the conference room, the DON was asked how often should residents be assessed for medication side effects and adverse drug reactions. The DON stated, Every time it is given. The DON was asked where should side effects and adverse drug reactions be charted. The DON stated, It is also in the MAR. The DON was asked if it would be acceptable to not have side effects or adverse drug reactions charted. The DON stated, No. The facility failed to follow care plan interventions for Resident #20 to monitor for side effects and/or adverse reactions from medications. 4. Medical Record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. (August/February), BMP (q 6 months (August/February), CBC yearly while on [MEDICATION NAME] (August). Review of the Care Plan for Resident #46 initiated 7/29/16 and revised 9/13/16 documented, .Will maintain therapeutic lab values . lab work or X-rays as ordered by physician . Review of the Pharmacy Recommendation for Resident #46 dated 9/7/16 documented, Please file to chart Lab results from August for the following labs BMP, LFT, Fasting Lipid Panel due every 6 months (February & August) and CBC due yearly (August). Review of the MAR for August and September 2016 revealed Resident #46 received [MEDICATION NAME]. There was no documentation labs were drawn for Resident #46 during the month of August. Interview with the DON on 9/24/16 at 1:28 PM, in the conference room, the DON was asked to review Resident #46's record for the August labs. The DON stated, I don't see the labs in the chart or where they were addressed by the doctor, I will check to see if we have them. The DON was asked why the labs were not on the chart if they were ordered in August. The DON replied, I don't know why. On 9/24/16 at 1:54 PM, the DON returned to the Conference room and stated, I didn't find any labs for August; it appears they were not drawn. The DON was asked if staff followed doctor orders for labs. The DON stated, it does not appear they did. The DON was asked what is the time frame for follow up with the pharmacy recommendations. The DON stated, usually we hand deliver them or fax them to him (physician) as soon as possible. If it's something critical we try to get it taken care of immediately. Otherwise we follow up in 24 hours. The DON was asked if the process was followed regarding Resident #46's August labs. The DON stated, I can't verify the labs were drawn, looks like we missed them. The DON was asked if staff followed Resident #46's care plan. The DON stated No. The facility failed to follow care plan interventions for Resident #46 by not obtaining and reporting lab results. 5. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order Summary Report dated 8/25/16 documented on 8/4/16 the physician ordered Oxygen (O2) at 4 liters (L) per minute (min) binasal cannula (BNC) continuously every shift. Review of the Care Plan dated 9/21/16 documented, .Alteration in Respiratory Status .Administer oxygen as needed per Physician order [REDACTED].Indwelling Urinary Catheter .Keep drainage bag of catheter below the level of the bladder at all times and off floor . Review of the August and September 2016 MARs revealed no documentation O2 administered at 4L/min. Observations in Resident #49's room on 9/19/16 at 12:35 PM, 9/20/16 at 4:55 PM, 9/21/16 at 8:37 AM, revealed Resident's Oxygen rate was at 2L/min. Observations in Resident #49's room on 9/20/16 at 4:55 PM, revealed the resident's urinary drainage bag was hanging from the side of the bed and touching the floor. Observation in the Therapy room on 9/22/16 at 2:44 PM, revealed the resident was sitting up in his wheelchair with his Oxygen rate set on 2L/min. Interview with RN #4 on 9/22/16 at 4:54 PM, in the south break room the RN was asked what Resident #49's O2 rate should have been. The RN stated, It should be on 4 (L/min.). The RN was asked if it would be acceptable for his O2 to be set on a rate of 2L/min. The RN stated, Not according to this order. Interview with Director of Nursing (DON) on 9/24/16 at 1:17 PM, in the conference room, the DON was asked if it was acceptable for a resident's O2 to be set on a rate of 2L/min. when it was ordered to be set at 4L/min. and the DON stated, No. The facility failed to follow care plan interventions for oxygen administration rate and keeping foley catheter drainage bag off of the floor for Resident #49. 6. Medical record review revealed Resident #53 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 14 day MDS dated [DATE] documented a BIMS of 13, indicating Resident #53 was cognitively intact. Section G documented the resident needed extensive assist by 2 people for bed mobility, transfers and locomotion on unit. The resident was limited assistance needed by one person for walking in room and corridor. Review of the care plan initiated on 8/4/16/ revealed Resident #53 was at risk of falls due to wekaness and required assistance. Interventions included the use of a wheelchair of the appropriate size, the resident's bed placed in low position, and footwear to prevent slipping. The resident also required extensive assistance with bed mobility, transfers and walking. A Physician order [REDACTED]. Observations in Resident # 53's room on 9/24/16 at 4:21 PM, revealed Resident #53 was sitting up in the chair. This surveyor raised the left side rail to the latched position to check the side rail gap between the rail and the mattress. Resident #53 stated that the rail would fall. The left rail then fell completely down. Resident stated, Both rails will fall . Interview with the Regional Nurse Consultant (RNC) on 9/4/16 at 5:08 PM, in Resident #53's room, the RNC was informed that both of the side rails would fall down even if they were in the latched position. The RNC raised the left side rail, shook the side rail and then the left side rail fell out of the latched position. Interview with Resident #53 on 9/27/16 at 4:26 PM, in the resident's room, the resident was asked if anyone had checked the side rails on the bed before the surveyor had checked them. Resident #53 stated, No, that was the first time anyone had come in here about the rail. Resident #53 was asked if anyone had asked her if she had any trouble with it. Resident #53 stated, No, none of these folks up here. They didn't ask me if I had had any trouble with it. One of the girls that gives a bath came in to empty my pot and the rail fell down and she put it back up because I asked her to. Resident #53 was asked if the rail fell while the staff was in the room. Resident #53 stated, No it fell before she came in here and I asked her to pull it up because I don't know how it works and I still don't know how it works. The resident was asked if she told the staff that it had fallen. Resident #53 stated, Yes, but I don't remember what she looks like. Resident #53 was asked if the rail had fallen since she received the new bed. Resident #53 stated, No. The facility failed to follow care plan interventions for providing assistance with bed mobility by using side rails for Resident #53. 7. Medical record review revealed Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#64 was to receive [MEDICAL TREATMENT] every Monday, Wednesday and Friday. Review of the Care Plan for Resident #64 dated 9/13/16 documented .Written Communication form with review of weights and any changes in condition between [MEDICAL TREATMENT] provider and living center . The facility was able to provide only 2 [MEDICAL TREATMENT]/OBSERVATION COMMUNICATION forms dated 9/12/16 and 9/14/16 between the [MEDICAL TREATMENT] provider and the facility to include weights and vital signs. The facility was unable to provide documentation of communication between the facility and the [MEDICAL TREATMENT] unit for 8/24/16, 8/26/16, 8/28/16, 8/31/16, 9/2/16, 9/5/16, 9/16/16 and 9/19/16 or 9/21/16. Resident #64 was hospitalized from [DATE]-9/11/16 and directly admitted to the hospital from the [MEDICAL TREATMENT] unit on 9/23/16. Interview with RN #4 on 9/23/16 at 10:25 AM, in the Conference room, RN #4 was asked how the facility and [MEDICAL TREATMENT] center communicated. RN #4 stated, .there are communication forms . RN #4 was asked where in the Resident record were the forms are located. RN #4 verified there were only two forms dated 9/12/16 and 9/14/16 in the resident record. RN #4 stated, Sometimes she doesn't bring the forms back . RN #4 was asked how did they know the status of what happened with the resident at [MEDICAL TREATMENT] if there were no Communication forms returned with Resident #64. RN #4 stated. .they call us if there is a problem . RN #4 was asked where are those conversations documented. RN #4 stated, They're not. RN #4 was asked if the facility followed the Resident #64's care plan for communication between the facility and the [MEDICAL TREATMENT] unit. RN #4 stated, No. Interview with the DON on 9/23/16 at 10:39 AM, in the Conference room, the DON confirmed Resident #64's medical record contained only 9/12/16 and 9/14/16 [MEDICAL TREATMENT] communication forms. The DON was asked if the staff followed the facility's policy or the resident's care plan for communicating with the [MEDICAL TREATMENT] unit, the DON stated No. The facility failed to follow Resident #64's interventions for communication with the [MEDICAL TREATMENT] unit. 8. Medical record review revealed Resident # 96 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented, .Appliances .Indwelling catheter . (check mark) . Review of the care plan dated 5/31/16 and revised 8/27/16 documented .Indwelling Urinary Catheter .Keep drainage bag of catheter below the level of the bladder at all times and off floor . Observations at the North Hall nurse's station on 9/21/16 at 11:30 revealed Resident #96 sitting in a wheelchair with his urinary drainage bag in a privacy bag on the back of the wheelchair with the Foley catheter tubing lying in the floor. Observations at the North Hall nurse's station on 9/21/16 at 11:58 AM, revealed Certified Nursing Assistant (CNA) #6 pushing Resident #96 into the North Hall Day room for lunch with the Foley catheter tubing dragging on the floor. Observations on North hall by room [ROOM NUMBER] on 9/21/16 at 4:55 PM revealed CNA #7 placed Resident #96's Foley drainage bag into a privacy bag on the back of his wheelchair, dragging the catheter tubing on the floor. Observations on North hall at Resident #96's room on 9/28/16 at 8:12 AM, revealed resident sitting in the doorway of his room with his Foley catheter tubing laying on the floor. The facility failed to follow care plan interventions to maintain Resident #96's foley catheter bag off of the floor.

Based on policy review, medical record review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care when 2 of 12 (Certified Nursing Assistant (CNA) # 3 and 10) CNAs stood while feeding a resident, 4 of 9 (Resident #15, 60, 56, and 35 ) residents were not served in a timely manner, 3 of 12 (CNA #10 and 6, Registered Nurse (RN# 2) staff failed to wait to be invited into a resident's room after knocking, random observations of staff not asking residents if they wanted a clothing protector, 2 of 12 (CNA #3 and 6) CNAs referred to the clothing protectors as bibs, 1 of 2 residents observed with served milk in the original carton, and a resident's meal tray was placed out of their reach. The findings included: 1. The facility's Dignity policy documented, All residents will be treated in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of his or her individuality .Maintaining Dignity .Respecting residents' private space and property .Promoting independence and dignity in dining . The facility's Nursing Responsibilities at Meal Service documented, .Staff should distribute food in a timely manner to patients .A meal sequence is used in dining rooms so all patients are served at the same time .Accommodate individual patient's needs . 2. Observations in Resident #11's room on 9/18/16 at 5:47 PM, revealed CNA #3 stood over Resident #11 while assisting the resident to eat. Observations in Resident #11's room on 9/19/16 at 12:34 PM, revealed CNA #10 stood over Resident #11 while assisting the resident to eat. Observations in Resident #117's room on 9/20/16 at 8:04 AM, revealed CNA # 10 stood over Resident #117 while assisting the resident to eat. Observations in Resident #11's room on 9/20/16 at 8:16 AM, revealed CNA #10 stood over Resident #11 while assisting the resident to eat. 3 (a). Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #15 had severe cognitive impairment and required extensive assistance with meals. (b). Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #60 had severe cognitive impairment and required extensive assistance with meals. (c). Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #56 had severe cognitive impairment and required total assistance with meals. (d). Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #35 had severe cognitive impairment and required total assistance with meals. (e). Observations in the North Hall Day room on 9/22/16 at 8:37 AM, revealed Resident #6, 63, and 24 were feeding themselves breakfast. CNA #2 assisted Resident #2 and CNA #12 assisted Resident #65. Resident #15, 60, 56, and 35 were observed sitting in their wheelchairs waiting to be assisted while the other residents ate their breakfast. Observations in the North Hall Day room on 9/22/16 at 8:47 AM, revealed CNA #2 began to feed Resident #15. Resident #2 waited 10 minutes to be assisted with her meal while watching other residents being fed. Observations in the North Hall Day room on 9/22/16 at 8:53 AM, revealed CNA #10 began to feed Resident #60. Resident #60 had to wait 16 minutes to be assisted with her meal while watching other residents being fed. Observations in the North Hall Day room at 9/22/16 at 8:55 AM, revealed CNA #2 began to feed Resident #56. Resident #56 had to wait 18 minutes to be assisted with her meal while watching other residents being fed. Observations in the North Hall Day room at 9/22/16 at 9:10 AM, revealed CNA #10 began to feed Resident #35. Resident #35 had to wait 33 minutes to be assisted with her meal while watching other residents being fed. Interview with CNA #2 on 9/22/16 at 8:40 AM, in the North Hall Day room, CNA #2 was asked if Resident #35, 56, 60, and 15 had eaten breakfast. CNA #2 stated, No, it's just two of us here assisting right now . Interview with the Director of Nursing (DON) on 9/22/16 at 10:50 AM, at the North Hall nurses' station, the DON was asked if it was appropriate and dignified for staff to stand over a resident while assisting the resident during a meal. The DON stated, No. The DON was asked if it was appropriate and dignified for a resident to wait while in the presence of other residents being fed. The DON stated, .No, I was trying to find people to assist . (f). Observations in Resident #12's room on 9/20/16 at 7:45 PM, revealed CNA #10 entered Resident #12's room after knocking but did not wait for permission to enter. Observations on the North Hall on 9/21/16 at 11:58 AM, revealed CNA #10 removed a tray from the meal cart, knocked on Resident #11's door, entered without waiting for permission to enter, and stated, Oh, did I wake you? Observations on the North Hall on 9/21/16 at 12:01 PM, revealed CNA #6 knocked on Resident #118's door and entered without waiting for a response. Observations on the North Hall on 9/21/16 at 12:13 PM, revealed CNA #6 took a clothing protector from the top of the meal cart, removed a tray from the meal cart, knocked on Resident #41's door and entered without waiting for permission to enter. Observation in Resident #96's room on 9/28/16 at 11:39 AM, while observing Foley catheter care on Resident #96 performed by CNA #2, RN #2 knocked on the door and opened the door without waiting for a response to enter. After RN #2 had already opened the door and stuck her head in, CNA #2 said come in. Resident #96 was not dressed or covered. Interview with the DON on 9/21/16 at 12:30 PM, at the North Hall nurses' station, the DON was asked what he expected his staff to do prior to entering a resident's room. The DON stated, .knock, ask permission to enter the room, and explain what they are getting ready to do . (g). Observations in the North Hall Day room on 9/21/16 at 12:16 PM, revealed CNA #6 placed a clothing protector on Resident #96 without asking his permission. Observations in the North Hall Day room on 9/21/16 at 12:21 PM, revealed CNA #6 placed a clothing protector on Resident #24 without asking her permission. Observations in the North Hall Day room on 9/21/16 at 12:25 PM, revealed CNA #6 placed a clothing protector on Resident #52 without asking her permission. Observations in Resident #76's room in 9/21/16 at 12:04 PM, revealed CNA #3 put a clothing protector on Resident #76 and stated, .this is a bib, I'm gonna put it around your neck . Observations in the North Hall Day room on 9/21/16 at 12:22 PM, revealed CNA #6 placed a clothing protector on Resident #24 and stated, Here's your bib. Interview with the DON on 9/21/16 at 10:53 AM, at the North Hall nurses' station, the DON was asked what he expected his staff to do before placing clothing protectors on the residents. The DON stated, .ask if it is okay . The DON was asked if it was appropriate to refer to the clothing protector as a bib. The DON stated, No. (h). Observations in the North Hall Day room on 9/21/16 at 12:17 PM, revealed CNA #6 served Resident #96 milk in it's original carton with a straw. Observations in the South Hall Day room on 9/22/16 at 8:52 AM, revealed Resident #101 was served milk in it's original carton with a straw. Interview with the DON on 9/24/16 at 1:17 PM, in the Conference room, the DON was asked if it was acceptable to leave milk in the carton while serving it to a resident. The DON stated, No. (i). Medical record review revealed Resident #49 was admitted to the facility 6/11/14 and readmitted [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #49's room on 9/21/16 at 8:37 AM, revealed Resident #49 sitting up in bed feeding himself. Observations in Resident #49's room on 9/22/16 at 8:16 AM, revealed CNA #8 had placed resident's meal tray on Resident #49's over-bed table out of his reach. Interview with the DON on 9/24/16 at 1:17 PM, in the Conference room, the DON was asked if it was acceptable for a resident's tray to be left out of the resident's reach when the resident is able to feed himself. The DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained as evidenced of meal plates not covered for 1 of 2 (9/19/16 lunch) dining observations, 3 of 16 (Certified Nursing Assistant (CNA) #2, 3, and 8) staff members handling food with their bare hands, 2 of 16 (CNA #2 and #3) staff did not perform hand hygiene during meal service, 5 of 8 (#1, 3, 6, 7, and 8) Dietary staff's (DS) hair not restrained, 1 of 8 (DS #7) Dietary Staff failed to perform hand hygiene in the kitchen, and unlabeled and undated food for 1 of 2 (9/21/16) days of observation. This had the potential to affect 57 of 59 residents receiving meal trays from the kitchen. The findings included: 1. The facility's Infection Control - Dining Services Employee Hair Guidelines documented, .Dining Services employees must wear hair restraints, such as hair coverings or nets, and beard restraints. These hair restraints must be designed and worn to effectively keep hair from contacting exposed food, equipment, utensils and unwrapped single-service . The facility's Nursing Responsibilities at Meal Service policy documented, .Staff should wash their hands as needed, such as after touching a patient .All food must remain covered or in an enclosed cart while being distributed through the hallways .through out meal service . 2. Observations on the North Hall on 9/18/16 at 6:37 PM, revealed CNA #6 and 9 carried meal trays down the hall with plates that were not completely covered and delivered the meal trays to residents rooms. Interview with CNA #6 on the North Hall on 9/18/16 at 6:45 PM, CNA #6 was asked why the lids did not cover the plates. CNA #6 stated, .there is a bowl with a piece of cornbread that is sitting on the plate . 3. Observations in Resident #84's room on 9/18/16 at 5:36 PM, revealed CNA #3 placed a meal tray on Resident #84's over-bed table, fluffed her pillows, raised the head of the bed, set up the tray, and removed the crackers from the package with her bare hands and placed the crackers on the plate without performing hand hygiene. Observations in the South Hall Day room on 9/21/16 at 12:15 PM, revealed CNA #8 set up Resident #21's meal tray, placed a clothing protector on Resident #116, touched Resident #46's wheelchair, set up Resident #46's tray and removed the crackers from the package with her bare hands without performing hand hygiene. Observations in the North Hall Day room on 9/21/16 at 12:28 PM, revealed CNA #2 set up Resident #2's meal tray and removed cake from its plastic wrap and placed it on the resident's tray without performing hand hygiene. 4. Observations in the South Hall Day room on 9/21/16 at 12:03 PM, revealed CNA #3 delivered a meal tray in room S15, removed another meal tray from the meal cart and went into Room S11. CNA #3 did not perform hand hygiene. Observations on the South Hall on 9/21/16 beginning at 12:04 PM, revealed CNA #3 set up Resident #86's meal tray, removed a tray from the meal cart, entered Resident #113's room and set up the meal tray without performing hand hygiene. CNA #3 removed another tray from the meal cart, entered Resident #7's room and set up resident's meal tray and assisted the resident up in the bed. CNA #3 did not perform hand hygiene. CNA #3 removed another meal tray, entered Resident #89's room with meal tray, put a clothing protector on the resident, touched her personal clothing, and set up the resident's meal tray and did not perform hand hygiene. CNA #3 removed a tray from the meal cart and delivered it to Resident #76's room, set up the meal tray, placed a clothing protector on Resident #76 and did not perform hand hygiene. CNA #3 removed another tray from the meal cart, entered Resident #30's room, set up the meal tray, and applied a clothing protector without performing hand hygiene. CNA #3 served Resident #21's meal tray in the South Day room and touched the resident's straw with bare hands and did not perform hand hygiene. CNA #3 placed a clothing protector on Resident #116, set up meal tray, touched the resident's straw with bare hands and did not perform hand hygiene. Interview with the Director of Nursing (DON) on 9/21/16 at 12:30 PM, at the North Hall nurse's station, the DON was asked if it was appropriate for staff to handle food with their bare hands. The DON stated, No. 5. Observations in the kitchen on 9/18/16 at 2:48 PM revealed Dietary Staff #1, 7 and 8 with unrestrained hair. Observations in the kitchen on 9/21/16 at 12:40 PM revealed Dietary Staff #1 and 3 with unrestrained hair. Observations in the kitchen on 9/24/16 at 8:20 AM revealed Dietary Staff #6 with unrestrained hair. Interview with the Certified Kitchen Manager (CDM) on 9/24/16 at 8:20 AM, in the CDM's office, the CDM was asked if it is acceptable for kitchen staff's hair to be out of the hairnet while in the kitchen. The CDM stated, .No, absolutely not . 6. Observation in the kitchen on 9/18/16 at 2:50 PM revealed Dietary Staff #7 picked butter up from the kitchen floor, removed gloves, moved clean cups to another counter in the kitchen, donned gloves and filled glasses with ice. Dietary Staff #7 did not perform hand hygiene. Interview with the CDM on 9/24/16 at 8:27 AM, in the CDM's office, the CDM was asked if it was acceptable to change gloves without washing hands. The CDM stated, No. 7. Observations in the kitchen on 9/21/16 at 12:49 PM, revealed a bag of mixed vegetables in the freezer that was unsealed, open to air, and did not have an opened date. Interview with the CDM on 9/21/16 at 12:50 PM, in the kitchen, the CDM was asked if the mixed vegetables in the freezer was opened and dated. The CDM stated, No .it does need to be closed .

AMENDED Based on policy review, medical record review, and interviews, it was determined the facility staff neglected to provide emergency resuscitation for 1 of 8 (Resident #1) sampled residents. The facility failed to immediately report the incident to the administrator and the facility administrator failed to report the incident of neglect to the state survey agency as required per state and federal regulations, this resulted in immediate jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation, has caused or is likely to cause, serious harm, injury, impairment or death. The interim Executive Director (ED) and the Director of Nursing Services (DNS) were informed of the IJ in the conference room on [DATE] at 3:15 PM. The IJ for F225 "J" constitutes Substandard Quality of Care. A partial extended survey was completed on ,[DATE]-,[DATE]. This IJ existed from [DATE] through [DATE]. The IJ was removed on [DATE]. Corrective actions were initiated at the time the incident was identified by staff on [DATE]. The facility's corrective action was received by the surveyor on [DATE] and corrective actions were validated on-site by the surveyor on [DATE]. F225 was lowered to a D level, on [DATE] when the facility notified the state agency of this reportable incident. The facility remains out of compliance at a scope and severity level of D, an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. the facility is required to submit a plan of correction for this citation. The findings included: Review of the facility's "Reporting Alleged Violations" policy documented "...It is the responsibility of all associates to immediately report any alleged violation of... neglect... Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness... Reporting of suspected alleged violations is encouraged by all staff... The ED (Executive director) notifies the appropriate state agency in accordance with state law.... The results of all investigations are reported to the ED or designee and to the appropriate state agency, as required by state law, within five working days of the alleged violation..." Closed medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician orders [REDACTED].#1's wife on [DATE], and signed by the resident's attending physician, documented the wife's wishes for Resident #1 was for him to have full code "...CARDIOPULMONARY RESUSCITATION (CPR)..." if he "...has no pulse and/or is not breathing..." Review of Resident #1's care plan initiated [DATE] documented, "...Patient has an advance Directive as evidenced by: Full code... CPR will be performed as ordered... Follow facility protocol for identification of code status..." Review of a nurse's note dated [DATE] at 4:16 AM documented Resident #1 was found unresponsive by certified nursing assistant (CNA) #1 at 3:40 AM. Nurse #1 assessed the resident and determined the absence of respirations and vital signs. There was no documentation the facility initiated CPR, according to the Advanced directive, when Resident #1 was found with no respirations or pulse. During an interview in the conference room on [DATE] at 4:40 PM, the interim Director of Nursing Services (DNS) was asked what she would have expected the staff to do when a resident was found unresponsive. The DNS stated, "...expect them to follow our policy... check the status... call the code..." During a telephone interview with Nurse #1 on [DATE] at 1:20 PM, Nurse #1 was asked what happened the night of [DATE] when Resident #1 died . Nurse #1, stated "...CNA (CNA #1) went in there to make their rounds around 3:40 (AM)... no respirations... no heart beat... he (Resident #1) was gone... no vital signs... cool to touch... called the supervisor (Nurse #2), the RNs (registered nurse) have to pronounce them..." Nurse #1 was asked if she checked Resident #1's code status. Nurse #1 stated, "No, Ma'am, I did not... didn't even cross my mind... I knew he was a full code... It just never crossed my mind..." Nurse #1 stated, "...I had seen he was a full code, because I questioned it... [MEDICAL CONDITION] I don't know why I didn't think of it... It just never crossed my mind... no one mentioned 'Code'..." During a telephone interview with Nurse #2 on [DATE] at 1:40 PM, Nurse #2 was asked about the night Resident # 1 died . Nurse #2 stated, "...I was under the assumption he was DNR (Do No Resuscitate)..." Nurse #2 was asked if she checked Resident #1's code status. Nurse #2 stated, "...I did not... should have asked her if he was a code..." During a telephone interview with CNA #1 on [DATE] at 5:35 PM, CNA #1 was asked about the night Resident #1 died . CNA #1 stated, "...I think it was around 3:30 AM or 3:40 AM, and he wasn't breathing... no pulse... went and got the nurse (Nurse #1)... paged the other nurse (Nurse #2)..." CNA #1 stated that a "Code Blue" was never paged. During a telephone interview on [DATE] at 11:42 AM, Nurse #1 was asked if she had reported the failure to conduct a code on Resident #1. Nurse #1 stated, "...The supervisor was supposed to handle that... I report to my supervisor... I don't know if she checked the chart or not... I didn't report it to anybody... not that night..." During a telephone interview with Nurse #2 (Supervisor) on [DATE] at 12:20 PM, Nurse #2 was asked when she became aware that Resident #1 was a full code. Nurse #2 stated, "...on [DATE]nd ([DATE])... I got a phone call from my DON (Director of Nursing)... I didn't report it to anyone... they (facility) reported it to me... I remember it like anything... I'll never forget it..." During the exit conference with the interim ED in her office on [DATE] at 3:50 PM, the interim ED stated "...I would have reported it..." During a telephone interview with the medical records nurse (Nurse #3) on [DATE] at 10:00 AM, Nurse #3 was asked about the incident with Resident #1. Nurse #3 stated, "...I do medical records... I worked that Sunday ([DATE])... they (staff) told me he (Resident #1) had died , so I pulled the chart to break it down... read the nurse's note... saw that he was a full code... called (named former DNS) to see if they had called her... she said they did... told her he was a full code, and she said 'he was already dead.' I said, but he was a full code... I brought it up the next morning, Monday, in morning meeting... nobody said anything (could not remember if the Administrator was in the meeting)... On the 28th ([DATE])... I have 30 days to close out a record... I went back to her (DNS) and told her I needed to close this (medical record for Resident #1) out... she said 'What do you want me to do?' ...I didn't feel right about it, so I got him (former Administrator) in my office and told him about it... He took it over and I didn't have anything else to do with it..." The facility failed to report this incident of neglect to the state survey agency within five days as required per federal regulations. This IJ was effective from [DATE] to [DATE]. The facility reported this incident to the state agency on [DATE], which removed the jeopardy. The facility's action plan was validated by the surveyor through review of documents, staff interviews, and observations conducted on site on [DATE] and [DATE]. The surveyor verified the facility's action plan by: 1. Interviewed the Medical Director and the interim ED and confirmed this incident was addressed by the QA committee and the monitoring is ongoing by the SSD and the interim ED. 2. Interviewed the Administrator, who confirmed reportable incidents will be report to the state agency as required. The Administrator stated she would have been report this incident if she had been the Administrator at the time of the incident. The Administrator confirmed that in the future reportable incidents will be reported to the state agency as required. F225 was lowered to a D level, on [DATE] when the facility notified the state agency of this reportable incident. The facility remains out of compliance at a scope and severity level of D, an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction for this citation.