Every finding on record at VMRC, Complete Living Care

Based on observation, staff interview and facility document review the facility staff failed to ensure food temperatures were obtained prior to serving food and failed to maintain food temperature logs in 4 of six houses ([NAME], [NAME], [NAME], [NAME]). Findings include: 1. The facility staff failed to ensure food temperatures were obtained prior to serving food and failed to maintain food temperature logs for the [NAME] House. On 03/13/23 at 12:13 PM in the [NAME] House, CNA # 1 (certified nursing assistant) was observed plating and serving food to the residents. CNA #1 was asked if she had checked the food temperatures for the food being served. CNA #1 stated that they (staff) had not checked the temps for lunch, but stated, I can do it now. CNA #1 was made aware that the food temperatures should be obtained prior to serving the food. CNA #1 stated, We did temps for breakfast, but not for lunch. CNA #1 was asked for the food temperature logs. CNA #1 presented a book for the [NAME] House. The food temps were reviewed and revealed that on 03/12/23 there were no temps recorded for dinner. The food temp log for 03/11/23 had temps for lunch and dinner, but not breakfast. CNA #1 stated that she didn't know why temps were not checked on those days, at those times. CNA #1 stated that the main kitchen will temp the food and that they ([NAME] House staff) are supposed to temp foods prior to serving. On 03/13/23 at 12:43 PM, LPN (Licensed Practical Nurse) #2 (also known as the Care Guide for [NAME] House) was made aware of the above information. LPN #2 stated that temps should be taken for each meal prior to plating and servicing the food. A policy was requested at this time on obtaining food temps. On 03/14/23 at 9:55 AM, the DON (director of nursing) presented a policy titled, Meal Service Policy. The policy documented, .comply with state and federal regulations concerning the holding and servicing temperature of foods .food safety requires temperatures are maintained at a controlled temperature from the time the food leaves the kitchen, during transportation and distribution .food temperatures will be obtained and monitored .temperatures will be logged as indicated . When asked if staff should be checking food temperatures before each meal, the DON stated, Yes Ma'am. On 03/14/23 at approximately 4:45 PM, the administrator and DON were again made aware of the above information in a meeting with the survey team. No further information and/or documentation was presented prior to the exit conference on 03/15/23 at 11:30 AM. 28107 2. The facility staff failed to ensure food temperatures were obtained prior to serving food and failed to maintain food temperature logs for the [NAME] House. Findings include: On 3/13/23 at approximately 12:30 p.m. a meal observation was conducted in [NAME] House. The staff did not obtain food temperatures prior to plating food and serving to the residents. On 3/13/23 at 3:00 p.m. LPN (licensed practical nurse) # 3 was asked to see the food temperature logs. The logs only documented breakfast and lunch temperatures from 3/1/23 through 3/7/23. There were no dinner temperatures recorded, and no breakfast, lunch or dinner temperatures recorded from 3/8/23 to 3/13/23. LPN # 3 was asked about the temperatures recorded, why there were no dinner temperatures, the lack of temperatures recorded for the dinner meal from 3/1/23 through 3/13/23, and no temperatures recorded 3/8/23 through 3/13/23. LPN # 3 stated, We used to to have a food service coordinator, but that person is gone, and the CNA's are responsible for getting the food cart from the main kitchen, putting the food in the preheated ovens, and then plating the food .I don't know what else to tell you, or how to fix it, and it seems like that's just one more thing for them to do .I've never had any complaint of cold food .it is literally taken out of the oven and served. The facility policy titled Meal Service Policy under Procedure directed Food temperatures will be obtained and monitored periodically throughout the meal service to ensure proper hot or cold holding temperatures are maintained. Temperatures will be logged as indicated. The administrator and DON were informed of the above findings during an end of the day meeting 3/14/23 at approximately 4:35 p.m. No further information was provided prior to the exit conference. 3. The facility staff failed to ensure food temperatures were obtained prior to serving food and failed to maintain food temperature logs for the [NAME] and [NAME] Houses Findings include: Review of the facility's policy titled meal Service Policy, revised 12/11/13, indicated Food temperatures will be obtained and monitored periodically throughout the meal service to ensure proper hot or cold temperatures are maintained. Temperatures will be logged as indicated . During an observation on 3/13/23 at 11:40 am, bulk food containers containing fried breaded chicken breasts, collard greens, macaroni and cheese, and rolls were observed on the kitchen island in [NAME] House. Certified Nurse Aide (CNA) 5 stated that the food had arrived from the main kitchen approximately five minutes earlier. During an observation on 3/13/23 at 11:40 am, CNA 4 and CNA 5 were observed serving food to the [NAME] House residents from the bulk containers. Food temperatures were not taken during the meal service. During an interview on 3/13/23 at 11:54 am, CNA 4 confirmed that the temperatures of the food had not been taken when it arrived from the kitchen or prior to beginning the food service. When questioned further, CNA 4 stated that the temperatures should be taken and documented on the food temperature logs kept at each house kitchen. Review of the food temperature logs, located in the [NAME] House kitchen, revealed no food temperature logs for 1/1/23 through 2/4/23. Incomplete logs were noted for meals on 2/5/23, 2/7/23, 2/18/23, and 2/20/23. There were no food temperature logs for 2/21/23 through 3/13/23. Review of the food temperature logs from [NAME] House, located in the cottage's kitchen and dated 1/12/23 through 3/12/23, reveled no food temperature had been recorded since 1/1/23. During an interview on 3/13/23 at 12:10 pm, CNA 6 stated that she did not know why the food temperatures had not been completed since 1/1/23 at [NAME] House. During an interview on 3/14/23 at 10:20 am, the Dietary Services Manager (DSM) stated that the only temperatures taken on bulk foods in the main kitchen were holding temperatures, which are taken approximately one hour before the food left the main kitchen for delivery to the cottages. The DSM provided a Food Safety Checklist, dated 3/13/23, which recorded the holding temperatures of the foods served for the noon meal on 3/13/23. The Checklist documented that the temperatures of the food from the stove on 3/13/23 at 10:30 am were as follows: fried chicken breast -165 degrees Fahrenheit (F); collard greens - 176 degrees F; and macaroni and cheese - 172 degrees F. During an interview on 3/13/23 at 9:20 am, the facility Dietician stated that the temperatures of the bulk foods should be taken moments prior to the food leaving the main kitchen for delivery to the cottages, prior to meal service, and periodically throughout the meal service. During an interview on 3/14/23 at 4:45 pm, the above findings were discussed with the Administrator and DON, who stated that it was the expectation that the food temperatures be taken prior to and during the service of the meal to residents, as indicated in the facility policy. No further information and/or documentation was provided prior to the exit conference.

Based on observation, staff interview, resident interview, and facility document review, the facility staff failed to accommodate food preferences, food intolerance's and/or allergies for two of 21 residents in the survey sample, Resident #71 and Resident #72. Findings include: 1. The facility failed to ensure Resident #71's food preferences were honored. Resident #71's diagnoses included, but were not limited to: diabetes mellitus, thrombocytopenia, chronic atrial fibrillation, gastric reflux and iron deficiency. The resident's most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. The resident was assessed as a 14 cognitively, which indicated the resident was intact for daily decision making skills. The resident was also assessed as requiring supervision with at least one person assist for most ADL's (activities of daily living) and supervision with set up only for eating/meal consumption. On 03/13/23 at approximately 12:00 PM, Resident #71 was observed sitting at the dining room table. The resident had a piece of boneless fried chicken, some macaroni and cheese, collard greens and a piece of apple pie. When the resident was asked how he liked the lunch, the resident stated that he did not like chicken and didn't eat chicken. The resident was asked if the staff were aware or knew that he didn't like chicken and the resident stated, yes. The resident was asked why he was given chicken, the resident stated he didn't know and then stated that it was ok and that he would eat what he wanted and wouldn't eat what he didn't like or didn't want. On 03/13/23 at 12:13 PM, CNA #1 was asked, why Resident #71 was served chicken when the resident stated that he didn't like chicken. The CNA stated that they ([NAME] house) didn't have a menu for this week yet and stated that they didn't know what they were having until they got it from the kitchen today. The CNA was asked again if she knew the resident didn't like chicken, the CNA responded yes. The CNA was asked again why the resident was served chicken if she knew he didn't like chicken. The CNA stated that she just found out when the food was served that he didn't like chicken. The CNA then went over to Resident #71 and asked him if wanted something else besides the chicken and the resident stated that he did not. On 03/13/23 at 2:53 PM, The resident was interviewed and asked about his food preferences. The resident stated that he tends to be picky and he just doesn't like chicken. The resident was asked if staff had asked him for his food pretences upon admission (November 2022). The resident stated that he didn't remember if they had. The resident stated that he likes hotdogs, hamburgers and raw vegetables, and further stated that he doesn't like cooked vegetables. The resident stated, I don't think you can get a hamburger around here. On 03/14/23 at approximately 10:00 AM, the administrator and DON (director of nursing) were asked where are residents food preference information and were asked for assistance in locating that information. On 03/14/23 at approximately 11:00 AM, the administrator presented a blank dining preference interview sheet and stated that each resident should have one of these forms and they are filed in a notebook in each house. On 03/14/23 at 1:51 PM, LPN (Licensed Practical Nurse) #2 (also known as the Care Guide for [NAME] House) was interviewed regarding the residents dining preference interview information. The LPN looked and found the sheets in a notebook (all were blank) and stated that they didn't have one filled out for Resident #71. The LPN stated that the forms were sent to her via email and she printed them off and put them in the book. The LPN was asked where was the completed form for Resident #71. The LPN stated that she got the sheets today and did not have one for Resident #71. The LPN stated that OS #1 (other staff), also known as the food service guide sent the email with the forms and stated that she (OS#1) will document in the resident's record the likes and dislikes and the forms are also completed and put in the notebook. No information was given why Resident #71 did not have a food preference sheet. A policy on food preferences was requested at this time. A policy titled, Dietary Preferences documented, .procedures related to obtaining food and beverage preferences for residents at the time of admission and periodically thereafter .when a new admission enters .preferences will be obtained at least by the completion of the initial comprehensive assessment's care plan meeting .reviewed during quarterly care plan meetings and updated when indicated .preferences are maintained in an accessible location for direct care staff . On 03/14/23 at approximately 5:00 PM, the administrator and DON were made aware of the above information. The DON stated that she would make sure that Resident #71 was made aware of the 'always available menu' that has hamburgers and other food items available everyday. No further information and/or documentation was presented prior to the exit conference on 03/15/23 at 11:30 AM. 2.) The facility failed to follow accommodate food allergy restrictions for Resident #72. Findings include A review of Resident # 72's (R72) Face Sheet, revealed R72 had diagnoses that included major depressive disorder, diarrhea, and essential hypertension. A review of R72's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/6/22, indicated R72 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R72 was cognitively intact. Review of R72's Care Plan, dated 3/3/23, indicated .Patient will be free from adverse reactions and/or complications related to allergy thru [sic] next review . The allergies listed included onions. During an observation on 3/13/23 at 12:40 PM, R72 was observed in her bedroom with her noon meal. R72 had not eaten the collard greens served with the meal. Onions were observed in the collard greens. R72 stated she liked the meal but could not eat the collard greens because they contain onions. R72 stated that she was allergic to onions and would break out in hives if they were consumed. On 3/13/23 at 12:45 PM, Certified Nursing Assistant (CNA) 4, who had served food during the meal service, stated she was aware that R72 had allergies to onions, but was not aware the collard greens contained onions. During an interview on 3/14/23 at 10:20am, the Dietary Services Manager (DSM) verified that the collard greens were mixed with onions during preparation. The DSM also stated that the food items on the menu that day are served to the cottages in bulk. The Food Service Guide (FSG) 1 stated that the facility had a computer program that matched food allergies with foods and ingredients served but it was not operational. A review of the noon meal menu dated 3/13/23, which was provided by the DSM, revealed that buttermilk fried chicken breast, macaroni and cheese, pot liquor collard greens, park house rolls, apple pie, and beverages were on the menu. A review of Recipe ID 820600, dated 3/2/23, which was provided by the DSM, revealed that onions were used in the preparation of the pot liquor collard greens. During this interview, the DSM verified that Recipe ID 820600 was the recipe used in the preparation of the pot liquor collard greens served on 3/13/23. During an interview on March 14th 2023 at 4:45 PM, the above findings were presented to the administrator and director of nursing, who stated that it was the expectation that food allergies would be accounted for during meal services. During an interview with Facility Dietician on 3/15/23 at 9:20, the Dietitian stated the current process was that food was provided in bulk and all resident allergies were listed on the refrigerator in note form in each building. The Dietitian stated that a computer was available for CNA's in each cottage to review the electronic medical record for the allergies of each resident. The Dietitian stated that if there was a food served that a resident was allergic to, the CNA was required to serve a substitute of nutritive value to the resident in question. The Dietitian stated that the main kitchen was responsible for ensuring foods were prepared in a manner that addressed food allergies. No further information and/or documentation was presented prior to the exit conference on 03/15/23 at 11:30 AM.

Based on a medication pass and pour observation, staff interview and facility document review, the facility staff failed to ensure infection control practices were followed for the administration of medications. Findings include: On 03/13/23 at approximately 3:58 PM, LPN (Licensed Practical Nurse) #1 prepared medications for Resident #43. LPN #1 donned (applied) gloves and prepared a glucometer to check the resident's blood glucose level. Once completed, LPN #1 discarded the glucometer strip, wiped off the glucometer, put it away and began to prepare medications for Resident #43. LPN #1 did not remove the gloves used to check the resident's blood glucose level after that task was completed. LPN #1 proceeded to dispense two Tylenol tablets into a plastic dispensing cup, then dispensed one Renvela, when attempting to dispense a second Renvela, the pill dropped to the floor. LPN #1 reached down with a gloved hand and picked the pill up and tossed it in the trash and resumed, by dispensing two more Renvela tablets (a total of three) into the cup. LPN #1 then took the medications and administered them to the resident. LPN #1 exited the room, returning to the medication cart, removed the gloves into the trash can and moved the cart down the hall and then sanitized her hands. At approximately 4:00 PM, LPN #1 was asked if she realized what she had done with the gloves (not removing) and dropping the pill on the floor and not removing the gloves and not handwashing and/or sanitizing her hands during that process and continuing to pull medications for administration for Resident #43. LPN #1 stated that she did realize what she had done after she had already done it. On 03/14/23 at approximately 3:00 PM, LPN #2 (also known as the Care Guide for [NAME] House) was interviewed and made aware of the above information and asked for a policy regarding infection control, hand washing and glove use during medication administration. A policy was presented titled, Infection Control During Medication/Treatment Administration .general infection control with the preparation and administration of medications .follow standard precautions (unless otherwise noted) and perform hand hygiene before, during and after medication/treatment administration .staff should not touch the medication .if a medication .is dropped, facility staff should discard it .discard used medication supplies .perform hand hygiene as indicated . A policy titled, Hand Hygiene documented, .wash your hands .before and after treating a cut or wound .touching garbage .before handling medications .regular handwashing, particularly before and after certain activities, is one of the best ways .to prevent the spread of germs .if soap and water are not available, use alcohol-based hand sanitizer . On 03/14/23 at approximately 4:30 PM, the administrator and DON (director of nursing) were made aware of the above findings in a meeting with the survey team. No further information and/or documentation was presented prior to the exit conference on 03/15/23 at 11:30 AM.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for one of thirteen residents in the survey sample. The Findings include: The facility nursing staff failed to enter a verbal physician's order into the electronic clinical record regarding Foley catheter placement for one of 21 residents, Resident #9. Diagnoses for Resident #9 included; Urine retention, inguinal hernia, depression, and congestive heart failure. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 2/3/23, Resident #9 was assessed with a cognitive score of 13 indicating cognitively intact. On 3/13/23 12:13 PM during an interview, Resident #9 was asked about his catheter. Resident #9 verbalized that he thought that the staff had placed the catheter because he was having trouble urinating and he possible had a urinary tract infection. Resident #9 went on to say the nurses are taking care of it and was not having any trouble with the catheter. On 3/13/23 Resident #9's clinical record did not indicate any orders for a Foley catheter to be placed or any orders for the care of a Foley catheter. On 3/14/23 at 1:50 PM license practical nurse (LPN #6) was interviewed regarding Resident #9's catheter orders. LPN #6 reviewed the clinical record and was able to find orders for Resident #9's catheter along with care orders for the catheter and according to the orders the catheter was placed on 3/11/23. Further review of the catheter orders documented that the orders were not created until 3/14/23. Nursing progress notes were then reviewed and revealed a progress note dated 3/11/23 that read in part: Patient only able to void a small amount 2 times this shift, urine noted to bed dark tea colored with small blood clots present. Abdomen noted to be slightly firm and tender upon palpation, bladder scan showed 417 milliliters, patient cathed with Foley, patient had 650 ml out, Foley left in place due to having retention greater than 400 ml [ .]. On 3/14/23 at 2:23 PM LPN #7 (the nurse that wrote the progress note) was interviewed. After reviewing her progress note, LPN #7 said she had talked with the physician at the time of the concern and had gotten a telephone order for placement of the catheter but failed to enter the physician order into the clinical record. On 3/14/23 at 4:08 PM LPN #7 (unit manager) was interviewed regarding catheter orders. LPN #7 said she (LPN #7) had created the orders earlier today and entered a start date of 3/11/23 after realizing there were no catheter orders for Resident #9. During the interview, LPN #7 also said that any nurse can put telephone orders in and orders should have been placed for the catheter and the care of the catheter when it was first ordered as this would alert other nursing staff to the catheter and catheter care instructions. A policy titled Telephone/Verbal Orders read in part: 1. When a new order is received from the provider [ .] nursing staff will enter a verbal order into the orders on the electronic medical record. 4. Telephone/verbal orders will be transcribed/transferred onto the electronic medication administration record. 5. The resident's medical record will reflect progress notes that describe the condition and communication that occurred between the nursing staff and the provider. On 3/14/23 at 4:34 PM the above information was presented to the administrator and director of nursing. No other information was provided prior to exit conference on 3/15/23.

Based on observations and staff interview, the facility failed to post nurse staffing information for all nursing areas. There was no nurse staffing posted for the six residential houses on the facility campus. The findings were During a meeting at 4:30 p.m. on 3/14/2023, that included the Administrator, Director of Nursing, and the survey team, the Administrator was asked where nurse staffing was posted. The Administrator said the staffing was posted in the lobby of the Oak Lea building. The Oak Lea building houses the administrative offices as well as the Transitional Care Unit. At approximately 10:00 a.m. on 3/15/2023, the nurse staffing was observed posted in the Oak Lea lobby. The posting included staffing for the Oak Lea Transitional Care Unit as well as six residential houses; the [NAME], [NAME], [NAME], [NAME], Warsack, and [NAME]. At approximately 10:15 a.m. on 3/15/2023, a tour of the six residential houses was conducted. At each house, the staff was asked if nurse staffing was posted for that particular house. In each of the six houses, staff responded that nurse staffing was not posted, but that it was posted in the Oak Lea lobby. At approximately 10:30 a.m., during a meeting prior to the Exit Conference, that included the Administrator, Director of Nursing, and the survey team, the failure to post nurse staffing in each of the six residential houses was discussed. It was pointed out that the posting is to be accessible to both residents and visitors. Residents of the six residential houses, some of whom were not mobile, would need to go to the Oak Lea lobby to view the nurse staffing. Visitors to any of the six residential houses are able to access the houses without passing through the Oak Lea lobby. Therefore, they would not be able to view the nurse staff posting. There was no further discussion prior to the Exit Conference.

Based on staff interview and clinical record review, the facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Fluid intake for Resident #37 and Resident #287 was not monitored and documented as ordered by the physician. The findings include: 1. Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Observation Assessment completed on 07/11/21 assessed Resident #37 as alert, and attentive. Oriented to person, place and time. Having an intact memory (past and present), with clear and organized thinking . On 07/21/21 Resident #37's clinical record was reviewed. Observed on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date: 07/11/2021. End Date: Open Ended. 1200ml (milliliters)/day fluid restriction 600-500-100. Three Times a Day: 06:00 - 14:00, 14:00 - 22:00, 22:00 - 06:00 . Observed on the care plans was the following: .Problem Start Date: 07/11/2021. Resident is at risk for alterations in fluid balance r/t (related to) diuretic and fluid restriction . A review of Resident #37's vitals report including fluid intake was reviewed for the period of 07/11/21 (readmission) through 07/21/21. For the 10 day period (7/10/21 through 7/21/21), the vitals report did not document fluid intake for 1 day (7/20/21) within a 24-hour period and only partial documentation for 9 days within the period reviewed. On 07/21/21 at 1:40 p.m., the unit manager (LPN #1) where Resident #37 resided was interviewed regarding the documentation of the fluid intake for residents with fluid restriction. LPN #1 stated the certified nursing assistants (CNA) were responsible for documenting the fluid the intake and if the information was not in the electronic record it may have been on the CNA's documentation sheet and not entered into the record yet. LPN #1 stated she would follow up with the information. On 07/21/21 at 1:53 p.m., LPN #1 returned and stated, the intakes are not there. LPN #1 was asked if the intakes were monitored and recorded at all. LPN #1 stated, I don't want to speculate, it must have been a staff oversight. These findings were discussed during a meeting on 07/21/21 at 3:00 p.m. with the administrator and director of nursing (DON). 2. Resident #287 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Observation assessment dated [DATE] assessed Resident #287 as, . alert and oriented to person, place, and time. Having an intact memory (past and present), with clear and organized thinking . On 07/21/21 Resident #287's clinical record was reviewed. Observed on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date: 07/16/21. End Date: Open Ended. Fluid Restriction 1500 daily. 800ml/600ml/100ml (milliliters). Every shift: 1st, 2nd, 3rd . Observed on the care plans was the following: .Problem Start Date: 07/16/2021. Resident is at risk for alterations in fluid balance r/t diuretics and fluid restriction . Approach: Document fluid intake A review Resident #287's vitals report including fluid intake was reviewed for the period of 07/16/21 through 07/21/21. Observed on Resident #287's report was no fluid intake documentation. On 07/21/21 at 2:22 p.m., the unit manager (LPN #1) where Resident #287 resident was interviewed regarding the fluid intakes not documented within the clinical record. LPN #1 stated she would check and follow-up. On 07/21/21 at 2:30 p.m., a copy of Resident #287's fluid intake was requested from the administrator. The administrator returned at 2:40 p.m. and stated there was no fluid intake documentation for Resident #287. These findings were discussed during a meeting on 07/21/21 at 3:00 p.m. with the administrator and director of nursing (DON). The DON was interviewed regarding Resident #287's clinical record missing the fluid intake documentation. The DON stated upon investigation it was discovered during the admission that the order was not included as a task on the CNAs task list which resulted in the CNAs not monitoring and documenting the resident's fluid intake. No other information was received by the survey team prior to exit on 07/21/21 at 4:45 p.m.

Based on staff interview and facility document review, the facility staff failed to implement a program for prevention of Legionella and other waterborne pathogens and failed to ensure infection control policies were reviewed annually. The facility failed to perform a risk assessment to identify where Legionella and other waterborne pathogens could grow and/or spread; failed to implement a water management program based upon industry standards and/or the CDC (centers for disease control) toolkit and; failed to perform and document specified testing for prevention of Legionella. In addition, the facility had performed no annual review of infection control policies. The findings include: 1. On 11/28/18 at 1:15 p.m., the maintenance director was interviewed about evidence of a water management program to prevent the growth and spread of Legionella and other waterborne pathogens. The maintenance director stated the facility had not set up a program yet to check for Legionella. The maintenance director stated they performed standard testing and maintenance on the boilers and water towers but had not implemented any testing regarding Legionella. The maintenance director stated, We have more questions than answers. The maintenance director stated the current water management vendor did not know what was required regarding Legionella. The maintenance director stated he had not reviewed or utilized the CDC toolkit regarding Legionella prevention. The maintenance director stated they were working with a new water management vendor but had not set up or implemented any protocols or testing regarding Legionella. The facility's policy titled Water Management Program (dated 11/28/18) documented, The purpose of this policy is to monitor and test water to prevent Legionnaire's Disease .This water management program will utilize the services of a third party company to monitor, test, and treat the heating, ventilation, and air conditioning (HVAC) water systems and domestic water systems. The procedures listed in the policy included, water treatment chemicals, maintenance and repair of water treatment equipment, water analysis with record keeping, identification of areas where Legionella could grow/spread, control measures and monitoring for compliance. There was no evidence any interventions were implemented in the facility for the prevention of Legionella or other waterborne pathogens. 2. On 11/29/18 at 8:08 a.m., the director of nursing (DON) was interviewed regarding annual review of the facility's infection control policies. The DON stated the policies were maintained on a computer database. Accompanied by the DON, the policies were reviewed on the computer. The policies listed had no indication of an annual review. The DON printed a copy of the policy titled Multi Drug Resistant Organism (MDRO) Management. This policy was originated on 3/1/12 and was most recently reviewed and/or revised on 8/15/16. This and other policies had no indication of an annual review by the medical director or any facility committee. The DON stated at this time there was no system set up to review the policies annually. The DON stated policies were updated as needed. These findings were reviewed with the administrator and director of nursing during a meeting on 11/28/18 at 5:00 p.m.

Based on observation, staff interview and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner in the main kitchen. Cole slaw, which temped at 53 degrees and was made with mayonnaise was served for the lunchtime meal in one of eight houses on the facility campus. Findings were: Initial tour of the facility was conducted on 11/27/2018 beginning at approximately 11:45 a.m. Upon arrival in one of the individual houses on campus, OS (other staff) #5 was observed in the kitchen, preparing to serve lunch. The menu for the day was stuffed pepper casserole, cole slaw and dessert. Lunchtime temperatures were obtained by OS #5. The temperature of the cole slaw was 53 degrees. OS #5 was observed plating the cole slaw and serving it to the the residents residing in the home. OS #5 was questioned about the cole slaw. She was asked if the cole slaw dressing was mayonnaise based. She stated Yes, I fixed it last evening (Monday 11/26/2018) and it has been in the refrigerator all night. She stated the refrigerator temperature was 40 that morning and she had just checked it again and it was 42 degrees. OS #5 was asked about the parameters for serving cold foods. OS #5 stated, They should be 40 degrees. She was asked about the cole slaw temperature. She stated, 53 degrees I wouldn't serve it much higher than that .to be honest the foods don't usually temp at 40, they are usually higher .I just serve them anyway because I know they have been in the refrigerator .sometimes I need to adjust the temperature on the fridge if the temperatures aren't reading right. OS #5 was asked if maintenance had looked at the refrigerator regarding temperatures. She stated, No. On 11/28/18 at approximately 3:45 p.m., OS #5 was interviewed about the food temperature of the cole slaw the previous day. She stated, I did a lot of tossing over that last night, I talked to my supervisor about it this morning .He told me to calibrate my thermometer. OS #5 was asked if she had calibrated it. She stated, Not yet. OS #5 was asked how often thermometers were calibrated. She stated, We have this log. She opened a notebook and said, Here it is. She presented a form titled Thermometer Calibration Log-One Form Per Month. OS #5 was asked what the log was for. She stated, This thermometer. She was asked when the log was filled out. She stated, When we calibrate it. Instructions listed on the thermometer on the log were: Check calibration of thermometers daily and when accidentally dropped. Thermometers must be accurate to at least +/- 2 (symbol for degrees) F (Fahrenheit) from 32 (symbol for degrees) F (or +/- 5 (symbol for degrees) C (Celsius) from 0 (symbol for degrees) C). Procedure: Fill Container with 50 % crushed ice and 50 % water (Use 60 %/40 % ratio for cubed ice and water); Place thermometer stern into ice water solution (sensor must be completely submerged); Read thermometer after 2 minutes; If thermometer does not read 32 (symbol for degrees) F (+/- 2 (symbol for degrees) or 0 (symbol for degrees) C (+/- 0.5 (symbol for degrees) C), adjust it accordingly; Complete appropriate columns below. Columns listed included the date, number of thermometers checked, number of thermometers correct; number of thermometers adjusted, comments, and employee initials. OS #5's initials were written on the log for 11/26/2018, 11/27/2018, and 11/28/2018. OS #5 was asked if the initials on the log were hers and was that her handwriting. She confirmed that the initials were hers and that it was her handwriting. She was asked if she had calibrated the thermometer earlier in the day. She stated, No. She was asked when the last time was that she calibrated it. She stated, Probably last week sometime. The top of the log was reviewed and OS #5 was asked if the calibration was suppose to be done daily and were her initials in the blanks as having completed the calibration. She stated, Yes. OS #5 was asked if she had done the calibration as she had previously stated she had not. She stated, No, I didn't do it. OS #5 was asked why her initials were on the log. She did not answer. OS #5 was asked to calibrate the thermometer at that time. She obtained two cups. She filled one with ice and water and the other with warm water. She placed the thermometer in the ice water cup first. The water temped at 32.5 degrees. She then placed the thermometer in the cup of warm water and the water temped at 73 degrees. She removed the thermometer from the warm water and put it back into the ice water, which temped at 32.3 degrees. She was asked why she used the warm water with the ice water. She stated, That's what they said to do in 'Food Safe'. OS #5 was asked if she had taken the 'Food Safe' class. She stated, Yes. OS #5 was asked what 'Food Safe had said about the serving temperature of cold foods. She stated, 40 degrees. On 11/28/2018 at 4:30 p.m., OS #4, the lead guide over food and safety in the houses was interviewed. The above information was explained to him. He stated, That should not have happened .I look at that thermometer log every day as part of my rounds .her initials on there tell me that she did what she was suppose to do .that's apparently not accurate. He was asked if there was a policy regarding at what temperatures food should be served. He stated, We follow the 'serve safe' guidelines .all of our food coordinators and the (name used a the facility for certified nursing assistants) go through the 'serve safe' training because they all work with and serve the food .the guidelines are very clear. Cold foods should be at 40 degrees or less .she (OS #5) talked to me today about what happened .I went over there and temped the refrigerators with a laser thermometer a little bit ago and the temperatures were correct in both the pantry and kitchen refrigerators .when the cole slaw didn't temp at 40 or below, it should have been tossed and not served .she should have made another side .that's the expectation. The above information was reviewed with the administrator and the DON (director of nursing) during an end of the day meeting on 11/28/2018 at approximately 5:00 p.m. No further information was obtained prior to the exit conference on 11/29/2018.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 25 residents was free from physical abuse that included restraint. A nurse forced Resident #56 to take medications by holding down her arms, pinching her nose closed until her mouth opened and pushing her lips against her teeth in an attempt to get her to swallow and/or take medications. The findings include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #56 with short and long-term memory problems and severely impaired cognitive skills. A facility reported incident form dated 7/12/18 documented certified nurses' aides (CNAs) reported they observed registered nurse (RN) #1 being rough and forceful with Resident #56 when giving oral medications on 7/12/18. This report documented, . (CNA #3) reported to (administrator) on (MONTH) 12, (YEAR), that she witnessed (RN #1) holding (Resident #56's) hands down. (CNA #3) reported that (RN#1) pushed the plastic spoon into (Resident #56's) mouth with medicine on it. (RN #1) then held (Resident #56's) lip into her teeth and pulled down to get her to open her mouth, wanting her to take a drink. (Resident #56) told her to get away but (RN #1) didn't stop. (RN #1) then squeezed (Resident #56's) nose to get her to open her mouth. The reporting staff intervened and attempted to assist (RN #1) to administer the drink to (Resident #56) The facility's investigation of this incident dated 7/17/18 documented that four CNAs witnessed RN #1 force Resident #56 to take oral medications on 7/12/18 using physical force/restraint and against the resident's wishes. Written statements from the CNAs that witnessed the incident of 7/12/18 documented RN #1 held down Resident #56's arms, shoved the spoon with medicine into the resident's mouth, pushed the resident's lips on the side in attempt to open her mouth and then held the resident's nose shut until she opened her mouth to breath. Statements documented RN #1 refused to stop holding down the resident's arm after CNA #3 intervened and told RN #1 to stop. Written witness statements of RN #1 administering medication to Resident #56 dated 7/12/18 were as follows. CNA #1 - .Noticed nurse (RN #1) pressing down on residents arms. At first I thought she was moving her arms down out of the way to give medicine but she was forcing her arms down. She then forced the medicine in her mouth. Resident stated no and said to stop leave me alone go away!. Nurse then was trying to force residents mouth open to give water .then immediately pinched her nose to get her to open up to push straw in. She held it till resident gasped + she put straw in. That is when (CNA #3) said 'you can not do that.' Nurse said 'She needs to take her medicine.' CNA # 3 said well you can't do that give me the water let me try. Nurse then was still pressing on her arm saying she has to take it. Then the phone rang that is when she finally gave (CNA 3) the water . (Sic) CNA #2 - .When I looked over the nurse (RN #1) was holding residents arms down and the resident was saying 'stop' 'stop' 'Get away' .she (RN #1) shoved the spoon of medicine and chocolate pudding into her mouth, held her arms more Forcefully pushed her lip in on side to try to Force her to swallow and get water in .(Resident #56) was jerking her head away, She then held (Resident #56's) nose shut and that forced her to open her mouth to breathe for the nurse to get the straw in .(CNA #3) said '(RN#1) no don't do that give me the water and let me try.' (RN #1) then said 'it's better than her spitting her medicine out.' Finally the nurse phone rang and she gave the water to (CNA #3) . (Sic) CNA #3 - I was in the kitchen and heard (Resident #56) say get away get away .I witnessed (RN #1) squeezing and holding (Resident #56's) hands down. She shoved the plastic spoon into (Resident #56's) mouth with medicine on it. (RN #1) then pushed (Resident #56's) lip into her teeth to get her to open her mouth again to get a drink. (Resident #56) kept telling her to get away but she wouldn't stop. (RN #1) then held (Resident #56's ) nose shut to get her to open her mouth .I told (RN #1) don't do that and she still kept pushing on (Resident #56's) arms. I went to (RN #1) and said here let me give it to her and she wouldn't give me the cup of water after I asked for it several times. She finally gave me the cup because the phone rang. CNA #4 - (Resident #56) was sitting beside the dining room table, near the counter when (RN #1) approached her. She started trying to give (Resident #56) the medicine and (Resident #56) was trying to refuse. I saw (RN #1) pull (Resident #56's) arms down to restrain her, (Resident #56) was trying to bite her to get (RN #1) to let go. She the (then) proceeded to plug (Resident #56's) nose and shove the medicine in her mouth. (Resident #56) was trying to spit the medicine out and get (RN #1) to let go. Then (RN #1) put her finger between her lips and pushed her lip down on her teeth to make her open her mouth to dump water in. That's when (CNA #3) stepped in and told (RN #3) to stop . (CNA #3) tried to help (Resident #56) sip her water, and I heard (Resident #56) say 'I told her to leave me alone'. (Sic) The facility's investigation dated 7/17/18 documented Resident #56 was assessed by the nursing supervisor on 7/12/18 and that there was no evidence of any injury or indication of abuse. A social worker note in the investigation folder dated 7/12/18 documented the resident was distracted and wanted to go to bed at the time of the assessment. This social worker note stated, She (Resident #56) voiced no concerns or anything that would cause me to think that she is troubled by the experience that she had. On 11/28/18 at 9:22 a.m., CNA #4 that witnessed the incident of 7/12/18 was interviewed. CNA #4 stated she was the food coordinator that day and she saw RN #1 battling to give medications to Resident #56. CNA #4 stated Resident #56 does not always want her medications. CNA #4 stated RN #1 held the resident's nose shut and when the resident opened her mouth to gasp for breath, RN #1 shoved the medicines into her mouth. CNA #4 stated RN #1 pinched the resident's lips against her teeth trying to get her to open and drink water. CNA #4 stated CNA #3 came over and told RN #1 to stop. CNA #4 stated Resident #56 pulled her shirt up over her mouth to avoid the medication. CNA #4 stated she then reported the incident to the administrator. CNA #4 stated she had seen other nurses give medications to Resident #56 and they sweet talk her or leave her alone and try at another time. On 11/28/18 at 3:47 p.m., the administrator and DON were interviewed about RN #1 physically forcing Resident #56 to take medications on 7/12/18. The DON stated they physically assessed the resident following the incident and did not find any evidence of physical abuse but they were concerned the resident's rights had been violated. The DON stated after reading the statements she determined that RN #1's intent was to get her to take the medications. The DON stated RN #1 should not have made her take the medication. The administrator stated after talking with RN #1, she felt RN #1's intention was not bad. On 11/29/18 at 7:08 a.m., CNA #3 was interviewed about Resident #56 with RN #1 on 7/12/18. CNA #3 stated she was in the dining area and heard Resident #56 say, No. Stop it. CNA #3 stated RN#1 was shoving the spoon of medicine in Resident #56's face. CNA #3 stated RN #1 was pulling the resident's arms down and digging her fingertips into the resident's forearm. CNA #3 stated RN #1 held the resident's nose shut until the resident opened her mouth to breath and then shoved the medicine into her mouth. CNA #3 stated Resident #56 was swatting at RN #1, turned her head away and spit out the pudding/medicines everywhere. CNA #3 stated she told RN #1 to stop several times and she did not stop until the telephone rang and she left to answer the phone. CNA #1 stated residents were afraid of RN #1. CNA #3 stated she had seen RN #1 force other residents to take medications but not this bad or with this amount of physical force. CNA #3 stated, This was to me major abuse, when she held her (Resident #56) nose closed and was pinching her arms. CNA #3 stated she tried to calm the resident and then reported the incident to the supervisor and administrator. Resident #56's plan of care (revised 10/24/18) documented the resident had a history of [REDACTED]. Interventions to minimize refusals and aggression included, .Be gentle and patient .Light and simple humor may be a distraction for her .Compliment for cooperative behavior .Explain what you are doing at all times .If possible, leave and return later to finish care .Talk while providing care .Offer simple choices for her to maintain some control .Use calm non-threatening tones when talking . The facility's policy titled Resident Abuse and Neglect (revised 6/6/18) documented, .Every (facility) resident has the right to be free from abuse, corporal punishment, involuntary seclusion, and suspected crime. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals .It is the policy of (facility) to provide care in a manner that is professional, [MEDICATION NAME], and respectful of the residents' rights .Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation .This includes, but is not limited freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom . These findings were reviewed with the administrator and director of nursing during a meeting on 11/28/18 at 5:00 p.m.

Based on medication pass and pour observation, staff interview and clinical record review, facility staff failed to administer a medication per manufacturer guidelines for one of 25 residents in the survey sample, Resident #52. Facility staff failed to administer [MEDICATION NAME] per manufacturer guidelines, (on an empty stomach) for Resident #52. Findings included: Resident #52 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 10/12/2018. Resident #52 was assessed as impaired in her short and long term memory and moderately impaired in her daily decision making skills. Resident #52 was observed eating breakfast with fell ow residents on 11/28/18 at approximately 8:15 a.m. During the medication pass and pour observation conducted 11/28/2018 at 8:36 a.m., Resident #52 was administered [MEDICATION NAME] 75 mcg by mouth, by LPN #1 (licensed practical nurse). LPN #1 was interviewed regarding the administration time of this medication. LPN #1 stated, It is actually scheduled for 8:00 a.m. I believe you should give one half hour before breakfast. [MEDICATION NAME] was reviewed in a nursing drug handbook with LPN #1. The nursing drug handbook included the following administration indication for [MEDICATION NAME], .Give drug at same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast . (1) LPN #1 stated, I need to change the time for this medication. Subsequent Review of the POS [REDACTED].Order Date: 12/26/2017, Start Date: 12/27/2017, [MEDICATION NAME] Sodium .tablet 75mcg (micrograms): Administer 1 Tablet By Mouth Per Day . The Administrator and DON (director of nursing) were informed of the above observation during an end of the day meeting with the survey team on 11/28/18. No further information was received by the survey team prior to the exit conference on 11/29/18. (1) Woods DNP, RN, Anne Dabrow. 39th Edition Nursing 2019 Drug Handbook. Philadelphia: Wolters Kluwer, 2019.

Based on staff interview, facility document review and clinical record review, the facility staff failed to honor the right to refuse medications for one of 25 residents in the survey sample. A nurse forced Resident #56 to take medications against her wishes by holding down her arms, pinching her nose closed until her mouth opened and pushing her lips against her teeth. The findings include: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #56 with short and long-term memory problems and severely impaired cognitive skills. A facility reported incident form dated 7/12/18 documented certified nurses' aides (CNAs) reported they observed registered nurse (RN) #1 being rough and forceful with Resident #56 when giving oral medications on 7/12/18. This report documented, . (CNA #3) reported to (administrator) on (MONTH) 12, (YEAR), that she witnessed (RN #1) holding (Resident #56's) hands down. (CNA #3) reported that (RN#1) pushed the plastic spoon into (Resident #56's) mouth with medicine on it. (RN #1) then held (Resident #56's) lip into her teeth and pulled down to get her to open her mouth, wanting her to take a drink. (Resident #56) told her to get away but (RN #1) didn't stop. (RN #1) then squeezed (Resident #56's) nose to get her to open her mouth. The reporting staff intervened and attempted to assist (RN #1) to administer the drink to (Resident #56) The facility's investigation of this incident dated 7/17/18 documented that four CNAs witnessed RN #1 force Resident #56 to take oral medications on 7/12/18 using physical force/restraint and against the resident's wishes. Written statements from the CNAs that witnessed the incident of 7/12/18 documented RN #1 held down Resident #56's arms, shoved the spoon with medicine into the resident's mouth, pushed the resident's lips on the side in attempt to open her mouth and then held the resident's nose shut until she opened her mouth to breath. Statements documented RN #1 refused to stop holding down the resident's arm after CNA #3 intervened and told RN #1 to stop. Written witness statements of RN #1 administering medication to Resident #56 dated 7/12/18 were as follows. CNA #1 - .Noticed nurse (RN #1) pressing down on residents arms. At first I thought she was moving her arms down out of the way to give medicine but she was forcing her arms down. She then forced the medicine in her mouth. Resident stated no and said to stop leave me alone go away!. Nurse then was trying to force residents mouth open to give water .then immediately pinched her nose to get her to open up to push straw in. She held it till resident gasped + she put straw in. That is when (CNA #3) said 'you can not do that.' Nurse said 'She needs to take her medicine.' CNA # 3 said well you can't do that give me the water let me try. Nurse then was still pressing on her arm saying she has to take it. Then the phone rang that is when she finally gave (CNA 3) the water . (Sic) CNA #2 - .When I looked over the nurse (RN #1) was holding residents arms down and the resident was saying 'stop' 'stop' 'Get away' .she (RN #1) shoved the spoon of medicine and chocolate pudding into her mouth, held her arms more Forcefully pushed her lip in on side to try to Force her to swallow and get water in .(Resident #56) was jerking her head away, She then held (Resident #56's) nose shut and that forced her to open her mouth to breathe for the nurse to get the straw in .(CNA #3) said '(RN#1) no don't do that give me the water and let me try.' (RN #1) then said 'it's better than her spitting her medicine out.' Finally the nurse phone rang and she gave the water to (CNA #3) . (Sic) CNA #3 - I was in the kitchen and heard (Resident #56) say get away get away .I witnessed (RN #1) squeezing and holding (Resident #56's) hands down. She shoved the plastic spoon into (Resident #56's) mouth with medicine on it. (RN #1) then pushed (Resident #56's) lip into her teeth to get her to open her mouth again to get a drink. (Resident #56) kept telling her to get away but she wouldn't stop. (RN #1) then held (Resident #56's ) nose shut to get her to open her mouth .I told (RN #1) don't do that and she still kept pushing on (Resident #56's) arms. I went to (RN #1) and said here let me give it to her and she wouldn't give me the cup of water after I asked for it several times. She finally gave me the cup because the phone rang. CNA #4 - (Resident #56) was sitting beside the dining room table, near the counter when (RN #1) approached her. She started trying to give (Resident #56) the medicine and (Resident #56) was trying to refuse. I saw (RN #1) pull (Resident #56's) arms down to restrain her, (Resident #56) was trying to bite her to get (RN #1) to let go. She the (then) proceeded to plug (Resident #56's) nose and shove the medicine in her mouth. (Resident #56) was trying to spit the medicine out and get (RN #1) to let go. Then (RN #1) put her finger between her lips and pushed her lip down on her teeth to make her open her mouth to dump water in. That's when (CNA #3) stepped in and told (RN #3) to stop . (CNA #3) tried to help (Resident #56) sip her water, and I heard (Resident #56) say 'I told her to leave me alone'. (Sic) The facility's investigation dated 7/17/18 documented Resident #56 was assessed by the nursing supervisor on 7/12/18 and that there was no evidence of any injury or indication of abuse. A social worker note in the investigation folder dated 7/12/18 documented the resident was distracted and wanted to go to bed at the time of the assessment. This social worker note stated, She (Resident #56) voiced no concerns or anything that would cause me to think that she is troubled by the experience that she had. On 11/28/18 at 9:22 a.m., CNA #4 that witnessed the incident of 7/12/18 was interviewed. CNA #4 stated she was the food coordinator that day and she saw RN #1 battling to give medications to Resident #56. CNA #4 stated Resident #56 does not always want her medications. CNA #4 stated RN #1 held the resident's nose shut and when the resident opened her mouth to gasp for breath, RN #1 shoved the medicines into her mouth. CNA #4 stated RN #1 pinched the resident's lips against her teeth trying to get her to open and drink water. CNA #4 stated CNA #3 came over and told RN #1 to stop. CNA #4 stated Resident #56 pulled her shirt up over her mouth to avoid the medication. CNA #4 stated she then reported the incident to the administrator. CNA #4 stated she had seen other nurses give medications to Resident #56 and they sweet talk her or leave her alone and try at another time. On 11/28/18 at 3:47 p.m., the administrator and DON were interviewed about RN #1 physically forcing Resident #56 to take medications on 7/12/18. The DON stated they physically assessed the resident following the incident and did not find any evidence of physical abuse but they were concerned the resident's rights had been violated. The DON stated after reading the statements she determined that RN #1's intent was to get her to take the medications. The DON stated RN #1 should not have made her take the medication. The administrator stated after talking with RN #1, she felt RN #1's intention was not bad. On 11/29/18 at 7:08 a.m., CNA #3 was interviewed about Resident #56 with RN #1 on 7/12/18. CNA #3 stated she was in the dining area and heard Resident #56 say, No. Stop it. CNA #3 stated RN#1 was shoving the spoon of medicine in Resident #56's face. CNA #3 stated RN #1 was pulling the resident's arms down and digging her fingertips into the resident's forearm. CNA #3 stated RN #1 held the resident's nose shut until the resident opened her mouth to breath and then shoved the medicine into her mouth. CNA #3 stated Resident #56 was swatting at RN #1, turned her head away and spit out the pudding/medicines everywhere. CNA #3 stated she told RN #1 to stop several times and she did not stop until the telephone rang and she left to answer the phone. CNA #1 stated residents were afraid of RN #1. CNA #3 stated she had seen RN #1 force other residents to take medications but not this bad or with this amount of physical force. CNA #3 stated, This was to me major abuse, when she held her (Resident #56) nose closed and was pinching her arms. CNA #3 stated she tried to calm the resident and then reported the incident to the supervisor and administrator. Resident #56's plan of care (revised 10/24/18) documented the resident had a history of [REDACTED]. Interventions to minimize refusals and aggression included, .Be gentle and patient .Light and simple humor may be a distraction for her .Compliment for cooperative behavior .Explain what you are doing at all times .If possible, leave and return later to finish care .Talk while providing care .Offer simple choices for her to maintain some control .Use calm non-threatening tones when talking . The facility's policy titled Resident Abuse and Neglect (revised 6/6/18) documented, .Every (facility) resident has the right to be free from abuse, corporal punishment, involuntary seclusion, and suspected crime. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals .It is the policy of (facility) to provide care in a manner that is professional, [MEDICATION NAME], and respectful of the residents' rights .Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation .This includes, but is not limited freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom . These findings were reviewed with the administrator and director of nursing during a meeting on 11/28/18 at 5:00 p.m.

Based on resident interview, clinical record review, and staff interview, the facility staff failed to follow physician's orders for one of 23 residents in the survey sample, Resident # 16. Resident # 16 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident did not have any completed MDS information available . The resident's admission assessment, assessed the resident as being A&O X 4 (alert and oriented times 4). The resident's clinical record was reviewed and documented that the resident lived at home and had a [MEDICAL CONDITION] episode, which resulted in a fall and [MEDICAL CONDITION] ankle; the resident was admitted to the facility for rehab. Resident # 16's current physician's orders were reviewed and included an order for [REDACTED]. On 08/10/17 at approximately 8:40 a.m., the resident was visited in her room. The resident was dressed, sitting on the side of her bed. The resident was observed with an ace type wrap/bandage on her right foot (toes exposed) extending up her ankle and on to about mid calf. The resident's right toes were exposed and were observed with dark pink nail polish on all five toes. The resident had a non-skid sock on the left foot. The resident interviewed and ask about the reason for admission. The resident stated that she had been at home and felt kind of sick to her stomach and then felt dizzy and the next thing she knew she had passed out and as a result she ended up with the fractured ankle. The resident was asked if the staff are checking the foot. The resident stated yes, and further stated that they (staff) check the pulse by feeling under the dressing. The resident was asked if the staff check a capillary refill (The capillary refill is a quick test done on the nail beds, it is used to monitor the amount of blood flow to tissue, which cannot be seen in the presence of nail polish covering the nail bed). The resident stated that she did not know what that was. The resident was asked how long her nail polish had been on her toes. The resident stated that it had been on since before she fell . The resident stated that she was supposed to take a trip to California and she and her daughter had got pedicures preparation and then she had the fall. The process of checking capillary refill was explained to the resident. The resident stated, Good, maybe they will take the polish off of both my feet. During the clinical record review on 08/101/17, Resident # 16's nursing notes were reviewed. A nursing note dated 08/06/17 documented, .circulation assessed and found intact with brisk capillary refill and normo-thermic (normal body temperature) to touch . A nursing note dated 08/08/17 documented, .capillary refill and pedal pulse obtained . On 08/10/17 at approximately 11:50 a.m., the administrator, DON and ADON were made aware of the above information. The DON was asked what was the expectation for checking a capillary refill on someone like Resident # 16. The DON stated that, that is the only way I know how to do it, is on the nail. The DON confirmed that it should also be done on the affected extremity. No further information and/or documentation was presented prior to the exit conference on 08/10/17.

Based on staff interview and clinical record review, the facility staff failed to review and revise the CCP (comprehensive care plan) for one of 23 residents in the survey sample, Resident # 9 regarding falls. Resident # 9 had a history of [REDACTED]. The resident's CCP was not updated with the resident's fall and/or interventions related to the falls. Findings include: Resident # 9 was admitted to the facility on [DATE], with the most current readmission on 01/30/17. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) assessment was dated 02/06/17, which assessed the resident as having short and long term memory impairment and as having severe impairment in daily decision making skills. The resident was also assessed as requiring assistance from at least one staff members for most ADL's (activities of daily living). The resident also triggered in the CAAS (care area assessment summary area) for falls on this MDS. During clinical record review on 08/09/17, Resident # 9's nursing notes were reviewed and revealed that the resident had approximately 9 falls from December 2016 through January 2017. The resident's CCP was reviewed and documented that anti roll back brakes were implemented on the resident's w/c (wheelchair) on 01/02/17, but did not have any of the falls listed during the above time frame and did not address any other interventions put in place for Resident # 9. On 08/09/17 at approximately 4:00 p.m., the DON (director of nursing), administrator and the ADON (assistant director of nursing) were made aware of concerns regarding Resident # 9 numerous falls and that the resident's CCP had not been updated to reflect the falls and/or any new interventions to address the continued falls. The DON stated that they (facility) would see what they could find. On 08/10/17 at approximately 9:45 a.m., the DON (director of nursing) and the ADON (assistant director of nursing) presented information regarding Resident # 9's interventions and/or care during this time. The ADON stated that the resident had a urinary tract infection and it was felt that caused the resident confusion and increased falls, the ADON stated that they assessed and treated the resident. The ADON also stated that the resident that family was involved with care and that a therapy screen had been ordered for the resident, and that the resident's bowel regimen had been changed during this time. The DON and ADON were made aware that the resident's CCP is where the resident's care is directed from and that the above information should be reflected in the resident's CCP. The DON and ADON agreed, but could not explain why the resident's CCP was not reviewed and/or revised regarding the resident's falls. No further information and/or documentation was presented prior to the exit conference on 08/10/17.

Based on staff interview and clinical record review, facility staff failed to develop a comprehensive care plan (CCP) related to personal safety for one of 23 residents in the survey sample, Resident #18. Facility staff failed to develop a CCP for Resident #18 regarding her spouse's sometimes loud, aggressive behaviors and episodes of anger during his visits with the resident. Findings included: Resident #18 was originally admitted to the facility on [DATE] and readmitted on ,[DATE] 16 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 06/27/17. Resident #18 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #18's clinical record was reviewed on 08/09/17 at approximately 2:55 p.m. During this review progress notes were noted that included the following documentation: 06/12/17 13:25 (1:25 p.m.) - .At this time, the family is making a huge adjustment by moving the husband in to the (facility initials) village in the (Name) bldg. (building) . 06/19/17 18:51 (6:51 p.m.) - Residents husband in just as resident is finishing her supper meal, took her to her room; this nurse took resident a cup of ginger ale (thickened) as she had asked for, and within just a few minutes, the husband brought the cup of ginger ale back to the kitchen area and thanked the food coordinator. (sic) Less than 5 mins later, resident's husband came out and was complaining that the room was 'too cold', Shahbaz followed the husband in and adjusted the temp. control. (sic) Immediately after that, the husband came to this nurse and was carrying the hearing aid chain and holder with only 1 hearing aid attached to it and raising his voice saying 'what do I do with this?' this nurse informed him that he really should leave the hearing aids in her ears until the Shahbaz get ready to put her to bed, continued to ask 'where is the other hearing aid?' (sic) in a loud, aggressive voice; this nurse responded by saying 'the hearing aid is on her, somewhere; please don't take then off until she is ready to go to bed'. (sic) This nurse then asked the resident, 'do you want the hearing aids on or off?' and the husband began answering and this nurse said 'I am asking her what she wants to do', (sic) resident stated, 'well, I guess I'll take them off . 06/19/17 22:49 (10:49 p.m.) - Resident's husband returned to this house about 20 minutes after leaving and came in and stated that he 'had lost his glasses' and he went directly into Room #(number), went to the resident's nightstand and picked up her glasses, this nurse said 'Mr (Name), are you sure that they are your glasses?' (sic) he stopped, looked at them and don't stated 'No, they are hers' and then he said to this nurse 'do you have my glasses?' I responded 'No sir I don't have your glasses .' (sic) He attempted to leave the house, but did not remember to put the # in the keypad and shook the door several times; Shahbaz reminded him about the keypad and assisted him out . 06/22/17 17:19 (5:19 p.m.) - .husband visits daily now that he has moved onto (initials) campus . 07/04/17 18:05 (6:05 p.m.) - Resident's husband came to this house just as resident was finishing her supper meal and began pulling backward on her w/c (wheelchair' several times, this nurse observed his actions and reminded him that he needs to release the brakes on the w/c before he can move it, he replies, 'oh, yeah, that's right' and released the brake, then pushed resident to her room. (sic) In just a few minutes, the husband pushing the resident in her w/c came to the Nurse's office and states, 'Do you know how to put a hearing aide in?' (sic) this nurse responded 'yes'; he then said 'well, here, then put this in' as he was holding the hearing aide holder strap; this nurse looked closer at the resident and stated 'the hearing aide is in her ear'; he said, 'Well, what is this?' and this nurse once again stated, 'that is her hearing aide' (sic) Resident and her husband both become very aggressive and demanding when they approach any staff member about any aspect of her care . 07/05/17 18:51 (6:51 p.m.) - Husband in to see this resident during supper meal and kept asking 'are you finished' - 'are you finished yet'??? (sic) After resident was finished with her supper meal, husband pushed resident to the TV room, but then he kept getting up and down and asking, 'can you put her down now?' (sic) Shahbaz attempted to explain to resident's husband several times that resident needs to sit upright for at least 30 minutes after finishing her meal in order to avoid vomiting related to GERD. (sic) The resident is not asking to be put to bed, the husband is the one who wants her to be put to bed before he leaves to go home; we have explained the situation to him numerous times. (sic) Husband now has resident sitting out in the Great Room and is pacing until the Shahbazim get her in the bed. 07/07/17 11:25 (a.m.) - Resident's husband came in at breakfast time and stayed until resident got up. Resident came to the table to eat about 1030 (10:30 a.m.), and resident's husband paced between the sun-room, where he was watching the news, and the table. She started to cough while eating, and he hovered over her, saying she shouldn't eat anymore and took her plate away. 07/08/17 07:00 (a.m.) - Resident was in her room with Shahbaz doing hs (bedtime) care, when resident's husband came into the house very hurriedly and wanted to see the resident, this nurse told him that she would be finished shortly, so he paced back and forth in the great room until the Shahbaz came out of the room. (sic) Husband entered the room and said 'Why doesn't she have any pants? What have you done with all of her pants?' Shahbaz said 'do you mean her slacks? Because she has 5 pair hanging here in the closet and I am going to wash the pair she just took off which will be ready for in the morning, so then she will have 6 pair.' (sic) Husband responded 'OK, well, I didn't think she had any pants to wear to church in the morning, so that's good, OK, see ya in the morning' (sic) Husband then left the house and was much calmer when he left. 07/08/17 15:15 (3:15 p.m.) - Today after lunch resident's husband started pushing resident from the table to take her to her room. When moving her the O2 (oxygen) tubing of another resident became tangled in the wheelchair of Mrs. (Name). Mr. (Name) was politely asked to wait for staff to help. He became angry and yelled at staff he was taking his wife to her room. We attempted to explain to him about the O2 tubing but he continued to be angry. We were able to show him the problem and he then stopped yelling and allowed staff to untangle the tubing. No injuries to anyone occurred. 07/12/17 18:28 (6:28 p.m.) - .Resident's husband now lives on campus and visits frequently and he can also get her very agitated . 07/16/17 18:32 (6:32 p.m.) - Resident's husband (Name) in to visit resident - noted immediately to go out on porch and move resident's WC back in the home-Staff approached resident and asked husband to allow resident to remain on porch until she is ready to go to bed. (sic) Husband became immediately angry; raised his voice; speaking loud and intimidating;behaving in a threatening manner with staff; and attempted to state 'This is my wife, I can do what I want!' (sic) Second nurse, then stepped in to the conversation and asked resident if she wants to remain outside. Resident states 'Yes.' Resident was returned to porch and husband accompanied. Staff spoke with resident regarding his behaviors in the home. 07/27/17 08:16 (a.m.) - Resident's husband came into the house, went immediately to the couch, took a blanket off of the back, and took it into resident's room. He then proceeded to go into another resident's room, take a blanket, and on his way into resident's room, this nurse explained that the blanket belonged to another resident, and returned it to that resident's room. (sic) The other resident's family had previously complained this week that her blanket had gone missing, and was found in this resident's room. 08/06/17 14:53 (2:53 p.m.) - At 1415 (2:15 p.m.) resident's husband came back into the house, 6-2 nurse informed him that she was in bed napping and asked him to wait for a while before waking her because on Sat. she did not get to lay down for a rest due to visiting with family; he agreed and asked 'how long should I wait', this nurse responded, 'at least 30 mins'. (sic) This nurse went next door to (Name) and completed the shift change and when we returned, we found that the resident's husband had gone in her room and shut the door . 08/07/17 18:12 (6:12 p.m.) - Resident continues to become agitated and very angry when she is confused - husband now lives on campus and is in/out of the house several times thru the day . (sic) 08/08/17 18:10 (6:10 p.m.) - At approx 1800 (6:00 p.m.) resident's husband entered the home and walked directly over to where resident was sitting at the dining table and attempted to remove her plate, stating 'You have had enough to eat.' Nurse intervened and asked husband to allow resident to decide when she had finished. At this time, resident states 'I am done.' (sic) Husband then removed resident from table via wheelchair and took her to her room; when attempting to move WC thru doorway, resident was heard yelling at husband for striking her feet on the door frame. (sic) Subsequent review of Resident #18's CCP did not reveal any approaches or interventions regarding Resident #18's personal safety when husband is being overly aggressive, loud or angry. The Administrator, DON (director of nursing) and ADON (assistant director of nursing) were informed of the above documentation during a meeting with the survey team on 08/09/17 at approximately 4:00 p.m. The ADON stated, We are aware of his behaviors and are working with him and the family. I believe we have addressed this in her care plan. Let me look into that and get back with you. He definitely dictates the mood of the house. During a meeting with the survey team on 08/10/17 at 11:40 a.m. the Administrator, DON and ADON agreed there was nothing included in the care plan to address Resident #18's spouse's behaviors and outbursts. The ADON stated, We will have to develop a behavior contract with him and call a special meeting with the family to discuss this. No further information was received by the survey team prior to the exit conference on 08/10/17.

Based on observation, staff interview and facility document review, the facility staff failed to ensure a sanitary, clean, orderly and comfortable interior for one of 23 residents in the survey sample, Resident # 6. Resident # 6's room was visibly dirty and unsanitary in condition. Resident # 6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 8, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance from at least two staff for transfers, and toileting and assistance from at least one staff member for dressing and hygiene. The resident did not ambulate. On 08/09/17 at approximately 11:00 a.m., Resident # 6 was visited in her room. The resident was in bed, covered with blankets. The resident's bed side table was close to the bed with a cup of water sitting on it. The bedside table was visibly soiled with white dried matter. The bedside table did not show signs of being wiped clean or sanitized. At approximately 11:05 a.m., a CNA (certified nursing assistant) came into the room and left a large water mug with a straw on the resident's nightstand. The nightstand had dried, white splatter marks on the front (drawers). In front of the nightstand was a small, white, wooden stool that had a 'motion detector' sitting on top of it. The stool had visible dirt/debris with dried spillage on it. The resident's floor was observed with dirt/debris and dried spillage marks. A soiled paper napkin was laying at the bottom of the resident's bed. The resident's recliner was observed with some type of food crumbs in the seat. On 09/10/17 at approximately 8:15 a.m., the resident was again visited in her room. The resident was in bed, covered with blankets. The resident's bedside table now had dried and wet spillage; the bedside table showed no signs of being wiped clean or being sanitized. The resident's floor, nightstand, recliner and stool were all in the same condition as the previous observation. The soiled napkin at the bottom of Resident # 6's bed had been removed. The privacy curtains (two), which separated Resident # 6 and her roommate were both visibly soiled with dirt and brownish stains. At approximately 8:20 a.m., CNA # 1 was asked about housekeeping services. The CNA stated that they have housekeepers that clean the main areas, but clean the resident rooms daily. At approximately 9:30 a.m., the administrator was asked for a policy and/or information regarding a cleaning schedule of resident rooms. At approximately 9:40 a.m., the administrator presented a job description/policy of the expectations of the housekeeping staff and presented a room cleaning schedule. According to the schedule Resident # 6's room is supposed to be 'deep cleaned' every Thursday. The administrator was then made aware of the numerous concerns (listed above) regarding the cleanliness and unsanitary conditions in Resident # 6's room. The administrator stated that he would observe the resident's room. The administrator returned after observing Resident # 6's room and stated that all of the concerns presented by this surveyor were completely validated and stated that he (the administrator) agreed that the room was not clean. The facility's policy/job description titled, Housekeeping Technician documented, .Resident Apartment/Rooms .thoroughly clean residents' .rooms .follows correct cleaning procedures for infection control and cleanliness in all phases of daily work .cleans beds weekly .cleans over-bed-table weekly and damp dust daily if needed .damp dust furniture daily if needed .damp dust all chairs, spokes, rungs, and under cushion weekly, daily if needed .keeps window drapes and cubicle curtains clean and free of stains and lint . The administrator stated that the privacy curtains are to be changed our every 6 months or as needed. The DON (director of nursing), the administrator and ADON (assistant director of nursing) were made aware in a meeting with the survey team at approximately 11:40 a.m. and again informed of concerns regarding Resident # 6's room. No further information and/or documentation was presented prior to the exit conference on 08/10/17.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure safety interventions for the prevention of falls for two of 23 residents in the survey sample, which resulted in harm for Resident # 4 and Resident # 3. 1. The facility failed to ensure two staff members were at Resident # 4's bedside, when the resident was being transferred via lift, as a result the resident fell off the side of the bed and incurred left zygomatic bone fracture (zygomatic arch or cheek bone is formed by the zygomatic process of temporal bone) with left eye/ left facial bruising and subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) and a subdural hematoma (usually the result of a serious head injury, with a collection of blood outside the brain). 2. The facility staff failed to ensure Resident # 3 had appropriate supervision during toileting, as a result the resident fell off the toilet and incurred a hip fracture. Findings include: 1. The facility failed to ensure two staff members were at Resident # 4's bedside, when the resident was being transferred via lift, as a result the resident fell off the side of the bed and incurred left zygomatic bone fracture (zygomatic arch or cheek bone is formed by the zygomatic process of temporal bone) with left eye/ left facial bruising and subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) and a subdural hematoma (usually the result of a serious head injury, with a collection of blood outside the brain). Resident # 4 was admitted to the facility on [DATE], with the most current readmission on 01/28/16. [DIAGNOSES REDACTED]. characterized by fluctuating weakness of voluntary muscles), and [DIAGNOSES REDACTED] (a chronic sleep disorder that causes overwhelming drowsiness). The most current full MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 9, indicating the resident had moderate impairment in daily decision making skills. This MDS also assessed the resident as requiring extensive to total assistance for bed mobility and transfers, with two staff members for physical assistance. This MDS also assessed that the resident had a fall with major injury in the last month. The resident triggered for falls in the CAAS (care area assessment summary) and the area was marked to be addressed in the resident's CCP (comprehensive care plan). The quarterly MDS assessment dated [DATE], just prior to the fall assessed the resident with a cognitive score of 9 and requiring extensive assistance from staff for most ADL's, with two staff assist. The most recent MDS assessment was a quarterly, reviewed for comparison dated 07/19/16. This MDS assessed the resident with a cognitive score of 9 and as requiring total assistance from staff for all ADL's (activities of daily living), with two staff member assist. During clinical record review on 08/23/16 through 08/25/16, Resident # 4's nursing notes were reviewed and documented that on 01/28/16 at approximately 7:30 a.m. Resident # 4 fell off the side of the bed, and was sent out to the hospital for evaluation. On 08/24/16 at approximately 9:40 a.m., the fall investigation for Resident # 4 was requested. The fall investigation for Resident # 4 was presented and reviewed and documented the following in summary: Resident # 4 was admitted on [DATE] following a hospitalization for a stroke. The resident's fall occurred on 01/23/16 at approximately 7:30 a.m. and there were two witnesses. CNA (certified nursing assistant) # 5 and RN (Registered Nurse) # 4, both were interviewed and provided statements. CNA # 5 was providing morning care to Resident # 4 and sat the resident on the side of the bed, with feet on floor and then the CNA used her radio to call for assistance with transferring. The lift was in the hallway outside of the resident's room, the resident asked CNA # 5 for facial cream and the CNA turned to get it off the bedside table and at that point RN # 4 was in the doorway of the resident's room and the resident fell forward from the sitting position on the bed to the floor. The resident was sitting on the side of the bed for a few minutes at most before the fall happened. The resident has a history of [DIAGNOSES REDACTED] and had been noted in the past to fall asleep prior to receiving her morning medications and at the time of the fall the resident had only received eye drops, no medication for [DIAGNOSES REDACTED] or any others. The resident hit her left side of her head hard on the floor. The patient was rolled onto her back and placed in a position of comfort, patient was alert and oriented prior to fall. The resident was in an unconscious state, with her eyes rolling around in her head. Resident # 4 was transported to the local hospital following a fall in her room at the facility, the resident was positive for a subdural hematoma and zygomatic fracture, she was admitted to the hospital and was discharged back to the facility on [DATE]. Resident # 4's CCP was then reviewed and documented the following: Start date 10/06/15 (under falls) .2 staff members to be with patient when sitting on side of bed prior to lift transfer .does not walk .keep bed at appropriate height for safe transfer .(ADL section) Transfers with mechanical lift and 2 assists . Resident # 4's physician's orders [REDACTED]. The resident's current physician's orders [REDACTED]. On 08/24/16 at 1:25 p.m., the DON (director of nursing) and ADON (assistant director of nursing) were interviewed in a meeting with the survey team. The DON and ADON were made aware of serious concerns regarding Resident # 4 falling and being seriously injured. The DON and ADON were asked about the resident's CCP fall interventions to have two staff members present while at the bedside for transfers. The DON and ADON agreed that interventions were not followed. The DON and ADON were asked if residents have a kardex or care sheet that staff go by for specific care information on residents. The DON stated, no. The DON was asked where do staff (Nurses and/or CNA's) get information regarding their resident's specific needs. The DON stated that, we encourage them to look at the care plans, but they don't have any kind of kardex or care sheet. The DON was asked, what does 'Fall Precautions' mean, as indicated on the physician's orders [REDACTED]. The DON stated that is a 'term' that the hospital uses and puts on there when a resident is readmitted . The DON was made aware that this was an actual current physician's orders [REDACTED]. The DON stated that they (facility staff) did not actually know what that means and again stated that is something that comes from the hospital and did not have a definition or description of what 'fall precautions' mean. A facility policy on fall prevention was presented and reviewed. The policy documented, Falls Prevention Protocol .early identification of risk factors and staff intervention can reduce the potential for falls .It is the responsibility of all staff to assist in identifying risk factors and carrying out established plans to minimize falls .identify residents at high risk of falling and to minimize or prevent any injury that occurs due to a fall .The resident will be consider (sic) at risk if the: score is 10 or greater on fall risk assessment . Resident # 4 had a fall risk assessment completed on admission 09/04/15, which gave the resident a score of 22. A fall risk assessment dated [DATE] gave the resident a score of 14. Resident # 4's hospital records were reviewed. A CT (computed tomography) of the brain and head dated 01/24/16, documented: .acute hemorrhage within the interhemispheric fissure .3.3 cm (centimeters) in length, 1.5 cm in maximal thickness .related to subdural and subarachnoid hemorrhage with possible small amount of parenchymal hemorrhage .evidence of developing subdural hematoma acute blood as well as more low attenuation fluid .developed from 01/23/16 .this measures approximately 5 mm (millimeters) in thickness .small subdural hematoma with subarachnoid hemorrhage .small amount of intraventricular hemorrhage left zygomatic arch fracture . On 08/25/16 at approximately 11:20 a.m., in a meeting with the survey team, the administrator and DON were informed of serious concerns related to Resident # 4 being harmed during a transfer, which resulted in a fall with extensive injuries. The administrator and DON were made aware that facility staff did not follow the resident's CCP (comprehensive care plan) for transfers, as indicated in the resident's plan of care. The administrator and DON agreed and were then asked if they had any additional information and/or documentation regarding the above. The DON stated, no and further stated that they (staff) presented all information. The administrator stated that all information has been presented to the survey team regarding Resident # 4's fall with injury and it had been reviewed by the facility's administrative team and they (staff) agreed that there was actual harm. The administrator stated that, the adminsitrative staff had provided all the information. No further information and/or documentation was presented prior to the exit conference on 08/25/16 at 12:45 p.m. to evidence that the facility staff implemented appropriate and/or adequate safety interventions in place for Resident # 4, to prevent a fall with major injury. 2. The facility staff failed to ensure Resident # 3 had appropriate supervision during toileting, as a result the resident fell off the toilet and incurred a hip fracture. Resident # 3 was admitted to the facility 1/3/16 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment dated [DATE]. Resident # 3 was coded as having short term and long term memory problems, and moderately impaired in daily decision making ability. This MDS also assessed the resident as requiring extensive to total assistance for bed mobility, transfers, and toileting with two staff members for physical assistance. The resident triggered for falls in the CAAS (care area assessment summary) and the area was marked to be addressed in the resident's CCP (comprehensive care plan). Section G0300 Balance During Transitions and Walking has Resident # 3 coded for Moving from seated to standing position and Surface-to-surface transfer as a 2. Not steady, only able to stabilize with human assistance. The clinical record was reviewed 8/23/16 at 1:45 p.m. It was noted Nursing notes dated 5/25/16 and 5/26/16 documented the following: 5/25/16 17:00 (5:00 p.m.) - Comments: General Quick Comments= Resident had unwitnessed fall from toilet. Nursing in to evaluate. VS (vital signs) obtained and found to be wnl (within normal limits). Residents wife was contacted with news of the fall and requests that he be sent to the ER for evaluation. (Name of physician assistant) contacted and informed of the fall and the request by family that he be sent out. (Name of transport company) called for transport to hospital. Ambulance arrived at approximately 1700 (5:00 p.m.) and transported resident to the emergency room . His wife states she will meet the resident at the ER. 5/26/16 11:37 a.m. Comments: General Quick Comments= Patient discussed in IDT (interdisciplinary team) meeting regarding fall. Private caregiver was present, and fell from toilet. Nurse provided education to caregiver regarding not leaving pt. unattended in bathroom. Pt. sent to ER and admitted . The CCP was then reviewed. The care plan was dated 1/27/16 for the identified areas of ADL (activities of daily living) and Falls. For the ADL section, under Problem was documented Resident needs ext-total (extensive to total) assistance with ADL care due to cognition impairment . Under Approach was included Start Date: 1/27/16- During transfers and/or position changes, maintain arms reach control for safety and stability. Under the section for Falls dated 1/27/16 was documented .has had a fall with fx (fracture); is at risk d/t (due to) poor safety awareness associated with dementia, unsteady gait/balance, pain meds. Under Approach was documented Start date 1/27/16- sitter to remain in bathroom with resident (5/25/16). On 8/24/16 at approximately 8:30 a.m. the ADON (assistant director of nursing) was asked for a copy of the fall investigation for Resident # 3. The investigation was presented and reviewed, and included the following documentation in summary: Incident Details 5/25/16 : Details of the incident- Resident was placed on toilet by his sitter and 1 staff member when the sitter left the bathroom and returned to sit in the residents room. The sitter states he heard a loud noise, and went to the bathroom and found the resident on the floor. The sitter states he got him up and placed him back on the toilet. One of our staff members then entered the bathroom and the sitter informed her of what happened and she immediately informed nursing of the incident. Nursing in to assess patient. He was very agitated and aggressive with those trying to assist and thorough assessment could not be performed. Staff attempted to determine if he was injured but he became combative at that point. Additional staff came into the room and it was determined that he would be transferred over to his wheelchair so he could be assessed more thoroughly. Staff attempted to stand the patient up but he was unable to bear weight. At that point he was seated back on the toilet. (Name of physician assistant and wife) were notified of the incident and (wife) requests he be sent out to the ER for evaluation. Private ambulance in to pick hip (sic) up but unfortunately he is still on the toilet. He was successfully transferred to the stretcher and talked to the hospital. Staff called to check on his status and were told he had fractured his right hip. On 08/24/16 at 1:25 p.m., the DON (director of nursing) and ADON (assistant director of nursing) were interviewed in a meeting with the survey team. The DON and ADON were made aware of serious concerns regarding Resident #3 falling from the toilet and being seriously injured. The facility staff were asked about the resident's CCP fall interventions to maintain arms reach for control and stability. The facility staff agreed that interventions were not followed. The DON and ADON were asked if residents have a kardex or care sheet that staff go by for specific care information on residents. The DON stated, no. The DON was asked where do staff (Nurses and/or CNA's, including the residents private sitter) get information regarding their resident's specific needs. The DON stated that, we encourage them to look at the care plans, but they don't have any kind of kardex or care sheet. The ADON was asked if the private sitter and/or the company for the sitter had any type of agreement or contract. The ADON stated that there was a contract that, on admission, was signed by the resident/POA (power of attorney) and a representative of the company as well as the facility. The ADON further stated that this contract had not been signed by the residents wife/POA until June 2016, after the fall. The DON stated that the intervention dated 5/25/16 on the resident's care plan had been an added as a result of the fall with injury for the sitter to remain in the bathroom with the resident. On 8/24/16 at 11:15 a.m. during an interview with Resident # 3's wife, she stated that the fall incurred by the resident had really upset the private sitter. She further stated I didn't have to hire a private sitter; I feel confident that the facility staff would take good care of him, but I can so I did. I know the sitter was so upset when that happened; he's been with him since he was admitted and this really caused him to be upset. I wasn't here when it happened, so I can't say exactly what happened, but the sitter will be here this afternoon. On 8/24/16 at 3:15 p.m. the private sitter was interviewed. The sitter was asked about the incident on 5/25/16 when the resident fell from the toilet and broke his hip. The sitter stated Everything about that day was normal; I got one of nurses to help me get him on the toilet. The wipes were over here on his bedside table, and I could smell that he had a bowel movement so I got up to get the wipes and then I heard a loud noise; he had attempted to get up, which he never does he usually won't stand up and will fight me but that day he got up. I learned a valuable lesson that day I learned that even if somebody does something the same way for [AGE] years, on year 21 they may do something unexpected. It kills me that this happened on my watch. The sitter was then asked how he received information on the resident's care. The sitter stated I usually get information from the nursing staff; I don't normally look at the care plan. On 08/25/16 at approximately 11:20 a.m., in a meeting with the survey team, the administrator and DON were informed of serious concerns related to Resident # 3 being harmed while unattended on the toilet, which resulted in a fall with a fractured hip. The administrator and DON were made aware that facility staff did not follow the resident's CCP (comprehensive care plan) for the intervention to maintain arms reach for control and stability, as indicated in the resident's plan of care. The administrator and DON agreed and were then asked if they had any additional information and/or documentation regarding the above. The DON stated, no and further stated that they (staff) presented all information. The administrator stated that all information has been presented to the survey team regarding Resident # 3's fall with injury and it had been reviewed by the facility's administrative team and they (staff) agreed that there was actual harm. The administrator stated that, we (staff) provided all the information and think you all (survey team) have identified an issue for us. No further information and/or documentation was presented prior to the exit conference on 08/25/16 at 12:45 p.m.

Based on observation, staff interview and clinical record review the facility staff failed to follow physician orders [REDACTED].# 8 and # 11. 1. Resident # 8 did not have TED (compression stockings) applied per physician orders. 2. Resident # 11's leg protectors were not applied per physician order. Findings include: 1. Resident # 8's TED hose were not applied as ordered by the physician. Resident # 8 was admitted to the facility 3/4/16 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 7/12/16 and had Resident # 8 with severe impairment in cognition with a total summary score of 05 out of 15. The clinical record was reviewed 8/24/16 beginning at 10:55 a.m. The August 2016 POS (physician order [REDACTED]. On 8/24/16 at 3:50 p.m. Resident # 8 was observed standing in her room with 2 CNA's (certified nursing assistants) present. This surveyor knocked on the door, and after being given permission to enter the room, went in to speak to Resident # 8. CNA # 2 stated they had heard the resident's alarm sounding and went to the room. The CNA's were getting the resident back to bed after toileting. This surveyor asked if the resident's legs could be observed once she was back in bed. CNA # 2 asked the resident if we could look at her legs, and the resident stated we could. CNA # 2 then pulled up Resident # 8's pants legs to her knees. Resident # 8 had on regular tan knee stockings on. This surveyor asked about the TED hose. CNA # 2 and CNA # 3 looked at each other and stated We didn't know she was to have TED hose on. This surveyor informed both CNA's of the order for Resident # 8, and also asked how they knew what care and services to provide for residents on their shift. CNA # 3 stated Usually it's on the paper what the resident needs. I'll go get it and show you. CNA # 3 left the room, and returned a few moments later with an oblong sheet of paper with resident names and divided columns of what treatments and/or services each resident was to receive each shift. CNA # 3 stated There isn't anything on here about (name of resident) having TED hose. On 8/24/16 during a meeting with facility staff beginning at 4:30 p.m. the DON (director of nursing) and the administrator were informed of the above observation. No further information was provided prior to the exit conference. 2. Resident #11 did not have physician ordered leg protectors in place. Findings include: Resident # 11 was admitted to the facility originally on 09/15/15. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was a quarterly assessment dated [DATE]. Resident #11 had long and short-term memory loss with severe cognitive impairment in daily decision making skills. Resident # 11's physician's orders [REDACTED]. Resident #11's care plan was then reviewed and revealed a care plan titled Potential for altered skin integrity ( .) An intervention with a date of 6/26/16 documented Use leg protectors to promote skin integrity and prevent injury. On 8/24/16 at 10:10 a.m. Resident #11 was observed sitting in a wheelchair in a common area and without leg protectors in place. At this time an interview with a certified nursing aide (CNA #1) was conducted concerning the observation. CNA #1 verbalized that she did not see the leg protectors when she was getting Resident #11 out of bed. This surveyor and CNA #1 then went to Resident #11's room to look for the leg protectors, but were unable to locate them. CNA #1 then verbalized that she (CNA #1) knew that Resident #11 was supposed to be wearing the leg protectors during the day. Resident #11's legs were then assessed by this surveyor and CNA #1. Resident #11 had some scattered bruising throughout both lower extremities, but no open areas. The above finding was brought to the attention of the director of nursing (DON) and the administrator on 8/24/16 at 4:30 p.m. No other information was presented prior to exit conference on 8/25/16.

Based on observation, staff interview and clinical record review the facility staff failed to ensure physician ordered heel boots were in place as ordered for one of 23 residents in the survey sample: Resident # 3. Findings include: Resident # 3, who had a history of [REDACTED]. Resident # 3 was admitted to the facility 1/3/16 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment dated [DATE]. Resident # 3 was coded as having short term and long term memory problems, and moderately impaired in daily decision making ability. The clinical record was reviewed 8/23/16 at 1:45 p.m. It was noted the August POS (physician order [REDACTED]. On 8/24/16 during an interview with OS (other staff) # 1 (a private sitter for the resident) Resident # 3 was observed in bed with eyes closed. Heel boots were observed lying on the extra bed in the resident's room, and OS # 1 was asked about the heel boots, and why the resident did not have them on. OS # 1 stated He only wears them when he's in bed. This surveyor acknowledged the resident was in bed at that time. OS # 1 then stated Oh, I mean when he's in bed for the night; like for the night. This surveyor informed OS # 1 the order and care plan did not indicate only at night, but when the resident was in bed. OS # 1 stated Oh, well, I just know that I think that's when the nurses put the boots on him. He doesn't have any sores on his heels right now; do you want to see? This surveyor stated Yes. OS # 1 then gently informed the resident of looking at his feet, and proceeded to lift each heel up for this surveyor to observe. Resident # 3's right heel had a slight reddened area on the heel approximately the size of a dime, but the skin was intact. The area was brought to OS # 1's attention, and he stated he did not realize the area was there. On 8/24/16 during a meeting with facility staff beginning at 4:30 p.m. the DON (director of nursing) and the administrator were informed of the above observation. No further information was provided prior to the exit conference.

Based on observation, staff interview and facility document review, facility staff failed to properly label a medication and ensure an expiration date was legible on the Massanutten unit. Facility staff failed to date an opened bottle of liquid Lorazepam stored in the locked box in the medication refrigerator. Also, the manufacturer expiration date was illegible. Findings included: On 08/24/2016 at approximately 2:55 p.m. this surveyor entered the medication room on Massanutten unit with RN #1 (registered nurse). A bottle of liquid Lorazepam was noted inside the locked box affixed inside the refrigerator. Upon inspection of the opened bottle of Lorazepam 2mg/ml (milligrams per milliliter) for a total of 30 ml, only 10 ml was left in the bottle. The bottle was not dated when it was opened and no expiration date was visible on the bottle. The box with the pharmacy label for the Lorazepam was noted also. The manufacturer expiration date was illegible. It had rubbed off of the label. RN #1 inspected the Lorazepam bottle and packaging box and agreed the open bottle had not been dated and there was no visible expiration date on the bottle or the pharmacy label. RN #1 was interviewed regarding labeling of opened medications. RN #1 stated, Yes ma'am, I date any medications when opened. If there isn't a place on the bottle I will write on a piece of tape and attach to the bottle. The Administrator and DON (director of nursing) were informed of the above information during a meeting with the survey team on 08/25/2016 at approximately 11:30 a.m. The DON stated, My expectation is that any medication should be dated when opened. The facility policy for Storage and Expiration of Medications, Biologicals, Syringes and Needles .Effective Date: 12/01/07 Revision Date: 01/01/13 . stated, .4. Facility should ensure that medications and biologicals: 4.1 Have an Expiration Date on the label; .5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container. 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels . No further information was received prior to the exit conference on 08/25/2016.

Based on observation and staff interview, the facility staff failed to store, prepare, distribute and serve food in a sanitary manner. 1. Ready for use food preparation/serving pans were stored nested and wet in the main kitchen. 2. The facility staff failed to ensure refrigerator temperatures in the pantries and kitchens of the Greenhouses in Woodland Park were within normal limits and were unable to verbalize the process for ensuring dishwasher temperatures were at proper levels. The findings include: 1. On 7/7/15 at 10:25 a.m. the facility's kitchen was inspected during the initial tour of the facility accompanied by the dietary services manager. Stainless steel preparation/serving pans, identified by the dietary services manager as clean and ready to use, were stacked on a storage rack. One large, 2 inch deep long pan was nested and wet; one of the pans had dried food particles that dislodged when the dietary services manager separated the pans. The dietary service manager put the two pans aside stating Those will be rewashed. Humidity and moisture were present on the inside pan surfaces and visible when the stacked pans were separated. The dietary services manager stated they routinely stored pans on a drying rack prior to stacking/nesting on the ready to use rack. The dietary services manager and this surveyor then continued to inspect 4 stacks of stainless steel preparation/serving pans identified as clean and ready to use stored on a shelf above the three compartment sink area. One of three six inch short pans and two of seven half pans were observed nested wet. Humidity and moisture were present on the inside surfaces and visible when these pans were separated also. The dietary manager again indicated the pans would be rewashed, and put the pans in a stack for staff to wash. No further information was provided prior to the exit conference. 2. The facility staff failed to ensure refrigerator temperatures in the pantries and kitchens of the Greenhouses in Woodland Park were within normal limits and were unable to verbalize the process for ensuring dishwasher temperatures were at proper levels. During initial tour of the facility on 07/07/2015 the three houses for residents, commonly referred to as the Greenhouses located in Woodland Park were toured. Each house/home had the capacity for ten residents. Each house was equipped with a full kitchen where all resident meals were prepared, as well as a pantry for food storage that included a freezer and refrigerator. As part of the initial tour, the kitchens and pantries were inspected for safe food storage and handling. The first home was the Showalter House. The refrigerator in the pantry was observed. There were two thermometers in the refrigerator. One thermometer read 6 degrees, the other read 18 degrees. This surveyor picked up a carton of milk located on the top shelf and shook it. The milk was not frozen. LPN (licensed Practical Nurse) #2, accompanied this surveyor. She was asked why there were two thermometers and why they were recording two different temperatures, both of which were below freezing. She stated, I don't know. A dietary aid, other staff #2 then came to the kitchen. She was asked the same questions. She stated, That's what I would like to know. The kitchen of the Showalter House was then observed. The temperature in the kitchen refrigerator was within normal range at 38 degrees. An under the counter dishwasher was observed in the kitchen. The door was open and the dish rack was pulled out exposing clean dishes. CNA (certified nursing assistant)/Shahbaz #1 was working in the kitchen. She was asked about the dishwasher and the dishwasher temperatures. She stated, I know the rinse cycle is suppose to be 180 degrees. The dishwasher log was requested. Temperatures recorded were wash 71 degrees and final rinse 82 degrees for each entry listed for July. CNA/Shahbaz #1 was asked about the temperatures. The administrator in training was in the Showalter House at that time and stated, The temperatures are recorded in Celsius not Fahrenheit. CNA/Shahbaz 31 stated, The temperatures are recorded on night shift, we don't do it during the day. This surveyor then went to the Yoder House. The pantry refrigerator also had two thermometers. One read 10 degrees, the other read 32 degrees. The food in the refrigerator was not frozen. The thermometers in the kitchen refrigerator read 16 degrees and 8 degrees. The Warsack House was toured next. The refrigerator in the pantry had temps of 32 degrees on both thermometers. The thermometers in the kitchen refrigerator read 28 degrees and 20 degrees. The dishwasher in the kitchen was observed to be running with a temperature range of 41 degrees to 63 degrees. The CNA/Shahbaz was not in the kitchen at the time. LPN #1 accompanied this surveyor at that time and was asked about the temperature on the dishwasher. She stated, I don't know. She was asked what cycle the dishwasher was in. She stated, I don't know. On 07/08/2015, the operations/dietary manager for the facility and the administrator in training came to the conference room to speak with this surveyor. The dietary manager stated, The thermometers weren't working correctly.I don't know if we got a bad batch or they were dropped or what. She was asked why each refrigerator had two thermometers. She stated, As a double check system so if one goes bad you know to replace it. She was asked who reviewed the temperature logs after the temps were recorded. She stated, They are reviewed at the end of each month when they are filed.the dietary aid (other staff) #2 is should have been looking at them when she delivered food. The administrator in training stated, We checked the food temperatures yesterday and everything was within normal range, we switched out the thermometers and inserviced the staff. The dishwasher was then discussed. The administrator in training stated, It is a commercial grade, domestic size, high temperature dishwasher. The dietary manager added, It has three wash cycles and two rinse cycles.they wash the dishes in the sink and rinse them, then put them in the dishwasher for sanitizing. Concerns were voiced to the dietary manager and the administrator in training that while temps were recorded on the 11-7 shift, the other shifts should also be aware of what normal washing/rinsing temperatures were and monitoring the process to ensure the temps were met. Facility staff had been unable to verbalize that information during initial tour. The dietary manager agreed. The administrator in training stated, We need to do some more education on this. Copies of temperature logs going back to January for the three homes were requested and received. From January 2015 to present the temperatures in the refrigerators of the pantries and kitchens of all three houses were recorded as below freezing. Concerns were voiced that facility staff did not question temperature variations between two thermometers in the same refrigerator or that the temperatures were reading below freezing and the food was not frozen. The dietary manager nodded her head up and down. No further information was obtained prior to the exit conference on 07/09/2015.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of nursing practice for one of 24 residents in the survey sample. There was no nursing assessment of Resident #21 following a report of the resident being lethargic. Resident #21 was administered a dose of the pain medication [MEDICATION NAME] after the nurse practitioner ordered to hold the medication. Nursing failed to document the verbal order to hold the dose of [MEDICATION NAME]. The nurse failed to document any of the events regarding the resident's lethargic condition and failed to convey information about the resident's condition to the oncoming shift. After administration of the dose of [MEDICATION NAME] against the practitioner's order, the resident was found unresponsive, was sent to the emergency room and required treatment with two doses of the opioid antagonist [MEDICATION NAME] to reverse the resident's sedation. The findings include: Resident #21 was admitted to the facility on [DATE] and was discharge home on 11/27/13. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #21 as cognitively intact. A facility reported incident report documented the following occurred on 11/6/13: "Resident was noted (with) increased lethargy. Nurse received verbal order from N.P. (nurse practitioner) to hold noon pain med. Nurse administered medication at 1:30 p.m. Resident had unresponsive episode later that day. (low) BP (blood pressure). (low) SAT (oxygen saturation) evaluated by N.P. [MEDICATION NAME] administered + resident evaluated in ER (emergency room ) + returned to facility." The facility's investigation documented the nurse practitioner (NP) evaluated Resident #21 on the morning of 11/6/13 for treatment of [REDACTED].#5 asked the NP if she should give the 12:00 p.m. dose of the medication [MEDICATION NAME] due to the patient's continued drowsiness. The report documented the NP gave an order to hold the noon dose of [MEDICATION NAME] on 11/6/13. The report stated on 11/6/13 at 3:30 p.m. the NP was notified by the on duty nurse that Resident #21 had low oxygen saturation levels (70's), low blood pressure (78/52) and had periods of apnea. The report documented the NP assessed the resident at this time and found the resident to have labored breathing, lethargy and was unable to answer questions. The NP ordered a dose of [MEDICATION NAME] which was administered prior to transport by ambulance to the emergency room . The report documented the resident received a second dose of [MEDICATION NAME] during transport to the hospital. The report listed the resident was diagnosed with [REDACTED]. The report documented the resident was alert upon arrival to the emergency room and later returned to the facility without any further treatment. Resident #21's closed clinical record was reviewed on 6/18/14. The record documented a physician's orders [REDACTED]. In addition the resident was prescribed/administered [MEDICATION NAME] 600 mg four times per day for [MEDICAL CONDITION] pain, [MEDICATION NAME] 30 mg twice per day for depression and [MEDICATION NAME] .5 mg twice per day for anxiety. A nurse practitioner's note dated 11/6/13 documented, "I was notified at approximately 1530 (3:30 p.m.) that the resident had O2 (oxygen) sats in the 70's on room air with BP 78/52...She was having periods of apnea...I gave a telephone order to send patient to the ED. Approximately 15 minutes later I was able to get to the patient to evaluate her myself. Breathing appeared labored with long periods of apnea. O2 sats were 90% on 4L (liters per minute). She was responding to verbal stimuli but immediately fell back to sleep and did not answer my questions. I gave an order for [REDACTED]. Other than the nurse practitioner's progress notes, there was no documentation in Resident #21's clinical record of an assessment on 11/6/13 regarding the resident's lethargy or the order to hold the [MEDICATION NAME]. The facility's investigation included statements from other caregivers for Resident #21 on 11/6/13. The investigation documented that the certified nurses' aide (CNA #4) caring for Resident #21 on 11/6/13 reported to LPN #5 the resident was slumped over and lethargic during her bath. CNA #4 stated LPN #5 came to the room and stated the resident's lethargy was due to her pain medications and then left the room. The investigation stated CNA #4 reported the resident was having difficulty holding her cup and eating food during lunch on 11/6/13. The facility's investigation stated LPN #5 spoke with the nurse practitioner (NP) about the resident's lethargy and was told to hold the noon dose of [MEDICATION NAME]. The investigation documented LPN #5 stated the resident requested her medications and LPN #5 administered the [MEDICATION NAME] around 1:30 p.m. against the NP order to hold the medicine. The report documented the 2nd shift nurse caring for Resident #21 was told the resident had some "increased sedation" but was not told about the verbal order to hold the noon dose of [MEDICATION NAME]. The clinical record documented on 11/6/13 at 3:38 p.m. the evening shift nurse assessed the resident with low oxygen saturation, lethargy and low blood pressure. The NP was notified and the resident was sent to the emergency room for treatment. The NP ordered a dose of [MEDICATION NAME] that was administered prior to the transport to the hospital. The hospital report dated 11/6/13 documented the resident was administered an additional dose of [MEDICATION NAME] on the way to the hospital. The resident was observed at the hospital but had no additional treatment in the emergency room . A nursing note dated 11/6/13 at 7:33 p.m. stated, "Patient returned to facility at 1845 (6:45 p.m.). Responsiveness back to baseline...No new orders from (emergency room )..." On 6/18/14 at 10:10 a.m. the director of nursing (DON) was interviewed about the medication [MEDICATION NAME] administered to Resident #21 on 11/6/13 against the verbal order by the nurse practitioner to hold the medicine. The DON stated CNA #4 had reported to LPN #5 the resident was lethargic/sleepy on the morning of 11/6/13. The DON stated later during the shift LPN #5 reported to the NP the resident was still lethargic and the NP gave a verbal order to hold the 12:00 p.m. dose of the medication [MEDICATION NAME]. The DON stated LPN #5 gave the [MEDICATION NAME] anyway. The DON stated when the second shift nurses came on duty the resident was assessed as unresponsive and with low oxygen saturation and low blood pressure. The DON stated the NP was notified and assessed the resident. The DON stated the NP ordered a dose of [MEDICATION NAME] prior to the ambulance arriving. The DON stated another dose of [MEDICATION NAME] was administered on the way to the hospital. The DON stated the resident refused further treatment at the emergency room and returned to the facility that evening. The DON stated when she talked with LPN #5 about administering the [MEDICATION NAME] LPN #5 stated she recalled the verbal order from the NP to hold the [MEDICATION NAME]. The DON stated LPN #5 reported she did not assess the resident regarding the report of lethargy from the CNA. The DON stated LPN #5 never wrote the verbal order from the NP in the clinical record and failed to convey to the oncoming shift about the resident's condition or the order. The DON stated, "She (LPN #5) failed to do what we consider basic nursing practice." The Drug Information Handbook for Nursing 13th Edition states on pages 12 concerning nursing responsibilities with medication administration, "Assessment is the primary action in the nursing process and it is also a vital part of optimal drug therapy. Assessment activities must precede administering any medication..." Page 13 of this reference states, "...at all times, the nurse responsible for administering the medication...is also responsible for monitoring effectiveness and adverse effects and communicating these details to the prescriber...When the patient is in danger it may be necessary to discontinue a medication and notify the prescriber. In other instances it will mean contacting the prescriber for further instruction...Awareness of the need for monitoring, the rationale behind monitoring instructions, and the type of monitoring required is a nursing responsibility..." (1) The Lippincott Manual of Nursing Practice 10th Edition states on page 16, "A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events." This reference on page 16 also states, "Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient...document appropriate information in the medical record, administer medications as ordered..." (2) The Drug Information Handbook for Nursing 13th Edition on pages 602 and 603 describes [MEDICATION NAME] as a combination opioid ([MEDICATION NAME]/[MEDICATION NAME]) [MEDICATION NAME] used for the relief of moderate to severe pain. This reference documents, "The Institute of Safe Medication Practices (ISMP) includes this medication among its list of drug classes which have a heightened risk of causing significant patient harm when used in error." (1) The Drug Information Handbook for Nursing 13th Edition on page 848 describes [MEDICATION NAME] as an opioid antagonist/antidote used for the "complete or partial reversal of opioid drug effects, including respiratory depression; management of known or suspected opioid overdose; [DIAGNOSES REDACTED]." (1) These findings were reviewed with the administrator and DON on 6/18/14 at 11:50 a.m. (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. (2) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 24 residents was free from a significant medication error. Resident #21, assessed as lethargic, was administered a dose of the medication [MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME]) after the nurse practitioner ordered to hold the medication The resident was later found unresponsive, was sent to the emergency room and required treatment with two doses of the opioid antagonist [MEDICATION NAME] to reverse the resident's sedation. The findings include: Resident #21 was admitted to the facility on [DATE] and was discharge home on 11/27/13. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #21 as cognitively intact. A facility reported incident report documented the following occurred on 11/6/13: "Resident was noted (with) increased lethargy. Nurse received verbal order from N.P. (nurse practitioner) to hold noon pain med. Nurse administered medication at 1:30 p.m. Resident had unresponsive episode later that day. (low) BP (blood pressure). (low) SAT (oxygen saturation) evaluated by N.P. [MEDICATION NAME] administered + resident evaluated in ER (emergency room ) + returned to facility." The facility's investigation documented the nurse practitioner evaluated Resident #21 on the morning of 11/6/13 for treatment of [REDACTED].#5 asked the NP if she should give the 12:00 p.m. dose of the medication [MEDICATION NAME] due to the patient's continued drowsiness. The report documented the NP gave an order to hold the noon dose of [MEDICATION NAME] on 11/6/13. The report stated on 11/6/13 at 3:30 p.m. the NP was notified by the on duty nurse that Resident #21 had low oxygen saturation levels (70's), low blood pressure (78/52) and had periods of apnea. The report documented the NP assessed the resident at this time and found the resident to have labored breathing, lethargy and was unable to answer questions. The NP ordered a dose of [MEDICATION NAME] which was administered prior to transport by ambulance to the emergency room . The report documented the resident received a second dose of [MEDICATION NAME] during transport to the hospital. The report listed the resident was diagnosed with [REDACTED]. The report documented the resident was alert upon arrival to the emergency room and later returned to the facility without any further treatment. Resident #21's closed clinical record was reviewed on 6/18/14. The record documented a physician's orders [REDACTED]. In addition the resident was prescribed/administered [MEDICATION NAME] 600 mg four times per day for [MEDICAL CONDITION] pain, [MEDICATION NAME] 30 mg twice per day for depression and [MEDICATION NAME] .5 mg twice per day for anxiety. The resident's Medication Administration Record [REDACTED]. A nurse practitioner's note dated 11/6/13 documented, "I was notified at approximately 1530 (3:30 p.m.) that the resident had O2 (oxygen) sats in the 70's on room air with BP 78/52...She was having periods of apnea...I gave a telephone order to send patient to the ED. Approximately 15 minutes later I was able to get to the patient to evaluate her myself. Breathing appeared labored with long periods of apnea. O2 sats were 90% on 4L (liters per minute). She was responding to verbal stimuli but immediately fell back to sleep and did not answer my questions. I gave an order for [REDACTED]. Other than the nurse practitioner's progress notes, there was no documentation in Resident #21's clinical record of an assessment on 11/6/13 regarding the resident's lethargy or the order to hold the [MEDICATION NAME]. The facility's investigation included statements from other caregivers for Resident #21 on 11/6/13. The investigation documented that the certified nurses' aide (CNA #4) caring for Resident #21 on 11/6/13 reported to LPN #5 the resident was slumped over and lethargic during her bath. CNA #4 stated LPN #5 came to the room and stated the resident's lethargy was due to her pain medications and then left the room. The investigation stated CNA #4 reported the resident was having difficulty holding her cup and eating food during lunch on 11/6/13. The facility's investigation stated LPN #5 spoke with the nurse practitioner (NP) about the resident's lethargy and was told to hold the noon dose of [MEDICATION NAME]. The investigation documented LPN #5 stated the resident requested her medications and LPN #5 administered the [MEDICATION NAME] around 1:30 p.m. against the NP order to hold the medicine. The report documented the 2nd shift nurse caring for Resident #21 was told the resident had some "increased sedation" but was not told about the verbal order to hold the noon dose of [MEDICATION NAME]. The clinical record documented on 11/6/13 at 3:38 p.m. the evening shift nurse assessed the resident with low oxygen saturation, lethargy and low blood pressure. The NP was notified and the resident was sent to the emergency room for treatment. The NP ordered a dose of [MEDICATION NAME] that was administered prior to the transport to the hospital. The hospital report dated 11/6/13 documented the resident was administered an additional dose of [MEDICATION NAME] on the way to the hospital. The resident was observed at the hospital but had no additional treatment in the emergency room . A nursing note dated 11/6/13 at 7:33 p.m. stated, "Patient returned to facility at 1845 (6:45 p.m.). Responsiveness back to baseline...No new orders from (emergency room )..." On 6/18/14 at 10:10 a.m. the director of nursing (DON) was interviewed about the medication [MEDICATION NAME] administered to Resident #21 on 11/6/13 against the verbal order by the nurse practitioner to hold the medicine. The DON stated CNA #4 reported to LPN #5 the resident was lethargic/sleepy on the morning of 11/6/13. The DON stated later during the shift LPN #5 reported to the NP the resident was still lethargic and the NP gave a verbal order to hold the 12:00 p.m. dose of the medication [MEDICATION NAME]. The DON stated LPN #5 gave the [MEDICATION NAME] anyway. The DON stated when the second shift nurses came on duty the resident was assessed as unresponsive and with low oxygen saturation and low blood pressure. The DON stated the NP was notified and assessed the resident. The DON stated the NP ordered a dose of [MEDICATION NAME] prior to the ambulance arriving. The DON stated another dose of [MEDICATION NAME] was administered on the way to the hospital. The DON stated the resident refused further treatment at the emergency room and returned to the facility that evening. The DON stated when she talked with LPN #5 about administering the [MEDICATION NAME] LPN #5 stated she recalled the verbal order from the NP to hold the [MEDICATION NAME]. The DON stated LPN #5 reported she did not assess the resident regarding the report of lethargy from the CNA. The DON stated LPN #5 never wrote the verbal order from the NP in the clinical record and failed to convey to the oncoming shift about the resident's condition or the order. The DON stated, "She (LPN #5) failed to do what we consider basic nursing practice." The Drug Information Handbook for Nursing 13th Edition on pages 602 and 603 describes [MEDICATION NAME] as a combination opioid ([MEDICATION NAME]/[MEDICATION NAME]) [MEDICATION NAME] used for the relief of moderate to severe pain. This reference documents "The Institute of Safe Medication Practices (ISMP) includes this medication among its list of drug classes which have a heightened risk of causing significant patient harm when used in error." (1) The Drug Information Handbook for Nursing 13th Edition on page 848 describes [MEDICATION NAME] as an opioid antagonist/antidote used for the "complete or partial reversal of opioid drug effects, including respiratory depression; management of known or suspected opioid overdose; [DIAGNOSES REDACTED]." (1) These findings were reviewed with the administrator and DON on 6/18/14 at 11:50 a.m. (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011.