Every finding on record at Willowbrooke Ct Skilled Care CTR at Magnolia Trace

Based on observations, staff interviews, and review of a facility policy titled, Culinary Services Manual . HAND WASHING PROCEDURE, the facility failed to ensure two Dietary Aides practiced proper handwashing/glove changes when going from touching potentially contaminated objects such as such as the hot box handle to retrieving hamburger buns from a plastic bag and placing them on residents' plates during the lunch meal on 5/14/22. This had the potential to affect 22 of 22 residents receiving meals from the dining room. Findings include: A review of a facility policy titled, HAND WASHING PROCEDURE, with a revised date of 12/07, documented: . POLICY: Each employee will wash their hands frequently to eliminate visible dirt and to reduce bacterial load and cross contamination. 1. Hands will be washed at the following times: . After: . U. Touching equipment . On 5/14/22 at 12:22 PM, Employee Identifier (EI) #4 and EI #5, Dietary Aides, were plating food from the steam table in the dining room. EI #4's and EI #5's hands were gloved. EI #4 and EI #5 were both observed leaving the steam table while still wearing their gloves, going to the hot box, opening the door by pulling the handle, and then going to the counter and getting hamburger buns from a plastic bag and placing them on residents' plates while still wearing the same gloves. On 5/15/22 at 3:04 PM, an interview was conducted with EI #4, Dietary Aide. EI #4 was asked when should gloves be changed when plating meals. EI #4 said before and after serving the meal and if they touched anything. When asked if she changed her gloves after she touched the potentially contaminated hot box handle and before she got hamburger buns out of the plastic bag on the counter, EI #4 said no, but she should have because that was cross contamination and residents could get sick. On 5/15/22 at 3:15 PM, an interview was conducted with EI #5, Dietary Aide. EI #5 was asked what did the policy say about changing gloves. EI #5 said any time she touched a contaminated surface she should take off her gloves, wash her hands, and put on clean gloves. EI #5 was asked if she changed gloves and washed her hands on 5/14/22 when she opened the hot box with the handle while wearing gloves and then took hamburger buns from the plastic bag on the counter wearing the same gloves. EI #5 said no, but now she realized that the hot box handle was a contaminated surface and that touching it and then getting hamburger buns from the plastic bag would contaminate the buns, and she should have changed her gloves. When asked what the concern was with not changing her gloves and washing her hands after touching the potentially contaminated hot box handle, EI #5 said cross contamination that could possibly cause food poisoning or infection. On 5/17/22 at 8:12 AM, an interview was conducted with EI #3, Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP). EI #3 was asked when staff should wear gloves when serving meals in the dining room. EI #3 said when preparing meals behind the steam table. EI #3 was asked should a dietary aide that was plating meals touch the hot box handle while wearing gloves and then get hamburger buns from a plastic bag while still wearing those same gloves. EI #3 said no, that was cross contamination, and they could introduce bacteria to the residents.

Based on observation, staff interviews, review of facility policies titled, GLOVES AND EYE DROPS, INSTILLATION, the facility failed to ensure: 1. Employee Identifier (EI) #6, a Recreational Assistant, changed gloves and sanitized hands after touching Resident Identifier (RI) #2's wheelchair handles while wearing gloves before she retrieved a plate from the steam table and served it to RI #12 while wearing the same gloves, and 2. EI #7, a Registered Nurse (RN), placed a barrier on the over-bed table before placing a container of eye drops on the table, and changed her gloves and sanitized hands before administering eye drops to RI #8. This affected RI #2 and RI #12, two of 22 residents observed during dining observations, and RI #8, one of five residents observed during medication pass. Findings include: 1) A review of an undated facility policy titled, GLOVES documented: . POLICY: To strive to ensure that gloves are worn . when handling or touching contaminated items or surfaces. PROCEDURE: . 3. Disposable gloves shall be replaced as soon as possible when contaminated. On 5/14/22 at 12:22 PM, EI #6, a Recreational Assistant, was observed serving meals to residents in the main dining room. While wearing gloves, EI #6 was observed placing both hands on the handles of RI #2's wheelchair to reposition the resident closer to the table. Then, while wearing those same gloves, EI #6 went back to the steam table to retrieve a plate for RI #12 and placed it on the table in front of him/her. On 5/14/22 at 12:48 PM, an interview was conducted with EI #6, Recreational Assistant. EI #6 was asked what she should do when wearing gloves if she touched wheelchairs or any other potentially contaminated object. EI #6 said change gloves and wash her hands. EI #6 was asked did she change her gloves and wash her hands after she moved RI #2's wheelchair closer to the table before getting RI #12's plate from the steam table. EI #6 said no. When asked what the concern was with not changing gloves and washing hands after touching potentially contaminated objects and serving another resident's plate, EI #6 said spreading germs. 2) A review of a facility policy titled, EYE DROPS, INSTILLATION, revised 12/2018, revealed: . PROCEDURE: 1. Wash your hands and apply gloves. 3. Remove the cap from the medication bottle and place it upright on a barrier . RI #8 was readmitted to the facility on [DATE]. On 5/15/2022 at 4:57 PM, EI #7, Registered Nurse (RN), was observed donning gloves at medication cart, entering RI #8's room and placing a med cup containing Tylenol and applesauce, and a container of eye drops on an over-bed table without a barrier. EI #7 administered RI #8's Tylenol and applesauce with a spoon, pulled a Kleenex from the box and handed it to resident, and while still wearing the same gloves, she administered RI #8's eye drops, removed her gloves, walked back to the medication cart and placed the eye drops back in the box without wiping off the container and placed it in the cart. On 5/15/2022 at 5:06 PM, an interview was conducted with EI #7, RN. EI #7 was asked when she should change gloves and sanitize her hands during medication pass. EI #7 said if they were soiled. EI #7 was asked if she changed her gloves and sanitized her hands after she administered RI #8's Tylenol with applesauce before she administered his/her eye drops. EI #7 said no. When asked if she placed a barrier on the table before she placed the eye drops container on it, EI #7 said no, but she should have. EI #7 was asked if she wiped the bottle of eye drops off before placing them back in the box after they were on the table. EI #7 said no, but she should have. When asked what the concern was with not changing gloves and sanitizing her hands after touching potentially contaminated objects before administering RI #8's eye drops, EI #7 said cross contamination. On 5/17/2022 at 8:12 AM, an interview was conducted with EI #3, RN/Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP). EI #3 was asked when nurses should change gloves and sanitize hands during medication pass. EI #3 said when they are visibly soiled or contaminated and before and after and in between each different route. EI #3 was asked should a nurse administer eye drops wearing the same gloves worn to administer by mouth medications. EI #3 said no. EI #3 was asked should an eye drop container be placed on an over-bed table without a barrier. EI #3 said no. When asked why not, EI #3 stated cross contamination.

Based on interview, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) #32's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/29/22 was accurately coded to reflect RI #32's active diagnoses. This affected one of 13 sampled residents for whom MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, dated October 2019, revealed: . SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. RI # 32 was admitted to the facility on [DATE]. A review of RI #32's admission MDS with an ARD of 4/29/22 documented RI #32 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of RI #32's medical record and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/22 at 12:00 PM an interview was conducted with Employee Identifier (EI) #1, Registered Nurse (RN)/Director of Nursing (DON). EI #1 was asked if RI #32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 stated no. EI #1 was asked why it was marked on RI #32's admission MDS that he/she had pneumonia and [CONDITION(S)]. EI #1 stated she was unsure why it was marked. EI #1 further stated the admission MDS was not correct because RI #32 did not have pneumonia or [CONDITION(S)]. EI #1 was asked why an MDS should reflect a resident's correct medical diagnoses. EI #1 stated for an accurate reflection of the resident's condition. An interview was conducted with EI #2, RN/MDS Coordinator, on 5/17/22 at 12:08 PM. EI #2 was asked when the admission MDS was completed for RI #32. EI #2 stated the ARD was 4/29/22. EI #2 was asked if RI #32's admission MDS indicated he/she had pneumonia and [CONDITION(S)] on admission. EI #2 stated yes, it was an error. EI #2 was asked if RI #32 had pneumonia or [CONDITION(S)] when admitted to the facility on [DATE]. EI #2 stated no, he/she did not. EI #2 was asked what the importance of accurate diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews, resident record reviews, facility documentation of a narcotic audit and a review of the facility's policy titled, Medication, Controlled Substances, the facility failed to ensure licensed staff documented correctly on administration of narcotics on the narcotic log and the Medication Administration Record (MAR). A facility narcotic audit was done of all narcotics on 07/14/2021 revealing: 1.) Employee Identifier (EI) #4, Registered Nurse (RN), failed to document narcotic medication administration on the MAR for Resident Identifier (RI) #3, RI #6, RI #8, RI #9, RI #10 and RI #11; 2.) to document on the narcotic log that narcotics were pulled for RI #2, RI #3, RI #4, RI #5, RI #7, RI #8 and RI #10; 3.) EI #4 document on the MAR only medication for RI #1 that was pulled and administered; and 4.) EI #5, Licensed Practical Nurse (LPN), document medication administration on the MAR for RI #12, RI #13, RI #14 and RI #15. This affected 15 out of 19 residents who received controlled medications from 07/01/2021 through 07/15/2021. Findings include: Review of the facility policy titled, Medication, Controlled Substances, issued 04/2006 and last revised 10/2018, revealed the following: . Policy: To strive to ensure that strict management of controlled substances is maintained as evidenced by special handling, storage, disposal and recordkeeping. Purpose: *To ensure the proper storage and security of controlled drugs. *To minimize the potential for abuse of controlled drugs. *To comply with state and federal regulations. Procedure: . 5. When a resident receives a narcotic, the licensed nurse signs off each dose of the controlled medication given by documenting the following on the narcotic sheet and the electronic medication administration record (MAR): a. Date medication given b. Time medication given c. Medication dose given d. Amount of medication remaining e. Signature of nurse administering medication . 1.) RI #3 was admitted to the facility on [DATE]. RI #3's Medication Review Report for July 2021 indicated [MEDICATION(S)]-Acetaminophen Tablet 5-325mg was ordered 05/28/2021 two tablets by mouth every four hours as needed for pain. A review of RI #3's Controlled Drug Record indicated EI #4, RN, administered one tablet [MEDICATION(S)]-Acetaminophen 5-325mg on 07/10/2021 at 10:15PM. A review of RI #3's Medication Administration Record for the month of July 2021 indicated no documentation of administration of [MEDICATION(S)]-Acetaminophen on 07/10/2021 at 10:15PM. In an interview on 10/26/2021 at 10:40AM, EI#3, Assistant Director of Nursing (ADON), stated EI #4 signed the narcotic log on 07/01/2021 but did not chart on the MAR. EI #3 stated EI #4 did not follow the facility's Controlled Medication Policy. In an interview on 10/27/2021 at 09:29AM, EI #2, Director of Nursing (DON), reported EI #4 signed the narcotic log that she pulled the [MEDICATION(S)] on 07/10/2021 but she did not chart the administration on the MAR. EI #2 stated EI #4 documented in one area but not the other. EI #2 stated EI #4 should have documented properly and ensured she gave the medication, then there would be no question whether the patient got the medication or not. EI #2 stated the record would not be considered complete and accurate if it was not documented on the MAR. The facility's policy was not followed. EI #2 stated if a record was not complete and accurate, it leaves a question as whether the resident received or did not receive the medication as ordered. An interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 signed on the narcotic log that she pulled the [MEDICATION(S)] on 07/10/2021 but she did not document on the MAR. EI #1 stated this was inaccurate documentation. EI #1 stated that when the medication was given, EI #4 should have documented on the narcotic log and the MAR. 2.) RI #6 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #6's Medication Review Report for July 2021 indicated [MEDICATION(S)] Tablet 5-325mg ([MEDICATION(S)]-Acetaminophen) was ordered 06/10/2021 one tablet by mouth every eight hours as needed for pain. A review of RI #6's Controlled Drug Record indicated EI #4, RN, administered one tablet of [MEDICATION(S)]-Acetaminophen 5-325mg on 07/11/2021 at 04:30PM. A review of RI #6's Medication Administration Record for the month of July 2021 indicated no documentation of administration of [MEDICATION(S)] ([MEDICATION(S)]-Acetaminophen) on 07/11/2021 at 04:30PM. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 documented on the narcotic log that [MEDICATION(S)] was given on 07/11/2021 but she did not document on the MAR. EI #2 stated this was a documentation issue. EI #2 stated the record would not be considered complete and accurate if the nurse did not document on the MAR. EI #2 stated facility policy for documentation was not followed. EI #2 stated if a record was not complete and accurate, it leaves a question whether the resident received or did not receive the medication as ordered by the physician. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 documented on the narcotic log that [MEDICATION(S)] was given on 07/11/2021 but she did not document on the MAR. 3.) RI #8 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #8's Medication Review Report for July 2021 indicated [MEDICATION(S)] Tablet 5-325mg ([MEDICATION(S)]-Acetaminophen) was ordered 09/09/2018 one tablet by mouth in the morning for pain. RI #8's Controlled Drug Record indicated EI #4, RN, administered one tablet of [MEDICATION(S)]-Acetaminophen 5-325mg on 07/01/2021 at 08:00PM. A review of RI #8's Medication Administration Record for the month of July 2021 indicated [MEDICATION(S)] ([MEDICATION(S)]-Acetaminophen) was not documented being administered on 07/01/2021 by EI #4. In an interview on 10/26/2021 at 10:40AM, EI #3, ADON, reported EI #4 signed out the [MEDICATION(S)] on the narcotic log but she did not sign the MAR. EI #3 stated EI #4 was not following the medication administration policy because she signed out the narcotic on the narcotic log but not on the MAR. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, stated the medication was ordered to be given in the morning. EI #4 worked 3PM-11PM. It was not documented on the MAR on 07/01/2021 because it was not time for it to be administered. EI #2 stated the record would not be considered complete and accurate if the medication was not documented on the MAR because facility policy was not followed. EI #2 stated if a record was not complete and accurate, it leaves a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 signed the narcotic log on 07/01/2021 that she pulled the [MEDICATION(S)] but it was not documented on the MAR since the MAR did not give an option to document since the medication was to be administered at 08:00AM and not 08:00PM. EI #1 stated the resident should receive the medication at the appropriate time given and the narcotic log and MAR should be signed. 4.) RI #9 was admitted to the facility on [DATE] with a readmitted [DATE]. RI #9's Medication Review Report for July 2021 indicated Oxycodone HCI Tablet 5mg was ordered 06/29/2021 one by mouth every four hours as needed for severe pain and changed on 07/06/2021 to two tablets by mouth every four hours as needed for severe pain levels of five or greater on the pain scale. RI #9 was also ordered [MEDICATION(S)] Capsule 30mg ([MEDICATION(S)]) on 07/01/2021, a capsule by mouth at bedtime as needed for three days and then one capsule by mouth as needed until 07/18/2021. A review of RI #9's Controlled Drug Record indicated EI #4, RN, administered Oxycodone HCI Tablet 5mg on 07/02/2021 at 09:00PM, 07/05/2021 at 04:00PM, 07/06/2021 at 04:00PM, 05:00PM and 09:00PM, 07/08/2021 at 8:30PM and 07/12/2021 at 03:30PM and 07:30PM. Documentation showed EI #4 also administered [MEDICATION(S)] 30mg on 07/05/2021 at 09:00PM, on 07/06/2021 at 09:00PM, on 07/10/2021 at 09:00PM, on 07/11/2021 at 09:15PM and on 07/12/2021 at 09:20PM. A review of RI #9's Medication Administration Record for July indicated EI #4 did not document administering Oxycodone HCI 5mg tablets to RI #9 on 07/02/2021 at 09:00PM, on 07/05/2021 at 04:00PM, on 07/06/2021 at 04:00PM, 05:00PM or 09:00PM, on 07/08/2021 at 8:30PM nor on 07/12/2021 at 03:30PM or 07:30PM. The MAR also indicated no documentation of EI #4 administering [MEDICATION(S)] 30mg on 07/05/2021 at 09:00PM, on 07/06/2021 at 09:00PM, on 07/10/2021 at 10:00PM, on 07/11/2021 at 09:15PM nor on 07/12/2021 at 09:20PM. In an interview on 10/26/2021 at 10:40AM, EI #3, ADON, stated EI #4 signed the narcotic log for the Oxycodone six different times but did not chart on the MAR. EI #3 stated EI #4 did not follow medication administration policy since she signed the narcotic log and not the MAR. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 signed the narcotic log for the Oxycodone on 07/02, 07/05, three times on 07/06, 07/08 and 07/12 but she did not chart on the MAR. EI #2 also reported EI #4 signed the narcotic log on 07/05, 07/06, 07/10, 07/11 and 07/12 for [MEDICATION(S)] but she did not sign the MAR for those dates. EI #2 reported these were documentation issues because EI #4 did not chart on the MAR. EI #2 stated EI #4 should have documented on the narcotic log and once she administered the medication, she should have documented on the MAR that the resident took the medication. EI #2 stated EI #4 was educated on the policy prior to the incidents. EI #2 stated the record would not be considered complete and accurate because the nurse did not document the medication administration on the MAR. Facility policy was not followed. EI #2 stated if a record was not complete and accurate, it leaves a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 signed for the Oxycodone on the narcotic log on 07/02, 07/05, three times on 07/06 and 07/08, but did not sign the MAR. EI #4 also charted on the narcotic log on 07/12 for two doses but did not chart on the MAR. EI #1 also reported EI #4 signed the narcotic log on 07/05, 07/06, 07/10, 07/11 and 07/12 for the [MEDICATION(S)] but EI #4 did not chart on the MAR. EI #1 stated these were inaccurate documentation issues because documentation on both the narcotic log and the MAR are required. 5.) RI #10 was admitted to the facility on [DATE] and readmitted [DATE]. RI #10's Medication Review Report for July 2021 indicated Acetaminophen-[MEDICATION(S)] Tablet 300-30mg was ordered 11/08/2018 one tablet given every six hours as needed for severe pain. A review of RI #10's Controlled Drug Record indicated EI #4, RN, administered Tylenol with [MEDICATION(S)] on 07/06/2021 at 07:00PM, 07/08/2021 at 09:00PM and 07/12/2021 at 10:00PM. A review of RI #10's Medication Administration Record for July 2021 indicated EI #4 did not document the administration of Tylenol with [MEDICATION(S)] on 07/06/2021, 07/08/2021 nor 07/12/2021 at 10:00PM. An interview on 10/27/2021 at 09:29AM, EI #2, DON, stated EI #4 signed out the Tylenol with [MEDICATION(S)] on the narcotic log 07/06, 07/08 and 07/12 but she did not document on the MAR. This was a documentation issue. EI #2 stated the medication was as needed so when the resident requested it, EI #4 should have gone to the narcotic box, removed the dose, ensured the count was correct, signed the narcotic log, administered to the patient and signed the MAR. EI #2 stated the record would not be considered complete and accurate if the MAR was not documented with the administration of the medication. EI #4 stated the facility's policies and procedures were not followed. EI #2 stated when a record was not complete and accurate, it leaves a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 documented Tylenol 3 on the narcotic log on 07/06, 07/08 and 07/12 but she did not chart on the MAR. EI #1 stated this was a documentation error. 6.) RI #11 was admitted to the facility on [DATE]. RI #11's Medication Review Report for July indicated [MEDICATION(S)] HCI Tablet 50mg was ordered 08/06/2020 to be given my mouth as needed for pain twice a day. A review of RI #11's Controlled Drug Record indicated EI #4 administered one 50mg tablet of [MEDICATION(S)] on 07/11/2021 at 04:25PM. A review of RI #11's Medication Administration Record indicated EI #4 did not document 50mg of [MEDICATION(S)] was administered on 07/11/2021. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 documented on the narcotic log on 07/11/2021 that she administered the [MEDICATION(S)] but EI #4 did not sign the MAR. EI #2 stated this was a documentation error. EI #2 stated the record would not be considered complete and accurate if the nurse did not document the administration on the MAR because the facility policy was not followed. EI #2 stated if a record was not complete and accurate, it leaves a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 signed out the [MEDICATION(S)] on the narcotic log on 07/11 but EI #4 did not sign the MAR. Error in documentation was identified. EI #1 stated EI #4 should have signed on the narcotic sheet and then documented administration on the MAR. EI #1 stated the record would have been complete and accurate if EI #4 had documented correctly but she did not. EI #1 stated the patient record was considered inaccurate. EI #1 stated a complete record is needed so the facility can determine whether they can provide a true assessment of the patient's care needs. 7.) RI #2 was admitted to the facility on [DATE] and readmitted [DATE]. RI #2's Medication Review Report for July 2021 indicated [MEDICATION(S)] Capsule 2.5mg ([MEDICATION(S)]) was ordered 06/24/2021 to be given by mouth two times a day for appetite for 30 days before morning and evening meals. A review of RI #2's Medication Administration Record indicated EI #4, RN, administered [MEDICATION(S)] 2.5mg capsule on 07/01/2021 at 04:00PM. A review of RI #2's Controlled Drug Record did not reveal that EI #4 signed for the [MEDICATION(S)] on 07/01/2021. In an interview on 10/26/2021 at 10:40AM, EI #3, ADON, reported EI #4 charted the [MEDICATION(S)] as administered but EI #4 did not sign the narcotic log. EI #3 stated the facility policy is to sign both the narcotic log and the MAR. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 charted on the MAR on 07/01 that [MEDICATION(S)] was administered but the narcotic log was not signed. EI #2 stated the medical record was not considered complete and accurate if the narcotic sheet was not signed. EI #2 stated this showed a discrepancy and left a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 signed on the MAR that the [MEDICATION(S)] was administered but she did not sign the narcotic sheet. EI #1 stated this was a documentation error. EI #1 stated if the medication was not given, EI #4 should not have documented on the MAR. 8.) RI #3's Medication Review Report for July 2021 indicated [MEDICATION(S)] Capsule 15mg ([MEDICATION(S)]) was ordered 05/05/2021 to be given at bedtime for sleep. A review of RI #3's Medication Administration Record for July 2021 indicated EI #4, RN, administered [MEDICATION(S)] 15mg capsule on 07/01/2021 at bedtime and on 07/11/2021 at bedtime. A review of RI #3's Controlled Drug Record did not reveal that EI #4 signed for the [MEDICATION(S)] on 07/01/2021 nor 07/11/2021. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 documented on the MAR on 07/01 and 07/11 that she gave the [MEDICATION(S)], but EI #4 did not sign out on the narcotic sheet. EI #2 stated this was a documentation issue because the medication was signed in one section but not the other. EI #2 stated she had questions when the Mar was signed but not the narcotic log because the MAR should be documented last in the process. EI #2 stated EI #4 should ensure she documented properly and she gave the medication. EI #2 stated the medical record was not considered complete and accurate if the narcotic sheet was not signed. EI #2 stated this showed a discrepancy and left a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 documented [MEDICATION(S)] on the MAR as administered on 07/01 and 07/11, but EI #4 did not sign on the narcotic log that the medication was administered. EI #1 stated this was a documentation issue. EI #1 stated EI #4 should have documented on the narcotic log and the MAR of the medication was administered. 9.) RI #4 was admitted to the facility on [DATE]. RI #4's Medication Review Report for July 2021 indicated [MEDICATION(S)] Tablet 0.5mg ([MEDICATION(S)]) was ordered 06/10/2021 to be given four times a day for Anxiety with the last dose before bed. A review of RI #4's Medication Administration Record indicated EI #4, RN, signed for the [MEDICATION(S)] on 07/02/2021 at evening and at bedtime and on 07/10/2021 at evening and at bedtime. A review of RI #4's Controlled Drug Record revealed that EI #4 signed for the [MEDICATION(S)] on 07/02/2021 at 07:40PM but at no other time during her shift. EI #4 signed for the [MEDICATION(S)] on 07/10/2021 at 09:15PM but at no other time during her shift. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 should have given the resident two doses during the 3-11 shift. EI #2 stated on 07/02, EI #4 documented two doses on the MAR but only signed the narcotic log at 07:40PM. EI #2 stated EI #4 did the same thing on 07/10, EI #4 charted two times on the MAR but only signed the narcotic sheet once at 09:00PM. EI #2 stated EI #4 should have removed the medication from the narcotic box, signed the narcotic sheet, taken the medication to the patient and signed the MAR. EI #2 stated the medical record was not considered complete and accurate if the narcotic sheet was not signed. EI #2 stated this showed a discrepancy and leaves a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 charted administration of the [MEDICATION(S)] on 07/02 but EI #4 did not sign the narcotic log. EI #1 stated this was inaccurate documentation. 10.) RI #5 was admitted to the facility on [DATE] and readmitted [DATE]. RI #5's Medication Review Report for July 2021 indicated [MEDICATION(S)]-Acetaminophen Solution 7.5-325mg/15ml was ordered 06/09/2021 10ml to be given by mouth at bedtime for pain. A review of RI #5's Medication Administration Record indicated EI #4, RN, administered [MEDICATION(S)]-Acetaminophen Solution 07/02/2021 at bedtime, 07/05/2021 at bedtime and 07/12/2021 at bedtime. A review of RI #5's Controlled Drug Record did not indicate EI #4 signed for the [MEDICATION(S)]-Acetaminophen on 07/02/2021, 07/05/2021 nor 07/12/2021. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 charted on the MAR administering [MEDICATION(S)] on 07/02, 07/05 and 07/12 but EI #4 did not document it on the narcotic log. EI #2 stated the medical record was not considered complete and accurate if the narcotic sheet was not signed. EI #2 stated this showed a discrepancy and left a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 charted on the MAR that [MEDICATION(S)] was administered 07/02, 07/05 and 07/12 but EI #4 did not document signing out the narcotic on the narcotic log. EI #1 stated this was a medication documentation error. EI #1 stated EI #4 should have provided the correct dose in the correct form and documented it on both the MAR and the narcotic log. 11.) RI #7 was admitted to the facility on [DATE] and readmitted [DATE]. RI #7's Medication Review Report for July 2021 indicated [MEDICATION(S)] Capsule 100mg ([MEDICATION(S)]) was ordered 08/12/2019 to be given by mouth two times a day for [CONDITION(S)]. A review of RI #7's Medication Administration Record indicated EI #4, RN, administered [MEDICATION(S)] 100mg the evening of 07/01/2021. A review of RI #7's Controlled Drug Record did not indicate EI #4 signed for the [MEDICATION(S)] on 07/01/2021. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 signed the MAR but not the narcotic sheet on 07/01 for the [MEDICATION(S)]. EI#2 stated EI #4 made documentation errors and the medication administration policy was not followed. EI #2 stated the medical record was not considered complete and accurate if the narcotic sheet was not signed. EI #2 stated this showed a discrepancy and left a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 documented the [MEDICATION(S)] on the MAR on 07/01/2021, but EI #4 did not document on the MAR. 12.) RI #8's Medication Review Report for July 2021 indicated [MEDICATION(S)] 400mg capsule was ordered 04/08/2018 to be given every 12 hours. A review of RI #8's Medication Administration Record for July 2021 indicated EI #4, RN, administered [MEDICATION(S)] 400mg on 07/01/2021 at 08:00PM, 07/02/2021 at 08:00PM, 07/05/2021 at 08:00PM, 07/10/2021 at 08:00PM and 07/16/2021 at 08:00PM. A review of RI #8's Controlled Drug Record did not reveal that EI #4 signed for the [MEDICATION(S)] on 07/01/2021, 07/02/2021, 07/05/2021, 07/10/2021 nor 07/16/2021. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #4 documented the [MEDICATION(S)] on the MAR for 07/01, 07/02, 07/05 and 07/10 but did not sign the medication out on the narcotic log. EI #2 stated EI #4 should have signed out the medication on the narcotic log, taken the medication to the patient, and document on the MAR once the patient took the medication. EI #2 stated the medical record was not considered complete and accurate if the narcotic sheet was not signed. EI #2 stated this showed a discrepancy and leaves a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 documented on the MAR the [MEDICATION(S)] was given 07/01, 07/02, 07/05 and 07/10 but EI #4 did not sign the narcotic log. 13.) A review of RI #10's Medication Administration Record for July 2021 indicated EI #4, RN, administered Acetaminophen-[MEDICATION(S)] 300-30mg on 07/11/2021 at 03:10PM, again at 03:10PM and a third time at 03:10PM, 03:15PM and 06:46PM. EI #4 also signed that she administered Acetaminophen-[MEDICATION(S)] on 07/12/2021 at 03:12PM, 03:20PM and 04:22PM. A review of RI #10's Controlled Drug Record indicated EI #4 signed for Acetaminophen-[MEDICATION(S)] on 07/11/2021 at 03:00PM. There were no other signatures for EI #4 on 07/11. EI #4 signed for Acetaminophen-[MEDICATION(S)] on 07/12/2021 at 05:00PM and 10:00PM, but not for 03:12PM, 03:20PM nor 04:22PM. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported the times on the control sheet do not match the MAR. EI #2 stated EI #4 had extra sign out time on the MAR that was not on the narcotic sheet. EI #2 stated this was a documentation error. EI #2 stated if a patient asked for medication, EI #4 should have taken the narcotic out of the box, ensured the count was correct, signed the narcotic log, gave the medication to the patient and signed the MAR. EI #2 stated the medical record was not considered complete and accurate if the narcotic sheet was not signed. EI #2 stated this showed a discrepancy and leaves a question whether the resident received or did not receive the medication as ordered. In an interview on 10/27/2021 at 12:47PM, EI#1, Administrator, reported EI #4 charted on the MAR on 07/11 four occurrences within the same timeframe which appeared to be duplicate entries and then one occurrence three hours later. EI #1 also stated EI #4 had duplicate entries on the MAR for 07/12 and only one signature on the narcotic log. EI #1 stated these were errors in documentation. 14.) RI #1 was admitted to the facility on [DATE]. RI #1's Medication Review Report for July 2021 indicated [MEDICATION(S)] (Concentrate) Solution 20mg/ml was ordered 01/23/2020 to be given by mouth every hour as needed for pain/Dyspnea. A review of RI #1's Medication Administration Record indicated EI #4, RN, administered the medication on 07/02/2021 at 05:09PM. In an interview on 10/26/2021 at 10:40AM, EI #3, ADON, reported that EI #4 documented on the MAR that medication was given but the medication was not available to give and it had not been pulled from OMNICELL, which was the back-up medication supply. EI #3 stated EI #4 did not follow the facility's Controlled Medication Policy. In an interview on 10/27/2021 at 09:29AM, EI #2, Director of Nursing (DON), reported EI #4 charted on the MAR that [MEDICATION(S)] was administered on 07/02/2021 but the medication was not available to give nor was it removed from OMNICELL. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 documented in the MAR that she administered a dose of [MEDICATION(S)] but the medication was not removed and documented on the narcotic log. EI #1 stated the medication was available but was not pulled. EI #1 stated EI #4 should not have documented on the MAR if the resident did not receive the medication. 15.) RI #12 was admitted to the facility on [DATE]. RI #12's Medication Review Report for July 2021 indicated [MEDICATION(S)]-Acetaminophen Tablet 7.5-325mg was ordered 06/18/2021 to be given every eight hours as needed for pain. A review of RI #12's Controlled Drug Record indicated EI #5, LPN, administered the [MEDICATION(S)]-Acetaminophen on 07/02/2021 at 08:00PM, 07/03/2021 at 06:00PM, 07/04/2021 at 08:00PM, 07/05/2021 at 08:00PM, 07/07/2021 at 08:30PM, 07/08/2021 at 08:00PM, 07/09/2021 at 08:00PM, 07/12/2021 at 08:30PM and 07/13/2021 at 07:00PM. A review of RI #12's Medication Administration Record revealed EI #5 did not document that she administered the [MEDICATION(S)]-Acetaminophen on 07/02/2021, 07/03/2021, 07/04/2021, 07/05/2021, 07/07/2021, 07/08/2021, 07/09/2021, 07/12/2021 nor 07/13/2021. In an interview on 10/26/2021 at 10:40AM, EI #3, ADON, reported an audit of all narcotics on carts in the facility revealed EI #5 pulled medication but did not document on the MAR. EI #3 stated EI #5 thought she was signing the sheet for both the count and the administration record. EI #3 stated EI #5 was not following the medication administration policy because she signed out the medication on the narcotic log but not the MAR. In a telephone interview on 10/27/2021 at 09:15AM, EI #5, LPN, reported she was busy and forgot to document on the MAR in July. EI #5 stated she was instructed to sign both the MAR and the narcotic book. EI #5 stated the resident's record was not complete and accurate if the MAR was not signed. EI #5 stated a complete and accurate record was needed so someone coming behind would know the medication had been administered. EI #5 stated she should have documented in the resident's MAR and the narcotic book. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #5 did sign the narcotic log but she did not sign the MAR. EI #2 stated EI #5 thought signing the narcotic log was sufficient. EI #2 stated the policy stated the narcotic log and the MAR were to be documented. EI #2 stated EI #5 received training on the policy at orientation. EI #2 stated the medical record was not complete because EI #5 did not complete both the narcotic sheet and the MAR. EI #2 stated the process was not complete and it could put into question which record was accurate. EI #2 stated when the resident asked for something for pain, EI #5 should have verified the order, taken out the amount into a cup, signed on the narcotic record and once the resident consumed the medication, recorded it on the MAR. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported an incorrect medication administration documentation error was identified because the narcotic log was signed but not the MAR. EI #1 stated the patient record was deemed inaccurate at that point. EI #1 stated a completed record was needed to determine whether the facility could provide a true assessment of the patient's care needs. EI #1 stated EI #5 should have documented the removal of the narcotic on the narcotic log and documented the administration of the narcotic on the MAR. 16.) RI #13 was admitted to the facility on [DATE] and readmitted [DATE]. RI #13's Medication Review Report for July 2021 indicated [MEDICATION(S)] Tablet 7.5-325mg ([MEDICATION(S)]-Acetaminophen) was ordered 06/24/2021 to be given every 12 hours as needed for pain. A review of RI #13's Controlled Drug Record indicated EI #5, LPN, administered [MEDICATION(S)]-Acetaminophen on 07/02/2021 at 08:00PM, 07/03/2021 at 08:00PM, 07/04/2021 at 08:00PM, 07/05/2021 at 08:00PM, 07/07/2021 at 07:00PM, 07/12/2021 at 07:00PM, 07/13/2021 at 06:00PM and 07/17/2021 at 07:00PM. A review of RI #13's Medication Administration Record indicated EI #5 did not sign that she administered [MEDICATION(S)]-Acetaminophen on 07/02/2021, 07/03/2021, 07/04/2021, 07/05/2021, 07/07/2021, 07/12/2021, 07/13/2021 nor 07/17/2021. In an interview on 10/26/2021 at 10:40AM, EI #3, ADON, reported an audit of all narcotics on carts revealed EI #5 pulled medication but did not sign the MAR. EI #3 stated EI #5 thought she was signing the sheet for both the count and the administration record. EI #3 stated EI #5 was not following the medication administration policy because she signed out the medication on the narcotic log but not the MAR. In a telephone interview on 10/27/2021 at 09:15AM, EI #5, LPN, reported she was busy and forgot to sign the MAR in July. EI #5 stated she was instructed to sign both the MAR and the narcotic book. EI #5 stated the resident's record was not complete and accurate if the MAR was not signed. EI #5 stated a complete and accurate record was needed so someone coming behind would know the medication had been administered. EI #5 stated she should have documented in the resident's MAR and the narcotic book. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported EI #5 did sign the narcotic log but she did not sign the MAR. EI #2 stated EI #5 thought signing the narcotic log was sufficient. EI #2 stated the policy stated the narcotic log and the MAR were to be documented. EI #2 stated EI #5 received training on the policy at orientation. EI #2 stated the medical record was not complete because EI #5 did not complete both the narcotic sheet and the MAR. EI #2 stated the process was not complete and it could put into question which record was accurate. EI #2 stated when the resident asked for something for pain, EI #5 should have verified the order, taken out the amount into a cup, signed on the narcotic record and once the resident consumed the medication, recorded it on the MAR. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported an incorrect medication administration documentation error was identified because the narcotic log was signed but not the MAR. EI #1 stated the patient record was deemed inaccurate at that point. EI #1 stated a completed record was needed to determine whether the facilit

Based on interviews, record reviews, a review of Potter and Perry, Fundamentals of Nursing, NINTH EDITION, and a review of the facility's policy titled, MEDICATION ADMINISTRATION & MANAGEMENT, the facility failed to ensure that Employee Identifier (EI) #4, Registered Nurse (RN), followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #4 administered [MEDICATION(S)]-Acetaminophen tablet instead of liquid [MEDICATION(S)]-Acetaminophen as ordered to Resident Identifier (RI) #5. EI #4 administered [MEDICATION(S)]-Acetaminophen to RI #8 at 08:00PM when it should have been administered at 08:00AM. This deficient practice affected RI #5 and RI #8, two out of 19 residents sampled for controlled medications. Findings include: Review of Potter and Perry's Fundamentals of Nursing, NINTH EDITION, page 31, revealed the following: .Chapter 23 Legal Implication in Nursing Practice .Health Care Provider's Orders. The health care provider (physician .) is responsible for directing medical treatment. Nurses follow health care provider's orders unless they believe the orders are in error or harm patients . Review of the facility's policy, titled, MEDICATION ADMINISTRATION & MANAGEMENT, issued 03/2012 and last revised 10/2019, revealed the following: .PROCEDURE: . 4. Prior to Medication Administration: All authorized community staff should adhere to the following guidelines: a. Verify the correct drug, correct dose, correct route, correct rate, correct time and the correct resident prior to each medication administration. 1.) RI #5 was admitted to the facility on [DATE] and readmitted [DATE]. RI #5's physician orders, Order Summary Report for June 2021 indicated [MEDICATION(S)]-Acetaminophen Tablet 5-325mg was ordered 06/08/2021 to be given one tablet by mouth at bedtime for pain. This order was discontinued on 06/09/2021. The physician ordered [MEDICATION(S)]-Acetaminophen Solution 7.5-325mg/ml on 06/09/2021 to be given 10ml by mouth at bedtime for pain. A review of RI #5's Controlled Drug Record indicated EI #4, RN, administered one [MEDICATION(S)]-Acetaminophen Tablet 5-325mg on 07/01/2021 at 09:00PM instead of the liquid solution. In an interview on 10/27/2021 at 09:29AM, EI #2, Director of Nursing (DON), reported EI #4 administered the last [MEDICATION(S)] 5-325mg pill to RI #5 on 07/01/2021 at 09:00PM. EI #2 stated it was an error because the wrong form of the medication was given. EI #2 stated the narcotic count was correct so it appeared EI #4 gave the tablet to the resident. EI #2 stated EI #4 should have read the order and followed the five rights from the facility policy. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 signed for the tablet on the narcotic log on 07/01/2021, which was the incorrect medication form. EI #1 stated RI #5 did not like taking pills. EI #1 stated EI #4 should have provided the correct dose and correct form as ordered by the physician. EI #1 stated EI #4 did not follow medication administration policy. EI #1 stated EI #4 did not meet professional standards of practice. 2.) RI #8 was admitted to the facility on [DATE] and readmitted [DATE]. RI #8's Medication Review Report for July 2021 indicated [MEDICATION(S)] Tablet 5-325mg ([MEDICATION(S)]-Acetaminophen) was ordered 09/09/2018 one tablet to be given by mouth in the morning (08:00AM) for pain. A review of RI #8's Controlled Drug Record indicated EI #4 administered one tablet of [MEDICATION(S)]-Acetaminophen on 07/01/2021 at 08:00PM. In an interview on 10/27/2021 at 09:29AM, EI #2, DON, reported RI #8's [MEDICATION(S)] 5-325mg was scheduled in the morning. EI #2 stated EI #4 worked 3-11PM. EI #2 stated dayshift gave the resident the medication. EI #4 signed out the medication again on 07/01/2021 at 08:00PM. EI #2 stated if EI #4 gave the medication to the resident, she gave it without an order. In an interview on 10/27/2021 at 12:47PM, EI #1, Administrator, reported EI #4 signed for the [MEDICATION(S)] on the narcotic log on 07/01/2021 but not on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #4 signed for it at 08:00PM. EI #1 stated the medication was given at the wrong time. EI #1 stated the resident should have received the correct medication at the appropriate time and it should be documented on the narcotic log and the MAR. EI #1 stated RI #8 received a dose at 08:00AM and then EI #4 administered the medication again at 08:00PM. EI #1 stated EI #4 did not follow the medication administration policy. EI #1 stated EI #4 did not meet professional standards of practice. ************************* The facility implemented the following corrective actions: *An investigation was conducted and EI #4 was suspended during the investigation. EI #4 was terminated 07/16/2021. *A house-wide audit completed 07/14/2021. *ADON notified the Medical Director on 07/13/2021. *Administrator notified the Pharmacy Consultant on 07/13/2021. *A Performance Improvement Plan was created and implemented. *All licensed nurses were re-educated on 07/13/2021 regarding Controlled Medication, Medication Storage and Medication Documentation and Administration. *EI #5 received one-on-one coaching regarding Medication Administration policy. Monthly medication pass observations for EI #5 began 07/2021 and will continue for six months. *Random Medication Pass Competencies on nurses were completed two times a week for four weeks and then weekly for four weeks. Completed 09/10/2021. *Narcotic Reconciliation Audits three times a week for four weeks, two times a week for four weeks and ongoing weekly. Two times a week completed 09/10/2021. Corrective actions began 07/13/2021 and were completed 09/10/2021. Therefore, past non-compliance was cited.

Based on observations, interviews, record review, and facility policies titled HAND WASHING AND HAND HYGIENE and NEBULIZER TREATMENT, the facility failed to ensure Employee Indentifer (EI) #1, a License Practical Nurse (LPN),: 1. washed her hands after she placed the oxygen finger probe, with both ungloved hands, on the fourth finger of Resident Indentifer (RI) #12's right hand, and prior to placing the inhalation vial medication in the reservoir of RI #12's breathing machine, and 2. rinsed and dried out the facemask of the nebulizer after RI #12's breathing treatment. The facility further failed to ensure EI #3, a Registered Nurse (RN),: 1. rinsed and dried out the facemask of the nebulizer of RI #178's breathing treatment, and 2. washed her hands after she placed RI #178's facemask in a plastic bag, and prior to setting up RI #178's breakfast meal tray. These deficient practice affected two of two residents observed with breathing treatments during medication pass, and two of two licensed nurses observed during medication pass. Findings Include: A review of a facility policy titled HAND WASHING AND HAND HYGIENE, with no date, revealed . POLICY: To strive to prevent infections through adequate hand washing . Procedure: . c. After contact with a resident's intact skin . After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident . A review of a facility policy titled NEBULIZER TREATMENT, with no date, revealed . Procedure: . 10. After the treatment . b. Open up the nebulizer and thoroughly rinse the nebulizer under running water. c. Air dry the nebulizer on a clean towel d. When the nebulizer is thoroughly dry store in a plastic baggie. 1.) RI #12 was readmitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 11, moderately impaired, and with [DIAGNOSES REDACTED]. On 10/17/2019 at 9:30 a.m., during observation of medication pass for RI #12, EI #1, a LPN, was observed and the following was not done: 1. wash her hands after she placed the oxygen finger probe, with both ungloved hands, on the fourth finger of RI #12's right hand, and prior to placing the inhalation vial medication in the reservoir of RI #12's breathing machine, and 2. rinse and dry RI #12's facemask of the nebulizer after RI #12's breathing treatment, prior to placing the facemask in the plastic bag on RI #12's bedside table. On 10/17/2019 at 12:33 p. m., an interview was conducted with EI #1. EI #1 was asked what should she have done after she put the oxygen finger probe, with both ungloved hands, on the fourth finger of RI #12's right hand. EI #1 stated she should have washed her hands. EI #2 was asked why did she not wash her hands after she put the oxygen finger probe on RI #12's fourth finger with both of her ungloved hands. EI #1 stated she was nervous. EI #1 was asked what would be the concern of a licensed nurse not having washed her hands after she came in contact with RI #12's skin. EI #1 stated RI #12 or herself could contact germs and become sick. EI #1 was asked what was the facility policy on hand hygiene after you touched a resident's skin with both ungloved hands. EI #1 stated you should wash your hands. EI #1 was then asked what should she have done after she removed RI #12's face mask of the nebulizer prior to having placed the face mask in the plastic bag on the bedside table. EI #1 stated she should have disconnected the facemask with the attached reservoir cup of the nebulizer, rinsed the facemask under running water, and air dried the facemask on a paper towel, prior to putting it in a plastic bag. EI #1 was asked why she did not rinse the facemask of the nebulizer under running water and air dry the nebulizer prior to have placed the face mask in the plastic bag. EI #1 stated she was nervous. EI #1 was asked what was the facility policy on care of the facemask after a resident had a breathing treatment. EI #1 stated you should disconnect the facemask with the attached reservoir cup of the nebulizer, rinse the facemask under running water, and air dry it on a paper towel prior to putting the facemask in a plastic bag. EI #1 was asked what would be the concern in a licensed nurse not rinsing the facemask of the nebulizer under running water, and air dry the nebulizer prior to placing the facemask in a plastic bag. EI #1 stated it could spread germs, and could cause a respiratory infection to the resident. On 10/17/2019 at 12:50 p.m., an interview was conducted with EI #2, the Infection Control Preventionist/Register Nurse. EI #2 was asked what would be the concern in a licensed staff nurse not washing their hands after she came in contact with a resident's skin. EI #2 stated it could spread infection to other residents. EI #2 was asked what was the facility policy on hand hygiene after a licensed nurse touched a resident's skin with both ungloved hands. EI #2 stated you should perform hand hygiene by hand washing or use of an alcohol based gel. EI #2 was asked what was the facility policy on care of the facemask after a resident had a breathing treatment. EI #2 stated you should rinse the nebulizer under running water, air dry on a clean towel, and once it was dry, store it in a plastic bag. EI #2 was asked what would be the concern in a licensed nurse not rinsing the facemask of the nebulizer under running water, and air dry both prior to have placed in a plastic bag. EI #2 stated it could cause an infection to the resident. 2.) RI #178 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 11, moderately impaired, and with [DIAGNOSES REDACTED]. On 10/17/19 at 09:06 a.m., during observation of medication pass for RI #178, Employee Identifier (EI) #3, a Registered Nurse (RN) was observed and the following was not done: 1. rinsed and dried out the facemask of the nebulizer of RI #178's breathing treatment, and 2. washed her hands after she placed RI #178's facemask in a plastic bag, and prior to setting up RI #178's breakfast meal tray. On 10/17/19 at 09:26 a.m., an interview was conducted with EI #3. EI #3 was asked, what happened after she removed the nebulizer mask off of RI #178. EI #3 replied she took the mask off RI #178, put it in a clear plastic bag, and placed it in the bedside drawer. The surveyor asked EI #3, what should have been done after taking the mask off RI #178. EI #3 replied, rinse the mask out and dry it with a clean towel before placing it in the plastic bag. EI #3 was asked, after she removed her gloves what should have been done before she gave RI #178's breakfast meal tray. EI #3 replied that she should have washed her hands or sanitized them. The surveyor asked EI #3, what did the facility policy say you are to do after you give a resident a breathing treatment. EI #3 answered, you should wash your hands. EI #3 was asked, did she follow the facility policy. EI #3 stated, no. EI #3 was asked, what was the potential concern of hands not washed after you give a breathing treatment. EI #3 stated it could cause an infection to the resident and she could spread a respiratory infection to another resident. On 10/17/19 at 10:20 a.m., a second interview was conducted with EI #3. EI #3 was asked, what was in the nebulizer mask in RI #178's room in the bedside drawer. EI #3 replied, several clear little fluids in facemask. EI #3 was asked, did she clean the facemask before putting in plastic bag and placing in bedside drawer. EI #3 said, no. EI #3 was asked, what should have been done after the breathing treatment was completed. EI #3 replied, clean the facemask, and rinse the nebulizer cup and let both dry completely before storing. The surveyor asked EI #3, was that done. EI #3 replied, no. EI #3 was asked, what was the potential concern of not rinsing out the nebulizer facemask before storing in a plastic bag. EI #3 replied, the risk of spreading infection. On 10/17/19 at 1:01 p.m., an interview was conducted with EI #2. EI #2 was asked, what would be the concern in a licensed staff nurse not washing hands after finishing a breathing treatment prior to setting up a breakfast meal tray for a resident. EI #2 replied, it could cause contamination. EI #2 was asked, what was the facility policy on hand hygiene after you give a resident a breathing treatment. EI #2 replied, you should perform hand hygiene with soap and water or use a alcohol based gel. The surveyor asked EI #2, what would be the concern in a licensed staff nurse not rinsing the facemask of the nebulizer under running water and air dry both prior to placing in a plastic bag. EI #2 replied, it could possibly cause an infection to the resident. EI #2 was asked, when should a licensed staff nurse wash their hands with soap and water. EI #2 replied, you should wash your hands with soap and water before and after contact with a resident.

Based on a review of the quarterly Quality Assurance/Performance Improvement (QAPI)committee attendance records, and interviews with the QAPI Coordinator and Medical Director, the facility failed to ensure the Medical Director attended and actively participated in three of four meetings from October 2016 through October 2017. Findings included: During the entrance conference on 10/03/17 at 4:00 p.m., the facility Administrator/QAPI Coordinator provided a copy of the facility's quarterly QAPI Sign In records, dated: 10/05/16, 01/25/17, 04/25/17 and 07/25/17. The records excluded the Medical Director's signature at the meetings of 10/05/16, 01/25/17 and 07/25/17. On 10/05/17 at at 8:15 a.m., the QAPI Coordinator (Employee Identifier/EI) #2 confirmed the integral people of this committee included the Medical Director, and their goal was to have him at the quarterly meetings. On 10/05/17 at 12:50 p.m., the Medical Director (EI #3) was contacted by telephone. EI #3 confirmed the facility conducted QAPI meetings on a quarterly basis. EI #3 stated he was given prior notice of each meeting and would respond whether or not he could attend. EI #3 explained it was up to the facility whether or not they rescheduled those meetings he was unable to attend. EI #3 affirmed it was important that he attend each meeting.

Based on observation, interview, review of FUNDAMENTALS OF NURSING by POTTER and PERRY, as well as review of facility records, the facility failed to ensure nursing staff washed their hands after removing soiled gloves and before applying new gloves during the provision of wound care for Resident Identifier (RI) #3. This affected 1 of 1 wound care observations. Findings include: FUNDAMENTALS OF NURSING by POTTER/PERRY, NINTH EDITION, 2017; Chapter 29 Infection Prevention and Control, page 458 and 465 revealed: .Boyce et al. (2002) and the (World Health Organization) WHO (2009) recommend the following hand hygiene guidelines: .3. If hands are not visibly soiled (WHO, 2009), use an alcohol based, waterless antiseptic agent for routinely decontaminating hands in the following clinical situations: .after removing gloves (Centers for Disease Control/CDC, 2008a) . Gloves . The CDC (2007) notes that you need to . change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with material that contains a high concentration of microorganisms . RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/05/2017 at 11:52 a.m., during wound care for RI #3, Employee Identifier (EI) #4, Assistant Director of Nursing, rolled the resident onto the left side and removed RI #3's dressing. Then, without washing or sanitizing her hands, EI #4 donned clean gloves. EI #4 then proceeded to clean the wound. Without first removing her gloves, washing her hands, and donning clean gloves, EI #4 measured the wound EI #5 (a Licensed Practical Nurse) took over wound care and cleaned the wound twice. EI #5 removed her gloves and then without washing her hands, EI #5 donned clean gloves and applied a skin preparation to the outer margin of the wound. EI #5 then applied the two-part dressing. EI #5 again removed her gloves and donned clean gloves, without washing or sanitizing her hands, and initialed and dated the dressing. On 10/05/2017 at 12:45 p.m., an interview was held with EI #5. EI #5 was asked what should be done once you have removed your gloves during wound care. EI #5 replied that you should wash your hands. EI #5 was asked did you do that during the observed wound care. EI #5 replied that she had washed once, when she removed the dressing. EI #5 was asked should you have removed your gloves and washed your hands after each glove removal, before donning clean gloves? EI #5 replied, Yes, normally. EI #5 was asked why not this time? EI #5 stated that she was holding the resident while EI #4 measured the wound, then she took her gloves off, but did not wash hands; It was an oversight. EI #5 was asked what was the potential harm of not washing your hands after removing your gloves, before donning clean gloves? EI #5 replied, Infection. On 10/05/2017 at 1:00 p.m. an interview was held with EI #4. EI #4 was asked during wound care what should you do after removing your gloves and before donning clean gloves. EI #4 replied that one should use an acceptable hand sanitizer or wash hands. EI #4 was asked did you do that during the wound care observed. EI #4 replied, I took my gloves off a couple of times and I omitted to wash or sanitize my hands before donning clean gloves. EI #4 was asked, what was the potential harm of not washing your hands after removing gloves and before donning clean gloves. EI #4 stated that if the area was soiled or any breakdown was present, you could transfer infection and/or bacteria to another site.

Based on interviews and record reviews the facility failed to ensure concerns documented in the Resident Council Meeting minutes were addressed and resolved for the months of January, March, May, July August and November 2016. This affected 6 of 12 months of Resident Council minutes reviewed. Findings Include: The facility policy titled Resident Council revised date of 06/09, documented: POLICY: The Resident Council strives to provide a monthly forum for residents to make recommendation and suggestions regarding any services and programs . PROCEDURE: Therapeutic recreation and social services will coordinate resident council meetings as follows: .3. Maintain a written record . of each meeting, including attendance sheets . commencement and closure times, review of last month's minutes, resolution, and all discussions and/or actions which take place.5. Retain a final copy of each meeting's minutes with all departments responses to concerns . During a review of the facility Resident Council Meeting minutes the following was revealed: January 2016- Concerns from Culinary (Dietary)- .Only serve white meat. Sometimes food is overcooked. Nursing - Sometimes forget return to room when they say they are going to bring you something. There was no documentation that these concerns were addressed or resolved. March 2016- Concerns from Culinary (Dietary)- Need better selection of food. Discussion/Open Forum -One resident suggested an orientation for new residents . There was no documentation that these concerns were addressed or resolved. May 2016-concerns from Culinary (Dietary) - .Food is better, but sometimes meat is too tough to chew. Laundry/Housekeeping- .sometimes clothing gets taken to laundry even when family washes clothes. Nursing- Sometimes can't find the call light button . There was no documentation that these concerns were addressed or resolved. July 2016- Concerns from Culinary - .Residents noted the food does not taste good (one resident) Would like fresh fruit and vegetables, (multiple residents) ; Would like fried fish and fried chicken, (one resident); Have poor selecting of food when you do not like the main option, (one resident); Meat is too tough (one resident), Laundry/Housekeeping - Deodorizer spray id too heavy (multiple residents); clothing is put in wrong closet when returned to the rooms from laundry, (multiple residents), Maintenance - Air conditioner is not working well in common areas, (one resident) Social Services - Did not follow up with resident after she said she would (one resident), Nursing - Showers are better, but sometimes the hot water does not last, (one resident) . There was no documentation that these concerns were addressed or resolved. August 2016- Concerns from Culinary - . One resident noted that the meat continues to be too tough . There was no documentation that these concerns were addressed or resolved. November 2016- Concerns from Social Services - . One resident noted that it can be difficult to see the social worker when you want to . There was no documentation that these concerns were addressed or resolved. Also noted there was no documentation to reflect that the previous minutes from the above meetings had been reviewed in the following month. On On 12/14/16 9:20 a.m. Employee Identifier (EI) #6, Social Worker, was asked who was responsible to follow up on concerns addressed in the Resident council Meetings. EI #6 replied each department head. EI #6 was asked how were they made aware of the concerns. EI #6 replied they started using a concern form in September 2016. EI #6 was asked what did she do before September. We just took care of it but did not document.

Based on observation, interview and record review the facility failed to shield the Foley catheter bag of Resident Identifier (RI) #9 from public view. On 12/13/16 at 1:45 P M during the initial tour, the resident was observed while in bed and the door was open to the hallway. The bag of urine was fully visible from the hallway. This affected one of fifteen sampled residents. Findings include: The facility POLICY AND PROCEDURES. CATHETER CARE, INDWELLING, with a revision date of 3/15 revealed: .9. Attach the drainage bag to the bed or chair frame, not to side rail. Note: Cover bag to maintain resident's dignity. RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum (MDS) data set [DATE], identified RI #9 with both long and short term memory loss and severely impaired decision making skills. RI #9 was dependent on staff for all activities of daily living. During the initial tour on 12/13/16, at 2:20 p.m., RI #9 was observed to be in the bed while the door was opened to the hallway. RI #9's catheter bag with no privacy covering, was hanging on the side of the bed clearly visible from the hallway. On 12/15/16 at 9:15 AM, Employee Identifier (EI) #2, Certified Nursing Assistant, stated the bag was usually put in the privacy bag. When asked if the bag was always put in a privacy bag, EI #2 replied, Not all the time, if it's in the room and not seen it is o.k. On 12/15/16 at 9:15 AM, EI #1, Licensed Practical Nurse stated if the bag was in an area where it could be seen it was a dignity issue.

Based on interview and record review the facility failed to report an allegation of abuse to the Online Reporting within 24 hours. This affected one of two allegations reviewed. Findings Include: The facility policy titled Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention with a revision date of 11/16 documented: POLICY: .Anyone may report any knowledge related to any allegation of abuse . Reporting: .2. Anyone who witnesses and/or suspects an incident of resident abuse . must immediately report the incident to his/her department supervisor. 3. The department supervisor must immediately notify the executive director, administrator or designee . 4. The executive director, administrator, or designee will take the following action: a. Notify the appropriate agency immediately (within 2 hours after the allegation is made, . (or not later than 24 hours if the allegation did not involve abuse or result in serious bodily injury) as to the nature of the allegation . During a review of the alleged abuse allegations the following was revealed: An allegation of sexual abuse was reported by a resident on May 28, 2016 to the facility. The incident was not reported to the State Agency online incident reporting system until June 01, 2016. On 12/15/16 at 8:30 a.m. Employee Identifier (EI) #3, Physical Therapist, was asked when was she made aware of the incident with Resident Identifier (RI) #14. EI #3 replied the resident had told her on Sunday the 29th of May, 2016. EI #3 was asked who and when did she report this to. EI #3 replied she reported it on Monday the 30th to her supervisor. EI #3 was asked what did her supervisor do. EI #3 replied she did not know. EI #3 was asked what did she know about reporting allegations of abuse. EI #3 replied to report directly to the supervisor and do an incident report. On 12/15/16 at 9:05 a.m. EI #4, Director of Therapy, was asked when was she made aware of the incident regarding RI #14. EI #4 replied the resident reported it to EI #3 on Sunday the 29th, and EI #3 reported it to me either on Monday the 30th or Tuesday June 1st, but she could not remember. EI #4 was asked what did she do after she was made aware of the incident. EI #4 replied she went and told the Administrator, EI #5, and the Director of Nurses. EI #4 was asked when EI #3 became aware of the incident what should she have done. EI #4 replied, EI #3 should have called EI #5. EI #4 was asked why EI #3 did not do that. EI #4 replied that EI #3 thought somebody else had reported it. EI #4 was asked did the therapy staff understand any allegation has to be reported within 24 hours. EI #4 replied they do now. On 12/15/16 at 11:25 a.m. EI #5, Administrator, Abuse Coordinator, was asked about the incident with RI #14. EI #5 replied the facility let the State Agency know about the incident as soon as they became aware of it on June 1st, 2016.

Based on observation, interviews and a review of the facility's policies, the facility failed to ensure: 1) 24 cartons of buttermilk dated 10/26/15, five cartons of thick and easy dairy dated 10/13/15, and 14 beef patties dated 10/19/15 stored in a zip lock bag were discarded by the designated use-by date; and 2) 14 beef patties stored in a zip lock bag dated 10/19/15 were not left opened in the freezer. This had the potential to affect all 51 residents for whom meals were provided by the facility during the survey. Findings include: A review of the facility's policy titled, DATE MARKING READY-TO-EAT-FOODS, with a revision date of 10/11, documented the following PROCEDURE: 1. All ready-to-eat foods will be labeled to include the following information: Product name and date (month, day, year) the product was prepared or opened and the date the product should be used by . 6. Serve or discard refrigerated, ready-to eat, potentially hazardous foods within 3 days. A review of the facility's document titled GUIDE TO PROPER FOOD STORAGE TECHNIQUES, dated 8/2010, documented the following: . Labeling *All food items outside of the original container must covered, labeled and dated. The label must include the name of the food (even if it is obvious), the date of preparation, and the date it should be discarded. All open food items should be discarded within 72 hours after preparation. During the initial tour of the kitchen on 10/27/15 at 12:15 PM, the surveyor noted in the walk-in cooler 24 cartons of buttermilk with an expire date of 10/26/15, and five cartons of thick and easy dairy with an expire date of 10/13/15. Also during the intial tour of the kitchen on 10/27/15 at 12:15 PM, the surveyor noted in the walk-in freezer, 14 prepared beef patties with a prepared date of 10/19/15 in a zip lock bag split open exposing the beef to the air. On 10/29/15 at 4:00 PM, Employee Identifier (EI) #3, the Director of Culinary Services was interviewed. EI #3 was asked what were the dates on the 24 cartons of buttermilk and the five cartons of thick and easy dairy. EI #3 replied, 10/26/15 for the buttermilk and I believe 10/15/15 for the thick and easy dairy. EI #3 was asked, if the 24 cartons of buttermilk and the five cartons of thick and easy dairy were expired. EI #3 stated, yes they were expired. EI #3 was asked, were the beef patties in the ziplock bag dated 10/19/15 split open. EI #3 stated, the bag was not completely sealed and beef patties were exposed. EI #3 was asked what is the potential harm with expired food or drinks. EI #3 stated, it could potentially make residents sick. EI #3 was asked what is the potential with frozen been being exposed in the freezer. EI #3 stated, Inferior quality of food.

Based on observation, interview and record review, the facility failed to ensure the medication order on the Medication Administration Record (MAR) for Resident Identifier (RI) #3 matched the label on RI #3's medication card for safe administration of medication. This affected RI #3, one of 12 resident's MARs reviewed during observation of medication administration. Findings include: A review of the facility's pharmacy titled, 6.0 General Dose Preparation and Medication Administration with an effective date of 12/01/07 revealed the following: . 3. Prior to Medication Administration: 3.1 .Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident. Resident Identifier (RI) #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's October, 2015 physician's orders [REDACTED]. CARB/LEV 25MG-100MG TABLET FOR>SINEMET 2 TABS BY MOUTH TWICE DAILY (NOON/4PM) . RI #3's medication administration card revealed a label with the following: . CARBIDOPA-LEVODOPA 25-100 TAB TAKE 1/2 TABLET EVERY 4 HOURS . On 10/28/15 at 5:30 PM, EI (Employee Indentifier) #2, a LPN (Licensed Practical Nurse), was asked if there was a discrepancy between the MAR and the labeling information on the medication administration card for RI #3's Sinemet. EI #2 stated, Yes ma'am it was. When asked to describe the discrepancy EI #2 stated the order on the MAR did not match the order on the medication administration card. EI #2 was asked what was the correct dose to be given at noon and what did she administer. EI #2 stated the correct dose was to give two tablets of Sinemet 25mg-100mg. EI #2 stated she gave that amount (two tablets). EI #2 was asked what was the facility's policy and how was she taught to correct this type of discrepancy. EI #2 stated when a discrepancy is found with any medication order the nurse should check the original order in the chart, call the pharmacy to send the correct dosage and directions for administration. EI #2 also stated that in the meantime a label noting Directions Changed-Refer to Chart should have been used. When asked what could be the potential harm for having different orders on the MAR and the medication administration card, EI #2 said that it could cause a medication error by other nurses and could cause the resident not to receive the correct amount of medication which could result in the resident's overall health and mental status to change. An interview was conducted on 10/15/15 at 3:30 PM with the Interim Director of Nursing (IDON), EI #1. EI #1 was asked what was the facility's policy when there is a change in a resident's medication order. EI #1 stated new orders are faxed to Omnicare Pharmacy and if a family uses an outside pharmacy, the order should also be faxed to that pharmacy as well. EI #1 was asked if RI #3's new Sinemet order dated 08/18/15 was faxed to Omnicare Pharmacy as well as CVS, the resident's outside pharmacy. EI #1 stated the order was faxed to Omnicare but not to CVS pharmacy. EI #1 was asked what was the potential in having different medication orders on a resident's MAR and medication administration card. EI #1 stated the medication could have been given incorrectly.

Based on observation, interview and document review the facility failed to ensure nurse staffing data was posted at the beginning of each shift rather than all three shifts. This was observed on three of three days during the survey. Findings include: A review of the facility's policy titled, Posting of Nursing Staff Information with a revision date of 07/11 revealed the following: . PURPOSE: To post staffing information at the beginning of each shift. On 10/27/15 at 1:35 PM, the nurse staffing data was posted on the nurses desk in a clear folder; evening and night shifts were posted for the day. On 10/28/15 at 7:55 AM and at 4:10 PM, nurse staffing data was posted in the same location and all shifts were posted for the day. On 10/29/15 at 7:50 AM, nurse staffing data was posted in the same location and all shifts were posted for the day. On 10/29/15 at 11:10 AM, an interview was conducted with EI (Employee Identifer) #1, the Interim Director of Nursing/Assistant Director of Nursing. EI #1 was asked who was responsible for posting daily nurse staffing. EI #1 stated, the night shift supervisor. EI #1 was asked how many shifts were posted. EI #1 stated, three shifts, days, evenings and nights. EI #1 was asked if she was aware of the regulation regarding the daily nurse staffing data should be posted prior to each shift. EI #1 stated, No, I am not familar with the regulation. EI #1 was asked if the facility kept 18 months of the daily nurse staffing data. EI #1 said, Yes ma'am. On 10/29/15, the surveyor observed the daily nurse staffing forms for February 2, 2014-October 29, 2015.

Based on record review, observations and interviews, the facility failed to ensure a licensed staff member did not place her ungloved index finger inside of the plastic packet when crushing medication during medication pass administration on 1/28/15. This affected 1 of 3 licensed staff members observed during medication pass administration on 1/28/15. The facility further failed to ensure a CNA ( Certified Nursing Assistant) washed or sanitized her hands after touching a urine soiled brief, cleaning the resident's buttocks and prior to touching a clean brief during the incontinent care of RI ( Resident Identifier) #6 on 1/28/15. This affected 1 of 2 CNAs observed performing incontinent care on 1/28/15. Findings Include: 1) On 1/28/15 at 8:20 AM, EI (Employee Identifier) #2, LPN (Licensed Practical Nurse) was observed preparing medication for PEG (Percutaneous Endoscopic Gastrostomy) tube administration. EI #2 had 3 medications that were to be crushed. EI #2 placed each medication inside of a separate plastic packet in order to crush the medications. EI #2 placed her right ungloved index finger inside of each of the plastic packets in order to open them and placed the medication inside. EI #2 proceeded to crush each medication and administer them to a resident via peg tube. On 1/28/15 at 9:00 AM, an interview was conducted with EI #2. EI #2 was asked how the plastic packet should be opened when placing medication inside to be crushed. EI #2 said not to put hands inside the open part of the packet. EI #2 was asked how she had opened the plastic packet when preparing the medication. EI #2 said she did not remember. The surveyor advised EI #2 that she was observed placing her index finger inside of each of the plastic packets. EI #2 was asked was it an acceptable practice of that facility if she opened the plastic packet by placing her index finger inside, placed the medication inside, crushed the medication and then administered the medication to a resident via peg tube. EI #2 said no. EI #2 was asked what the potential harm was if she opened the plastic packet with her index finger, placed the medication inside, crushed the medication and then administered the medication to a resident via peg tube. EI #2 said she could have bacteria or anything on her hand and she had not washed her hands in between, it could affect the resident. On 1/29/15 at 10:17 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked how should the plastic packet used for crushing medication be opened. EI #1 said ideally, try to pull it open below the mouth of the bag. EI #1 was asked was it an acceptable practice of that facility for a nurse to place an ungloved index finger inside of the plastic packet to open it, place the medication inside of the bag, crush the medication and then administer the medication to a resident. EI #1 said, "You wouldn't want to do that." EI #1 was asked what the potential harm was if a nurse placed an ungloved index finger inside of the plastic packet to open it, place the medication inside of the bag, crush the medication and then administer the medication to a resident. EI #1 said infection or cross contamination. A review of a facility policy titled, "HAND WASHING AND HAND HYGIENE" with a revised date of 05/12 revealed: "...1. Indications for hand washing and hand antisepsis: ... c. Always decontaminate hands: ... After contact with body fluids or excretions, ... After removing gloves ... 3. Other Aspects of hand hygiene a. The use of gloves does not eliminate the need for hand hygiene...." A review of a facility policy titled, "UNIVERSAL PRECAUTIONS" with a revised date of 06/08 revealed: " ...UNIVERSAL PRECAUTIONS: ... 3. ...Hands should be washed immediately after gloves are removed...." A review of a facility sign-in sheet where the training subject was hand washing, revealed EI #3, CNA attended the class on 10/13/14. A review of an inservice sign-in sheet titled, "Restorative or Knowledge Pathway Incontinence/Review Pericare & (and) Handwashing" revealed EI #3 attended this inservice on 7/7/14. 2) RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/21/2015 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4 which indicated RI #6 was severely cognitively impaired. The MDS also revealed the resident required extensive assistance with ADLs (Activities of Daily Living) and was always incontinent of bowel and bladder. On 1/28/15 at 11:17 AM, EI #3 was observed performing incontinent care for RI #6. EI #3 donned 3 pair of gloves and performed perineal care for the resident. EI #3 removed 1 pair of gloves and removed the urine soiled brief from the resident. EI #3 cleaned the resident's buttocks, removed the second pair of gloves and touched the clean brief and placed it underneath the resident. EI #3 did not wash or sanitize her hands after removing 2 pair of gloves or prior to touching the clean brief. On 1/29/15 at 9:56 AM, an interview was conducted with EI #3. EI #3 was asked when performing perineal care, when are hands supposed to be washed or sanitized. EI #3 said before perineal care was started, before the back was started and after the whole process was finished. EI #3 was asked at what point did she wash or sanitize her hands when performing perineal care for RI #6. EI #3 said before she started and after she was finished. EI #3 was asked should she have washed or sanitized her hands after she removed the urine soiled brief, cleaned RI #6's buttocks and before she touched the clean brief and placed it underneath the resident. EI #3 said yes ma'am. EI #3 was asked why she did not wash or sanitize her hands after she removed the urine soiled brief, cleaned RI #6's buttocks and before she touched the clean brief and placed it underneath the resident. EI #3 said her nerves. EI #3 was asked how many pair of gloves she put on when she began perineal care for RI #6. EI #3 said three. EI #3 was asked what the facility policy said about triple gloving. EI #3 said she didn't think they had one. EI #3 was asked if she was allowed to triple glove during perineal care. EI #3 said she had no idea. EI #3 was asked what the potential harm was if she did not wash or sanitize her hands after touching a urine soiled brief, cleaning the resident's buttocks and then touching a clean brief. EI #3 said they can get a UTI (Urinary Tract Infection) or bacteria could set in. On 1/29/15 at 10:10 AM, an interview was conducted with EI #1. EI #1 was asked at what point during perineal care should a CNA wash or sanitize their hands. EI #1 said anytime they were contaminated. EI #1 was asked if it was an acceptable practice of that facility for a CNA to triple glove and wash their hands at the end of perineal care. EI #1 said it was not listed specifically in their policy. EI #1 was asked if the CNA should wash or sanitize their hands after touching a urine soiled brief, cleaning the resident's buttocks then removing gloves before they touch a clean brief. EI #1 said they probably should sanitize their hands. EI #1 was asked what the facility policy said about triple gloving. EI #1 said they did not have it one way or the other. EI #1 was asked if it was an acceptable practice of that facility for a CNA to wear triple gloves, touch a urine soiled brief, clean the resident's buttocks and touch a clean brief without washing or sanitizing their hands. EI #1 said no. EI #1 was asked what the potential for harm was if a CNA touched a urine soiled brief, cleaned the resident's buttocks and touched a clean brief without washing their hands. EI #1 said infection and cross contamination. On 1/29/15 at 10:22 AM, an interview was conducted with EI #4, ADON (Assistant Director of Nursing) /Infection Control Nurse. EI #4 was asked how infections were prevented in the facility. EI #4 said proper hand washing, education and treating everything as if it were an infectious disease. EI #4 was asked how infections were controlled in the facility. EI #4 said depending on what type, they looked at their policy and procedure to see what they wanted them to do in accordance with any orders from the medical director. EI #4 was asked if direct care staff were washing their hands and changing gloves according to facility protocol. EI #4 said she believed they were. EI #4 was asked how direct care staff was monitored to ensure they were washing their hands and changing their gloves. EI #4 said the nurses had started performing perineal care checks where the procedure was monitored. EI #4 was asked if it was an acceptable practice of that facility for a CNA to triple glove during perineal care. EI #4 said no, it was not acceptable because hand washing would have to be incorporated in between periods of care. EI #4 was asked if it was an acceptable practice of that facility for a CNA to touch a urine soiled brief, clean a resident's buttocks and touch a clean brief without washing or sanitizing their hands. EI #4 said no because the CNA would have just contaminated. EI #4 was asked if it was an acceptable practice of that facility for a nurse to place an ungloved index finger inside of the plastic bag used to crush medication and then give the medication to the resident. EI #4 said no, it was not because that was contamination and an infection control violation. EI #4 was asked what the potential harm was if a CNA touched a urine soiled brief, cleaned a resident's buttocks and touched a clean brief without washing or sanitizing their hands and if a nurse placed an ungloved index finger inside of the plastic bag used to crush medication and then gave the medication to the resident. EI #4 said possible introduction of infection and both were infection control issues.

Based on observation, interviews and review of the 2013 Food Code, the facility failed to ensure food debris was not accumulated under the dumpster. This affected one of one compacting dumpster. Findings include: The 2013 Food Code by the United States Public Health Service and the Food and Drug Administration included the following: " ... 5-501.15 Outside Receptacles. ... (B) Receptacles and waste handling units for REFUSE and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit. On 04/02/14 at 10:50 AM, an observation was made of the compacting dumpster area with Employee Identifier (EI) #1, the Dietary Manager. Underneath the compacting dumpster were the following: half of a lemon, one pack of mayonnaise, one red potato, a metal food can, a water bottle, six gloves and a four-ounce cranberry juice cup. EI #1 stated the area beneath the compactor is cleaned when the compactor is emptied once per week. EI #1 was asked what would be the problem with built-up food trash under the dumpster. EI #1 answered, "Pest control." On 04/03/14 at 8:20 AM, EI #2, the Culinary Chef, provided the Stat Surveyor with a document titled "Sanitation Cleaning List." When asked what does scrub and clean back dock entail, EI #2 sated this included cleaning around and under the dumpster. According to this list, the dumpster area was last cleaned on 03/29/14. EI #2 said garbage should not be left under the dumpster because it would draw pests.

Based on observation, interview and record reviews, Employee Identifier (EI) #1, a Registered Nurse, failed to timely administer medications as ordered by the physician to Resident Identifier (RI) #18 on 01/02/13. This affected RI #18, one of 15 residents observed for medication pass. Findings include: The facility's policy titled "6.2 Medication Administration Times" with an effective date of 12/01/07, documented "... Procedure ... 2. The Facility should commence medication administration within sixty (60) minutes before the designated times of administration and sixty (60) minutes after the designated times of administration ... ." "Fundamentals of Nursing Eighth Edition" with a copyright date of 2013, Chapter 23 Legal Implications in Nursing Practice, page 305 documents "Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients... ." Chapter 31 Medication Administration, page 584 documents "...Standards... To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medications errors can be linked, in some way, to an inconsistency in adhering to these six rights: ...5. The right time... ." RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's January 2013 "physician's orders [REDACTED]." The undated facility's medication "Pass Times Worksheet" indicated medications ordered every day will be administered at 8:00 AM, medication ordered twice daily will be administered at 8:00 AM and 4:00 PM, and medications ordered at bedtime will be administered at 8:00 PM. On 01/02/13 at 10:58 PM, EI #1, a Registered Nurse, prepared medications for RI #18. EI #1 placed three [MEDICATION NAME] pills into a medicine cup, followed by one [MEDICATION NAME] pill and one [MEDICATION NAME] pill. EI #1 then drew up 12 units of [MEDICATION NAME] into a syringe. EI #1 then entered RI #18's room and administered the medications. In an interview with EI #1 on 01/02/13 at 11:25 PM, he verified he had administered [MEDICATION NAME] and [MEDICATION NAME] to RI #18 at 10:58 PM. EI #1 was asked what were the time frames for administering medications in the facility. EI #1 said one hour before or one hour after they are due/scheduled. When asked the importance of administering medications in a timely manner, EI #1 said to make sure all medications are separated so they don't interact with other medications and that some medications might conflict with the absorption rate of other medications. When asked about the facility's policy on administration of late medications, EI #1 stated medications are not normally administered this late. RI #18's "Nurse's Notes" written by EI #1 and dated 01/02/13 at 11:50 PM documented "In bed resting... No signs of distress or discomfort noted. Medication administered late due to human factors... No adverse reaction noted. Resident was monitored for any abnormalities... ." The facility's "Medication and Treatment Error or Omission" report indicated four medications ([MEDICATION NAME], Senna Plus, [MEDICATION NAME] and [MEDICATION NAME]) were administered to RI #18. The time and date of the event was listed as 01/02/13 11:20 PM. The type of variance checked was wrong time, with human factors as the possible cause. There errors were listed as "Category B: An error occurred that reached the patient but did not cause patient harm ... ." This deficiency was cited as a result of the investigation of complaint/report number AL 138.

Based on observation, interviews and record review, the facility failed to provide perineal care in a manner to prevent the potential for infection. This affected Resident Identifier (RI) #1, one of two sampled residents observed for perineal/incontinent care. Findings include: The facility's policy and procedure entitled: "Perineal Care" with a revised date of 03/10, documented "POLICY: To strive to promote cleanliness of the perineal area and prevent infection ... PROCEDURE: ... FEMALE RESIDENT 1. Separate the labia with one hand and wash with the other, using gentle downward [MEDICAL CONDITION] from the front to the back of the perineum ... 5. Clean, rinse and dry the anal area and buttocks, starting at the posterior vaginal opening and wiping from front to back ... ." Resident Identifier (RI) #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 02/24/12, identified RI #1 as being always incontinent of bowel and bladder, requiring extensive assistance of one person for toilet use. On 05/17/12 at 10:00 AM, Employee Identifier (EI) #1 and EI #2, both Certified Nursing Assistants (CNAs) were observed providing perineal care for RI #1. During this observation, EI #1 did not open RI #1's labia while performing the care. Furthermore, when EI #1 was cleaning RI #1's anal area she wiped from RI #1's anus toward the perineal area with the soapy wash cloth and repeated the procedure while rinsing the anal area. During an interview on 05/17/12 at 10:35 AM, EI #2 acknowledged that she observed EI #1 providing perineal care on RI #1. When asked if EI #1 opened RI #1's labia, EI #2 replied, "No." EI #2 was asked when EI #1 cleaned the anal area did she wipe from front to back. EI #2 said, "No, I (EI #2) told her (EI #1) after you (surveyor) left out that she did so wrong." When asked, how should EI #1 have cleaned the labia, EI #1 said she should have opened the labia, cleaned one side from front to back, then the other side the same and straight down the middle. EI #2 was then asked how should EI #1 have cleaned RI #1's anal area. EI #2 said start closest to the vaginal area toward the back of the buttocks. EI #2 was asked what was the importance of opening the labia. She said to make sure you clean all bacteria, urine or any bowel movement out. EI #2 was asked what was the potential for harm if the labia and the perineal area were not cleaned properly. EI #2 said, "It can cause an infection." During an interview on 05/17/12 at 10:45 AM, EI #1 verified that she did not open RI #1's labia when she performed perineal care. When asked, what is the importance of opening the labia, EI #1 said "to make sure you got it clean on the inside." EI #1 was asked, what is the potential for harm if the labia is not opened and cleaned. EI #1 replied "She (RI #1) could get an infection." The surveyor asked, what should she have done while cleaning RI #1's labia and EI #1 said that she should have opened and cleaned each side and down the center. EI #1 also verified that she began at RI #1's coccyx area and wiped toward the perineal area. When asked, what should have been done when she cleaned RI #1's anal area, EI #1 said that she should have started from the peri area toward the anal area instead of from the anal area toward the peri area.

Based on interview, record review and review of the facility's abuse policy, Employee Identifier (EI) #1, the Director of Nursing (DON) failed to recognize an allegation of physical and verbal abuse by a staff member, EI #2 (a Certified Nursing Assistant (CNA)) toward a resident Resident Identifier (RI) #7, as abuse. EI #1 further failed to protect RI #7 and the other residents in the facility, by not suspending EI #2 at the time the allegation was made, nor did she enforce the facility's Abuse Policy and Procedure, nor did she inform the facility's administrator of this allegation. After an allegation of abuse EI #1, the DON failed to protect residents from further abuse by not following the policies and procedures as outlined in the administration manual and the nursing manual. On 7/23/11, EI #5, a Licensed Practical Nurse (LPN) charge nurse informed EI #1, the DON, of a report from EI #4 (a CNA) that involved an incident with EI #2 (another CNA). EI #5 (LPN Charge Nurse) did not give other information, but stated that EI #4 (CNA) had said it was bad, and to contact EI #4 (a CNA who witnessed the incident). EI #1 did not contact EI #4 (CNA witness), but instead instructed EI #5 (the LPN) to get documentation, and to send EI #2 (alleged abusive CNA) back to her (assigned) floor and to stay away from the unit (where RI #7 resided). EI #1 (DON) failed to investigate and report an allegation of abuse within twenty-four hours, after it was brought to her attention by EI #5, the LPN, on the day of the event. EI #1 (DON) further failed to interview any of the staff on duty at the time and also failed to interview RI #7's wife who witnessed the abuse. EI #4 (CNA) witnessed EI #2 (CNA) grab the wrists of RI #7 and state to RI #7, "You are not going to hit my girls" (referring to CNAs, EI #3 and 4). After EI #4 (CNA) informed EI #5 (charge nurse), EI #5, spoke to RI #7's wife, who witnessed the interchange. Then, EI #5 (LPN charge nurse) called EI #1 (DON) and informed her of the event. EI #5 (LPN charge nurse) informed EI #1 (DON) that the witnesses used the terms verbal and physical abuse, and that EI #4 (CNA) had stated it was bad. EI #1 (DON) told EI #5 (LPN charge nurse) to have the CNAs write statements and to tell the resident's wife that the DON (EI #1) would speak with her (RI #7's wife) on Monday, 2 days after the occurrence. The alleged perpetrator , CNA/EI #2, was allowed to continue to work and actually worked on RI #7's locked unit for three days. There was no further investigation and no further actions until after the surveyors began to investigate the event. This deficient practice affected RI #7, one of three sampled residents for abuse / neglect, and threatened the health and safety of residents, as it was likely to cause serious injury, harm or death. On 8/1/2011 at 5:30 PM, the survey team notified the facility's Administrator and the Executive Director that immediate jeopardy at a "J" level had been identified in F 490. The immediate jeopardy (IJ) began on 07/23/11, and was relieved on 08/02/11 at 10:30 AM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any future recurrence. The scope / severity was lowered to a "D" level to allow the facility time to monitor and / or revise their corrective actions as needed to achieve substantial compliance. Refer to F 223, F 225 and F 226. Findings include: See F 223, F 225 and F 226. A review of the Nursing Manual of policies and procedures for Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention, with the revised date of 03/10, documented, "... Protecting ...2. During allegations of abuse or neglect, all individuals involved will be protected from further abuse and neglect ...Reporting ... 2. anyone who witnesses and/or suspects an incident of resident abuse, neglect, involuntary seclusion and misappropriation of property must immediately report the incident to his/her department supervisor. 3. The department supervisor must immediately notify the executive director, administrator or designee, who in turn will notify the corporate director of resident health services. 4. The executive director, administrator or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours ...) as to the nature of the allegation, name of resident and individuals involved. " Under the heading of "ALABAMA" the policy documented to immediately report to one of the following: "Eldercare hotline ...Eldercare Fax line ... e-mail ... " all numbers are clearly listed along with the e-mail addresses and also the website to find official reporting forms. "...D. if an employee is accused by name of committing any act of abuse, neglect, involuntary seclusion, and misappropriation of property, (or medication), immediate suspension from duty is mandatory until the investigation is completed. Once the investigation is completed, the executive director, administrator and appropriate corporate/regional representative will collaborate regarding the corrective action to be taken." On 7/23/2011, the LPN charge nurse (EI #5) reported an allegation of abuse to the DON (EI #1) via telephone, because the Director of Nursing (DON) was the Nursing / Administration representative on-call for the weekend of 7/23/11. In an interview on 8/1/2011 at 10:25 AM, EI #1 (DON) confirmed she was the Abuse Prevention Coordinator on 7/23/2011. On the same date at 1:05 PM, EI #1 stated she had not called CNAs, EIs #3 or #4, about the incident which they (EI #3 and 4) had witnessed. In hindsight, EI #1 (DON), said that she (DON/EI #1) should have come into the facility, and should have called EI #4 (CNA). EI #1 said that it had not dawned on her that it was an abuse complaint. Furthermore, EI #1 said that EI #4 (CNA witness) was difficult to talk to and understand; EI #1 (DON) explained that she couldn't tell if the CNA (EI #4) was joking or serious. When asked about the facility's Policy and Procedures for handling abuse allegations, EI #1 stated that abuse was abuse, and all abuse allegations should be reported within 24 hours. EI #1 (DON) said that the person involved should be removed/suspended immediately until the investigation was completed (within 5 days), as per the facility's abuse / neglect policy. Seven days after the incident, EI #1 (DON) stated the investigation was ongoing and EI #2, the alleged CNA perpetrator, had been suspended on 7/28/2011, (six days after the occurrence). EI #1 (DON) further stated she had notified the Administrator (EI #9) of the allegation on the night of 7/28/2011, (five days after the incident) only after the surveyors' investigation was underway and she (DON/EI #1)had been questioned about the event. A review of RI #7's physician orders [REDACTED]. This 7/23/11 order also documents that a psychiatric consult could be obtained if the medication ([MEDICATION NAME]) was ineffective. Another order dated 7/23/11, documents that RI #7 was transferred to a hospital for evaluation and treatment as needed. A 7/24/11, order documents that the resident was discharged from the facility and admitted to a hospital's psychiatric unit on 7/24/11. According to the "Facesheet" in RI #7's medical record, the resident was readmitted to the facility on [DATE] at 1:40 PM. A review of the facility staffing July 2011 revealed that: On 7/23/11, EI #2 (CNA perpetrator) was allowed to continue to work on her assigned unit for the remainder of the shift. On 7/24/11, EI #2 (CNA perpetrator) worked on an adjacent unit; on 7/25/11, she (EI #2) worked on the locked dementia unit. On 7/26/11, EI #2 (CNA perpetrator) worked on the locked dementia unit with RI #7, and on 7/27/11, EI #2 (CNA perpetrator) worked on the locked dementia unit with RI #7. EI #2 (CNA perpetrator) was off the schedule for 7/28/11, but returned to work the adjacent unit on 7/29/11. Eight days after the incident, a typewritten untitled document dated, 7/31/2011 at 11:20 p.m., revealed that EI #1 (DON) had phoned EI #2 (CNA perpetrator), and suspended the CNA (EI #2) until further investigation. EI #1 also wrote, "I came into work on Monday (7/25/11) and noted the copy and the original from EI #2 (the alleged perpetrator,) and read it. At no time were there any words of abuse used that caused me to think that an abuse situation had occurred. Nor any indication that abuse occurred, however I felt that her actions to the wife were unprofessional..." On 8/1/11, the ninth day after the alleged incident, at 7:50 AM, EI #1/DON submitted a copy of her typewritten statement, dated 7/31/11 at 7:45 PM, to the surveyors. Although there were appropriate guidelines available, EI #1, the Director of Nursing, who was a member of the administration for the facility failed to follow those guidelines. As a result of EI #1's failure, deficient practice was identified and citations were written in F223, F 225, and F226. This deficiency is written as a result of the investigation of complaint / report #AL 879. [MEDICATION NAME][MEDICATION NAME][MEDICATION NAME][MEDICATION NAME] Facility allegation of compliance F490 Facility Administration failed to recognize abuse and failed to notify Administrator. Plan of action: 1. Director of Nursing was suspended pending probable termination 08/01/2011. 2. All staff is currently being in-serviced on Abuse beginning 08/01/2011. No staff member will be allowed to report to work without first attending mandatory Abuse in-service. The Allegation of Compliance was reviewed and accepted. The in-service training for Abuse Identification and reporting didactic was reviewed. The state surveyor monitored one of the presentations to validate teaching of materials and participation of staff. the monitored class was comprised of staff from different departments to include nursing, housekeeping and activity departments. Random staff was interviewed to validate learning of the materials presented. Interviews included Registered Nurse, Licensed Practical Nurse and Certified Nursing Assistant. After reviewing and verifying the implementation of the facility's allegation of credible compliance, the immediate jeopardy was relieved on 08/02/2011 at 10:30 AM and lowered to a "D" level to allow the facility time to monitor and/or revise their corrective actions to sustain compliance.

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #2, did not abuse Resident Identifier (RI) #7, a non-agitated resident by physically restraining him by the wrists while two other CNAs (EI #3 and #4) assisted the resident with toileting on 07/23/11. RI #7 was admitted to the locked dementia unit 16 days prior to the incident. RI #7 required extensive assist of one for dressing and toileting. On the morning of 7/23/11, the two CNAs (EI #s 3 and 4) assigned to the unit were assisting RI #7 to the bathroom for toileting. Just prior to being taken to the bathroom, RI #7 showed signs of being confused and not following commands, but with the help of his wife and the two CNAs he had become calmer and the personal care had continued. Although RI #7 was moving from side to side and calling his wife's name, he was not being combative. A third CNA (EI #2), who was not assigned to work on the dementia unit, entered the room, looking for her sister (EI #3), who was one of the CNAs providing care to RI #7. EI #2 grabbed RI #7 by both wrist, turned his arms to make them palm-side up and held them down in his lap, all the while telling him he could not hit her girls (referring to EI #3 and #4). RI #7's wife overheard EI #2 hollering at RI #7 that he could not hit her girls (EI #3 and #4) and entered the bathroom to see what was happening. RI #7's wife saw one of the White CNAs (EI #2) restraining RI #7 by holding the resident by the wrist and demanded that the CNA (EI #2) stop and release her husband (RI #7). When RI #7's wife informed the CNA (EI #2) that she would reported, the CNA responded in a loud and threatening / challenging demeanor for RI #7's wife to go ahead with reporting her (EI #2). EI #2 reminded RI #7's wife that she knew her (EI #2) by name, then the CNA held her name badge / picture identification badge up in RI #7's wife face. RI #7's wife reported that a White CNA had verbally and physically abused her husband (RI #7) to the Licensed Practical Nurse (LPN) in Charge (EI #5). The LPN Charge Nurse (EI #5) went to the nurse's station and asked a CNA (EI #4) who RI #7's wife was talking about. The CNA (EI #4) identified EI #2 (CNA) by name and commented that it (the incident) was bad. The LPN Charge Nurse (EI #5) notified the Director of Nursing (DON), EI #1, via phone that EI #2 (a CNA) had abused RI #7, and received instructions to keep EI #2 (CNA) off the dementia unit, and have the CNAs involved to write witness statements. EI #2 (CNA) returned to her assigned unit and was allowed to continue to provide direct care to residents, contrary to facility policy. After the incident on 07/23/11, RI #7 became increasingly agitated and had to be sent out of the facility for psychiatric evaluation and treatment. On 07/26/11, RI #7 was readmitted to the dementia unit, and EI #2, the CNA who had restrained the resident by the wrist on 7/23/11, was working on the dementia unit. This deficient practice affected RI #7, one of three sampled residents for abuse / neglect, and threatened the health and safety of residents, as it was likely to cause serious injury, harm or death. On 8/1/2011 at 5:30 PM, the survey team notified the facility's Administrator and the Executive Director that substandard quality of care at the immediate jeopardy level of "J" had been identified in F 223. The immediate jeopardy (IJ) began on 07/23/11, and was relieved on 08/02/11 at 10:30 AM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any future recurrence. The scope / severity was lowered to a "D" level to allow the facility time to monitor and / or revise their corrective actions as needed to achieve substantial compliance. Findings include: The facility's policy / procedure for Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention (A-02), with a revision date of 03/10, defines abuse as the, "Willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain and/or mental anguish. Abuse may be committed by employees, other residents, family members, visitors and/or others. Verbal abuse: use of oral, written or gestured language that includes willful, disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. ... Physical abuse: Hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment...." This abuse policy further documents: Identification: ...2. Ongoing supervision of the staff to identify inappropriate behaviors will occur (i.e. rough handling of residents) ... Protecting ...2. During allegations of abuse or neglect, all individuals involved will be protected from further abuse and neglect ...Reporting ... 2. Anyone who witnesses and/or suspects an incident of resident abuse, neglect, involuntary seclusion and misappropriation of property must immediately report the incident to his/her department supervisor. 3. The department supervisor must immediately notify the executive director, administrator or designee, who in turn will notify the corporate director of resident health services. ...4. The executive director, administrator or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours ...) as to the nature of the allegation, name of resident and individuals involved. ...D. If an employee is accused by name of committing any act of abuse, neglect, involuntary seclusion, and misappropriation of property, (or medication), immediate suspension from duty is mandatory until the investigation is completed. Once the investigation is completed, the executive director, administrator and appropriate corporate/regional representative will collaborate regarding the corrective action to be taken...." Resident Identifier (RI) #7 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7 was admitted to the hospital on [DATE] for psychiatric evaluation / treatment and was readmitted to the facility on [DATE]. The admission Minimum Data Set ((MDS) dated [DATE] identified RI #7 with BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15. RI #7 is coded as sometimes having the ability to make himself understood by others, and as sometimes being able to understand others. RI #7 required limited assistance of one person with transfers and personal hygiene. This assessment identified RI #7 as requiring extensive physical assistance of one staff member for toilet use, and as being frequently incontinent of both bowel and bladder. On 7/28/2011 at 4:20 PM, EI #4, a CNA described the events of Saturday 7/23/2011 in an interview. She stated she was in the bathroom assisting EI #3 (another CNA) clean up RI #7 at about 10:45 to 10:50 AM, when EI #2 (another CNA) came and asked if EI #3 was ready for break. EI #4 described RI #7 as not following simple commands, but not agitated or combative. EI #4 said RI #7 was sitting on the commode mumbling and calling for his wife by name, which was usual behavior for the resident. EI #2 (CNA) grabbed RI #7's wrists and told him he was not going to hit her girls (referring to EI #3 and 4). RI #7's wife walked into the bathroom and said, "You let him go, you let him go now." According to EI #4 (CNA), EI #2 (CNA) continued to hold RI #7's wrists, and the resident's wife then said, "You're not going to talk to him (RI #7) like that; you let him go." Then, RI #7's wife threatened to report EI #2 (CNA). In response to RI #7's wife planning to report the incident, EI #2 (CNA) extended her name / picture identification badge into the resident's wife face, and said in a loud, threatening / challenging demeanor for RI #7's wife to go ahead and make a report. EI #4 (CNA) said RI #7's wife was visibly upset and crying. According to EI #4 (CNA), EI #2 (CNA) let go of RI #7's arms when they stood him up; and, EI #2 (CNA) commented there there was going to be trouble; so, she needed to get out of there. EI #2 left the room to go to lunch with her sister, EI #3 (CNA). On 07/30/11 at 10:30 AM, the survey team received a copy of the facility's summary of the investigation of RI #7's abuse allegation report, which documents that RI #7's wife had been attempting to assist RI #7 in the bathroom and the resident started getting combative. At that time, two CNAs (EI #3 and 4) came in to assist RI #7's wife with the resident, followed by a third CNA (EI #2). RI #7's wife peeked into the bathroom to see what was going on. RI #7 was standing in the bathroom nude and hitting the staff. RI #7's wife said that EI #2 (CNA) grabbed RI #7's wrist and said, "you have been hitting my girls and you can't do that." RI #7's wife told EI #2 (CNA) to let RI #7 go and not to talk to the resident in that way. RI #7's wife told EI #2 (CNA) that she was going to report her (EI #2) for speaking to RI #7 that way. EI #2 (CNA) responded that she understood, gave her (EI #2's) name and showed her name / picture identification badge to RI #7's wife. According to this investigation summary report, EI #5's (LPN Charge Nurse's) statement documents that RI #7's wife reported that a CNA had been rude and rough with RI #7 in the restroom. EI #5 (LPN Charge Nurse) apologized to RI #7's wife, reported the incident to the Director of Nursing (EI #1), and instructed EI #2 (CNA) not to come back in to the dementia unit. On 07/28/11 at 2:00 PM, the survey team attempted to interview RI #7's wife about the 7/23/11, incident between the CNAs and RI #7. At this time, RI #7's wife said that she did not feel at liberty to speak, and refused to talk about the incident. RI #7's wife communicated to the surveyor that she was not in a position to become involved with anything due to her own health condition. RI #7's wife explained that she had just come from the doctor and had been talking about hospice services for RI #7. RI #7's wife shared that she had spoken to the nurse (EI #5) about the incident. When RI #7's niece entered the room, RI #7's wife explained to the niece that the surveyors were investigators and would find out (referring to the incident of 7/23/11). In another interview on 7/31/11 from 12:20 PM until 1:00 PM, EI #4 (CNA) clarified that EI #2 (CNA) had grabbed RI #7's wrists and turned the resident's arms so RI #7's hands were palms up. EI #4 said RI #7 was sitting calmly on the toilet when EI #2 did this and RI #7 began struggling after EI #2 had grabbed the resident. According to EI #4 (CNA), RI #7 was not fighting, hitting or swinging at anyone, when EI #2 (CNA) grabbed the resident's wrist. On 7/29/2011 at 3:45 PM, EI #5 the LPN/Charge Nurse explained during her rounds, around 2:00 PM on 7/23/11, she had gone to check on RI #7. RI #7's wife reported there had been three CNAs in RI #7's bathroom. One of the White CNAs had grabbed RI #7, (indicating his upper arms) and had been very forceful, very rude and was not going to do things a certain way. RI #7's wife also reported that the CNA had been rude to her too, when she had tried to intervene. When EI #5 (LPN Charge Nurse) asked RI #7's wife if the CNA had been verbally and physically abusive, RI #7's wife affirmed that the CNA had been physically and verbally abusive. Then, EI #5 (LPN Charge Nurse) went to the nurse's station and asked EI #4 (CNA) to clarify who was involved. EI #4 (CNA) responded to EI #5 (LPN Charge Nurse) by identifying EI #2 (CNA), and commented that it (the incident) was bad. EI #5 (LPN Charge Nurse) did not ask EI #4 (CNA) for any other details of the incident, but left to call EI #1, the Director of Nursing (DON). EI #5 (LPN Charge Nurse) informed EI #1 (DON) via phone that RI #7's wife reported that a CNA (EI #2) had been verbally and physically abusive. EI #5 (LPN Charge Nurse) said that she told the DON (EI #1) that she (EI #5) did not know exactly what happened, but identified EI #4 (CNA) by name as being present during the incident. A review of RI #7's physician orders [REDACTED]. This 7/23/11 order also documents that a psychiatric consult could be obtained if the medication ([MEDICATION NAME]) was ineffective. Another order dated 7/23/11, documents that RI #7 was transferred to a hospital for evaluation and treatment as needed. A 7/24/11, order documents that the resident was discharged from the facility and admitted to a hospital's psychiatric unit on 7/24/11. According to the "Facesheet" in RI #7's medical record, the resident was readmitted to the facility on [DATE] at 1:40 PM. A review of the facility staffing for July 2011, revealed that: On 7/23/11, EI #2 (CNA who allegedly abused RI #7) was allowed to continue to work on her assigned unit for the remainder of the shift; on 7/24/11, she (EI #2 / CNA) worked on the adjacent unit; on 7/25/11, EI #2 (CNA) worked on the locked dementia unit; on 7/26/11, EI #2 (CNA) worked on the locked dementia unit with RI #7; and, on 7/27/11, she (EI #2) also worked on the locked dementia unit with RI #7. EI #2 was scheduled off on 7/28/11, but returned to work on the adjacent unit on 7/29/11. On 7/29/2011 at 10:30 AM, Employee Identifier, (EI) #2, confirmed her work schedule in an interview. On 8/1/2011 at 1:05 PM, the Director of Nursing (DON), EI #1, said that EI #2 (CNA who allegedly abused RI #7) had been suspended the previous day (7/29/11, six days after the incident,) because the CNA (EI #2) should have been suspended at the time (of the incident on 7/23/11), and that the investigation was still ongoing and had not yet been completed (a full seven days after the incident). A typed untitled document dated 7/31/11 at 11:20 PM, documents, "Called (name of EI #2), CNA and suspended her (EI #2) until further investigation. This document has the names of EI #1 (DON) and EI #13 (Assistant DON) typed below the above statement. This deficiency is written as a result of the investigation of complaint / report #AL 879. [MEDICATION NAME][MEDICATION NAME][MEDICATION NAME] This constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. F 223 Failure to ensure CNA did not abuse resident by holding wrists of resident #7 that affected 1 out of 5 residents. Plan of action: 1. CNA suspended until abuse/dementia/professionalism training is completed and further follow-up investigation. 2. Staff re-in-serviced on abuse/grievance training beginning 7/29/2011. 3. Director of Nursing suspended 08/01/2011 after completion of statements to state survey team, with pending termination. The Allegation of Compliance was reviewed and accepted. The in-service training for Abuse Identification and reporting didactic was reviewed. The state surveyor monitored one of the presentations to validate teaching of materials and participation of staff. the monitored class was comprised of staff from different departments to include nursing, housekeeping and activity departments. Random staff was interviewed to validate learning of the materials presented. Interviews included Registered Nurse, Licensed Practical Nurse and Certified Nursing Assistant. After reviewing and verifying the implementation of the facility's allegation of credible compliance, the immediate jeopardy was relieved on 08/02/2011 at 10:30 AM, and lowered to a "D" level to allow the facility time to monitor and/or revise their corrective actions to sustain compliance.

Based on interview and review of the facility's Policy and Procedure Manuals the facility failed to ensure the facility staff reported an allegation of abuse to the administrator and the allegation of abuse was identified and reported to the Alabama Department of Public Health, Provider Services within the required twenty-four hour time frame. The facility also failed to promptly conduct a thorough investigation by not obtaining written statements nor interviewing staff members or visitors with knowledge of the incident. In addition, with no prompt investigation started, the completed report was not forwarded to the state agency within the five day limit. Employee Identifier (EI) #1, the Director of Nursing (DON), failed to identify the allegation as reportable; although, the Licensed Practical Nurse (LPN), EI #5, notified the DON (EI #1) by phone of the event on the day it occurred (07/23/11). EI #5 (LPN) told the DON (EI #1) that RI #7's wife used the terms verbal and physical abuse and EI #4 ( a CNA) described the incident by saying that it was bad. Refer to F 223. This deficient practice affected RI #7, one of three sampled residents for abuse / neglect, and threatened the health and safety of residents, as it was likely to cause serious injury, harm or death. On 8/1/2011 at 5:30 PM, the survey team notified the facility's Administrator and the Executive Director that substandard quality of care at the immediate jeopardy level of "J" had been identified in F 225. The immediate jeopardy (IJ) began on 07/23/11, and was relieved on 08/02/11 at 10:30 AM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any future recurrence. The scope / severity was lowered to a "D" level to allow the facility time to monitor and / or revise their corrective actions as needed to achieve substantial compliance. Findings include: Refer to F 223. The facility's policy and procedure for Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention (A-02), revised 03/2010, defines abuse as the, "willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain and/or mental anguish.... "Verbal abuse: use of oral, written or gestured language that includes willful, disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability." " ... Physical abuse: Hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment." This abuse policy (A-02) further documents: "... Protecting ...2. During allegations of abuse or neglect, all individuals involved will be protected from further abuse and neglect ...Reporting ... 2. Anyone who witnesses and/or suspects an incident of resident abuse, neglect, involuntary seclusion and misappropriation of property must immediately report the incident to his/her department supervisor. 3. The department supervisor must immediately notify the executive director, administrator or designee, who in turn will notify the corporate director of resident health services. ...4. The executive director, administrator or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours ...) as to the nature of the allegation, name of resident and individuals involved. " Under the heading of "ALABAMA" the policy documents to immediately report to one of the following: "Eldercare hotline ...Eldercare Fax line ... e-mail ... Five (5) day report to: Alabama Department of Public Health Division of Health Care Facilities...ATTN: Complaint Unit... D. If an employee is accused by name of committing any act of abuse, neglect, involuntary seclusion, and misappropriation of property, (or medication), immediate suspension from duty is mandatory until the investigation is completed.... ...Investigation: 1. ...f. Accused employee's statement or explanation of what happened. g. Statements from any witness to the event... j. Interviews with all potential witness(es) (e.g. other staff members, residents, visitors, etc.)...." During the survey, the surveyors received a complaint of possible abuse concerning RI #7. During interviews with the staff on 7/28/11, the survey team learned that an event occurred on the previous Saturday, 7/23/2011 around 10:45 AM; it was alleged to be verbal and physical abuse involving EI #2 (CNA) against RI #7. On 7/29/2011 at 3:45 PM, EI #5 the LPN/Charge Nurse explained what had happened on 7/23/11 as; around 2:00 PM, when she had gone to check on RI #7, the resident's wife reported there had been three CNAs in RI #7's bathroom. One of the CNAs had grabbed RI #7, (indicating his upper arms) and had been very forceful and very rude. RI #7's wife also reported that the CNA (later identified as EI #2) had been rude to her too, when she had tried to intervene. EI #5 (LPN Charge Nurse) said the resident's wife reported that the CNA (EI #2) had been both physically and verbally abusive. EI #5 reported she had called EI #1, the DON, shortly after this. EI #5 reported to EI #1 the DON, that she didn't know exactly what had happened, but EI #4 (CNA) had been present. According to EI #5 (LPN Charge Nurse), she told the DON (EI #1) that EI #4 (CNA) had identified EI #2, as the CNA involved, and said that it (the incident) was bad. EI# 5 (LPN Charge Nurse) also said that she told EI #1 (DON) that RI #7's wife reported that EI #2 (CNA) was physically and verbally abusive. According to EI #5, no one had talked to her about the incident, (which had been six days prior) and she had not been told to write up a statement. EI #5 said the DON (EI #1) had instructed her to have the CNAs write statements, to keep EI #2 (the alleged abusive CNA) off the hall (where RI #7 lived) and that the DON (EI #1) would talk to RI #7's wife on Monday, (two days later.) On July 28, 2011, the surveyor requested from the Director of Nursing, (DON) Employee Identifier (EI) #1, and the designated Abuse Prevention Coordinator, documentation of any abuse investigations since the last survey. At that time, EI #1 (DON) stated that no allegations had been investigated. EI #1, the Director of Nursing, stated in an interview on 7/30/2011 at 4:30 PM, that she knew EI #5 (LPN Charge Nurse) called her and said RI #7's family had a complaint. She also stated she asked EI #5 (LPN Charge Nurse) what it was about and she said she really didn't know. Then, EI #1 (DON) said that EI #4 (CNA) had said it was bad and it involved EI #2 (CNA.) EI #1 (DON) said she asked if EI #2 (CNA) was working back there (referring to the unit where RI #7 resided) and EI #5 (LPN Charge Nurse) answered that EI #2 (CNA) was not. EI #1 (DON) said she told EI #5 (LPN Charge Nurse), to tell EI #2 (CNA) to go back to her floor and stay away from RI #7's unit. EI #1 (DON) also said she did not hear anything else about the incident until she returned to work on Monday (7/25/11), when she found a written statement from EI #2 (CNA who allegedly abused RI #7). EI #1 said she spoke to RI #7's wife on Tuesday, (7/26/2011, three days after the incident to find out what had happened.) EI #1 (DON) reported RI #7's wife told her a third girl (a CNA. later identified as EI #2) came into the bathroom and took RI #7 by both wrists and told RI #7 he didn't need to be hitting her girls, (referring to the other CNAs.) Later in this conversation, EI #1 (DON) was asked if she had thought it seemed excessive that EI #2 (CNA) had grabbed RI #7's wrists and EI #1 (DON) replied that it was. EI #1 said that she had RI #7's wife to clarify if it was the resident's hands or wrists, and RI #7's wife answered that it was the resident's wrist. EI #1 explained that staff should never grab/hold the elderly by the wrists, and commented that they bruise. In an interview on 7/30/11 at 4:30 PM, the DON, EI #1 stated she had a statement from EI #2 (the alleged abusive CNA), but none from EI #'s 3 or 4, the other two CNA involved in the 7/23/11 incident. According to EI #1 (DON), EI #3 (CNA and sister of EI #2) recalled giving a statement to one of the LPNs (EI #5). The DON (EI #1) was unable to provide documentation of interviews with the involved staff. On 7/30/11, there was no documentation of a written statement from EI #3 (CNA and EI #2's sister); although, she (EI #3) recalled giving one to the LPN (EI #5). There were no interviews documented with the two CNA's, EI #'s 3 and 4, involved in the incident. There was never a written statement obtained from EI # 4 (CNA). The written statement from EI #3 (CNA) was obtained after she was interviewed by EI #1 (DON) on 7/28/11, however, the original statement was not available. RI #7's wife was interviewed on Tuesday, 7/28/11, the fifth day after the incident. There was no report to the administrator until 7/28/11. On 8/1/2011 at 1:05 PM, Employee Identifier (EI) #1, the DON, said she did not call EI #4, the CNA who was present during the incident and who had told EI #5, (LPN) that it was bad. In hindsight, EI #1 (DON) said that she should have contacted EI #4 (CNA). EI #1 also said she should have also came into the facility. When asked about the facility's Policy and Procedures for handling abuse allegations, EI #1 stated that abuse was abuse, and all abuse allegations should be reported within 24 hours. She further stated the investigation was still ongoing and had not yet been completed (seven days after the incident), contrary to the facility's abuse / neglect policy. This deficiency is written as a result of the investigation of complaint / report #AL 879. [MEDICATION NAME][MEDICATION NAME][MEDICATION NAME][MEDICATION NAME] Allegation of compliance dated 8/1/11 F225 Failure to report allegation of abuse within 24 hours and failure to interview key witnesses. Plan of action: 1. Key witnesses were interviewed and statements taken. 2. Allegation of abuse was reported July 29, 2011 at 2:09 PM. 3. All staff members are currently being in-serviced beginning July 29, 2011. No staff members will be allowed to work until completion of in-service on abuse. 4. Director of Nursing suspended 08/01/2011 after completion of statements to state survey team, with pending termination. The Allegation of Compliance was reviewed and accepted. The in-service training for Abuse Identification and reporting didactic was reviewed. The state surveyor monitored one of the presentations to validate teaching of materials and participation of staff. The monitored class was comprised of staff from different departments to include nursing, housekeeping and activity departments. Random staff was interviewed to validate learning of the materials presented. Interviews included Registered Nurse, Licensed Practical Nurse and Certified Nursing Assistants. After reviewing and verifying the implementation of the facility's allegation of credible compliance, the immediate jeopardy was relieved on 08/02/2011 at 10:30 AM and lowered to a "D" level to allow the facility time to monitor and/or revise their corrective actions to sustain compliance.

Based on interviews, record review, and review of the facility's abuse policy and procedure, the facility failed to ensure Employee Identifier (EI) #1, the Director of Nursing (DON), implemented the protecting, reporting, and investigating components of the facility's abuse policy and procedures as outlined in the administration and nursing manuals. After becoming aware of an allegation of abuse on 7/23/11, EI #1, the Director of Nursing (DON), failed to protect residents from further abuse by not suspending the alleged perpetrator, EI #2, a Certified Nursing Assistant (CNA) who was not immediately suspended but allowed to continue to work. EI #1 failed to investigate and report an allegation of abuse within twenty-four hours, after it was brought to her attention by EI #5, the Licensed Practical Nurse (LPN) charge nurse on the day of the event. EI #1 further failed to interview any of the staff on duty at the time and also failed to interview Resident Identifier (RI) #7's wife who witnessed the abuse. EI #4 (CNA) witnessed EI #2 (CNA) grabbing RI #7 by the wrist, telling RI #7 that he was not going to hit her girls (referring to EI #3 and 4). EI #5 (LPN Charge Nurse) spoke to RI #7's wife, who witnessed the interchange, and to EI #4 (CNA witness) before she called EI #1 (DON) and informed the DON (EI #1) that there had been an incident. EI #5 (LPN Charge Nurse) informed EI #1 (DON) the witnesses used the terms verbal and physical abuse and EI #4 (CNA) had stated it was bad and involved EI #2 (CNA). EI #1 (DON) told EI #5 (LPN Charge Nurse) to have the CNAs write a statement and she would see the resident's wife on Monday (7/25/11), two days after the occurrence . This deficient practice affected RI #7, one of three sampled residents for abuse / neglect, and threatened the health and safety of residents, as it was likely to cause serious injury, harm or death. On 8/1/2011 at 5:30 PM, the survey team notified the facility's Administrator and the Executive Director that substandard quality of care at the immediate jeopardy level of "J" had been identified in F 226. The immediate jeopardy (IJ) began on 07/23/11, and was relieved on 08/02/11 at 10:30 AM, when the facility implemented immediate corrective actions to remove the immediacy and prevent any future recurrence. The scope / severity was lowered to a "D" level to allow the facility time to monitor and / or revise their corrective actions as needed to achieve substantial compliance. Findings include: The Nursing Manual of policies and procedures for Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property Prevention with the Revised date of 03/10 identified, "Protecting ...2. During allegations of abuse or neglect, all individuals involved will be protected from further abuse and neglect ...Reporting ... 2. anyone who witnesses and/or suspects an incident of resident abuse, neglect, involuntary seclusion and misappropriation of property must immediately report the incident to his/her department supervisor. 3. The department supervisor must immediately notify the executive director, administrator or designee, who in turn will notify the corporate director of resident health services. 4. The executive director, administrator or designee will take the following actions: A. Notify the appropriate state agency immediately (within 24 hours ...) as to the nature of the allegation, name of resident and individuals involved:...ALABAMA... to immediately report to one of the following: "Eldercare hotline ...Eldercare Fax line... E-Mail... D. if an employee is accused by name of committing any act of abuse, neglect, involuntary seclusion, and misappropriation of property, (or medication), immediate suspension from duty is mandatory until the investigation is completed... Investigation: 1. The executive director, administrator, or designee will immediately initiate an investigation of the alleged incident and include the following: a. Type of allegation being reported (i.e. physical, sexual, verbal abuse, neglect... f. Accused employee's statement or explanation of what happened... j. Interviews with all potential witness(es)(e.g. other staff members, residents, visitors, etc.)... 3. Witness(es) should submit written statements. These statements must be in the witnesses own handwriting. 4. The executive director, administrator or designee must ensure that the report is completed and sent per state/federal requirements to the appropriate state office within the following time frames: Alabama within 5 working days..." RI #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #7 was admitted to the hospital on [DATE] and was readmitted to the facility on [DATE]. The Admission Minimum (MDS) data set [DATE], identified RI #7 with a BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15. RI #7 required limited assistance of one person with transfers and personal hygiene but required extensive assistance with dressing and toileting. RI #7 is frequently incontinent of both bowel and bladder. On 7/29/2011 at 3:45 PM, EI #5 the LPN/Charge Nurse explained what had happened on 7/23/11 as; around 2:00 PM, when she had gone to check on RI #7, his family member reported there had been three CNAs in RI #7's bathroom. One of the CNAs had grabbed RI #7, (indicating his upper arms) and had been very forceful and very rude. RI #7's wife also told EI #5 (LPN Charge Nurse) that the CNA (later identified as EI #2) had been rude to her too, when she had tried to intervene. EI #5 (LPN Charge Nurse) said that RI #7's wife reported that the CNA/EI #2 was both physically and verbally abusive. EI #5 (LPN Charge Nurse) reported she had called EI #1 (DON) shortly after this and reported that she (EI #5) didn't know exactly what had happened, but EI #4 (CNA) had been there and said it was bad and involved EI #2 (CNA). EI# 5 (LPN Charge Nurse) also said she told EI #1 (DON) that RI #7's wife had said EI #2 (CNA) was physically and verbally abusive. According to EI #5 (LPN Charge Nurse), no one had talked to her about the incident, (which had been six days prior) and she had not been told to write up a statement. EI #5 (LPN Charge Nurse) said the DON (EI #1) had given instructions for the CNAs to write statements, to keep EI #2 (CNA who allegedly abused RI #7) off the hall (where RI #7 lived), to tell RI #7's wife that the DON (EI #1) would speak with her (RI #7's wife) on Monday (7/25/11), (two days later). On 7/30/2011 at 4:30 PM, (EI) #1, the DON was interviewed. When EI #1 was asked when she first became aware of the incident involving RI #7, she replied, EI #5 (the LPN) had called her (by phone) on the day of the incident (Saturday, 7/23/2011) to report that RI #7's family member had a complaint, EI #4 (CNA) said it was bad and it involved EI #2 (CNA). EI #1 (DON) stated that she told EI #5, the LPN, to get documentation and to send EI #2 (CNA who allegedly abused RI #7) back to her unit and for the CNA (EI #2) to stay there. EI #1 (DON) also said she did not hear anything else about the incident until she returned to work on Monday (7/25/11) when she found a written statement from EI #2 (the alleged abusive CNA). EI #1 (DON) said she spoke to RI #7's wife on Tuesday, (7/26/2011, three days after the incident to find out what had happened). EI #1 (DON) reported that RI #7's wife reported that a third girl (EI #2/CNA) came in (to the bathroom) and grabbed RI #7 by both wrists and told RI #7 he didn't need to be hitting her girls, (referring to the other CNAs). EI #1 (DON) stated she never saw any written statement from EI #4 (the CNA present during the incident and the one who had said it was bad,) nor did she see a statement from EI #3 (the other CNA present during the incident,) until after the surveyors spoke to EI #3, (on 7/28/11, 5 days after the incident). EI #1 (DON) revealed she had not informed the Administrator (EI #9) of the incident until Tuesday night (7/26/11, 3 days after the incident). Later in this conversation, EI #1 (DON) was asked if she had thought it seemed excessive that EI #2 had grabbed RI #7's wrists . EI #1 replied that she thought it was excessive, and commented that she asked RI #7's wife to clarify if the resident had been grabbed by the hands or the wrist. According to EI #1 (DON), RI #7's wife answered that it was by the wrist. Then, EI #1 commented that staff should never grab/hold the elderly by the wrists, and said that they (residents) bruise. On 7/28/2011 at 4:20 PM, Employee Identifier (EI) #4 (a CNA) described the events of Saturday 7/23/2011 in an interview. She stated she was in the bathroom assisting EI #3 (another CNA) clean up RI #7 at about 10:45 to 10:50 AM, when EI #2 came and asked if EI #3 was ready for break. EI #4 described RI #7 as not following simple commands, but not agitated or combative. EI #4 (CNA) said RI #7 was sitting on the commode mumbling and calling for his (RI #7's) wife by name, which was usual behavior for him, when EI #2 (CNA) grabbed RI #7's wrists and told him he was not going to hit her girls. RI #7's wife walked into the bathroom and said, "You let him go, you let him go now." EI #4 (CNA) said EI #2 (CNA) continued to hold RI #7's wrists and the resident's wife then said, "You're not going to talk to him like that, you let him go", and then told EI #2 (CNA) they were going to report her. EI #4 (CNA) said that EI #2 (CNA) extended her name badge and told the resident's wife in a loud voice, with a threatening demeanor to go ahead and report her. EI #4 (CNA) said RI #7's wife was visibly upset and crying. EI #4 (CNA) stated that EI #2 (CNA) said that she (EI #2) needed to get out of there, there was gonna be trouble, and then, she (EI #2) left to go for lunch with her (EI #2's) sister, EI #3 (CNA). In another interview with EI #4 (CNA) on 7/31/11 at 12:20 PM until 1:00 PM, she clarified by demonstration what EI #2 (CNA) had done as, grabbing RI #7's wrists and turned them so his hands were palms up. EI #4 (CNA) said RI #7 was sitting calmly on the toilet when EI #2 (CNA) did this, and RI #7 began struggling after EI #2 (CNA) grabbed him. EI #4 stated she had prepared a statement on 7/23/11, but tore it up and wrote another one on 7/29/2011 (six days after the incident). A review of RI #7's physician orders [REDACTED]. This 7/23/11 order also documents that a psychiatric consult could be obtained if the medication ([MEDICATION NAME]) was ineffective. Another order dated 7/23/11, documents that RI #7 was transferred to a hospital for evaluation and treatment. A 7/24/11, order documents that the resident was discharged from the facility and admitted to a hospital's psychiatric unit on 7/24/11. According to the "Facesheet" in RI #7's medical record, the resident was readmitted to the facility on [DATE] at 1:40 PM. A review of the facility staffing for July 2011, revealed that: On 7/23/11, EI #2 (CNA who allegedly abused RI #7) was allowed to continue to work on her assigned unit for the remainder of the shift; on 7/24/11, she (EI #2 / CNA) worked on the adjacent unit; on 7/25/11, EI #2 (CNA) worked on the locked dementia unit; on 7/26/11, EI #2 (CNA) worked on the locked dementia unit with RI #7; and, on 7/27/11, she (EI #2) also worked on the locked dementia unit with RI #7. EI #2 was scheduled off on 7/28/11, but returned to work on the adjacent unit on 7/29/11. On 7/29/2011 at 10:30 AM, Employee Identifier, (EI) #2, confirmed her work schedule in an interview. On 8/1/2011 at 1:05 PM, the Director of Nursing (DON), EI #1, said that she did not call EI #4, the CNA who was present during the incident and who had told the LPN Charge Nurse (EI #5) that it (the incident / situation) was bad. She stated in hindsight, she should have talked to the employee (referring to EI #4, a CNA) and she should have also come in (to the facility). According to EI #1, she found EI #4 (CNA) difficult to talk to and difficult to understand (couldn't tell if she was joking or serious). When asked about the facility's Policy and Procedures and handling abuse allegations, EI #1 stated, Abuse was Abuse, and all abuse allegations should be reported within 24 hours. EI #1 said that he person involved should be removed/suspended immediately until the investigation was completed (within 5 days.) per the facility's policy. EI #1 (DON) revealed EI #2 (CNA) had been suspended the previous day (7/29/11, six days after the incident,) because the CNA (EI #2) should have been suspended at the time (of the incident), and that the investigation was still ongoing and had not yet been completed (a full seven days after the incident). This deficiency is written as a result of the investigation of complaint / report #AL 879. [MEDICATION NAME][MEDICATION NAME][MEDICATION NAME] Facility allegation of compliance: F226 Failure to implement Policy and Procedure of Abuse and Investigate Incident. Plan of action: All staff members are currently being in-serviced beginning July 29, 2011 on Policy and Procedure of Abuse and reporting abuse. No staff members will be allowed to report to work without first attending mandatory Abuse in-service. The Allegation of Compliance was reviewed and accepted. The in-service training for Abuse Identification and reporting didactic was reviewed. The state surveyor monitored one of the presentations to validate teaching of materials and participation of staff. the monitored class was comprised of staff from different departments to include nursing, housekeeping and activity departments. Random staff was interviewed to validate learning of the materials presented. Interviews included Registered Nurse, Licensed Practical Nurse and Certified Nursing Assistant. After reviewing and verifying the implementation of the facility's allegation of credible compliance, the immediate jeopardy was relieved on 08/02/2011 at 10:30 AM and lowered to a "D" level to allow the facility time to monitor and/or revise their corrective actions to sustain compliance.