Every finding on record at Aspen Ridge Transitional Rehab

Based on interview and record review, it was determined that for 1 of 5 sampled residents that the facility did not ensure that the resident's medical record indicated that the resident either received the influenza immunization or did not receive the influenza vaccination immunization due to medical contraindications or refusal and that the facility did not ensure that the resident's medical record included documentation that the resident either received the pneumococcal immunization due to medical contraindication or refusal. Specifically, there was not documentation that the facility provided or that the resident refused the pneumonia and influenza immunization. Resident Identifier: 28. Findings Include: Resident 28 was admitted on [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing, urinary tract infection, and hypertensive heart disease with heart failure. Resident 28's medical record was reviewed 1/14/25 though 1/16/25. A form labeled PNA [pneumonia], FLU [influenza], COVID [coronavirus] Psychotherapeutic Medication Consents was located in resident 28's medical record. The form was signed by resident 28 and dated 11/29/24. The form contained checkboxes to mark resident 28 as up-to-date on both the influenza and pneumonia vaccinations, to mark that resident 28 gave the facility permission to administer both of the vaccines, or to mark that resident 28 declined to give the facility permission to receive both of the vaccines. None of the checkboxes were marked on the form. On 1/16/25 at 1:32 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that nursing staff needed to ensure that the vaccination consent form was fully completed before staff or the resident signed the form.

Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, a resident reported constipation with no bowel movement for 4 days and treatment was not provided. Resident identifier: 13. Findings included: Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which consisted of displaced intertrochanteric fracture of right femur, sondylosis, chronic kidney disease, and malignant neoplasmof prostate. On 1/14/25 at 9:43 AM, an interview was conducted with resident 13. Resident 13 stated that he was constipated from his narcotic pain medication and it had been 4 days since he had a bowel movement. Resident 13 stated that they gave him some medication this morning for the constipation. On 1/1/25, the admission Minimum Data Set (MDS) assessment documented that resident 13 required supervision with toileting. Review of resident 13's point of care (POC) documentation for bowel and bladder documented the following: a. On 1/1/25 - no bowel movement (BM). b. On 1/6/25 - no bowel movement. c. On 1/7/25 - no bowel movement. Resident 13's vital signs under output - bowel movement documented the following: a. On 12/30/24 at 10:59 AM, resident 13's documentation for BM documented a large BM. b. On 1/7/25 at 2:04 PM, resident 13's documentation for BM documented a small BM. Resident 13's physician orders revealed the following: a. Senna tablet 8.6 milligram (mg), Give 1 tablet by mouth two times a day for constipation and oxycodone use. b. Day 3 (Bowel Brigade) = Administer Milk of Magnesia 30 cubic centimeters (cc) by mouth in the morning as needed. c. Day 4 (Bowel Brigade) = Administer Dulcolax 10 mg by mouth or per rectum in the morning as needed. d. Day 5 (Bowel Brigade) = Administer Fleets Enema or Enemeez as needed in the morning. e. Day 6 (Bowel Brigade) = If no BM in greater than 5 days, notify the physician for further orders. Resident 13's January Medication Administration Record (MAR) revealed: a. On 1/4/25 at 9:36 AM, the Bowel Brigade Day 3 was administered and was documented as SE (Semi-effective). b. On 1/7/25 at 8:19 AM, the Bowel Brigade Day 3 was administered and was documented as not effective. c. On 1/7/25 at 11:35 AM, the Bowel Brigade Day 4 was administered and was documented as not effective. d. On 1/7/25 at 1:37 PM, the Bowel Brigade Day 5 was administered and was documented as effective. On 1/7/25 at 1:46 PM, resident 13's nursing progress note documented, Pt [patient] has not had BM for 6 days, MOM [Milk of Magnesia] given, no BM, suppository given, still no BM, Enema given, in house provider notified. On 1/7/25, the abdomen xray for resident 13 documented increased fecal material noted throughout the colon, no evidence of mechanical obstruction. On 1/15/25, resident 13 had a care plan initiated for Alteration in Elimination: Patient had constipation. Interventions included assist resident to utilize the toilet, commode or bedpan as needed; keep accurate records of bowel movements to avoid complications; administer medications per the physician orders; encourage fluids as allowed; and follow facility bowel protocol. On 1/16/25 at 8:41 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 13 had just started walking to the bathroom with therapy the day before yesterday. CNA 1 stated that prior to walking to the bathroom resident 13 used a bedside commode. CNA 13 stated that they were encouraging resident 13 to go to the bathroom with assistance, and he required a two-person assist with toileting. CNA 1 stated that she charted documented the resident BM in the chart. CNA 1 stated that the nurse would also ask to make sure he had one. CNA 1 stated that resident 13 had complained of constipation yesterday and asked the nurse for a stool softener. On 1/16/25 at 8:51 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that they had a facility bowel protocol for residents if they were on opioid medications. RN 1 stated that the resident would have orders for Mirilax or Senna daily. RN 1 stated that after 3 days without a BM they would give the resident Milk of Magnesia. RN 1 stated that if the resident did not have a BM after 4 days they administered a suppository. RN 1 stated that if the resident continued to not have a BM then on day 5 they administered an enema. RN 1 stated that most residents usually had a BM after the suppository. RN 1 stated that depending on the resident they could adjust the protocol and give the suppository early on day 3. RN 1 stated that the night shift nurse monitored each resident's bowel movements and printed a report daily that indicated if the resident had not had a BM. RN 1 stated that the nurse would then report during shift change if the bowel protocol had been initiated. RN 1 stated that resident 13 was given Milk of Magnesia yesterday and it was day 4 without a BM for resident 13. RN 1 stated if the patient was alert and oriented then they told the nurse if they need something for a BM. RN 1 stated that she talked with the Nurse Practitioner (NP) and yesterday bowel brigade day 4 and MOM were administered. RN 1 stated that morning she talked to the patient and offered a suppository or enema. RN 1 stated resident 13 declined the suppository but wanted the enema. RN 1 stated the enema was administered between 7:30 AM and 8:00 AM. RN 1 stated resident 13 had a small BM twice but was complaining of lower abdominal pain. RN 1 stated she notified the NP and the NP ordered Lactulose 30 ml and an x-ray to see if resident 13 had a bowel obstruction. RN 1 stated resident 13 was taking as needed Oxycodone and he did not want to move much. RN 1 stated the NP said resident 13 might need his daily laxative dose adjusted. RN 1 stated resident 13 had complained of constipation about a week ago and was administered the bowel protocol which included adding Senna and Miralax daily. RN 1 stated resident 13 doing okay but was constipated again. RN 1 stated that resident 13 informed her yesterday that his last BM was day 4 ago. RN 1 stated on 1/3/25 they should have started the bowel protocol for no BM. RN 1 stated that typically MOM, a suppository and an enema were not administered all in the same day. RN 1 stated that with a suppository and enema they waited a couple of hours to see if it was effective. On 1/16/25 at 9:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the bowel protocol standing orders for medications based on how many days a resident had not had a bowel movement. The DON stated the physician was to be contacted if the resident did not have a bowel movement for 7 days. The DON was observed to review resident 13's BM documentation. The DON stated resident 13 had a BM on 12/30/24 and no BM from 12/31/24 through 1/6/25. The DON stated resident 13 should have the bowel brigade protocol on 1/2/25 which included MOM. The DON stated a suppository was administered on 1/3/25 suppository, enema on 1/4/25, and the physician was notified on day 6. The DON stated there was not another order in place to override the bowel brigade. The DON verified with the MAR that the protocol was administered all on 1/7/25.

Based on interview and record review, it was determined that for 1 of 21 sampled residents that the facility did not ensure that the attending physician or prescribing practitioner documented their rationale as to why PRN [as needed] medication order was extended beyond 14 days. Specifically, the resident had a PRN order for clonazepam, an anti-anxiety medication. The order had no end date and no rationale from the prescribing practitioner was documented in the medical record as to why the order was longer than 14 days. Resident Identifier: 23 Findings Include: Resident 23 was admitted on [DATE] with diagnoses which included anxiety disorder unspecified, major depressive disorder recurrent unspecified, and unspecified mood [affective] disorder. Resident 23's medical record was reviewed from 1/14/25 through 1/16/25. A physician's order dated 12/20/24 with no end date revealed, Clonazepam - Schedule IV table; 0.5 mg [milligrams]; amt: [amount] 0.5 mg; Quantity: 42; oral Special Instructions: DX: [diagnosis] ANXIETY -DO NOT administer within 1 hour of opioids d/t [due to] risk of respiratory depression - Every 8 hours. A progress note entered by the Director of Nursing (DON) dated 12/20/24 stated, provider reviewed resident's PRN [as needed] Clonazaepam and decided to keep it on his medication regimen as resident is using it and reports that it is helping with his anxiety. The resident's physician progress notes and nurse practitioner progress notes were reviewed for the following dates: 11/15/24, 11/18/24, 11/19/24, 11/27/24, 11/29/24, 12/2/24, 12/10/24, 12/11/24, 12/12/24, 12/16/24, 12/17/24, 12/18/24, 12/24/24, 12/26/24, 12/30/24, 1/3/25, and 1/7/25. Four of the progress notes did note that Resident 23's anxiety symptoms were controlled. However, none of the notes had a documented rationale as to why the order placed for PRN Clonazepam on 12/20/24 had been in place for longer than 14 days. On 1/16/25 at 10:20 AM, an interview was conducted with the DON. The DON stated that if a resident was admitted with a PRN order for psychotropic medication, then the facility notified the facility physician and added a stop date on the order within 14 days of admission. The DON stated that after those 14 days, the physician evaluated if the resident was utilizing the medication and if the resident still needed the medication. The DON stated that if the resident was not using the medication or the medication was not working by day 14, then the order was discontinued. The DON stated that the prescribing provider should document in the resident's medical record a rationale for any PRN psychotropic medications orders. The DON stated that the facility physician or provider verbally ordered if the medication was to be continued or discontinued, but that he was unsure if the physician documented the rationale anywhere in the medical record.

Based upon observation and interview, it was determined that the facility did not ensure that medications were labeled or stored appropriately. Specifically, insulin pens were not dated as to their opening date/expiration date, and labeling indicated that they should be refrigerated but were stored at room temperature. Findings include: On 11/9/21 at 12:30 PM, the medication cart in the 100 to 118 hallway was observed. The medication cart was observed to contain eight insulin pens that had been opened, but were not labeled with an open date. In addition, the pens were labeled as requiring refrigeration, but had been placed in the medication cart instead of the medication refrigerator. On 11/9/21 an interview was conducted with the Director of Nursing (DON). The DON confirmed that the insulin pens should have been labeled with an open date.

Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a partially vaccinated resident was not placed on isolation precautions, a nurse was observed to not perform hand hygiene prior to administering eye drops to a resident, a nurse was observed to place medications into her hand while wearing a contaminated glove, and staff were observed to not be wearing the appropriate Personal Protective Equipment (PPE). Resident identifiers: 84. Findings include: 1. Resident 84 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/8/21 at 12:10 PM and 1:20 PM, resident 84's room was observed. No isolation cart was observed to be placed outside of resident 84's room. No signage was observed to be on resident 84's door to indicate that the resident was on isolation precautions. On 11/8/21 at 1:20 PM, an interview was conducted with resident 84. Resident 84 stated that she had one COVID-19 vaccination in January of 2021. Resident 84 stated that she received a Pfizer vaccine, but that it made her feel ill, so she had chosen not to receive the second dose. Resident 84's medical record was reviewed on 11/8/21. Resident 84's vaccination record indicated that resident 84 had received her first dose of the COVID-19 vaccine in January 2021. The vaccination record did not indicate if resident 84 had received the second dose. On 11/9/21 at 12:30 PM, an interview was conducted with the facility Director of Nursing (DON) and the Infection Preventionist (IP). The DON stated that if residents were vaccinated, then they were not placed on isolation precautions upon admit. The DON stated that if residents were unvaccinated, then residents were placed on isolation precautions for 14 days. When asked about resident 84, who was partially vaccinated, the DON stated that resident 84 did not want to be placed on isolation precautions, so the facility honored her request despite her not being fully vaccinated. 2. On 11/8/21 at 12:02 PM, the Administrator (ADM) was observed to be in the 101 to 118 hall. The ADM stated that the doors to this hall were closed because a staff member had recently tested positive for COVID-19, and the residents in this hall had been exposed. At 12:03 PM, in the 101-108 hall the following observations were made: a. Certified Nursing Assistant (CNA) 1 was observed to have eyeglasses on, but no eye protection. In addition her mask had been pulled down below her chin. b. The Business Office Manager (BOM) was not wearing eye protection. c. CNA 2 was wearing her face shield on top of her head. d. The Administrative Assistant (AA) was not wearing eye protection. e. An unidentified staff member was not wearing eye protection. 3. On 11/8/21 at 12:19 PM, CNA 1 was observed to be at the nurses station with her eye protection on her head. 4. On 11/8/21 at 12:37 PM, the AA was observed to be at the nurses station with no eye protection. 5. On 11/8/21 at 1:00 PM, the Registered Dietitian was in resident 84's room, and was not wearing eye protection, a gown or gloves. 6. On 11/9/21 at 9:00 AM, the the AA was observed to be at the nurses station with no eye protection 7. On 11/9/21 at 9:03 AM, a dietary staff member and the BOM were observed to be walking in the hall by the nurses station without eye protection. 8. On 11/9/21 at 9:14 AM, 9:35 AM, 10:03 AM, and 10:13 AM Registered Nurse (RN) 1 was observed to be walking in the hall by the nurses station without eye protection. 9. On 11/9/21 at 10:16 AM, the BOM was observed to be walking in the hall by the nurses station without eye protection. On 11/9/21 an interview was conducted with the facility DON and IP. The DON stated that he thought that eye protection only needed to be worn during patient care, and would reeducate his staff. Per the State of Utah, eye protection should be worn in all areas of the facility except employee only areas during an outbreak or high community transmission rates https://coronavirus-download.utah.gov/Health-provider/Staff_PPE_Requirements_Chart_9.17.2021.pdf 10. On 11/9/21 at 7:30 AM, RN 1 was observed during a medication pass. RN 1 was observed to don gloves and then touch multiple surfaces of the medication cart and medication blister pack prior to dispensing the medication from the blister pack directly into her gloved hand. RN 1 was then observed to drop the medication into the medication cup for residents. RN 1 was then observed to document the medication had been administered in the computer, using her gloved hands. RN 1 then was observed to dispense the resident's next medication, using her contaminated gloves, again placing them directly into her hands, and repeating the process until all of the resident's medications were in the medication cup. This was observed for a total of 25 medications that were administered by RN 1 to multiple residents. 11. On 11/9/21 at 7:30 AM, RN 1 was observed to administer eye drops to a resident. RN 1 did not perform hand hygiene prior to administering the eye drops.

Based on record review and interview, the facility did not inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Findings include: On 11/8/21 at 8:30 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that there was a staff member who had tested positive for COVID-19 on 11/5/21. The ADM stated that when there was a new COVID-19 case, the facility communicated the information to residents and their representatives via a website. On 11/8/21, the website provided by the ADM was reviewed. The website indicated that it was last updated on 11/1/21. On 11/8/21, an interview was conducted with the facility Director of Nursing (DON). The DON confirmed that the website was not updated properly, and that the Therapy Director (TD) was responsible for updating the website timely. The DON confirmed that a staff member had tested positive on 11/5/21, and a resident had tested positive on 11/4/21. On 11/9/21 at 2:45 PM, an interview was conducted with the TD. The TD confirmed that he was supposed to update the website daily if there was a change.

Based on interview and record review, it was determined the facility did not immediately consult with the resident's physician when there was a need to alter treatment significantly. Specifically, for 1 of 18 sampled residents, the physician was not notified of high blood glucose measurements in accordance with physician-ordered parameters. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Insulin . Per Sliding Scale; If Blood Sugar is 150 to 200, give 1 Units. If Blood Sugar is 201 to 250, give 2 Units. If Blood Sugar is 251 to 300, give 3 Units. If Blood Sugar is 301 to 350, give 4 Units. If Blood Sugar is 351 to 400, give 5 units. If Blood Sugar is greater than 400, call MD (physician) . Resident 13's Medication Administration Record [REDACTED] a. On 9/15/19 during the 11:30 (AM) - 12:15 (PM) administration time frame, resident 13's blood glucose was measured to be 472 milligrams per deciliter (mg/dL). There was no documentation that the physician was notified of this blood glucose measurement that was greater than 400 mg/dL. b. On 9/21/19 during the 11:30 - 12:15 administration time frame, resident 13's blood glucose was measured to be 494 mg/dL. There was no documentation that the physician was notified of this blood glucose measurement that was greater than 400 mg/dL. c. On 9/21/19 during the 17:30 (5:30 PM) - 18:15 (6:30 PM) administration time frame, resident 13's blood glucose was measured to be 404 mg/dL. There was no documentation that the physician was notified of this blood glucose measurement that was greater than 400 mg/dL. Resident 13's nursing progress notes were reviewed from 8/5/19 through 10/9/19. There was no documentation that the physician was notified of the blood glucose measurements that were greater than 400 mg/dL on 9/15/19 and 9/21/19. On 10/8/19 at 3:12 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a resident had a blood glucose that measured greater than 400 mg/dL, she would notify the physician in order to receive an order for [REDACTED]. On 10/9/19 at 8:46 AM, an interview was conducted with RN 2. RN 2 stated if a resident had a blood glucose that measured greater than 400 mg/dL, she would notify the physician and write a progress note documenting that she had notified the physician. On 10/9/19 at 8:54 AM, an interview was conducted with the Nurse Manager (NM). The NM stated an additional insulin administration order was typically received after a resident's blood glucose measured greater than 400 mg/dL, and that order signified that the physician was notified. The NM further stated there were no additional insulin administration orders following resident 13's blood glucose measurements that were greater than 400 mg/dL on 9/15/19 and 9/21/19. On 10/9/19 at 10:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated he would have expected to see an insulin administration order in response to a resident's blood glucose that measured greater than 400 mg/dL, and that was the facility's typical process. The DON further stated he was unable to locate insulin administration orders in response to resident 13's blood glucose measurements that were greater than 400 mg/dL on 9/15/19 and 9/21/19.

Based on observation, interview, and record review it was determined, for 1 of 2 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff failed to get a follow up orthopedic appointment for a resident who had been admitted to the facility after a fall, left [MEDICAL CONDITION] and a left hip arthroplasty and no documentation could be located that the was receiving consistent cleaning and dressing changes to the left hip surgical site. In addition, the resident's IVAD (Implantable Venous Access Device) Port ([MEDICAL CONDITION] treatments and blood draws) was left open after being accessed during her stay in the facility. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/31/18 resident 1's medical record was reviewed. 1. Nursing progress notes and a physician progress notes [REDACTED]. a. 8/13/18 AT 8:26 PM, L (left) hip cleansed and Telpha placed over incision. Incision edges well approximated with yellow green drainage throughout old dressing Pt (patient) R (right) IVAD (Implantable Venous Access Device) was accessed in the hospital on 8/7, site flushes easily and is clean with no s/s (signs or symptoms) of any redness or swelling b. 8/14/18 at 1:35 PM, DRSG (dressing) changed to hip/thigh); incisions were clean, dry and well approximated c. 8/20/18 at 9:35 PM, Dsg (dressing) tp (sic) left hip incision dry and intact d. 8/21/18 at 11:18 AM, Left hip incision dressing dry and intact e. 8/22/18 at 2:41 PM, DRSG changed to Lt (left) Hip/Thigh: incisions were clean, dry and well approximated. No signs of infection observed f. 8/23/18 at 2:45 PM, No signs of infection observed to Lt hip g. 8/26/18 at 1:20 PM, Dressings to L hip are CDI (clean, dry and intact) h. 8/28/18 at 1:32 PM, Incision to Lt hip were clean, dry and well approximated. No signs of infection observed. i. 8/29/18 at 10:11 AM, Left hip hematoma; I will order an ultrasound since he (she) had (a)big hematoma in his (her hip) and alert orthopedic surgeon to see if it needs to be evacuated j. 8/30/18 at 10:45 AM, Pt has been working with PT/OT (physical and occupational therapy) and nursing to get her ready for safe discharge to home. Dressing to hip changed, 4x4 (gauze) was soaked with red blood, sutures in place, no redness noted k. 9/11/18 at 1:34 PM, Large/hardened lump observed under top incision to lt hip. Some bleeding observed. Stitches in place. CNM (Clinical Nurse Manager) notified to ask house MD (Medical Doctor) (Name of Physician) to see pt when he comes today l. 9/12/18 at 3:46 PM, L hip is clean and covered with a new bandage from prior shift m. 9/14/18 at 2:52 PM, Patient discharged to home with (Name of Home Health) PT/OT/RN (Registered Nurse) services. Stitches removed by CNM. physician's orders [REDACTED]. Diet Instructions: regular diet. Activity Instructions: WBAT (weight bearing as tolerated), currently needing walker and assist for ambulation. Medication List: [MEDICATION NAME]-Clavulanic 875-125 mg two times a day through 8/17/18 Calcium 600-200 mg (milligram)-unit [MEDICATION NAME] 40 mg/0.4 ml (milliliter) subcutaneously every 24 hours through 9/4/18. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, take 1-2 tablets by mouth every 4 hours as needed Insulin [MEDICATION NAME], Inject 0-14 units subcutaneously 4 times daily before meals and nightly. (NOTE: The Insulin [MEDICATION NAME] order came with instructions for a sliding scale administration of the Insulin.) Polyethylene [MEDICATION NAME] 17 g (grams) by mouth 2 times daily as needed Senna 8.6 mg, take 2 tablets by mouth 2 times a day [MEDICATION NAME] 10 mg, take 0.5 (1/2 tablet or 5 mg) by mouth daily Insulin [MEDICATION NAME], 8 units subcutaneously at bedtime [MEDICATION NAME] 10 mg, 1 tablet by mouth every morning [MEDICATION NAME]-[MEDICATION NAME] Cream Apply topically to affected area as needed. Apply generous amount to port site and cover with plastic wrap 30 minutes before accessing port Losartan 50 mg, take 1 tablet by mouth daily [MEDICATION NAME] 40 mg delayed release capsule, take 1 capsule by mouth twice daily Vitamin D3 2000 units, take 1 capsule by mouth daily Additional Appointments (MONTH) 22, (YEAR) (MONTH) 12, (YEAR) (NOTE: Both appointment dates were three associated appointment times together at [MEDICAL CONDITION] facility for a visit with the nurse, the MD and the infusion visit. The facility CNM stated that the daughter had canceled both appointments.) Problem List [MEDICAL CONDITION] requiring operative repair, left, closed [MEDICAL CONDITION], stage 4, left Diabetes Mellitus, type 2 Goals of care, counseling/discussion UTI (Urinary Tract Infection) due to indwelling foley catheter Pseudophakia Bilateral dry eyes [DIAGNOSES REDACTED] (sic) Arteritic anterior ischemic optic [MEDICAL CONDITION] of left eye PCO (Posterior [MEDICATION NAME] Opacification), right GCA ([DIAGNOSES REDACTED]) Diabetic Peripheral [MEDICAL CONDITION] Low Iron [MEDICAL CONDITION] (NOTE: No order for a follow up appointment could be located in the above orders provided by the facility.) Physician orders [REDACTED]. The two additional pages revealed the following orders: Discharge Summary admitted : 8/6/18 discharge date : 8/13/18 Reason for Admission: 86 yo (year old) female with stage 4 metastatic [MEDICAL CONDITIONS](hypertension), DM (diabetes mellitus) who suffered a GLF (ground level fall) and presented to the ED (emergency department) with left hip pain. W/U (unknown) revealed a left intertrochanteric [MEDICAL CONDITION] and underwent intraoperative fixation on 8/7 with ortho surgery Discharge Diagnosis [MEDICAL CONDITION] requiring operative repair, left, closed. Other Diagnosis (listed above) AMS (Altered Mental Status) in the setting of dirty UA (Urinalysis) Hypoxemia: new O2 (oxygen) need this admit that resolved by discharge. Left [MEDICAL CONDITION] WBAT (weight bearing as tolerated) PT/OT Initially PCA (patient controlled [MEDICATION NAME]) f/u (follow up) with ortho surgery in 2 weeks [MEDICATION NAME] (NOTE: It was unknown where the order for the follow up with ortho was misplaced since the facility CNM did not know where the order was.) A facility physician's orders [REDACTED]. Change PRN (as needed). Special Instructions: Report s/s (signs and symptoms) infection to CNM/MD. The facility Treatment Administration Record (TAR) for resident 1 revealed that there was no documentation from 8/13/18 through 9/12/18 that resident 1's surgical site had been cleansed daily and a dressing applied except for the dates noted in the nursing progress notes. The dates included 8/13/18, 8/14/18, 8/22/18, 8/30/18 and 9/12/18. On 10/31/18 at 11:31 AM, an interview was conducted with the facility CNM. The facility CNM stated that she thought there was no documentation of daily cleaning and dressing change, because of the change prn at the end of the physician's orders [REDACTED]. A facility physician progress notes [REDACTED]. (none so far!) A facility physician's orders [REDACTED]. On 10/31/18 at 11:31 AM, an interview was conducted with the facility CNM. The facility CNM stated that she did not know why they did not receive the orders to send resident 1 to a follow up appointment with the orthopedic surgeon. The facility CNM stated that good clinical practice was to send all residents with [MEDICAL CONDITION] and surgical incisions back for follow up appointments. The CNM stated that follow up appointments were for the surgeon to check the surgical incision, possibly remove sutures and to inform the facility of any changes with that incision. The facility CNM stated that she had noted the physician's progress note written on 8/30/18, and realized that the physician had not written the order, so she wrote the order and sent the copies of the order to transportation for the appointment to be set up. The CNM stated that she did not know where the ball was dropped. On 10/31/18 at 11:43 AM, an interview was conducted with the facility van driver. The facility van driver stated that she had not been driving during the admission of resident 1, as she was home after having knee surgery and that Certified Nursing Assistant (CNA) 1 had taken over the van driving. On 10/31/18 at 11:55 AM, an interview was conducted with CNA 1. CNA 1 stated that although she was driving the residents to their appointments, she had not set up the appointments and that the facility van driver was still setting up the appointments while at home. A History and Physical (H&P) dated 9/17/18 from the hospital revealed that Patient presents with her case manager. She was recently discharged from (Name of Skilled Nursing Facility). The nurse case manager reports that on discharge from the SNF the patients hip wound was draining bloody drainage. The stitches from her surgery were still in place. The nurse case manage(r) reports the patient had elevated body temp to 99.4 at home. She endorses continued hip pain. She has been walking with a walker. She has been soaking through several bandages a day with bloody drainage. Objective: Left hip surgical wound central 1 cm (centimeter) section is dehisced and draining fluid c/w (consistent with) retained hematoma. Distal surgical incision is well healed Assessment and plan: (Resident Name) hip wound is concerning for a deep surgical site infection. I have reviewed her situation with (Name of surgeon). We would like to perform an irrigation and debridement tomorrow. At SNF (Skilled Nursing Facility) she had lapses in care including reported delayed suture removal 3-4 weeks after surgery, port access open during entire patient stay, and weekly instead of biweekly dressing changes. Patient reports that she participated effectively in physical therapy, but that she had pain and bleeding from the wound site that would soak her bedsheets and clothes Orthopedics called oncology to admit for irrigation and debridement of the wound On 10/31/18 at approximately 1:46 PM, The facility CNM stated that she had taken a picture of resident 1's surgical site the day of discharge, about 5 minutes before she discharged and that the site was red and irritated looking. The CNM showed the text message that was sent to the facility physician, and reported to him (Resident 1's) family is concerned, wondering if anything needs or started to be done before she was discharged in a few minutes The facility CNM stated that the facility physician answered her that the site was just irritated because of the stitches and to remove the stitches prior to going home. The facility CNM showed the text message from the physician and he responded, Those stitches need to come out unless otherwise instructed by the surgeon. (NOTE: The picture of the wound that was sent to the physician on 9/14/18, revealed redness around the entire surgical site, stitches in place and scant bloody drainage on the dressing.) 2. Nursing progress notes revealed the following entries: a. c. 8/14/18 at 4:23 PM, Spoke with (Name of Hospital), they do not want us to access or flush IVAD site. DC'ed (discontinued) orders accordingly. b. 8/14/18 at 4:23 PM, Spoke with (Name of Hospital), they do not want us to access or flush IVAD site. DC'ed (discontinued) orders accordingly. c. 8/24/18 at 4:00 PM, Phlebotomist reported that he was unable to obtain blood sample from patient's upper extremities. She stated that when tourniquet is applied the limbs swell and veins are undistinguishable (NOTE: No order for facility staff to flush the IVAD port could be located in the above orders.) A H&P from the hospital dated 9/17/18 revealed that At SNF (Skilled Nursing Facility) she had lapses in care including reported delayed suture removal 3-4 weeks after surgery, port access open during entire patient stay, and weekly instead of biweekly dressing changes. Patient reports that she participated effectively in physical therapy, but that she had pain and bleeding from the wound site that would soak her bedsheets and clothes Orthopedics called oncology to admit for irrigation and debridement of the wound On 10/31/18 at 11:31 AM, an interview was conducted with the facility CNM. The facility CNM stated that she had called (Name of Hospital) to clarify the orders for the IVAD port because they had not received any specific orders to flush the port. The facility CNM stated that they discontinued the order for the [MEDICATION NAME]-[MEDICATION NAME] Cream as they were not to do anything with the port. The facility CNM stated that the phlebotomist was unable to access the port to obtain any labs and wondered if he was just lacking in experience and wondered if that was why the resident had some bruising on her arms.

Based on observation, interview and medical record review, it was determined for 3 of 24 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, three residents who were admitted after having falls and fractures at home, had physician orders [REDACTED]. Resident identifiers: 30, 141 and 144. Findings include: 1. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/24/18 at 10:33 AM, an observation was made of resident 30 in bed. Resident 30 was observed in bed without fall mats on either side of the bed. Additionally, resident 30's bed was observed to be raised and not to be in a low position. On 9/25/18 resident 30's medical record was reviewed. Physician orders [REDACTED]. Verify placement QS (every shift). A Fall Risk assessment dated [DATE] for resident 30, revealed that resident 30 scored 16, indicating that she was a moderate risk for falls. The 48 hour care plan associated with the assessment, revealed that resident 30 was to have fall mats to the sides of resident 30's bed while in bed as well as Bed to lowest position r/t (related to) x1 (times 1) GLF (ground level fall). 2. Resident 141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/24/18 at 10:49 AM, an observation was made of resident 141 in bed. Resident 141 was observed in bed without fall mats on either side of the bed. On 9/25/18 resident 141's medical record was reviewed. physician's orders [REDACTED]. Verify placement QS. The Fall Risk assessment dated [DATE] for resident 141, revealed that resident 141 scored 12, meaning that resident 141 was a moderate risk for falls. The 48 hour care plan associated with the risk assessment, revealed that resident 141 was to have fall mats to either side of the bed when in bed. 3. Resident 144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/24/18 at 9:35 AM, an observation was made of resident 144 in bed. Resident 144 was observed to have a fall mat placed on the floor on the right side. No observation was made of a fall mat to resident 144's left side. Resident 144 was observed to be lying on the left side of the bed and close to the edge. In addition, resident 144's bed was observed to be raised and not in a low position. On 9/25/18 at 7:49 AM, an observation was made of resident 144 in bed. No observation was made of resident 144 having fall mats placed to either side of the bed. Resident 144's bed was observed to be raised and not in a low position. On 9/25/18 resident 144's medical record was reviewed. physician's orders [REDACTED]. Verify placement QS. The Fall Risk assessment dated [DATE] for resident 144, revealed that resident 144 scored 13, meaning that resident 144 was a moderate risk for falls. The 48 hour care plan associated with the risk assessment, revealed that resident 144 was to have Fall Mats to the floor. The physician order [REDACTED]. On 9/25/18 at 2:17 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that all of the needs for every resident were carried out on the brains or the paperwork that each Certified Nursing Assistants (CNAs) carried with them daily. The facility DON stated that from that paperwork, the CNAs knew who needed the low positioning of the bed and fall mats each resident. The facility DON stated that sometimes therapy would take residents to the therapy room, and not put those things back into place when the resident was returned to the room.

Based on interview and record review it was determined that for 2 of 24 sample residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility administered doses of PRN (as needed) pain medications that were higher than pain scores indicated as prescribed by the residents' physicians. Resident identifiers: 1 and 189. Findings include: 1. Resident 189 was admitted to the facility 9/18/18 with [DIAGNOSES REDACTED]. 9/25/18 at 1:10 PM, an interview was conducted with resident 189. Resident 189 stated she received Tylenol, [MEDICATION NAME] and [MEDICATION NAME] for pain. Resident 189 stated that when she had knee and neck surgery that she became addicted to [MEDICATION NAME], which she took every 5 hours for a prolonged period of time. Resident 189 stated that when nurses offered pain medication, that she always asked for two tablets ([MEDICATION NAME] 10 mg); not that she was having intense pain, but because it made her body feel better. Resident 189 stated her physician recently started her on [MEDICATION NAME] and [MEDICATION NAME] to relieve leg spasms. Resident 189 stated that her physician wanted her to go to a pain specialist 4 weeks after discharge from this facility to help ween her off pain medications. On 9/25/18 at 1:51 PM, resident 189's medication orders and medication administration report (MAR) were reviewed. Resident 189 had the following medication orders for pain: a. [MEDICATION NAME] 650 milligrams (mg) orally every 6 hours. Start Date: 9/18/18 End Date: 9/28/18 b. [MEDICATION NAME] 10 mg orally every 3 hours as needed (PRN) for Pain Scale 8-10 Start Date: 9/18/18 End Date: Open Ended c. [MEDICATION NAME] 5 mg orally every 3 hours PRN for Pain Scale 3-7 Start Date: 9/18/18 End Date: Open Ended d. [MEDICATION NAME] 50 mg orally every 6 hours PRN for Pain Scale 1-3, Use for pain not controlled by Tylenol Start Date: 9/18/18 End Date: Open Ended e. [MEDICATION NAME] 10 mg orally twice a day for spasms Start Date: 9/21/18 End Date: Open Ended f. [MEDICATION NAME] 600 mg orally twice a day for pain Start Date: 9/22/18 End Date: Open Ended [MEDICATION NAME] 10 mg were administered to resident 189 where the resident's pain score was less than 8 on a pain scale from 0 to 10, with 0 meaning no pain and 10 meaning the most intense pain. Using the PRN pain medication listed above, resident 189 should have only received [MEDICATION NAME] 5 mg for pain scores 3-7. The Medication Administration Record (MAR) revealed that resident 189 was administered [MEDICATION NAME] 10 mg on the following dates: a. 9/19/18 at 00:28 AM, Pain Score: 5 b. 9/19/18 at 11:07 AM, Pain Score: 5 c. 9/20/18 at 6:21 AM, Pain Score: 4 d. 9/20/18 at 12:10 PM, Pain Score: 5 e. 9/20/18 at 16:49 PM, Pain Score: 7 f. 9/21/18 at 00:29 AM, Pain Score: 5 g. 9/21/18 at 5:17 AM, Pain Score: 5 h. 9/21/18 at 8:47 AM, Pain Score: 4 i. 9/21/18 at 17:04 PM, Pain Score: 4 j. 9/22/18 at 2:06 AM, Pain Score: 6 k. 9/22/18 at 22:36 PM, Pain Score: 6 l. 9/23/18 at 7:33 AM, Pain Score: 6 m. 9/23/18 at 16:58 PM, Pain Score: 7 n. 9/24/18 at 8:15 AM, Pain Score: 6 o. 9/24/18 at 11:14 AM, Pain Score: 4 p. 9/24/18 at 15:34 PM, Pain Score: 6 q. 9/24/18 at 20:16 PM, Pain Score: 6 r. 9/25/18 at 3:28 AM, Pain Score: 5 s. 9/25/18 at 7:52 AM, Pain Score: 5 On 9/26/18 at 8:25 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated pain medications should be given as ordered by the physician. LPN 1 reviewed resident 189's MAR stated that resident 189 was receiving [MEDICATION NAME] 10 mg (2-tablets) orally every 3 hours even when the resident reported pain scores less than 8 using a pain scale of 1 to 10. LPN 1 stated if the resident requested two tablets of [MEDICATION NAME] with a pain score less than 8, that he would give the resident two tablets (10 mg) and then contact the resident's physician to request the order changed per resident's request. On 9/26/18 at 8:37 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the pain medication orders should have been given as ordered by the resident's physician. The DON also reviewed resident 189's MAR and stated that the resident was routinely receiving 10 mg orally (2-tablets) for pain even though the recorded pain scores were less than 8. The DON also stated that if the resident requested two tablets of [MEDICATION NAME] with a reported pain scale less than 8, that she would give two tablets (10 mg) and then contact the resident's physician to request updated pain medication orders. The DON stated she would contact the resident's physician to address her current pain medication orders. On 9/26/18 at 9:35 AM, the DON reported that she contacted resident 189's physician. The DON stated that resident 189's physician was unaware of the patient's opioid dependence. The Physician stated that he would be coming to the facility today to assess and adjust resident 189's pain medications if needed. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/24/18 at 9:54 AM, an interview was conducted with resident 1. Resident 1 stated, I'm always in pain, all the time and that he would take [MEDICATION NAME] PRN. Resident 1 stated, I never get just one [MEDICATION NAME], I always get two. On 09/25/18 at 10:14 AM, a review of resident 1's medical record was completed. physician's orders [REDACTED]. The first order was for one [MEDICATION NAME] 5 mg tablet if the resident rated his pain between a 1 and 5 on a 1 through 10 scale, with 1 being no pain and 10 being severe pain. The second order was for two [MEDICATION NAME] 5 mg tablets, 10 mg total, if the resident rated his pain between a 6 and 10 on a 1 through 10 scale. The MAR for resident 1 for (MONTH) (YEAR) revealed the following: a. On 9/14/18 at 4:49 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. b. On 9/14/18 at 8:07 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. c. On 9/14/18 at 1:59 PM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. d. On 9/14/18 at 5:24 PM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 4 out of 10. e. On 9/14/18 at 9:34 PM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. f. On 9/15/18 at 8:01 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. g. On 9/15/18 at 12:09 PM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. h. On 9/17/18 at 6:19 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. i. On 9/17/18 at 11:11 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 4 out of 10. j. On 9/17/18 at 1:57 PM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. k. On 9/18/18 at 12:26 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. l. On 9/18/18 at 6:17 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. m. On 9/18/18 at 5:47 PM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. n. On 9/18/18 at 11:18 PM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. o. On 9/19/18 at 3:18 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. p. On 9/19/18 at 6:06 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. q. On 9/20/18 at 12:04 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. r. On 9/20/18 at 3:38 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. s. On 9/23/18 at 4:16 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. t. On 9/24/18 at 11:50 PM resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. u. On 9/26/18 at 12:54 AM, resident 1 was administered 10 mg [MEDICATION NAME] for pain documented as a 5 out of 10. (NOTE: At no time during the month of (MONTH) was resident 1 offered only one 5 mg tablet of [MEDICATION NAME] per the physician's orders [REDACTED].) On 9/26/18 at 2:41 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 1 had two PRN orders of [MEDICATION NAME] for pain management. RN 1 stated that she was aware of the difference in the orders and that they should have been giving the [MEDICATION NAME] according to the pain level prescribed by the physician.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, multi dose vials of insulin on the medication cart had multiple dates written, or had open dates smudged off. The medication room refrigerator contained multiple medications for residents that were no longer in the facility. One medication cart was observed to be left unlocked and unattended. One nurse was observed to leave medication on top of the medication cart when she walked into a resident room. Findings include: 1. On 9/24/18 at 7:10 AM, an observation was made of the Hall 1 Medication Cart. The Hall 1 Medication cart contained the following: a. One multi dose vial of [MEDICATION NAME] with an open date of 9/21/18 and a date of 10/4/18 for resident 246. b. One multi dose vial of [MEDICATION NAME] for resident 1, with the open date smeared off. On 9/24/18 at 7:11 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he did not know why the [MEDICATION NAME] for resident 246 had two dates on it. LPN 1 stated that he did not know what the [MEDICATION NAME] open date was for resident 1, and that he would just order a new vial. On 9/24/18 at 7:13 AM, an observation was made of the facility medication room. The refrigerator in the facility medication room contained the following: a. One multi dose vial of [MEDICATION NAME] 2 mg for a resident who was no longer in the facility. b. One multi dose vial of [MEDICATION NAME] for a resident who was no longer in the facility. c. One multi dose vial of [MEDICATION NAME] Insulin with an open date of 8/3/18, one vial of Humalog Insulin without an open date and one vial of [MEDICATION NAME] 70/30 Insulin with an open date of 8/8/18 for a resident who was no longer in the facility. d. Fourteen IV (intravenous) [MEDICATION NAME] for resident 9. Per Registered Nurse (RN) 1, the IV [MEDICATION NAME] had been discontinued about a week ago. Additionally, twelve of the IV [MEDICATION NAME] were stored in the resident food refrigerator in the facility medication room. On 9/24/18 at 9:53 AM, an observation was made of the Hall 2 Medication Cart. The Hall 2 Medication Cart was observed to be unlocked and unattended while down the resident hallway. On 9/25/18 at 7:59 AM, an observation was made of LPN 2 as she prepared Tylenol 500 mg 2 tablets for a resident. LPN 2 was observed to leave the Tylenol 500 mg 2 tablets on top of the Hall 1 Medication Cart as she left to attend to a resident request in the room during the medication pass observation. On 9/25/18 at 11:30 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that medications should not be left in the medication refrigerator after residents had been discharged . The facility DON stated that medications should not be put in the resident food refrigerator and that all of the nursing staff know that. The facility DON stated that all multi dose vials should be accurately marked with an open date so that staff know when to discard the multi dose vials.

Based on interview and record review it was determined, for 1 of 24 sample residents, that the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care within 48 hours of a resident's admission. Specifically, one resident who had a femur fracture and was non weight bearing on the right leg, had physician orders [REDACTED]. In addition, the resident did not have an ADL (Activities of Daily Living) care plan. Resident identifier: 144. Findings include: Resident 144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/24/18 at 9:35 AM, an interview was conducted with resident 144. Resident 144 stated that she waited for long periods before getting assistance after calling on the call light, to get her wet brief changed. On 9/24/18 at 9:35 AM, an observation was made of resident 144 in her bed. An observation was made of a floral pillow case on the pillow between resident 144's knees for padding. The floral pillow case was observed to have a dried brown stain that appeared to be dried urine. In addition, resident 144 was observed to have a fall mat placed on the floor on the right side. No observation was made of a fall mat to resident 144's left side. Resident 144 was observed to be lying on the left side of the bed and close to the edge. In addition, resident 144's bed was observed to be raised and not in a low position. On 9/25/18 at 7:49 AM, an observation was made of resident 144 in her bed. Resident 144's bed was observed to be raised and not in a low position. On 9/25/18 resident 144's medical record was reviewed. physician's orders [REDACTED]. The Fall Risk assessment dated [DATE] for resident 144, revealed that resident 144 scored 13, meaning that resident 144 was a moderate risk for falls. The 48 hour care plan associated with the risk assessment, revealed that Bed to lowest position while in bed was not included in the care plan. In addition, no 48 hour care plan could be located in the medical record to address resident 144's ADL needs. On 9/25/18 at 2:17 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that all of the needs for every resident were carried out on the brains or the paperwork that each Certified Nursing Assistants (CNAs) carry with them daily. The facility DON stated that from that paperwork, the CNAs knew who needed the low positioning of the bed and how to carry out ADL's for each resident. The facility DON stated that sometimes therapy would take residents to the therapy room, and not put those things back into place when the resident was returned to the room. On 9/25/18 at 2:24 PM, an interview was conducted with the facility Unit Manager. The facility Unit Manager stated that she had gone into resident 144's room yesterday at about 7:30 AM, and that resident 144 was upset about not being changed throughout the night. The facility Unit Manager stated that resident 144 was pretty wet. The facility Unit Manager that asked the CNAs to come in to change resident 144. The facility Unit Manager stated that she did not notice the brown stain on the pillow case because she was more focused on getting someone in to help her.

Based on observation and record review it was determined, for 1 of 24 sample residents, that the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Resident identifier: 144. Findings included: Resident 144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/24/18 at 9:35 AM, an interview was conducted with resident 144. Resident 144 stated that she waited for long periods before getting assistance after calling on the call light, to get her wet brief changed. On 9/24/18 at 9:35 AM, an observation was made of resident 144 in her bed. An observation was made of a floral pillow case on the pillow between resident 144's knees for padding. The floral pillow case was observed to have a dried brown stain that appeared to be dried urine. On 9/25/18 resident 144's medical record was reviewed. physician's orders [REDACTED]. No 48 hour care plan could be located in the medical record to address resident 144's ADL needs. On 9/25/18 at 2:17 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that all of the needs for every resident were carried out on the brains or the paperwork that each Certified Nursing Assistants (CNAs) carry with them daily. The facility DON stated that from that paperwork, the CNAs knew how to carry out ADL's for each resident. On 9/25/18 at 2:24 PM, an interview was conducted with the facility Unit Manager. The facility Unit Manager stated that she had gone into resident 144's room yesterday at about 7:30 AM, and that resident 144 was upset about not being changed throughout the night. The facility Unit Manager stated that resident 144 was pretty wet. The facility Unit Manager that asked the CNAs to come in to change resident 144. The facility Unit Manager stated that she did not notice the brown stain on the pillow case because she was more focused on getting someone in to help her.

Based on interview and record review it was determined, for 1 of 24 sample residents, that the facility did not develop and implement a comprehensive, person-centered care plan. Specifically, the facility did not develop a tube feeding care plan that included measurable objectives, interventions and timeframe's in order to evaluate the resident's progress toward her goal. Resident identifier: 24. Findings include: Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/24/18 at 2:00 PM, an interview was conducted with resident 24. Resident 24 stated she felt pain and fullness in her upper abdomen and chest that made it difficult to breath. Resident 24 stated, I'm so full all the time. It hurts ever since I got this tube put in. Resident 24 and her daughter stated they did not know why the feeding tube was placed. Resident 24's husband stated, I think it was for low protein. On 9/24/18 at 2:28 PM, resident 24's medical record was reviewed. A physician's orders [REDACTED]. No feeding tube care plan could be located in resident 24's medical record. On 09/25/18 at 1:45 PM, an interview was conducted with resident 24 and her family. Resident and family stated they did not know when the tube was coming out or if there were any goals or benchmarks associated with having the feeding tube removed. On 9/25/18 at 2:12 PM, an interview was conducted with the director of nursing (DON). The DON stated, We don't have a policy on nasogastric (NG) tubes because we don't place them here. The resident is always sent out to have them placed. The DON stated the doctor monitors the resident's progress so they had no set guidelines for tube removal.

Based on observation and interview it was determined that the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, the facility infection control nurse documented that there was a pattern of urinary tract infections with Escherichia coli for a year; additionally some of the organisms were incorrectly identified in the tracking and trending as Escherichia coli rather than the organism that was in the urinary tract infections. One resident's antibiotics was transcribed into the medical record incorrectly and the resident received the incorrect number of doses of an antibiotic. There were multiple observations of breaches in isolation precautions for a resident who had Clostidium Difficile. Resident identifiers: 29, 53, 60, and 228. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/26/17 resident 29's medical record was reviewed. The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 29 required extensive one person assistance with toilet use. A laboratory result for a urine culture dated 6/21/17, revealed that resident 29 had an urinary tract infection (UTI) and that the organism was Escherichia coli (e-coli). 2. Resident 53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/26/17 resident 53's medical record was reviewed. The MDS assessment dated [DATE] revealed that resident 53 required extensive two person assistance with toilet use. A laboratory result for a urine culture dated 6/7/17, revealed that resident 53 had an UTI and that the organism was e-coli. 3. Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/26/17 resident 60's medical record was reviewed. The MDS assessment dated [DATE] revealed that resident 60 required extensive two person assistance with toilet use. physician's orders [REDACTED]. A Culture and Sensitivity dated 5/25/17 revealed that resident 60 had a UTI and that the organism was e-coli. physician's orders [REDACTED]. The May 2017 MAR (Medication Administration Record) for resident 60 revealed that resident 60 was started on [MEDICATION NAME] 100 mg BID (twice daily) x 28 doses rather than QID and that resident 60 received two doses of the [MEDICATION NAME] rather than the four on 5/25/17. The May 2017 MAR for resident 60 revealed that the physician's orders [REDACTED]. The MAR further revealed that resident 60 received the full 28 doses of the [MEDICATION NAME] starting on 5/26/17, thus revealing that resident 60 received a total of 30 doses rather than the 28 as ordered by the physician. On 6/28/17 at 1:50 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the [MEDICATION NAME] had been entered into the medical record incorrectly by the nurse, that she noticed the mistake the next day and that the order was put into the medical record correctly that day. The facility DON stated that the nurse had not taken into account the two doses of the [MEDICATION NAME] had already been administered to resident 60 prior to putting in the correct order into the medical record. The facility's Infection Control Tracking was reviewed for the last year and revealed the following: a. In July 2016, the facility identified seven UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for all seven UTI's. The Monthly Infection Control Report (MICR) completed 8/5/16 revealed the UTI's were identified as an infection control problem for July 2016 and that the actions taken relating to the problem were handwashing, wipe front to back. b. In August 2016, the facility identified three UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for all three UTI's. The MICR completed 9/8/16 revealed that UTI's were identified as an infection control problem for August 2016 and that the actions taken relating to the problem were handwashing, wipe front to back. c. In September 2016, the facility identified three UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for all three UTI's. The MICR completed 10/10/16 revealed that pneumonia and cellulitis were identified as infection control problems for September 2016. There was no documentation regarding the E-coli UTI's nor any actions taken for the UTI's. d. In October 2016, the facility identified four UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for all four UTI's. The MICR completed 11/8/16 revealed that UTI's were identified as an infection problem for October 2016 and the actions taken relating to the problem were handwashing, wipe front to back. e. In November 2016, the facility identified four UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for three of the four UTI's. The MICR completed 12/6/16 revealed that UTI's were identified as an infection problem for November 2016 and the actions taken relating to the problem were handwashing. f. In January 2017, the facility identified nine UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for seven of the nine UTI's. The MICR completed 2/6/17 revealed that UTI's, especially catheter associated were identified as an infection problem for January 2017 and that the actions taken relating to the problem were d/c (discontinue) catheters on admit if no qualifying dx (diagnoses), handwashing. g. In February 2017, the facility identified five UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for three of the five UTI's. The MICR completed 3/7/17 revealed that UTI's were identified as an infection problem for February 2017 and the actions taken relating to the problem were handwashing, wipe front to back. h. In March 2017, the facility identified two UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for both UTI's. The MICR completed 4/7/17 revealed that cellulitis was identified as an infection control problem for March 2017. There was no documentation regarding the E-coli UTI's nor any actions taken for the UTI's. i. In April 2017, the facility identified three UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for all three UTI's. The MICR completed 5/5/17 revealed UTI's were identified as an infection problem for April 2017 and the actions taken relating to the problem were handwashing, wipe front to back. j. In May 2017, the facility identified four UTI's. There was no indication that these UTI's were acquired prior to admission to the facility. E-coli was identified as the organism for three of the four UTI's. The MICR completed 5/31/17 revealed UTI's were identified as an infection problem for May 2017 and the actions taken relating to the problem was handwashing. On 6/28/17 at 12:15 PM, the Director of Nursing (DON) and Infection Control Nurse (ICN) were interviewed. The ICN stated that the only trends she noted over the last year were increases in flu during certain times of the year, and the appearance of increased skin infections. The ICN stated that frequently during the monthly staff meetings they would cover basic infection control practices. The ICN could not identify any training's done specifically to address the high incidences of UTI's with e-coli in the facility. The ICN could not identify how the information gathered from the infection control tracking and MICR reports was used to improve infection control methods in the facility. The DON stated that staff were continually trained on proper wiping techniques and to not reuse wipes, however she stated that nothing was done specifically to address the high incidences of UTI's with e-coli within the facility. On 6/29/17 at approximately 8:00 AM, the Corporate Resource Nurse was interviewed. The CRN stated that the facility nursing staff had reviewed the e-coli UTI's the previous night and discovered that many of the UTI's were not in fact e-coli. The CRN stated that when the ICN completed the MICR forms she was often doing it from memory and just filled in the organism with e-coli. On 6/29/17 the CRN provided the culture and sensitivity laboratory result reports for the residents with UTI's that were incorrectly identified as e-coli UTI's on the MICR and patient infection reports. The laboratory results revealed the following information: a. In August 2016, one of the three UTI's identified as e-coli on the MICR and patient infection reports was not an e-coli UTI. The lab report revealed that one resident had a negative result. b. In September 2016, one of the three UTI's identified as e-coli on the MICR and patient infection reports was not an e-coli UTI. The lab provided revealed that one resident UTI had the organism Proteus Mirabilis. c. In November 2016, one of the four UTI's identified as e-coli on the MICR and patient infection reports was not an e-coli UTI. The lab provided revealed that one resident UTI had the organism Citrobacter Freundii. d. In January 2017, four of the seven UTI's identified as e-coli on the MICR and patient infection reports was not an e-coli UTI. For one of the seven UTI's identified as an e-coli UTI on the MICR and patient infection report, a culture and sensitivity had not been completed by the laboratory. The lab provided revealed that one resident UTI had the organism Citrobacter Freundii and [MEDICAL CONDITION][MEDICATION NAME], one resident UTI had the organism Raoultella Ornithinolytica and a Proteus Species and one resident UTI had the organism [MEDICATION NAME] Faecalis. e. In February 2017, two of the three UTI's identified as e-coli on the MICR and patient infection reports was not an e-coli UTI. The lab provided revealed that one resident UTI had the organism [MEDICATION NAME] Cloacae and Pseudomonas Aeruginosa, and one resident UTI had [DIAGNOSES REDACTED] Oxytoca and Citrobacter Freundii. On 6/29/17 at 9:10 AM, a follow up interview was conducted with the ICN. The ICN stated that she had filled out many of the patient infection reports based on memory, and in doing so had incorrectly identified infections as e-coli when they were caused by another organism. The ICN stated that she knew some of the UTI's were e-coli but on others she had guessed. The ICN stated that during training she was taught that it was the antibiotic that the facility was most concerned with, not the organism. The ICN agreed that they could not have an effective infection control tracking program if the MICR and patient infection reports were inaccurate and would not know if cross contamination was a problem. 4. On 6/26/17 at 7:15 AM, an observation was made of an isolation precautions sign posted on the door of resident 228's room. Next to the door of resident 228's room a translucent storage container with personal protective equipment (PPE) consisting of gowns, gloves, and masks was observed. On 6/26/17 at 7:15 AM, an interview was conducted with Certified Nurses Assistant (CNA) 1. CNA 1 stated that resident 228's room was under isolation precautions because resident 228 had[DIAGNOSES REDACTED] (Clostridium Difficile). CNA 1 stated PPE had to be put on before entering a room under isolation precautions. On 6/26/17 at 1:14 PM, an observation was made of a resident's family member in resident room [ROOM NUMBER], providing food and cares for the resident. The family member was not wearing the PPE that was provided by the facility. The family member was then observed to walk throughout the facility. On 6/26/17 resident 228's medical record was reviewed. Progress notes for resident 228 dated 6/25/17 revealed, Pt (patient) . on isolation precautions for[DIAGNOSES REDACTED]. 5. On 6/27/17 at 10:27 AM, the daughter of resident 228 was observed in resident 228's room not wearing PPE. The daughter of resident 228 was observed to exit resident 228's room. Resident 228's daughter was then observed to walk through the halls of the facility and enter the common dining area where breakfast was being served. The daughter of resident 228 was observed to interact with residents and staff. The daughter of resident 228 was observed to lean up against a countertop where the residents food was served. On 6/27/17 at 2:15 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that she had knowledge that the daughter of resident 228 had entered resident 228's room and did not use the PPE that had been provided by the facility. The DON stated that the daughter of resident 228 had been educated regarding the necessity of donning PPE when entering resident 228's room due to isolation precautions The DON stated that she would reeducate the daughter of resident 228 to use PPE before entering resident 228's room. The facility's Infection Control Surveillance policy and procedure was reviewed and revealed the following information: Reason: To effectively monitor infections within the facility by gathering data and assessing possible trends; to assist in minimizing the spread of infection within the facility 3. The ICN will review all physician orders, daily report sheets, alert charting and nursing communication forms to identify patients which may have an infection 6. Utilizing the 'Infection Criteria Checklist' with a complete assessment of the patient and review of the clinical documentation, the ICN will evaluate the available data to determine the suspected infection's classification 10. To qualify or be counted as a Nosocomial infection, the suspected infection must: a. Meet the infection criteria as identified on the 'Infection Criteria Checklist' b. Have an onset date greater than 72 hours post admission to the facility 13. The ICN will evaluate all Nosocomial, Community Acquired and Unsubstantiated infections for appropriate interventions such as isolation precautions and other patient care practices to reduce the spread of infectious organisms and maintain a safe and healthy environment for patients, employees, and visitors 17. The ICN will present the 'Monthly Infection Control Report' to the Infection Control Committee and/or Quality Assurance Committee as scheduled no greater than every 3 months. 18. The 'Monthly Infection control Report' shall include: a. Identified trends and abnormalities with recommendations for resolution to include specific interventions and a time frame for completion as well as follow-up for previously identified problems/concerns. b. A summary of Nosocomial Infections categorized by site of infection and building location or hall

Based on observation, it was determined that the facility did not post the nurse staffing requirements, facility name, current date, registered nurses and the total number of actual hours worked, in a prominent place readily accessible to residents and visitors. Findings include: During initial tour of the facility on 6/26/17 at 7:00 AM an observation was made of the nurse staff posting at the welcome desk. The nurse staff posting was posted for 6/23/17 and 6/24/17. There was no nurse staff posting of the previous day, 6/25/17, or the current date, 6/26/17 visible. On 6/29/17 at approximately 10:00 AM, the Director of Nursing (DON) was interviewed. The DON stated that on the the weekends the staff posting was prepared ahead of time and the charge nurse would update it.

Based on observation interview and record review, it was determined that the facility did not have the correct phone numbers posted for the State Survey and Certification agency and the State Licensure Office, thus not allowing residents to file a complaint with the State Survey and Certification agency concerning resident abuse, neglect and misappropriation of resident property in the facility. Findings include: On 6/26/17 at 7:15 AM, an observation was made in the resident library of a posted document with client advocate addresses and phone numbers. The phone number for the State Survey Agency for the purpose of reporting grievances was listed as [PHONE NUMBER]. This phone number was called and the party that answered indicated the phone number belonged to (local golf course). (Note: Correct phone numbers for the State Survey Agency for the purpose of reporting grievances are [PHONE NUMBER] and [PHONE NUMBER].) On 6/27/16 a review of a resident's record revealed a Grievance Policy and Procedure document signed and dated by the resident upon admission. Review of the document revealed, Grievances may also be filed through the following organizations: State Survey Agency.801-535-6158. On 6/28/16 at 8:45 AM, the Director of Nursing (DON) reviewed with surveyors a blank resident admission package for the facility that included the Grievance Policy and Procedure document with the incorrect phone number of [PHONE NUMBER] for the State Survey Agency. On 6/29/17 at 7:30 AM, an interview was conducted with Corporate Resource Nurse (CRN). The CRN was shown the phone number for the State Survey Agency on the facility client advocate posting and the Grievance Policy and Procedure document. The CRN confirmed the phone number was not correct. The CRN stated she would let everyone know and get it changed.

Based on observation, interview and record review, it was determined that the facility failed to maintain a Quality Assessment and Assurance Committee that developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility had multiple instances in the last 12 months of residents with Urinary Tract Infections resulting from cross contamination from Escherichia Coli. Several Urinary Tract Infections were recorded in the facility tracking and trending as Escherichia Coli when the lab report had different organisms, resulting in an ineffective infection control program. One resident who was on isolation precautions for [MEDICAL CONDITION] had staff members as well as family members who did not use the Personal Protective Equipment provided by the facility. Resident Identifiers: 29, 53, 60, and 228. The facility Administration failed to ensure that residents were free from cross contamination for urinary tract infections involving Escherichia Coli. The facility Administration failed to ensure that isolation precautions were taken for a resident who had [MEDICAL CONDITION]. (Cross refer to F-441)

Based on observation and interview, it was determined for 2 of 24 sample residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 29 medication opportunities on 6/29/17 revealed six medication errors which resulted in a 20.6% error rate. Specifically, one resident's medications were not administered timely and one resident's hypertension medications were administered to the resident while the BP (blood pressure) was outside of the parameters set by the physician. Resident identifiers: 89 and 190. Findings include: 1. Resident 89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/29/17 at 8:04 AM, an observation was made of Registered Nurse (RN) 1 as he administered medications to resident 89 including four hypertension medications [MEDICATION NAME] ER 30 mg (milligrams), [MEDICATION NAME] 40 mg, [MEDICATION NAME] 25 mg, and [MEDICATION NAME] 10 mg. On 6/29/17 at 8:04 AM, an interview was conducted with RN 1. RN 1 stated that resident 89's BP (blood pressure) was 138/50. On 6/27/17 at 8:30 AM, resident 89's medical record was reviewed for the reconciliation of medications. According to physician's orders [REDACTED].< (less than) 100 or a DBP (diastolic blood pressure) < 65. 2. Resident 190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/27/17 at 7:41 AM, an observation was made of Licensed Practical Nurse (LPN) 1 as he administered medications to resident 190 including [MEDICATION NAME] 5 mg and [MEDICATION NAME] 75 mg. On 6/27/17 at 8:40 AM, resident 190's medical record was reviewed for the reconciliation of medications. According to physician's orders [REDACTED]. The [MEDICATION NAME] 5 mg and [MEDICATION NAME] 75 mg were administered approximately 1 hour and 11 minutes after they were due. On 6/27/17 at 9:15 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the BP medications should have been held according to the physician's orders [REDACTED]. The facility DON stated that the pain medications should have been administered sometime between 6:00 AM and 7:00 AM.

Based on observation and interview, it was determined for 2 of 24 sample residents, that the facility did not ensure that each resident's right to personal privacy was followed including protecting residents personal information on the computer screens. Specifically, on multiple occasions during the survey, the nursing station computer screen was open with residents' personal information fully visible. Resident identifiers: 89 and 233. Findings include: 1. On 6/26/17 at 12:20 PM, an observation was made of a computer screen at the central nurses station. The computer screen was left open to resident 89's medical record. No staff were observed to be at the nurses station. Approximately 10 minutes later the Corporate Resource Nurse (CRN) was observed to return to the computer. 2. On 6/27/17 at 8:55 AM, an observation was made of a computer screen at the central nurses station. The computer screen was left open to a spreadsheet containing multiple resident names and their diagnoses. There was no staff present at the nurses station. At 8:59 AM, Certified Nursing Assistant (CNA) 2 was observed to go to the computer. 3. On 6/29/17 at 7:20 AM, an observation was made as Licensed Practical Nurse (LPN) 1 walked away from the medication cart. LPN 1 was observed to leave the computer screen open to resident 233's personal medical information.

Based on observations and interviews, it was determined the facility did not ensure the resident environment was as free of accident hazards as possible. Specifically, water temperatures at the hand sinks eight resident rooms plus one public restroom posed a risk of serious thermal burns in a short period of time. The temperature of the hot water was determined to represent an Immediate Jeopardy to resident safety. Resident rooms: 105, 111, 116, 119, 121, 123, 126 and 137, plus the women's restroom. The Administrator was notified of the conditions representing Immediate Jeopardy on 9/21/10. On 9/22/10, the Administrator provided the surveyors a corrective action plan that listed the steps taken by the facility to abate the Immediate Jeopardy. It was determined the facility had removed the conditions that represented Immediate Jeopardy on 9/21/10. Additionally, at a level that did not represent Immediate Jeopardy, the facility did not ensure that chemicals with cautionary labels were secured when not in use. Findings include: 1. HOT WATER On 9/21/10, between 12:55 PM and 1:35 PM, during the general environment inspection of the facility, water temperatures were measured. Each resident room included a small counter with a hand sink. The water temperatures were measured in degrees Fahrenheit (F) with a digital probe thermometer. The following water temperatures measured at levels that represented a significant risk for thermal burn injury: a) Room 126 - The hand sink hot water temperature was 146.5 degrees F at 12:55 PM; b) Room 123 - The hand sink hot water temperature was 145.8 degrees F at 1:03 PM; c) Room 119 - The hand sink hot water temperatures was 146.3 degrees F at 1:04 PM; d) Room 137 - The hand sink hot water temperature was 145.6 degrees F at 1:05 PM; e) Room 121 - The hand sink hot water temperature was 146.5 degrees F at 1:06 PM; f) Room 116 - The hand sink hot water temperature was 134.8 degrees F at 1:20 PM; g) Room 111 - The hand sink hot water temperature was 122.2 degrees F at 1:18 PM; h) Room 105 - The hand sink hot water temperature was 126.5 degrees F at 1:27 PM. i) The hot water temperature at the hand sink in the women's restroom was 125.6 degrees F at 1:35 PM. This restroom was located in a common area of the facility and accessible to residents, staff and visitors. The temperature of the thermostatic water controller, mixing valve, between the two hot water tanks was observed at 1:31 PM in the presence of a Life Safety Code surveyor. The thermostatic water controller was set at 150 degrees F. INTERVIEWS Interviews were held with the Administrator and Director of Nursing on 9/21/10 at 1:42 PM. The Administrator stated that the Director of Nursing had the log of hot water temperature monitoring. The Director of Nursing stated that a company maintenance supervisor checked hot water temperatures every Wednesday. The Director of Nursing then came back to the surveyor and reported that the company maintenance supervisor did not check hot water temperatures. The company maintenance supervisor was interviewed on 9/21/10 at 1:44 PM, and stated that he did not monitor hot water temperatures in this building. The company maintenance supervisor was re-interviewed at 1:55 PM and stated, "I thought they had it handled". The company maintenance supervisor was asked if he checked the mixing valve or hot water tanks in the facility. He responded that he did not. The Administrator was informed of the hot water temperatures at 2:20 PM. The Administrator, company maintenance supervisor and surveyor went to the janitor's room that housed the hot water tanks at that time. The temperature on digital read out of the hot water tanks were observed. One tank was set at 135 degrees F and the other tank was set at 152 degrees F. The temperature at the mixing valve was observed to be 150 degrees F. The Administrator turned the temperature down to 115 degrees F on both hot water tanks at approximately 2:25 PM. At this time the Administrator stated that possibly a housekeeper monitored the hot water temperatures and that he had called the employee. The Administrator also stated that he had not seen a hot water temperature monitoring log. The Food Service Director was interviewed on 9/21/10 at 3:10 PM. The Food Service Director stated that he supervised the housekeeping staff and that the housekeeper staff did not monitor and record hot water temperatures at the facility. 2. UNSECURED CHEMICALS During general tour of the facility on 9/21/10, the door to the storage room across from the dining room was observed unlocked at 8:45 AM and 9:20 AM. The storage shelves on the back wall of the room held chemicals that had cautionary labels. The cautionary labels included warning that the chemicals may be harmful if ingested and/or cause skin irritations. The chemicals included carpet and upholstery cleaner, defoamer, multiple purpose cleaner, oven cleaner, stainless steel wipes, freezer cleaner, descaler, butane fuel and chafing dish fuel. The Food Service Director was interviewed on 9/21/10 at 1:07 PM, regarding the storage room. The Food Service Director stated that the room should be kept locked and that the staff obtain a key from the nurse in order to get ice for residents since the ice machine was also in this storage room.