Every finding on record at Western MD Hospital Center

Based on interviews it was determined that the facility failed to employ a qualified food service director. This was found to be evident for the one food service director and has the potential to affect all residents. On 11/20/25 the Food Service Director (FSD #13) confirmed that he is not a Certified Dietary Manager (CDM). The FSD reported he has taken the class and is eligible to take the exam but was not yet scheduled for the test. On 11/21/25 at 12:51 PM the FSD reported the facility has a dietitian (#11) who they consult and contact for guidance. On 11/21/25 at 12:51 PM interview with the dietitian revealed she works at the facility 20 hours per week conducting primarily clinical work such as nutritional assessments. The dietitian reported she does answer kitchen questions as needed but confirmed she is not involved in the day-to-day running of the kitchen. On 11/21/25 at 2:50 PM surveyor reviewed with the Nursing Home Administrator the concern regarding the failure to have a qualified food service director. As of time of survey exit on 12/2/25 at 1:50 PM no documentation was provided to indicate the current food service director had the required credentials.

Based on observation and interview it was determined that the facility failed to ensure staff identified when the automatic dishwasher was in need of maintenance and repair, and failed to ensure containers used for food preparation and service were stored in a sanitary manner. This was found to be evident during 3 out of 3 observations made in the kitchen during the survey and has the potential to affect all residents.The findings include: 1.On 11/19/25 at 8:45 AM surveyor started the initial tour of the kitchen. Dietary Clerk (#14) informed the surveyor that the Food Service Director was not working today and indicated she would get a supervisor. During this tour the surveyor observed the automatic dishwasher was running and the final rinse temperature was ranging between 192-200 degrees F. The Food Service Supervisor (FSS #12) arrived during this observation and reported the staff have no control over the temperature of the dishwashing machine. The surveyor then observed the final rinse temperature was 205 and this reading was confirmed by FSS #12.On 11/19/25 at 12:45 PM surveyor discussed with Dietary Clerk (#14) the final rinse temperature being above 200 and the concern that if the temperature is too high the water would evaporate before the rinse was completed. The Dietary Clerk (#14) indicated she would contact the dishwasher manufacturer.Review of the operation manual for the dishwasher revealed the minimum temperature for the rinse cycle was 160 and the final rinse was 180.On 11/20/25 the surveyor addressed the concern regarding the dishwasher final rinse temperature with the Food Service Director (FSD #13), who stated he did not know the temperature could be too high and indicated he would contact the manufacturer.On 11/21/25 surveyor obtained a copy of the Dishwasher Temperature Log from the main dishwasher area from the FSD #13. Review of this log revealed the final rinse temperature was recorded as being at or above 200 degrees on 45 out of 61 occasions.On 11/21/25 at 2:18 PM surveyor and the FSD #13 observed the dishwasher while it was running. The rinse temperature maxed at 155 and the final rinse temperature reading went as high as 218 then dropped to 199-202. The FSD confirmed that he had not yet contacted the manufacturer.On 11/21/25 at 2:25 PM surveyor reviewed the potential concern regarding the final rinse temperature being too high with the FSD. He indicated he would tell the Maintenance Director that the rinse was not high enough and the final rinse may be too high.On 11/21/25 at 3:10 PM the Maintenance Director #1 provided an update to surveyor regarding the dishwasher, stating : you are correct. The Maintenance Director reported that he had spoken with the manufacturer, and they confirmed the Rinse should be at 160, ours is getting to 155; and final rinse should be 180 and that our machine is too high. The Maintenance Director also reported that the manufacturer would be coming out to the facility the following week and they had indicated that it could just be that a sensor was wrong. Surveyor discussed the concern that no one at the facility had identified this as a potential concern, despite staff documenting the final rinse temperature at or above 200 on multiple occasions.On 12/2/25 at approximately 1:45 PM the facility provided a copy of the [Manufacturer] Service Repair Estimate Summary, dated 11/25/25. Review of this document revealed Summary of Work: needs new final rise sprayers because they are clogged.2.During the 11/19/25 initial kitchen tour that was started at 8:45 AM, surveyor observed, with FSS #12, shelving near the three compartment sink that contained metal pans like those used to store food during the tray line service. A small amount of water was observed in 2 out of the 3 nested metal pans observed. The practice of storing dishes prior to being completely air dried is known as wet nesting. Wet nesting creates conditions in which microorganism can grow.On 11/20/25 at 11:57 AM surveyor and the FSD #13 observed the shelving near the three-compartment sink. Three out of three of the metal pans were found to be dry, but one out of one large plastic nested container observed revealed water was present.On 11/21/25 at approximately 12 noon the FSD #13 reported they had ordered a new drying rack for the dish pan area to address the problem with the wet nesting in that area.

Based on interview and record review it was determined that the facility failed to ensure that resident personal funds accounts were held in an interest-bearing account. This was evident for 1 resident (Resident #51) of 4 residents who had personal funds accounts held by the facility.The findings include:During the initial screening resident interviews on 11/19/25, one resident (Resident #35) indicated that he/she had a personal funds account at the facility. When asked if he/she received periodic statements, the resident stated he/she was unsure. This triggered an investigation of the facility task for Personal Funds.As part of the Personal Funds task investigation, on 11/24/2025 at 12:10 PM, the facility was asked to provide a list of all residents who had personal funds accounts. On 11/24/2025 at 1:06 PM two lists were provided by the Fiscal Accounts Technician (Staff #8). One list had 12 resident names listed in one column and the other column titled BANK had the notation PNC for each resident. The other list had 4 resident names listed in one column and in the column titled BANK had the notation HOUSE. Staff #8 explained that the list which indicated the bank was HOUSE meant that those resident funds were kept by the facility.On 11/24/2025 at 3:05 PM another interview was conducted with Staff #8. When asked if any of the in house accounts earned interest, she said she was not sure. The surveyor requested copies of the in house resident personal funds statements. On 11/24/2025 at 3:32 PM Staff #8 provided the requested statements of accounts and was interviewed as the four account statements were reviewed. One of the statements (Resident #51) had a balance of over $100. Resident #51's statement was opened on 12/01/21 with an opening balance of $500. There were two deposits: $60 on 1/06/23, and $40 on 5/15/23. Resident #51's statement did not include any withdrawals or earned interest, and the ending balance was $600. When asked about earned interest, Staff #8 said she thought that if the facility held the account, no interest was paid.On 11/25/25 in the afternoon an interview was conducted with the Nursing Home Administrator (NHA) to review the finding that 1 resident who qualified to have an interest-bearing account had not earned interest on their balance which was over $100. The NHA said that he was unaware that interest needed to be paid on that account.On 11/25/25 at 3:40 PM the Fiscal Services Chief was interviewed to review that the facility failed to pay interest on facility-held personal funds accounts for 1 of 4 residents. No further information regarding these accounts was received by the end of the survey.

Based on record reviews and interviews, it was determined that the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days. This was evident for 1 (Resident #5) of 5 residents reviewed for unnecessary medications. The findings include: Resident #5 was admitted into the facility in mid-2025. Diagnosis includes but is not limited to schizoaffective disorder.Schizoaffective disorder is a mental health condition that combines symptoms of both schizophrenia, like hallucinations and delusions, and a mood disorder, such as bipolar disorder or depression. Symptoms include psychotic features and significant mood shifts that are intense enough to cause distress or interfere with daily life. Treatment typically involves a combination of medication and counseling to manage these complex symptoms. A review of Resident #5's medical record on 11/20/25 at 1:28 PM, revealed that s/he was taking an antipsychotic medication routinely and on a as needed (PRN) basis. The PRN antipsychotic medication order had a start date of 11/14/25. However, the order did not indicate a stop date for the medication.The Director of Nursing (DON) was interviewed on 11/24/25 at 10:09 AM. During the interview, she explained the facility's process with psychotropic medications (Including antipsychotic medications) noting that when these medications are prescribed on a PRN basis, they put a 14-day limit for its use.A copy of the facilities policy for psychotropic medication monitoring and assessment was provided and reviewed with the DON on 11/24/25 at 10:30 AM. The review revealed that PRN psychotropic medications are limited to 14 days.The [NAME] was asked to look up Resident #5's medical orders, specifically the PRN antipsychotic medication on 11/24/25 at 10:31 AM. She confirmed that the order did not indicate a limit and/or end date. The concern was discussed that the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days. the DON acknowledged the concern.A subsequent review of Resident #5's medical record on 11/25/25 at 3:24 PM revealed that the PRN antipsychotic medication order had been discontinued on 11/24/25 at 2:03 PM.

Based on observation, record reviews and interviews, it was determined that the facility failed to ensure residents with pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #7) of 2 residents reviewed for pressure ulcer/injury. The findings include: Resident #7 was admitted into the facility in late 2020 with diagnosis that include unstageable pressure ulcers of the left and right buttocks, Alzheimer's disease, and type 2 Diabetes melllitus. A review of the resident's medical record on 11/19/25 at 1:28 PM indicated that the resident currently had pressure ulcers.On 11/19/25 at 3:45 PM, an observation was made of Resident #7 being transferred by 2 staff using a mechanical lift, from a wheelchair to the resident's bed. The resident's bed was equipped with an air mattress with its controls located at the foot of the bed. The air mattress control indicated that it was set to alternating and on max weight setting of 400 lbs.A subsequent review of Resident #7's medical record on 11/20/25 at 11 AM revealed that his/her most recent weight was 115.8 lbs. taken on 11/19/25 at 9:43 AM.On 11/21/25 at 3:03 PM, Resident #7 was observed in bed with the air mattress setting still at 400 lbs.The Registered Nurse (RN #10) currently assigned to Resident #7 was interviewed regarding the use of air mattresses on 11/21/25 at 3:05 PM. During the interview, RN #10 explained that her usual practice is to ensure that the mattress is on and inflated during her shift. She did not indicate that she checks the weight setting to confirm that it is appropriate to the resident's weight. RN #10 was asked to accompany the surveyor to Resident #7's room on 11/21/25 at 3:10 PM. At this time, RN #10 confirmed the resident's air mattress weight setting to be 400 lbs. RN #10 reported that she did not know the resident's weight but indicated that it was not 400 lbs. RN #10 indicated that the facility's wound nurse (RN #4) was responsible for setting up and ensuring settings for use of air mattresses were appropriate to the residents. RN #4 Was interviewed on 11/21/25 at 3:17 PM. During the interview, she reported her process with air mattresses and indicated that choosing the appropriate air mattress was also based on the resident's weight. She also reported and confirmed that she was responsible for ensuring the residence is weight matched the setting for the air mattress.RN #4 conducted an observation of resident #7 with the surveyor on 11/21/25 at 3:25 PM. During the observation, RN# 4 confirmed the resident's mattress setting to be 400 lbs. and stated, It obviously needs to be adjusted. RN #4 reported that she sees the resident 1-2 times per week for wound management and part of that is to ensure that the bed settings are appropriate. RN #4 stated, it got missed referring to checking the resident's mattress settings. The concern was discussed with the Director of Nursing (DON) on 11/24/25 at 11:12 AM that Resident #7's mattress setting was not appropriate for prevention and treatment of pressure ulcers/injuries. The DON acknowledged the concern.

Based on observation and interview it was determined that the facility ownership failed to ensure identified issues with the roof were repaired. This was found to be evident on one of the three nursing units observed.The findings includeOn 11/19/25 at approximately 11:15 AM surveyor observed on the 2 East hallway, across from room H E232, that one of the ceiling tiles was askew with a gap running the length of the tile. A clear plastic tube about 1.5 inches in diameter was extended from the ceiling down to a large (approximately 3 feet tall) metal can with a green liner and a sign that read: THIS CAN IS NOT FOR TRASH !!!. The can was sitting on a white bath towel.A resident was assigned to the H E232 room at the time of the survey.On 11/19/25 at 2:06 PM the Maintenance Director (#1) reported that there was a roof leak on 2 East and when it leaks water drips and that whole section of floor gets wet. In regard to the tubing and the can, he reported about a year or so ago they established this system so the water would funnel into the can rather than the floor and risk someone falling. He indicated they check the can about once a week.The Maintenance Director went on to report the issue with the roof has been going on for seven years and that funding has not been approved for a new roof. He reported that the Department of General Services (DGS) has inspected but they have not approved the money yet.On 11/21/25 at 2:50 PM the surveyor reviewed with the Nursing Home Administrator (NHA) the concern regarding the leaking roof and that the facility should be in good repair. The NHA re-iterated the Maintenance Director's report that they are waiting on approval of funding; and confirmed that he has seen the tube coming down from the ceiling.On 12/2/25 at approximately 1:45 PM the facility provided documentation to support that they have been attempting to obtain approval to initiate repairs on the roof for several years. This documentation included a Project Justification Form FY 25 , with a date of 1 [DATE], to replace the entire roof; a Project Manual for Roof Replacement from the DSG dated 1/8/24, as well as multiple emails from the facility to DGS since December 2023. No documentation was found to indicate a request for bids had been initiated.

Based on observations and interviews, it was determined that the facility failed to ensure nurse staffing information was posted on a daily basis. This deficient practice was evident for 7 of the 8 days of the recertification survey.The findings include: The facility lobby was observed on 11/19/25 at approximately 8:30 AM. During the observation, it was noted that a whiteboard was in the central area of the lobby that indicated the facility name, current date, and census of each unit of the facility. However, there was no indication of the staffing information.The assistant Director of Nursing (ADON) was interviewed about the federal regulation about posting the nurse staffing information, on 12/1/25 at 3:11 PM. The ADON referred to the whiteboard located in the facility's lobby and reported that they used to post on that whiteboard the complete schedule, including staff names. He indicated that they stopped posting the staffing information since it became a safety concern, as a resident's family member started looking up staff names in social media platforms.The ADON also reported that staffing information is posted in each unit of the facility in front of the nursing stations.On 12/1/25 at 3:31 PM, during an interview with the Nursing Home Administrator (NHA), he confirmed that the facility had stopped posting the staffing information on the whiteboard in the facility lobby. He indicated that this practice was started in November 2025. The concern was discussed with the NHA that federal regulation requires the facility to post daily, the facility's staffing information in a prominent place readily accessible to residents, staff, and visitors. The NHA verbalized understanding and acknowledged the concern.On 12/2/25 at 10:25 AM, an observation of the whiteboard in the facility's lobby revealed a printed paper was posted on it that indicated the facility name, current date, facility census, and staffing hours of corresponding licensed and unlicensed staff.

Based on review of medical records and facility investigation documentation and interviews it was determined that the facility failed to ensure respiratory care was provided consistent with professional standards. This was found to be evident for one (Resident #40) out of four residents reviewed for respiratory care. This failure resulted in a determination on 5/31/24 at 9:45 AM of an Immediate Jeopardy for Resident #40. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 5/24/24. The findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility in February of 2024 with a history of stroke and dependence on mechanical ventilation due to respiratory failure. The resident had severe cognitive impairment and was non-verbal. On 5/20/24 the resident was observed resting in bed but did not respond to surveyor's greeting. Tubing connecting the ventilator to the tracheostomy tube was in place with no identified concerns at that time. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and remove secretions from the lungs. Residents with prolonged dependence on a ventilator for breathing will often have a tracheostomy. (www.hopkinsmedicine.org) Review of a 4/26/24 primary care physician (Staff #40) progress note revealed ventilator dependent respiratory failure -- stable on current vent settings. Not a candidate for vent weaning/decannulation at this time due to neurologic status remaining largely unchanged. Weaning refers to a process of gradually reducing the amount of ventilator support. Decannulation refers to the removal of the trach tube after it is no longer needed. Review of the progress notes revealed a note, dated 5/14/24 at 4:37 PM, by respiratory therapist (Staff #46) which stated: At approximately 1520 [3:20 PM] while documenting at the nursing station I heard a ventilatory alarming. After getting up and determining where the alarm sound was coming from I made my way to [Resident #40]'s room. When I arrived I witnessed that the patient was in the process of being transferred by two nursing assistants from [his/her] bed to a recliner chair via the hoyer lift and the patient had become disconnected from [his/her] ventilator. I stretched the ventilator to the patient as they were finishing the transfer to the chair and reconnected [Resident #40]. Immediately upon reconnection, the ventilator stopped alarming and the patient began to be ventilated again. The patient did not appear to be in distress at any time that I witnessed. Review of the progress notes revealed a note, dated 5/14/24 at 5:40 PM, by nurse (Staff #48) which documented: While transferring [Resident #40] from the bed to recliner, the nursing assistant disconnected the trach tube from the patient for the transfer. Vent alarm sounded and respiratory therapist responded to Pt.[patient] room and reconnected the airway to the ventilator. The disconnect time was approximately 2 minutes as per the vent alarm record. Clinical manager was notified. Review of the initial report from the facility for incident MD00205708 revealed that on 5/14/24 the Respiratory therapist reported he heard the vent alarm going off in the resident's room and immediately checked on the resident, when he entered the room, he saw the resident was disconnected from the ventilator while two GNA's [geriatric nursing assistants] were transferring the resident. The respiratory therapist immediately responded to the alarming ventilator and reconnected the ventilator to the resident. The respiratory therapist reported the resident was not in distress after the incident. The nurse assessed the resident after the incident and reported the resident was at baseline. The assigned nurse to this resident educated the GNA on proper ADL care with ventilators. Nursing management was notified, and they took both GNA's off the unit to the nursing manager's office and educated them. The nurse manager and two respiratory therapists were involved in the education. The ADON met with both GNA's after the education and educated them too. Review of a statement dated 5/15/24 and signed by GNA Staff #49 revealed that it was in regard to the incident that occurred on 5/14/24 while transferring a resident. The statement included: I was not aware that I am not supposed to transfer vent residents unless there is a respiratory staff to watch the process. Review of a statement dated 5/14/24 and signed by Staff #48 revealed Nurses aide stated to this nurse that she disconnected the Pt. [patient] vent tube from the patient to transfer [him/her] to the chair. On 5/31/24 at 7:46 AM, after a review of his signed statement, Staff #48 confirmed that the GNA referenced was GNA #49 and that the GNA had said that s/he had un-hooked the resident. On 5/30/24 at 2:30 PM, upon interview, GNA #49 reported she was an agency GNA and had been working at this facility for about 3 months. She confirmed the last time she worked with a resident on a ventilator was 5/14/24. She reported that if transferring a resident on a ventilator she would call staff from the respiratory therapy (RT) department. After review of her statement about the 5/14/24 incident GNA #49 confirmed that she did not call RT that time, and denied having been told prior to that incident that she needed to do so but confirmed that she had received education since then. GNA #49 denied that the tubing was disconnected and stated that it was stretched but it was attached. Review of the Competency: New Employee GNA/CNA staff form for GNA #49 revealed documentation to indicate Competency in regard to: Staff is able to verbalize the safe manner to provide care when working with ventilators and patients & residents with tracheostomies; and Staff is able to discern the difference between the various alarms on the ventilators and the appropriate response. The Respiratory Care Evaluator (RT supervisor Staff #47) signed this form on 2/15/24. On 5/31/24 at approximately 8:00 AM RT supervisor (Staff #47) was interviewed regarding the orientation process. Staff #47 reported that they would have covered that an RT needs to be in the room during a transfer. She also confirmed that there was an RT available on the unit 24 hours per day 7 days per week and they carried radios so they could always be reached. When asked what the Respiratory Care Evaluator Signature indicated, Staff #47 reported it meant they have been oriented. Review of a statement written by GNA (Staff #52) revealed s/he had precepted GNA #49. The statement included: I fully educated [him/her] on the transfer of [name of Resident #26], a ventilator patient. I neither disconnected the vent or tube feed from the patient. All tubes were in place during the entire transfer. Review of a statement dated 5/14/24 and signed by GNA (Staff #50) revealed that GNA (Staff #49) had requested assistance with providing care for Resident #40 and included the following: .At the verge of the transfer the vent was disconnected. I queried this action but my partner overrode my reservation and against my better judgment I went along. The resultant beeping attracted the prompt arrival of a respiratory therapist who quickly remediated the situation . Review of a statement signed by respiratory therapist (Staff #45) revealed that on 5/14/24 respiratory therapist (Staff #46) had alerted her to the incident and that she reported it to unit nurse manager (Staff #3). The statement indicates education was immediately provided to both GNAs involved. The statement includes the following: [GNA #50] stated that [s/he] told her not to disconnect the patient and her reply was it is only for a second. On 5/31/24 at 10:54 AM respiratory therapist (Staff #45) reviewed her written statement and confirmed it's accuracy. Staff #45 also reported that they do inform the GNAs not to disconnect residents as part of the orientation and that a respiratory therapist will help with moving or transporting a resident. Review of a statement dated 5/14/24 and signed by the unit nurse manager (Staff #3) revealed that upon learning of the event from respiratory therapists (Staff #46 and #45) at approximately 4:00 PM, the unit nurse manager immediately identified the two GNA's involved (Staff #49 and #50). The GNAs were then both educated by RT (Staff #45) on the importance of never disconnecting a resident from the ventilator as this is their 'life support' and could die from being disconnected. Further review of the unit nurse manager (Staff #3)'s statement revealed: [GNA #50] expressed remorse for following [GNA #49]'s lead and not being more forceful in stopping [GNA #49] from disconnecting the resident from the vent. On 5/31/24 at 9:21 AM during an interview with Staff #3 surveyor read this portion of the statement to Staff #3 and when asked if this was accurate, Staff #3 stated: absolutely correct. Staff #3 also confirmed that she was told by GNA #49 that she had disconnected the vent. On 5/31/24 at 7:13 AM GNA #50 reported he is employed by a staffing agency and had worked at this facility 3-4 days per week for the past year. GNA #50 reviewed his written statement and confirmed it's accuracy. GNA #50 reported the GNA who was the lead thought it was ok to transfer the resident without a respiratory therapist and during that process the tubing got extended and it got pulled off. During this interview, GNA #50 denied that the other GNA disconnected the vent but reported that it came off during the transfer and that the section of the statement about overrode my reservation was that he told the other GNA they should have a therapist in the room but the other GNA said no it would be easy. GNA #50 went on to report that he has received education regarding this issue and that he can no longer be assigned as the primary GNA for a resident with a vent. On 5/31/24 at 10:12 AM during an interview, the respiratory therapist (Staff #46) reiterated what was in the note he wrote on 5/14/24. Staff #46 also reported when he arrived the ventilator was 7 - 8 feet away from the resident, the tubing wasn't stretched out and it was sitting with the ventilator. Staff #46 also reported that staff were supposed to have an RT called in prior to a transfer and indicated that no one said anything about moving the resident to him prior to the incident. Further review of facility documentation revealed a statement that RT (Staff #45) verbally educated GNA #49 on the following: 1. Never disconnect a ventilator circuit or remove a resident from a ventilator during transfer or dressing or removing clothing. Not even for a moment. This also pertains to the trached residents who are on jet neb or room air. Always get a nurse or respiratory therapist for help. 2. Never stretch the ventilator circuit too far from the resident as this can cause a disconnection of the circuit from the resident's trach or it may cause decannulation from the resident's stoma [name of the hole the trach tube is inserted through]. Decannulated trachs may not be immediately visible, it can come out and lay on the chest under the trach dressing. Do not try to insert the trach. 3. Ventilators are needed to keep residents alive. This is how they breathe. They are on a ventilator because they cannot breathe on their own. If disconnected from a ventilator whether accidentally or intentionally, the resident could possibly pass away due to lack of oxygen. 4. There are always respiratory therapists on staff who are willing to help get residents out of bed to handle the ventilators and tubing. Please get them to help with any ventilator residents, even if it is for care while the resident is in bed. This document included the statement I agree that I have been educated by Respiratory Therapist on the topics stated above on May 14, 2024 witnessed by [RT Staff #46 and Unit Nurse Manager Staff #3]. The form was signed by GNA #49 and by Staff #3 on 5/14/24. On 5/30/24 review of the completed facility-reported incident follow-up investigation report regarding the 5/14/24 incident revealed the following statement: Summary of the interviews include that the GNA disconnected the resident from the ventilator to transfer the resident. This was observed by another GNA in the room. Further review of the follow-up investigation report revealed the following corrective action was taken: Agency GNAs are not to be assigned to ventilator-dependent residents and all GNAs receiving education by the respiratory therapist regarding proper care of ventilator/tracheostomy residents. Further review of the facility documentation revealed an Education Sign-in Sheet for GNA Respiratory Education for May 20 - 24, 2024 that included 28 GNA signatures. Review of the list of GNAs who work at the facility revealed 25 employees and 5 agency GNAs. On 5/30/24 at 4:10 PM the NHA confirmed education was completed by May 24, except for one GNA who was on leave and then provided documentation that GNA was educated on 5/28 when she returned to work. NHA also indicated one of the 5 agency GNAs has not worked at the facility since the incident but has been made aware will need to be educated prior to working again. Review of the GNA Respiratory Education sheet revealed the following were covered in the training: 1. Never disconnect the ventilator circuit or remove a patient from the ventilator during transfer, or to dress/remove clothing from a patient. Always ask the respiratory therapist for assistance. 2. Vent tubing placement- Make sure that vent tubing moves freely to prevent pulling of the trach while performing patient care. 3. Decannulation - If the trach becomes dislodged during patient care, call for respiratory to re-insert the trach back into the stoma. Do NOT attempt to re-insert the trach yourself. 4. Do NOT silence the alarm on the ventilator by hitting the Silence Alarm button. 5. Suction regulators should not be turned on FULL suction while performing mouth care. Regulators should be turned no higher than 150 mmHg. Regulators should also be turned back down when finished. On 5/30/24 based on review of facility documentation and interview with several GNAs surveyor confirmed the facility completed the GNA training. On 5/31/24 at 8:00 AM the NHA confirmed that they will be following up in Quality Assurance regarding this issue and indicated that they address all their facility-reported incidents in QA. NHA also reported that they will be reviewing their training materials. Review of GNA #49's employee file revealed a Nursing Service Orientation Topic Validation 2023 form that was noted to be blank. On 5/31/24 at 9:28 AM the NHA reported that this form had not been implemented prior to the event on 5/14/24. This form included a section for Respiratory Training/Ventilator Equipment: Types of Tracheostomies & Tracheostomy Care; Ventilator Functionality; T-piece functionality - Aides Should Not Disconnect to Move Patient; Turning and Positioning Safety for Patient with Tracheostomy; Trach Collar, Respiratory Training/Ventilator Equipment and Ventilator Alarm Recognition & Safety: Disconnections etc. On 5/31/24 at 9:30 AM the NHA confirmed that moving forward they will be utilizing the Nursing Service Orientation Topic Validation form and will also be including the training that was completed with all of the GNAs post incident for new hires.

Based on medical record review and staff interview, it was determined the facility failed to 1.) to have a process in place to ensure that the resident's wishes for resuscitation were communicated to staff so that the staff would know immediately what action to take during an emergency. This resulted in harm to Resident #96, who had a do not resuscitate (DNR) order, receiving cardiopulmonary resuscitation (CPR). The resident was resuscitated, remained at the hospital for 8 days, and returned to the facility with a chest tube inserted in each lung; 2.) reveal evidence that the resident was informed of their right to formulate an advanced directives by failing to document discussions regarding advanced directives and the outcome of the discussion in the resident's medical record and failed to ensure Do Not Resuscitate orders were followed. This was evident for 1 (Resident #6) of 2 residents reviewed for advanced directives, and 1 (Resident #96) out of 1 resident reviewed for choices during a survey. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual was not able to make their own decisions. 1. On [DATE] at 8:38 AM, a medical record review revealed Resident # 96 was a long-term resident of the facility. Further review revealed Resident #96 was on a vent to help him/her breathe. On [DATE] at 3:00 PM, a review of Resident #96 ' s hard chart revealed a Medical Order for Life-Sustaining Treatment (MOLST) form, dated [DATE]. A review of the MOLST form revealed that Resident #96 was not to receive CPR. Further review revealed orders for the resident to receive assistance with breathing, but resuscitation attempts did not include CPR and allowed death to occur naturally. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form documents a resident's specific wishes for life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. On [DATE] at 8:40 AM, a review of progress notes dated [DATE] at 8:00 AM; revealed that Resident # 96 became apneic, unresponsive, and no pulse was detected. CPR was initiated for 3 cycles of 100 compression. Further review revealed that the MOLST form was reviewed by staff and determined that Resident #96 ' s code status was do not resuscitate. CPR was stopped and the local emergency medical service transported Resident # 96 to the hospital. On [DATE] review of a Physician's note dated [DATE] revealed that the resident was resuscitated with CPR by nursing staff regained his/her pulse and blood pressure, and then transferred to the hospital. On [DATE] at 9:00 AM, continued review of progress notes, nursing note dated [DATE] at 4:23 PM, revealed that Resident #96 was admitted to the hospital and had bilateral chest tubes placed. On [DATE] at 12:00 PM, review of progress notes revealed resident #96 was discharged from the hospital and returned to the facility on [DATE]. On [DATE] at 9:20 AM, during an interview with RN supervisor #13, she reported that she was working on the unit during the incident involving Resident #96 on [DATE]. She reported that the usual procedure is that someone is designated to retrieve the resident's hard cart and the MOLST form is verified before starting CPR. On [DATE] at 12:41 PM, review the facility policy titled Cardiopulmonary Resuscitation (CPR) Criteria, Standards, and Licensed Nurse Protocol. (revised date [DATE]) section V. Procedures revealed, The licensed nurse/licensed clinician will assess the situation, review the code status, and determine the need to call a code blue and initiate CPR if the patient/resident is a Full code. On [DATE] at 2:32 PM during an interview with the administrator, she reported that the root cause analysis of the incident was the failure of the staff to verify the MOLST form before initiating CPR and she expects nurses to verify a resident ' s MOLST form status before starting CPR. In addition, she reported training to correct the situation had begun and was still in progress. 37276 2. On [DATE] at 12:00 PM, an initial review of Resident #6's medical record Resident #6's EMR (electronic medical record) and paper medical record failed to reveal evidence that Resident #6 had an advanced directive in place. On [DATE] at 11:30 AM, a review of Resident #6's medical record revealed the resident resided in the facility for long term care since February 2020. Review of the resident's most recent quarterly assessment with an assessment reference date (ARD) of [DATE] revealed documentation indicating Resident #6 was cognitively intact. Section C, Cognitive Patterns, Staff Assessment for Mental Status documented Resident #6's short term memory and long-term memory was okay, the resident was able to recall the current season, the location of his/her own room, staff names and faces, that the resident was in a nursing home and Resident #6 was independent in making decisions regarding tasks of daily life. Further review of Resident #6's medical record failed to reveal evidence that Resident #6 had an advanced directive, and no documentation was found to indicate the facility periodically informed the resident of his/her right to formulate an advanced directive, or the resident's potential response. On [DATE] at 12:14 PM, an interview was conducted with Social Worker(SW)(Staff #6). During the interview, the SW stated information about formulating an advanced directive was included in the admission packet which was provided to the resident upon admission to the facility and discussed with the resident during the initial care plan meeting. The SW stated if the resident had an advanced directive, the SW would ask for a copy, and the advanced directive would be placed in resident's medical record. If the resident did not have an advanced directive, the SW would educate the resident on what an advanced directive meant and, if s/he wanted an advanced directive and needed help, the SW would assist the resident to complete an advanced directive. The SW stated that the resident's advance directives and MOLST (Maryland Orders for Life-Sustaining Treatment) were reviewed with the resident at least annually as part of the care plan meeting. Following the interview, the SW was made aware of the above concerns and the surveyor requested documentation of any discussions the SW had with Resident #6 advising the resident of his/her right to formulate an advanced directive. In response, the SW confirmed Resident #6 did not have an advance directive, and indicated that the resident's right to formulate an advanced directive had been discussed with Resident #6, however it was unlikely these discussions had been documented in the resident's medical record. As of the time of the exit from the facility on [DATE], no additional documentation was provided to indicate the facility periodically informed Resident #6 of his/her right to formulate an advanced directive.

Based on pertinent documentation review and interviews, it was determined that the facility failed to have a current written transfer agreement with a local hospital. This has the potential to affect all residents in the facility. The findings include: On 6/4/24, review of facility assessment failed to reveal a written agreement with a local hospital that is willing to accept residents transported from the facility. On 6/04/24 at 2:00 PM, during an interview with the Director of Quality, she reported that she could not provide a written transfer agreement between the facility and a local hospital. She reported that the facility had routinely transferred the residents to the local hospital without incident. No additional documentation was provided prior to the end of survey.

Based on records review and interviews, it was determined that the facility failed to include staff competencies that are necessary to provide the level and types of care needed for the resident population. This deficient practice has the ability to affect all residents in the facility. The findings include: On 6/4/24 at 12:34 PM, a review of the facility assessment had identified about 23 to 34% of the facility's resident population sampled over the last year had behavioral health needs. However, in reviewing the list of annual competencies that the facility had identified and recommended to provide to their staff, behavioral health training was not part of the list. On the same day at 3:15 PM, a sample of employee files were reviewed for competencies and revealed no evidence for behavioral health training. Later at 3:50 PM, the Director of Quality (Staff #11) who was part of the staff listed as involved in the completion of the facility assessment, was interviewed. The concern was discussed with Staff #11 that the competencies listed in the facility assessment did not cover the level and type of care needed for all the identified resident populations. Staff #11 acknowledged the concern and stated, There is a lot of training that the staff need for our residents, and we are working on it.

Based on observations and interviews with facility staff, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: 1) On [DATE] at 8:49 AM, an initial tour of the facility's kitchen was conducted by two surveyors. An observation of the kitchen's walk-in freezer noted a metal container with pureed turkey covered with saran wrap dated [DATE]-[DATE]. The facility's food service administrator (Staff #53), was present during the tour and stated that the expiration date should have been [DATE]. Continued observation noted semi-mac and cheese in a metal bin covered with aluminum foil dated [DATE]-[DATE] and semi-turkey in a metal bin covered with aluminum foil dated [DATE]-[DATE]. Staff #53 stated they were all expired and took them to discard. Further observation of the facility's walk-in refrigerator on [DATE] at 8:55 AM showed the following: a metal bin covered with saran wrap, labeled Tropical fruit for dinner expires [DATE], a plastic bin with mandarin oranges dated ,d+[DATE]-,d+[DATE] and a small metal bin with meatballs covered with saran wrap dated ,d+[DATE] -,d+[DATE]. Staff #53 confirmed they were all expired and should have been discarded. He removed them to discard them. The surveyor continued the observation of the kitchen and noted a walk-in refrigerator that led to a freezer. The observation found the following: Liquid eggs in a metal bin thawing out with no date marked when they were pulled or the use-by date, liquid eggs labeled with a pulled date of ,d+[DATE], but no use-by date was noted. Staff #53 said the eggs were frozen and took ,d+[DATE] days to get thawed. Continued observation showed a container of Ken's Italian dressing that had been opened, and about half of it had been used. However, no date was marked as to when it was opened. Further observation on [DATE] at 9:15 AM noted the kitchen's walk-in dry food area. The observation found a large, dented can with diced pears on the floor under a metal shelving on the right side. Staff #53 picked up the can, confirmed it was dented, and stated he did not know how it got to the floor but should be discarded. The above concerns were discussed with the Nursing Home Administrator on [DATE] at 12:10 PM, who acknowledged the concerns at that time. 45139 2) On [DATE] at 1:54 PM, the Food service administrator (Staff # 53) reported that his department provided the temperature logs for refrigerator that contain residents' personal food and that records the temperatures. The kitchen then maintains the completed temperature logs for residents' refrigerators. The logs contained a space to document a daily refrigerator temperature and a space for initials. On [DATE] at 2:05 PM, Observation was made of Nursing unit 1 East refrigerator revealed a document attached to the refrigerator titled, Daily Freezer refrigerator Temperature Log, dated [DATE]. Review of the temperature log revealed that temperatures should be maintained between 33 degrees Fahrenheit (F.) and 41 degrees F. Review of the temperature log for the 1 East resident refrigerator revealed that the temperatures that were documented were outside of the recommended temperature range in 26 out of the 31 days that temperatures were recorded. [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 29 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 29 F [DATE] temp recorded as 30 F [DATE] temp recorded as 32 F [DATE] temp recorded as 32 F [DATE] temp recorded as 32 F [DATE] temp recorded as 32 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 32 F [DATE] temp recorded as 32 F [DATE] temp recorded as 32 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F [DATE] temp recorded as 30 F On [DATE] at 2:23 PM, an observation of Resident #12's personal room refrigerator was made with GNA # 59 and the Food Service Administrator Staff #53. Observation revealed a document titled Daily Freezer/Refrigerator Temperature Log was secured to the side of the refrigerator. Further review of the document revealed the date of [DATE], Resident #12's name and spaces to document the daily temperatures and initials of the recorder. Continued review of the March temperature log revealed only 5 out of 31 days had documented temperatures accompanied by initials. On [DATE] at 2:23 PM, during a brief interview GNA staff #59 reported that it was the responsibility of the dietary staff to record the temperatures of the refrigerators that contained residents' personal food. GNA failed to provide Resident's #12 refrigerator logs for the months of April and [DATE]. On [DATE] at 2:34 PM and during a brief interview with the Food Service Administrator #59 he reported that there was a temporary halt in the dietary staff coming up to the nursing units during a COVID outbreak. In addition, he reported he was unable to provide Resident's #12 refrigerator logs for the months of April and [DATE]. On [DATE] the facility policy titled Resident Outside Food Storage on Unit was reviewed. The review revealed that the Hostess service will maintain daily temperature log recording and daily cleaning for resident personal food items. On [DATE] at 2:34 PM, observation of Resident #9 room revealed a small personal refrigerator with a lock on it. Further observation failed to reveal a temperature log. On [DATE] at 2:36 PM the Food Service Administrator reported that the term Hostess refers to the dietary staff. He reported that the facility had a policy that dietary staff did not come up on the units during the COVID outbreak and there was a break in the monitoring of the refrigerators.

Based on observation, medical record review and staff interview, it was determined the facility failed to review and revise resident care plans after each assessment. This was evident for 2 (Resident #13 and #6) of 24 residents reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) Review of Resident #13's medical record, on 5/20/24, revealed the resident had resided at the facility for several years, was alert and oriented and able to verbally communicate. Resident #13 was currently receiving treatment for a UTI with intravenous antibiotics. On 05/20/24 at 02:16 PM, the surveyor conducted an interview with Resident #13. She/He explained that she/he gets recurring UTIs, one after another. Current treatment of the UTI is with an intravenous (IV) antibiotic which just finished. Medical record review, on 5/28/24 at 01:49 PM, revealed the resident had a UTI in March 2024 which was treated with a course of oral antibiotics. Review of the medical record on 5/22/24 at 1:16 PM, revealed a current care plan addressing risk for renal impairment because of his/her chronic history of renal stones and UTI. The interventions included: Administer antibiotics as ordered Follow-up with urologist as ordered Monitor for emesis, unable to keep any liquids down Monitor for signs of infection (change in vitals, fever, change in cognition) Monitor for urinary output and input as well as for fluid volume overload Monitor pain, offer medications as ordered. On 05/28/24 at 01:28 PM, review of medical record revealed the most recent Minimum Data Set (MDS) assessment was on 4/27/24. Further review of the medical record revealed on 5/4/2024 at 5:48 PM a note was completed by Licensed Practical Nurse (Staff #33) that included Resident #13 saying, I think I might have another UTI. Further review of the medical record revealed a 5/7/24 care plan update note completed by MDS Nurse Coordinator (Staff #5) which failed to address the resident's risk for renal impairment related to chronic UTIs. The note fails to address the fact that the resident was treated with an antibiotic for a UTI since the previous assessment period or that the resident was currently experiencing potential signs and symptoms of another infection. Further review of medical record revealed on 5/9/24 a urinalysis was ordered by Primary Care Provider, OD (Staff #40). Further record review revealed that on 5/9/2024 a Care Plan Update note by Licensed Social Worker (Staff #6) mentioned a care plan conference was held but the note did not address the UTI. Further record review on 05/28/24 at 02:10 PM revealed a treatment order on 5/13/24 that included, Encourage 480 mL water to drink twice daily (day and evening). During an interview, on 5/28/24 at 2:18 PM, the Licensed Practical Nurse (Staff #36) reported that the resident always wants to drink soda and that they have to encourage the resident to drink water. Further review of medical record on 5/29/24 revealed a urologist's note dated 8/28/23 including recommendations to maintain oral hydration with water and limit dark soda. Further review of medical record on 05/28/24 revealed that the Resident #13's care plan failed to include to encourage the resident to drink more water or to discourage dark sodas. During an interview on 05/29/24 at 10:55 AM, the surveyor conducted a review of findings with the Unit Nurse Manager (Staff #3) about failure to update care plan related to UTIs. Unit Nurse Manager (Staff #3) stated, If it's not there in the chart, it wasn't done. On 05/31/24 at 04:24 PM, the surveyor reviewed concern to the Director of Nursing (Staff #18), and Assistant Director of Nursing (Staff #2) regarding the failure to update the resident's care plan related to continued UTIs. 2a) On 5/21/24 at 3:15 PM, a review of Resident #6's medical record revealed the documentation that the resident resided in the facility for long term care since February 2020. Review of Resident #6's most recent quarterly MDS with an assessment reference date (ARD) of 4/13/24 revealed documentation that Resident #6 was always incontinent of bowels, and had multiple diagnosis which included constipation, and full incontinence of feces. On 5/22/24 at 11:31 AM, a review of facility reported incident, MD00193931 revealed documentation that indicated that in June 2023, while in the hospital emergency room (ER) Resident #6 had a diagnosis of fecal impaction which could be resolved in the ER. Further review of Resident #6's May 2024 electronic medication administration record (eMar) revealed the resident received routine laxative medications for constipation. In the eMAR, Resident #6 had a 6/15/23 order for Bisacodyl (laxative) suppository rectally 2 x day, a 5/20/23 order for Lactulose (laxative), by mouth one time a day, and a 6/23/23 order for Linzess (laxative) by mouth one time a day which were signed off as administered as ordered every day 5/1/24 to 5/21/24. In addition, resident had an 8/8/23 order for mineral oil enema rectally one time a day as needed. Review of Resident #6's care plans revealed a care plan, at risk for constipation r/t (related to) decreased mobility and medication regimen, with the goal, will have regular bowel movement (BM) daily x 3 months, and the interventions: - Encourage fluids: encourage extra 480 ml fluids twice per day, - Provide bowel medications as ordered - Monitor BM and record - Monitor BMs for amount and consistency, medicate a/o monitor effectiveness of medication - Monitor for complaints of abdominal pain or discomfort and eval. causal factor; receives iron - Monitor resident for c/o constipation or clinical s/s of constipation and report to PA (Physician's Assistant), NP (Nurse Practitioner) or MD (Medical Doctor) - Monitor medications for potential causal factor of constipation - Offer high fiber diet to assist with bowel management - Offer fluids upon every bedside interaction; he likes water, cranberry juice, soups - Monitor and record fluid and meal intakes - May place rectal tube to alleviate excessive gas if a change in position does not effectively alleviate Continued review of Resident #6's medical record failed to reveal documentation to indicate, that following each assessment, the staff evaluated the resident's progress toward reaching his/her goal or the resident's response to the approaches. 2b) Resident #6's quarterly MDS with an ARD of 4/13/24 also documented Resident #6 had a diagnose of bipolar disorder (manic depression) (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and received an antidepressant in the MDS 7 day look back period. Review of Resident #6's May 2023 Electronic Medication Administration Summary (eMAR) revealed a 9/27/22 order for Mirtazapine (Remeron, an antidepressant) Tablet by mouth one time per day for bipolar disorder that was documented as given every day as ordered from 5/1/24 to 5/21/24. Review of Resident #6's care plans revealed a care plan, At risk for depression due to previous history, with the goal: [Resident #6] does not want to be depressed like in the past and wants to be taken care of, that had the interventions, - Consult psychology as needed - Encourage [Resident #6] to verbalize concerns and actively participate in treatment - Explain all procedures/activities prior to initiation - [Resident #6] has had a history of refusing parts of his care and eating - Maintain consistent caregivers and consistent routine as much as possible - Monitor for changes in body language, increased restlessness, and/or decreased communication - Investigate changes for medical and psychiatric causes - Monitor psychotropic medications for effectiveness and for any adverse effects. Report as needed to physician for follow-up - Refer to physician or psychiatrist for needed changes in medications The care plan was not resident centered, and the care plan goal was not measurable. In addition, continued review of Resident #6's medical record failed to reveal evidence that following each assessment, the staff evaluated the resident's progress toward reaching his/her goal or the resident's response to the approaches and revised the care plan based on the resident's changing goals, preferences and needs of the resident and in response to current interventions The above concerns were discussed with unit nurse manager (Staff #3), on 5/22/24 at 1:31 PM. Staff #3 acknowledged the concerns at that time and stated that following the assessments, the nurses updated the evaluation date in the care plan, however, the resident care plans were not being evaluated. Staff #3 stated that the facility staff had identified issues with the care plan process, and the Assistant Director of Nurses (ADON) had put a performance improvement plan (PIP) in place to address the concerns with their care plan process. She also reported arrangements had been made for consulting firm to come to the facility to assist the staff with the care plan process.

Based on observations, records review, and interviews, it was determined that the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment. This was evident for 1 (Resident #16) of 3 residents reviewed for accidents. The findings include: Resident #16 had been a resident of the facility since 2016. During an interview with the resident, s/he reported weakness on the left arm and would use the bed rails for position and mobility. An observation of the resident's bed rails during the interview revealed that they were loose as the resident would pull or push on them demonstrating his/her use of the bed rails. On 5/29/24 at 1:41 PM, the Unit Nurse Manager (UM Staff #3) was interviewed about bed rails and reported that there are several assessments that pertain to bed rails. Some of the assessments can be found in the electronic health record while some are in the hard charts. On 5/29/24 at 2:01 PM, Resident #16's medical records were reviewed and revealed consent and side rail utilization assessment but did not reveal documentation regarding regular inspections for bed and bed rails. On the same day at 3:05 PM, the UM was again interviewed about bed rails, and she reported that regular maintenance of beds and bed rails were conducted by the Maintenance Director (Staff #55). Soon after at 3:14 PM, Staff #55 was interviewed about bed rails, and he reported that the Nursing department calls him whenever bed rails needed to be installed or removed, but as far as regularly inspecting them for maintenance, he does not do them. Staff #55 further stated, we are guilty with that, we didn't know we were supposed to do that. On 5/31/24 at 4:09 PM, the concern that regular inspection of the bed and bed rails were not being done was discussed with the Nursing Home Administrator (NHA), Director of Nursing, and Assistant Director of Nursing. The NHA indicated that Staff #55 might have misunderstood the question because she recalls going around the units and taking measurements of resident beds and bed rails with Staff #55 a few weeks prior to the start of the survey. The NHA also indicated that she would provide the documentation from the inspection she had done with Staff #55. On 6/3/24 at 11:46 AM, the Director of Quality (Staff #11) came to see the surveyor and reported that the NHA is out of the facility and asked if there was anything that the surveyor needed. The surveyor explained the prior conversation with the NHA regarding bed rails and the documentation she was supposed to provide the surveyor. Staff #11 indicated that she would collect the documents as discussed. Later that day at 2:03 PM, Staff #11 provided the documents titled Bed Rail Safety Inspection and reported that they were done by Staff #55. A review of the documents revealed that the inspection was all done on the same day (6/3/24). Staff #11 was interviewed about the inspection and confirmed that it was not being done prior to the start of the survey and stated, You're looking for what was done in the past right? It was not done. At the time of the survey exit conference on 6/4/24 at 5:10 PM with the facility staff, including the NHA who joined via phone conference, the concern that the facility was not conducting regular inspection of resident beds and bed rails was brought up and no further comments or documentation was provided by the facility.

Based on pertinent document review, and interviews it was determined that the facility failed to establish a quality assurance committee which would include an Infection Preventionists at every committee meeting. The findings include: On 5/31/2024 at 1:15 PM, The Administrator provided the attendance sign in sheet for the facility QAPI committee meetings May 2023 through May 2024. Review of the attendance sign in sheets failed to reveal that the infection Preventionists attended the QAPI meetings for 6 consecutive months: The months that did not have a infections preventionist attend were as follows. 4/17/24, 3/20/24, 2/21/24, 1/17/24, 12/20/23, 11/15/23. On 6/04/24 at 12:02 PM, the Director of Quality was interviewed. During the interview she confirmed that the infection preventionists failed to attend the above-mentioned committee meetings. She reported that in 2023 the Infection preventionist was not required to attend every QAPI meeting, however beginning in January 2024 the Infection preventionists were required to attend every meeting.

Based on records review and interviews, it was determined that the facility failed to develop a comprehensive care plan with measurable objectives and timeframe to meet the resident's medical needs. This was evident for 4 (Resident #6, #34, #9 and #24) out of of 24 residents reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) On 5/21/24 at 3:15 PM, a review of Resident #6's medical record revealed the resident resided in the facility for long term care since February 2020 and had multiple diagnosis which included a seizure disorder. Review of Resident #6's most recent quarterly assessment, with an assessment reference date (ARD) of 4/13/24, revealed in Section I: Active Diagnose of seizure disorder or epilepsy. Review of Resident #6's May 2023 Electronic Medication Administration Summary (eMAR) revealed a 9/27/22 order for Lamotrigine (anticonvulsant) tablet by mouth 3 times a day for seizure disorder, which was documented as given every day as ordered from 5/1/24 to 5/21/24, and an order for Levetiracetam (anticonvulsant) tablet by mouth 2 times a day for seizure disorder, which was documented as given every day from 5/1/24 to 5/21/24 as ordered. Review of the physician orders also revealed an 11/2/22 order for seizure precautions. Continued review of Resident #6's care plans failed to reveal evidence a comprehensive care plan with measurable goals had been developed to address the resident's seizure disorder and use of anticonvulsant medications. The above concerns were discussed with the unit nurse manager (Staff #3), Registered Nurse (RN), on 5/22/24 at 1:31 PM. Staff #3 acknowledged the concern and offered no further comment at that time. 48259 2) A record review on 5/28/24 at 11:25 AM revealed that Resident #34 was admitted to the facility in January 2023 with diagnoses including dementia, depression, and a history of Post-traumatic stress disorder (PTSD). Continued review showed an MDS assessment dated [DATE] that documented that Resident #34 had severe cognitive impairment. Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event. People may experience a range of reactions after trauma, and those who continue to experience problems may be diagnosed with PTSD. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event. A trigger is a psychological stimulus that prompts a recall of a previous traumatic event, even if the stimulus is not traumatic or frightening. A subsequent review on 5/28/24 at 1:35 PM found a care plan for Resident #34 that contained a statement that [Resident #34] has a history of PTSD. The goal of the care plan stated, [Resident #34] will not experience the trigger of PTSD. The intervention stated, Staff will avoid the trigger and allow [Resident #34] to cooperate. However, the review failed to show Resident #34's potential triggers, which may re-traumatize the Resident, along with interventions to address the possible triggers. During an interview on 5/29/24 at 2:57 PM with Staff #3, a unit nurse manager, she stated that Resident #34's care plan for PTSD was not person-centered and should have contained his/her specific triggers to avoid re-traumatization. In a subsequent interview on 5/31/24 at 11:47 AM, Staff #2, the assistant director of nursing, reported that Resident #34's responsible party was contacted after the surveyor's intervention and the Resident's care plan for the history of PTSD was updated. 50573 3) Review of Resident #9's medical record on 5/20/24 revealed the resident has resided at the facility for several years, was alert and oriented and able to verbally communicate. Resident #9 was dependent on staff for transfers out of bed and mobility due to weakness. An interview with Resident #9 on 05/20/24 at 3:02 PM revealed that she/he has been experiencing frequent tooth pain. Review of the minimum data set (MDS) with an assessment reference date (ARD) of 1/5/24 revealed in Section L Oral/Dental status that the resident was experiencing mouth or facial pain, discomfort or difficulty with chewing. Review of Resident #9's medical record revealed that on 1/19/24 Licensed Social Worker (Staff #6) documented a care plan update progress note that indicated dental issues were discussed, and the goals to resolve the dental care issue and to find dental care for the resident. However, review of the resident's care plan failed to reveal documentation to indicate the dental issues or the need to identify a dentist for the resident were added to the care plan. Further review of Resident #9's medical record on 05/22/24 at 09:40 AM revealed that there was frequent documentation that noted the resident experiencing tooth pain in February and March 2024. Review of the 3/30/24 MDS assessment revealed that the resident had been experiencing mouth pain under the oral/dental status section. Further review of the medical record revealed a Care Plan Update note, dated 4/3/24,written by Social Worker (Staff #6) that documented that a care plan meeting was held and the resident opted not to attend. No documentation was found in this note to indicate the dental concerns were addressed during this meeting. Further review of Resident #9's medical record on 05/22/24 at 11:43 AM revealed that there was no documentation of a dental care plan and tooth pain was not covered under Resident #9's current pain care plan. On 05/31/24 at 04:28 PM, the surveyor reviewed concern to the Director of Nursing (Staff #18), and Assistant Director of Nursing (Staff #2) regarding the failure to update the resident's care plan related to frequent tooth pain. 48470 1) Resident #24 had been residing in the facility since 2020. A review of the facility matrix on 5/20/24 at 12:29 PM identified the resident as having a pressure ulcer/injury. On 5/22/24 at 2:35 PM, Resident #24's care plan for pressure ulcer was reviewed and revealed a care plan goal that stated, resident will maintain and/or maximize healing process related to wounds. No other care plan goal related to the resident's pressure ulcer was documented with a measurable objective and time frame. Earlier that day at 2:21 PM, the Wound Nurse/Registered Nurse (RN Staff #9) was interviewed about her process with wound care. When Staff #9 was asked about wound measurements, she stated, I would have to say they are not done. She further indicated that floor nurses assess residents with wounds and perform treatments but are not responsible or trained in measuring them. Staff #9 further reported that she used to measure the wounds to track progress but does not anymore because of lack of time since she had been given other roles in the facility. Staff #9 also confirmed that she was responsible for formulating and updating the resident's care plan regarding wound care. At the time of survey Exit on 6/4/24 at 5:09 PM, the concern was discussed with the Director of Nursing, Assistant Director of Nursing, Director of Quality, Chief Medical Officer, Minimum Data Set Coordinator, and the Nursing Home Administrator (joined via phone call) that the care plan did not have measurable objectives and timeframe to meet the resident's needs. All staff acknowledged the concern.

Based on record review and interviews, it was determined that the facility staff failed to report an allegation of abuse to the Office of Health Care Quality in a timely manner. This was evident for 1 (Resident #31) out of 6 residents reviewed for abuse during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A record review on 5/21/24 at 11:29 AM revealed that Resident #31 was admitted to the facility in August 2022 with diagnoses including Dementia. Continued review showed an MDS assessment dated [DATE] that documented that Resident #31 had severe cognitive impairment. Further review on the same day of a facility-reported incident related to Resident #31 with MD00202413 was conducted. The review showed that an allegation of abuse was reported to the Nursing Home Administrator (NHA) on 2/7/24 at approximately 4:20 PM. A subsequent review of the investigation into the allegation of abuse on 6/3/24 at 7:46 AM contained a statement: After reviewing these notes, the Administrator decided on 2/9/24 at 8:15 AM a self-report would be sent, and an investigation would be completed. Review of the facility Abuse, Neglect, Injury of unknown origin, & Misappropriation of Property revealed a statement that The NHA or Quality Director and/or designee will notify the appropriate agencies of such an incident within 24 hours (within 2 hours for serious bodily injury or allegation of abuse). However, the review failed to show that the facility first reported the allegation of abuse to the state agency immediately but not later than 2 hours. During an interview with the NHA on 6/4/24 at 10:17 AM, she reported that she was not in the building when the allegation was first reported to the social worker on 2/7/24. The NHA confirmed that the allegation of abuse was not reported to the state agency until 2/9/24.

Based on record review and interviews, it was determined that the facility failed to provide the resident or the resident's responsible party with written notice of a room change, including the reason for the change before the resident's room was changed. This was evident for 2 (Resident #31 and #9) out of 4 residents reviewed for choices during the survey. The findings include: 1) A record review on 5/20/24 at 11:00 AM revealed that Resident #31 was admitted to the facility in August 2022 with diagnoses including Dementia. Continued review showed an Minimum Data Set (MDS) assessment dated [DATE] that documented that Resident #31 had severe cognitive impairment with short- and long-term memory loss. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A subsequent record review revealed that Resident #31 had a room change on 4/18/24. However, the review failed to show that the Resident's responsible party or family was notified of the Resident's room change before the change. The continued review contained a progress note for Resident #31 that recorded that the Resident's room was changed again on 5/7/24. However, the review failed to show that a written notice, including the reason for the change, was given to Resident #31's responsible party before the room change. During an interview on 5/30/24 at 11:25 AM, Staff #37, a social worker, reported that she did not give written notice with reasons to residents or their responsible parties before room changes. Staff #37 continued to say that Resident #31's responsible party did not agree with the room change on 5/7/24. In a subsequent interview on 5/30/24 at 12:07 PM, Staff #3, a unit nurse manager, reported that if a responsible party were not agreeable to a room change, the facility would not move the Resident. However, Resident #31's room was changed after the responsible party voiced disagreement with the move on 5/7/24. A review of the facility's policy titled Room move notification contained the statement that if a resident or legal representative is not in agreement with the room move, they should be given 30 days written notice, and an interdisciplinary team meeting should be held to discuss their concerns or other room move options. However, the review failed to show documentation of a discussion of Resident 31's responsible party's concerns about the room change. 50573 2) Review of Resident #9's medical record on 5/20/24 revealed the resident has resided at the facility for several years, is alert and oriented and able to verbally communicate. Resident #9 is dependent on staff for transfers out of bed and mobility due to weakness. During an interview on 5/20/24 at 2:43 PM, Resident #9 reported a recent room change and expressed concerns about the new room. Review of the progress notes revealed that on 5/3/24 the Social Worker (Staff #37) had a meeting with Resident #9 to discuss a potential room change. The note indicates the resident was in agreement with the move after the discussion but failed to include documentation that written notice was provided to the resident about the room change. Record review revealed that on 5/4/2024 at 11:06 AM Registered Nurse (Staff #20) documented Resident #9's official room move. Further review of medical record failed to reveal documentation indicating written notice was provided to Resident #9, including the reason for the room change, prior to the room change. An interview with Nursing Home Administrator (Staff #1) on 05/28/24 at 11:22 AM revealed that social work will talk with the residents about room changes and if they are not able to understand, social work will call and talk with the family. Further interview with Staff #1 revealed that she is not sure if anything is given in writing about room changes. An interview with Licensed Certified Social Worker (Staff #37) on 05/28/24 at 12:19 PM revealed that residents are not given written notice for room changes and that if room changes are planned they are given verbal notice and when they agree it is documented as so. On 05/31/24 at 4:26 PM, the surveyor reviewed concern with the Director of Nursing (Staff #18), and Nursing Home Administrator (Staff #1) regarding the failure to provide written notice to the resident prior to a room change.

Based on observation and interview it was determined that the facility failed to ensure areas in need of repair were identified and work orders were implemented. This was found to be evident for 2 out of 2 nursing units observed. The findings include: On 5/20/24 at 1:59 PM surveyor observed water stains on the ceiling above the foot of one of the residents' bed in room K on unit 1 East. On 5/20/24 at 2:34 PM surveyor observed a wall protector below the hand rail across from room E on unit 1 [NAME] was noted to be cracked. On 5/31/24 at 2:15 PM the Maintenance Director (Staff #55) reported that if problems are reported they can put in an e work order which is a program to request repairs. And if there is damage the nurse usually calls and puts an order in. He went on to report they do room checks every week and a walk thru every morning. On 5/31/24 a tour of the facility was conducted with the Maintenance Director between 2:27 - 2:42 PM. The areas identified on 5/20/24 of the cracked wall protector in the 1 [NAME] hallway and of the ceiling in room K on 1 East were still present. Additionally a ceiling tile in the 1 East hallway was noted with an approximately 3 inch brownish stain, which the Maintenance Director confirmed was a water stain. In regard to the damage to the ceiling in Room K, the Maintenance Director reported at 3:37 PM that there is a chiller pipe just above, and the insulation is bad but there is no way to get to the insulation. When asked if there was a permanent fix to this problem, the Maintenance Director responded: probably not. At the end of the tour the surveyor requested work orders, if there were any, for the areas identified above. The maintenance director indicated there would not be work orders for these areas. On 6/03/24 at 3:13 PM Maintenance Director confirmed there were no work orders for the areas identified above.

Based on pertinent documentation review and interviews, it was determined that the facility failed to provide documentation that a thorough investigation of potential abuse was completed. This was evident for 3 (Resident #98, #15, and #9) out of 6 residents reviewed for abuse during the survey. The findings include: 1) On 5/22/24, review of facility report revealed that Resident # 98, a long-term resident of the facility, reported an allegation that he/she received abuse from a facility staff member. On 5/29/24 at 9:37 AM, review of social service progress notes dated 7/27/22, revealed that Resident #98 reported to social worker that he/she had received maltreatment by staff. Further review revealed that the resident was unable to provide any further identifying information and that the allegation was reported to nursing staff and administrator who was the abuse coordinator. The facility reported this allegation to the Office of Health Care Quality (OHCQ). On 5/22/24 at 12: 30 PM, the Administrator provided a 1-page document of the facility's findings in their investigations of Resident #98 allegation of abuse. Further review revealed the documents were a summary of the abuse allegation reported to OHCQ. However, she reported she could not provide any of the employee statements or resident interviews that comprised the investigation. On 5/29/24 at 9:45 AM, the Administrator reported she had no additional information or documentation regarding the abuse allegation reported by Resident #98. She reported she was not the administrator at the time the investigation occurred. The Administrator failed to locate the investigation file. 50573 2) Review of Resident #9's medical record on 5/20/24 revealed the resident has resided at the facility for several years, was alert and oriented and able to verbally communicate. Resident #9 was dependent on staff for transfers out of bed and mobility due to weakness. Review of MD00188264 revealed that on 1/23/23 Resident #9 reported to the psychologist (Staff #54) an allegation of abuse related to an incident during the administration of a medication. The facility reported it to the Office of Health Care Quality (OHCQ) and then initiated an investigation. On 5/21/24 at 2:10 PM surveyor requested the investigation documentation for MD00188264 from the Nursing Home Administrator. On 05/22/24 at 8:45 AM, the Nursing Home Administrator (Staff #1) told the surveyor that she is still looking for additional information on the abuse allegation for Resident #9. On 05/22/24 at 12:30 PM, the Nursing Home Administrator (Staff #1) provided documents for the abuse allegation on Resident #9 and stated she had no additional information. On 5/22/24 at 12:32 PM, review of the documentation provided by the facility revealed the final report submitted to OHCQ which concluded no evidence to substantiate the allegation of abuse. Further record review on 5/22/24 of the documentation provided for MD00188264 revealed two facility report sheets from psychologist (Staff #54) to the facility management about the incident based on what Resident #9 had explained. These reports included the full name of Resident #9, Licensed Practical Nurse (Staff #41), and the first name of a GNA who was a witness to the event. No supporting documentation was found to indicate interviews were conducted with staff or residents regarding this allegation. No documentation was found that identified the full name of the GNA who was a witness to the event. On 05/31/24 at 04:21 PM, the surveyor reviewed the concern with the Director of Nursing (Staff #18), and Nursing Home Administrator (Staff #1) regarding the failure to provide documentation of interviews conducted as part of the facility investigation. 3) Review of Resident #15's medical record revealed the resident has a past medical history of brain damage, weakness, stiffness of right and left ankle, and a mood disorder that can affect a person's feelings, thoughts, and behavior. Review of MD00190623 revealed that on 3/23/23 staff identified a blister on the resident's leg that was of unknown origin, the facility submitted a report to the Office of Health Care Quality (OHCQ) and then initiated an investigation. Review of the final report indicated an investigation was completed and abuse was not substantiated. On 5/21/24 at 2:10 PM surveyor requested the investigation documentation for MD00190623. On 5/23/24 the Nursing Home Administrator reported she was still looking for investigation documentation. On 5/31/24 at 9:00 AM review of the documentation provided by the facility revealed the final report submitted to OHCQ and a report from the police department. Review of the final report revealed that there was no indication that the injury was caused by abuse. The police report concluded there was no indication that the blister was caused by abuse or neglect and it required no criminal investigation. No documentation was provided to indicate which staff were interviewed during the investigation or what they reported. On 05/31/24 at 08:59 AM, review of final report revealed that the facility attempted to interview Resident #15 on how the blister happened, but the resident was unable to report how it happened. On 05/31/24 at 04:21 PM, the surveyor reviewed the concern with the Director of Nursing (Staff #18), and Nursing Home Administrator (Staff #1) regarding the failure to have evidence that a thorough investigation was completed.

Based on observation and interview with staff, it was determined that the facility failed to ensure that a medication cart was locked when a medication pass was being conducted. This is true for 1 out of 2 medication carts observed. The findings include: During medication observation on 2 east side A on 7/29/14 at 9:15 AM, surveyor observed Staff # 1 walk away from the medication cart and enter room C. The surveyor then observed Staff # 2 enter room C and inform Staff # 1 that the medication cart was unlocked. Staff # 1 exited the resident's room and locked the cart. Staff # 1 stated "I made a mistake by leaving the cart unlocked and I take full responsibility for not locking the cart". During an interview on 7/29/14 at 9:20 AM, Staff # 1 again acknowledged that he made a mistake. The surveyor asked Staff # 1 about the process of medication cart monitoring. Staff # 1 informed the surveyor that the medication monitor ensures that the medication cart is locked when unattended. If the medication cart is noted to be unlocked, the monitor is to inform the responsible nurse, who then locks the cart. During an interview with the DON (director of nursing) on 7/29/14 at 9:45 AM to discuss the medication cart being unlocked, she informed the surveyor that the person monitoring the medication cart may lock the cart if it is noted to be unlocked.

Based on observation, resident interview, staff interview, and clinical record review, it was determined that the facility administrator failed to ensure that resources were used effectively to manage operations in order to meet the health and safety needs of the residents. Nursing services lacked leadership with no Director of Nursing (DON), for four months from 12/13/13 to the end of the survey (05/07/14). Although there was an acting DON, abuse allegations were not reported and/or investigated, residents were not appropriately assessed after falls or falls were not appropriately reviewed. In addition, the facility staff failed to make the proper notifications consistently following adverse events including falls, administration failed to ensure quality assurance activities were in place that could identify and correct inappropriate care processes/standards which includes but is not limited to medication errors, and securing medications as required. Refer F157 Refer F225 Refer F309 Refer F323 Refer F333 Refer F334 Refer F520 The findings include: 1. Resident #4 had a [MEDICAL CONDITION] and received oxygen through a Jet neb at 35%. She had been hospitalized at an acute care hospital from 12/20/13 to 12/26/13, according to a hospital discharge note dated 12/26/13, for a urinary tract infection and bilateral pneumonia. Review of the medical record failed to reveal that an assessment of the resident had been done on readmission to the facility on [DATE]. This was confirmed by the director of nursing, on 5/6/14 at 9:45 AM. A note had been entered by social services, on 12/27/13 at 8:14 AM, that the resident had returned from an acute care hospital last evening. Further review of the medical record revealed a progress note, written at 2:49 AM on 12/27/13, stating that the resident was having labored breathing and audible wheezing, but refused to be suctioned. The progress note continued, noting that education was provided to the resident regarding the importance of suctioning. No further assessment of the resident's condition was found in the medical record. No pulse oxygen level was found, no vital signs, no lung sounds and no assessment related to skin color. Interview of nurse #1, on 05/05/14 at 11:45 AM, revealed that, if she gave the resident her 8 AM medications on 12/27/13, which were documented on the medication administration record as given, or if there had been a change in the resident's condition she would have done an assessment and notified the physician of the changes. She also stated that it was not unusual for the resident to refuse treatments. At 9:50 AM on 12/27/13 respiratory therapist #1 found the resident unresponsive, provided care, and notified registered nurse (RN) #1. RN #1 called the physician and did an assessment of the resident. The resident was sent emergently to an acute care hospital for unresponsiveness. Review of the resident's hospital discharge summary, dated 1/2/14, listed discharge [DIAGNOSES REDACTED]. 2. Resident # 3 was admitted to the facility with a complex medical history including a [DIAGNOSES REDACTED]. A review of the falls incident detail sheet, on 05/02/14 at 10:00 AM, revealed that the facility staff documented that resident #3 had a fall on 01/16/14, and on 3/30/14. Further review of the incident detail sheet revealed that, on 01/16/14 at 9:20 AM, the resident was found on the floor and that the resident's BP (blood pressure) was 89/55. A normal blood pressure is a systolic of less than or equal to 120 and a diastolic (bottom number) of less than or equal to 80. If an individual's blood pressure becomes too low they are at risk for dizziness and increase risk of falls. During an interview with the resident's physician on 05/02/14 at 12:15 PM, the surveyor asked him if he was aware of the blood pressure reading that was obtained after the 01/16/14 fall. The physician reported to the surveyor that he was not aware of the blood pressures and if he had known about the blood pressure he probably would have asked for additional information. Further review of the facility incident detail sheet indicated that on 3/30/14 the resident's responsible party was notified of the fall; however, there was no documentation indicating that the physician was made aware of the fall of 03/30/14. 3. A surveyor review of a facility reported incident regarding resident #23 revealed that the resident acquired an injury to his right humerus from an unknown cause. Further review revealed that the resident's certified nursing assistant (CNA) reported to the resident's assigned registered nurse (RN) for the night of 2/13/14, that the resident was exhibiting signs of pain. Per the report, the RN proceeded to the resident's room, did not complete a comprehensive assessment related to the resident's complaint of arm pain, however, proceeded to medicate resident. Review of Resident #23's medical record revealed a delay in the notification to the physician, and an x-ray was not completed and read until after 1:00 PM on 2/14/14, when the resident was subsequently sent to the emergency room for further evaluation and treatment. physician progress notes [REDACTED]." On 4/30/2014, the surveyor asked the facility for documentation that the information was conveyed to the next shift or the appropriate staff. The facility did have the Clinical Data Evaluation (CDE), which did not have any documentation regarding the severity of the resident's injury, or notification to the physician or family at that time. There was no documented information that the resident's clinical status was passed on to the next shift. Surveyor discussed findings with the facility DON , NHA and the CEO on 4/30/2014 at 5:00 PM, and again on 5/2/2014 at 5:00 PM. Facility could not produce additional documents at either time regarding reporting to the physician a new injury of unknown origin, or reporting to the OHCQ within the required time period. Surveyor interviewed the assigned RN from the night of the incident, on 5/2/2014 at 7:00 PM. The staff member was asked if she was familiar with the resident, she verbalized no. She was asked if a full assessment was done at any point in her shift, she verbalized "in the beginning". RN#14 reported to the surveyor that, around 5:00 AM, she was notified that resident #23 was in pain, went to assess, and he was too combative, so she just medicated him. She further proceeded to fill out a CDE and would pass along the information to the next shift. Surveyor interviewed the night supervisor from 2/13/2014. Per the supervisor, RN #15's report, and statement of the facility investigation, she told the night RN#14 to call the on-call physician, or make sure it was passed on first thing in the morning regarding the resident's complaints of pain. Medical record review, on 5/2/2014 of resident #23, revealed a delay in the notification to the physician, and power of attorney (POA). There was no initial assessment for a resident with new onset complaints of pain, and no follow-up assessment related to the effectiveness of the pain medication administered to the resident. 4. On 04/30/14 at 9:12 AM, surveyor observed the medication cart on 1 East to be unlocked and unattended. Surveyor was able to gain access to several drawers containing residents' medications. At 9:15 AM, nurse #2 informed the surveyor that the cart was broken and she was unable to lock it. She stated that the carts belonged to the pharmacy and that they have to replace them. Nurse# 2 also informed the surveyor that she had not reported this to the supervisor. Nurse #2 was then observed walking away from the cart. The surveyor asked nurse #2 where she was going and the nurse responded "to report this to a supervisor." On 04/30/14 at 9:40 AM the shift supervisor (nurse #3) informed the surveyor that the cart was not broken and that the nurse was unsure how to lock it. The surveyor then informed the shift supervisor that this was still a concern that the cart was left unlocked and unattended. Later that morning the acting director of nursing was informed of the medication cart being unlocked and unattended. 5. On 05/03/14 at 2:55 PM surveyor tour of the 1 East-A side shower room revealed that the following items were stored next to the residents shower and body wash: a spray bottle of Vespene II SE, a ready to use one step germicidal detergent. Further review of the bottle revealed label warnings which included that the product is corrosive to tissues. Inhalation of product mists may irritate mucous membranes. Additionally, Surveyor found 4 bottles of Cen-Kleen IV, labeled for external used only and had a warning label that indicated that it causes irreversible eye damage and skin burns. These products were not locked and were accessible to residents. The surveyor notified the NHA of the findings at 3:25 PM on 05/03/14. 6. Review of resident #33's medical record revealed that the resident had difficulty speaking and was deemed by two physicians to be incapable of making his/her own health care decisions. The medical record revealed a progress note written by nurse #14 on 12/5/2014 which stated:" At 2:00 PM on 12/3/13, met with spouse of (resident #33) (name of physician), case manager and DON to discuss the concerns of (#33's RP). The topics that were addressed included ....(resident #33) being punished by having her curtain pulled around her, and another (resident) presenting with verbal abuse, intimidating behaviors and a spirit of bullying..." On the afternoon of 4/30/2014, resident #33's responsible party (RP) was interviewed. During this interview, the RP reported concerns regarding the staff and stated that he had submitted a formal written complaint to the facility. A review of a written complaint, dated 4/2/2014 revealed the following: Summary of Complaint (written by #33's responsible party): "The GNA did not tell me the truth about putting (spouse) to bed Not toileted for 6+ hours since I reported her she is (intimidating) ..... I have lost trust in all GNA 99% anyway. She talks loud and disrespectful when she knows I can hear her. She glares at me constantly when passing me in the hall. She forces me to step aside when walking towards her." On the back of the form there was a written statement from the responsible party that indicated the GNA used her position to intimidate, she used foul language, and others followed her. The responsible party further noted that the GNA is in charge and not the supervisors, and wanted the facility to take back control. Again, the responsible party mentioned that the resident (spouse) was left wet for a long period of time. The document contained actions which were taken by the facility. This section was completed by the administrator. The administrator talked with the RP about the concerns and then talked with the staff person who had been accused of not changing the resident timely, and intimidating behaviors, etc. Outcome (completed by administrator): "Spoke with staff member w/(DON) present. Staff member states she was unaware there was any problem between her and (#33's RP). I shared (33's RP) concerns with her. This is not an issue with her, but also on day shift. Discussed working together to accomplish care. GNA instructed to accommodate requests for staffing to the extent possible. Discussed (33's RP) wish to have (spouse) toileted at 4:00 and put to bed between 6:30 - 7:00. GNA voiced understanding. Spoke with (33's RP) and told him to see me w/ anymore problems. The administration did not talk with other residents assigned to the GNA nor staff who worked on the same unit with the GNA. On 5/9/2014, the administrator reported that she had not submitted a report to the Office of Health Care Quality (OHCQ). On 5/12/2014 at 12:51 PM during a phone interview, the administrator reported to the surveyor that there was no other documentation related to the complaint.

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to assure that services provided to residents meet professional standards of quality by ensuring that physician orders [REDACTED].#29) residents reviewed for medication pass. The findings include: On 7/29/14 at 10:15 AM, Resident #29's medical record was reviewed. A review of the physician orders [REDACTED].d. [MEDICATION NAME] is a medication used to treat [MEDICAL CONDITION]. The resident was to receive 24.3 ml by way of his gastrostomy tube (a tube directly inserted into the stomach). During medication pass for the resident, staff # 1 obtained the [MEDICATION NAME] from the medication drawer, checked the bottle with the orders, repeated the order out loud "resident is to get 24.3 ml", and repeated it to the surveyor. Staff # 1 was then observed pouring the [MEDICATION NAME] into a medication cup. A medication cup is a translucent cup suitable for dispensing both liquid and dry medications Medicine cups are calibrated from 5-30 ml and cc in increments of 5 ml. The surveyor observed staff # 1 pour the medication in the medicine cup and say that should be around the right dose. During an interview with the DON on 7/29/14 at 10:30 AM, she acknowledged that the correct way to administer the medication is to use a syringe with the accurate dose of 4.3 ml to add to the 20 ml.

Based on observations, interviews, a review of medical records and other facility documents, it was determined that the facility failed to ensure that medication carts were locked when unattended, and medications and other nursing supplies were not left out accessible to vulnerable residents, staff, and visitors. In addition, the facility failed to secure cleaning products. There were 4 separate observations over 4 days on two nursing units involving the medication carts resulting in an immediate jeopardy being called on 05/01/14. After the immediate jeopardy was called there were at least 3 more surveyor observations related to medication carts left unlocked and unattended and/or cleaning products found in areas accessible to residents. In addition, the facility staff failed to thoroughly investigate the cause of a fall for 1 out of 32 residents in the Stage II sample (# 52). The findings include: 1. During a tour of Unit 2 East-A side on 04/28/14 at 7:10 AM, Surveyor observed an unlocked medication cart in front of room D. Surveyor continued to observe the unattended medication cart for approximately 1-2 minutes until RN #1 arrived. The surveyor informed the RN #1 that the cart was unlocked and unattended. The response from RN #1 was "Oh, OK." 2. On 04/28/14 at 1:28 PM, the surveyor and nurse #2 were at the medication cart, located in the hallway of the 1 East unit B side, when nurse #2 left the cart to go administer a medication. After the nurse left the medication cart, the surveyor observed that the cart was not locked. Surveyor remained with the cart until the nurse returned a few minutes later. Upon return, the surveyor confirmed with nurse #2 that the cart was left unlocked. Nurse #2 reported that she normally locked the cart. Surveyor asked if she left it unlocked because surveyor was watching and nurse #2 responded "yes." The nurse utilizing the medication cart is responsible for securing the medication cart and for following acceptable standards of practice. On 4/28/2014, a surveyor observed Resident #1 wheeling her/his self independently around the unit. The resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 based on the 2/28/2014 minimum data set (an assessment tool) which indicates severe cognitive impairment. 3. On 04/30/14 at 9:12 AM, a surveyor observed the medication cart on 1 East to be unlocked and unattended. Surveyor was able to gain access to several drawers containing residents' medications. At 9:15 AM, nurse #2 informed the surveyor that the cart was broken and she was unable to lock it. She stated that the carts belonged to the pharmacy and that they have to replace them. Nurse# 2 also informed the surveyor that she had not reported this to the supervisor. Nurse #2 was then observed walking away from the cart. The surveyor asked nurse #2 where she was going and the nurse responded "to report this to a supervisor." On 04/30/14 at 9:40 AM, the shift supervisor (nurse #3) informed the surveyor that the cart was not broken and that the nurse was unsure how to lock it. The surveyor then informed the shift supervisor that this was still a concern that the cart was left unlocked and unattended. Later that morning the acting director of nursing was informed of the medication cart being unlocked and unattended. Resident #1 was observed by the surveyor in his/her wheelchair moving freely throughout the first floor at various times and days during the survey. The unlocked medication and treatment carts posed a safety risk to this resident and other residents. 4. On 05/01/14 at 11:58 AM on 1 East-A side, the surveyor observed an unattended medication cart sitting in front of room D with the bottom drawer open with bottles of medication visible. Resident #47 had a BIMS score of 8 out of 15 based on her 2/28/2014 minimum data set (MDS) which indicates moderate cognitive impairment. The resident was observed proceeding down the hall in his/her wheelchair independently and stopped in front of the medication cart, looked around, then continued down the hall. At 12:02 PM, RN #4 approached the cart and was questioned by the surveyor why the cart was opened and unattended. She stated, "Well I was just in there," and pointed to the nurses' station. RN #4 further indicated that she was just in the nurses' station to get a cord for the computer that is on top of the medication cart. The surveyor asked if the cart locks and she stated "Yes." Surveyor informed RN #4 that the cart cannot be left unattended and RN #4 responded "Sorry." On 05/01/14 at 3:30 PM surveyors informed the acting DON of concerns regarding multiple observations of medication carts being unlocked and unattended. The unlocked medication cart posed a safety risk to this resident as well as other residents. 5. On 05/02/14 at 3:58 PM surveyor observed a resident using a wheelchair passing an unattended medication cart sitting in front of room K on 1 East unit with a carrying case of short acting insulin sitting on top of the cart. There were no staff in view of the cart. At 4:03 PM Nurse # 5 appeared at the entrance of the room and pulled the cart into the room. 6. During a tour on 05/03/14 at 11:41 AM of unit 1 East- B side, the Surveyor noted that in room 104 there were open treatment carts and an Intravenous Catheter (IV) placement cart visible from the hallway. The surveyor entered the room and observed premixed, unlabeled prescribed creams on top of the other treatment cart. Additionally, the cart was observed unlocked. Inside the IV treatment cart included pre-drawn normal saline syringes, heparin syringes and Braun 20 gauge Introcan syringes. Surveyor observations showed that Resident #21 who requires assistance with getting into the wheelchair had a BIMS score of 1 out of 15 which indicates severe cognitive impairment based on the 4/18/2014 MDS data. The resident was observed by the surveyor on various survey days moving freely about the first floor. Resident #1 was also observed by a surveyor in his/her wheelchair moving freely throughout the first floor at various times and days during the survey. The unlocked medication and treatment cart posed a safety risk to these residents as well as other residents. 7. On 05/03/14 at 2:55 PM surveyor tour of the 1 East-A side shower room revealed that the following items were stored next to the residents shower and body wash: a spray bottle of Vespene II SE, a ready to use one step germicidal detergent. Further review of the bottle revealed label warnings which included that the product is corrosive to tissues. Inhalation of product mists may irritate mucous membranes. Additionally, surveyor found 4 bottles of Cen-Kleen IV, labeled for external used only and had a warning label that indicated that it causes irreversible eye damage and skin burns. These products were not locked and were accessible to residents. The surveyor notified the NHA of the findings at 3:25 PM on 05/03/14. The surveyor observed Resident #1 moving about the first floor area freely in his wheelchair at various times on various days throughout the survey. Resident #21 was observed by a surveyor on various survey days moving freely about the first floor. The chemical products that were not locked and stored in resident shower rooms posed a safety risk to these residents as well as other residents. 8. On 05/03/14 at 4:03 PM Surveyor tour of the 2 East shower room revealed the following items stored next to the residents shower and body wash: a spray bottle of Vespene II SE, a ready to use one step germicidal detergent. Further review of the bottle revealed label warnings including; concentrated product is corrosive to tissues. Inhalation of product mists may irritate mucous membranes. Additionally, Surveyor found 2 bottles of Cen-Kleen IV, labeled for external used only. Product had label warning; hazards to humans and domestic animals, causes irreversible eye damage and skin burns. Surveyor notified the shift supervisor of the findings at 4:07 PM on 05/03/14. 9. Resident #56 resided on Unit 1. Her 4/24/2014 MDS indicated that she was able to self-perform locomotion activities on and off the unit. The resident's BIMS score was 15 out of 15 indicating no real cognitive impairment; however, the resident's face sheet and eMARs indicated that he/she has [DIAGNOSES REDACTED]. The resident can independently move about in the wheelchair based on the MDS data. The current physician's orders [REDACTED]. The unlocked medication and treatment carts as well as the cleaning products in the resident's shower rooms posed a safety risk to the resident. The unlocked medication and treatment carts as well as the cleaning products in the resident's shower rooms posed a safety risk to this resident. 10. Resident #13 also resided on Unit 1. The resident's 3/14/2014 MDS reflected that the resident can move about the unit and off the unit independently with initial one person assist. Resident #13 has a BIMS score of 14 which means the resident is cognitively intact. The MDS data showed that the resident has some visual impairment (sees large print not regular print). [DIAGNOSES REDACTED]. The resident based on the above MDS data receives antianxiety, antidepressant, and pain medications. These type of medications can have an impact on an individual's ability to think clearly at times. The unlocked medication and treatment carts as well as the cleaning products in resident shower rooms posed a safety risk to this resident and other residents. 11. A review of Resident # 52's clinical record on 05/02/14 revealed that the resident fell on [DATE] at 9:30 PM. A review of the nursing progress notes revealed that "(name of resident) was found on floor per resp.(respiratory) therapist who was working with other pt (patient) in rm (room)." Further review of this progress note revealed, "the chr (chair's) brakes were not on per resident." A review of the facility fall investigation revealed there were no staff interviews regarding the resident's statement that the brakes to the wheelchair were not on. The resident was not interviewable. The Administrator was interviewed on 05/02/14 at 3:46 PM and she confirmed that the nursing staff were not interviewed to determine who was responsible for ensuring the brakes were locked and she replied "I agree" when asked if the nursing staff should have been interviewed. The survey team identified ongoing noncompliance after an initial Immediate Jeopardy was called on May 1, 2014 and an acceptable plan of correction was submitted and accepted. Another Immediate Jeopardy was called related to the ongoing issues with resident safety and the storage of corrosive cleaning products in unsecured areas. The OHCQ required the facility to respond to a directed plan of correction to abate the multiple incidents of Immediate Jeopardy. The facility took steps to abate the Immediate Jeopardy on May 7, 2014.

Based on reviews of medical records, facility policies and facility investigations, interviews with staff, and resident's responsible parties, it was determined that the facility failed to report allegations of abuse as required, failed to thoroughly investigate allegations of abuse, failed to report to the physician and to the State Agency an injury of unknown origin, and to report a missing bracelet to the State Agency (#33, # 2, # 23, and # 27). This was evident for 4 out of 32 residents reviewed in Stage Two of the survey. The findings include: 1. Review of resident #33's medical record revealed that the resident had difficulty speaking and was deemed by two physicians to be incapable of making his/her own health care decisions. The medical record revealed a progress note written by nurse #14 on 12/5/2013 which stated:" At 2:00 PM on 12/3/13, met with spouse of (resident #33) (name of physician), case manager and DON to discuss the concerns of (#33's RP). The topics that were addressed included ....(resident #33) being punished by having her curtain pulled around her, and another (resident) presenting with verbal abuse, intimidating behaviors and a spirit of bullying..." On the afternoon of 4/30/2014, resident #33's responsible party (RP) was interviewed. During this interview, the RP reported concerns regarding the staff and stated that he had submitted a formal written complaint to the facility. A review of a written complaint, dated 4/2/2014 revealed the following: Summary of Complaint (written by #33's responsible party): "The GNA did not tell me the truth about putting (spouse) to bed Not toileted for 6+ hours since I reported her she is (intimidating) ..... I have lost trust in all GNA 99% anyway. She talks loud and disrespectful when she knows I can hear her. She glares at me constantly when passing me in the hall. She forces me to step aside when walking towards her." On the back of the form there was a written statement from the responsible party that indicated the GNA used her position to intimidate, she used foul language, and others followed her. The responsible party further noted that the GNA is in charge and not the supervisors, and wanted the facility to take back control. Again, the responsible party mentioned that the resident (spouse) was left wet for a long period of time. The Actions Taken to Resolve the Complaint (completed by the administrator): "NHA (nursing home administrator) spoke with (responsible party) about the concerns he had with staff member. I told (RP) I would speak with the staff member and to let me know if he continued having problems." Outcome (completed by administrator): "Spoke with staff member w/(DON) present. Staff member states she was unaware there was any problem between her and (#33's RP). I shared (33's RP) concerns with her. This is not an issue with her, but also on day shift. Discussed working together to accomplish care. GNA instructed to accommodate requests for staffing to the extent possible. Discussed (33's RP) wish to have (spouse) toileted at 4:00 and put to bed between 6:30 - 7:00. GNA voiced understanding. Spoke with (33's RP) and told him to see me w/ anymore problems. He agreed." This form was signed by the administrator and dated 4/3/2014. On 5/9/2014, the administrator reported that she had not submitted a report to the Office of Health Care Quality (OHCQ), which is the State survey and certification agency, regarding the allegations made in the 12/5/2013 meeting with Resident #33's responsible party. On 5/12/2014 at 12:51 PM during a phone interview, the administrator reported to the surveyor that the 4/2/2014 complaint form was the only documentation that they have regarding this complaint. 2. Resident #2's medical record was reviewed over several days during the annual survey. This review revealed the following progress note written on 2/23/2014 by the respiratory therapist (RT #2) : "...but the (responsible party) was direct and made some comments about patient abuse of (resident #2) in front of the four of us and also, named a patient care provider he singled out. This was none of our business and not appropriate to mention in front of us........The nursing supervisor on duty was notified and I was asked to document this situation." During an interview on 4/29/2014 at 2:00 PM with Resident #2's responsible party, he reported that he witnessed, about one year ago, a current staff member (nurse # 7) twisting the ear of another resident. He went on to state that he had reported this allegation of abuse by a staff member to the chief executive officer (CEO) approximately 8 weeks ago. He also reported having observed blood in resident #2's ear, and that he had reported this to nursing staff, but was unsure which staff member. On 5/1/2014 at 11:00 AM during an interview with the CEO, she confirmed that the responsible party did make an allegation about a current employee twisting a resident's ear, but that the event he was reporting had occurred two years ago. When asked if the responsible party had made any abuse allegations, the CEO responded that he makes complaints, will talk about blood in the ears, but has never shown this to anyone. On 5/2/2014 at 5:30 PM, the administrator was interviewed regarding resident #2's responsible party's allegation of abuse against a current staff member, that had been made to the CEO. The administrator reported that they had investigated the allegation and were unable to substantiate the abuse. The surveyor then requested a copy of the referenced investigation. The only documentation provided regarding the investigation, was a print out on plain white paper of some notes, with the last name of the resident at the top of the page. The notes were in narrative form, and did not indicate who had written them. There were entries dated 3/11/14, 3/14/14, and 3/17/14. On 5/2/2014, the director of nursing (DON) reported that the notes had been written by her. Review of the notes revealed that, on 3/11/14, the responsible party made an allegation of abuse against a staff member. The 3/11/14 entry also stated that the responsible party said that the resident had blood in his ear. The 3/17/14 entry included a statement that the responsible party "insists that she (nurse # 7) twisted another resident's ear...". On 5/2/2014 at 5:30 PM, the administrator reported that she did not report the above mentioned allegation of abuse by resident #2's responsible party to the OHCQ. In regard to the need to report allegations of abuse, the administrator stated 'I get it now." On 5/6/2014 at 9:52 AM, the surveyor reviewed the 2/22/2014 therapist note with the DON. She confirmed that the report of abuse needed to be reported and investigated. Surveyor requested any information they had regarding this allegation. On 5/7/2014 at 11:20 AM, surveyor interviewed the nursing home administrator in regards to the investigation of abuse referenced in the respiratory therapist note from February, and the administrator replied that she had no information. 3. A surveyor review of a facility reported incident regarding resident #23 revealed that the resident acquired an injury to his right humerus from an unknown cause. Further review revealed that the resident's certified nursing assistant (CNA) reported to the resident's assigned registered nurse (RN) for the night of 2/13/14?, that the resident was exhibiting signs of pain. Per the report, the RN proceeded to the resident's room, did not complete a comprehensive or complete assessment related to the resident's complaint of arm pain; however, proceeded to medicate resident. Review of Resident #23's medical record revealed a delay in the notification to the physician, and an x-ray was not completed and read until after 1:00 PM on 2/14/14, when the resident was subsequently sent to the emergency room for further evaluation and treatment. physician progress notes [REDACTED]." On 4/30/2014, the surveyor asked the facility for documentation that the information was conveyed to the next shift or the appropriate staff. The facility did have the Clinical Data Evaluation (CDE) which did not have any documentation regarding the severity of the resident's injury, or notification to the physician or family at that time. There was no documented information that the resident's clinical status was passed on to the next shift. Surveyor discussed findings with the facility DON , NHA and the CEO on 4/30/2014 at 5:00 PM, and again on 5/2/2014 at 5:00 PM. Facility could not produce additional documents at either time regarding reporting to the physician a new injury of unknown origin, or reporting to the OHCQ within the required time period. Surveyor interviewed the assigned RN from the night of the incident, on 5/2/2014 at 7:00 PM. The staff member was asked if she was familiar with the resident, she verbalized no. She was asked if a full assessment was done at any point in her shift, she verbalized "in the beginning". RN#14 reported to the surveyor that, around 5:00 AM, she was notified that resident #23 was in pain, went to assess, and he was too combative, so she just medicated him. She further proceeded to fill out a CDE and would pass along the information to the next shift. Surveyor interviewed the night supervisor from 2/13/2014. Per the supervisor, RN #15's report, and statement of the facility investigation, she told the night RN#14 to call the on-call physician, or make sure it was passed on first thing in the morning regarding the resident's complaints of pain. Medical record review, on 5/2/2014 of resident #23, revealed a delay in the notification to the physician, and power of attorney (POA). There was no initial assessment for a resident with new onset complaints of pain, and no follow-up assessment related to effectiveness of the pain medication administered to the resident. 4. An interview with Resident # 27, on 5/2/14 at 2:10 PM, revealed that a silver bracelet was reported to the facility staff to have been found missing, 1 to 2 months prior to the day of the interview. A review of the facility's Security Incident form, on 5/2/14, revealed the resident reported to the facility staff on 4/8/14 that a silver bracelet was missing from the resident's room. Staff searched for the bracelet, but could not find it. Further review revealed that the facility staff did not report that the item was missing to the State agency. Review of the facility's policy for: Resident/Patient Abuse: Screening, Training, Prevention, Identification, Protection and Reporting -- Objectives/Outcome: 2. "All alleged violations involving resident/patient neglect, abuse, injuries of an unknown source, and misappropriation of resident property are to be reported immediately to the Nursing Shift Leader, Program Director, Clinical Manager, Chief Nursing Officer, Medical Director, or Corporate Compliance Officer. They will provide direction to ensure that appropriate actions are taken. 3. All alleged violations will be investigated by the Program Director or their designee and findings reported to the proper agencies and authorities. The Program Director or designee shall report the alleged abuse by phone, email, or fax to all the authorities below. "The contact information for the three parties to be contacted are then listed". 4. "All alleged violations must be reported as soon as possible." The Acting Director of Nursing was interviewed on 5/2/14 at 2:35 PM, and she stated that the facility did not report the missing item to the state agency as required. The survey team identified ongoing noncompliance with reporting requirements, therefore, a second Immediate Jeopardy was called at 5:01 PM. OHCQ required the facility to respond to a directed plan of correction to abate the multiple incidents of Immediate Jeopardy. The facility took steps to abate the Immediate Jeopardy on May 7, 2014 at 9:05 PM.

Based on review of the self-report documentation, facility investigative reports, and interview with staff, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported to the administrator immediately and thoroughly investigated. The findings include Review of the facility abuse policy on 7/30/14 revealed that employees, facility consultants and/or attending physicians, must report any suspected abuse, incidents of abuse or neglect, or allegations of abuse to the Nurse Supervisor immediately. Any individual observing an incident of resident abuse must promptly report any such incident as well. Review of the self-report incident forwarded to the state revealed an incident of resident abuse by staff person #6, who threatened to withhold treatment/medication for resident #33. The incident occurred on 7/11/14 on 1 east nursing station, and was witnessed by staff members. Review of the investigation revealed that the facility obtained a statement from staff member #1 on 7/17/14, about the incident that he witnessed on 7/11/14. Further review of the investigation revealed that the facility failed to ensure that all staff who witnessed the incident on 7/11/14, were interviewed, and statements obtained. During an interview with the Nursing Home Administrator on 7/30/14, she could not explain why an allegation of abuse that occurred on 7/11/14 was not reported to the administrator until 7/17/14. While reviewing the facility abuse policy and procedure on 7/30/14 with the nursing home administrator, she acknowledged that management was not timely notified, and that a thorough investigation was not done.

Based on observations, interviews, and medical record reviews, it was determined that staff failed to administer medications as ordered, conduct comprehensive assessments, report changes in medical status to the physician in a timely manner, investigate allegations of abuse, and make proper notifications related to allegations of resident abuse, and resident incidents/events. This deficient practice was evident for at least 6 of 32 residents ( #3, #13, #23, #26, #41, and #52). In addition, there were 4 separate observations over 4 days on two nursing units involving unattended and unlocked medication carts, when an immediate jeopardy was called on 5/1/14. After the immediate jeopardy was called, there were at least 3 more surveyor observations related to medication carts being left unlocked and unattended in areas accessible to residents. Refer F333 Refer F225 Refer F309 The findings include: 1. During a tour of Unit 2 East-A side on 4/28/2014 at 7:10 AM, Surveyor observed an unlocked medication cart in front of room D. The surveyor continued to observe the unattended medication cart for approximately 1-2 minutes until RN #1 arrived. The surveyor informed RN #1 that the cart was unlocked and unattended. Her response was " Oh, OK. " 2. On 4/28/2014 at 1:28 PM, the surveyor and nurse #2 were at the medication cart, located in the hallway of the 1 East unit B side, when nurse #2 left the cart to go administer a medication. After the nurse left the medication cart, surveyor observed that the cart was not locked. Surveyor remained with the cart until the nurse returned a few minutes later. Upon return, the surveyor confirmed with nurse #2 that the cart was left unlocked. Nurse #2 reported that she normally locked the cart. Surveyor asked if she left it unlocked because surveyor was watching and nurse #2 responded "yes." The nurse utilizing the medication cart is responsible for securing the medication cart and for following acceptable standards of practice. 3. On 4/30/2014 at 9:12 AM, surveyor observed the medication cart on 1 East to be unlocked and unattended. The surveyor was able to gain access to several drawers containing residents' medications. At 9:15 AM, nurse #2 informed the surveyor that the cart was broken, that she was unable to lock it, that the carts belonged to the pharmacy, and that they have to replace them. Nurse# 2 also informed the surveyor that she had not reported this to the supervisor. Nurse #2 was then observed walking away from the cart. Surveyor asked Nurse #2 where she was going and the nurse responded "to report this to a supervisor." On 4/30/2014 at 9:40 AM, the shift supervisor (nurse #3) informed the surveyor that the cart was not broken, and that the nurse was unsure how to lock it. The surveyor then informed the shift supervisor that this was a concern that the cart was left unlocked and unattended. Later that morning, the acting director of nursing was informed of the medication cart being unlocked and unattended. 4. On 5/1/2014 at 11:58 AM on 1 East-A side, the surveyor observed an unattended medication cart sitting in front of room D, with the bottom drawer open with bottles of medication visible. Resident #47 was observed at this time proceeding down the hall in her wheelchair, stopped in front of the cart, looked around, then proceeded down the hall. At 12:02 PM, RN #4 approached the cart and was questioned by the surveyor why the cart was opened and unattended, she stated " Well I was just in there, " and pointed to the nurses' station. RN #4 further indicated that she was just in the nurses' station to get a cord for the computer that is on top of the medication cart. The surveyor asked if the cart locks and she stated "Yes". When the surveyor informed RN #4 that the cart cannot be left unattended RN #4 responded " Sorry. " On 5/1/2014 at 3:30 PM, surveyors informed the acting DON of concerns regarding multiple observations of medication carts being unlocked and unattended. The director of nursing was informed of the immediate jeopardy on 05/01/14 at 7:30 PM. 5. On 5/2/14 at 3:58 PM, surveyor observed a resident using a wheelchair passing an unattended medication cart sitting in front of room K on 1 East unit with a carrying case of short acting insulin, sitting on top of the cart. There were no staff in view of the cart. At 4:03 PM, Nurse # 5 appeared at the entrance of the room, and pulled the cart into the room. 6. During a tour on 05/03/14 at 11:41 AM, of unit 1 East- B side, the surveyor noted that, in room [ROOM NUMBER], there were open treatment carts and an Intravenous Catheter (IV) placement cart visible from the hallway. The surveyor entered the room and observed premixed, unlabeled prescribed creams on top of the other treatment cart. Additionally, the cart was observed unlocked. Inside the IV treatment cart were pre-drawn normal saline syringes, [MEDICATION NAME] syringes and Braun 20 gauge Introcan syringes. 7. On 05/03/14 at 2:55 PM, Surveyor tour of the 1 East-A side shower room observed that the following items were stored next to the residents' shower and body wash: a spray bottle of Vespene II SE, a ready to use one step germicidal detergent. Further review of the bottle revealed label warnings which included that the product is corrosive to tissues. Inhalation of product mists may irritate mucous membranes. Additionally, the surveyor found 4 bottles of Cen-Kleen IV labeled for external use only. There was a warning label indicating that it causes irreversible eye damage and skin burns. The products were not locked and were accessible to residents. The surveyor notified the nursing home administrator (NHA) of the findings at 3:25 PM on 05/03/14. 8. On 5/3/2014 at 4:03 PM, the surveyor toured the 2 East shower room which had the following items stored next to the residents' shower: body wash: a spray bottle of Vespene II SE, and a ready to use one step germicidal detergent. Further review of the bottle revealed label warnings including; concentrated product is corrosive to tissues. Inhalation of product mists may irritate mucous membranes. Additionally, the surveyor found 2 bottles of Cen-Kleen IV, labeled for external use only. The products had label warnings; hazards to humans and domestic animals, causes irreversible eye damage and skin burns. The surveyor notified the Shift Supervisor of the findings at 4:07 PM on 05/03/14 9. A review of Resident # 52's clinical record, on 5/2/14, revealed that the resident fell on [DATE] at 9:30 PM. A review of the nursing progress notes revealed that "(name of resident) was found on floor per resp.(respiratory) therapist who was working with other pt (patient) in rm (room). "Further review of this progress note revealed "The chr (chair's) brakes were not on per resident." A review of the facility fall investigation revealed there were no staff interviews regarding the resident's statement that the brakes to the wheelchair were not on. The administrator was interviewed on 5/2/14 at 3:46 PM, and she confirmed that the nursing staff were not interviewed to determine who was responsible for ensuring the brakes were locked, and she replied "I agree" when asked if the nursing staff should have been interviewed. The survey identified noncompliance with Federal and State requirements that were reviewed in relationship to observations and clinical record review. Immediate Jeopardy was identified on May 1, 2014 at 7:30 PM. The facility took steps to abate the Immediate Jeopardy on May 7, 2014 at 9:05 PM. The Office provided a directed action plan to abate the multiple incidents of Immediate Jeopardy. 10. On 5/2/2014 at 7:00 PM, the surveyor interviewed the RN assigned to resident #23 on the night of 2/13/2014, related to a facility reported incident. RN #14 was asked if she was familiar with the resident, she verbalized no, then, she was asked if a full assessment was done at any point in her shift (2/13/2014). She stated to the surveyor that an assessment was done at the beginning of the shift. The incident report revealed that the resident acquired an injury to his right humerus from an unknown cause. RN #14 reported to the surveyor that "sometime after 4:00 AM care," she was notified that resident #23 was in pain, went to assess and the resident was too combative, so she just medicated the resident". She further proceeded to fill out a Clinical Data Evaluation (CDE), and would pass along the information to the next shift. Further review revealed that the resident's certified nursing assistant (CNA) reported to the resident's assigned RN for the night around 5:00 AM, that the resident was exhibiting signs of pain. Per the report, the RN proceeded to the resident's room, did not complete a full assessment of the resident in the area of the complaint, however, proceeded to medicate resident at 6:45 AM. Resident #23's medical record showed a delay in the notification to the physician, and an x-ray was not completed and read until after 1:00 PM on 2/14/14, when resident was subsequently sent to the emergency room for further management and assessment. A physician progress notes [REDACTED]." The surveyor interviewed the night supervisor from 2/13/2014. Per the night supervisor's report of events, (RN#15), and statement on the facility investigation, she told the night RN #14 to call the on-call physician, or make sure it was passed on first thing in the morning regarding the resident's complaints of pain. Additional review of the facility report to the OHCQ revealed that notification occurred at 7:00 PM on 2/15/2014, greater than 36 hours after the initial report from the CNA, and the resident's new onset of complaints of pain. A Notice of Disciplinary Action form dated 2/21/2014 showed that the facility did discipline the RN #14 for not assessing Resident #23 on 2/13/2014 and for failing to notify the physician which delayed treatment for [REDACTED]. The surveyor discussed findings with the facility DON, NHA and the CEO on 4/30/2014 at 5:00 PM, and again on 5/2/2014 at 5:00 PM. Facility could not produce additional documents at either time regarding a report to resident #23's physician regarding a new injury of unknown origin, or reporting to the OHCQ within the required time period. Medical record review of resident #23 on 5/1/2014 at 12:00 PM revealed a fall occurrence on 4/6/2014 with no ongoing assessments per physician's orders [REDACTED]. The resident's right arm was in a sling secondary to an oblique fracture of his humerus from February 2014. Medical record review and interview with facility staff on 5/2/2014 at 2:13 PM failed to provide documentation of ongoing assessments as ordered by physician. Documentation was requested from the facility staff on 5/3/2014 regarding this occurrence. Facility staff reported back to the survey team on 5/4/2014 that an investigation was not completed. Further record review, conducted on 5/1/2014 at 1:00 PM, revealed an incident on 4/10/2014 at 11:00 PM, where resident #23 was found banging his head on his dresser and injuring himself. There was no incident report, no notification to the physician or to the family related to the incident. The care plan revealed that, when the resident was having episodes of agitation, to "assesses for possible correctable causes, example pain ... " Ongoing review of the medical record revealed; failure of the facility staff to document on the behavior monitoring flow record, and assess resident for pain. Progress notes for resident #23, on 4/10/2014 at 11:00 PM, failed to report on vital signs or pain level. In addition, there was no documentation of vital signs until 4/10/2014 at 1:55 AM, showing resident with a pulse rate of 105, with no follow-up until 8:07 AM on 4/11/2014 when his pulse was documented as 82. On 5/3/2014, the surveyor requested any documentation regarding the 4/10/2014 incident and, on 5/4/2014, facility staff reported to the survey team that there was no assessment, no incident report, and no notifications documented in the resident's chart. Another fall, on 4/12/2014 at 11:27 AM, was noted in the record. Facility staff did not have any documentation related to a pain assessment post fall. The staff documented that resident #23 exhibited behaviors consistent with his care plan regarding the need for reassessment for pain including; hitting, scratching and resisting care. The resident's Behavior Monitoring Flow record for April 13, 2014 showed that there was an increase in the amount of documented behaviors exhibited by the resident, with no pain assessment or other modalities documented in his care plan. Documentation regarding this incident was requested from the facility on 5/3/2014. The facility reported back to the survey team on 5/4/2014, that there was no further documentation in the resident chart. 11. Review of the medical record, on 5/2/14 at 3:30 PM, revealed that resident # 26 was admitted to the facility in June 2010 with a complex medical history including; dementia (the loss of mental functions such as thinking, memory, and reasoning that can interfere with a person's daily functioning), [MEDICAL CONDITION] (is a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body tissues) and failed right hip replacement. Medical record review revealed that, on 12/7/13 at 10:26 PM, the resident had a fall. Further review of the fall incident flow sheet , dated 12/8/13, revealed that the resident did not have an assessment done until 12/18/13 and neither the physician or responsible person were made aware of the fall that had occurred on 12/7/13. Review of the medical records revealed that the resident also had a fall on 12/15/13 at 5:00 AM and the resident's responsible person was not made aware of this fall either. The resident's medical record showed that on 12/17/13 the resident had a fall at 5:15 PM and again at 7:40 PM, and only one assessment and one fall incident sheet was completed for the two falls. Review of the notification section on the fall incident sheet indicated that the physician and responsible party were notified at 6:45 of the first fall and not notified of the second fall. On 12/25/13 at 7:25 PM the resident had a fall. A fall incident detail record revealed that the resident complained of pain to the back and tailbone at 7:43 PM and received routine pain medication at 8:00 PM. The facility failed to reassess the resident's pain. Again, on 1/11/14 at 12:08 AM the resident had a fall. The fall incident flow record showed that the resident did not have an assessment completed until 1/13/14 at 10:47 AM and at that time complained of right knee pain. According to the January 2014 medication administration record (MAR), the resident was not given any medication for pain. Staff did not notify the physician or the responsible party. 12. Review of the medical records on 4/30/14 at 12:30 PM revealed resident # 3 was admitted to the facility in March 1982 with a complex medical history which includes motor vehicle accident resulting in an [MEDICAL CONDITIONS] which occurs when the brain does not receive oxygen. Cells in the brain need oxygen to survive and function. Medical record review revealed that on 1/16/14 at 9:20 PM the resident had a fall. Review of the resident's fall incident sheet reveals that the blood pressure was 89/55. A normal blood pressure is a systolic of less than or equal to 120 and a diastolic (bottom number) of less than or equal to 80. If an individual's blood pressure becomes too low they are at risk for dizziness and an increase risk for falls The incident sheet indicated that the resident's blood pressure had not been re-checked and there was no documentation of the fall or blood pressure in the progress note. During an interview with the surveyor on 5/1/14, the physician acknowledged that he was aware of the resident's fall but that the blood pressure was not been reported to him. The resident had another fall on 3/30/14 at 6:30 PM. There was no documentation of an assessment, no progress notes related to the fall or any revision to the care plan. All findings discussed with staff # 8 on 5/2/14 at 3 PM and on 5/7/2014. 13. On 4/29/2014 Resident #13's medical record was reviewed. This review indicated that the resident was admitted to the facility in November 2013 with [DIAGNOSES REDACTED]. The resident had a fall on 12/15/13 and on 12/17/13, yet, there was only one fall incident flow sheet which was for the first fall. Facility staff wrote a note on the resident but failed to do an assessment on the fall the occurred on 12/17/14. All findings confirmed with nurse # 8 on 5/7/14 at 2:30 PM. 14. An observation was made on 5/5/14 at 5:55 p.m. of Nurse # 13 at the medication cart on the first floor. The nurse was preparing an intravenous (IV) antibiotic in a IV bag when the computer that was on top of the medication cart failed to allow her to log on to see the electronic medication administration record (eMAR). Nurse # 13 proceeded to push the medication cart back to the nursing station so that she could plug the computer in so the battery would charge. During this time Nurse # 13 revealed she was still doing the 4:00 PM medication pass. When the surveyor asked why the medication pass was so late Nurse # 13 stated "because the med cart was down being cleaned. Only housekeeping can steam clean the cart." At that time the surveyor asked for all the names of the residents that were being given medications so that the eMar documentation could be reviewed. Resident #41 is a [AGE] year old female with [DIAGNOSES REDACTED]. Review of Resident #41's eMAR documentation on 5/5/14 at 7:10 PM showed that the physician ordered 11:00 AM [MEDICATION NAME] R (Insulin) was given at 12:50 PM and the 3:00 PM dose was given at 4:56 PM. The blood sugar testing (BS) done at the same time of the [MEDICATION NAME] R injections revealed BS of 280 mg/dl at 12:50 PM and 318 mg/dl at 4:56 PM. [MEDICATION NAME] R is a short acting man made insulin that is similar to the insulin produced by the human pancreas. When blood sugar (glucose) is elevated, insulin is needed to help get the sugar into the cells and not build up in the blood. If insulin is not given correctly, at the ordered times, the sugar could build up in the blood and cause complications in the body. Normal blood sugar levels in the blood range from 70 mg/dl to 130 mg/dl. Further review of Resident #41's eMAR revealed on 5/4/14 the 3:00 PM dose was given at 4:15 PM with a BS of 324 mg/dl and the 10:00 PM dose was given at 11:14 PM with a BS of 351 mg/dl. On 5/3/14 the resident received the physician ordered [MEDICATION NAME] R dose for 10:00 PM at 8:21 PM with a BS of 332 mg/dl. On 5/2/14 the ordered 3:00 PM dose of [MEDICATION NAME] R was given at 5:42 PM with a BS 253 mg/dl. On 5/1/14 the 3:00 PM dose of [MEDICATION NAME] R was given at 5:50 PM with a BS 289 mg/dl. There was no documentation found on the eMARs or in the nursing notes as to the reason for the late administration of the [MEDICATION NAME] R (insulin) and the (1) early dose for a diabetic patient whose nutrition and glucose control are totally dependent on the nursing staff. The surveyor spoke to Nurse # 13 on 5/5/14 at 8:15 PM regarding the late administration of the insulin. Nurse # 13 went through the eMAR and stated that "the nurses sign off the meds when given and I don't know why the insulin was not given on time." The survey team identified ongoing noncompliance even after an initial Immediate Jeopardy was called on May 1, 2014 and an acceptable plan of correction was submitted and accepted. Another Immediate Jeopardy was called related to the ongoing issues. The OHCQ required the facility to respond to a directed plan of correction to abate the multiple incidents of Immediate Jeopardy. The facility took steps to abate the Immediate Jeopardy on May 7, 2014.

The facility failed to ensure that nursing staff provided needed care based on generally accepted standards of clinical nursing practice which jeopardized the health and safety of residents. Nursing staff failed to conduct comprehensive assessments and/or do accurate and complete assessments for residents including those related to adverse events/incidents, and make proper notifications, administer medications correctly and secure medications and treatments. In addition, nursing services lacked leadership with no Director of Nursing (DON), for four months from 12/13/13 to the end of the survey (05/07/14). Although there was an acting DON, abuse allegations were not reported and/or investigated, falls were not appropriately reviewed and care processes were not adequately monitored. This deficient practice impacted resident care throughout the facility; however was evident for at least 11 ( #2, #3, #4, #20, #23, #25, #33, #39, #41, #43 and #47) of the 32 Stage 2 sampled residents. Refer to F157, F225, F272, F279, F280, F309, F323, F333, F514, and F520 The findings include the following: 1. The surveyor review of a facility reported incident regarding resident #23 revealed that the resident acquired an injury to his right humerus from an unknown cause. Further review revealed that the resident's certified nursing assistant (CNA) reported to the resident's assigned registered nurse (RN) for the night of 2/13/14, that the resident was exhibiting signs of pain. Per the report, the RN proceeded to the resident's room, did not complete a comprehensive or complete an assessment related to the resident's complaint of arm pain; however, proceeded to medicate resident. Review of Resident #23's medical record revealed a delay in the notification to the physician, and an x-ray was not completed and read until after 1:00 PM on 2/14/14, when the resident was subsequently sent to the emergency room for further evaluation and treatment. physician progress notes [REDACTED]." On 4/30/2014, the surveyor asked the facility for documentation that the information was conveyed to the next shift or the appropriate staff. The facility did have the Clinical Data Evaluation (CDE) which did not have any documentation regarding the severity of the resident's injury, or notification to the physician or family at that time. There was no documented information that the resident's clinical status was passed on to the next shift. The surveyor findings were initially discussed with the DON, NHA, and CEO on 4/30/2014. The incident was also not reported within the required time period to the Office of Health Care Quality. The surveyor also conducted interviews with the DON, NHA, CEO, RN #14 and her supervisor (RN #15) who were on duty 2/13/2014. The interviews took place on 5/2/2014 between 5:00 PM and 7:00 PM. RN #14 indicated that she did not complete an assessment of the resident on the day of the incident because the resident was combative but did medicate the resident. There is no documentation in the medical record regarding the resident's combativeness during that time period. RN # 15 reported that she informed RN #14 to call the on-call physician, or make sure the information was passed on to the next shift. Medical record review, on 5/2/2014 of resident #23, revealed a delay in the notification to the physician, and power of attorney (POA). There was no initial assessment for a resident with new onset complaints of pain, and no follow-up assessment related to effectiveness of the pain medication administered to the resident. A Notice of Disciplinary Action form dated 2/21/2014 showed that the facility did discipline RN #14 for not assessing Resident #23 on 2/13/2014 and for failing to notify the physician which delayed treatment for [REDACTED]. 2. Review of resident #33's medical record revealed that the resident had difficulty speaking and was deemed by two physicians to be incapable of making his/her own health care decisions. The medical record revealed a progress note written by nurse #14 on 12/5/2014 which documented that the DON, case manager, met with the resident's responsible party on 12/3/2013 to discuss his concerns related to staff punishing resident #33 by pulling the curtain around her, intimidating behaviors and bullying. On the afternoon of 4/30/2014, resident #33's responsible party (RP) was interviewed by the surveyor. During this interview, the RP reported concerns regarding the staff and stated that he had submitted a formal written complaint to the facility. A review of a written complaint, dated 4/2/2014 revealed the following: The GNA did not tell me the truth about putting (spouse) to bed Not toileted for 6+ hours since I reported her she is (intimidating) ..... I have lost trust in all GNA 99% anyway. She talks loud and disrespectful when she knows I can hear her. She glares at me constantly when passing me in the hall. She forces me to step aside when walking towards her." The back of the complaint had a written statement from the responsible party that indicated a GNA used her position to intimidate, she used foul language, and other staff followed her. The responsible party further noted that the GNA is in charge and not the supervisors, and wanted the facility to take back control. The responsible party mentioned again that the resident (spouse) was left wet for a long period of time (6 1/2 hours). The Actions Taken to Resolve the Complaint (completed by the administrator): The administrator spoke to the staff person in the presence of the DON. The GNA did not acknowledge that there was any problems and was instructed to accommodate resident #33's ARP request for toileting his/her spouse (Resident #33) at 4:00 PM and putting the resident back to bed between 6:30 PM and 7:00 PM. The RP was informed to see the administrator if there were any other issues. On 5/9/2014, the administrator reported that she had not submitted a report to the Office of Health Care Quality (OHCQ), which is the State survey and certification agency, regarding the allegations made in the 12/5/2013. On 5/12/2014 at 12:51 PM during a phone interview, the administrator reported to the surveyor that the 4/2/2014 complaint form was the only documentation that they have regarding this complaint. The facility administration did not interview other residents who were cared for by this GNA or family members of residents who reside on the same unit regarding staff treatment nor other staff. 3. An observation was made, on 05/05/14 at 5:55 PM, of Nurse #13 at the medication cart on the first floor. Nurse #13 revealed that she was doing the 4:00 PM medication pass. When the surveyor asked why the medication pass was so late, the nurse stated "because the med cart was down being cleaned. Only housekeeping can steam clean the cart." The surveyor reviewed the following eMARs.Resident #41 is a [AGE] year old female with [DIAGNOSES REDACTED]. The eMAR documentation on 05/05/14 at 7:10 PM showed that the physician ordered 11:00 AM [MEDICATION NAME] R (Insulin) which was given at 12:50 PM and the 3:00 PM dose was given at 4:56 PM. The blood sugar testing (BS) done at the same time of the [MEDICATION NAME] R injections revealed BS of 280 mg/dl at 12:50 PM and 318 mg/dl at 4:56 PM. Normal blood sugar levels in the blood range from 70 mg/dl to 130 mg/dl. Further review of Resident #41's eMAR revealed on 05/04/14 the 3:00 PM dose was given at 4:15 PM with a BS of 324 mg/dl and the 10:00 PM dose was given at 11:14 PM with a BS of 351 mg/dl. On 05/03/14 the resident received the physician ordered [MEDICATION NAME] R dose for 10:00 PM at 8:21 PM with a BS of 332 mg/dl. On 05/02/14 the ordered 3:00 PM dose of [MEDICATION NAME] R was given at 5:42 PM with a BS 253 mg/dl. On 05/01/14 the 3:00 PM dose of [MEDICATION NAME] R was given at 5:50 PM with a BS 289 mg/dl. There was no documentation found on the eMARs or in the nursing notes as to the reason for the late administration of the [MEDICATION NAME] R (insulin) doses and the (1) early dose for a diabetic patient whose nutrition and glucose control are totally dependent on the nursing staff. There was no documentation that late doses were reported to the nursing supervisor or to the physician prior to administration. The surveyor spoke to Nurse #13 on 05/05/14 at 8:15 PM regarding the late administration of the insulin. Nurse #13 went through the eMAR and stated that "the nurses sign off the medications when given and I don't know why the insulin was not given on time." 4. Review of the eMAR documentation for Resident #39 revealed on 05/05/14 the 8:00 AM dose of [MEDICATION NAME] ([MEDICATION NAME]) 50mg (milligrams) was given at 10:23 AM. The resident's blood pressure at the time was noted to be 99/60. The physician's orders [REDACTED]." Further review revealed on 05/02/14 the 8:00 AM dose was given at 10:14 AM and the blood pressure was 104/63 with the systolic number being less than 110. The nurse failed to follow the physician's orders [REDACTED]. The surveyor spoke with Nurse #12 on 05/05/15 at 11:10 PM about the medication being given.Further review of Resident #39's eMAR revealed on 05/05/14 the resident received her 4:00 PM ordered [MEDICATION NAME] at 5:50 PM, at 5:17 PM on 05/04/14 and 5:22 PM on 04/30/14. The resident received this medication 3 times a day. Resident #39 received [MEDICATION NAME] 1 mg every 8 hours for increased secretions. On 05/05/14 her midnight dose was given at 1:31 AM and her 4:00 PM dose was given at 5:49 PM. Resident #39 also received [MEDICATION NAME] for nerve pain. The medication is to be given every 8 hours. On 05/05/14 she received her 4:00 PM dose at 5:50 PM and on 04/30/14 at 5:22 PM. There was no documentation to show that these medication errors were reported to nursing and/or to the physician. 5. There were at least 3 surveyor observations from 4/28/2014 to 4/30/2014 at various times of the day that noted the nurses on Unit 2 East-A side and Unit 1 East B side leave medication carts unattended and unlocked. The nurses were interviewed a few minutes after each of the separate observations and offered no clear explanation for the practice of leaving the carts open and unattended. During one of the 4/28/2014 observations, the surveyor noted that Resident #1 was wheeling her/his self independently around the unit. Resident #1's medical record indicated that the resident had a Brief Interview for Mental Status (BIMS) score 4 out of 15 based on the 2/28/2014 minimum data set (an assessment tool) which indicates severe cognitive impairment. On 4/30/2013 the shift supervisor nurse #3 and acting DON were made aware of the surveyor observations and findings. Then again on 5/1/2014 at 11:58 AM on 1 East-A side, the surveyor observed an unattended medication cart sitting in front of room D, with the bottom drawer open with bottles of medication visible. Resident #47 had a BIMS score of 8 out of 15 based on her 2/28/2014 minimum data set which indicates moderate cognitive impairment. The resident was observed proceeding down the hall in her wheelchair and stopped in front of the medication cart, looked around, then continued down the hall. At 12:02 PM, RN #4 approached the cart and was questioned by the surveyor why the cart was opened and unattended, she stated " Well I was just in there, " and pointed to the nurses' station. RN #4 further indicated that she was just in the nurses' station to get a cord for the computer that is on top of the medication cart. The surveyor asked if the cart locks and she stated "Yes." When the surveyor informed RN #4 that the cart cannot be left unattended RN #4 responded " Sorry. " On 5/1/2014 at 3:30 PM, surveyors informed the acting DON of concerns regarding multiple observations of medication carts being unlocked and unattended. The acting director of nursing was informed of the immediate jeopardy on 05/01/14 at 7:30 PM. After the immediate jeopardy was called, the surveyors continued to observe unattended and unlocked medication and treatment carts on the units. On 5/2/14 at 3:58 PM, a surveyor observed a resident using a wheelchair passing an unattended medication cart sitting in front of room K on 1 East unit with a carrying case of short acting insulin, sitting on top of the cart. There were no staff in view of the cart. At 4:03 PM, Nurse # 5 appeared at the entrance of the room, and pulled the cart into the room. During a tour on 05/03/14 at 11:41 AM, of unit 1 East- B side, the surveyor noted that, in room [ROOM NUMBER], there were open treatment carts and an Intravenous Catheter (IV) placement cart visible from the hallway. The surveyor entered the room and observed premixed, unlabeled prescribed creams on top of the other treatment cart. Additionally, the cart was observed unlocked. Inside the IV treatment cart were pre-drawn normal saline syringes, [MEDICATION NAME] syringes and Braun 20 gauge Introcan syringes. 6. Resident #4 had a [MEDICAL CONDITION] and received oxygen through a Jet neb at 35%. The resident had been hospitalized at an acute care hospital from 12/20/13 to 12/26/13 according to a hospital discharge note dated 12/26/13, for a urinary tract infection and bilateral pneumonia. Review of the medical record showed that a re-assessment had not been done on readmission (12/26/2013). A note had been entered by social services on 12/27/13 at 8:14 AM that the resident had returned from an acute care hospital last evening. A progress note written at 2:49 AM on 12/27/13 revealed that the resident was having labored breathing and audible wheezing but refused to be suctioned. The progress note showed that the nurse documented that the resident was educated regarding the importance of suctioning. No further assessment of the resident's condition was found in the medical record. No pulse oxygen level was found, no vital signs, no lung sounds and no assessment related to skin color. Another note in the record indicated that at 9:50 AM on 12/27/13 respiratory therapist #1 found the resident unresponsive and provided care and notified registered nurse (RN) #1. RN #1 called the physician and did an assessment of the resident. The resident was sent emergently to an acute care hospital for unresponsiveness. Review of the resident's hospital discharge summary dated 1/2/14 listed discharge [DIAGNOSES REDACTED]. The nurse was interviewed on 5/5/2014 at 11:45 AM. She indicated that she gave the resident her medications at 8 AM on 12/27/2013 and that there was no change in the resident's condition and indicated it was not unusual for the resident to refuse treatments. On 5/6/14 at 9:45 AM, the surveyor interviewed the DON who confirmed that the nurse did not complete a comprehensive assessment on readmission. The generally accepted standard of nursing care is to complete a comprehensive assessment upon readmission after at least a 6 day hospital stay a resident who was treated for [REDACTED]. 7. During an interview with the Nursing Home Administrator (NHA) and the acting Director of Nursing (DON) on 05/02/14 at 10:03 AM, it was reported that the facility governing body had been without an active director of nursing (DON) for more than 4 months. Further discussion with the NHA revealed that the previous DON resigned in December of 2013, and there had been no full-time replacement. Duties of the DON were delegated to various employees of the hospital staff, including the current Chief Nursing Operator (CNO) who also carried the title of "interim DON." Additionally, it was reported that other hospital staff had been assigned duties of the DON, such as Quality Assurance. An interview with the facility Chief Executive Officer (CEO), on 05/01/14 at 11:00 AM, revealed that the facility still did not have full-time dedicated DON coverage at the time of the survey. The facility staff who shared DON responsibilities were required to understand what those responsibilities were in order to ensure resident health and safety needs were met based on the requirements. The facility administration delegated the DON responsibilities to various employees but there were no mechanisms in place to monitor or oversee that those responsibilities for nursing services were consistently carried out. 8. The following are a few examples of facility incident details reports that were not reviewed and signed as per facility specifications by the DON and/ or acting DON. Resident #3 fell out of bed on 1/16/2014 at 9;20 AM and on 3/30/2014 at 6:30 PM the resident was found on the floor at that time his blood pressure was 99/59. Resident #20 had a fall on 12/15/2013 and sustained a minor injury at 3:15 PM. This resident had a fall on 12/07/2013 at 10:26 PM and had another fall from the bed on 12/15/2013 at 5:00 AM. The same resident had two falls on 12/17/2014. This Resident #20 had another fall on 12/25/2013 and again fell on [DATE]. Resident #2 was noted to have a small skin tear right posterior hand and on 1/14/2014 was noted to have a small skin tear on right hand. The resident's incident detail report dated 2/13/2014 noted the resident had a red rash. Based on the incident details report, resident #2 was noted to have an abrasion on the right buttock on 3/1/2014. On 3/5/2014 at 1:00 PM the incident detail report indicated the resident was found with an abrasion on the right leg. Resident #45 was found on the floor on 3/31/2014 at 2:21 AM. Resident #43 had a fall from the bed on 3/19/2014. According to the incident details document, resident #25 had a fall from bed on 12/24/2013 at 4:30 AM. Resident #23 on 4/12/2013 had a fall from the bed where the incident details report indicated that there was a bed alarm on the bed but was not connected to the wall "cord left in previous room," the resident had no apparent injuries. However, the resident complained of arm pain on 2/13/2014, was medicated and was sent for an X-ray on 2/14/2014 which showed a "spiral type [MEDICAL CONDITION] humeral metadiaphysis." When an incident management process is fully implemented it can help to ensure that appropriate actions are taken to address the cause of the incident, prevent reoccurrence and ensure the identification of trends/patterns and that reporting requirements are met.

Based on observations, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to consistently maintain a Quality Assurance (QA) committee that met the following regulatory requirements: the committee composition, developing appropriate plans to address identified problems/deficiencies, implementing those plans, and monitoring the effectiveness of the process to ensure correction. The facility failed to report and/or thoroughly investigate allegations of abuse and injuries of unknown origin for 3 out of 32 residents in the Stage II sample (# 2, # 23, and # 27). This is a repeat deficient practice which was identified and cited in February 2014 and in July 2013. The committee also failed to adequately assess and monitor the delivery of nursing services which includes clinical assessments and generally accepted standards of practice for at least 11 out of 32 residents in the Stage II sample ( # 4, # 13, # 14, # 18, # 20, # 21, # 23, #33, #41, #39 and #52). The physician failed to attend all of the quarterly meetings held between April 2013 and April 2014. Refer F225 Refer F272 Refer F281 Refer F309 Refer F323 Refer F333 The findings include: A review of the survey results of complaint surveys completed in July 2013 and February 2014 revealed that the facility was cited for failing to report suspected abuse, as well as not doing thorough investigations for injuries of unknown origin. The QA committee failed to properly and consistently execute the plans of correction for both of these surveys. 1. Review of resident #33's medical record revealed that the resident had difficulty speaking and had been deemed by two physicians to be incapable of making own health care decisions. The medical record revealed a progress note written by nurse #14 on 12/05/14 which stated: "At 2:00 PM on 12/03/13 met with spouse of (resident #33), (name of physician), case manager and DON to discuss the concerns of (#33's RP). The topics that were addressed included ....(resident #33) being punished by having her curtain pulled around her, and another (resident) presenting with verbal abuse, intimidating behaviors and a spirit of bullying..." On the afternoon of 04/30/14, resident #33's responsible party (RP) was interviewed. During this interview the RP reported concerns regarding the staff and stated that he had submitted a formal written complaint to the facility. A review of the written complaint, dated 04/02/14 revealed the following: Summary of Complaint (written by #33's responsible party): "The GNA did not tell me the truth about putting (spouse) to bed Not toileted for 6+ hours since I reported her she is (intimidating)." "She talks loud and disrespectful when she knows I can hear her. She glares at me constantly when passing me in the hall. She forces me to step aside when walking towards her." On the back of the form, there was a written statement from the responsible party that alleged that the GNA used her position to intimidate, she used foul language, and others followed her. The responsible party further implied that the GNA was in charge and not the supervisors and wanted the facility to take back control. Again, the responsible party mentioned that the resident was left wet for a long period of time. The Actions Taken to Resolve the Complaint revealed the following that the Nursing Home Administrator (NHA) spoke with the RP about the concerns he had with a staff member. The LHA informed the RP that the LHA would speak with the staff member and if there were further problems the RP was to inform the LHA. Outcome (completed by administrator): "Spoke with staff member w/(DON) present. Staff member states she was unaware there was any problem between her and (#33's RP). I shared (33's RP) concerns with her. This is not an issue with her, but also on day shift. Discussed working together to accomplish care. GNA instructed to accommodate requests for staffing to the extent possible. Discussed (33's RP) wish to have (spouse) toileted at 4:00 and put to bed between 6:30 - 7:00. GNA voiced understanding. Spoke with (33's RP) and told him to see me w/ anymore problems. He agreed." This form was signed by the administrator and dated 04/03/14. On 05/09/14, the administrator reported that she had not submitted a report to the Office of Health Care Quality (OHCQ) which is the State Agency, regarding the allegations made in the 12/05/13 meeting with Resident #33's RP. On 05/12/14 at 12:51 PM, in a phone interview with the surveyor, the administrator reported that the 04/02/14 complaint form is all the documentation that was available regarding this complaint. The facility's "Center Policy: Resident/Patient Abuse- Screening, Training, Prevention, Identification, Protection, and Reporting" document clearly indicates that a summary report of all abuse investigations is to be submitted to the QA Committee for review. There was no evidence that a summary report was submitted to the QA committee related to the above complaint of staff abuse that was reported to facility staff by Resident #33's RP. 2. Resident #2's medical record was reviewed over several days during the annual survey. This review revealed the following progress note written on 2/23/2014 by the respiratory therapist (RT #2) : "...but the (responsible party) was direct and made some comments about patient abuse of (resident #2) in front of the four of us and also, named a patient care provider he singled out. This was none of our business and not appropriate to mention in front of us........The nursing supervisor on duty was notified and I was asked to document this situation." During an interview on 4/29/2014 at 2:00 PM with Resident #2's responsible party, he reported that he witnessed, about one year ago, a current staff member (nurse # 7) twisting the ear of another resident. He went on to state that he had reported this allegation of abuse by a staff member to the chief executive officer (CEO) approximately 8 weeks ago. He also reported having observed blood in resident #2's ear, and that he had reported this to nursing staff, but was unsure which staff member. On 5/1/2014 at 11:00 AM during an interview with the CEO, she confirmed that the responsible party did make an allegation about a current employee twisting a resident's ear, but that the event he was reporting had occurred two years ago. When asked if the responsible party had made any abuse allegations, the CEO responded that he makes complaints, will talk about blood in the ears, but has never shown this to anyone. On 5/2/2014 at 5:30 PM, the administrator was interviewed regarding resident #2's responsible party's allegation of abuse against a current staff member, that had been made to the CEO. The administrator reported that they had investigated the allegation and were unable to substantiate the abuse. The surveyor then requested a copy of the referenced investigation. The only documentation provided regarding the investigation, was a print out on plain white paper of some notes, with the last name of the resident at the top of the page. The notes were in narrative form, and did not indicate who had written them. There were entries dated 3/11/14, 3/14/14, and 3/17/14. On 5/2/2014, the director of nursing (DON) reported that the notes had been written by her. Review of the notes revealed that, on 3/11/14, the responsible party made an allegation of abuse against a staff member. The 3/11/14 entry also stated that the responsible party said that the resident had blood in his ear. The 3/17/14 entry included a statement that the responsible party "insists that she (nurse # 7) twisted another resident's ear...". On 5/2/2014 at 5:30 PM, the administrator reported that she did not report the above mentioned allegation of abuse by resident #2's responsible party to the OHCQ. In regard to the need to report allegations of abuse, the administrator stated 'I get it now." On 5/6/2014 at 9:52 AM, the surveyor reviewed the 2/22/2014 therapist note with the DON. She confirmed that the report of abuse needed to be reported and investigated. Surveyor requested any information they had regarding this allegation. On 5/7/2014 at 11:20 AM, surveyor interviewed the nursing home administrator in regards to the investigation of abuse referenced in the respiratory therapist note from February, and the administrator replied that she had no information. The facility's "Center Policy: Resident/Patient Abuse- Screening, Training, Prevention, Identification, Protection, and Reporting" document clearly indicates that a summary report of all abuse investigations is to be submitted to the QA Committee for review. There was no evidence that a summary report was submitted to the QA committee related to the above complaint of staff abuse. 3(a). An observation was made on 05/05/14 at 5:55 PM of Nurse #13 at the medication cart on the first floor. During this time Nurse #13 revealed she was still doing the 4:00 PM medication pass. When the surveyor asked why the medication pass was so late Nurse #13 stated "because the med cart was down being cleaned. Only housekeeping can steam clean the cart." At that time, the surveyor asked for all the names of the residents that were being given medications so that the eMar documentation could be reviewed.Resident #41's [DIAGNOSES REDACTED]. Review of Resident #41's eMAR documentation, on 05/05/14 at 7:10 PM, showed that the physician ordered 11:00 AM [MEDICATION NAME] R (Insulin) was given at 12:50 PM and the 3:00 PM dose was given at 4:56 PM. The blood sugar testing (BS) done at the same time of the [MEDICATION NAME] R injections revealed BS of 280 mg/dl at 12:50 PM and 318 mg/dl at 4:56 PM. [MEDICATION NAME] R is a short acting man made insulin that is similar to the insulin produced by the human pancreas. When blood sugar (glucose) is elevated, insulin is needed to help get the sugar into the cells and not build up in the blood. If insulin is not given correctly, at the ordered times, the sugar could build up in the blood and cause complications in the body. Normal blood sugar levels in the blood range from 70 mg/dl to 130 mg/dl. Further review of Resident #41's eMAR revealed that, on 05/04/14, the 3:00 PM dose was given at 4:15 PM with a BS of 324 mg/dl and the 10:00 PM dose was given at 11:14 PM with a BS of 351 mg/dl. On 05/03/14, the resident received the physician ordered [MEDICATION NAME] R dose for 10:00 PM at 8:21 PM with a BS of 332 mg/dl. On 05/02/14, the ordered 3:00 PM dose of [MEDICATION NAME] R was given at 5:42 PM with a BS 253 mg/dl. On 05/01/14, the 3:00 PM dose of [MEDICATION NAME] R was given at 5:50 PM with a BS 289 mg/dl.There was no documentation found on the eMARs, or in the nursing notes, as to the reason for the late administration of the [MEDICATION NAME] R (insulin) doses and the (1) early dose, for a diabetic patient whose nutrition and glucose control are totally dependent on the nursing staff. The surveyor spoke to Nurse #13, on 05/05/14 at 8:15 PM, regarding the late administration of the insulin. Nurse #13 went through the eMAR and stated that "the nurses sign off the meds when given and I don't know why the insulin was not given on time." 3(b). Review of the eMAR documentation for Resident #39 revealed on 05/05/14 the 8:00 AM dose of [MEDICATION NAME] ([MEDICATION NAME]) 50mg (milligrams) was given at 10:23 AM. The resident's blood pressure at the time was noted to be 99/60. The physician's orders [REDACTED]." Further review revealed on 05/02/14 the 8:00 AM dose was given at 10:14 AM and the blood pressure was 104/63 with the systolic number being less than 110. The nurse failed to follow the physician's orders [REDACTED]. The surveyor spoke with Nurse #12 on 05/05/15 at 11:10 PM about the medication being given.Further review of Resident #39's eMAR revealed on 05/05/14 the resident received her 4:00 PM ordered [MEDICATION NAME] at 5:50 PM, at 5:17 PM on 05/04/14 and 5:22 PM on 04/30/14. The resident received this medication 3 times a day. Resident #39 also received [MEDICATION NAME] 1 mg every 8 hours for increased secretions. On 05/05/14 her midnight dose was given at 1:31 AM and her 4:00 PM dose was given at 5:49 PM. Resident #39 also received [MEDICATION NAME] for nerve pain. The medication is to be given every 8 hours. On 05/05/14 she received her 4:00 PM dose at 5:50 PM and on 04/30/14 at 5:22 PM.There is no evidence to show that nursing services or the QA committee had a system in place to identify the noncompliance with generally accepted standards of practice related to medication administration. The surveyor identified at least 10 significant errors in medication administration related to giving medications when physician's orders [REDACTED]. 3(c). Resident #4 had a [MEDICAL CONDITION] and received oxygen through a Jet neb at 35%. She had been hospitalized at an acute care hospital from 12/20/13 to 12/26/13 according to a hospital discharge note dated 12/26/13, for a urinary tract infection and bilateral pneumonia. Review of the medical record failed to reveal that an assessment of the resident had been done on readmission to the facility on [DATE]. This was confirmed by the acting director of nursing on 05/06/14 at 9:45 AM. A progress note, dated 12/27/13 for 2:49 AM, documented that resident #4 was having labored breathing and audible wheezing, but refused to be suctioned. The progress note continued noting that education was provided to the resident regarding the importance of suctioning. No further assessment, vital signs, lung sounds or documentation of pulse oxygen level was found in the medical record regarding the residents health status with this incident.A social services note, dated 12/27/13 for 8:14 AM, stated that the resident had returned from an acute care hospital on the evening of 12/26/13. An interview with nurse #1, on 05/05/14 at 11:45 AM, revealed that, if she gave the resident her 8:00 AM medications on 12/27/13, which were documented on the medication administration record as given, and if she noted a change in the resident's condition at that time, she would have done an assessment and then notified the physician of the changes. She also stated that it was not unusual for the resident to refuse treatments. At 9:50 AM on 12/27/13, respiratory therapist #1 found the resident unresponsive, provided care and notified registered nurse (RN) #1. RN #1 called the physician and did an assessment of the resident. The resident was sent emergently to an acute care hospital for unresponsiveness. Review of the resident's hospital discharge summary dated 01/02/14 listed discharge [DIAGNOSES REDACTED]. 3(d). On 04/29/14, Resident #13's medical record was reviewed. This review revealed that the resident was admitted to the facility in November 2013 with [DIAGNOSES REDACTED]. Review of the medical records showed that the resident had a fall on 12/15/13 and on 12/17/13. Further review of the medical records revealed that the facility completed a fall incident flow sheet for the fall that occurred on 12/15/13 but the fall that occurred on 12/17/13. Medical record review indicated that the facility failed to do an assessment on the fall that occurred on 12/17/14. All findings confirmed with nurse #8 on 05/07/14 at 2:30 PM. 3(e). A surveyor review of a facility reported incident regarding resident #23 revealed that the resident acquired an injury to his right humerus from an unknown cause. Further review revealed that the resident's certified nursing assistant (CNA) reported to the resident's assigned registered nurse (RN) on the night of 2/13/14, that the resident was exhibiting signs of pain. Per the report, the RN proceeded to the resident's room, did not complete a comprehensive assessment related to the resident's complaint of arm pain; however, proceeded to medicate resident. Review of Resident #23's medical record revealed a delay in the notification to the physician, and an x-ray was not completed and read until after 1:00 PM on 2/14/14, when the resident was subsequently sent to the emergency room for further evaluation and treatment. physician progress notes [REDACTED]." On 4/30/2014, the surveyor asked the facility for documentation that the information was conveyed to the next shift or the appropriate staff. The facility did have the Clinical Data Evaluation (CDE) which did not have any documentation regarding the severity of the resident's injury, or notification to the physician or family at that time. There was no documented information that the resident's clinical status was passed on to the next shift. Surveyor discussed findings with the facility DON , NHA and the CEO on 4/30/2014 at 5:00 PM, and again on 5/2/2014 at 5:00 PM. Facility could not produce additional documents at either time regarding reporting to the physician the discovery of a new injury of unknown origin, or reporting to the OHCQ within the required time period. Surveyor interviewed the assigned RN from the night of the incident, on 5/2/2014 at 7:00 PM. The staff member was asked if she was familiar with the resident, she verbalized no. She was asked if a full assessment was done at any point in her shift, she verbalized "in the beginning." RN#14 reported to the surveyor that, around 5:00 AM, she was notified that resident #23 was in pain, went to assess, and he was too combative, so she just medicated him. She further proceeded to fill out a CDE and would pass along the information to the next shift. Surveyor interviewed the night supervisor from 2/13/2014. Per the supervisor, RN #15's report, and statement of the facility investigation, she told the night RN#14 to call the on-call physician, or make sure it was passed on first thing in the morning regarding the resident's complaints of pain. Medical record review, on 5/2/2014 of resident #23, revealed a delay in the notification to the physician, and power of attorney (POA). There was no initial assessment for a resident with new onset complaints of pain, and no follow-up assessment related to effectiveness of the pain medication administered to the resident. 3(f). The following are of facility incident details reports that were not reviewed and signed as per facility specifications by the DON and/ or acting DON. Resident #3 fell out of bed on 1/16/2014 at 9;20 AM and on 3/30/2014 at 6:30 PM the resident was found on the floor at that time his blood pressure was 99/59. Resident #20 had a fall on 12/15/2013 and sustained a minor injury at 3:15 PM. This resident had a fall on 12/07/2013 at 10:26 PM and had another fall from the bed on 12/15/2013 at 5:00 AM. The same resident had two falls on 12/17/2014. This Resident #20 had another fall on 12/25/2013 and again fell on [DATE]. Resident #2 was noted to have a small skin tear right posterior hand and on 1/14/2014 was noted to have a small skin tear on right hand. The resident's incident detail report dated 2/13/2014 noted the resident had a red rash. Based on the incident details report, resident #2 was noted to have an abrasion on the right buttock on 3/1/2014. On 3/5/2014 at 1:00 PM the incident detail report indicated the resident was found with an abrasion on the right leg. Resident #45 was found on the floor on 3/31/2014 at 2:21 AM. Resident #43 had a fall from the bed on 3/19/2014. According to the incident details document, resident #25 had a fall from bed on 12/24/2013 at 4:30 AM. Resident #23 on 4/12/2013 had a fall from the bed where the incident details report indicated that there was a bed alarm on the bed but was not connected to the wall "cord left in previous room," the resident had no apparent injuries. However, the resident complained of arm pain on 2/13/2014, was medicated and was sent for an X-ray on 2/14/2014 which showed a "spiral type [MEDICAL CONDITION] humeral metadiaphysis." There is no evidence that nursing or the QA committee had processes in place to identify the ongoing nursing assessment issues and the lack of of oversight related to the incident detail reports which contained at least 10 fall incidents. The facility's "Fall Reduction Program" Clinical Policy with a revision date of 1/2014 reflects that the effectiveness of the program will be monitored on an ongoing basis and data will be shared with risk management and the performance improvement committees. 6. A review of QA meeting sign-in sheets by the surveyor showed that the physician attended 3 out of 4 quarterly meetings from April 2013 to April 2014. The acting Director of Nursing was interviewed on 05/02/14 at 3:45 PM, and she confirmed that the Medical Director failed to attend all of the quarterly QUA meetings as required.

Based on interviews, and record reviews, it was determined that the facility administrator failed to effectively manage operations and there was a failure in governance of the administration when systemic concerns of abuse (refer to F157, F225, F226), communication, reporting and safety were identified (refer to F226, F281, F309, F323, & F520). The cumulative effect of these facility governance concerns resulted in the facility's inability to ensure the provision of quality care and services in a safe environment for residents. The findings include: During an interview with the Nursing Home Administrator (NHA) and the interim Director of Nursing (DON) on 05/02/14 at 10:03 AM, it was reported that the facility governing body had been without an active director of nursing (DON) for more than 4 months. Further discussion with the NHA revealed that the previous DON resigned in December of 2013, and there had been no full-time replacement. Duties of the DON were delegated to various employees of the hospital staff, including the current Chief Nursing Operator (CNO) who also carried the title of "interim DON." Additionally, it was reported that other hospital staff had been assigned duties of the DON, such as Quality Assurance. Examples of areas with systemic concerns related to the failure to ensure dedicated DON coverage include: 1. Review of facility incident reports revealed reviews of resident falls occurring 1-2 weeks after the occurrence. The resulting facility investigations were incomplete and notifications to physician and resident Power of Attorney were at times not done. 2. Delayed and/or incomplete investigations into allegations of abuse. An interview with the facility Chief Executive Officer (CEO), on 05/01/14 at 11:00 AM, revealed that the facility still did not have full-time dedicated DON coverage at the time of the survey. 3. Resident #2's medical record was reviewed over several days during the annual survey. The review revealed the following progress note written on 2/23/2014 by the respiratory therapist (RT #2) : "...but the (responsible party) was direct and made some comments about patient abuse of (resident #2) in front of the four of us and also, named a patient care provider he singled out. This was none of our business and not appropriate to mention in front of us........The nursing supervisor on duty was notified and I was asked to document this situation." During an interview on 4/29/2014 at 2:00 PM with Resident #2's responsible party, the RP reported that about a year ago he witnessed a current staff member (nurse # 7) twisting the ear of another resident. He indicated to the surveyor that he reported this allegation of abuse by a staff member to the chief executive officer (CEO) approximately 8 weeks ago. He also reported having observed blood in resident #2's ear, and that he had reported this to nursing staff, but was unsure which staff member. On 5/1/2014 at 11:00 AM the surveyor interviewed the CEO. She confirmed that the responsible party did make an allegation about a current employee twisting a resident's ear, but that the event he was reporting had occurred two years ago. When asked if the responsible party had made any abuse allegations, the CEO responded that he makes complaints, will talk about blood in the ears, but has never shown this to anyone. On 5/2/2014 at 5:30 PM, the administrator was interviewed regarding resident #2's responsible party's allegation of abuse against a current staff member which had been made to the CEO. The administrator reported indicated that the allegation was investigated. The facility was unable to substantiate the allegation of abuse. The surveyor then requested a copy of the referenced investigation. The administrator reported that she did not report the above mentioned allegation of abuse by resident #2's responsible party to the OHCQ. In regard to the need to report allegations of abuse, the administrator stated 'I get it now." The only documentation provided regarding the investigation, was a print out on plain white paper of some notes, with the last name of the resident at the top of the page. The notes were in narrative form, and did not indicate who had written them. On 5/2/2014, the director of nursing (DON) reported to the surveyor that the notes had been written by her. The notes did not show that a thorough investigation had been completed regarding the allegation. The review of the notes revealed that, on 3/11/14, the responsible party made an allegation of abuse against a staff member. The 3/11/14 entry also stated that the responsible party said that the resident had blood in his ear. The 3/17/14 entry included a statement that the responsible party "insists that she (nurse # 7) twisted another resident's ear...". 4. The Incident details report document clearly shows that the reports were to be signed by the DON as well as the Administrator. The following examples of fall and other incident type reports were not signed and reviewed by the Administrator. Resident #3 fell out of bed on 1/16/2014 at 9;20 AM and on 3/30/2014 at 6:30 PM the resident was found on the floor at that time his blood pressure was 99/59. Resident #20 had a fall on 12/15/2013 and sustained a minor injury at 3:15 PM. Resident #20 had a fall on 12/07/2013 at 10:26 PM. The resident had another fall from the bed on 12/15/2013 at 5:00 AM and had two falls on 12/17/2014. This same resident had another fall on 12/25/2013 and again fell on [DATE]. Resident #2 was noted to have a small skin tear right posterior hand and on 1/14/2014 again was noted to have a small skin tear on right hand. The resident's incident detail report dated 2/13/2014 noted the resident had a red rash. Based on the incident details document, Resident #2 was noted to have an abrasion on the right buttock on 3/1/2014. On 3/5/2014 at 1:00 PM the incident detail report indicated the resident was found with an abrasion on the right leg. Resident #45 was found on the floor on 3/31/2014 at 2:21 AM. Resident #43 had a fall from the bed on 3/19/2014. According to the incident details document, Resident #25 had a fall from bed on 12/24/2013 at 4:30 AM. Resident #23 on 4/12/2013 had a fall from bed where the incident details report indicated that there was a bed alarm on the bed but was not connected to the wall "cord left in previous room," the resident had no apparent injuries. However, the resident complained on arm pain on 2/13/2014, was medicated and was sent for an X-ray on 2/14/2014 which showed a "spiral type [MEDICAL CONDITION] humeral metadiaphysis." Administration failed to fully investigate injuries of unknown origin related to a fracture; allegations of abuse;causes related to multiple falls and submit reports to OHCQ as required.