Every finding on record at The Windsor Place

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to provide necessary treatment and services to promote healing and prevent new ulcers from developing for (1) one of five (5) residents with wounds reviewed. Resident #39 Findings include: A review of the facility policy titled, Overview of Skin and Wound Care Management, revealed, the facility staff strives to prevent/patient skin impairment. The Interdisciplinary team works with the resident and family to identify and implement interventions to prevent and treat potential skin integrity issues.Components of the skin care and wound management program include, but are not limited to, the following: 2.) Implementation of prevention strategies to minimize the potential for developing pressure ulcers and skin integrity issues. An interview with Resident # 39 on 10/07/24 at 11:24 AM, revealed she had a pressure sore on her lower buttocks that she got while in the facility. A record review of the Wound Assessment Report dated 8/23/24 revealed Resident #39 was assessed to have excoriation to the buttocks area with a new treatment order for Calmoseptine treatment to the buttocks. A record review of the Order Summary Report for Resident #39 and interview with the Infection Control Nurse on 10/8/24 at 2:05 PM, she stated she was unable to find the physician's order for the Calmoseptine treatment to the excoriation on the buttocks was even entered into the computer system on 8/23/24 and confirmed that the facility failed to implement the physician's order. A record review of the August 2024 Treatment Administration Record (TAR) for Resident #39 and interview with the Infection Control Nurse on 10/8/24 at 2:10 PM she revealed she was unable to find where a treatment was initiated on 8/23/24 for the excoriation to the buttocks and confirmed that not performing the treatment as ordered may have contributed to the acquired pressure ulcer. Record review of the Wound Assessment Report dated 8/27/24 for Resident #39 completed by Registered Nurse (RN) #1 revealed a new stage (2) two pressure ulcer to the right buttock measuring 1 centimeter (CM) in length, 1.5 CM in width, and 0.1 CM in depth. Review of the Order Summary Report for Resident # 39 revealed an order dated 8/27/24 Cleanse stage 2 to the right buttock with (NS) normal saline, pat dry, apply collagen, and cover with dry dressing every day (QD) and as needed (PRN). Monitor dressing to the right buttock for soilage/dislodgement as needed. Review of the August 2024 TAR for Resident # 39 revealed cleanse stage 2 to the right buttock with NS, pat dry, apply collagen, and cover with dry dressing QD and PRN. Monitor dressing to the right buttock for soilage/dislodgement as needed dated 8/27/24. An interview with Registered Nurse (RN) #1 on 10/8/24 at 3:15 PM, he revealed on 8/27/24 Resident #39 was assessed to have a stage 2 pressure ulcer to the right buttock/ischial area. He revealed that he and the treatment nurse obtained an order for Collagen treatment from the provider and treated the wound. An interview with the Director of Nursing (DON) on 10/08/24 at 3:30 PM, she revealed after reviewing the August 2024 TAR for Resident #39 she was unable to find where the treatment for the excoriation to the buttocks was ever started. An interview with the Assistant Director of Nursing (ADON) on 10/09/24 8:45 at AM she revealed the physician's order for the Calmoseptine treatment on 8/23/24 for Resident #39 was accidentally missed and it could have contributed to the deterioration of the area to the buttocks. Review of the Admission Record revealed the facility admitted Resident # 39 on 8/23/24 with a diagnosis of Encounter for orthopedic aftercare following surgical amputation. Record review of Resident # 39's Section C of the Admission Minimum Data Set (MDS) revealed on 8/29/24 a Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact.

Based on staff interview, record review and facility policy review, the facility failed to develop a baseline care plan related to skin integrity concerns for a resident with excoriation to the buttocks. The resident developed a pressure ulcer within four days of admission to the facility. This was for one (1) of 28 care plans reviewed. Resident #39. Cross reference: F686 Findings include: A review of the facility policy titled, Care Plan Policy, revealed, on admission a care plan must be completed. A review of the Baseline Care Plan dated 8/23/24 for Resident #39 revealed Skin risk: current skin integrity issues checked.Specific skin integrity issue: Excoriation to buttock Physician orders: see Medication Administration Record (MAR) and Treatment Administration Record (TAR). A record review of the Wound Assessment Report dated 8/23/24, the day of admission, revealed Resident #39 was assessed to have excoriation to the buttocks area, with a new treatment order for Calmoseptine for excoriation to the buttocks. On 10/8/24 at 2:05 PM, in a record review of the Order Summary Report for Resident #39 and interview with the Infection Control Nurse stated she was unable to find where the physician's order for the treatment of the excoriation to the buttocks was entered into the computer system on 8/23/24. On 10/8/24 at 2:10 PM, during a record review of the August 2024 TAR for Resident #39 and an interview with the Infection Control Nurse on she revealed she was unable to find where a treatment was initiated on 8/23/24 for the excoriation to the buttocks and she confirmed that the resident now has a Stage 2 pressure ulcer to the buttocks. An interview with the Minimum Data Set (MDS) Coordinator on 10/09/24 at 8:23 AM, she revealed that they failed to develop the baseline care plan for Resident #39 and failed to implement the new skin orders on the day of her admission for the excoriation to the buttocks. She revealed the purpose of the baseline care plan is to give staff a guide to the care the residents requires until the comprehensive care plan can be developed. Review of the Admission Record revealed the facility admitted Resident # 39 on 8/23/24 with a diagnosis of Encounter for orthopedic aftercare following surgical amputation.

Based on observation, staff interview, and facility policy review, the facility failed to label and date open items in the pantry, refrigerator, and freezer for one (1) of two (2) kitchen tours during the survey. Findings Include: Review of the facility policy titled Food Storage undated, revealed under, Policy . Foods will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination . 14. Refrigerated food storage . f. All foods should be covered, labeled and dated. Also revealed under, 15. Frozen Foods: c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. During initial tour of the kitchen on 10/7/24 at 11:20 AM, with the Dietary Manager (DM) #1, an observation of the walk-in refrigerator revealed, a 5-pound (lb.) clear bag of shredded mozzarella cheese that had been opened and had one-fourth (1/4) of the bag remaining, which was unlabeled and undated. Also revealed a 5 lb. container of low-fat cottage cheese that was opened and was undated. An observation of the walk-in pantry revealed a 32-ounce (oz) box of chicken broth, which was open and undated. DM #1 confirmed the box read refrigerate after opening and revealed it was not stored properly after opening and must be trashed. An observation of the walk-in freezer revealed a blue bag of six meat-like patties, which the DM confirmed were pork fritters and had not been labeled and dated after opening. Also revealed a blue bag that contained a round breaded food that the DM #1 confirmed was breaded squash and was opened and was also not labeled and dated. An interview with the Dietary Manager #1 on 10/7/24 at 11:55 AM, revealed the kitchen staff had been educated on making sure foods were labeled and dated when they were opened to ensure they use the oldest foods first. She confirmed, if the food was not dated when opened or stored appropriately, it could make someone sick. An interview with the Administrator (ADM) on 10/9/24 at 9:34 AM revealed his expectations were for the kitchen staff to label and date things that were opened and to ensure the foods were not out of date and stored appropriately. He confirmed this should be done so it did not make anybody sick.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an account of all controlled medications and provide evidence of periodic reconciliation for two (2) of five (5) medication carts reviewed during medication pass. 100 hall and 200 hall. Findings include: Record Review of the facility policy titled, Pharmacy Delivery, Revised 9/4/15, revealed the policy read, The dispensing pharmacy will transport medication to the facility in a manner that prevents contamination, degradation, and diversion of medications. Review of Resident #80's Physician orders dated 08/01/2024 revealed Hydrocodone/APAP(acetaminophen) 10-325 MG(milligrams), Give 1/2 TABLET by mouth every 4 hours as needed for pain. The label on the medication card was not changed to reflect the new order. Observation of Resident #80's Controlled Substance Record during medication pass on 10/09/24 at 8:10 AM revealed instructions for Hydrocodone/APAP 10-325 MG, Give 1 TABLET by mouth every 4 hours as needed for pain. On 09/25/2024, 09/26/2024, 09/28/2024, 09/29/2024, and 10/07/2024 the record revealed (1) tablet signed out by Licensed Practical Nurse (LPN) #7 but 1/2 tablet was not recorded as wasted or witnessed. Review of the medication card for Resident #80's Hydrocodone/APAP 10-325 MG, revealed dose #41 was missing from the card and was not accounted for on the Controlled Substance Record. Interview on 10/09/2024 at 8:10 AM with LPN #4 on 100 Hall revealed LPN #4 confirmed 09/25/2024, 09/26/2024, 09/28/2024, 09/29/2024, and 10/07/2024 (1) tablet signed out by LPN #7 but 1/2 tablet was not recorded as wasted for Resident #80. LPN #4 also confirmed a missing tablet and stated the card was received from the pharmacy with dose #41 missing. Review of the pharmacy delivery Packing Receipt dated 5/4/24 revealed LPN #6 and LPN #4 signed as receiving the 60 Hydrocodone/APAP 10-325 MG pills medication card with no notation of a missing dose. Review of the Controlled Substance Record narcotic count record revealed 60 Hydrocodone/APAP 10-325 MG pills received by LPN #6 with no notation of pill missing for dose #41. Review of the shift count signature records revealed no notations of a missing dose or waste of Hydrocodone/APAP 10-325 MG dose #41. Record review of the facility's narcotic sheets Controlled Substance Record revealed no Received By (Sign): Date nurse signature or date received for 18 Controlled Substance Records. In an interview on 10/09/24 at 9:15 AM, the facility's Consultant Pharmacist stated he performs random audits of the narcotic sign in sheets and narcotic counts but has not noted any issues during the audits. The facility's Consultant Pharmacist stated he did not have evidence of audits, but the facility keeps a record of medication deliveries. Interview by phone on 10/09/24 at 11:45 AM with the Pharmacy Technician from (proper name of pharmacy) revealed that the pharmacy delivers resident medications as needed and facility keeps the original receipt sheet then faxes a copy signed by a facility nurse back to the pharmacy. Interview on 10/09/24 at 12:50 PM with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) revealed the facility keeps the pharmacy medication delivery receipts in the business office. DON stated that discontinued narcotics are removed from the carts and placed in a locked box in the medication room which is also locked. She stated that when the pharmacist makes monthly rounds, the DON and Pharmacist remove the narcotics and destroy the medications with a liquid designed for this purpose and then disposed. DON provided the logbook with evidence of destruction with signatures of Pharmacist and DON noted. An interview on 10/09/24 at 1:50 PM with the Business Office Representative confirmed the pharmacy medication delivery receipts were kept by the business office. Record review of the pharmacy medication delivery receipts Packing Slip revealed receiving nurse's signature on each delivery form.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were initiated for one (1) of five (5) residents reviewed for EBP. Resident #370 Findings include: Review of the facility's Enhanced Barrier Precautions Policy, dated 04/2024, revealed, Purpose: Enhanced Barrier Precautions (EBP) refer to infection control interventions designed to reduce transmission of multidrug-resistant organisms (MDRO) by wearing gown and gloves during high contact resident care activities. The use of EBP does not restrict room placement or out of room activities. 4. High-contact resident care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes On 10/08/24 at 10:40 AM, observation revealed Registered Nurse (RN) #1 performed hand hygiene and used a barrier on overbed table for supplies. Resident #370's RN #1 accessed the Peripheral Inserted Central Catheter (PICC) line using standard precautions. EBP was not done during the administration of the medication. Observation also revealed no EBP sign posted on the room door for Resident #370. On 10/08/24 at 11:40 AM, an interview with RN #1 revealed she was unaware of the need to implement EBP for a resident with a PICC line. On 10/08/24 at 11:55 AM, an interview with the facility's Training Coordinator and Director of Nurses (DON) revealed the facility policy is for EBP to be used with central lines which would include Resident #370. Record review of Resident #370's Admission Record revealed the facility admitted the resident on 10/07/24.

Based on interview, record review, and facility policy review, the facility failed 1) to ensure a medication order, medication administration record, and narcotic record label were all labeled correctly for one (1) of five (5) medication carts reviewed during medication pass, (100 hall medication cart) and; 2) the facility failed to securely store medications when two medication capsules were found sitting in a clear medication cup in a resident's room for 1 of 124 residents observed on initial tour. (Resident #28). Findings include: 100 Hall Medication Cart Review of the facility policy, Narcotic Medication Accountability updated 1/02, revealed 3. As narcotic medication is used/wasted, the nurse responsible should document the usage and any wastage on the accountability record. Observation of Resident #80's Controlled Substance Record revealed instructions for Hydrocodone/APAP(acetaminophen) 10-325 MG (milligrams), Give 1 TABLET by mouth every 4 (four) hours as needed for pain. Review of Resident #80's Physician orders dated 08/01/2024 revealed Hydrocodone/APAP 10-325 MG, Give 1/2 TABLET by mouth every 4 hours as needed for pain. The label on the medication card was not changed to reflect the new order. Interview on 10/09/2024 at 8:10 AM with Licensed Practical Nurse (LPN) #4 on 100 Hall revealed LPN #4 confirmed 09/25/2024, 09/26/2024, 09/28/2024, 09/29/2024, and 10/07/2024 (1) tablet signed out by LPN #7 but 1/2 tablet was not recorded as wasted for Resident #80. LPN #4 also confirmed a missing tablet and stated the card was received from the pharmacy with dose #41 missing. Resident #28 During the initial tour rounds on 10/07/24 at 11:00 AM, an observation of Resident # 28's room from the hallway doorway revealed a clear medication cup with what appeared to medication in the cup sitting next to the television. Upon entrance to the room, the clear medication cup sitting next to the television on the dresser contained two bright yellow and white capsules. An observation of the two yellow and white capsules in Resident # 28 room with Registered Nurse (RN) # 1 on 10/07/24 at 11:05 AM, he confirmed the capsules were on the dresser and should not be in the room and removed the capsules from the room. In a continued observation with RN #1 of Resident#28's medications, he revealed the yellow and white capsules that were found in Resident #28's room were identified as Gabapentin 300 milligrams (mg) and confirmed Resident #28 receives one 300 mg tablet every night at bedtime. He also confirmed the resident did not have an order to self-administer medications and revealed that staff should always ensure each resident has taken their medications before leaving the resident. RN #1 then stated concerns about medications being left in the room is that the resident could have taken the extra pills and had a reaction. Review of the Active Orders for Resident #28 revealed and order for Gabapentin 300 mg capsule give one capsule by mouth at bedtime. In an interview with Resident # 28 on 10/07/24 at 11:10 AM, he revealed that the pills in his room were for his bowels and stated the nurse last night left him an extra pill, and he was saving them until he needed them. He then stated, I will take them both when I get back to the room. In an interview with LPN # 3 on 10/07/24 at 11:22, she confirmed that Resident #28 cannot self-administer medications and revealed that staff should always watch residents take their medications. She then revealed that with the medications being left in the room, it placed residents at risk for accidentally ingesting the medications, causing possible adverse reactions. In an interview with the Director of Nursing (DON) on 10/08/24 at 11:38 AM, she revealed no medications should ever be left in a resident's room. She stated the resident could have accidentally ingested extra doses, or a wandering resident could have gotten the medication. The DON stated she spoke with Resident #28 on 10/7/24 and stated he was saving the medication to give it back to the nurse, and he stated he paid for it and was not going to waste it. The DON revealed in her professional opinion that the nursing staff could not have observed Resident #28 take his medications because if they did, he would not have been able to save the medications that were found in his room. Review of the Admission Record revealed the facility admitted Resident # 28 on 8/20/24 with a diagnosis of Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety. Record review of Resident # 28's Section C of the Admission Minimum Data Set (MDS) revealed on 8/26/24 a Brief Interview for Mental Status (BIMS) score was 11, indicating the resident was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure an informed consent was obtained for the application of bed rails for one (1) of 25 sampled residents. Resident #30 Findings Include: Review of the facility policy titled Side Rails Policy with a revision date of 10/19 revealed under, Policy: it is the policy of this facility to keep residents as safe as possible while they are in the bed, as well as enable them to be as active in their care physically as they are able. An observation of Resident #30 on 10/7/24 at 4:05 PM revealed he was lying in bed. The left side of the bed was against the wall, and one-half (1/2) side rails were raised on both sides of the bed. Record review of the Physician's Orders for Resident #30 revealed an order dated, 10/27/20, 1/2 (one half) siderails up x (times) 2 (two) when in bed for increased bed mobility & (and) independence. An interview with the Minimum Data Set (MDS) Nurse on 10/9/24 at 8:20 AM revealed bed rail assessments were completed on admission and quarterly. She revealed the benefits, and the risk of the bed rails were explained to the family and a consent was signed as part of the admission paperwork. Record review of the Bed Rail assessment dated [DATE] for Resident #30 revealed, Bilateral Side Rails/Assist Bar are indicated and serve as an enabler to promote independence. Record review of the Resident Dashboard revealed, Resident #30 required one-person extensive assist with bed mobility. An interview with the Assistant Director of Nursing (ADON) on 10/9/24 at 10:20 AM, confirmed a consent was not signed for bed rails for Resident #30 and revealed this should have been done before applying the bed rails to ensure the family was notified of the risk. Record review of the Resident Dashboard revealed the facility admitted Resident #30 on 10/26/20 with a medical diagnosis of Hemiplegia following cerebral infarction affecting the left non-dominant side.

Based on observation, resident and staff interview, and record review the facility failed to ensure the residents had a environment free of potential hazards as evidenced by cleaning chemicals not being securely locked in a janitors storage closet for two (2) of five (5) units in the building. 400 Hall and Dementia Unit. Findings include: Review of a document provided by the facility,on facility letterhead revealed the facility does not currently have a formal written policy specific to resident accident prevention or monitoring. An observation on 10/7/24 at 11:20 AM on the Dementia Unit revealed a door with a sign that read Janitor's Closet was unlocked and held three full bottles of disinfectant. An interview and observation on 10/7/24 at 11:25 AM with Certified Nurse Assistant (CNA) #1 confirmed the Janitors Closet has a coded lock that was broke and the room was unlocked. She confirmed there were three full bottles of liquid disinfectant in the closet. She stated that she had not told maintenance and is not sure if they know. She revealed that the closet with the cleaning supplies should always be locked. This observation revealed this unit was an open unit with all resident rooms, day room and janitors closet within view from all areas and the nurses station is directly across from the janitors closet. She confirmed that the janitors closet could always be seen by the staff because it is a small open unit with three (3) CNA's and one nurse in the unit at all times. An observation on 10/7/24 at 11:45 AM of the 400-hall revealed there was a door labeled Janitors Closet that had a coded lock that was not locked with four bottles of liquid disinfectant. An interview and observation on 10/7/24 at 11:50 AM with Licensed Practical Nurse (LPN) #1 confirmed that the Janitors Closet on the 400 hall was unlocked but should always be locked, because there were chemicals that they would not want the residents to have access to. This observation revealed the janitors closet was directly across from the nurses station and was in view from the 300 and 400 hall. She confirmed that there was a staff member that sat at the nurses desk at all times, answering phone calls and call lights and also the dining area was open and within view of the closet. An interview on 10/7/24 at 11:55 AM with Housekeeping #1 confirmed that the Janitors Closet on the 400 hall had a coded lock that had been broken for a few days, but she is not sure if maintenance knows about it. An interview on 10/8/24 at 9:15 AM with Maintenance #2 confirmed that the locks on the Janitors Closets on the 400 hall and the Dementia Unit were both broken. He stated he put batteries in the lock on the 400-hall last week and thought it was fixed, but he had not been told about the one on the Dementia Unit. An interview on 10/8/24 at 9:30 AM with the Administrator confirmed the Janitors Closets should always be locked.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to shave a resident that was dependent on staff for care for one (1) of three (3) residents reviewed for Activities of Daily Living (ADL). Resident #80 Findings include: Record review of facility policy titled, Activities of Daily Living Policy, undated, revealed, It is the policy of the facility to encourage resident choice and participation in activities of daily living (ADL) and provide oversight cuing and assistance as necessary. ADL's included bathing, dressing, grooming, hygiene, toileting, and eating. CNA (Certified Nursing Assistant) will review the resident care card for information on individual care needs and preferences. CNA will provide needed oversight, cuing or assistance to resident. CNA will report any changes in ability or refusals to the nurse. During an observation and interview on 10/07/24 at 12:30 PM, Resident #80 stated he wanted to be shaved and felt that the staff would do this today since it was shower day. He stated he was unsure when he was last shaved and he told his family that if they would bring him a razor, he would shave himself. Observation revealed the resident had an approximate one-third inch scruffy stubble of facial hair on bearded areas of his cheeks, chin, and upper lip. An observation and interview on 10/8/24 at 8:40 AM, revealed Resident #80 was still unshaved and stated he preferred to be clean shaven and was not used to being unshaven. Resident #80 was observed on 10/8/24 at 2:30 PM and was still unshaved. He stated the staff had not shaved him and he wanted this to be done. The Director of Nursing (DON) came to the resident and Resident #80 informed her that he wanted to be shaved and had asked staff for this, but it had not been done. The DON informed him that it was the responsibility of the Certified Nursing Assistants (CNAs) to shave him and she assured him she would get this done for him. The DON acknowledged that grooming and shaving was part of the bathing activity of daily living (ADL) care and confirmed the facility failed to shave the facial hair of a resident that preferred to be clean shaven. Record review of an ADL care summary revealed Resident #80 was scheduled for baths on Monday, Wednesday, and Friday. Record review of Resident #80's Admission Record revealed the facility admitted the resident on 6/22/22. Diagnoses included Type 2 Diabetes Mellitus and Osteoarthritis. Record review of Resident #80's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for shaving a dependent resident for one (1) of 25 resident care plans reviewed. Resident #80 Findings include: Record review of facility policy titled, Care Plan Policy dated 11/21, revealed, It is the policy of this facility that an individualized, interdisciplinary care plan will be developed and maintained for each resident in the facility. If the resident has a working care plan, you may use this and update it as indicated. Record review of Resident #80's Care Plan date initiated 9/4/24 revealed, the resident has an ADL, self-care performance deficit related to congestive heart failure and diabetes mellitus which includes an intervention for bathing/showering. On 10/07/24 at 12:30 PM, during an observation and interview Resident #80 stated he wanted to be shaved and felt that the staff would do this today since it was shower day. He stated he was unsure when he was last shaved and told his family that if they would bring him a razor, he would shave himself. Observation revealed the resident had an approximate one-third inch long, scruffy stubble of facial hair on bearded areas of his cheeks, chin, and upper lip. On 10/8/24 at 8:40 AM, an observation and interview revealed Resident #80 was still unshaved. He stated he preferred to be clean shaven and was not used to being unshaven. On 10/8/24 at 2:30 PM Resident #80 was observed and interviewed in the hallway propelling himself in the wheelchair and was still unshaved. He stated the staff had not shaved him and he wanted this to be done. During an interview on 10/8/24 at 2:40 PM, the Director of Nursing (DON) stated the resident was scheduled for bathing and showering on Monday, Wednesday, and Friday, and he did not typically refuse care, but the care record from yesterday revealed the resident refused his shower. She stated each resident has the right to refuse care, but the process to ensure care is done as desired included any refusal of care to be reported to the nurse and the nurse should followed up with the resident for options for care and document that in the resident's notes and that was not done. She also stated the staff are to follow up with the resident at a later time to see if care is wanted at that time and there was no documentation that was done. The DON acknowledged that grooming and shaving was part of the bathing activities of daily living (ADL) care. She confirmed the facility failed to shave the facial hair of a resident that preferred to be clean shaven. She confirmed the care plan was to give staff information on the care needed and preferences of each resident and the ADL care plan was developed but it was not followed since shaving and grooming was a part of the bathing care plan. An interview with the Minimum Data Set (MDS) Coordinator on 10/9/24 at 9:15 AM revealed she was the person responsible for the development of care plans and stated the care plan should be followed by the staff since it guides the staff in the care and preferences of each resident. She stated this resident had a care plan developed for ADL bathing care which included grooming/shaving, but confirmed this was not followed. Record review of Resident #80's Admission Record revealed the facility admitted the resident on 6/22/22. Diagnoses included Type 2 Diabetes Mellitus and Osteoarthritis. Record review of Resident #80's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment.

Based on observation and staff interview, the facility failed to ensure a resident had a wheelchair in good repair for one (1) of 86 residents requiring a wheelchair for mobility. Resident #51 Findings include: The facility provided a statement on letter head that read, The Proper Name of facility does not, currently, have a formal written policy regarding resident equipment being in good condition. Any issues of resident equipment not being in good condition or malfunctioning are to be reported to maintenance upon discovery. An observation on 10/7/24 at 12:05 PM, revealed Resident #51 sitting in his wheelchair with arm rests on the wheelchair that were torn and tattered with sharp plastic edges and the yellow foam visible. An observation on 10/8/24 at 11:01 AM, revealed Resident #51 lying in bed. His wheelchair was in the room, with the arm rest in disrepair. The right arm rest had the yellow foam torn away, and the black hard plastic was exposed, which had jagged edges. The left arm rest had the black vinyl torn, and the yellow foam was exposed. An interview with Licensed Practical Nurse (LPN) #1 on 10/8/24 at 11:04 AM, confirmed Resident #51's arm rest needed to be repaired and revealed the resident could scratch the skin on his arms. She revealed the resident's equipment should be in good repair and explained that staff must let maintenance know by telling him or doing a work order for issues to be addressed. An interview with Maintenance #2 on 10/8/24 at 11:14 AM, revealed he would be responsible for any maintenance on the wheelchairs. He revealed the staff fill out a work order for anything that needs repairing. He revealed he had not received a work order for Resident #51's wheelchair and explained he was not aware it was in bad condition. Record review of the Admission Record revealed the facility admitted Resident #51 on 1/17/18 with a medical diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting the left non-dominant side.

Based on staff and Resident Representative (RR) interviews, record review, and facility policy review, the facility failed to notify the physician of a significant change in a resident's physical status for one (1) of three (3) residents samples. Resident #1 Findings include: Record review of facility policy titled, Change in Resident's Medical Status Policy, with revision date of 4/19, revealed, It is the policy of this facility to notify the resident's physician in any of the following circumstances: . 2. A significant change in resident's physical, mental, or psychosocial status (i.e. [for example], deterioration in health, mental, or psychosocial status in either life-threatening or clinical complications). During a phone interview with Resident #1's RR on 5/16/24 at 9:30 AM, the RR reported the resident had a decrease in blood pressure and had a urinary tract infection. The RR stated she did not feel like the physician was notified regarding these issues. An interview with the Assistant Director of Nursing (ADON) on 5/16/24 at 12:20 PM, revealed Resident #1 had a urine culture obtained on Wednesday, 4/3/24 at 5:05 PM, and the lab had the results available on Friday, 4/5/24 at 9:24 PM. This report was not obtained by the facility until Monday, 4/8/24, at which time the physician was notified, and antibiotics were started for the resident. She confirmed that the facility staff should have contacted the lab to obtain results over the weekend and should have notified the physician. During a phone interview on 5/16/24 at 3:00 PM, the facility's physician confirmed he was not notified of the urine culture results until 4/8/24, when the antibiotics were started. He confirmed timely treatment was needed for resident's well-being. A phone interview on 5/16/24 at 3:45 PM, with the Nurse Practitioner (NP) revealed she was not notified of Resident #1's urine culture results which were available on 4/5/24. She stated notification to the physician and NP allows for timely treatment. An interview with the Administrator on 5/16/24 at 4:00 PM, revealed he was unaware that the staff did not contact the hospital lab to obtain culture results timely. He confirmed the facility failed to notify the physician timely when lab results were ready. Record review of the Culture Urine report revealed the specimen was collected on 4/3/24 at 17:05 (5:05 PM). The last result time and date was listed as 4/5/24 at 21:25 (9:25 PM). This report also noted that it was printed by facility staff on 4/8/24 at 7:25 AM, and the Medical Director was notified on 4/8/24 and an order for an antibiotic was given. Record review of Resident #1's Face Sheet, revealed an admitted [DATE]. Diagnoses included Type 2 diabetes mellitus and Cystitis.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to report an allegation of abuse to the appropriate state agencies for one (1) of 32 residents reviewed. Resident #84 Findings Include: Record review of the facility policy titled Abuse, Neglect, Exploitation, and the Vulnerable Adults Act Policy with a revision date of 2/6/23 revealed, It is the policy of this facility that residents and patients are to be treated with dignity and respect at all times under any circumstance. Mistreatment in the form of verbal or physical abuse of any nature will not be tolerated. Also revealed under, Procedure: . b. Who is responsible for reporting abuse? i. Any care facility employee, or health care professional, working in connection with the facility who has knowledge or reasonable cause to believe that a patient or resident of a care facility has been the victim of abuse, exploitation, or neglect. The employee must immediately report all alleged violations to their supervisor then he/she will notify Administrator and Director of nursing immediately i. The employee or healthcare professional is to report knowledge or reasonable cause to believe that any patient or resident of a care facility has been the victim of abuse, neglect, or exploitations . Record review of the Record of Concern dated 5/18/23 revealed resident #84's daughter called the facility and spoke with the Social Worker (SW) on 5/18/2023 at 1:53 PM to report an incident that occurred on 5/17/2023 around 8/8:30 PM. The residents' daughter stated that Resident # 84 had pushed her call light to be changed. The resident waited for a while, and no one ever responded to her call light. The resident transferred herself into the wheelchair and propelled herself to the nurse's station, where she reported several staff members standing around. Resident #84 asked if someone would change her and put her in bed, and a staff member responded, You got yourself in the wheelchair, so you can get back in bed; We aren't coming to your room. Resident # 84 stated, I need changed. The staff member responded, I already changed you and I will change you during my last rounds. Record of Concern revealed under, Action taken at time of concern; Reported to the Charge Nurse. Revealed under, Investigation Activity if needed; Upon investigation resident was assisted back to bed and changed. Also revealed under, Action taken/Findings; Verbal counseling attached to the Record of Concerns provided to the State Agency (SA) was a Disciplinary Report that was signed by the Administrator (ADM) and Director of Nursing (DON) with a date of 5/23/23 and under Offense warrants suspension or discharge: Yes; No was left blank. An interview with Resident #84 on 7/27/23 at 9:20 AM, revealed she recalled the incident. She stated, I was told by someone behind the desk that I could put myself back to bed; I'm not coming down to your room. She revealed that she did not recall the name of the staff member and described her as an African American female. The resident stated, I reported it to Registered Nurse (RN) # 1. An interview with the Director of Nursing (DON) on 7/27/23 at 9:30 AM revealed she was aware of the incident that occurred to Resident #84 on 5/17/23. She confirmed that she did sign off on a disciplinary action form on 5/23/23 for Certified Nurse Aide (CNA) # 7, and she was given a verbal counseling by the Registered Nurse (RN) supervisor. She revealed that the CNA no longer worked at the facility and that she quit shortly after the incident. She stated that the RN supervisor on the floor was responsible for the investigation and the required action for the Record of Concerns and then they came to her and the Administrator for review and further action. She revealed she had not received any other complaints on CNA #7 before, and she didn't think any further action was warranted and the DON confirmed that she did not report the allegation of abuse to the appropriate state agencies. An interview with the ADM on 7/27/23 at 9:45 AM, revealed he did sign off on a disciplinary action form for Certified Nurse Aide (CNA) #7 regarding the incident that occurred on 5/17/23 He stated, She should have been suspended immediately until an investigation was done, and we should have reported it to the state. He stated, I should have told them to get some interviews from other residents to see if there were other residents with concerns and reported it. An interview with Licensed Practical Nurse (LPN) #1 on 7/27/23 at 10:35 AM, revealed she was working 3PM-11PM shift on 5/17/23 and was the nurse for Resident #84. The Resident propelled herself in the wheelchair down to the nurse's station and stated she wanted to be changed and to go to bed. She revealed that CNA # 7 stated, You can get back in bed the same way you got out. She revealed that Resident #84 stated, I'm wet and CNA # 7 replied, I'm going to change you when I make my next round. LPN # confirmed the alleged statements were made to Resident # 84 and stated, Yes, she made those statements to Resident # 84. LPN # 1 stated that she notified the charge nurse the next day of the incident. An interview with the Administrator (ADM) on 7/27/23 at 11:25 AM, revealed that Certified Nurse Aide (CNA) # 7 was in his office on 5/22/23 where she was spoken to by him and the Assistant Director of Nursing (ADON) regarding the incident. He confirmed that he didn't write any kind of statement or put anything on paper after speaking with her and confirmed that the allegation of Resident #84's mistreatment was never reported to the state agency. He stated, Any further investigation that was not completed was on me; I should have further investigated and reported the incident. Record review of the Face Sheet revealed that Resident #84 was admitted to the facility on [DATE] with diagnosis which included Diabetes, Anxiety Disorder and Depression. Record review of the most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/29/23 revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating full cognitive ability.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to complete a through investigation of alleged abuse for one (1) of 32 residents in initial pool. Resident #84. Findings include: Record review of the facility policy Abuse of a Resident Policy dated 3/6/15, revealed, It is the policy of this facility to strictly prohibit abuse, mistreatment, neglect, or exploitation of all residents .All allegations reported to the facility will be thoroughly investigated and handled in accordance with guidelines in this policy .6. Investigation-It is the policy of this facility to investigate, and report alleged incidents of abuse .The investigation will be completed by, but not limited to, the key staff responsible for that department and the Administrator . Record review of the Record of Concern dated 5/18/23 revealed Resident #84's daughter called the facility and spoke with the Social Worker (SW) on 5/18/2023 at 1:53 PM to report an incident that occurred on 5/17/2023 around 8/8:30 PM. The residents' daughter stated that Resident # 84 had pushed her call light to be changed. The resident waited for a while, and no one ever responded to her call light. The resident transferred herself into the wheelchair and propelled herself to the nurse's station, where she reported several staff members standing around. Resident #84 asked if someone would change her and put her in bed, and a staff member responded, You got yourself in the wheelchair, so you can get back in bed; We aren't coming to your room. Resident # 84 stated, I need changed. The staff member responded, I already changed you and I will change you during my last rounds. Record of Concern revealed under, Action taken at time of concern; Reported to the Charge Nurse. Revealed under, Investigation Activity if needed; Upon investigation resident was assisted back to bed and changed. Also revealed under, Action taken/Findings; Verbal counseling attached to the Record of Concerns provided to the State Agency (SA) was a Disciplinary Report that was signed by the Administrator (ADM) and Director of Nursing (DON) with a date of 5/23/23 and under Offense warrants suspension or discharge: Yes; No was left blank. During an interview with on 7/27/23 at 9:20 AM,Resident #84 revealed she recalled the incident. She stated, I was told by someone behind the desk that I could put myself back to bed; I'm not coming down to your room. She revealed that she did not recall the name of the staff member and described her as an African American female. The resident stated, I reported it to Registered Nurse (RN) # 1. During an interview with the Director of Nursing (DON) on 7/27/23 at 9:30 AM, revealed she was aware of the incident that occurred to Resident #84 on 5/17/23. She confirmed that she did sign off on a disciplinary action form on 5/23/23 for Certified Nurse Aide (CNA) # 7, and she was given a verbal counseling by the Registered Nurse (RN) supervisor. She confirmed that no further investigation was completed. She stated that the RN supervisor on the floor was responsible for the investigation and the required action for the Record of Concerns and then they came to her and the Administrator for review and further action. During an interview on 7/27/23 at 9:45 AM, with the ADM revealed he did sign off on a disciplinary action form for CNA #7 regarding the incident that occurred on 5/17/23 He confirmed that a thorough investigation was not conducted into the incident. He stated, She should have been suspended immediately until an investigation was done. He stated, I should have told them to get some interviews from other residents to see if there were other residents with concerns. In an interview on 7/27/23 at 10:35 AM, with Licensed Practical Nurse (LPN) #1, she revealed she was working 3-11 shift on 5/17/23 and was the nurse for Resident #84. The resident pushed her call light, and she told CNA # 7 that Resident #84's call light was on. She stated that CNA # 7 replied, I went down there, and she didn't want nothing. She revealed that later on, the resident propelled herself in the wheelchair down to the nurse's station and stated she wanted to be changed and to go to bed. She revealed that CNA # 7 stated, You can get back in bed the same way you got out. She revealed that Resident #84 stated, I'm wet and CNA # 7 replied, I'm going to change you when I make my next round. LPN # confirmed the alleged statements were made to Resident # 84 and stated, Yes, she made those statements to Resident # 84. LPN # 1 revealed that she took the resident back to her room and helped her back into bed that night. LPN # 1 stated she notified the charge nurse the next day of the incident, and the CNA was written up. LPN #1 revealed the Administrator (ADM) and the Assistant Director of Nursing (ADON) were called and notified by Registered Nurse (RN) #1. During an interview on 7/27/23 at 10: 50 AM, with the Social Worker (SW) revealed that she started the Record of Concern form for the incident that occurred on 5/17/23 for Resident #84. She revealed that Resident #84's daughter called in the concern to her, and she filled out the necessary form and took it to the morning meeting to discuss with administration. She revealed that she did not recall if the Administrator or Director of Nursing was in the meeting that day. She revealed following the meeting, she gave the Record of Concern to the charge nurse. During an interview with Resident #84's daughter on 7/27/23 at 11:00 AM, revealed that her mother called her on 5/17/23 and told her of the incident that occurred. She revealed she called and spoke with the Social Worker (SW) the following day and filed a grievance related to statements made to her mother. The daughter stated, Those aides need to realize that they can leave the facility, my mother is helpless, and she relies on them for everything. An interview with the ADM on 7/27/23 at 11:25 AM, revealed that CNA # 7 was in his office on 5/22/23 where she was spoken to by him and the ADON regarding the incident. He confirmed that he didn't write any kind of statement or put anything on paper after speaking with her, and confirmed that a thorough investigation of Resident #84's allegations was never conducted. He stated, Any further investigation that was not completed was on me; I should have further investigated. An interview with the Administrator on 7/27/23 at 3:30 PM, revealed CNA # 7 was no longer employed at the facility due to no call, no show which resulted in termination. He confirmed that he should have done a more in-depth facility investigation into Resident #84's allegations and stated, It's nobody's fault but my own. The facility provided documentation on letterhead dated July 27, 2023, that read, After initial investigation at time of incident regarding Resident # 84 and Certified Nurse Aide (CNA) # 7, CNA was written up for her behavior and directed to apologize to Resident # 84. A follow-up thorough investigation was not conducted afterwards.

Based on staff and pharmacist interviews, record review, and facility policy review, the facility failed to ensure a resident on an as needed (PRN) psychotropic medication had a stop date for one (1) of six (6) medication reviews. Resident #17 Findings Include: Review of the facility policy titled Psychotropic Medication Policy and Procedure revealed under, Standards: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risk and /or benefits. Revealed under, Physician/NP/mental health NP (When available to a facility) . 3. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. Also revealed under, Consultant pharmacist: 1. Monitors psychotropic drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration. 2. Notifies the physician and the nursing unit if whenever a psychotropic medication is past due for review. Record review of Resident # 17's Medication Administration Record (MAR) for the month of July 2023 revealed an order dated 6/30/23, Ativan 1 mg (milligram) tablet take one tablet by mouth every 6 hours as needed related to agitation and anxiety with no stop date. Resident #17 received seven (7) doses from 7/1/23 - 7/25/23. An interview with the Assistant Director of Nursing (ADON) on 7/25/23 at 4:00 PM, confirmed that Resident #17 did not have a stop date for as needed (PRN) Ativan that was ordered on 6/30/23. The ADON stated, Yes, it should have one. An interview with the Pharmacy Consultant on 7/25/23 at 4:10 PM, confirmed that Resident #17 did not have a stop date for as needed (PRN) Ativan and acknowledged that it should have a stop date. An interview with the Director of Nursing (DON) on 7/26/23 at 8:40 AM, confirmed that all as need (PRN) orders for psychotropics medications should have a stop date so that the physician can re-evaluate and extend the order out if the medication was still needed. Record review of the Face Sheet for Resident #17 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Schizoaffective Disorder, Unspecified Dementia, Generalized Anxiety Disorder and Type 2 Diabetes Mellitus.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to maintain adequate staffing to assist residents in getting the care needed for seven (7) of 109 residents upon initial tour. Resident # 14, #64, #84, #87, #96, #98, and #101. Findings include: The facility provided documentation on letterhead dated July 27, 2023, The Windsor Place does not currently have a written general policy as related to staffing. Resident #14 During the resident council meeting on 07/25/23 at 2:30 PM, Resident #14 revealed that they were sometimes late on getting her showers and she sometimes had to wait awhile when she pushed her call light because of not having enough people to work the halls. Record review of Resident #14's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 07/06/23 under Section C documented her Brief Interview for Mental Status (BIMS) Score of 15 which indicated resident was cognitively intact. Resident #64 On 7/25/23 at 2:30 PM, during Resident Council, Resident #64 revealed that he felt like the Certified Nursing Assistants (CNAs) got their training and then they just didn't come back to work. He stated that he sometimes had to wait awhile for his call light to be answered and it was mainly on the 11PM - 7AM shifts that they were so shorthanded. He revealed that so many people just don't come in and it happens often. Record review of Resident #64's MDS with ARD 06/19/23 under Section C documented BIMS Score of 15 which indicated resident was cognitively intact. Resident #96 An interview on 07/24/23 at 03:55 PM, Resident #96 revealed, sometimes they will tell us on the weekend they can't get us up because they don't have enough help. She revealed the staff is really good but there is just not enough help. I don't know why they they have so many people calling in on the weekends. Record review of the MDS with an ARD of 5/26/23 revealed a BIMS score of 15 which indicated Resident #96 was cognitively intact. Resident #98 An interview on 07/24/23 at 11:21 AM, Resident #98 revealed, I have to wait a while to be changed. The aides come sit in the room on their phone. Sometimes it takes an hour. They are running around now because they know y'all are here. Resident #98 revealed, I don't get up everyday because it's hard to get put back to bed, and it hurts sitting in the wheelchair for a long time. She revealed it happens during the week and weekend because they don't have enough help. On 07/26/23 at 10:35 AM, interview with Resident # 98 revealed I would like to get up more often but I don't because it's so hard to be put back to bed, She revealed they will tell us they are short and I have to wait so I choose to just stay in the bed to avoid that. She revealed that she has told staff about this before but nothing gets done. Observation and interview on 07/27/23 at 1:45 PM, SA heard and observed a call light when entering the hall going off for Resident #98's room. SA spoke to Resident #98 briefly and observed call light going off. SA mentioned call light and Resident #98 revealed she hadn't pushed it not sure why it was on. SA observed room-mate squirming around with covers, call light noted on her covers. SA exited the room and walked to nurses desk. Observed the Registered Nurse (RN) supervisor at the desk on the computer and Certified Nursing Assistant (CNA) #6 sitting at a desk with head down looking at a cell phone on her lap. SA inquired what the sound was that was beeping, CNA #6 looked up from the cell phone and said that's a call light and got up. The nurse at the desk said, I'm sorry I was working on an admission. An interview with CNA #6 revealed she usually works in medical records but comes over at times to help answer call lights. An interview 07/27/23 2:00 PM, the SA spoke with the DON regarding CNA #6, the DON revealed, that aide normally works in medical records and I'm not sure why she was over here but she shouldn't have been on her phone. The DON revealed she may have been called over to assist with answering call lights during lunch breaks. She confirmed that she shouldn't have been on her phone and she should have answered the call-light. An interview on 07/27/23 02:38 PM the Administrator revealed that CNA #6 works PRN (as needed) and works mainly in medical records, he revealed she can answer the call lights to see what the residents may need but is not able to render care at this time. He confirmed that she could have answered the call light instead of being on her phone. Record review of Resident #98's MDS with an ARD of 6/12/23 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #87 An interview on 07/24/23 02:45 PM Resident # 87 revealed, Sometimes I have to wait 30 minutes or more for help. I like to lay down about 3:30 for a nap before dinner. He revealed I've sat in this chair before up to 5:00. He revealed last night there were only two (2) CNAs on shift for 3-11. I just wish I didn't have to wait so long. When they come in late they always say well you know we are short handed. On 07/26/23 at 09:05 AM, an interview with Resident # 87 revealed to SA that he has been told several times when I asked about laying down for my nap that I would have to wait until the aide got here. He revealed the problem is really bad on the 3-11 shift and weekends also. Record review of Resident #87's MDS with an ARD of 6/6/23 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #84 An interview on 07/25/23 at 10:15 AM, with Resident # 84 revealed that when she pushed her call light for assistance with changing her brief, the staff would come in and tell her, It's going to be a while. She revealed it takes a long time to get changed. SA (Survey Agent) inquired about an estimate of the time that she usually waits, and she stated, Sometimes an hour. She stated, When they come into my room, they tell me that it's only 2 or 3 of them working, and you're going to have to wait. Resident revealed she doesn't think the facility had enough staff to care for the residents at the facility. An interview with the Registered Nurse #1 on 7/27/23 at 9:15 AM revealed that Resident #84 was totally incontinent of bowel and bladder. She revealed that the resident would push her call light and let the staff know when she was wet or had a bowel movement and needed to be changed. An interview with Resident # 84's daughter on 7/27/23 at 10:55 AM, revealed the facility had staffing issues, especially on the weekend. She revealed the weekends were so short-staffed, and it's nothing like during the week. She stated the call lights take a lot longer to be answered. She stated, They need help. Record review of the Face Sheet for Resident #84 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Psychosis, Cardiac Arrhythmia, Hyperlipidemia, Major Depressive Disorder, Anxiety Disorder and Type 2 Diabetes Mellitus. Record Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/29/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #84 is cognitively intact. Section H revealed that Resident #84 is always incontinent of bladder and bowel. Resident #101 During the resident council meeting on 07/25/23 at 2:30 PM, Resident #101 revealed that she felt like they needed more hall keepers (Nurse Aides). She confirmed that staffing was worse on weekends and sometimes during the week. She also revealed that sometimes they only had two Certified Nursing Assistants (CNAs) on the halls and the facility would have to send one to another hall (B-Hall) to help out and then sometimes they had to request one to be pulled to this side (A-Hall) to help. She stated that they were supposed to have four or five aides working the halls and they don't. She confirmed that not having enough to work the halls caused a longer wait time to get call lights answered. Record review of Resident #101's MDS with ARD of 07/24/23 under Section C documented BIMS Score of 15 which indicated resident was cognitively intact. ******** On 07/26/23 at 08:37 AM, an interview with the Activity Director revealed the residents have voiced some concern in resident council about staffing. She revealed after the meeting I fill out a concern form and give it to the appropriate departments. She revealed for staffing I give it to the nursing department, we discuss the concerns that were voiced at the next morning meeting. She revealed a lot of the residents has voiced staffing issues in the past and the DON came to the June Resident council meeting and addressed staffing concerns. On 07/26/23 at 08:45 AM, an interview with DON revealed any issues or concerns that have been voiced during resident council the activities director fills out a concern form and gives it to the appropriate department and then we also discuss it in the morning meeting. State Agent inquired if there have been any issues voiced during resident council regarding staffing concerns. DON revealed, not as far as being short-staffed but rather not answering the call lights timely. She revealed she met with the resident council members last month. She revealed I didn't document any of the issues that were discussed and can't remember what exactly they were, the activities director should have documented the issues. She revealed I just don't recall discussing any staffing issues. In an interview on 07/26/23 at 2:35 PM, the Administrator confirmed that staffing is a constant issue and he has actually put a stop on admissions due to low staffing in the past but right now admissions are still being accepted. He confirmed that staffing the 3-11 shift was a challenge due to call ins and sometimes day shift staff will stay over and the 11PM-7AM shift would come in early. An interview with Certified Nurse Aide (CNA) # 8 on 7/26/23 at 9:02 AM, revealed she was working on B-hall, and they have a total of 3 CNAs' working 7-3 shift. She revealed she was assigned to care for 9 residents. She stated, We work short all the time. She revealed that working with only 2 aides on the hall makes caring for the residents difficult. She stated that to ensure that her assigned residents' needs were met, she had to stay over until 3:30 or 4:00 PM to complete all her documentation. She revealed that when she had multiple call lights alarming at once, she would step into the rooms and let the resident know she was tied up across the hall and would come back as soon as she could. She revealed that the facility frequently asked her to stay late or come in early, but she has only come in early once. An interview with CNA #10 on 7/26/23 at 9:40 AM, revealed that the facility does not have enough aides, and they frequently work short with only 4 aides (2 aides on each unit) on 3-11/11-7 shift. She stated, If I'm in another room and have other call lights going off, they will still be going off when I come out. She revealed the nurses do not help to answer any call lights. An interview with CNA #11 on 7/26/23 at 9:55 AM, revealed they do work short some days due to call ins. She stated we all have to work together to get things done and try to get the lights answered. An interview with the DON on 7/26/23 at 2:10 PM, revealed they had a nurse who handled staffing, but she would be working another shift tonight to fill a position. Survey Agent (SA) inquired from the DON how the facility ensured they met resident needs, and she replied, I'm not certain how she (the staffing nurse) handles that, but I know if we have a higher acuity on a hall we try to staff up. She revealed any call in was received at the nurse's desk and was then relayed to the staffing nurse who tried to fill the position. She revealed that she had not had any workload concerns brought to her attention by the CNA's or families. An interview with CNA #12 on 7/26/23 at 6:20 PM, revealed she worked 3-11 shift. She revealed they do sometimes work short-staffed, and it makes it hard on them because they have more residents to care for. An interview with CNA #13 on 7/26/23 at 6:30 PM, revealed she worked part-time. She stated that one day last week they worked with 2 aides on B hall and that the resident needs were met to the best of their ability. An interview with the ADM on 7/27/23 at 8:20 AM, confirmed that he was aware of the staffing issue. He confirmed that they do have a lot of call ins and that he had people in the office that would come out to help the CNA's.

Based on observations, staff interviews, and facility policy review, the facility failed to prevent the likelihood of the spread of infection as evidenced by staff not cleaning and disinfecting a multi-use resident device used to check vital signs between each resident use for one (1) of four (4) survey days. Findings include: A review of the facility's Clinical Equipment policy, undated, revealed, It is the policy of this facility to provide clean equipment and help promote a sanitary environment. For all clinical equipment, the manufacturer's recommendations for cleaning or disinfecting are followed for type of clean or disinfectant and how often to clean or disinfect .Procedure: 1. Clinical equipment includes the following equipment .e. Vital signs equipment . On 07/25/23 at 2:55 PM, an observation revealed Certified Nurse Aide (CNA) #2 pushed a vital sign machine down the hall and entered room [ROOM NUMBER], CNA #2 then exited the room and did not clean the vital sign machine and immediately entered room [ROOM NUMBER], CNA #2 exited the room and did not clean the vital sign machine and was stopped by the State Agent (SA) before proceeding into another room. An interview on 07/25/23 at 3:05 PM, CNA #2 revealed, we are supposed to clean the vital sign machine equipment by using alcohol wipes between each of the residents' rooms to sanitize it. She confirmed she had not cleaned it between the rooms and there were no alcohol wipes on her cart to do so. She revealed it is my responsibility to clean the equipment between each resident's room and by not cleaning it, it could possibly spread infection between the residents. An interview on 07/25/23 at 3:20 PM, the Infection Control Nurse revealed, the vital sign machines are to be cleaned after leaving a resident's room and before entering another resident room. She revealed the cleaner wipes are to be in the basket on the front of each machine and the cleaner is called Oxivir 1 wipes. She confirmed that not properly disinfecting the machines between resident rooms could transmit infections among the residents. An interview on 07/25/23 at 3:25 PM, Registered Nurse (RN) #1 revealed, the aides are supposed to be keeping alcohol wipes in the basket of the machines to wipe them down between resident rooms to prevent any spread of infection. An interview on 07/25/23 at 4:15 PM, the DON revealed all equipment that is used between the resident rooms is to be cleaned between each room. The staff is to use the germicidal disposable wipe. She confirmed that the vital sign machines not being cleaned between resident rooms could cause the spread of infection between residents.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to resolve a grievance in a timely manner for four of five residents in Resident Council. Resident # 14, Resident #64, Resident #96, and Resident #101. Findings Include: Record review of the Facility's Grievance Policy dated February 8, 2023, revealed, Policy: It is the policy of (facility name) to investigate all concerns/grievances and provide the results of the investigation to the party filing the concern/grievance .Standard: .The facility will make prompt efforts to resolve all grievances .Policy Explanation and Compliance Guidelines: Process 5. All staff involved in a grievance investigation shall take steps to preserve the confidentiality of files and records relating to grievances and share only with those who have a need to know. 6. The Grievance Official or designee shall keep the resident appropriately apprised of progress towards resolution of the grievances. During interviews in the Resident Council Meeting held on 07/25/23 at 2:30 PM, with five residents in attendance revealed that when they have a grievance voiced in resident council, they do not always hear back about the resolution for their grievances that are voiced. Resident #96, Resident Council President, revealed during the meeting that she felt like all the staff who come to work really worked hard, there's just not enough of them. She stated that there just didn't seem to be enough staff to take care of everybody at times. Resident #96 revealed that they used a stand-up lift to help her to the bathroom during the day; but there had been times when getting to the bathroom was an issue. She revealed that she had to take diuretics and laxatives and getting the staff to get her to the bathroom when she needed to go was often a problem. She stated, When you take these medicines, you can't wait very long when the urge hits you. She revealed that when they didn't have time to get her to the bathroom right away, they would sometimes tell her, Go in the bed and we will be happy to clean you up. She could not recall the date or the staff member who told her this; but she just couldn't do that. She also stated that there had been times they were so short staffed, that they could not get her up at all and she had to stay in the bed all day and night. She confirmed that this happened more often on the weekend and stated, Short staffed is the name of the game especially on the weekend. She also revealed that the facility had addressed the issue before back several months ago; but it continues to be a problem and they voice it all the time and they never hear back from their grievance. She revealed that she still had to wait until later in the day to be assisted out of bed because of the staffing issues here and this was unacceptable. She stated that back in January that low staffing issues began to be discussed and voiced in resident council and it was supposed to be fixed; but Easter Weekend was also not a good time due to low staffing. During the resident council meeting, Resident #14 revealed that they always tried to fix problems brought to their attention, but they sometimes just couldn't do it. She revealed that they were sometimes late on getting her showers and she sometimes had to wait awhile when she pushed her call light because of not having enough people to work the halls. Resident #96 revealed that issues brought up in Resident Council Meetings were written down by the Activities Director and she stated, We don't always know that it ever goes further than the meeting. She also revealed that when she gets the Resident Council Minutes back to file, resolved was often marked under old business but that she (Resident #96) didn't always know what had been done to resolve the issues or if it had been resolved because nobody told them any resolutions to the problems. Resident #64 revealed that he felt like the Certified Nursing Assistants (CNAs) got their training and then they just didn't come back to work. He stated that he sometimes had to wait awhile for his call light to be answered and it was mainly on the 11PM - 7AM shifts that they were so shorthanded. He revealed that so many people just don't come in and it happens often. Resident #101 revealed that she felt like they needed more hall keepers (Nurse Aides). She confirmed that staffing was worse on weekends and sometimes during the week. She also revealed that sometimes they only had two Certified Nursing Assistants (CNAs) on the halls and the facility would have to send one to another hall (B-Hall) to help out and then sometimes they had to request one to be pulled to this side (A-Hall) to help. She stated that they were supposed to have four or five aides working the halls and they don't. She confirmed that not having enough to work the halls caused a longer wait time to get call lights answered and that the staff members were not updating the residents on the status of their grievances reported. She revealed that they did bring up old business at the resident council meetings, but this was the only communication they had regarding their issues. These complainants confirmed that they had discussed these issues in previous resident council meetings, but it had not been resolved and they feel like the facility does not have enough staff on duty and they do not answer all of their grievances and do not update them on progress of grievances and when they are resolved. On 07/26/23 at 8:37 AM, an interview with the Activities Director revealed the residents have voiced some concerns in resident council about staffing and she stated that she filled out a concern form and gave it to the appropriate departments. Then the next morning in the staff meeting, they discussed the concerns that were addressed during the resident council meeting. She revealed a lot of the residents have voiced staffing issues in the last several resident council meetings and that the Director of Nursing (DON) came to the last resident council meeting and addressed questions and concerns which included staffing. She confirmed the DON was aware of the staffing issue. On 07/26/23 at 8:45 AM an interview with the DON revealed any issues or concerns that had been voiced during resident council was handled by the Activities Director. She revealed that the Activities Director filled out a concern form and gave it to the appropriate department and then the grievances were discussed in the morning meetings. She also revealed that whenever there was a grievance with anything regarding nursing, that either she (DON) or the charge nurse would address the issue and then would be signed off by herself (DON) and the Administrator. The State Agency inquired if there had been any issues voiced during resident council regarding staffing concerns and the DON stated not as far as being short staffed but rather not answering the call lights timely. The DON revealed that she met with the resident council members last month, but she did not document any of the issues that were discussed and can't remember what exactly they were, and stated that the activities director should have documented the issues and that she didn't recall discussing any staffing issues. On 07/27/23 at 9:55 AM, an interview with Licensed Social Worker (LSW), revealed that anyone could write up a grievance; then the grievance would be taken to the appropriate supervisor who would investigate the issues and would be signed off by Director of Nursing and Administrator. She also revealed that the grievances were all brought up and discussed in morning meetings. The LSW revealed that she logged in all grievances and that they were usually resolved within a week. She also revealed that they were supposed to let the resident or family members who filed the grievance know when the issue was resolved and what the resolution was to the issue. An interview on 07/26/23 at 2:35 PM, with the Administrator confirmed that staffing is a constant ongoing issue and confirmed that it was hard to resolve the issues residents have sometimes when his staff members wouldn't show up to work. He revealed that he was trying to hire more staff; but it was hard to keep them. He confirmed that staffing the 3PM-11PM shift was a challenge due to call ins and sometimes day shift staff will stay over and the 11PM-7AM shift would come in early. Record review of the Resident Council Meeting Minutes revealed the following: Record review of Resident Council minutes, dated 01/13/23 revealed . Told that weekend is rest day and CNA not getting her up or that they are short. Record review of Resident Council minutes dated 2/6/23 revealed . old business from 1/13/23 regarding .weekend rest day was not mentioned as unresolved or resolved. Record review of Resident Council Minutes dated 03/08/23 documented under List of old business (unresolved): All resolved. The list of old business included Customer Service with Staff. Review of Resident Council Minutes dated 04/10/23 documented under Summary of the issue . CNA Shortage and Call Ins. Record review of Resident Council Minutes dated 5/1/23 revealed .No list of old business resolved. Record review of Resident Council Minutes dated 6/5/23 revealed, Activities Director, Dietary Manager, DON, and Infection control nurse present .Resident #96 had questions concerning nursing dept. DON answered all questions and some vaccination questions. Record review of Grievances form titled, Record of Concern, included statement of concern, investigation, action taken/findings and were found to have been completed on the problems discussed in Resident Council Meetings on 01/13/23, 02/06/23, and 05/01/23. The previous documents mentioned were signed as completed; but, based on resident interviews and information collected during the Resident Council Meeting on 07/25/23, the problems resulting from being short-staffed continues. Record review of Resident #14's Face Sheet revealed that she was admitted on [DATE] with the following diagnoses to include: Unspecified osteoarthritis, Muscle Weakness, Need for assistance with personal care, and Chronic Systolic (congestive) heart failure. Record review of Resident #14's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 07/06/23 under Section C documented her Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Record review of Resident #64's Face Sheet revealed that he admitted on [DATE] with the following diagnoses to include: Cerebral Infarction, Essential Hypertension, History of Falling, and Unspecified Dementia. Record review of Resident #64's MDS with ARD 06/19/23 under Section C documented BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #96's Face Sheet revealed admitted [DATE] with the following diagnoses to include: Chronic Obstructive Pulmonary Disease, Rheumatic Heart Disease, Chronic Atrial Fibrillation, Muscle Weakness, and Dysphagia following Cerebral Infarction. Record review of Resident #96's MDS with an ARD 05/26/23 under Section C documented a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #101's Face Sheet revealed admitted [DATE] with the following diagnoses to include: Essential Hypertension, Scoliosis, Muscle Weakness, and Need for assistance with personal care. Record review of Resident #101's MDS with ARD of 07/24/23 under Section C documented BIMS score of 15 which indicated resident was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to update Advance Directives for code status to ensure the residents' preferences were honored for three (3) of 32 residents in the initial pool. Resident #16, Resident #81 and Resident #99. Findings included: Record review of facility policy titled, Advance Directives Policy, dated 04/2021, revealed, Upon admission, the facility shall provide information regarding Advance Directives to the resident and/or the responsible party in accordance with the state law. The facility will observe the wishes of the resident and/or responsible party in regard to the Advance Directives. Advance Directives will be updated annually and/or as needed pending a change in resident condition to ensure that is valid and current. An interview on 7/25/23 at 4:00 PM, with Social Service Assistant #2 revealed Resident #16, Resident #81, and Resident #99 did not have an Advance Directive in place and on the medical record. She stated these residents were cognitive and the Resident/Family Consent for Cardiopulmonary Resuscitation forms were signed by each Resident's Representative. An interview on 7/26/23 at 9:00 AM, with Social Service Designee #1 revealed the Admission Nurse and the Social Service Representative meet with the resident and/or Resident Representative on admission and that the Advance Directive was signed by the resident or the resident's representative during this meeting. She confirmed that if the resident has a Power of Attorney in place, a copy is placed in the resident's chart. The interview revealed that the Advance Directive is reviewed yearly and updated depending on the resident's or the representative's choice. An interview with Social Service Designee #2 on 7/26/23 at 9:10 AM, revealed the Advance Directive is signed on admission and updated yearly or with any significant change. She stated that if a resident was alert and oriented or had a high Brief Interview for Mental Status (BIMS) score, they would usually sign the form, but there are times the resident's representative signed, even if the resident was capable. She revealed on admission, Social Services, Admission Nurse or Charge Nurse, and the resident and/or family are in the admission meeting. An interview with the Licensed Social Worker on 7/26/23 at 9:40 AM, revealed the Advance Directive is signed on admission and annually and that the Advance Directive is discussed during care plan meetings quarterly with long term care residents and more frequently with the Medicare residents. She confirmed that residents' Advance Directives were not updated when the resident's abilities improve, therefore, it was possible that the resident's desires were not documented. An interview with the Administrator on 7/27/23 at 11:12 AM, revealed the resident's Advance Directive should indicate the wishes of the resident and it was each resident's right to choose end of life care. He confirmed the facility failed to ensure that once a resident was able to receive the information and to state his or her wishes related to end of life care, they were not given the opportunity to sign the Advance Directive for their preference to be honored. Record review of Resident #16's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses of Hypertension, Type 2 Diabetes Mellitus, acquired absence of left leg below knee, acquired absence of right leg above knee. Record review of Resident #16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/13/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Record review of Resident #16's Resident/Family Consent for Cardiopulmonary Resuscitation dated 5/7/21, revealed the Resident's Representative signed the form on admission. Notation dated 2/10/22 on this form revealed No change in code status remain a full code per RP (Responsible Party) and patient request without the signature of resident. Record review of Resident #81's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses of Heart Disease, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Hypertension, and Chronic Kidney Disease Stage 4. Record review of Resident #81's MDS with an ARD of 6/15/23, revealed a BIMS of 10 which indicated mild cognitive impairment. Record review of Resident #81's Resident/Family Consent for Cardiopulmonary Resuscitation dated 6/9/23 revealed the Resident's Representative signed the form. Record review of Resident #99's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease Stage 4 and Muscle Weakness. Record review of Resident #99's MDS with an ARD of 6/19/23, revealed a BIMS of 15 which indicated the resident was cognitively intact. Record review of Resident #99's Resident/Family Consent for Cardiopulmonary Resuscitation dated 12/13/22, revealed the Resident's Representative signed this consent.

Based on resident and staff interviews, record review and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of 32 residents reviewed. Resident #84. Findings include: Record review of the facility policy titled Abuse, Neglect, Exploitation, and the Vulnerable Adults Act Policy with a revision date of 2/6/23 revealed, It is the policy of this facility that residents and patients are to be treated with dignity and respect at all times under any circumstance. Mistreatment in the form of verbal or physical abuse of any nature will not be tolerated . Record review of the Record of Concern dated 5/18/23 revealed resident #84's daughter called the facility and spoke with the Social Worker (SW) on 5/18/2023 at 1:53 PM to report an incident that occurred on 5/17/2023 around 8/8:30 PM. The residents' daughter stated that Resident # 84 had pushed her call light to be changed. The resident waited for a while, and no one ever responded to her call light. The resident transferred herself into the wheelchair and propelled herself to the nurse's station, where she reported several staff members standing around. Resident #84 asked if someone would change her and put her in bed, and a staff member responded, You got yourself in the wheelchair, so you can get back in bed; We aren't coming to your room. Resident # 84 stated, I need changed. The staff member responded, I already changed you and I will change you during my last rounds. Record of Concern revealed under, Action taken at time of concern; Reported to the Charge Nurse. Revealed under, Investigation Activity if needed; Upon investigation resident was assisted back to bed and changed. Also revealed under, Action taken/Findings; Verbal counseling attached to the Record of Concerns provided to the State Agency (SA) was a Disciplinary Report that was signed by the Administrator (ADM) and Director of Nursing (DON) with a date of 5/23/23 and under Offense warrants suspension or discharge: Yes; No was left blank. On 7/27/23 at 9:20 AM, an interview with Resident #84 revealed she recalled the incident. She stated, I was told by someone behind the desk that I could put myself back to bed; I'm not coming down to your room. She revealed that she did not recall the name of the staff member and described her as an African American female. The resident stated, I reported it to Registered Nurse (RN) # 1. On 7/27/23 at 9:30 AM, interview with the Director of Nursing (DON) revealed she was aware of the incident that occurred to Resident #84 on 5/17/23. She confirmed that she did sign off on a disciplinary action form on 5/23/23 for Certified Nurse Aide (CNA) # 7, and she was given a verbal counseling by the Registered Nurse (RN) supervisor. On 7/27/23 at 9:45 AM, an interview with the ADM revealed he did sign off on a disciplinary action form for Certified Nurse Aide (CNA) #7 regarding the incident that occurred on 5/17/23 He stated, She should have been suspended immediately until an investigation was done. On 7/27/23 at 10:10 AM, interview with Registered Nurse (RN) #1 revealed that she was summoned to the room of Resident # 84 on 5/18/23, which was the next day after the incident occurred, after being notified of the incident. She revealed that she spoke with Resident #84 regarding the incident and after speaking with her, she tried to find out who the assigned aide was. She revealed she identified Certified Nurse Aide (CNA) #7 as the assigned aide for Resident #84 on 5/17/23 3PM-11PM shift. She confirmed that a nurse overheard CNA #7 make the alleged statements and identified the nurse who witnessed the incident to be Licensed Practical Nurse (LPN) # 1. RN #1 stated that CNA # 7 was called into the conference room and given a verbal disciplinary action on 5/18/23, of which the CNA did sign. She revealed that CNA # 7 denied making the statements to the resident. RN #1 confirmed that she called and notified Resident #84's daughter of the disciplinary action taken regarding the CNA. On 7/27/23 at 10:35 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed she was working 3PM-11PM shift on 5/17/23 and was assigned to Resident #84. She revealed the resident pushed her call light and she told Certified Nurse Aide (CNA) # 7 that Resident #84's call light was on. She stated that CNA # 7 replied, I went down there, and she didn't want nothing. She revealed that later, the resident propelled herself in the wheelchair down to the nurse's station and stated she wanted to be changed and to go to bed. She revealed that CNA # 7 stated, You can get back in bed the same way you got out. She revealed that Resident #84 stated, I'm wet and CNA # 7 replied, I'm going to change you when I make my next round. LPN # confirmed the alleged statements were made to Resident # 84 and stated, Yes, she made those statements to Resident # 84. LPN # 1 revealed that she took the resident back to her room and helped her back into bed that night. LPN # 1 stated that she notified the charge nurse the next day of the incident, and the CNA was written up. LPN #1 revealed the Administrator (ADM) and the Assistant Director of Nursing (ADON) were called and notified by Registered Nurse (RN) #1. LPN #1 confirmed that she did not notify anyone until the next day about the incident. On 7/27/23 at 10: 50 AM, an interview with the Social Worker (SW) revealed that she started the Record of Concern form for the incident that occurred on 5/17/23 for Resident #84. She revealed that Resident #84's daughter called in the concern to her, and she filled out the necessary form and took it to the morning meeting to discuss with the Administration. On 7/27/23 at 11:00 AM, an interview with Resident #84's daughter revealed that her mother called her on 5/17/23 and told her of the incident that occurred. She revealed she called and spoke with the Social Worker (SW) the following day and filed a grievance related to statements made to her mother. The daughter stated, Those aides need to realize that they can leave the facility, my mother is helpless, and she relies on them for everything. On 7/27/23 at 11:25 AM, an interview with the ADM revealed that CNA # 7 was in his office on 5/22/23 where she was spoken to by him and the ADON regarding the incident. He revealed that he directed her to go and apologize to Resident # 84 and stated that the CNA was upset and stated she did not make the alleged statements. He confirmed that the CNA wanted to leave work, and he asked her to gather herself and go apologize. On 7/27/23 at 12:52 PM, a telephone interview with CNA # 7 revealed that she did recall Resident #84 and the incident that occurred on 5/17/23. She stated that she only worked with the resident that one time. She revealed that on that night, the resident came to the desk in her wheelchair and asked to speak to someone. She stated there were about 4-5 staff members at the desk at the time. She stated she had just completed hall rounds and changed everyone, and she told the resident, You shouldn't get out of your bed, sweetheart; You could have fallen. She revealed that she did not recall making the alleged statements. CNA # 7 stated, I was written up, and I told the ADON and the Administrator that I didn't say that; I don't know why they put that on me. CNA # 7 revealed that she did not quit working at the facility and that she only worked PRN (as needed), and they just took her off the schedule after 06/27/23. Record review of Certified Nurse Aide (CNA) # 7's Timecard revealed the CNA worked 17 days at the facility following the alleged incident on 5/17/23. CNA # 7 worked 5/18/23, 5/22/23, 5/23/23, 5/24/23, 5/25/23, 5/29/23, 6/2/23, 6/3/23, 6/5/23, 6/6/23, 6/7/23, 6/8/23, 6/12/23, 6/13/23, 6/21/23, 6/22/23, and 6/27/23. On 7/27/23 at 3:30 PM, an interview with the Administrator revealed CNA # 7 was no longer employed at the facility due to no call, no show which resulted in termination. Record review of documentation on facility letterhead dated July 27, 2023, revealed, Certified Nurse Aide (CNA) # 7's last day working at the facility June 27, 2023. Record review of CNA # 7's personnel file revealed a Criminal History Record Check dated March 13, 2023, that found no violations. Also revealed CNA received and signed policy and in-services for, Resident's Right under Federal Law, Abuse of a Resident, and Abuse, Neglect, Exploitation, and the Vulnerable Adults Act dated 3/13/23. The Survey Agency (SA) did not find any further disciplinary actions in the employee file. Record review of the Face Sheet revealed that Resident #84 was admitted to the facility on [DATE] with diagnosis which included Diabetes, Anxiety Disorder and Depression. Record review of the most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating full cognitive ability.

Based on record review, staff and family interview and facility policy review the facility failed to revise a fall care plan for Resident #111 after multiple falls that occurred for 1 of 5 falls reviewed. Findings include: Record review of the facility policy titled Care Plan Policy with revision date 4-2019 revealed Policy It is the policy of this facility that an individualized, interdisciplinary care plan will be developed and maintained for each resident in the facility. Procedure: It is the responsibility of each nurse to update care plans. When an order is written or an incident occurs, it is the responsibility of the nurse taking the order, or the RN desk nurse documenting the incident to: #7 Stop and update the care plan immediately . If a resident has a fall or skin tear, you must attempt to have a new intervention for each one since the previous interventions didn't work. Record review of the care plan problem dated 8/23/21 revealed, FALLS: I am at risk for falls Record review of the care plan goal dated 8/23/21 revealed, I will remain free from any major fall-related injuries thru next review. Record review of the care plan approaches dated 8/23/21 revealed, Educate resident in safety awareness, Remind resident to call when needing assistance, Keep call light within reach as well as frequently used items, Make sure lighting is appropriate to optimize vision and reduce glare on flooring, Encourage me to wear appropriate foot coverings to prevent slipping/falling, Communication/consult with therapy as needed, Make sure you utilize appropriate lifts at all times, Monitor for fall risk every shift, concave mattress on bed for safety. Record review of the Instant Care Plan dated 8/31/21 revealed Fall/Trauma-found on floor beside bed with Interventions that apply to this event noted as; check resident often and neuro checks per protocol. Record review of the Instant Care Plan dated 9/5/21 revealed Fall/Trauma with interventions that apply to this event noted as; evaluate for fall precautions, check resident often and neuro checks per protocol. Record review of the Instant Care Plan and dated 9/12/21 revealed Fall/Trauma-witnessed fall and injury described as bruise to right (R)hip. Interventions that apply to this event noted as, check resident often. Record review of the Instant Care Plan and dated 9/13/21 revealed Fall/Trauma-unwitnessed fall, no injuries with no interventions that apply to this event noted. Record review of the Instant Care Plan dated 9/13/21 revealed Fall/Trauma-2nd unwitnessed fall, neuro checks within normal limits, complaint of pain to left cheek bone, egg size swelling noted to left back of head with no interventions that apply to this event noted. It revealed that an order was obtained from Medical Director (MD) to send to emergency room (ER) for evaluation. Record review of the Instant Care Plan dated 10/3/21 revealed Fall/Trauma Injury noted as right hip pain and right hip fracture with note that states, resident impulsive, fast paced, will not call for assist Record review of the Instant Care Plan dated 10/26/21 revealed, Fall/Trauma with interventions that apply to this event noted as; evaluate for fall precautions, check resident often and neuro checks per protocol. Review of the Face Sheet revealed the facility admitted Resident #111 on 8/23/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed in Significant Change-Minimum Data Set (MDS) assessment dated [DATE] that her BIMS score was 99, indicating that the resident was unable to be assessed. An interview on 10/28/21 at 9:43 AM with the Registered Nurse (RN) #1 revealed that Instant care plans should have updated interventions, but they feel they have done all they know to do with Resident #111. An interview on 10/28/21 at 9:55 AM with the Director of Nurses (DON) revealed that after a fall the care plan would need to be updated or an instant care plan used with the date of the fall and any interventions that has been put into place The DON confirmed that anyone with a history of falls should have specific interventions on their care plan. The DON confirmed that Resident 111's care plan update after her falls was an Instant Care Plan and had no specific interventions regarding how often to check the resident. The DON revealed that Resident #111's fall care plan on admission had interventions regarding educating and reminding the resident regarding safety measures. The DON confirmed that based on Resident #111's cognitive ability that her fall care plan interventions regarding educating and reminding were not pertinent for this resident. An interview on 10/28/21 at 11:30 AM, with Registered Nurse (RN) #2 revealed the facility has meetings every morning and go over reports, such as falls. She stated that they talk about interventions for the falls. She stated that the QA nurse was responsible for putting new interventions on the care plans. She confirmed that Resident #111's care plan had not been updated after her falls with significant in juries.

Based on observation, staff and family interviews, record review and facility policy review, the facility failed to provide increased supervision for a resident who had sustained ten (10) falls with two (2) resulting in major injuries that included a Subarachnoid Hemorrhage and a [CONDITION(S)] from 8/31/21 to 10/26/21 for one (1) of five (5) residents reviewed for falls, Resident #111. Findings include: Review of the facility policy titled, Fall Prevention Policy, with a revision date of 04-01 revealed Policy: It is the policy of this facility that each resident will be assessed upon admission, re-admission, quarterly, and annually or with a significant change for their fall risk potential. Procedure: .2 incorporate individualized measures and interventions into the resident's care plan for residents who are identified to be at risk for falls . An observation on 10/25/21at 3:30 PM, revealed Resident #111 sitting on her bed with the Assistant Director of Nursing (ADON) present in the room. As soon as this surveyor came into the room the resident stood up, placed her hands on her walker and began trying to have a conversation. During the conversation, after the first few words, the resident's speech was garbled and not understandable. An interview, on 10/25/21 at 6:41 PM, with Registered Nurse (RN) #1 revealed Resident #111 fell in her bathroom because she had gotten up unassisted and caused a hip fracture and four to six weeks prior, she fell in the Alzheimer's Unit and caused a head injury that she thought was a bleed. Record review of Resident #111's Incident Report dated 8/31/21 at 11:45 PM revealed in Narrative of Incident and description of injuries. Resident was found on the floor beside the bed. Attempted to get resident up out of the floor and resident became combative with this nurse attempting to hit and screaming. Cursing at this nurse. Resident got herself out of the floor. Moves all extremities well. No complaint of pain voiced. Refused all vital signs (v/s) and care at this time . Immediate Action's Taken: Attempted to observe resident for injuries and assist from floor. Unable to do either at this time. Record review of the Resident #111's Incident Report dated 9/05/21 at 01:51 AM revealed, Resident was found on floor next to bed. Resident was laying on right side legs wrapped up in bed spread, pillow was on floor near head, resident was asleep, aroused when spoke to. It appears that resident rolled out of bed when turning over. She then turned onto knees and pulled self up holding on to staff. Ambulated to bathroom and back to bed without difficulty. No apparent injuries. Record review of the Resident #111's Incident Report dated 9/08/21 at 01:40 PM revealed, Resident was attempting to sit down in a dining room chair. She sat on the arm and slid to the floor. Did not hit head; moves all extremities. Record review of the Resident #111's Incident Report dated 9/10/21 at 02:55 PM revealed, Resident was in the dining area attempting to get into the snack cart when redirected by Certified Nursing Assistant (CNA) , resident became belligerent and attempted to grab the portable kitchen barrier causing herself to lose balance and falling to the floor. Resident did not hit her head. No injuries noted. Record review of the fall Incident Report, dated 9/12/21 at 05:55 AM, revealed Resident #111 was leaning over to pick at the floor when she lost her balance and went down on her bottom. The nurse assessed for injuries and assisted resident back up and placed in chair with 2 persons assist. Bruise noted to right side. Resident would not allow the nurse to measure area. Record review of the Incident Report, dated 9/13/21 at 04:15 PM, revealed, nurse was called to room by CNA; resident found on floor between door and roommates bed; c/o pain to head and L (left) cheek; egg size raised area noted to left/back of head; no redness noted to face; able to move all extremities without difficulty; neuro check within normal limits (WNL); assisted from floor; order obtained to send resident to ER for evaluation; ambulance called at approximately 4:30 PM; ambulance arrived at approximately 4:45 PM to transport resident to ER; Responsible Party (RP) notified. Record review of the hospital History and Physical dated 9/14/21 revealed the resident was admitted to the hospital with an admitting diagnosis of Subarachnoid hematoma. Record review of a Physician's Order dated 9/24/21 on hospital return revealed, Admit to skilled services for intracranial hemorrhage w(with)/new peg tube placement. Record review of the Incident Report dated 10/03/21 at 03:01 PM, revealed Resident #111 had gotten up from bed. She was yelling/crying out. Upon entering room, she was found on floor in bathroom. Her head was against the bathroom wall near the toilet. Her legs were towards door. She was not wearing shoes but did have on grip socks. There was feces on the toilet and on resident. Injuries noted as right hip pain and disposition noted as hospital admission. Record review of a Physician's Order dated 10/3/21 at 3 PM revealed, Send to ER for evaluation related to fall with right hip pain. Record review of the hospital Admission History and Physical dated 10/3/21 revealed the resident was admitted to the hospital with an admitting diagnosis of fracture at her right hip. Record review of a Physician's Order dated 10/8/21, for Resident #111's re-admission to the facility revealed, Admit to skilled services Right Hip fracture repair with/previous Intracranial Hemorrhage (ICH) and recent peg (Percutaneous Endoscopic Gastrostomy) tube placement. Record review of the Incident Report dated 10/19/21 at 06:40 PM, revealed Resident #111 self-propelled her wheelchair in the foyer in front of the couch and was trying to transfer unassisted and slid to her knees. She sustained a superficial skin tear to the left knee measuring 2.0 cm(centimeters) X 1.0 cm. Record review of Resident #111's Incident Report dated 10/26/21 at 05:46 PM, revealed This writer was sitting at desk when I heard a loud bang. Upon entering room resident was lying flat on her back with overbed table underneath her head. Her legs were stretched out straight towards foot of bed. She had gotten up from the bed unassisted. She was wearing shoes. No injury noted. Transfered to the ER for an evaluation. A telephone interview, on 10/26/21 at 4:20 PM, with Resident #111's Responsible Party (RP) revealed to the State Agency (SA) that the facility staff told the family they could stay with Resident #111 24/7 or hire a sitter. The RP stated that they would not have put her in the nursing home if they could afford a sitter. She stated that she did not feel like they were watching her as close as they should. An interview, on 10/27/21at 9:00AM with RN #1 revealed the resident had a fall yesterday afternoon on 10/26/21 as she was getting out of bed and fell back and hit her head on the floor and she had to be admitted to the hospital. An interview, on 10/27/21 at 2:25 PM, with Registered Nurse (RN) #1 revealed Resident #111 usually does not let us know when she needs something, we just have to ask or watch her. RN #1 stated that she has noticed if Resident #111 was fidgeting or squirming around she needed to go to the bathroom and she would ask her. An interview, on 10/27/21 at 2:28 PM, with Certified Nursing Assistant (CNA) #1 revealed that the resident sometimes tells us when she needs something and sometimes, she doesn't. CNA #1 revealed that Resident #111 sometimes refuses care, such as baths or changing her, but when they go back in an hour or so she will agree. An interview, on 10/28/21 at 9:43 AM with RN #1 revealed that they have not done a toileting program, because she has been in and out of the facility so much. RN#1 stated that after a fall, they try to get the Certified Nursing Assistants (CNA) posted outside Resident #111's door as much as they can. RN #1 stated that the CNAs know what they need to do because they are given verbal report that tells them any changes. RN #1 stated that the standard for checking on residents is every two hours, but we do not have it documented anywhere that shows we checked on Resident #111 more often. RN #1 confirmed that there should have been specific times to increase checks on Resident #111 and confirmed that they had not put into place any more frequent checks other than every two hours. An interview, on 10/28/21 at 9:55 AM with Director of Nurses (DON) revealed that when Resident # 111 came back from the hospital after her last fall the Social Worker offered to find sitters that the family could pay for and asked the RP if they wanted to sit with her and they refused. The DON revealed they had put Resident #111's bed in the low position and were using a concave mattress. The DON revealed we cannot do a fall mat because it is a trip hazard. The DON confirmed that the facility failed to provide more frequent supervision checks on the resident after each fall and had every two hours supervision checks currently on Resident #111 and they failed to provide increased supervision to prevent further falls and said that the facility couldn't provide someone to sit with the resident because they just weren't able. The DON confirmed that the staff will bring her out to the desk at times and watch her but that they don't have anything documented to provide supervision more frequent than every two hours. An interview, on 10/28/21 at 10:25 AM, with Licensed Practical Nurse (LPN) #1 revealed that there was a lot of one-on-one time spent with Resident #111 and she thinks that is the best defense for her. An interview on, 10/28/21 at 10:28 AM with the Therapy Supervisor regarding Resident #111 revealed that they usually try to educate the family that staff will try to keep a closer eye on her and due to her stroke, her decision making is not to the best. The Therapy Supervisor revealed that they update the resident's family at the care plan meeting regarding her progress and therapy plan. Therapy supervisor revealed that therapy relays information about any changes in resident's plan of care to the nursing staff verbally. Therapy supervisor revealed that they have focused on strengthening for Resident # 111 due to her hip fracture, because she sometimes is not willing or does not understand. Record review of the Face Sheet revealed Resident #111 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] ([CONDITION(S)]), Trauma Subarachnoid Hemorrhage ; Cerebral Infarction, [CONDITION(S)], Dementia, Type 2 Diabetes mellitus, Major Depressive Disorder, Unspecified [CONDITION(S)] of liver, Dysphagia, Cognitive Communication deficit, [CONDITION(S)], [CONDITION(S)], Rheumatic multiple valve disease, Metabolic [CONDITION(S)]; Hypothyroidism; Chronic pain syndrome; Hyperlipidemia; Other abnormalities of gait and mobility; Anxiety; Encounter for attention to gastrostomy; Hypertension; Hypomagnesemia; Muscle weakness; Unspecified lack of coordination; Difficulty in walking; Anemia; Fracture of right femur; and Alzheimer's disease. Record review of the Significant Change-Minimum Data Set (MDS) assessment dated [DATE] revealed the residents Brief Interview for Mental Status (BIMS) score as 99, indicating that the resident did not participate in the assessment or was unable to complete the interview due to severe cognitive ability.

Based on staff interview, record review, review of the manufacturer's Sabina Lifts With Care instructions, Sabina Lift Instruction Guidelines for Training and facility policy review, the facility failed to prevent a fall from a Sabina lift, as evidenced by Certified Nursing Assistants (CNAs) failed to secure the leg (calf) strap on a Sabina lift used to transfer Resident #1 resulting in the resident falling and sustained fractures which required outside medical treatment for one (1) of four (4) residents reviewed for safe use of a lift. (Resident #1). Findings include: Review of the facility's policy titled, Fall Prevention Policy, revised ,[DATE], revealed it is the policy of this facility that each resident will be assessed upon admission, readmission, quarterly, and annually or with a significant change for their fall risk potential. Incorporate individualized measures and interventions into the resident's care plan for residents who are identified to be at risk for falls. Be aware of and utilize the fall precautions as appropriate for each individual resident. Review of the facility's policy titled, Sizing, Application, and Use of the Lifts revealed it is the policy of this facility to follow the manufacturer's instructions for sizing, application, and use of the Sabina sling. Review of the Sabina II Lift Instruction Guidelines for Training, copyright 2012, revealed when preparing the patient on the lift, position the individual's shins against the lower leg support, readjusting the support when necessary. Review of the Sabina lift manufacturer's instructions, (no date) revealed on page 10: Secure calf strap. A padded calf strap holds the legs securely in place. Simple length adjustment. Review of the facility's Incident Investigation, dated [DATE] at 11:30 AM, revealed upon investigation of this incident, the writer of the report was notified of the Resident #1's fall and went to the resident's room immediately. Resident #1 was lying on her bed, alert and oriented. Staff had already transferred the resident back to bed. No distress was noted. The writer asked the resident what caused her to fall out of the sling of the Sabina lift and she responded she became very weak all of a sudden and nauseous and she just felt her body going down and she could not continue to stand or to hand onto the bars of the lift. Resident #1 said she had just stood up and the girl (CNA #4) was about to pull her out of the bathroom when she told her she was sliding. CNA #4 stated she was on the other side of the lift and the resident was still in the bathroom, but she was on the outside and unable to get to the resident before she started to go down to the floor with her legs twisted under her. Registered Nurse (RN) #1 reported when she arrived the resident was still attached to the lift, but could not recall just how. Resident #1 was lifted off the floor with the Viking lift and the CNAs and RN #1's assistance. Resident #1 did complain of pain in both of her legs. 911 was called and Resident #1 was transferred to the hospital. Resident #1 did not complain of nausea, and said it just occurred like a flash wave, she got weak and very sick at her stomach and was not able to hold onto the lift bars. There was another CNA in the room, (CNA #3), the writer asked if she was in the room during the incident and both CNAs said no, she came in to assist with getting Resident #1 off the floor, but she did say she did not think the strap on the Sabina lift no longer tightened all the way and therefore unable to hold the resident on the lift properly. The Maintenance was notified and checked all three Sabina lifts in the facility for function and found no problems with the lift straps. The lifts were returned to the floors. On [DATE], the writer returned to work and the Maintenance Manager, who had checked the lifts on [DATE], came to her regarding a lift he found on the hall that he noticed the strap was attached through the buckle causing the strap not to tighten. The CNA probably believed it was working properly. On [DATE], the writer added to the report Resident #1 was recently sent to the emergency room (ER) after a fall from the Sabina Lift. She was found to have a heart rate in the 40's and was readmitted to the facility on [DATE] status [REDACTED]. The resident is in stable condition now, has a sling to her left arm, denies any real pain as she put it, just tenderness and soreness to her chest. Record Review of the POS [REDACTED]. Review, of the written statement given by CNA #3, revealed she had asked CNA #4 to assist with taking Resident #1 to the bathroom. She was called out of the room and when she came back to the nurse's station, she was told her Resident #1 was in the floor. She went to the resident's room with other staff. She wrote that the sling was still hooked up, the leg band was on but it wasn't tight and the waist sling was under the resident's breasts. CNA #3 said she thought CNA #4 was going to help Resident #1 to the bathroom. Review, of a written statement by CNA #4, revealed Resident #1 was being lifted with the Sabina lift and her legs gave out and she slipped to the floor. A telephone interview, on [DATE] at 11:55 AM with RN #1, revealed she was the charge nurse on [DATE]. She stated she was at the desk and someone said Resident #1 was in the floor. She stated she immediately went to the room and found Resident #1 in the bathroom with the Sabina lift on. She stated Resident #1 was in the lift leaning to her right side. She stated the waist strap was on, but it was so far up her back because she had slid so much. She had slid out on her right side. RN #1 stated Resident #1's right leg was up under her and her left leg was extended out and back on the base of the Sabina lift. RN #1 stated she threw the leg strap was out of the way when she was assessing the resident. She confirmed the leg strap was not on and fastened as it should have been. RN #1 confirmed Resident #1 complained of pain in her legs. RN #1 stated they did several demonstrations after the fall using the Sabina lift and those demonstrations revealed if the leg strap had been on, Resident #1 would not have slid out. Review of Resident #1's Care Plan, dated [DATE], revealed the Problem/Need for Activities of Daily Living (ADL) deficit which included a need for transfer assistance. The Approaches included the use of a Sabina lift for transfer with one person assistance. The Sabina lift is a sit to stand lift. On [DATE], the Sabina lift was crossed out and the Viking lift was handwritten on the care plan with two person assistance. The Viking lift is a total body lift. Review of Resident #1's Care Guide, dated [DATE], revealed her transfers required the Sabina lift with one person assistance. Her fall risk was moderate. Review of the Emergency Department (ED) note, dated [DATE] at 12:31 PM, revealed Resident #1's chief complaint included: Fall, Knee Pain, Hip Pain and Shoulder Pain. The report stated the history was provided by the patient. The pain level was severe with complaint of right hip and knee pain due to a fall. The Physical Examination revealed the resident was in no acute distress. She was alert and oriented. She exhibited tenderness to right hip and knee. Resident #1 was admitted to the hospital. X-ray to the right femur revealed a fracture involving the distal femoral metaphysis just above a knee prothesis. The X-ray of the right knee revealed an acute comminuted [MEDICATION NAME] displaced fracture involving the distal femur, immediately proximal of the left knee prothesis. The X-ray of the left knee revealed an acute oblique, [MEDICATION NAME] displaced fracture involving the distal diaphysis of the left femur. The fracture involves the femur about eight centimeters (8 cm) proximal to the prothesis. All X-rays were done on [DATE]. The Patient Care Timeline revealed Resident #1 was admitted to the hospital, on [DATE], for surgery in the morning. Review of the hospital Discharge Summary, dated [DATE], revealed Resident #1 was admitted due to right and left femur fractures. The note further stated Resident #1 was admitted for femur fractures and underwent surgical repairs on [DATE]. Review of the facility's ,[DATE] Shift B-Side Daily Assignment Sheet, dated [DATE], revealed CNA #4 was assigned to rooms 300 to 306 and CNA #3 was assigned to rooms 414 to 418, which included Resident #1. Review of Resident #1's physician's orders [REDACTED]. Review of the facility's Sabina Lift II Skills Checklist, dated [DATE], revealed CNA #3's signature at the end of the checklist which included Review of the facility's Sabina Lift II Skills Checklist, dated [DATE], revealed CNA #4's signature at the end of the checklist. Review of the facility's Viking and Sabina Training is performed on Orientation and Annually, no date) revealed, Ensure leg strap is in place and taut after resident has placed feet onto foot tray. Legs should be touching the leg cushion. An interview, on [DATE] at 10:00 AM with the Assistant Director of Nursing (ADON) revealed Resident #1 was an alert and oriented resident. She stated she always liked to be up with her make-up on. The ADON stated Resident #1 was sent to the emergency room after the fall and returned to the facility after having surgery to her legs. She stated Resident #1 received therapy, but expired several weeks later. She stated the resident had some complications not related to the fall. The ADON confirmed Resident #1 required one (1) person assist for the Sabina lift and her care plan indicated this. She stated Resident #1 was assigned to Certified Nursing Assistant (CNA) #3 and she didn't know why CNA #4 was assisting her. The ADON stated CNA #3 and CNA #4 were terminated. The ADON stated that Registered Nurse (RN) #1 told them the leg strap was not hooked when she got to the bathroom immediately after the fall because she stated she moved it to the side. The ADON stated CNA #1 had reported to them that the leg strap was not on and she had gone into the room immediately after the fall occurred. An interview, on [DATE] at 10:14 AM with Certified Nursing Assistant (CNA) #1 revealed that when she heard that the Resident #1 had fallen, she went into the resident's room and the resident was sitting on the bathroom floor by the toilet with the Sabina lift in the bathroom. CNA #1 stated the waist belt was around Resident #1's back because it had to be removed. She stated the lift had a strap for the legs, but it was not secured in place. CNA #1 stated when she went to Resident #1's room earlier, CNA #3 and CNA #4 was in the room. The resident was in the bathroom. CNA #1 told CNA #3 there were some visitors here to see her, so CNA #3 left the room and CNA #1 went back to the desk. CNA #4 stayed with Resident #1. During an interview, on [DATE] at 11:21 AM, with the Administrator (ADM), stated he felt like Resident #1 would not have fallen if the leg strap had been put around her legs like it was supposed to be. An interview, on [DATE] at 4:45 PM, with CNA #2 revealed she had been trained to use the lift by watching videos and in-service. She stated they had done training with the lift in person with staff as the resident. CNA #2 stated if the straps are not on correctly it can hurt the resident or you could hurt yourself. She stated the leg strap keeps the resident connected to the lift. She stated she felt it was the most important part because if the resident got weak it would keep them connected. An interview, on [DATE] at 4:55 PM, with Licensed Practical Nurse (LPN) #1, revealed she was responsible for Minimum Data Set (MDS) and Care Plans. She stated that the staff is taught during orientation on how to use the lifts and should use the proper technique. She felt the care plan was followed because a one person lift was used and that was what was care planned. She stated that if they did not apply the lift properly that was different. She stated the staff is trained and they learn when they come to work here how to use the lifts. Review of the manufacturers information for the Sabina lift revealed a padded calf strap holds the legs securely in place. Simple length adjustment. Review of the Face Sheet revealed the facility admitted Resident #1, on [DATE] and readmitted her on [DATE], with the included [DIAGNOSES REDACTED]. Review of Resident #1's Minimal Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Basic Interview for Mental Status (BIMS) score was 13, which indicated no cognitive impairments.

Based on staff interview, facility policy review, and record review, the facility failed to follow the comprehensive care plan related to the use of a Lap Buddy for Resident #2, for one (1) of eighteen (18) care plans reviewed. Findings include: Review of the facility's policy entitled, Care Plan, dated 09/22/15, revealed: It is the policy of this facility to create and maintain an individualized, interdisciplinary care plan for each resident in the facility. Objective: 3. To provide information for assignments for staff. Review of Resident #2's Comprehensive Care Plan for a Lap Buddy when up in the wheelchair revealed: Resident #2 should have a Lap Buddy when up in the wheelchair related to decreased cognitive status, weakness, and to improve positioning while up in wheelchair. Review of Certified Nursing Assistant (CNA) #1's Assignment Sheet dated 09/18/15, for Resident #2 revealed Resident #1 has a restraint, a lap buddy when up in the wheelchair. Review of the facility's investigation related to Resident #2's fall on 09/18/15, revealed CNA #1 failed to apply Resident #2's lap buddy as ordered, resulting in Resident #2 falling out of the wheelchair, and suffering a closed [MEDICAL CONDITION] of her right femur, head injury, and a scalp hematoma. Interview on 12/29/15 at 4:30 PM, with CNA #1 revealed she provided care to Resident #1 on 09/18/15. CNA #1 stated she did not put the lap buddy on Resident #2 because she didn't know the resident needed one. CNA #1 stated she had an assignment sheet for Resident #2, and she glanced over it, but did not pay it much attention. CNA #1 stated she has since learned she needs to read it (assignment sheet) more carefully. Interview on 12/29/15 at 5:00 PM, with the Director of Nursing (DON) revealed CNA #1 failed to follow the Comprehensive Care Plan as established for Resident #2. The DON stated CNA #1 also failed to follow her care guide for Resident #2. The DON revealed CNA #1 had received training in orientation on use of the care guide, and following the care guide. CNA #1 received a verbal counseling on 9/18/15. CNA #1 was hired on 07/09/15. Review of Verbal Counseling sheet conducted with CNA #1 by RN Desk Supervisor on 9/18/15, revealed in a statement signed by CNA #1, I, (name of CNA #1) understand that 2 CNA including nurse have to be in room at get up time and lap buddy have to be placed on her (Resident #2) when she gets in chair. Review of the facility's Face Sheet revealed the facility admitted Resident #2 on 10/03/07, and readmitted her on 12/31/13 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/15, revealed Resident #2's Cognitive Skills for Daily Decision Making was coded a three (3), which indicated a severely impaired cognitive status.

Based on record review, staff interview, and facility policy review, the facility failed to implement interventions to ensure adequate supervision was in place to prevent a fall with serious injury, as evidenced by: Certified Nursing Assistant (CNA) #1 failed to apply a Lap Buddy to Resident #2's wheelchair, resulting in Resident #2 falling out of the wheelchair, and sustaining a fracture, which required outside medical treatment, for one (1) of nine (9) residents reviewed for falls. Findings Include: Review of the facility's policy entitled, Restraint Use, dated 02/19/13 revealed: It is the policy of this facility to use restraints to treat the resident's medical symptom and assist the resident in maintaining the highest practicable level of physical and psychosocial well-being. Review of the facility's policy entitled, Fall Prevention, (not dated) revealed: Incorporate individualized measures and interventions into the resident's care plan for residents who are identified to be at risk for falls. Be aware of and utilize the fall precautions as appropriate for each individual resident. Review of the Emergency Department provider notes for Resident #2 dated 09/18/15 at 10:35 AM, revealed a Computed Tomography (CT) Scan of Head was performed, and revealed Resident #2 had a large scalp hematoma to the right frontal region, but the skull was intact. Resident #2 had a X-ray of the Pelvis performed which revealed a linear irregularity involving the right femoral neck suggesting an acute fracture here. The Clinical Impression from the emergency room documentation reflected Resident #2 had a fall from a wheelchair, closed fracture of the neck of the right femur, head injury, and scalp hematoma. Resident #2 was returned to the Nursing Home for management. Review of Resident #2's Resident Incident Report dated 09/18/15 at 6:30 AM, revealed, Licensed Practical Nurse (LPN) #1 entered Resident #2's room after hearing the roommate screaming for help, and discovered Resident #2 lying in the floor with her upper body laying on the floor, and with her legs still laying in her wheelchair. Resident #2 was noted to have a skin tear to the left hand, and to be moving her upper and lower extremities Resident #2 was placed back in bed by two certified nursing assistants (CNAs), and the nurse, who assessed for injuries, and performed neurological checks. Resident #2 only complained of her left hand hurting at this time. Review of the facility's investigation dated 09/18/15, revealed CNA #1 did not apply Resident #2's lap buddy after getting Resident #2 up to the wheelchair that morning. Interview with CNA #1 on 12/29/15 at 4:30 PM, revealed she provided care to Resident #2 on 09/18/15. CNA #1 stated she did not put the lap buddy on the resident because she didn't know she needed one. CNA #1 stated she had an Assignment Sheet that night, and had glanced over it, just did not pay it much attention. CNA #1 stated, I have since learned to read it carefully. CNA #1 stated she had received training on following the Care Guide by the Director of Nursing, and during orientation. Review of Resident #2's monthly Physician order [REDACTED]. Review of the Daily Assignment Sheet revealed Certified Nursing Assistant (CNA) #1 was assigned to care for Resident #2 on 09/18/15, during the 11 PM -7 AM shift. Review of the CNA Assignment Sheet 9/18/15, for Resident #2 revealed: Restraints: Lap Buddy when in wheelchair. Interview with LPN #1 on 12/30/15 at 5:15 AM, revealed she went in the room to assist CNA #1 to get Resident #2 up as per the care plan on 09/18/15. LPN #1 stated after Resident #2 was placed in the wheelchair she left out of the room, and CNA #1 would have been responsible for completing Resident #2's care by placing the pillows, blanket, and lap buddy as ordered. Review of the Nurses Notes dated 09/18/15 at 7:05 AM, revealed LPN #1 administered Tylenol 325 Milligrams (mg) to Resident #2 for constant complaint of pain to her left hand. Review of Nurses Notes dated 09/18/15 at 7:34 AM, revealed Resident #2's Physician was notified of the resident being found in the floor with severe complaints of pain to the left hand that was not relieved by the PRN (as needed) pain medicine. The Physician ordered to send the resident to the emergency room for evaluation. Interview with the Director of Nursing (DON) on 12/29/15 at 5:00 PM, revealed CNA #1 had a care guide to follow that gave her directions on the care for Resident #2. The DON stated CNA #1 should have read her care guide prior to providing care to the resident, and failed to do so. The DON stated CNA #1 had received training in orientation on the use of the care guide, and following care guides. Review of the Verbal Counseling form dated 9/18/15, for CNA #1 revealed: CNA assigned to resident (Name of Resident #2) did not follow assignment sheet by not placing lap buddy on resident. The form was signed by the Desk Supervisor, and CNA #1. Review of the facility's Face Sheet revealed the facility admitted Resident #2 on 10/03/07, and readmitted her on 12/31/13 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/15, revealed Resident #2's Cognitive Skills for Daily Decision Making was coded a three (3), which indicated severe cognitive impairment.

Based on review of professional standards of practice, incident reports, staff interviews, record reviews, preceptor list, and facility policy review, the facility failed to follow the professional standards of practice when the facility Licensed Practical Nurse (LPN) allowed a Student Nurse to administer medications unsupervised which resulted in misidentification of the resident and a medication error for one (1) of six (6) residents reviewed. The facility's failure to use professional standards of practice on 06/21/15 when the facility Licensed Practical Nurse (LPN) allowed an unsupervised student nurse to administer insulin without a physician's order to Resident #1 placed Resident #1 and other residents of the facility in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) conducted an abbreviated complaint survey from 7/7/15 through 7/10/15. During the investigation, the State Agency found the facility not in compliance with requirements for participation in Medicare and Medicaid and cited regulatory deficiencies. Based on State Agency (SA) Administrative review, and Quality Assurance review, it was determined the facility was not in past noncompliance and a partial extended survey was required due to the State Surveyor's identification on 7/7/15 and 7/10/15 of facility staff borrowing insulin from another resident and unlabeled and undated punctured insulin vials in the medication cart. The State Agency notified the facility of the removal of the past noncompliance and changed the findings to Immediate Jeopardy on 7/21/15. The SA re-entered the facility and conducted an extended survey from 07/21/15 through 07/23/15. The State Agency identified an Immediate Jeopardy (IJ) that began on 6/21/15 when the student nurse, being precepted by a facility nurse, administered insulin unsupervised to Resident #1 who did not have an order for [REDACTED]. The facility submitted a Credible Allegation of Compliance (AoC) and alleged removal of the IJ on 7/22/15. The SA validated the credible AoC on 7/23/15 and determined the IJ was removed 7/22/15. Therefore, the scope and severity was lowered to a D for 42 CFR 483.20(k)(3)(i) Professional Standards (F281), while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the Facility and the Local Community College Cooperative Agreement of Affiliation dated 8/08, revealed Student and Faculty shall abide by the existing policies/procedures and regulations of Health Agency during clinical hours. The Health Agency shall be responsible for informing, and keeping informed, all of its personnel regarding the rights and privileges of the College's faculty and student. Review of the facility's policy entitled, Medication Administration-Preparation and General Guidelines, dated 06/2011, revealed Medication is administered only by licensed nursing, medical, pharmacy, or other personnel authorized personnel authorized by state laws and regulations to administer medications. Medications are administered in accordance with written orders of the attending physician. The person who prepares the dose for administration is the person who administers the dose. The residents are identified before medication is administered using (two) methods of identification. Methods of identification include: a. Checking Identification band, b. Checking photograph attached to medical record, c. Calling resident by name, d. If necessary, verifying resident identification with other facility personnel. Medications supplied for one resident are never administered to another resident. Review of the Mississippi Board of Nursing's letter entitled Delegation, revised 03/19/2009, revealed Scope of Practice, According to Chapter III of the Mississippi Board of Nursing Rules and Regulations. 2. Assign the duties of administration of patient medications to other licensed nurses only either a Registered Nurse or Licensed Practical Nurse. Tasks Not Appropriate for Delegation to Auxiliary Workers/Unlicensed Personnel: Including, but not limited to. 7. Medication administration Resident #1 Review of the facility investigation for Resident #1 revealed on 6/24/15 at approximately 9:00 AM, the resident's Responsible Party (RP) reported to the Registered Nurse/Charge Nurse on Sunday 6/21/15, at approximately 5:15 PM, the student nurse took Resident #1's blood sugar. The blood sugar reading was 158. The student nurse administered two (2) units of regular sliding scale insulin to Resident #1. The student nurse reported to the resident's family that Licensed Practical Nurse (LPN) #1 instructed her to give Resident #1 two (2) units of sliding scale (s/s) insulin. On Monday, June 22, 2015, the RP stated LPN #2 reported Resident #1 was not on sliding scale insulin. Review of the facility's Medication Error Report on, 6/24/15, for Resident #1 revealed on 6/21/15 between 5:15-6:00 PM, the facility nursing staff, LPN #1, allowed an unlicensed student nurse to administer s/s insulin unsupervised. The facility LPN #1 failed to supervise an unlicensed Student Nurse while the Student Nurse administer two (2) units of Regular Insulin to Resident #1, who did not have sliding scale insulin ordered. LPN #1 was a designated preceptor for the student nurse. Resident #1 received insulin in error based on, Resident #6's sliding scale insulin orders. Resident #6 was out of the building at the time of the incident. Review of the facility Preceptor Assignments list emailed to the facility on [DATE] at 12:57 PM from the local community college revealed LPN #1 was designated as the Student Nurse's preceptor. Interview on, 7/7/15 at 7:05 PM, with Resident #1's RP revealed on, Sunday 6/21/15 about 5:15 PM, an unsupervised student nurse took Resident #1's blood sugar and administered 2 units of insulin to the resident. The RP stated, On 6/24/15 about 9:00 AM, I requested a computer copy of the resident's medication and reported the above incident to the charge nurse. In a meeting with the facility staff on Friday evening 6/26/15, I was told (Resident #1) received 2 units of regular insulin from his roommate's insulin (Resident #6) on, 6/21/15 by the student nurse. I was told both of residents had the same first name and the nurse was suspended. I observed on 6/26/15 the facility staff running around putting name band on the residents' arm. Previously the resident's names band was attached to the arm of the resident's wheelchair. Interview, on 7/9/15 at 1:15 PM, with Resident #1 revealed he remembered the insulin injection but there was no problem and no problem with the facility's care or meals. Review of the Physician's Orders for Resident #1 revealed the resident did not have a physician order for [REDACTED]. Record review revealed there was no documented evidence the Student Nurse was orientated to the facility's residents. There was no documented evidence the facility nurses received training related to being a preceptor for the local community college student nurses. On 7/9/15 at 5:45 PM, an interview with the Staff Development Nurse verified there was no training provided by the facility related to facility nurses being a preceptor and the local college instructor made assignments to the preceptors. Interview on, 7/10/15 at 10:53 AM, with the Nursing School Director, and the Instructor from the local community college confirmed there was no training provided by the local college to the facility nurses on being preceptors for the student nurses. The Nursing School Director and Instructor also confirmed there was no orientation of the student nurses to the facility residents. The Nursing School Director, and the Instructor reported the Student Nurse informed them on, 6/25/15 that she administered two (2) units of Regular insulin to Resident #1 on, 6/21/15, after being told to do so by LPN #1. Interview with LPN #1, on 7/8/15 at 1:35 PM, confirmed she allowed the student nurse to administer two (2) units of insulin unsupervised to Resident #1. LPN #1 stated she was made aware of the medication error on 6/24/15 by the Assistant Director of Nursing (ADON). LPN #1 stated the facility nor the local community college provided training for preceptor prior to accepting the student nurses. LPN #1 also confirmed there were no physician's orders for sliding scale insulin for Resident #1. On 7/21/15 at 2:00 PM, an interview with the Quality Assurance Nurse (QA) #2, who was acting DON at the time of the preceptor agreement, revealed she received a phone call in June 2015 from the local community college instructor requesting nursing preceptors for the student nurses. The QA Nurse stated she asked the facility nurses about being preceptors and placed their names on a list. She stated she left the list for the DON. Interview on 7/9/15 at 5:35 PM, with the Director of Nurses (DON) confirmed the nurses were asked by the QA Nurse, while acting as DON, about being a preceptor for student nurses from the local community college. The DON explained she was out of town due to training during the agreement. Review of Resident #1's face sheet revealed the resident was admitted by the facility on 6/3/15, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of 7/1/15 revealed a Brief Interview for Mental Status (BIMS) score of 14 that indicated the resident was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 7/22/15 for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following measures to remove the IJ. Immediate actions: 1. On 6/24/15 at 2:30 pm the Assistant Director of Nursing began to investigate the alleged incident. 2. The Assistant Director of Nursing validated that Residents #1 current condition was stable 6/24/15 approximately 2:30 pm. - No adverse reaction was noted. The Electronic Medical Administration Record shows that resident #1 blood sugar on June 215' before supper was 158. 6/22 - 145, 6/23 - 233, 6/24 - 117. 3. The Assistant Director of Nursing reviewed other residents on the hallway with Diabetes 6/24/15 at approximately 2:45 pm and no other resident was noted with adverse reactions. 4. On 6/24/15 the Assistant Director of Nursing validated that student nurse #1 did give the insulin in the lobby to Resident #1 on 6/21/15 at 6:29 pm unsupervised by LPN #1. 5. The facility Medical Director was also notified on the incident 6/24/15 at 2:46 pm. 6. On 6/24/15 at 2:46 pm the facility notified Resident #1 primary care physician and responsible party. 7. On 6/25/15 approximately 10 am the Quality Assurance Nurse #2 interviewed Resident #1. He is cognitively intact and he remembered getting an injection on Sunday 6/21/15. Asked if he had any problems from the injections and he said No, I am doing well. 8. On 6/25/2015 about 12:30 pm Quality Assurance Nurse #2 notified the Nursing Instructor #1 from local community college. Instructor #1, instructor #2, Instructor #3 and the nursing student #1 came to the facility 6/25/15 at approximately 2:30 pm to discuss the incident and to review the preceptor process. Registered Nursing Program Director was also made aware by the other instructors on 6/25/15 at approximately 12:30 pm. It was decided in the meeting that the local community college would implement a class for students before the next preceptorship in the fall to prepare student for preceptor program. The instructors agreed that all students will complete a Pharmacology final check off sheet prior to starting the preceptor program. 9. On 6/25/15 Resident arm bands were checked and replaced as needed on every resident with the exception of residents refusing to wear the arm band. This is reflected in their care plan that arm bands were placed on their wheelchairs. An entry to document placement of arm bands was placed on Medication Administration Record to be checked every shift by the medication nurses. 10. On 6/25/15 approximately 2:00 pm the Pharmacy consultant was notified of the incident and provided the facility information for the in-service which included: a. There is an acceptable time when taking blood sugars and giving insulin. You do not take every blood sugar and then go back and give the insulin. It is too much time difference, b. How to identify residents: by picture on the EMAR and that it can be enlarged by tapping the picture, resident's name outside the door, arm bands on wrist, ask C.N.A.'s and nurses, and the resident. c. How to make sure that resident has an arm band: It will be placed on the E-MAR for nurses to sign every shift. d. Rules for facility nurses and student nurses: No accuchecks in common area or dining rooms. No insulin given in halls or dining rooms, give only behind closed doors. No meds given in dining room after the trays come out. Do not leave meds at bedside table for resident to take on their own. You must watch resident swallow the medication. Insulin if needed should follow glucometer check immediately. When there is a preceptor, nurse must stay with preceptor and do not have them doing anything without nurse. if the preceptor prepares the medication, she must give it. If the nurse prepares the medication, she must give it. e. The 5 rights of medication administration: the right resident, the right drug, the right dose, the right route, the right time. f. Explain to resident what you are going to do at the time. g. Nurses and other staff to report unusual events to supervisor immediately. 11. In-servicing was started 6/25/2015 6:30 pm by Quality Assurance nurse #2 for nurses on Medication Administration- General Guidelines. 98% of nursing staff completed the in-service on 6/25/15 with completion date of 7/12 except for one employed on a part time basis completing the in-service 7/20/15 before being allowed to return to work. 12. The Pharmacy registered nurse consultant began med pass check-offs with medication nurses on June 30th and completed 6 med pass check-offs on 6/30/15. 13. Licensed Practical Nurse #1 was suspended 6/30/15 approximately 5:00 pm for failure to supervise Student Nurse #1. Licensed Practical Nurse #1 was required to take a Mississippi Board of Nursing approved 6 hour course: Medication Safety: Assuring Safe Outcomes and she successfully completed on 7/1/15, Licensed Practical Nurse #1 completed a Med Pass Check-off 7/2/15. 14. The Medication carts were checked by facility staff and the Director of Nursing on 7/10/15 at approximately 6:00 pm for any open undated multi dose vials. All multi dose vials had puncture dates. 15. On 7/10/15 at approximately 6:00 pm Licensed Practical Nurse #2 was questioned by the Director of Nursing about the incident of borrowing medication. Licensed Practical Nurse #2 was required to write a statement with an her action plan and understanding of what to do in the future when needing medication for a resident. 16. The Mississippi State Board of Health and the Mississippi Attorney General's office were verbally notified 6/25/2015. A written report was submitted to The Mississippi State Board of Health on 6/29/2015 and the Mississippi Attorney General's office 6/29/2015 at 10:49 am. The Mississippi State Board of Nursing was notified 07/10/2015 by mail. 17. An in-service was started on 7/21/15 at 4:30 pm by the Staff Development Nurse on Medication Guidelines including the administration of medication by following the physician orders, the medication ordering process, checking the Emergency Kit for medications if needed, do not borrow medications from one resident for another resident, documentation of medications immediately following administering to a resident, and dating multi-dose vials when opening. No nurse will be allowed to work until they have completed the in-service orientation. 18. On 6/25/2015 at 3:00 pm the Director of Nursing, Administrator, 2 Quality Assurance nurses, medical Director, and the Staff Development nurse conducted a Quality assurance meeting via conference call and discussed situation of the medication error and reviewed actions being taken to prevent further errors. On 7/10/2015 at 6:30 pm the Director of Nursing, Administrator, Quality Assurance nurses #1 and #2, Medical Director, and the Staff Development nurse conducted a Quality assurance meeting via conference call and discussed situation of the medication error found during survey 7/7/15 - 7/10/15 and reviewed actions being taken to prevent further errors. The Director of Nursing reviewed and revised the facility policies on 7/21/15 at 2:00 pm and presented for review and approval in the Quality Assurance meeting at 6:30 pm regarding: a. Medication Administration Staff Assessment and Orientation Tool -Changed to use the Pharmacy Medication audit form. b. Diabetic/[DIAGNOSES REDACTED] protocol - Updated to include the 4 ounces of orange juice to give for blood sugar less than 60. 19. Medication Pass check-offs were started by the Staff Development nurse on 7/21/15 at 5:00 pm for all medication nurses. All medication nurses will be checked off as they report to work and will not be allowed to return to work until completing the check-off. The facility alleged the Immediate Jeopardy was removed on 7/22/15. On, 7/23/15, the State Survey Agency (SA) validated the facility had implemented the following measures to remove the Immediate Jeopardy. An Acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services on 7/23/15. 1. The SA validated by interview and record review the Assistant Director of Nursing (ADON) began to investigate the alleged incident on 6/24/15. 2. The SA validated by record review of the nurses notes that the facility assessed Resident #1 on 6/21/15 through 6/24/15 for signs and symptoms of adverse effects related to the medication error. 3. The SA validated through documentation of nurses notes that the ADON assessed other residents with Diabetes on 6/24/15 and the residents showed no signs and symptoms of adverse reaction. 4. The SA verified by record review and interviews that the ADON validated on 6/21/15 the student nurse did give the insulin in the lobby to Resident #1 and was not supervised. 5. The SA verified by telephone interview and record review the ADON notified the Medical Director on 6/24/15 of the medication error. 6. The SA validated by interview and record review on 6/24/14 the ADON notified Resident #1's primary care physician and RP of the medication error. 7. The SA surveyor validated by record review and interview the Quality Assurance Nurse #2 interviewed Resident #1 on 6/25/15 and the resident was cognitively intact and reported no problems. 8. The SA verified by interview, and record review with the ADON that on 6/25/15 the facility notified the Nursing Program Director and the Instructor at the Community College of the medication error on 6/25/15. 9. The SA verified nurses attendance by interview and review of the sign in sheets of the medication administration in-services on 6/25/15 on how to identify residents, reviewed residents' arm bands, reviewed physicians hypo/[MEDICAL CONDITION] protocol, rules for facility's nurses and student nurses, the five rights of medication administration, explain to resident what going on, and the nurses and other staff to report unusual events to supervisor immediately. 10. The SA verified by interview and record review that in-serving was started on 6/25/15 by Quality Assurance Nurse #2. The SA verified the nursing staff completed the in-service on 7/12/15 with the exception of one employee on a part time basis required to complete the training before being allowed to return to work. 11. The SA verified by interview and record review the Pharmacy Registered Nurse Consultant completed six (6) med pass check offs on 6/30/15. 12. The SA verified by interview and record review that LPN #1 was suspended on 6/30/15 and then required to take a Mississippi Board of Nursing approved six (6) hours course and passed the Medication Safety: Assuring Safe Outcomes test on 7/1/15. LPN #1 completed a med pass check-off 7/2/15. SA validated LPN #1's test results and med pass check off by employee file review. 13. The SA verified by interview and observation the DON and other facility staff checked the medication carts for any opened undated multi-dose vials and checked that multi dose vials had puncture dates on 7/10/15. 14. The SA validated by interview and written documentation on 7/10/15 that LPN #2 wrote an action plan to know what to do in the future when med was needed for a resident. 15. The SA validated by interview, and written documentation the Mississippi State Board of Health and the Mississippi Attorney General's office was verbally notified on 6/25/2015. A written report was submitted to the Mississippi State Board of Health and the Mississippi Attorney General's office 6/29/15, and the Mississippi State Board of Nursing was notified by mail on 7/10/15. 16. The SA verified by interview, and record review an in-service was start on 7/25/15 by the Staff Development Nurse on Medication General Guidelines including the administration of medication by following the physician orders, medication ordering process, checking the Emergency kit for medication if needed, do not borrow medications from one resident for another resident, and dating multi-dose vials when opening. The SA validated no nurse was allowed to work until completion of the in-service orientation. 17. The SA verified by interview, and record review on 6/25/15 the DON, Administrator, two (2) Quality Assurance Nurses, the Medical Director, and the Staff Development nurse conducted a QA meeting via conference call, and discussed the medication error and reviewed actions being taken to prevent further errors. The SA verified by interview, and record review another QA meeting was held on 7/10/15 with the DON, Administrator, Quality Assurance Nurses #1 and #2, the Medical Director, and the Staff Development nurse via conference call. The QA Committee discussed the situation during survey, 7/7/15 - 7/10/15, and reviewed actions being taken to prevent further error. The facility policies were reviewed and approved by the Medical Director during the Quality Assurance meeting regarding: a. Medication Administration Staff Assessment and Orientation Tool-Changed to use the Pharmacy Medication audit form. b. Diabetic/[DIAGNOSES REDACTED] protocol - Updated to include the four (4) ounces of orange juice to give for blood sugar less then 60. 18. The SA verified by interview and record review the Medication Pass check-off was started by the Staff Development nurse on 7/21/15 for all medication nurses. All medication nurses were checked off as they reported to work and were not allowed to return to work until completing the check off. The SA validated the facility showed substantial compliance as of 7/22/2015 to remove the Immediate Jeopardy.

Based on record review, staff interview, care plan review, and facility policy review, the facility failed to ensure Resident #1's care plan was implemented for administration of the correct medication for one (1) of six (6) residents reviewed and failed to ensure Resident #4's care plan was implemented related to the resident's indwelling catheter tubing being secured with a leg strap to prevent the potential for discomfort, irritation, and/or tension on the urethra/bladder for one (1) of two (2) residents receiving indwelling catheter care. The facility's failure follow the resident's care plan on 06/21/15 when the facility's Licensed Practical Nurse (LPN) allowed an unsupervised student nurse to administer insulin without a physician's orders [REDACTED].#1 and other residents of the facility in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) conducted an abbreviated complaint survey from 7/7/15 through 7/10/15. During the investigation, the State Agency found the facility not in compliance with requirements for participation in Medicare and Medicaid and cited regulatory deficiencies. Based on State Agency (SA) Administrative review, and Quality Assurance review, it was determined the facility was not in past noncompliance and a partial extended survey was required due to the State Surveyor's identification on 7/7/15 and 7/10/15 of facility staff borrowing insulin from another resident and unlabeled and undated punctured insulin vials in the medication cart. The State Agency notified the facility of the removal of the past noncompliance and changed the findings to Immediate Jeopardy on 7/21/15. The SA re-entered the facility and conducted an extended survey from 07/21/15 through 07/23/15. The State Agency identified an Immediate Jeopardy (IJ) that began on 6/21/15 when the student nurse, being precepted by a facility nurse, administered insulin unsupervised to Resident #1 who did not have an order for [REDACTED]. The facility submitted a Credible Allegation of Compliance (AoC) and alleged removal of the IJ on 7/22/15. The SA validated the credible AoC on 7/23/15 and determined the IJ was removed 7/22/15. Therefore, the scope and severity were lowered to a D for 42 CFR 483.20 (k)(3)(ii) Services per Care Plan (F282), while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility policy entitled, Care Plan, undated, revealed, An individualized, interdisciplinary care plan will be developed and maintained for each resident in the facility. To provide an individualized, interdisciplinary, physician approved plan of care, which demonstrates all services are integrated. To promote continuity of resident care. To provide information for assignments for staff. Resident #1 Review of Resident #1's care plan revealed a care plan with a focus area for potential adverse drug reactions with a problem onset date of 6/3/15 for potential for complications with Diabetes. The goal was the Resident blood sugars will stay WNL (within normal limits) and the goal date was 7/17/15. The approaches read, Resident is prescribed [MEDICATION NAME] ER 2.5 MG Tablet by mouth daily for DM (Diabetes Mellitus) and Monitor for S/SX (signs symptoms) of hypo/[MEDICAL CONDITION]. Record review revealed the facility failed to implemented Resident #1's care plan by allowing an unlicensed Student Nurse to administered two (2) units of regular insulin to the resident without a physician orders [REDACTED]. Review of the facility's investigation report revealed on Sunday 6/21/15 at approximately 5:15 PM a student nurse took Resident #1's blood sugar with a result of 158. The student nurse proceeded to administer two (2) units of regular sliding scale insulin to Resident #1. According to the report, on Monday June 22, 2015, the RP reported LPN #2 explained that Resident #1 was not on sliding scale insulin. Interview on 7/8/15 at 1:35 AM, with LPN #1 confirmed she failed to follow Resident #1's care plan by allowing the Student Nurse to administer two units of regular insulin unsupervised to Resident #1 without a physician's orders [REDACTED]. Resident #1's June 2015, Physician order [REDACTED]. Review of June 2015, Physician order [REDACTED]. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 6/3/15 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of 7/1/15 revealed a Brief Interview for Mental Status (BIMS) score of 14 that indicated the resident was cognitively intact. Resident #4 Review of facility's Care Plan for Resident #4 revealed the Problem Onset: 1/6/15 Resident is continent of urine via 20 French/10 cc (cubic centimeters) Foley catheter r/t (related to) wounds and is at risk for UTIs (Urine Tract Infections). The Goal for this problem was No complications r/t Foley catheter. An approach read, Change Foley catheter with 20 French with 10 cc bulb on the 26th of every month using sterile technique Secure with leg strap. Resident #4's July 2015 Physician order [REDACTED]. Observation on 7/8/15 at 3:30 PM, of Registered Nurse (RN) #2 and Licensed Practical Nurse/Treatment Nurse (LPN) #3 providing wounds care for Resident #4 revealed the resident's indwelling Foley catheter tubing was not secured. The facility nurses failed to secure the catheter tubing while changing the resident's positions during the treatments of Resident #4's wounds. On 7/8/15 at 4:40 PM an interview with LPN #3 confirmed Resident #4's indwelling catheter tubing was not secured. In an interview on 7/9/15 at 5:35 PM with the Director of Nurses (DON), the DON explained the nursing staff was to follow the care plan and ensure Resident #4's Foley catheter tubing was secured. Review of Resident #4's Face Sheet revealed the facility admitted the resident on 1/26/15, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for Resident #4 with an Assessment Reference Date of 4/28/15 revealed Cognitive skills for Daily Decision Making was a three (3), Severely impaired-never/rarely made decisions. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 7/22/15 for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following measures to remove the IJ. Immediate actions: 1. On 6-24-15 at 2:30 pm the Assistant Director of Nursing began to investigate the alleged incident. 2. The Assistant Director of Nursing validated that Residents #1 current condition was stable 6/24/15 approximately 2:30 pm. - No adverse reaction was noted. The Electronic Medical Administration Record shows that resident #1 blood sugar on June 215' before supper was 158. 6/22 - 145, 6/23 - 233, 6/24 - 117. 3. The Assistant Director of Nursing reviewed other residents on the hallway with Diabetes 6/24/15 at approximately 2:45 pm and no other resident was noted with adverse reactions. 4. On 6/24/15 the Assistant Director of Nursing validated that student nurse #1 did give the insulin in the lobby to Resident #1 on 6/21/15 at 6:29 pm unsupervised by LPN #1. 5. The facility Medical Director was also notified on the incident 6-24-15 at 2:46 pm. 6. On 6-24-15 at 2:46 pm the facility notified Resident #1 primary care physician and responsible party. 7. On 6/25/15 approximately 10 am the Quality Assurance Nurse #2 interviewed Resident #1. He is cognitively intact and he remembered getting an injection on Sunday 6/21/15. Asked if he had any problems from the injections and he said No, I am doing well. 8. On 6/25/2015 about 12:30 pm Quality Assurance Nurse #2 notified the Nursing Instructor #1 from local community college. Instructor #1, instructor #2, Instructor #3 and the nursing student #1 came to the facility 6/25/15 at approximately 2:30 pm to discuss the incident and to review the preceptor process. Registered Nursing Program Director was also made aware by the other instructors on 6/25/15 at approximately 12:30 pm. It was decided in the meeting that the local community college would implement a class for students before the next preceptorship in the fall to prepare student for preceptor program. The instructors agreed that all students will complete a Pharmacology final check off sheet prior to starting the preceptor program. 9. On 6/25/15 Resident arm bands were checked and replaced as needed on every resident with the exception of residents refusing to wear the arm band. This is reflected in their care plan that arm bands were placed on their wheelchairs. An entry to document placement of arm bands was placed on Medication Administration Record to be checked every shift by the medication nurses. 10. On 6-25-15 approximately 2:00 pm the Pharmacy consultant was notified of the incident and provided the facility information for the in-service which included: a. There is an acceptable time when taking blood sugars and giving insulin. You do not take every blood sugar and then go back and give the insulin. It is too much time difference, b. How to identify residents: by picture on the EMAR and that it can be enlarged by tapping the picture, resident's name outside the door, arm bands on wrist, ask C.N.A.'s and nurses, and the resident. c. How to make sure that resident has an arm band: It will be placed on the E-MAR for nurses to sign every shift. d. Rules for facility nurses and student nurses: No accuchecks in common area or dining rooms. No insulin given in halls or dining rooms, give only behind closed doors. No meds given in dining room after the trays come out. Do not leave meds at bedside table for resident to take on their own. You must watch resident swallow the medication. Insulin if needed should follow glucometer check immediately. When there is a preceptor, nurse must stay with preceptor and do not have them doing anything without nurse. if the preceptor prepares the medication, she must give it. If the nurse prepares the medication, she must give it. e. The 5 rights of medication administration: the right resident, the right drug, the right dose, the right route, the right time. f. Explain to resident what you are going to do at the time. g. Nurses and other staff to report unusual events to supervisor immediately. 11. In-servicing was started 6/25/2015 6:30 pm by Quality Assurance nurse #2 for nurses on Medication Administration- General Guidelines. 98% of nursing staff completed the in-service on 6/25/15 with completion date of 7/12 except for one employed on a part time basis completing the in-service 7/20/15 before being allowed to return to work. 12. The Pharmacy registered nurse consultant began med pass check-offs with medication nurses on June 30th and completed 6 med pass check-offs on 6/30/15. 13. Licensed Practical Nurse #1 was suspended 6/30/15 approximately 5:00 pm for failure to supervise Student Nurse #1. Licensed Practical Nurse #1 was required to take a Mississippi Board of Nursing approved 6 hour course: Medication Safety: Assuring Safe Outcomes and she successfully completed on 7/1/15, Licensed Practical Nurse #1 completed a Med Pass Check-off 7/2/15. 14. The Medication carts were checked by facility staff and the Director of Nursing on 7/10/15 at approximately 6:00 pm for any open undated multi dose vials. All multi dose vials had puncture dates. 15. On 7/10/15 at approximately 6:00 pm Licensed Practical Nurse #2 was questioned by the Director of Nursing about the incident of borrowing medication. Licensed Practical Nurse #2 was required to write a statement with an her action plan and understanding of what to do in the future when needing medication for a resident. 16. The Mississippi State Board of Health and the Mississippi Attorney General's office were verbally notified 6/25/2015. A written report was submitted to The Mississippi State Board of Health on 6/29/2015 and the Mississippi Attorney General's office 6/29/2015 at 10:49 am. The Mississippi State Board of Nursing was notified 07/10/2015 by mail. 17. An in-service was started on 7/21/15 at 4:30 pm by the Staff Development Nurse on Medication Guidelines including the administration of medication by following the physician orders, the medication ordering process, checking the Emergency Kit for medications if needed, do not borrow medications from one resident for another resident, documentation of medications immediately following administering to a resident, and dating multi-dose vials when opening. No nurse will be allowed to work until they have completed the in-service orientation. 18. On 6/25/2015 at 3:00 pm the Director of Nursing, Administrator, 2 Quality Assurance nurses, medical Director, and the Staff Development nurse conducted a Quality assurance meeting via conference call and discussed situation of the medication error and reviewed actions being taken to prevent further errors. On 7/10/2015 at 6:30 pm the Director of Nursing, Administrator, Quality Assurance nurses #1 and #2, Medical Director, and the Staff Development nurse conducted a Quality assurance meeting via conference call and discussed situation of the medication error found during survey 7/7/15 - 7/10/15 and reviewed actions being taken to prevent further errors. The Director of Nursing reviewed and revised the facility policies on 7/21/15 at 2:00 pm and presented for review and approval in the Quality Assurance meeting at 6:30 pm regarding: a. Medication Administration Staff Assessment and Orientation Tool -Changed to use the Pharmacy Medication audit form. b. Diabetic/[DIAGNOSES REDACTED] protocol - Updated to include the 4 ounces of orange juice to give for blood sugar less than 60. 19. Medication Pass check-offs were started by the Staff Development nurse on 7/21/15 at 5:00 pm for all medication nurses. All medication nurses will be checked off as they report to work and will not be allowed to return to work until completing the check-off. The facility alleged the Immediate Jeopardy was removed on 7/22/15. On, 7/23/15, the State Survey Agency (SA) validated the facility had implemented the following measures to remove the Immediate Jeopardy. An Acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services on 7/23/15. 1. The SA validated by interview and record review the Assistant Director of Nursing (ADON) began to investigate the alleged incident on 6/24/15. 2. The SA validated by record review of the nurses notes that the facility assessed Resident #1 on 6/21/15 through 6/24/15 for signs and symptoms of adverse effects related to the medication error. 3. The SA validated through documentation of nurses notes that the ADON assessed other residents with Diabetes on 6/24/15 and the residents showed no signs and symptoms of adverse reaction. 4. The SA verified by record review and interviews that the ADON validated on 6/21/15 the student nurse did give the insulin in the lobby to Resident #1 and was not supervised. 5. The SA verified by telephone interview and record review the ADON notified the Medical Director on 6/24/15 of the medication error. 6. The SA validated by interview and record review on 6/24/14 the ADON notified Resident #1's primary care physician and RP of the medication error. 7. The SA surveyor validated by record review and interview the Quality Assurance Nurse #2 interviewed Resident #1 on 6/25/15 and the resident was cognitively intact and reported no problems. 8. The SA verified by interview, and record review with the ADON that on 6/25/15 the facility notified the Nursing Program Director and the Instructor at the Community College of the medication error on 6/25/15. 9. The SA verified nurses attendance by interview and review of the sign in sheets of the medication administration in-services on 6/25/15 on how to identify residents, reviewed residents' arm bands, reviewed physicians hypo/[MEDICAL CONDITION] protocol, rules for facility's nurses and student nurses, the five rights of medication administration, explain to resident what going on, and the nurses and other staff to report unusual events to supervisor immediately. 10. The SA verified by interview and record review that in-serving was started on 6/25/15 by Quality Assurance Nurse #2. The SA verified the nursing staff completed the in-service on 7/12/15 with the exception of one employee on a part time basis required to complete the training before being allowed to return to work. 11. The SA verified by interview and record review the Pharmacy Registered Nurse Consultant completed six (6) med pass check offs on 6/30/15. 12. The SA verified by interview and record review that LPN #1 was suspended on 6/30/15 and then required to take a Mississippi Board of Nursing approved six (6) hours course and passed the Medication Safety: Assuring Safe Outcomes test on 7/1/15. LPN #1 completed a med pass check-off 7/2/15. SA validated LPN #1's test results and med pass check off by employee file review. 13. The SA verified by interview and observation the DON and other facility staff checked the medication carts for any opened undated multi-dose vials and checked that multi dose vials had puncture dates on 7/10/15. 14. The SA validated by interview and written documentation on 7/10/15 that LPN #2 wrote an action plan to know what to do in the future when med was needed for a resident. 15. The SA validated by interview, and written documentation the Mississippi State Board of Health and the Mississippi Attorney General's office was verbally notified on 6/25/2015. A written report was submitted to the Mississippi State Board of Health and the Mississippi Attorney General's office 6/29/15, and the Mississippi State Board of Nursing was notified by mail on 7/10/15. 16. The SA verified by interview, and record review an in-service was start on 7/25/15 by the Staff Development Nurse on Medication General Guidelines including the administration of medication by following the physician orders, medication ordering process, checking the Emergency kit for medication if needed, do not borrow medications from one resident for another resident, and dating multi-dose vials when opening. The SA validated no nurse was allowed to work until completion of the in-service orientation. 17. The SA verified by interview, and record review on 6/25/15 the DON, Administrator, two (2) Quality Assurance Nurses, the Medical Director, and the Staff Development nurse conducted a QA meeting via conference call, and discussed the medication error and reviewed actions being taken to prevent further errors. The SA verified by interview, and record review another QA meeting was held on 7/10/15 with the DON, Administrator, Quality Assurance Nurses #1 and #2, the Medical Director, and the Staff Development nurse via conference call. The QA Committee discussed the situation during survey, 7/7/15 - 7/10/15, and reviewed actions being taken to prevent further error. The facility policies were reviewed and approved in the Quality Assurance meeting regarding: a. Medication Administration Staff Assessment and Orientation Tool-Changed to use the Pharmacy Medication audit form. b. Diabetic/[DIAGNOSES REDACTED] protocol - Updated to include the four (4) ounces of orange juice to give for blood sugar less then 60. 18. The SA verified by interview and record review the Medication Pass check-off was started by the Staff Development nurse on 7/21/15 for all medication nurses. All medication nurses were checked off as they reported to work and were not allowed to return to work until completing the check off. The SA validated the facility showed substantial compliance as of 7/22/2015 to remove the Immediate Jeopardy.

Based on review of the facility medication error report and incident report, staff interview, record review, and facility policy review, the facility failed to ensure that Resident #1 was free of any significant medication errors for one (1) of six (6) residents reviewed. The facility's failure to prevent a significant medication error on 06/21/15 when the facility's Licensed Practical Nurse (LPN) allowed an unsupervised student nurse to administer insulin without a physician's orders [REDACTED].#1 and other residents of the facility in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) conducted an abbreviated complaint survey from 7/7/15 through 7/10/15. During the investigation, the State Agency found the facility not in compliance with requirements for participation in Medicare and Medicaid and cited regulatory deficiencies. Based on State Agency (SA) Administrative review, and Quality Assurance review, it was determined the facility was not in past noncompliance and a partial extended survey was required due to the State Surveyor's identification on 7/7/15 and 7/10/15 of facility staff borrowing insulin from another resident and unlabeled and undated punctured insulin vials in the medication carts. The State Agency notified the facility of the removal of the past noncompliance and changed the findings to Immediate Jeopardy on 7/21/15. The SA re-entered the facility and conducted an extended survey from 07/21/15 through 07/23/15. The State Agency identified an Immediate Jeopardy (IJ) that began on 6/21/15 when the student nurse, being precepted by a facility nurse, administered insulin unsupervised to Resident #1 who did not have an order for [REDACTED]. The facility submitted a Credible Allegation of Compliance (AoC) and alleged removal of the IJ on 7/22/15. The SA validated the credible AoC on 7/23/15 and determined the IJ was removed 7/22/15. Therefore, the scope and severity were lowered to a D for 42 CFR 483.25(m)(2) Free of Significant Medication Errors (F333) while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy entitled, Medication Administration-Preparation and General Guidelines, dated 06/2011, revealed Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions of if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. supplied for one resident are never administered to another resident. Review of a Medication Error Report dated 6/24/15 revealed on 6/21/15 between 5:15 and 6:00 PM, LPN #1 allowed an unlicensed unsupervised Student Nurse to administer 2 units of Regular Insulin to Resident #1. The resident did not have sliding scale insulin ordered. LPN #1 was assigned as a preceptor for the Student Nurse. Resident #1 received the 2 units of insulin in error based on Resident #6's Sliding Scale Insulin Medication Administration Record. Resident #6 was Resident #1's roommate. Review of Resident #1's June 2015 Physician order [REDACTED]. The Physician order [REDACTED]. Interview on 7/7/15 at 7:05 PM with Resident #1's RP revealed that on Sunday 6/21/15, a Student Nurse administered 2 units of insulin to the resident unsupervised. On Monday, June 22, 2015, the RP reported this to the facility and LPN #2 said Resident #1 was not on sliding scale insulin. On 7/9/15 at 1:15 PM, an interview with Resident #1 revealed he remembered receiving the insulin injection and had no problem with the injection. Resident #1 stated he had no problem with the facility's care or meals. Review of the facility's investigation for Resident #1 revealed on 6/24/15 at approximately 9:00 AM Resident #1's Responsible Party (RP) reported to the Registered Nurse/Charge Nurse that on Sunday 6/21/15 at approximately 5:15 PM, the student nurse took Resident #1's blood sugar, and the blood sugar reading was 158. The RP reported the student nurse then administered two (2) units of regular sliding scale insulin to Resident #1. The RP reported LPN #2 said on Monday, June 22 that Resident #1 was not on sliding scale insulin. Interview with LPN #1 on, 7/8/15 at 1:35 AM, confirmed she allowed the Student Nurse to administer 2 units of regular insulin unsupervised. LPN #1 reported she was made aware of the above medication error by the Assistant Director of Nurses on 6/24/15. On 7/10/15 at 10:53 AM, the Nursing School Director and the Instructor from the local community college reported the Student Nurse informed them on 6/25/15 that she made an error by administering two (2) units of Regular Insulin to Resident #1. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 6/3/15, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of 7/1/15, revealed a Brief Interview for Mental Status (BIMS) score of 14 that indicated the resident was cognitively intact. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 7/22/15 for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following measures to remove the IJ. Immediate actions: 1. On 6-24-15 at 2:30 pm the Assistant Director of Nursing began to investigate the alleged incident. 2. The Assistant Director of Nursing validated that Residents #1 current condition was stable 6/24/15 approximately 2:30pm. - No adverse reaction was noted. The Electronic Medical Administration Record shows that resident #1 blood sugar on June 215' before supper was 158. 6/22 - 145, 6/23 - 233, 6/24 - 117. 3. The Assistant Director of Nursing reviewed other residents on the hallway with Diabetes 6/24/15 at approximately 2:45 pm and no other resident was noted with adverse reactions. 4.On 6/24/15 the Assistant Director of Nursing validated that student nurse #1 did give the insulin in the lobby to Resident #1 on 6/21/15 at 6:29 pm unsupervised by LPN #1. 5. The facility Medical Director was also notified on the incident 6-24-15 at 2:46 pm. 6. On 6-24-15 at 2:46 pm the facility notified Resident #1 primary care physician and responsible party. 7. On 6/25/15 approximately 10 am the Quality Assurance Nurse #2 interviewed Resident #1. He is cognitively intact and he remembered getting an injection on Sunday 6/21/15. Asked if he had any problems from the injections and he said No, I am doing well. 8. On 6/25/2015 about 12:30 pm Quality Assurance Nurse #2 notified the Nursing Instructor #1 from local community college. Instructor #1, instructor #2, Instructor #3 and the nursing student #1 came to the facility 6/25/15 at approximately 2:30 pm to discuss the incident and to review the preceptor process. Registered Nursing Program Director was also made aware by the other instructors on 6/25/15 at approximately12:30 pm. It was decided in the meeting that the local community college would implement a class for students before the next preceptorship in the fall to prepare student for preceptor program. The instructors agreed that all students will complete a Pharmacology final check off sheet prior to starting the preceptor program. 9. On 6/25/15 Resident arm bands were checked and replaced as needed on every resident with the exception of residents refusing to wear the arm band. This is reflected in their care plan that arm bands were placed on their wheelchairs. An entry to document placement of arm bands was placed on Medication Administration Record to be checked every shift by the medication nurses. 10. On 6-25-15 approximately 2:00 pm the Pharmacy consultant was notified of the incident and provided the facility information for the in-service which included: a. There is an acceptable time when taking blood sugars and giving insulin. You do not take every blood sugar and then go back and give the insulin. It is too much time difference, b. How to identify residents: by picture on the EMAR and that it can be enlarged by tapping the picture, resident's name outside the door, arm bands on wrist, ask C.N.A.'s and nurses, and the resident. c. How to make sure that resident has an arm band: It will be placed on the E-MAR for nurses to sign every shift. d. Rules for facility nurses and student nurses: No accuchecks in common area or dining rooms. No insulin given in halls or dining rooms, give only behind closed doors. No meds given in dining room after the trays come out. Do not leave meds at bedside table for resident to take on their own. You must watch resident swallow the medication. Insulin if needed should follow glucometer check immediately. When there is a preceptor, nurse must stay with preceptor and do not have them doing anything without nurse. if the preceptor prepares the medication, she must give it. If the nurse prepares the medication, she must give it. e. The 5 rights of medication administration: the right resident, the right drug, the right dose, the right route, the right time. f. Explain to resident what you are going to do at the time. g. Nurses and other staff to report unusual events to supervisor immediately. 11. In-servicing was started 6/25/2015 6:30 pm by Quality Assurance nurse #2 for nurses on Medication Administration- General Guidelines. 98% of nursing staff completed the in-service on 6/25/15 with completion date of 7/12 except for one employed on a part time basis completing the in-service 7/20/15 before being allowed to return to work. 12. The Pharmacy registered nurse consultant began med pass check-offs with medication nurses on June 30th and completed 6 med pass check-offs on 6/30/15. 13. Licensed Practical Nurse #1 was suspended 6/30/15 approximately 5:00 pm for failure to supervise Student Nurse #1. Licensed Practical Nurse #1 was required to take a Mississippi Board of Nursing approved 6 hour course: Medication Safety: Assuring Safe Outcomes and she successfully completed on 7/1/15, Licensed Practical Nurse #1 completed a Med Pass Check-off 7/2/15. 14. The Medication carts were checked by facility staff and the Director of Nursing on 7/10/15 at approximately 6:00 pm for any open undated multi dose vials. All multi dose vials had puncture dates. 15. On 7/10/15 at approximately 6:00 pm Licensed Practical Nurse #2 was questioned by the Director of Nursing about the incident of borrowing medication. Licensed Practical Nurse #2 was required to write a statement with an her action plan and understanding of what to do in the future when needing medication for a resident. 16. The Mississippi State Board of Health and the Mississippi Attorney General's office were verbally notified 6/25/2015. A written report was submitted to The Mississippi State Board of Health on 6/29/2015 and the Mississippi Attorney General's office 6/29/2015 at 10:49 am. The Mississippi State Board of Nursing was notified 07/10/2015 by mail. 17. An in-service was started on 7/21/15 at 4:30 pm by the Staff Development Nurse on Medication Guidelines including the administration of medication by following the physician orders, the medication ordering process, checking the Emergency Kit for medications if needed, do not borrow medications from one resident for another resident, documentation of medications immediately following administering to a resident, and dating multi-dose vials when opening. No nurse will be allowed to work until they have completed the in-service orientation. 18. On 6/25/2015 at 3:00 pm the Director of Nursing, Administrator, 2 Quality Assurance nurses, medical Director, and the Staff Development nurse conducted a Quality assurance meeting via conference call and discussed situation of the medication error and reviewed actions being taken to prevent further errors. On 7/10/2015 at 6:30 pm the Director of Nursing, Administrator, Quality Assurance nurses #1 and #2, Medical Director, and the Staff Development nurse conducted a Quality assurance meeting via conference call and discussed situation of the medication error found during survey 7/7/15 - 7/10/15 and reviewed actions being taken to prevent further errors. The Director of Nursing reviewed and revised the facility policies on 7/21/15 at 2:00 pm and presented for review and approval in the Quality Assurance meeting at 6:30pm regarding: a. Medication Administration Staff Assessment and Orientation Tool -Changed to use the Pharmacy Medication audit form. b. Diabetic/[DIAGNOSES REDACTED] protocol - Updated to include the 4 ounces of orange juice to give for blood sugar less than 60. 19. Medication Pass check-offs were started by the Staff Development nurse on 7/21/15 at 5:00pm for all medication nurses. All medication nurses will be checked off as they report to work and will not be allowed to return to work until completing the check-off. The facility alleged the Immediate Jeopardy was removed on 7/22/15. On, 7/23/15, the State Survey Agency (SA) validated the facility had implemented the following measures to remove the Immediate Jeopardy. An Acceptable Credible Allegation of Compliance was verified by staff interviews, and record review of in-services on 7/23/15. 1. The SA validated by interview and record review the Assistant Director of Nursing (ADON) began to investigate the alleged incident on 6/24/15. 2. The SA validated by record review of the nurses notes that the facility assessed Resident #1 on 6/21/15 through 6/24/15 for signs and symptoms of adverse effects related to the medication error. 3. The SA validated through documentation of nurses notes that the ADON assessed other residents with Diabetes on 6/24/15 and the residents showed no signs and symptoms of adverse reaction. 4. The SA verified by record review and interviews that the ADON validated on 6/21/15 the student nurse did give the insulin in the lobby to Resident #1 and was not supervised. 5. The SA verified by telephone interview and record review the ADON notified the Medical Director on 6/24/15 of the medication error. 6. The SA validated by interview and record review on 6/24/14 the ADON notified Resident #1's primary care physician and RP of the medication error. 7. The SA surveyor validated by record review and interview the Quality Assurance Nurse #2 interviewed Resident #1 on 6/25/15 and the resident was cognitively intact and reported no problems. 8. The SA verified by interview, and record review with the ADON that on 6/25/15 the facility notified the Nursing Program Director and the Instructor at the Community College of the medication error on 6/25/15. 9. The SA verified nurses attendance by interview and review of the sign in sheets of the medication administration in-services on 6/25/15 on how to identify residents, reviewed residents' arm bands, reviewed physicians hypo/[MEDICAL CONDITION] protocol, rules for facility's nurses and student nurses, the five rights of medication administration, explain to resident what going on, and the nurses and other staff to report unusual events to supervisor immediately. 10. The SA verified by interview and record review that in-serving was started on 6/25/15 by Quality Assurance Nurse #2. The SA verified the nursing staff completed the in-service on 7/12/15 with the exception of one employee on a part time basis required to complete the training before being allowed to return to work. 11. The SA verified by interview and record review the Pharmacy Registered Nurse Consultant completed six (6) med pass check offs on 6/30/15. 12. The SA verified by interview and record review that LPN #1 was suspended on 6/30/15 and then required to take a Mississippi Board of Nursing approved six (6) hours course and passed the Medication Safety: Assuring Safe Outcomes test on 7/1/15. LPN #1 completed a med pass check-off 7/2/15. SA validated LPN #1's test results and med pass check off by employee file review. 13. The SA verified by interview and observation the DON and other facility staff checked the medication carts for any opened undated multi-dose vials and checked that multi dose vials had puncture dates on 7/10/15. 14. The SA validated by interview and written documentation on 7/10/15 that LPN #2 wrote an action plan to know what to do in the future when med was needed for a resident. 15. The SA validated by interview, and written documentation the Mississippi State Board of Health and the Mississippi Attorney General's office was verbally notified on 6/25/2015. A written report was submitted to the Mississippi State Board of Health and the Mississippi Attorney General's office 6/29/15, and the Mississippi State Board of Nursing was notified by mail on 7/10/15. 16. The SA verified by interview, and record review an in-service was start on 7/25/15 by the Staff Development Nurse on Medication General Guidelines including the administration of medication by following the physician orders, medication ordering process, checking the Emergency kit for medication if needed, do not borrow medications from one resident for another resident, and dating multi-dose vials when opening. The SA validated no nurse was allowed to work until completion of the in-service orientation. 17. The SA verified by interview, and record review on 6/25/15 the DON, Administrator, two (2) Quality Assurance Nurses, the Medical Director, and the Staff Development nurse conducted a QA meeting via conference call, and discussed the medication error and reviewed actions being taken to prevent further errors. The SA verified by interview, and record review another QA meeting was held on 7/10/15 with the DON, Administrator, Quality Assurance Nurses #1 and #2, the Medical Director, and the Staff Development nurse via conference call. The QA Committee discussed the situation during survey, 7/7/15 - 7/10/15, and reviewed actions being taken to prevent further error. The facility policies were reviewed and approved in the Quality Assurance meeting regarding: a. Medication Administration Staff Assessment and Orientation Tool-Changed to use the Pharmacy Medication audit form. b. Diabetic/[DIAGNOSES REDACTED] protocol - Updated to include the four (4) ounces of orange juice to give for blood sugar less then 60. 18. The SA verified by interview and record review the Medication Pass check-off was started by the Staff Development nurse on 7/21/15 for all medication nurses. All medication nurses were checked off as they reported to work and were not allowed to return to work until completing the check off. The SA validated the facility showed substantial compliance as of 7/22/2015 to remove the Immediate Jeopardy.

Based on staff interview, family interview, policy review, and record review for one(1) of six (6) closed records, the facility failed to honor Resident 23's rights as requested in his advanced directive for a full code status. The facility failed to administer Cardio-Pulmonary Resuscitation (CPR) and failed to contact emergency personnel when Resident #23 was found unresponsive by Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2 on [DATE] at 1:05 a.m. The facility's failure to honor Resident #23's advance directive of a full code status and to initiate CPR, placed residents with advance directives of full code status in a situation that was likely to cause serious injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:05 p.m. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 3:08 p.m. The IJ was identified beginning on [DATE] and was removed on [DATE]. Based on the facility's implementation of corrective actions and the verification of corrective actions outlined in the AoC, the IJ was lowered from a "J" to a "D", which constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. **Upon direction of CMS, additional verification of the AoC and the facility's corrective actions was conducted by the state agency on [DATE]-[DATE]. The facility will remain out of substantial compliance with F-155, 42CFR 483.10 (b) (4) Right to Refuse; Formulate Advance Directives while the facility develops and implements a Plan of Correction to achieve substantial compliance with the regulation and while the facility's QA Program continues to monitor the effectiveness of staff education/in-services regarding facility policy and procedures related to honoring advance directives and the chart audits regarding accuracy of the residents' advanced directives. Findings include: Resident #23 Cross refer to F-309 for the facility's failure to provide appropriate care for Resident #23 by failing to administer Cardio-Pulmonary Resuscitation (CPR) and failure to contact emergency personnel. Resident #23 was determined to have a full code status and was found unresponsive on [DATE] at 1:05 a.m. by Registered Nurse (RN #1) and Licensed Practical Nurse (LPN #2). The facility's failure to honor Resident #23's full code status by not performing CPR and by not contacting emergency personnel when he was found unresponsive in his room by RN #1 and LPN #2, was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:05 p.m. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 3:08 p.m. The IJ was identified beginning on [DATE] and removed on [DATE]. Based on the facility's implementation of corrective actions and verification of those corrective actions, the IJ was removed. Upon direction of CMS, additional verification of the facility's corrective actions was conducted by the state agency on [DATE]-[DATE]. Resident #23 was admitted to (name of the facility) on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the (nurse's notes in the medical record stated that at 8:00 p.m., RN #1's entry stated, "While administering meds this writer noticed the resident needed to be suctioned. Upon trying to suction resident, he bit the yanker and shook his head no. When asked if he wanted to be suctioned he said no. Elevated the resident more and he stated he was not in any pain." The next entry by RN #1 was at [DATE], 11:30 p.m.: "Checked on resident and he was resting. Attempted to suction again with little success." "On [DATE] at 1:05 a.m., RN #1's entry in the record stated, "LPN #2 and this writer went to check on resident and discovered he had expired. " On [DATE] at 1:10 a.m., RN #1 ' s entry in the record stated, "Contacted RP, coroner, doctor, ADON (Assistant Director of Nursing) , Chaplain and left phone message for Administrator to advise them according to Windsor Place protocol. " On [DATE] at 1:30 a.m., RN #1 made another entry that stated: "deputy coroner official pronouncement." On [DATE] at 2:30 a.m., RN #1 recorded that, "Body released to the funeral home per family request." The incident occurred on the weekend of [DATE]. On [DATE] at 10:27 a.m., the Director of Nursing (DON) reviewed the nurse's notes of Resident #23 and determined that the documentation was not sufficient to address the code status of Resident #23 related to his death. The DON texted, [DATE], RN #1 (who was at her full time job) to come in to make a late entry about no cardio [MEDICAL CONDITION] resuscitation (CPR) being performed on Resident #23. RN #1 replied, "Ok, will do." RN #1 works full time at a hospital in Alabama, where RN's are authorized to pronounce death. RN #1 failed to make a late entry in Resident #23's medical record. On [DATE], RN #1 wrote the following statement: "Upon entering his room he was unresponsive, pupils fixed, body cold and arms mottled. CPR was not initiated related to the condition of the resident." RN #1's employment at the facility was terminated effective [DATE] for failure to comply with company policy and procedure. RN #1's failure to follow the code status election of the resident was reported to: the Mississippi Department of Health Abuse Hotline on [DATE] at 3:55 p.m.; the Attorney General of Mississippi on [DATE] at 3:57 p.m.; and the Mississippi Board of Nursing on [DATE] at 4:00 p.m. Immediately upon learning of the deficient occurrence on [DATE] at 2:30 p.m., in order to assure that this does not recur, and since the deficient practice had the potential to harm all residents, code status verification was performed on 100% of current residents to assure code status accuracy and compliance with the resident's wishes and or physician's orders [REDACTED]. This was completed by QA Nurse, MDs RN, Scheduler LPN, LPN #3, and LPN #4. In addition, the facility Staff Development Nurse immediately started in-servicing all nurses present on following the facility's CPR policy and Advance Directives Policy. The facility provided a credible Allegation of Compliance (AoC) on [DATE] at 4:30 p.m. ALLEGATION OF COMPLIANCE The following actions were implemented to ensure that the deficient practice does not recur: 1) Facility has reviewed code status of all residents to verify code status and proper placement of the status in the resident's medical record. 2) Code status continues to be indicated in the resident medical record on the first page of the record. Code status will be either Full Code or Do Not Resuscitate (DNR). 3) All nursing staff was present on [DATE], at 5:00 p.m., and have been in-serviced on proper Code Status procedures to include how to identify the status of each resident and to initiate resuscitation cardio [MEDICAL CONDITION] resuscitation (CPR) on Full Code residents until authorized to stop by a physician. 4) All nurses will be in-serviced on the facility policy and procedure prior to assuming duties and sign the in-service attendance record to indicate their understanding of policy and their intention to comply. (A copy of the facility Advance Directives and Cardio [MEDICAL CONDITION] Resuscitation policies are attached.) 5) By 6:00 p.m., on [DATE], all nurses, with the exception of two nurses that were not scheduled to work, will have completed the in-service training and no nurse will be allowed to assume shift duties without completing the training to observe Windsor Place's policies on CPR and Advance Directives. In addition all nurses will become certified to perform CPR according to American Heart Association (AHA) no later than [DATE]. 6) The admission's nurse will obtain the code status of each resident from the resident/responsible party/physician upon admission and place the notification page in the resident's medical record as the first page of the record. The desk nurse will update all changes in the medical record. New nurses will continue to review the facility policy regarding crash cart use, Advance Directives and Cardio [MEDICAL CONDITION] Resuscitation during orientation. The following new practices will be implemented: a) All nurses will become CPR certified by American Heart Association certified instructor, receive training on crash cart, CPR policy, and Advance Directive Policy on a yearly basis. b) Nurses will be in serviced monthly for 6 months on facility code status procedures to include identifying the code status of each resident by checking the first page of the resident's medical record and to review the facility cardio [MEDICAL CONDITION] (CPR) policy. Windsor Place intends to monitor the performance in the following ways: ? Medical Records Clerk will verify the placement of the code status page at the front of the resident's medical record upon admission and with each change in code status and notify the Quality Assurance (QA) Nurse, Director of Nursing (DON) and Administrator weekly of code status changes for six months. ? ? The QA nurse will spot check 10% of the resident's code status for accuracy and report findings to the Quality Assurance Committee monthly to assure continued compliance. Upon direction of CMS, additional verification of the facility's corrective actions was conducted by the state agency on [DATE]-[DATE] which included the following: 1. Review of RN #1's personnel file revealed that termination was effective [DATE] for failure to comply with full code status during a resident code. 2. Review of fax confirmations dated [DATE] and review of the facility's written reports revealed that the Mississippi State Department of Health, Board of Nursing, and the Attorney General's office was notified concerning the incident with Resident #23's code status. 3. Review of an "Advanced Directive Audit" dated [DATE] and interview with the QA Nurse, MDS RN #A, Scheduler LPN, LPN #A and MDS RN #B on [DATE] at 10:00 a.m., revealed that 100% of Resident charts were reviewed on [DATE] to ensure that each resident's code status was verified and in compliance with the physician's orders [REDACTED]. 4. Review of an in-service with an initiation date of [DATE] and completed [DATE] that was cross-referred to the nursing roster and [DATE] nursing schedule revealed that all licensed nurses were trained, prior to working the next shift, on the Cardio-Pulmonary Resuscitation policy/procedure which included CPR to be initiated for residents in the event of cardio-pulmonary arrest, unless MD orders and Advanced Directives specify DNR (Do not resuscitate) status and that CPR was to continue until EMS staff arrive and take over. Training also included the location of the code to be the first page in the medical record. 5. Review of a monthly in-service dated [DATE] revealed that licensed nurses and CNAs were trained on Advanced Directives with update, CPR policy, crash cart/equipment review and abuse/neglect. 6. Random interviews with licensed nurses on all three shifts on [DATE], (15 on ,[DATE], 7 on ,[DATE] and 5 on ,[DATE]) revealed that they had attended training on the facility's CPR/Advanced Directive policy/procedure which included the location of the code status in the front of the resident's chart, activating 911 and initiating CPR if the Resident was a full code, continuing CPR until EMS arrived or the MD ordered CPR to stop, and location and checking supplies on the crash cart. 7. Review of a "CPR Certification" Roster revealed that all licensed nurses were currently certified in CPR and no certifications were out of date. All certifications reviewed in a binder at the facility and cross referred to the current nursing schedule to ensure that all licensed nurses were certified. 8. A written statement from the Administrator on [DATE] verified that no new licensed nurses had been hired since [DATE]. 9. Review of a "Code Status Verification" form and interview with the Medical Records Clerk on [DATE] at 10:30 a.m. revealed that newly admitted residents were reviewed to verify proper documentation and placement of the code status in the medical record as well as any new changes in code status for residents. 10. Review of a "Code Status of Residents" form dated February 2013 and interview with the QA Nurse on [DATE] at 9:50 a.m. revealed that 10% or 14 residents were reviewed on February 28, 2013 to ensure accuracy of resident's code status that included verifying the code status on the Advanced Directive, Signed physician's orders [REDACTED]. 11. Review of the " Monthly Quality Assurance Committee Meeting " sign in sheet and agenda dated [DATE] revealed that the audits for code status were completed and discussed. 12. Random review of five (5) resident charts on all (3) stations on [DATE] revealed that the code status, advanced directive information, and orders all matched and were placed appropriately in the front of the resident's chart. 13. Review of six (6) sampled and four (4) un-sampled resident's records revealed that the code status, advanced directives and physician's orders [REDACTED]. 14. Review of the "Discharge Report from [DATE]-[DATE] revealed that there had been six (6) residents that expired in the facility. Of the six (6), all had physician's orders [REDACTED]. Nurse's notes of the six (6) residents were reviewed for completeness of documentation and appropriate actions per code policy.

Based on staff interview, record review, and facility policy review, the facility failed to provide appropriate care for Resident #23 by failing to administer Cardio-Pulmonary Resuscitation (CPR) and failed to contact emergency personnel for one (1) of six (6) closed records (Resident #23). Resident #23 was determined to have a full code status and was found unresponsive on [DATE] at 1:05 a.m., by Registered Nurse (RN#1) and Licensed Practical Nurse (LPN #2), The facility's failure to provide CPR and contact emergency personnel placed all residents with full code status in a situation that was likely to cause serious injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:05 p.m. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 3:08 p.m. The IJ was identified beginning on [DATE] and was removed on [DATE]. **Upon direction of CMS, additional verification of the AoC and the facility's corrective actions was conducted by the state agency on [DATE]-[DATE]. Based on the facility's implementation of corrective actions and the verification of the corrective actions outlined in the AoC, the IJ was lowered from a "J" to a "D", which constitutes no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility will remain out of substantial compliance with F-309; 42CFR 483.25 Quality of Care - Provide Care Services for Highest Well-Being while the facility develops and implements a Plan of Correction to achieve substantial compliance with the regulation and while the facility's QA Program continues to monitor the effectiveness of staff education/in-services regarding proper code status procedures, facility policy and procedures, the implementation of Cardiopulmonary Resuscitation (CPR), the CPR certification for all nurses, and the audits of charts to ensure accuracy of residents' code status. Findings include: Resident #23 Review of Resident #23's medical record revealed that he was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident was admitted with [DIAGNOSES REDACTED]. Resident #23 had a Percutaneous Endoscopic [DEVICE] (peg tube). Review of Resident #23's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed that Resident #23 had a Brief Interview Mental Status (BIMS) score of 03, which indicated Resident #23 had severely impaired cognitive status. Review of Resident #23's admission documentation forms titled, "Resident/Family Consent for Cardiopulmonary Resuscitation" revealed that Resident #23's Responsible Party (RP) elected the statement, "I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in the case of an extreme emergency." This form was dated [DATE] and was signed by Resident #23's RP and witnessed by RN #2. Review of Resident # 23's record further revealed the form titled, "OBRA Directives, Acknowledgement Certificate." Resident #23's RP elected the statement, "Reject DNR. I direct that the facility to administer all available indicated medical care. In the event of cardiac or [MEDICAL CONDITION] arrest, CPR should be initiated if available. The facility may defer CPR to an emergency agency and reserves the right to do so." This form was dated [DATE] and was signed by Resident #23's RP and witnessed by RN #2. Review of the Daily Assignment Sheet for the 11:00 p.m. through 7:00 a.m. shifts on the night of [DATE] revealed that RN #1 and CNA #3 were assigned to Resident #23. Review of Resident #23's Nurses' Notes dated [DATE] at 8:00 p.m., documented by RN #1, revealed the following documentation: "While administering meds, this writer noticed the resident (Resident #23) needed to be suctioned. Upon trying to suction the resident, he hit the yanker and shook his head no. Elevated the resident more and he stated that he was not in any pain." On [DATE] at 11:30 p.m., RN #1 wrote, "Checked on resident (Resident #23) and he was resting. Attempted to suction again with little success." Next entry by RN #1 was dated [DATE] at 1:05 a.m. and stated, "(LPN #2) and this writer went to check on resident and discovered he had expired." Next entry dated [DATE] at 1:10 a.m., RN #1 wrote: "Contacted RP, Coroner, and contacted Resident #23 ' s physician, Assistant Director of Nursing (ADON ), Chaplain, and left message for Administrator to advise them according to Windsor Place protocol." On [DATE] at 1:30 a.m., RN #1 notated that the deputy coroner made an official pronouncement and that Resident #23's body was released to the funeral home on [DATE] at 2:30 a.m. No further documentation in Nurses' Notes was found in Resident #23's record. Review of the Certificate of Death revealed that Resident #23 was pronounced dead on [DATE] at 1:39 p.m. The cause of death was listed on the death certificate as "due to Cardiopulmonary Arrest and Hypertension [MEDICAL CONDITION]." This form was signed by the Deputy Medical Examiner and dated [DATE]. Interview with RN #1 on [DATE] at 2:30 p.m., completed by phone, and revealed that RN #1 recalled events of Resident #23's condition on [DATE] through [DATE]. RN #1 confirmed that Resident #23 had a full code status. RN #1 stated that Resident # 23 had "rattling in his chest which was not new." RN #1 confirmed attempts to suction twice but was unsuccessful. RN #1 confirmed that she did not attempt to call RP or physician regarding change in Resident #23's condition. RN #1 confirmed that no other staff, including Certified Nursing Assistant (CNA) reported any changes on Resident #23's condition between the hours of 8:00 p.m. on [DATE] and 1:05 a.m. on [DATE], when resident was found expired. RN #1 confirmed that she did not call 911 for emergency personnel and did not initiate CPR. RN #1 further confirmed that initiating CPR and calling 911 is facility protocol when finding a resident with no pulse or respirations that have a full code status. Interview with LPN #2 on [DATE] at 4:04 p.m., completed by phone, revealed that LPN #2 confirmed being with RN #1 when Resident #23 was found on [DATE] at 1:05 p.m. LPN #2 stated, "Rigor mortis had set in. I remember that particular case. He (Resident #23) was mottled and his mouth was open. It was obvious that he had been dead a while." LPN #2 confirmed that she did not initiate CPR or call 911. LPN #2 confirmed that she was not aware of RN #1 initiating CPR or calling 911. Interview with CNA #3 on [DATE] at 1:55 p.m., revealed that CNA #3 recalled Resident #23 and providing care to Resident #23 on [DATE]. CNA #3 stated that she entered Resident #23's room at 12:30 a.m. on [DATE] to provide incontinent care to resident and also stated that she was in room for ,[DATE] minutes. CNA #3 further stated that when she exited the room, Resident #23 was still alive and responsive. CNA #3 stated after exiting the room, she (CNA #3) went to the restroom and when she returned from the restroom was informed by RN #1 that Resident #23 had expired. CNA #3 could not recall if 911 emergency personnel were called or CPR initiated. CNA #3 confirmed that she could not recall being trained on procedures to take during a code situation. Interview with Resident #23' s RP on [DATE] at 3:20 p.m., confirmed that Resident #23 was admitted to facility on [DATE] after hospitalization for pneumonia and peg tube placement. RP stated, "I hoped that he would get stronger and he could go back to the assisted living." RP stated that she was at the facility on [DATE] to visit Resident #23 at 6:00 p.m. and remained at the facility about an hour. RP stated, "I had visited that afternoon and my father is usually talkative but he wasn't that afternoon and he was less responsive with fluid you could hear in his throat. His roommate told me that he had gurgled all day. I asked the nurse if he needed to go to the hospital and she told me, 'No, I don't think so. I think he will be fine.' "RP could not recall nurses name but relayed that she (RP) " thought she (nurse), was an LPN because she told me that she would get the RN to suction him because she could not do it. RP confirmed that she was not contacted throughout the evening with any changes or concerns until being notified that he had expired. RP further confirmed that she wanted all measures exhausted in the event that he stopped breathing. Interview with LPN #1 on [DATE] at 12:40 p.m., confirmed that LPN #1 was responsible for Resident #23's care on [DATE] from 7:00 a.m. until 7:00 p.m. LPN #1 recalled that RP was present while she attempted to suction Resident #23 at the end of her shift and that Resident #23 would not allow her to do this, "shaking his (Resident #23's) head no. " LPN #1 stated that she could not recall having a conversation with RP about sending Resident #23 to hospital and that Resident #23's vital signs had been normal. RN #2 interview on [DATE] at 11:00 a.m. revealed that RN #2 recalled completing admission documentation with Resident #23's RP and confirmed that she is responsible for completing admission paperwork with new residents in the facility. RN #2 confirmed that she discussed code status with RP, and RP elected Full Code status for Resident #23. RN #2 acknowledged her signature on both forms, "Resident/Family Consent for Cardiopulmonary Resuscitation" and "OBRA Directives, Acknowledgement Certificate", validating that she witnessed RP ' s signature and choice of full code status. When questioned as to the discussion of this election that she utilizes during routine admissions to facility, RN #2 stated, "We are capable of performing chest compressions and calling 911 if someone is found not breathing. We are certified to do that." RN #2 further recalled Resident #23, stating, "On that Friday, I thought that he was a little more alert. He acknowledged me, knew who I was during daily charting. I thought he was doing a little better that Friday." Interview with Resident #9, Resident #23's former roommate, on [DATE] at 11:00 a.m., revealed that Resident #9 recalled the night of [DATE]. Resident #9 stated, "He had been alert but he wasn't that night. They had come in there to suction him but he wouldn't let them, so they were just coming by ever so often to check on him until he died ." Review of Resident #9's MDS revealed a BIMS score of 15 with an ARD of [DATE], indicating resident was cognitively intact. Interview with DON on [DATE] at 11:15 a.m., Director of Nursing (DON) confirmed that she has not had training on when to detect when a deceased resident has entered into rigor mortis stage and does not expect that her staff would be able to assess that a resident would be in the rigor mortis stages. DON confirmed that the facility does not have a skills check off system or formal training in place to assess staffing ability to perform CPR or their knowledge of the crash cart and its location. Interview with DON on [DATE] at 2:30 p.m., DON confirmed that it is the facility protocol for the physician to be contacted, CPR performed and 911 contacted in the event that a full code resident is found without pulse or respirations. Interview with Resident #23's physician by phone on [DATE] at 9:35 a.m. revealed that he could not recall being notified related to Resident #23's condition. Review of Resident #23's physician orders on [DATE] at 1:15 a.m., revealed "Discharge to funeral home of choice." Signature of staff member is unreadable. No other Physician Orders noted in Resident #23's record for [DATE] or [DATE]. No physician orders were found during chart review that acknowledged Resident #23's election of Full Code status by RP. Interview with Staff Development Coordinator at [DATE] at 10:30 a.m., revealed that the facility does not require nursing staff including CNA's, to be CPR certified. Staff Development Coordinator also confirmed that they do not train on the use of the equipment on the crash cart or have any way to assess the staff's knowledge on how to perform CPR during a code. Staff Development Coordinator stated that they do not perform skills check off assessments on the crash cart or performing a code in the event of an emergency. Review of form titled, "Checklist for Emergency Care", reflected that RN #1 initialed that she checked the crash cart on [DATE] to ensure necessary supplies available. In-service documentation records for RN #1, provided by facility, were reviewed. The facility documented the form titled, "Additional In-service Hours" that RN #1 completed an in-service titled, "Abuse, neglect, exploitation/missing/damaged property" on [DATE] and "Abuse AG" dated [DATE]. Review of facility's provided documentation entitled, "In-Service Log", further recorded that RN # 1 completed in-service entitled, "Resident Abuse/Vulnerable person (Attorney General ' s Office)" on [DATE]. (Although documentation for in-services was provided by facility with dates and hours of RN #1's completed education at facility, no documentation of RN #1's signature was noted on these records.) Review of documentation provided by the facility revealed RN #1 has completed certification to provide CPR by the American Heart Association, issue date of [DATE], and also certified by the American Heart Association with Advanced Cardiovascular Life Support, with an issue date of [DATE]. The facility provided a letter regarding CPR certification and training, on [DATE]. Facility stated in this document, "The Windsor Place does not require CPR certification for nursing staff." This statement signed by the DON. Review of facility's policy and procedure "Resident Abuse" with no date of revision noted revealed: "It is the policy of this facility to strictly prohibit abuse, mistreatment, neglect, or exploitation of all residents." Review of the facility policy and procedure, "CPR Status" with a revision date of [DATE] stated, "Each resident's CPR status will be determined on admission and updated as requested by the resident and/or responsible party as reflected on the OBRA Advance Directive Forms and the Resuscitation Status Form." This policy further stated, "An order to do CPR will be obtained on the admission order and signed by the attending physician on residents as indicated by the Advanced Directive and the Resuscitation Status Form." The procedure outlined in the CPR Status Policy stated, "5. CPR orders will appear on the admission orders [REDACTED]." Review of the facility's policy and procedure on "Cardio-Pulmonary Resuscitation" with a revision date of ,[DATE], stated, "CPR will be initiated for a resident in the event of cardio-pulmonary arrest, unless M.D. Orders and Advance Directives specify DNR status or Limited Resuscitation Status." This policy further outlines steps for procedure of this policy stating, "1. Assess resident for vital signs and check for absence of pulse and/or respiration. 2. One staff member should call 911 and notify physician on call while other staff members initiate CPR. 3. Perform CPR according to current standards as established by AHA until EMS staff arrives and takes over CPR. 4. Chart all information regarding the incident in Nurse's Notes." Review of the facility's policy on "Advance Directives", with no revision date, revealed, "On the admission this facility shall provide information regarding advance directives to the resident and/or responsible party in accordance with state law." Review of the facility's policy titled, " Crash Cart," with no revision date, revealed "It is the policy of this facility for the crash cart located at each nurse's station to be checked every shift by the Charge Nurse and to document in log in binder at each crash cart." The Administrator and DON of the facility were notified at 3:15 p.m. on [DATE] of the Immediate Jeopardy (IJ) findings for Resident #23 and an Allegation of Compliance was requested. The facility submitted a credible AoC on [DATE]. ALLEGATION OF COMPLIANCE Resident #23 was admitted to Windsor Place Nursing and Rehab Center on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the record reflects that at 8 p.m., RN #1 entry stated "While administering meds this writer noticed the resident needed to be suctioned. Upon trying to suction resident, he bit the yanker and shook his head no. When asked if he wanted to be suctioned he said no. Elevated the resident more and he stated he was not in any pain. The next entry by RN #1 was at [DATE], 11:30 p.m.: "checked on resident and he was resting. Attempted to suction again with little success". On [DATE] at 1:05 AM, RN #1 entry in record stated "LPN #2 (proper name) and this writer went to check on resident and discovered he had expired." On [DATE]/at 1:10 AM RN #1 entry in record stated "Contacted RP (proper name), coroner (proper name), Dr (proper name), ADON (proper name), Chaplain (proper name)and left phone message for Administrator (proper name) to advise them according to Windsor Place protocol." On [DATE] at 1:30 AM RN #1 made another entry that stated: "deputy coroner (proper name) official pronouncement" . On [DATE] at 2:30 AM RN #1 recorded that "Body released to (proper name) funeral home per family request." The incident occurred on the weekend of [DATE]. On [DATE] at 10:27 am the Director of Nursing (DON) reviewed the nurse's notes of Resident #23 and determined that the documentation was not sufficient to address the code status of Resident #23 related to his death. The DON texted, [DATE], RN #1 (who was at her full time job) to come in to make a late entry about no cardio [MEDICAL CONDITION] resuscitation (CPR) being performed on Resident #23. RN #1 replied, "Ok, will do." RN #1 works full time at a hospital in Alabama, where RN's are authorized to pronounce death. RN #1 failed to make a late entry in Resident #23's medical record. On [DATE], RN #1 wrote a statement stating: "Upon entering his room he was unresponsive, pupils fixed, body cold and arms mottled. CPR was not initiated related to the condition of the resident." RN #1 ' s employment at Windsor Place was terminated effective [DATE] for failure to comply with company policy and procedure. RN #1's failure to follow the code status election of the resident was reported to the Mississippi Department of Health Abuse Hotline at 3:55 p.m. on [DATE], the Attorney General of Mississippi at 3:57 P.M. on [DATE] and the Mississippi Board of Nursing at 4:00 P.M. [DATE]. Immediately upon learning of the deficient occurrence at 2:30 P.M. on [DATE] and in order to assure that this does not recur and since the deficient practice has the potential to harm all residents, code status verification was performed on 100% of current residents to assure code status accuracy and compliance with the resident's wishes and or physician's order. Facility has reviewed code status of all residents to verify code status and proper placement of the status in the resident's medical record on [DATE]. This was completed by QA Nurse, MDS RN, Scheduler LPN, LPN 3, and LPN 4. In addition, the facility Staff Development Nurse immediately started in-servicing all nurses present on following facility CPR policy and Advance Directives Policy. The following actions were implemented to ensure that the deficient practice does not recur: 1) Facility has reviewed code status of all residents to verify code status and proper placement of the status in the resident's medical record. 2) Code status continues to be indicated in the resident medical record on the first page of the record. Code status will be either Full Code or Do Not Resuscitate (DNR). 3) All nursing staff was present on [DATE], at 5:00 p.m. , and have been in-serviced on proper Code Status procedures to include how to identify the status of each resident and to initiate resuscitation cardio [MEDICAL CONDITION] resuscitation (CPR) on Full Code residents until authorized to stop by a physician. 4) All nurses will be in-serviced on the facility policy and procedure prior to assuming duties and sign the in-service attendance record to indicate their understanding of policy and their intention to comply. (A copy of the facility Advance Directives and Cardio [MEDICAL CONDITION] Resuscitation policies are attached.) 5) By 6:00 p.m., on [DATE], all nurses, with the exception of two nurses that were not scheduled to work, will have completed the in-service training and no nurse will be allowed to assume shift duties without completing the training to observe Windsor Place's policies on CPR and Advance Directives. In addition all nurses will become certified to perform CPR according to American Heart Association (AHA) no later than [DATE]. 6) The admission's nurse will obtain the code status of each resident from the resident/responsible party/physician upon admission and place the notification page in the resident's medical record as the first page of the record. The desk nurse will update all changes in the medical record. New nurses will continue to review the facility policy regarding crash cart use, Advance Directives and Cardio [MEDICAL CONDITION] Resuscitation during orientation. The following new practices will be implemented: a) All nurses will become CPR certified by American Heart Association certified instructor, receive training on crash cart, CPR policy, and Advance Directive Policy on a yearly basis. b) Nurses will be in serviced monthly for 6 months on facility code status procedures to include identifying the code status of each resident by checking the first page of the resident's medical record and to review the facility cardio [MEDICAL CONDITION] (CPR) policy. Windsor Place intends to monitor the performance in the following ways: ? Medical Records Clerk will verify the placement of the code status page at the front of the resident's medical record upon admission and with each change in code status and notify the Quality Assurance (QA) Nurse, Director of Nursing (DON) and Administrator weekly of code status changes for six months. ? ? The QA nurse will spot check 10% of the resident's code status for accuracy and report findings to the Quality Assurance Committee monthly to assure continued compliance. Additional verification of the facility's corrective actions were conducted on [DATE]-[DATE] which included the following: 1. Review of RN #1's personnel file revealed that termination was effective [DATE] for failure to comply with full code status during a resident code. 2. Review of fax confirmations dated [DATE] and review of the facility's written reports revealed that the Mississippi State Department of Health, Board of Nursing, and the Attorney General's office was notified concerning the incident with Resident #23's code status. 3. Review of an "Advanced Directive Audit" dated [DATE] and interview with the QA Nurse, MDS RN #A, Scheduler LPN, LPN #A and MDS RN #B on [DATE] at 10:00 a.m., revealed that 100% of Resident charts were reviewed on [DATE] to ensure that each resident's code status was verified and in compliance with the physician's order and Advanced Directive chosen by the resident and/or family and properly placed in the medical record. 4. Review of an in-service with an initiation date of [DATE] and completed [DATE] that was cross-referred to the nursing roster and [DATE] nursing schedule revealed that all licensed nurses were trained, prior to working the next shift, on the Cardio-Pulmonary Resuscitation policy/procedure which included CPR to be initiated for residents in the event of cardio-pulmonary arrest, unless MD orders and Advanced Directives specify DNR (Do not resuscitate) status and that CPR was to continue until EMS staff arrive and take over. Training also included the location of the code to be the first page in the medical record. 5. Review of a monthly in-service dated [DATE] revealed that licensed nurses and CNAs were trained on Advanced Directives with update, CPR policy, crash cart/equipment review and abuse/neglect. 6. Random interviews with licensed nurses on all three shifts on [DATE], (15 on ,[DATE], 7 on ,[DATE] and 5 on ,[DATE]) revealed that they had attended training on the facility ' s CPR/Advanced Directive policy/procedure which included the location of the code status in the front of the resident's chart, activating 911 and initiating CPR if the Resident was a full code, continuing CPR until EMS arrived or the MD ordered CPR to stop, and location and checking supplies on the crash cart. 7. Review of a "CPR Certification" Roster revealed that all licensed nurses were currently certified in CPR and no certifications were out of date. All certifications reviewed in a binder at the facility and cross referred to the current nursing schedule to ensure that all licensed nurses were certified. 8. A written statement from the Administrator on [DATE] verified that no new licensed nurses had been hired since [DATE]. 9. Review of a "Code Status Verification" form and interview with the Medical Records Clerk on [DATE] at 10:30 a.m. revealed that newly admitted residents were reviewed to verify proper documentation and placement of the code status in the medical record as well as any new changes in code status for residents. 10. Review of a "Code Status of Residents" form dated February 2013 and interview with the QA Nurse on [DATE] at 9:50 a.m. revealed that 10% or 14 residents were reviewed on February 28, 2013 to ensure accuracy of resident's code status that included verifying the code status on the Advanced Directive, Signed physician's order if DNR, Code status on the MAR and on the front page of the chart. 11. Review of the "Monthly Quality Assurance Committee Meeting" sign in sheet and agenda dated [DATE] revealed that the audits for code status were completed and discussed. 12. Random review of five (5) resident charts on all (3) stations on [DATE] revealed that the code status, advanced directive information, and orders all matched and were placed appropriately in the front of the resident's chart. 13. Review of six (6) sampled and four (4) un-sampled resident's records revealed that the code status, advanced directives and physician's orders all matched and were in the front of the resident's chart. 14. Review of the "Discharge Report" from [DATE]-[DATE] revealed that there had been six (6) residents that expired in the facility. Of the six (6), all had physician's orders for DNR, advance directives/consents signed and the DNR code status was in the front of the resident's medical record. Nurse's notes of the six (6) residents were reviewed for completeness of documentation and appropriate actions per code policy.