Every finding on record at Ahc Mckenzie

Based on facility policy review, medical record review, observations, and interviews, the facility failed to report suspected abuse for 1 of 19 (Resident #4) sampled residents reviewed for abuse. The findings included: 1. Review of the facility policy titled, Abuse Prohibition Plan, revised on 11/2/2023, revealed .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies.The state licensing/certification agency responsible for surveying/licensing the facility.The local/state ombudsman.The resident's representative.Adult protective services (where state law provides jurisdiction in long-term care).Law enforcement officials.The resident's attending physician.The facility medical director.Immediately is defined.within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Cerebral Infraction (stroke), Anarthria (complete loss of ability to articulate speech), Hemiplegia (severe or complete paralysis of one side of the body) and Hemiparesis (partial weakness or inability to move one side of the body). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 3 on the Brief Interview for Mental Status (BIM) assessment, which indicated she was severely cognitively impaired. She required total assistance with all Activities of Daily Living (ADLs). Review of the Care Plan revised on 3/25/2026, revealed Resident #4 had no updates related to bruising. During an observation and interview in Resident #4's room on 3/31/2026 at 2:35 PM, Licensed Practical Nurse (LPN) B did a skin assessment and observed bruising on resident's upper arm. LPN B was asked if she discovered bruising on a resident, what would she do. LPN B stated, .report to Director of Nursing, write a progress note regarding findings, I would look to see if resident had a recent fall that would explain bruising .do required skin assessment paperwork to document findings . During an interview on 3/31/2026 at 2:50 PM, the Administrator was asked if she was aware of an incident on 3/20/2026 involving Resident #4 and bruising to her upper right inner arm. The Administrator stated, No, I am unaware of any issues involving [Named Resident #4]. The Administrator was then told about the bruising to the Resident's arm that the sister noticed on her visit on 3/20/2026. The Administrator confirmed this was the first time she had heard of the incident and she would investigate the incident. The Administrator stated, .I expect all forms of abuse to be reported immediately . Review of the progress note dated 3/31/2026 at 5:31 PM, revealed the Director of Nursing (DON) documented .This nurse made aware per Administrator that resident's sister reported that she had observed bruising to upper ext. [extremity] around 3/20/2026. Upon assessment revealed 2 small areas mild discoloration areas to right upper arm on inner aspect . Review of the weekly comprehensive skin evaluation/assessments revealed there were no newly identified or existing wounds or skin integrity concerns documented on 3/4/2027, 3/11/2026, 3/18/2026 and 3/30/2026. No skin assessment was performed on 3/25/2026. During a phone interview on 3/31/2026 at 7:30 PM, the Treatment Nurse was asked if she worked on 3/20/2026. The Treatment Nurse stated Yes. The Treatment Nurse was asked if she recalled Resident #4's sister showing her bruising on the Resident's upper right inner arm. The Treatment Nurse stated .Yes, she had bruising on her upper right arm, it was faded yellow in color, not dark or purple in color, it was old, you could barely see it . The Treatment Nurse confirmed she had not reported the bruising to anyone. During an interview on 4/1/2026 at 10:10 AM, Certified Nursing Assistant (CNA) F stated, .the last shift I worked on 3/27/2026, we were giving report and [Named Resident #4]'s sister walked up .her sister was upset .and she said she had pictures of her [Resident #4's] arm with bruising. CNA F was asked if she told anybody about the sisters' concerns. CNA F stated, No. CNA F was asked if she should have reported it. CNA F stated, Yes. During an interview on 4/1/2026 at 10:20 AM, CNA E was asked about the incident on 3/27/2026 with Resident #4's sister. CNA E stated, .We were giving report, and [Named Resident #4]'s sister walked down the hall .she showed me the pictures of her upper right arm, in the pictures the bruising was very visible and looked bad . CNA E was asked if she reported what she saw in the pictures to anybody. CNA E stated, No. She was then asked if she should have reported it. CNA E stated, Yes. During an interview on 4/1/2026 at 12:10 PM, the DON was asked if she expected staff to notify her if they suspect abuse. The DON stated, Yes. The DON was asked if she should have been notified of the incident on 3/27/2026. The DON stated, Yes, abuse should always be reported. The facility's staff failed to report allegations of abuse related to unknown bruising found on Resident #4's arm on 3/20/2026 and 3/27/2026.

Based on medical record review and interview, the facility failed to maintain accurate medical records related to dietary intake for 2 of 3 sampled residents (Resident #16 and #53) reviewed for Nutrition. The findings include: Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief interview for Mental Status (BIMS) score of 15, which indicated Resident #16 was cognitively intact and required set-up help only with dining. Review of the Activity of Daily Living (ADL) Verification Worksheet dated 4/1/2022 - 4/30/2022, revealed incomplete documentation of the dietary intake for the following days: 4/1/2022-4/9/2022- No documentation for dinner. 4/11/2022- No documentation for dinner. 4/14/2022- No documentation for lunch or dinner. 4/15/2022-4/17/2022- No documentation for dinner. 4/20/2022-4/30/2022- No documentation for dinner. No meal percentages were recorded for the entire day on 4/10/2022. Review of the ADL Verification Worksheet dated 5/1/2022 - 5/9/2022, revealed incomplete documentation of the dietary intake for the following days: 5/1/2022- No documentation for dinner. 5/2/2022- No documentation for dinner. 5/5/2022 -No documentation for lunch. 5/6/2022 -No documentation for dinner. 5/8/2022 -No documentation for dinner. No meal percentages were recorded for the entire day on 5/3/2022. Review of the medical record, revealed Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5 day admission MDS dated [DATE] revealed a BIMS score of 0, which indicated Resident #53 had severe cognitive impairment and she was totally dependent on staff for eating. Review of the ADL Verification Worksheet dated 4/1/2022 - 4/30/2022, revealed incomplete documentation of the dietary intake for the following days: 4/8/2022- No documentation for dinner. 4/9/2022- No documentation for breakfast or lunch. 4/28/2022- No documentation for dinner. 4/29/2022- No documentation for dinner. No meal percentages were recorded for the entire day on 4/10/2022, 4/14/2022, and 4/30/2022. Review of the ADL Verification Worksheet dated 5/1/2022 - 5/9/2022, revealed incomplete documentation of the dietary intake for the following days: 5/3/2022- No documentation for dinner. 5/6/2022- No documentation for dinner. No meal percentages were recorded for the entire day on 5/7/2022 and 5/8/2022. During an interview on 5/11/2022 at 2:12 PM, the Director of Nursing (DON) confirmed dietary intake was not recorded for every meal for Resident #16 and #53. The DON confirmed staff should record all meal percentages in the electronic medical record.

Based on manufacturer's guidelines, observation, and interview, the facility failed to ensure blood glucose meters were appropriately monitored for accuracy for 1 of 3 (Station 3) blood glucose meters. The findings include: The (Named Blood Glucose Meter) Control Solution manufacturer's guidelines dated ,[DATE], documented .Control Solutions are for use .to check that the meter and the test strips are working properly and that you are performing the test correctly .Check the expiration date shown on the vial label. Do not use if expired . Observations of the Station 3 medication cart on [DATE] at 2:42 PM revealed 2 bottles of blood glucose monitoring control solution with an expiration date of ,[DATE] and an open date of [DATE]. Review of the Blood Glucose Monitoring System Daily Quality Control Record revealed the blood glucose meter for Station 3 nurse's station was monitored for accuracy utilizing the blood glucose monitoring control solutions that had an expiration date of ,[DATE] on ,[DATE]-[DATE], ,[DATE]-[DATE], [DATE], ,[DATE]-[DATE], ,[DATE]-[DATE] and ,[DATE]-[DATE]. Controls on the blood glucose meter were not performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. Interview with Registered Nurse (RN) #1 on [DATE] at 2:43 PM in the Station 3 Medication Storage Room, RN #1 confirmed the blood glucose monitoring control solutions were expired when they were opened and had been used to test the accuracy of the blood glucose meter. Interview with the Director of Nursing (DON) on [DATE] at 11:21 AM in the Conference Room, the DON confirmed that between [DATE] and [DATE] the blood glucose meter had been monitored with blood glucose monitoring control solutions that had an expiration date of ,[DATE].

Based on policy review, observation, and interview the facility failed to ensure medications were not expired in 2 of 9 (medication storage rooms on station 1 and 2) medication storage areas and that narcotic cards were unopened for 2 of 9 (medication carts for station 1 and station 3) medication storage areas. The findings included: 1. The facility's MEDICATION STORAGE policy documented, .Routine checks must be accomplished to ensure that expired medications are discarded . 2. Observations in the medication storage room station 1 on 11/15/17 at 10:06 AM, revealed 2 light sensitive bags with Ativan, Benadryl, Haldol, and Reglan gel for Resident #25, that expired on 9/28/17 and 11/2/17. Observations in the medication storage room station 2 on 11/15/17 at 10:26 AM, revealed 1 light sensitive bag with Ativan, Benadryl, Haldol, and Reglan gel for Resident #72, that expired on 9/28/17. 3. Interview with Assistant Director of Nursing (ADON) on 11/15/17 at 10:43 AM, in the medication storage room station 2, the ADON was asked if expired medications should be on the units. The ADON stated No . 4. Observations at the station 1 medication cart on 11/15/17 at 10:06 AM, revealed a HYDR(NAME)ODONE/APAP 5 MG (milligrams) /325 MG (a narcotic medication) card for Resident #124 had the seals broken behind pills #7, 10, 12, 15, 16, 21, 22, and 23 with tape sealing the medications in place. Observations at the station 1 medication cart on 11/15/17 at 10:06 AM, revealed a HYDR(NAME)ODONE/APAP 7.5/325 MG card for Resident #96 had the seals broken behind pills #9, 15, and 18 with tape sealing the medications in place. Observations at the station 3 medication cart on 11/15/17 at 10:43 AM, revealed a DIPHENOXYLATE/ATROP (atropine) 2.5-.025 MG (a narcotic medication) card for Resident # 11 had a seal broken behind pill #16 with tape sealing the medication in place. 5. Interview with the consulting Pharmacist on 11/15/17 at 3:46 PM, by telephone, the Pharmacist was asked if the seal is broken on a medication card should the pill be taped back in. The Pharmacist stated, .If it comes out it needs to be destroyed .if you put it back in the card they are pharmacy dispensing and they don't have the authority to dispense .

Based on resident rights and interview, the facility failed to ensure the residents were allowed to receive mail on Saturday. This practice could have affected all of the residents in the building receiving mail. The facility reported a census of 82. The findings included: The facility's Welcome Booklet documented, .Mail will be delivered to you each day . Interview with Resident #26 on 11/13/17 at 3:53 PM, in the resident's room, Resident #26 stated, .no mail on Saturday for the past 2 years .Resident Council has discussed mail not being delivered on Saturday .it would be nice to receive mail on Saturday . Interview with the Activities Director on 11/13/15 at 4:49 PM, in her office, the Activities Director was asked if residents received mail on Saturdays. The Activities Director stated, .they receive mail on Monday through Friday .the business office is closed on Saturday . Interview on 11/13/17 at 11:11 AM, outside the activity room, the Administrator was asked if the residents receive mail on Saturday. The Administrator stated .They were told and were ok not getting mail on Saturday .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 3 of 7 (Station 3, Station 2, and Station 1 medication carts) medication storage areas as evidenced by open and undated multi-dose vials of medication, expired medications, and various loose pills inside the medication carts. The findings included: 1. The facility's MEDICATION STORAGE POLICY documented, .Medications must be properly stored in medication rooms and medication carts .Whenever the seal of a multi-dose vial of medication is broken it must be initialed and dated by the nurse with an opened date; also suggested is to label the vial with the expiration date. The nurse must be aware of days of the month and count the days accordingly. The vial must be discarded after 28 days unless the manufacturer specifies a shorter expiration date. 2. The facility's Routine Cleaning of Equipment policy documented, .med (medication) carts should be kept clean at all time by the Charge Nurse. When a spill occurs, it should be cleaned up at that time . 3. Observations in the Station 3 medication cart on 8/31/16 at 3:29 PM, revealed the following: a. 1 open and undated multi-dose vial of Lantus Insulin b. 1 open and undated multi-dose vial of Levemir insulin c. 1 open and undated multi-dose vial of Novolog insulin d. 1 Novolog Flexpen with an opened date of 7/27/16 and an expiration date of 8/23/16 e. 1 multi-dose vial of Novolog insulin with an opened date of 7/24/16 and an expiration date of 8/20/16 f. 1 multi-dose vial of Lantus insulin with an opened date of 7/19/16 and an expiration date of 8/13/16 Interview with Licensed Practical Nurse (LPN) #1 on 8/31/16 at 3:35 PM, at the Station 3 nurse's station, LPN #1 confirmed the opened multi-dose vials were undated. LPN #1 was asked how long are you supposed to keep insulin once it's been opened. LPN #1 stated, 28 days, I believe. LPN #1 confirmed the medications were expired by stating,If that's their expiration date, they're expired . 4. Observations in the Station 2 medication cart on 8/30/16 at 3:56 PM, revealed the following: a. 1 open and undated multi-dose vial of Lidocaine HCL (Hydrochloride) 1% (percent) b. 1 open multi-dose vial of Lidocaine HCL 1% with an opened date of 6/14/16 c. 4 loose pills lying in the bottom of the medication drawer Interview with LPN #2 on 8/30/16 at 3:59 PM, at the Station 2 nurse's station, LPN #2 was asked how long Lidocaine can be kept once it was opened, LPN #2 stated, .this is something that has to be removed . LPN #2 was asked if she knew what the loose pills were. LPN #2 stated, I think it's just where somebody popped it out and they didn't go back and clean it out .can't use them once they hit the dirty area . 5. Observations in the Station 1 medication cart on 8/30/16 at 4:16 PM, revealed over 70 assorted loose pills scattered throughout the bottoms of 2 medication drawers. Interview with LPN #3 on 8/30/16 at 4:17 PM, at the Station 1 nurse's station, LPN #3 was asked if it was acceptable for the loose pills to be in the bottoms of the drawers in the medication cart. LPN #3 stated, No . Interview with the Director of Nursing (DON) on 8/30/16 at 4:34 PM, in the DON office, the DON was asked what she expected her nurses to do when they opened multi-dose vials of medication. The DON stated, Put the date opened and expiration date. The DON was asked if it was acceptable to keep medications past their expiration date. The DON stated, No ma'am. The DON was asked if it was acceptable to have loose pills inside the medication carts. The DON stated, No ma'am.

Based on medical record review, observation, and interview, the facility failed to follow fall care plan interventions for 1 of 16 (Resident #62) sampled residents of the 29 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 8/19/16 documented, .at risk for injury from falls r/t (related to) impaired mobility and cognitive impairment .Interventions .Brake extenders applied to w/c. STATUS: Active (Current) . Observations in the dinning room on 8/31/16 at 7:33 AM, revealed Resident #62 sitting up in a wheelchair eating breakfast. There were no brake extenders noted on the wheelchair. Interview with the Minimum Data Set (MDS) Coordinator on 8/31/16 at 11:10 AM, in Resident #62's room, the MDS Coordinator was shown Resident #62's wheelchair and was asked if there were brake extenders on Resident #62's wheelchair. The MDS Coordinator confirmed the brake extenders were not on Resident #62's wheelchair and stated, .that (the brake extenders) was an intervention .must have left them off . Interview with the Director of Nursing (DON) on 8/31/16 at 11:16 AM, in the DON's office, the DON was asked what the fall interventions were for Resident #62 for the fall on 5/7/16. The DON stated, Brake extenders . The DON was asked if she would expect the brake extenders to be on Resident #62's wheelchair. The DON stated, Yes . The DON and the surveyor walked to Resident #62's room and the DON confirmed the brake extenders were not on Resident #62's wheelchair.

Based on medical record review, observation, and interview, the facility failed to implement accident prevention interventions for 1 of 3 (Resident #62) sampled residents of the 3 residents reviewed for accidents. The findings included: Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was severely cognitively impaired, required limited assistance from 1 person for transfers and ambulation, and had 1 fall without injury since the previous assessment. The Comprehensive Care Plan dated 8/19/16 documented, .at risk for injury from falls r/t (related to) impaired mobility and cognitive impairment .Interventions .Brake extenders applied to w/c. STATUS: Active (Current) . Observations in the dinning room on 8/31/16 at 7:33 AM, revealed Resident #62 sitting up in a wheelchair eating breakfast. There were no brake extenders noted on the wheelchair. Interview with the MDS Coordinator on 8/31/16 at 11:10 AM, in Resident #62's room, the MDS Coordinator was shown Resident #62's wheelchair and was asked if there were brake extenders on Resident #62's wheelchair. The MDS Coordinator confirmed the brake extenders were not on Resident #62's wheelchair and stated, .that (the brake extenders) was an intervention .must have left them off . Interview with the Director of Nursing (DON) on 8/31/16 at 11:16 AM, in the DON's office, the DON was asked what the fall interventions were for Resident #62 for the fall on 5/7/16. The DON stated, Brake extenders . The DON was asked if she would expect the brake extenders to be on Resident #62's wheelchair. The DON stated, Yes . The DON and the surveyor walked to Resident #62's room and the DON confirmed the brake extenders were not on Resident #62's wheelchair.

Based on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the spread of infection in 4 of 30 (room [ROOM NUMBER], 104, 101, and 403) shared resident bathrooms. The findings included: Observations throughout the facility made with the Director of Nursing (DON) on 8/30/16 beginning at 3:21 PM, revealed the following: a. room [ROOM NUMBER] shared resident bathroom revealed a dirty plastic shelf container that had a build up of a white and brown substance in the bottom and contained a toothbrush, toothpaste, and a dirty plastic cup with a dried brown substance. Interview with the DON on 8/30/16 at 3:22 PM, in shared resident bathroom [ROOM NUMBER], the DON was asked what the white and brown substance was on the plastic container. The DON stated, .oh wow .looks like dried toothpaste . The DON was handed the dirty plastic cup with a dried brown substance on it. The DON was asked if she would expect to have a dirty cup and a dirty container in resident bathrooms. The DON stated, .no ma'am, not at all . b. room [ROOM NUMBER] shared resident bathroom revealed three unlabeled tooth brushes in a single cup sitting on the counter. Interview with the DON on 8/30/16 at 3:28 PM, in room [ROOM NUMBER] shared resident bathroom, the DON was asked how the staff would identify which toothbrush belongs to which resident. The DON stated, .oh, wow .I wouldn't know .no way to identify . c. room [ROOM NUMBER] shared resident bathroom revealed an unlabeled denture cup with dentures. Interview with the DON on 8/30/16 at 3:30 PM, in room [ROOM NUMBER] shared resident bathroom, the DON was asked if the denture cup should be labeled with a resident's name. The DON stated, Yes and confirmed the denture cup was unlabeled. d. room [ROOM NUMBER] shared resident bathroom revealed 2 toothbrushes lying on the bathroom counter. Interview with the DON on 8/30/16 at 3:33 PM, in room [ROOM NUMBER] shared resident bathroom, the DON was asked if the toothbrushes should be lying on the bathroom counter. The DON stated, .should be in holders .

Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dented can, an unlabeled white substance in a plastic pitcher, an unlabeled sandwich in the resident nourishment refrigerator, a brown greasy substance and a gold greasy substance on the convection oven racks and on the base of the oven, a gold greasy substance on the right front leg of the convection oven, a brown substance on the floor, and grease build-up on the stove. The facility had a census of 82, with 78 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's can defect policy documented, .can goods must be inspected for defects by the Kitchen Supervisor. any can that is classified as a. defect cannot be used in preparation. must be placed in a designated area. clearly labeled. non-use dented cans. The Kitchen Supervisor will contact. vendor for pick-up. Observations in the kitchen on 9/8/15 at 9:25 AM, and on 9/9/15 at 7:55 AM, revealed a dented 46 ounce (oz) can of tomato juice stored with the emergency food supply. Interview with the Dietary Manager (DM) on 9/8/15 at 9:26 AM, in the kitchen, the DM was asked if dented cans should be included with the emergency food supply. The DM stated, No, they should be separated from the supply. and returned to the vender. should not be in emergency supply. 2. Observations in the kitchen on 9/8/15 at 9:30 AM, revealed a white substance in a plastic pitcher sitting on a hydration cart that was not labeled. Interview with the DM on 9/8/15 at 9:32 AM, in the kitchen, the DM was asked if the pitcher with the white substance should be labeled. The DM stated, It should be labeled and dated. We don't know what it is if it is not labeled. 3. The facility's bedtime (HS) snacks policy documented, .diabetic snacks are labeled with the patient's name and room number. Observations on 9/8/15 at 4:20 PM, at the wildcat avenue nurses' station, revealed an unlabeled sandwich wrapped in plastic wrap in the resident nourishment refrigerator. Interview with Licensed Practical Nurse (LPN) #1 on 9/8/15 at 4:25 PM, at the wildcat avenue nurses' station, the LPN was asked about the sandwich in the nourishment refrigerator. The LPN stated, Snack for diabetic, not labeled. Should be labeled and dated. 4. The facility's dietary services training manual documented, .ovens will be clean and free of build-up of grease or spills. Ovens will be cleaned weekly and as spills occur. Remove oven racks. wash them in pot sink in hot detergent water. Wipe interior. exterior of ovens with warm detergent water. Ranges will be kept clean and free of spills and grease. range tops should be cleaned daily. Wipe up spills as they occur. Remove each section of the cooking surface and wash. Observations in the kitchen on 9/8/15 at 9:40 AM, and on 9/9/15 at 7:55 AM, revealed the following: a. Brown, greasy substance and gold greasy substance on the convection oven racks and inside base of the convection oven. b. Gold greasy substance dripping down the right front leg of the convection oven and pooling in the floor under the convection oven. c. Brown substance on the floor underneath the deep fat fryer. d. Thick black grease build up on the front right and left burners of the stove Interview with the Registered Dietician (RD) on 9/9/15 at 8:10 AM, in the kitchen, the RD was asked about the brown greasy substance and gold greasy substance on the convection oven racks and inside base of oven. The RD stated, It's either food or grease. Interview with the RD on 9/9/15 at 8:13 AM, in the kitchen, the RD was asked about the gold greasy substance dripping down the right front leg of the oven. The RD stated, Oh my, that is grease. Yes, fire hazard. We need to get that cleaned up right now. Interview with the RD on 9/9/15 at 8:15 AM, in the kitchen, the RD was asked about the substance under the deep fat fryer. The RD stated, That's dirt, needs to be cleaned. Interview with the RD on 9/9/15 at 8:19 AM, in the kitchen, the RD was asked about the black grease build up on the stove. The RD stated, Well it looks better than it did yesterday. They tried to clean it last night. Looks like they couldn't get it all cleaned off. I don't know if they can.

Based on medical record review and interview, the facility failed to follow the care plan for monitoring the wanderguard each shift for 1 of 18 (Resident #26) sampled residents reviewed of the 32 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 8/5/15 documented, .(Resident #26) has exhibited Wandering Behavior. Intervention. check wanderguard q (every) shift. Review of the annual Minimum Data Set ((MDS) dated [DATE] documented Resident #26's Brief Interview for Mental Status (BIMS) was 6, indicating the resident was severely cognitively impaired. Review of the Wanderguard Control Form dated 8/7/15 to 9/9/15 revealed the wanderguard was monitored daily and not every shift as care planned. Interview with the Administrator on 9/9/15 at 2:45 PM, in the Administrator's office, the Administrator was asked if the care plan documented that the wanderguard was to be checked every shift, would you expect to find documentation that the wanderguard had been checked every shift. The Administrator stated, I would.

Based on medical record review, observations and interviews, it was determined the facility failed to revise the care plan for the recommendations noted on the Pre-Admission Screening and Resident Review (PASRR) assessments for 1 of 29 (Resident #1) sampled residents reviewed of the 29 residents included in the stage 2 review. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/7/13 had no documentation for the recommendations by PASRR Case Summary. Recommendations were Occupational Therapy (OT) to assess and treatment to increase independence with Activities of Daily Living. Currently Resident #1 relies on staff and family to do most everything for him, yet he appears to have functional use of his hands. Recommendations were for Speech Therapy to assess for development of mealtime guidelines to promote safety and independence at mealtime. Review of the Case Summary dated 3/5/13 documented, "...He receives total care... He receives total care with dining..." Observations in Resident #1's room on 4/18/13 at 12:30 PM, revealed Resident #1 was being fed his lunch without any attempt to help himself. During an interview in the Conference Room on 4/18/13 the Administrator stated, "I can't find an OT Assessment."

Based on policy review, medical record review, observation and interview, it was determined the facility failed to develop a care plan for [MEDICAL TREATMENT] for 1 of 17 (Resident #11) residents with care plans reviewed of the 29 residents included in the stage 2 review. The findings included: Review of the facility's "[MEDICAL TREATMENT] PATIENT SERVICES" policy documented, "...There are several special interventions to be implemented with a patient receiving [MEDICAL TREATMENT]... Care plan must include: Care of [MEDICAL TREATMENT] patient with emergency procedures... Potential problems... Any non-compliance issues..." Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 4/16/13 documented, "[MEDICAL TREATMENT] M (Monday) -W (Wednesday) -F (Friday)... Pre & (and) Post wts (weights) MWF... CHECK THRILL AND BRIUT (bruit) TO SHUNT SITE EVERY SHIFT..." Review of the Admission Minimum Data Set ((MDS) dated [DATE] documented, "...Section O... Special Treatments, Procedures, and Programs... J. [MEDICAL TREATMENT]... (checked) 1. While NOT a Resident... (checked) 2. While a Resident..." Review of the 60-day MDS dated [DATE] documented, "...Section O... Special Treatments, Procedures, and Programs... J. [MEDICAL TREATMENT]... (checked) 2. While a Resident..." Review of the comprehensive care plan dated 1/28/13 documented no care plan for [MEDICAL TREATMENT] which included emergency procedures, potential problems or non-compliance issues. Observations in Resident #11's room on 4/16/13 at 8:45 AM, revealed Resident #11 had an arteriovenous shunt in left forearm. Skin over the shunt was dry and intact with a small amount of bruising. During an interview at Nurses' Station 2 on 4/16/13 at 4:30 PM, the Assistant Director of Nursing (ADON) was asked if assessment of the [MEDICAL TREATMENT] and procedures for emergency bleeding should be on the care plan. The ADON stated, "I would expect to see it..." During an interview in the Conference Room on 4/17/13 at 1:20 PM, the MDS Coordinator for skilled residents was asked if the facility had a care plan for [MEDICAL TREATMENT]. The MDS Coordinator for skilled residents stated, "We do..." The MDS Coordinator for skilled residents confirmed Resident #11 had no care plan for [MEDICAL TREATMENT].

Based on medical record review, observation and interview, it was determined the facility failed to provide specialized rehabilitation services for 1 of 29 (Resident #1) sampled residents of the 29 residents included in the stage 2 review. The findings included: Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 1/7/13 had no documentation for the recommendations by Pre-Admission Screening Resident Review (PASRR) Case Summary recommendations were for Occupational Therapy (OT) to assess and treatment to increase independence with Activities of Daily Living. Currently Resident #1 relies on staff and family to do most everything for him, yet he appears to have functional use of his hands. the facility was unable to provide an OT assessment. Observations in Resident #1's room on 4/18/13 at 12:30 PM, revealed Resident #1 was being fed his lunch without any attempt to help himself. During an interview in the Conference Room on 4/18/13 at 8:35 AM, the Administrator stated, the case summary "comes from the state people that come see him, Community Select Program. (named registered Nurse) comes every other week." During an interview in the Conference Room on 4/18/13 at 8:35 AM, the Administrator stated, "I can't find an OT Assessment."

Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure that a resident with falls had new interventions implemented after each fall and failed to follow current interventions for 1 of 7 (Resident #7) sampled residents with falls. The findings included: Review of the facility's "Fall Risk / Fall Prevention Guidelines" policy documented, "...Purpose: To provide a coordinated system to identify patients at risk for falls and develop an individualized interdisciplinary care plan to minimize the incidence of falls and subsequent injury..." Review of the facility's "Care Plans" policy documented, "...The care plan process must begin upon admission into the facility and be fluid and changeable representing the patient's status until the patient is discharged from the facility or is deceased ..." Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses' event notes documented the following falls and interventions: a. [DATE] - "...To ER (emergency room ) for Eval (evaluation) - meds (medications) review..." b. [DATE] - "...personal body alarm in place @ (at) all x's (times)..." c. [DATE] - "...Medication review..." d. [DATE] - "...will keep in eye sight after meals..." e. [DATE] - "...keep in sight of staff when ^ (symbol for up) in w/c (wheelchair)..." f. [DATE] - "...Apply non-slip dycem to recliner seat..." g. [DATE] - "...Will be in area where can be monitored by staff when in w/c..." h. [DATE] - "Res (resident) to be ambulated c (symbol for with) Restorative therapy..." i. [DATE] - "...Family Education..." Review of the restorative nursing documentation dated [DATE], [DATE] and [DATE] documented, "...2. Ambulate pt (patient) c HHA (hand held assistance) 100 ft (feet) or to pt's tolerance..." The [DATE] intervention to ambulate resident with restorative therapy was already in place. Review of the care plan dated [DATE] and updated [DATE] failed to document the [DATE] fall or an intervention. The interventions on [DATE], [DATE] and [DATE] all addressed keeping resident in sight of staff. Observations in Resident #7's room on [DATE] at 4:20 PM, revealed no dycem in the wheelchair seat or the recliner seat. Observations in the station 2 dining room on [DATE] at 8:00 AM, revealed Resident #7 seated in the wheelchair with no dycem in the chair. Observations in Resident #7's room on [DATE] at 8:50 AM, revealed Resident #7 seated in the recliner. There was no dycem in the recliner or in the seat of the wheelchair. During an interview in Resident #7's room on [DATE] at 8:50 AM, Nurse #1 was asked if there was a dycem in the recliner or the wheelchair. Nurse #1 stated, "...No..." During an interview in the classroom on [DATE] at 8:50 AM, Nurse #2 confirmed the [DATE], [DATE] and [DATE] interventions on the nurses' event notes all addressed keeping the resident in sight of staff, no documentation of the [DATE] fall or intervention was on the care plan and the [DATE] intervention to ambulate by restorative therapy was not a new intervention.

Based on review of "Long-Term Care Pocket Guide for Infection Control A Resource for Frontline Staff", medical record review, observation and interview, it was determined 1 of 6 (Director of Nursing) nurses failed to follow infection control practices to prevent the potential spread of infection by placing an uncapped intravenous (IV) tubing on a towel prior to insertion of the tubing into a peripheral intravenous central catheter (PICC) during medication pass. The findings included: Review of the "Long-Term Care Pocket Guide for Infection Control A Resource for Frontline Staff" documented, "...Disease control and prevention... 4. Common vehicle transmission... Transmitted by contaminated... medical devices, and equipment..." Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #5's room on 1/17/12 at 4:00 PM, the Director of Nursing (DON) removed the cap from the end of the IV tubing, placed the uncapped IV tubing on a towel, primed the tubing, cleaned the PICC port with alcohol, then placed the uncapped tubing that had been placed on the towel into the PICC port and started the IV medication. During an interview in the hall outside the classroom on 1/19/12 at 7:50 AM, the DON was asked if she would expect a nurse to place an uncapped IV tubing on a towel, then place the tubing in a PICC. The DON stated, "...No..." During an interview in the hall outside the classroom on 1/19/12 at 7:55 AM, the DON confirmed that she had placed the uncapped tubing on the towel and then placed the tubing into the PICC.

Based on policy review, review of the "Medication Guide for the Long-Term Care Nurse", review of the facility's meal times, medical record review, observations and interviews, it was determined the facility failed to ensure 4 of 5 nurses (Nurses #1, 2, 4 and 5) administered medications with a medication error rate of less than five percent (%). The nurses made 4 errors out of 47 opportunities for error which resulted in a medication error rate of 8.51%. The findings included: 1. Review of the facility's Medication Pass Policy documented "...MEDICATIONS (meds) BEFORE MEALS ...6:30AM - 11;30AM - 5PM ALL MEDS WITH FOOD: 8:00 AM --1:00PM --6:00PM..." Review of the facility's Meal Service Begins times documented "...Supper: 5:10 p.m... Order of Delivery... Station 1 (400) hall & (and) Dining Room... Station 2 (200) hall... Station 3 (300) hall... Approximate Meal Departure Times... Supper... Station 3... 5:25 p.m..." Review of the "Medication Guide for the Long-Term Care Nurse", page 68, documented "...4. When medications are ordered before or after meals, be sure the medicine is given correctly in relationship to meals..." a. Medical record review for Random Resident (RR) #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 10/14/10 documented "[MEDICATION NAME] TAB 10MG (milligrams) ONE TAB IN THE MORNING & WITH SUPPER..." Observations in RR #1's room on Station 2 on 10/18/10 at 3:55 PM, revealed Nurse #1 administered [MEDICATION NAME] to RR #1. The failure to administered the medication with supper as ordered resulted in medication error #1. b. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 9/22/10 documented "...GERI-TONIC LIQ (liquid) 15 MLS (milliliters) BEFORE MEALS..." Observations in Resident #10's room on Station 3 on 10/18/10 at 4:05 PM, revealed Nurse #2 administered the Geri-Tonic to Resident #10. The failure to administer the Geri-Tonic before a meal as ordered resulted in medication error #2. During an interview at Station 3 on 10/18/10 at 4:07 PM, Nurse #2 was asked when the supper meal was served. Nurse #2 stated, "...5:30 (PM)..." During an interview at Station One on 10/19/10 at 8:14 AM, the Director of Nursing (DON) was asked when she would expect medications ordered before meals to be given. The DON stated, "...It should be 30 minutes to an hour..." The DON was asked when medications would be given if it was ordered with a meal. The DON looked at the Medication Pass Policy and stated, "...It would be 8 (AM) 1 (PM) and 6 (PM)..." The DON was asked when she would expect a medication to be given when it is ordered with supper. The DON stated, "...it would be 5 to 5:30 (PM)..." 2. Medical record review for RR #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 10/14/10 documented "[MEDICATION NAME] SYP (syrup) 100/5ML 10CC (cubic centimeters) (200MG) BY MOUTH EVERY FOUR HOURS..." Observations in RR #2's room on 10/19/10 at 7:20 AM, revealed Nurse #4 cut a [MEDICATION NAME] ([MEDICATION NAME]) 400 mg tablet in half and administered one half of the [MEDICATION NAME] tablet to RR #2. The failure to administer the [MEDICATION NAME] as ordered resulted in medication error #3. During an interview at Station 2 on 10/19/10 at 7:55 AM, Nurse #4 was asked about the order for liquid [MEDICATION NAME]. Nurse #4 stated, "...They (physician) changed it..." Nurse #6 was at the nurses' station, and looked through RR #2's medical record. Nurse #6 was asked if she found an order to change the medications from liquid to tablet. Nurse #6 stated, "...No, it's (order) not (in the record)... have to write an order..." 3. Medical record review for Resident #9 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 9/22/10 documented "[MEDICATION NAME] TAB (tablet) 5MG ONE TAB... PER PEG TUBE EVERY DAY...(check) Blood Pressure..." Observations in Resident #9's room on 10/19/10 at 9:40 AM, revealed Nurse #5 prepared Resident #9's medications, crushed them and mixed them with water, and took them into Resident #9's room. Nurse #5 placed a pulse oximeter on Resident #9's right middle finger. Nurse #5 was asked what she was checking. Nurse #5 stated, "...Pulse...she gets [MEDICATION NAME]" Nurse #5 was not able to obtain a pulse with the oximeter, so she checked a radial pulse which she stated was "64". Nurse #5 then administered the medication via the PEG tube to Resident #9. The failure to check the resident's blood pressure prior to administering the [MEDICATION NAME] resulted in medication error #4.

Based on policy review, medical record review and observation, it was determined the facility failed to provide the necessary treatment and services to promote the healing of pressure sores for 1 of 2 Random Residents (RR #3) observed during a dressing change. The findings included: Review of the facility's "Dressing Changes" policy documented, "...11. Clean wound per order. Cleanse away from debris and drainage from wound, moving from center outward; use a new pad for each area cleaned, discarding the old pads..." Medical record review for RR #3 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in RR #3's room on 10/19/10 at 9:45 AM, revealed RR #3 laying in bed on her right side. Nurse #6 removed the sock from RR #3's right foot and applied skin prep to the wound area, let the area air dry, then reapplied the sock that was removed. Nurse #6 did not clean the wound. During an interview at Station 1 on 10/19/10 at 1:55 PM, Nurse #6 was asked to find the order in the chart for wound care of RR #3's right medial foot. After reading the order Nurse # 6 stated, " ...yeah, I did not clean (the wound) with Normal Saline, I know, I was thrown when the surveyor ask me about the foot, I was not prepared, it (surveyor asking about the wound) threw me off... Yes, I did not clean with Normal Saline as order states..."

Based on medical record, observation and interview, it was determined the facility failed to ensure the Foley catheter tubing was kept off of the floor for 1 of 5 (Resident #3) sampled residents with a Foley catheter. The findings included: 1. Medical record review for Resident #3 documented an admission date of [DATE] with a current [DIAGNOSES REDACTED]. Observations in the main dining room on 10/19/10 at 7:15 AM and on 10/19/10 at 11:45 AM and 12:05 PM, revealed Resident #3 sitting in a wheelchair with the Foley catheter tubing touching the floor. Observations in Resident #3's room on 10/19/10 at 8:35 AM, revealed Resident #3 seated in a wheelchair with the Foley catheter tubing laying on the floor underneath the wheelchair. Nurse #5 administered medications to Resident #3, but did not move the catheter tubing off of the floor. Observations on the 400 hall on 10/19/10 at 9:15 AM, revealed Resident #3 sitting in a wheelchair with the Foley catheter tubing touching the floor. Observations in Resident #3's room on 10/19/10 at 11:15 AM, revealed Resident #3 in a wheelchair with the Foley catheter tubing touching the floor. During an interview outside the Registered Nurse's office on 10/20/10 at 4:15 PM, Nurse #8 confirmed that the Foley catheter tubing should never be on the floor.

Based on observation, it was determined 1 of 5 (Nurse #5) nurses administering medications failed to ensure medications were stored in locked compartments when Nurse #5 left medications at residents bedside out of her view. The findings included: 1. Observations during medication pass in Resident #3's room on 10/19/10 at 8:35 AM, Nurse #5 left medications on the bedside table out of her view while she washed her hands in the bathroom. 2. Observations during medication pass in Resident #9's room on 10/19/10 at 9:58 AM, Nurse #5 left eye drops on the bedside table out of her view while she washed her hands in the bathroom.