Every finding on record at Azalea Health and Rehabilitation

Based on record review, staff interviews, and review of the facility policy titled Patient's Plan of Care, the facility failed to ensure the care plan was followed for two (R) (R78 and R31) of 37 residents related to Activities of Daily Living Care for R78 and R31 related to medication parameters. Harm was identified to have occurred on 12/13/2024 when Certified Nursing Assistant (CNA) EE was providing ADL care alone, resulting in R78 falling out of bed and sustaining a sub-capital fracture of the femoral neck.Findings included:1. A review of the Patient's Plan of Care dated 12/29/2023, revealed each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs.A review of the medical record for R78 revealed the resident was initially admitted to the facility on [DATE] with the following diagnosis's not limited to fracture of unspecified part of neck of right femur, initial encounter of closed fracture, Parkinson's disease without dyskinesia without mention of fluctuations, unspecified dementia severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease, unspecified, and schizoaffective disorder, unspecified.A review of Quarterly Minimum Data Set (MDS) dated [DATE] (MDS at time of fall) revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of four, indicating severe cognitive impairment. Section GG (functional abilities and goals) revealed the resident was dependent on staff for self-care and mobility (required 2 persons).A review of the care plan dated 6/10/2024 revealed the resident is a fall risk. Interventions included but are not limited to two-person assist with bed mobility.An interview on 9/10/2025 at 8:45 am with the Director of Nursing (DON) revealed that the fall with injury occurred when CNA EE provided care to the residents. The DON confirmed that the resident was a two-person assist for bed mobility and that the CNA was the only staff providing care. The DON stated she expects that staff follow care plans and provide a two-person assist when requiredAn interview with Registered Nurse (RN) MDS Coordinator on 9/11/2025 at 11:37 am revealed that care plans are developed as a team. She is responsible for completing the MDS assessment. She confirmed that the resident was coded as a two-person assist for bed mobility in the MDS and care plan at the time of the fall. She stated the resident should have had two staff assisting her and that the staff are aware of a resident's care level because it is listed in their charting system. 2. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R31 had presented with a Brief Interview for Mental Status (BIMS) score of 00, indicating that R31 was totally dependent on activities of daily living (ADL) care.A review of the care plan dated 8/19/2025 revealed that R31 was at risk for Phenytoin (Dilantin) Toxicity related to Dilantin and Levetiracetam. The goal was for the R31 will be free of any discomfort or adverse side effects and will be injury-free during the review period. The interventions include, but are not limited to, holding g-tube feeding one hour before and one hour after Dilantin administration.A record review for R31 revealed that the resident's tube feeds were to be held one hour before and one hour after the administration of phenytoin (Dilantin).During an interview with RN FF on 9/11/2025 at 1:07 pm revealed that the care plan states to hold tube feeds one hour before and one hour after administration of phenytoin (Dilantin). She admits that she did not hold the medication. She admits that she did not realize that she needed to hold the medication. She states that the parameters should she added to the physician's orders. She admits that she only reviews care plans if there is a change in a resident's condition.An interview with the Minimum Data Set (MDS) coordinator on 9/11/2025 at 1:15 pm states that parameters for medication are found in the medication administration record. Everyone on the interdisciplinary team is responsible for the care plan. The care plan does include medication parameters. In the electronic record, that is a tab with recommendation parameters for staff to follow.An interview with the Director of Nursing (DON) on 9/11/2025 at 1:25 pm reveals that the expectation is that the nurse follows the care plan. Parameters for medications are in order. The nurses have access to the care plan for review.

Based on record review, staff interviews, and review of policy titled Falls Management, the facility failed to provide care by two staff members for one of two residents (R) (R78) reviewed for falls. Harm was identified on 12/13/2024 when resident R78 fell from bed during care, resulting in a right hip fracture.Findings included: A review of the facility policy dated 12/29/2023 titled Falls Management revealed upon admission/readmission, the nurse will complete the Falls Risk Assessment and address the risk factors related to the patient on the plan of care and implement appropriate interventions as identified.A review of the medical record for R78 revealed the resident was initially admitted to the facility on [DATE] with the following diagnosis's not limited to fracture of unspecified part of neck of right femur, initial encounter of closed fracture, Parkinson's disease without dyskinesia without mention of fluctuations, unspecified dementia severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease, unspecified, and schizoaffective disorder, unspecified. A review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] (MDS at time of fall) revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of four, indicating severe cognitive impairment. Section GG (functional abilities and goals) revealed the resident was dependent on staff for self-care and mobility (required two persons). A review of a progress note dated 12/13/2024 at 6:55 am revealed the resident rolled out of the bed onto the floor during patient care. The fall was observed by Certified Nurse Assistant (CNA) EE, the CNA who was assisting the resident with patient care. The resident complained of pain in the right knee. The resident's granddaughter and physician were notified, and the resident was transferred to the emergency room by rescue.A review of the hospital emergency room report on 12/13/2024 revealed an X-ray report that listed a subcapital fracture of the femoral neck. Attempts were made to contact the resident's representative, but were unsuccessful.During an interview on 9/11/2025 at 9:10 am with CNA EE confirmed she was the only CNA providing care to the resident when the resident required a two-person assist. CNA EE revealed she received a corrective action and was given a verbal/written warning. She was provided with education on bed mobility.During an interview on 9/10/2025 at 8:45 am with the Director of Nursing (DON) revealed that the fall with injury occurred when CNA EE provided care to the resident without the assistance of another staff member. The DON confirmed that the resident was a two-person assist for bed mobility and that the CNA was the only staff providing care. The DON revealed CNA EE received a corrective action and revealed CNA EE, along with all clinical staff, including CNA's were provided education on bed mobility. The DON completed nurse aide competency checklists on turning and repositioning a patient in bed, as well as audits/monitoring. A review revealed a facility document titled on-site in-service, dated 12/13/2024, documented that all nursing staff were provided education by the DON. The topic, Subject: adl plan of care/care plan, bed mobility. The fall management policy was attached. Staff signed their name as an acknowledgement of attending the in-service. A review revealed A corrective action that was given to CNA EE on 12/13/2024. She received a verbal and written warning. It was signed by the CNA.A review revealed a written statement by CNA EE on 12/13/2024---I, CNA EE was doing patient care on R78. I was changing her brief and bed. I turned her over to her right side, pointing towards the door. As I rolled the sheet over to the other side of the bed, R78 fell out of the bed to the floor. Immediately, I called for help. If you have any questions, please call me.A review revealed competency checklists on repositioning and bed mobility were completed with staff. Verified by DON on 9/11/2025 at 2:00 pm, and with staff interviewed. During an interview on 9/11/2025 at 11:30 am with Certified Medication Assistant (CMA) AA revealed she has been working for one year. She revealed she received training on bed mobility and following care plans. She stated she is aware of what a resident's care level is by looking at the medical chart. She stated that all staff should know a resident's care level before completing care with a resident to ensure safety. During an interview on 9/11/2025 at 11:43 am with CMA GG revealed she has been with the facility for five months. She stated she had training on bed mobility and care plans.During an interview on 9/11/2025 at 11:45 am with Registered Nurse FF, revealed that they have been employed for a year. She confirmed she had training on bed mobility and care plans. She stated that all staff have access to the resident's level of care, and that is how they know if a resident requires a two-person assist. During an interview on 9/11/2025 at 11:48 am with CMA HH revealed she has been employed with the facility for a year. She confirmed she had training on bed mobility and care plans. She stated that the medical chart has the resident care level.

Based on observations and staff interviews, the facility failed to ensure vents were free from dust and grime buildup in five resident rooms on one of two halls (Hall B).Findings included:An observation on 9/9/2025 at 12:04 pm revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 11:32 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 11:11 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 10:16 am observed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].An observation on 9/9/2025 at 10:43 am revealed that the air vent was covered in dust buildup in Hall B in room [ROOM NUMBER].During an interview on 9/10/2025 at 2:02 pm, the Maintenance Director revealed that he is responsible for cleaning the filters. He confirmed that the filters were dirty and possibly last cleaned in August 2025. An additional interview at 2:52 pm with the Maintenance Director revealed that it takes days to clean the filters and that he takes them outside he places a purple cleaning solution on the filters, and then cleans them off with a water hose. He attempts to clean one hall at a time. He reports that the last time they were cleaned was on 8/13/2025.During an interview on 9/10/2025 at 2:02 pm, the Environmental Services Director confirmed that the air filters were dirty. She stated that the cleaning is tracked in Telles' maintenance system. The subsequent interview at 2:52 pm revealed that the facility does not have a policy for the cleaning or maintenance of air filters or air conditioning units. The facility just tracks the information in its maintenance system. During an interview on 9/10/2025 at 2:02 pm, the Administrator confirmed that the observed air filter in room [ROOM NUMBER] was dirty. Subsequent interviews with the Administrator on 9/11/2025 at 10:51 am revealed that he expected that when they are dirty, like the observation of the filter, the filter should be cleaned immediately.

Based on observations, staff interviews, record review, and review of the facility's policy titled Pharmacy Services, the facility failed to ensure one of 37 sampled residents (R) (R40) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility. Findings included:A review of the facility policy titled Pharmacy Services: dated 12/31/2024 revealed that the facility will facilitate a process for safe self -administration of medications by patients when appropriate each patient who desires to self administer medication is permitted to do so if the nursing center's interdisciplinary team has determined that the practice would be safe for the patient and other patients of the nursing center and that the patient can accurately self-administer. A review of clinical records for R40 revealed the following diagnoses, but not limited to, vascular dementia, paroxysmal atrial fibrillation, hypertension, and chronic obstructive pulmonary disease. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R40 presented with a Brief Interview Mental Status Score (BIMS) of five, indicating severe cognitive impairments. An observation on 9/9/2025 at 12:28 pm revealed the following over-the-counter medications: a bottle of antacid tablets and a small tube of sterile lubricant eye ointment (style) lying on a nightstand.A review of clinical records for R40 revealed an omission of a completed assessment to determine whether or not the resident was capable of Self-Administration of Medications.During an interview at the time of observation of R40's room on 9/9/2025 at 4:01 pm, with Certified Medical Assistant (CMA) HH, CMA HH reported being unaware of medications in the resident room. She reported receiving prior in-services to monitor for unauthorized medications in resident rooms. CMA described R40 's cognition as having periods of confusion, which would make her incapable of self-administering medications without supervision During an observation of R40's room on 9/9/1025 at 4:13 pm, with Licensed Practical Nurse (LPN) LPN BB, LPN BB confirmed the unauthorized medication in the resident room. She removed the medications from the room. LPN BB reported R40 was not assessed to self-administer medications and described her mental status as being very confused. LPN BB reported that most likely the resident's family brought the meds into the room. She reported that her expectations are for the nursing staff and certified medical assistant (CMA) to monitor the residents' rooms for medications. During an interview on 9/10/2025 at 10:20 am, the Director of Nursing (DON) reported being unaware of medications in R40's room. She reported that the IDT (Interdisciplinary Team) determines the patient's ability to self-administer medications, and at this time, the IDT had not assessed any residents to self-administer medication. The DON reported that after the deficient practice was brought to her attention yesterday, she and her staff did a scan of all residents' rooms for unauthorized meds and conducted an in-service on unauthorized meds with staff.

Based on observations, staff interviews, record review, and a review of the facility policies titled Medication Administration-General and Insulin Administration, the facility failed to ensure a medication error rate of less than five percent for three of five residents (R) (R39, R14, and R31). There were three errors from 47 opportunities observed for a medication error rate of 6.38 percent. Findings included:A review of the Medication Administration-General policy revealed that medications are administered as prescribed, in accordance with good nursing principles. Under the guidelines revealed that a joint responsibility of the center and the pharmacy is to facilitate accurate medication administration.A review of the Insulin Administration policy revealed that insulin was to be administered correctly and safely. Under bullet point number five, instruct to prime the pen and clear air from the needle: Turn the dose knob at the end of the pen to 1 or 2 units. Hold the pen with the needle pointing upward Press the dose knob while watching for the insulin drop or stream to appear Repeat, if needed, until insulin is seen at the tip. The dial should be back at zero after priming is complete.Step six states that after priming then turn the dose knob to dial in the insulin dose.A review of the manufacturer's instructions for the use of the Lantus pen revealed that in step three, always perform the safety test before each injection to ensure that the pen and needle work properly and remove air bubbles. The first step is to select a dose of two units by turning the dose selector. The pen is to be held pointing upwards, then tap the insulin reservoir so that any air bubbles rise towards the needle. Finally, press the injection button all the way in, and check if insulin comes out of the needle tip. Check the dose window shows 0 following the safety test, then select the required dose by turning the selector clockwise.A review of the manufacturer's instructions for use revealed that in step seven, the Tresiba FlexTouch pen dose selector is turned to two units. Step eight proceeds to instruct that the pen was to be held with the needle pointing up, then tap the top of the pen gently a few times to let any air bubbles rise to the top. Press and hold the dose button until the dose counter shows zero.A review of physician orders revealed that R 39 was to receive Lantus 20 units subcutaneously every 12 hours.An observation of Licensed Practical Nurse (LPN) BB on 9/10/2025 at 8:26 am revealed that she did not prime the Lantus before administration. During the interview after administration, she states that she primed the pen with 1 unit. She stated that she turned the pen to 20 units, then squirted a little out.A review of the physician orders revealed that R39 was to receive Tresiba FlexTouch 100 units/ml 10 units subcutaneously once a day.An observation and interview with LPN BB on 9/10/2025 at 8:34 am revealed that she did not prime the pen before administration. She turned the pen into 11 units. Observed pen read 11 units. She proceeded to push out one unit, but then she pushed out six units. She stated she pushed too hard. She then turned the dial to 10 units. During the interview, she states that you prime the pen with one unit. An interview with the Director of Nursing on 9/11/2025 at 12:06 pm revealed that insulin should be primed one to two units before administering the dose. The policy says to prime with one to two units before dialing the dose.An observation and concurrent interview with Registered Nurse (RN) FF on 9/10/2025 at 10:36 am revealed that R31 was receiving a continuous tube feed infusion through a gastrostomy tube. RN FF stopped the feeding infusion. She checked placement, then began administering the phenytoin (Dilantin) with a water flush before and after medication. She then reconnected the tube feed infusion to the gastrostomy and then restarted the feeding pump. During an on 9/11/2025 11:54 am, RN FF revealed that she crushed phenytoin (Dilantin) and then administered it between the medications through the tube. She paused the tube feeding and then continued the tube feeding after the medication was administered.During an interview on 9/11/2025 at 11:36 am, the Pharmacist Consultant revealed that the recommendation was to stop tube feedings for one hour before and one hour after the administration of phenytoin (Dilantin). She stated that the staff usually sends her an email if they have questions, and she checks the resident's chart and asks questions about the resident. She stated, A resident with tube feeds needs the tube feed stopped before administering phenytoin (Dilantin) or complete frequent labs to make sure that the phenytoin levels are maintained; this is up to the prescriber.An interview with the Director of Nursing (DON) on 9/11/2025 at 12:06 pm revealed that administering phenytoin (Dilantin) is based on whatever the orders say, but usually the nurses should hold the feeding for 30 minutes, then they give based on flush instructions. If a nurse has questions about how to administer medication, they would come to me for assistance. If there are questions about the orders, the nurse would speak with the prescriber. Phenytoin is based on the orders for how often the lab work is checked. If there are continued questions about medication administration, then we reach out to the Pharmacist consultant.

Based on observation, staff interviews, record review, and facility policies titled, Medication Storage in the Care Center and Multi-dose of Medication Storage Conditions and Expiration Date Factsheet, the facility failed to ensure that medications, biologicals, and supplies were stored properly following manufacturers' recommendations or those of the suppliers, including expiration dates for two of two medication carts. This deficient practice has the potential to place residents at high risk for potential clinical, psychosocial, and mental harm.Findings included:A review of policy titled Medication Storage in the Care Center with a last review date of [DATE], revealed that the facility was to facilitate safe, secure, and proper storage of medications and biologicals following the manufacturer's recommendations or those of the supplier. Bullet point 13 revealed that medications requiring refrigeration are kept in a refrigerator with a thermometer to allow for temperature monitoring.An observation and interview with Certified Medication Assistant (CMA) AA on [DATE] at 11:39 AM on B hall medication cart revealed lubricated jelly dated [DATE] and diclofenac sodium topical gel 1% expired in [DATE]. CMA AA admits that the lubricated jelly and diclofenac sodium topical gel 1% had expired. She stated that the lubricated jelly should have been discarded. She states that the lubricated jelly was used for Foley insertion and to check the rectum for impactionAn interview with Licensed Practical Nurse (LPN) BB admits that the diclofenac sodium topical gel 1% had expired in [DATE]. She states the lubricated gel expired in [DATE]. Subsequent interview on [DATE] at 4:29 pm revealed that it is a joint effort with night shift, but night shift was ultimately the one to manage the medication cart.An interview with LPN CC on [DATE] at 4:41 pm revealed that the expectation was that medication carts are clean and everything labeled, and medication is to be discarded timely.An interview with the Assistant Director of Nursing (ADON) revealed that the expectation is that nurses and CMAs must check the cart when coming on and as they give out medications for expiration dates.A review of the factsheet Multi-dose Packages of Medication Storage Conditions and Expiration Dates revealed that Rocklanta unopened should be stored at two to eight degrees or 36-46 degrees Fahrenheit.An observation and interview with Registered Nurse (RN) FF on A hall medication cart on [DATE] at 1:46 pm revealed that the medication eye drops that were unopened required refrigeration before use. There was a label on the box that stated to refrigerate before use. She is unsure how long the box was in the cart. RN FF admits that eye drops were not refrigerated and admits that they should be refrigerated.An interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:46 pm revealed that the eye drops were not open and required refrigeration.An interview with the Director of Nursing (DON) and the Facility Regional nurse on [DATE] at 2:50 pm revealed that the eye drop medication should be refrigerated until it opens. An interview with a Pharmacy Consultant on [DATE] at 11:36 am revealed that the Rocklanta eye drops are to be refrigerated until opened.

Based on observations, record reviews, staff interviews, and a review of the facility policy titled, Medication Administration - General, the facility failed to ensure the medication error rate was not 5% or greater. Observation of medication administration revealed there were two errors out of 35 opportunities observed for 2 of 3 residents (R) (#33 and #6), which resulted in a medication error rate of 5.71 percent (%). Findings included: A review of the facility's undated policy titled, Medication Administration - General, dated 2019 revealed, Prior to medication administration: The nurse should read the administration directions on the MAR (medication administration record) and verify correct medication, dose and direction for use. 1. During a medication administration observation and interview on 01/31/2023 at 7:34 a.m., Licensed Practical Nurse (LPN) 4 prepared medication for R#33 to administer orally and in the eyes. The following medications were prepared and given to the resident: - CertiVite, one tablet - baclofen 20 milligrams (mg), one tablet - citalopram hydrobromide 20 mg, one tablet - famotidine 20 mg, one tablet - levetiracetam 500 mg, one tablet - medroxyprogesterone 10 mg, one tablet - docusate sodium 100 mg, one capsule - vitamin D3 1000 international units (IU)/25 micrograms (mcg), one tablet - polyvinyl alcohol 1.4 % eye drops, one drop in each eye Prior to administering the medication, LPN 4 verified there were eight pills in the medication cup. A record review of the EMAR (electronic medication administration record) and active physician's orders for R#33 revealed that during the 8:00 a.m. medication administration, the resident was to receive the following medications: - multivitamin with minerals. Give one tablet by mouth one time a day as a supplement. - baclofen 20 mg tablet. Give one tablet by mouth three times a day for muscle spasm. - citalopram hydrobromide 20 mg. Give one tablet by mouth once a day for depression. - famotidine 20 mg. Give one tablet by mouth two times a day for reflux. - levetiracetam 500 mg. Give one tablet by mouth two times a day for seizures. - polyvinyl alcohol 1.4 % eye drops. Instill one drop in both eyes four times a day for dry eyes. - Provera (Medroxyprogesterone Acetate) 10 mg. Give one tablet by mouth one time per day for sexual inappropriate behaviors. - Colace (docusate sodium) 100 mg capsule. Give two capsules by mouth two times a day for constipation. - Vitamin D3 25 mcg (1000 units) tablet. Give one tablet by mouth once a day for vitamin D deficiency. The record review revealed that docusate sodium was not administered to R#33 as ordered. Interview on 01/31/2023 at 10:26 a.m., LPN 4 stated that the resident should have received two capsules of docusate sodium and that she probably didn't drop two in there. That was an error on my part. 2. During a medication administration observation and interview on 01/31/2023 at 7:52 a.m., Licensed Practical Nurse (LPN) 5 prepared medication for R#6 to administer orally and subcutaneously. The following medications were prepared and given to the resident: - Lantus pen, 30 units - amlodipine 10 milligrams (mg), one tablet - clopidogrel 75 mg, one tablet - escitalopram oxalate 20 mg, one tablet - furosemide 40 mg, one tablet - hydralazine 25 mg, one tablet - lisinopril 40 mg, one capsule - metoprolol tartrate 25 mg, one tablet - Vitamin B complex, one tablet - Vitamin D3 5000 international units (IU)/125 micrograms (mcg), one tablet - Januvia 50 mg, one tablet - calcium 600 mg/Vitamin D3 10mcg, one tablet - loratadine 10 mg, one tablet - aspirin 81 mg chewable, one tablet Prior to administering the medication, LPN 5 verified that there were 13 pills in the medication cup. A record review of the EMAR (electronic medication administration record) and active physician's orders for R#6 revealed that during the 8:00 a.m. medication administration, the resident was to receive the following medications: - amlodipine 10 mg. Give one tablet by mouth once a day for high blood pressure. - aspirin 81 mg delayed release (DR/EC). Give one tablet by mouth once a day for coronary artery disease. Do not crush. - B Complex-Vitamin B12 (Vitamin B Complex). Give one tablet by mouth one time a day as a supplement. - calcium carbonate 600 mg/Vitamin D3 10mcg. Give one tablet by mouth one time a day as a supplement. - cholecalciferol (vitamin D3) 125 mcg (5,000 units). Give one tablet by mouth once a day for vitamin D deficiency. - clopidogrel 75 mg. Give one tablet by mouth one time a day for stroke. - furosemide 40 mg. Give one tablet by mouth once a day for congestive heart failure. - hydralazine 25 mg. Give one tablet by mouth three times a day for high blood pressure. - Januvia 50 mg. Give one tablet by mouth once a day for diabetes. - Lantus Solostar U-100 insulin (100 unit/mL (milliliter) 3mL) subcutaneous pen. Inject 30 units subcutaneously one time a day for diabetes. - Lexapro (escitalopram oxalate) 20 mg. Give one tablet by mouth one time a day for depression. - lisinopril 40 mg. Give one tablet by mouth one time a day for high blood pressure. - loratadine 10 mg. Give one tablet by mouth once a day for allergies. - metoprolol tartrate 25 mg. Give one tablet by mouth two times a day for high blood pressure. The record review revealed that the aspirin 81 mg delayed release (DR/EC) was not administered to R#6 as ordered. Interview on 01/31/2023 at 4:01 p.m., LPN 5 stated R#6 should have received an 81 mg aspirin. LPN 5 then reviewed the resident's physician's orders and stated that the resident should have received a delayed release aspirin. She stated she gave the resident a chewable aspirin because it was the only aspirin on the medication cart. LPN 5 went to the medication cart and looked for a delayed release aspirin and was unable to locate any in the cart. She then went to the medication room and came out with a bottle of enteric coated 81 mg aspirin. Interview on 02/02/2023 at 2:21 p.m., the Director of Nursing (DON) stated that medications should be given as ordered. The DON stated that if the medication was not located in the medication cart and it was an over-the-counter medication, the facility should have the medication in stock, and the nurse should check the medication storage areas to make sure the medication was in the building. If the medication were not in the building, the DON would request that the pharmacy deliver the medication. Interview on 02/02/2023 at 4:56 p.m., the Administrator stated that the nurse should follow the facility policy regarding medication administration and should follow the physician's orders. The Administrator stated that if a medication was not located in the medication cart, the nurse should check the emergency kit or call the pharmacy to have the medication delivered. If the pharmacy could not deliver, the nurse should contact the facility's backup pharmacy. For over-the-counter medications, the nurse should look to see if the medication was in stock.

Based on observation, staff interviews, record review, and a review of the facility policy titled, Pharmacy Services Medical Administration - General, the facility failed to store medications properly for 3 of 22 residents (R) (#14, #21, #30) on Hall B's medication cart. Findings included: Review of the policy titled, Pharmacy Services Medical Administration - General, dated 2019, revealed Medications should be prepared immediately prior to administration. Medications should not be pre-poured. 1. Review of the most recent quarterly Minimum Data Set (MDS) for R#14, dated 12/27/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the physician's orders for R#14's dated 01/2023 revealed the resident was receiving the following medication: - calcium acetate (a calcium supplement) 667 milligrams (mg), one capsule by mouth twice daily; - cholecalciferol (vitamin D3 supplement) 125 microgram (mcg) capsule, one capsule by mouth every day; - clopidogrel (a blood thinner) 75 mg, one tablet by mouth every day; - Lexapro (treats depression)10 mg, one tablet by mouth every day; ferrous sulfate (iron supplement) 325 mg, one tablet by mouth every day; - folic acid (vitamin B supplement) 1 mg, by mouth every day; - Lasix (diuretic/water pill) 80 mg, one by mouth every day; - gabapentin (treats nerve pain and seizures) 300 mg, one by mouth every day; - oxycodone-acetaminophen (a narcotic pain medication) 10 mg-325mg, one tablet by mouth every day; and - sodium bicarbonate (treats heartburn) 650 mg, give two tablets by mouth three times every day. Interview with R#14 on 02/02/2023 at 2:08 p.m., the resident stated the nurse brought the medications to the resident's room in the morning, and the resident did not go to the desk for medications. 2. Review of the most quarterly Minimum Data Set for R#30, dated 11/08/2022, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. A review of the physician's orders for R#30 dated 01/2023 revealed the resident was receiving the following medication: - Lasix (diuretic/water pill) 40 mg, one by mouth every day; - potassium chloride ER (extended-release potassium supplement) 10 milliequivalent (mEq) one by mouth every day; - Prozac (antidepressant) 20 mg, one by mouth every day; - Senna Plus (treats constipation) 8.6 mg-50 mg tablet, give two tablets by mouth every day; and - Vraylar 3 mg, one capsule by mouth for bipolar disorder. Interview on 02/02/2023 at 2:09 p.m. with R#30, the resident stated the nurse brought medications to their room in the morning. 3. Review of the most recent quarterly Minimum Data Set assessment for R#21, dated 12/06/2022, revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. A review of physicians orders R#21 dated 01/2023 revealed the resident was receiving the following medication: - amlodipine 5 mg, one tablet by mouth every day; - Cholecalciferol (vitamin D3) 125 mcg capsule, one capsule by mouth every day; - clopidogrel (a blood thinner) 75 mg, one by mouth every day; - Colace (a stool softener) 100 mg, one capsule by mouth twice daily; - Eliquis (a blood thinner) 5 mg, one by mouth twice daily; - ferrous sulfate (an iron supplement) 325 mg, one by mouth every day; - losartan (treats high blood pressure) 25 mg, one by mouth every day; and - multivitamins, one by mouth every day. Interview on 02/02/2023 at 2:06 p.m. with R#21, the resident stated that when they received their medications in the morning, the nurse brought the medications to the resident's room. During an observation on 01/30/2023 at 8:47 a.m. with Licensed Practical Nurse (LPN) 17, revealed that the LPN 17 opened the second drawer of the medication cart to begin a medication pass. An unlabeled medication cup that contained medications was observed sitting in the far-left divided area of the drawer. R#30's name was observed on pre-dispensed medication packets behind the unlabeled medication cup. The nurse then closed the drawer and opened the third drawer. Two additional unlabeled medication cups were observed pre-filled with medications in the divided areas. R#14 and R#21's pre-dispensed packets of medications were observed behind each unlabeled medication cup in the divided areas. Further observation on 01/30/2023 at 8:47 a.m. revealed that the medication cart had divided areas in the second and third drawers, with room numbers on each divided area. There were no resident names alongside the room number. Each divided area contained pre-packaged medications. R#30's medication was in the second drawer labeled B7A (R#30 did not reside in that room), R#21's medication was in the third drawer labeled B16B (R#21 did not reside in that room), and R#14's medication was in the third drawer labeled B15A (R#14 did not reside in that room). Interview on 01/30/2023 at 8:47 a.m. with LPN 17, she stated the residents were coming to the main desk for their medications, so she pulled the medications, which made them easier to give. Interview on 02/02/2023 at 2:22 p.m. with LPN 4, she stated the medications were in the drawer according to the order the residents appeared on the EMAR (electronic medication administration record). The first resident on the EMAR screen would be the first medication in drawer one to the far left, and the medications for residents moved to the right in the drawer according to the next resident name on the screen. LPN 4 confirmed that the numbers on the dividers did not necessarily coordinate with the resident's room number. Interview on 01/31/2023 at 10:17 a.m. with the Director of Nursing (DON), she stated medications should be given when the nurse approached the resident's room or the location of the resident and given immediately. The DON stated nursing 101 spoke to never pulling medications ahead of time. Interview on 02/02/2023 at 11:06 a.m. with the Consultant Pharmacist, she stated that as a pharmacist, she did not recommend pulling medications early as a mistake could be made, and another resident could receive the incorrect medication. She further stated that the facility had pre-packaged medications for each resident, and the package could be opened and placed in the medication cup when the nurse was ready to administer the medication to a resident. Interview on 02/02/2023 at 1:37 p.m. with the Administrator, he stated his expectation would be that policy would be followed and the nursing staff would administer medications immediately after placing them in the medication cups. He stated that no medication cups should be pre-filled to be given later.

Based on staff and resident interviews, record review, and review of the facility policy, Changes in a Patient's Condition, review, the facility failed to notify the resident's physician in a timely manner when there was a change in condition for 1 of 3 sampled residents (R) (#46) reviewed for change of condition. Specifically, Resident R#46 complained of weakness and an unsteady gait, and the right lower leg was bothering the resident. The resident requested that their physician order a scan, but the facility failed to immediately notify the resident's physician, and the physician did not see the note and order a scan of R#46's leg until two days later. The scan was not completed until four days after the resident requested a scan. Findings included: A review of the facility's Changes in a Patient's Condition, dated 2020, revealed it was the intent of this center to notify the patient, his/her attending physician, and responsible party/patient representative of changes in the patient's condition and/or status. Nursing services should be responsible for notifying the patient's attending physician when: There is a significant change in the patient's physical, mental, or emotional status; Deemed necessary or appropriate in the best interest of the patient. Further review revealed, Notification, other than for medical emergency, should be made as soon as practical, but should not exceed twenty-four (24) hours. A review of the Face Sheet for R#46 revealed that the facility admitted the resident with diagnoses that included peripheral vascular disease (PVD). A review of the most recent quarterly Minimum Data Set (MDS) for R#46, dated 08/05/2022, revealed that R#46 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. R#46 was independent and required no physical assistance for bed mobility, transfers, or walking in the room and/or corridor. The MDS indicated the resident was steady at all times while walking and used a walker. A review of the Care Plan R#46, initiated on 02/11/2022, indicated the resident was taking an anticoagulant for peripheral vascular disease and a heart attack. The facility developed interventions to administer medications as ordered and to notify the doctor as indicated. The care plan also indicated care areas related to an infection and/or cellulitis, antiplatelet use, cognitive deficit, limited mobility, manipulative behaviors, smoking, decreased cardiac output, pain risk, and the resident planned to discharge home with a caregiver. Review of a Nurses Note, dated 02/10/2022 at 11:43 a.m., revealed the facility admitted R#46 to the facility with a history of cellulitis of the right lower limb. According to the note, the resident was admitted to the facility with a dressing on the right lower leg where there had been a previous infection. Review of a Progress Note for R#46, completed by the Advanced Practice Registered Nurse (APRN), indicated that on 08/11/2022, R#46 was seen for a follow-up for PVD and suspected cellulitis to the right leg. The APRN indicated that the previous cellulitis to the resident's right lower leg had healed. The resident had PVD with a previous right femoropopliteal bypass (surgery to bypass an area of the artery and create a new route for blood flow to the leg), with patency (open, not blocked), which was verified in March by the vascular center. The APRN indicated that the resident reported erythema (redness), edema (swelling), and pain to the resident's right lower extremity (RLE) that started approximately 72 hours before. Per the APRN, the resident suspected an infection in the leg again and asked for something to treat it, as well as additional pain medication. The APRN indicated the RLE was mildly edematous from the knee distally (below the knee) and had nonpitting edema (does not respond to applied pressure). The APRN's plan was to start Bactrim DS (an antibiotic), one tablet twice a day for seven days. Review of a Nurses Note for R#46 dated 08/13/2022, at 5:44 p.m. indicated Licensed Practical Nurse (LPN) 10 noted R#46 complained of weakness and an unsteady gait and requested to work with therapy for walking/strengthening. The resident told LPN 10, My right leg has been bothering me lately. Can the dr (doctor) order a scan for it? According to the note, LPN 10 completed an MD (medical doctor) Communication form and placed it in the doctor's box. LPN 10 indicated in the note that she would continue to observe the resident. Review of the Fax Form for Physician Communication, dated 08/13/2022, revealed R#46 complained of weakness, an unsteady gate, and the resident's leg was bothering the resident lately. The resident wanted the doctor to order a scan. According to the form, a therapy referral was submitted related to weakness. Further review revealed that the doctor responded to the fax request on 08/15/2022 and ordered a venous doppler ultrasound of the resident's right lower extremity. The fax was noted on 08/16/2022 by Licensed Practical Nurse (LPN) 5. Review of a Nurses Note, dated 08/16/2022 at 4:32 p.m., revealed the APRN ordered a venous doppler ultrasound (US) to the right lower extremity. Review of Care Plan Conference notes completed on 08/17/2022 with R#46, and the resident's representative revealed updates regarding the resident's care were provided, and the resident was to have a doppler of his/her leg completed that day (08/17/2022). Review of a Nurses Note, dated 08/17/2022 at 11:10 a.m., revealed there was redness noted to the resident's right leg, and the resident complained of pain in the right leg. The note also indicated that the resident was able to walk on the leg without difficulty. Review of a Patient Report on 08/17/2022 at 11:35 a.m., R#46 had a duplex scan of extremity veins related to right lower extremity pain. The impression indicated there was no evidence of deep venous thrombosis (DVT or blood clot) visualized in the right lower extremity veins. Telephone interview on 02/02/2023 at 7:36 p.m. with LPN 10 stated R#46 always complained of pain in the right leg. She stated that the resident had voiced that the pain had increased. She stated she assessed the resident's leg and asked where the pain was located. LPN 10 stated that the resident then pointed to the spot where the resident previously had cellulitis. She stated there were no open areas in the skin and no redness. She stated she wrote the communication form to the physician, voicing the resident's complaint. She stated she did not call the physician because the resident always complained of pain in the right leg. She stated that the resident usually complained of pain about the time the resident's pain medication was due, and she believed that was why she did not call the physician. LPN 10 further stated that R#46 requested to work with therapy and complained of pain. Subsequently, she filled out the communication form and placed it in the doctor's box for the physician to address. Interview on 02/02/2023 at 8:50 a.m., LPN 5 stated she could not remember when the resident first complained of pain in the right leg. She stated she did not remember much about the incident. LPN 5 stated she could not answer why the Fax Form for Physician Communication dated 08/13/2022 was not noted by her until 08/16/2022. LPN 5 stated that communication forms went into the doctor's box in the fax room at the facility. When the doctor arrived at the facility, the doctor checked the box and signed off on the form. LPN 5 further revealed that the doctor would then place the fax in a basket in the hall where the resident resided or bring the form to the nurse's desk and give it to the nurse. Interview on 02/02/2023 at 10:09 a.m. with, Licensed Practical Nurse (LPN) 1, stated she could not remember when R46 first complained of pain in the right leg. LPN 1 stated that if the resident had a change in condition, staff would notify the physician via telephone. If the concern was not urgent, the staff would notify the doctor through written communication, which was placed in the doctor's box in the copy room. The APRN came to the facility twice a week, and the doctor came once a week. LPN 1 stated that if the concern happened over the weekend, the facility used the on-call service. Interview on 02/02/2023 at 12:28 p.m., the APRN stated the resident was being followed by the vascular clinic for PVD and was seen by the APRN on 08/11/2022. The APRN stated the resident had cellulitis that he thought had healed, but the resident suspected the leg had become infected again. The APRN stated he started the resident on Bactrim. The APRN stated that the resident had also requested an increase in pain medication, and the APRN wanted to talk to the MD about the request for an increase in pain medication. He stated that the facility staff did not call him regarding the resident's complaint that was documented on the 08/13/2023 communication form. He stated in the note that the resident did not complain of pain, just that the resident's leg was bothering them. He stated that if the facility had called the APRN or noted that it was swollen and hot to touch, then a phone call would have been appropriate, but the facility staff wrote the concern as weakness and unsteady gate, which was not urgent. The APRN stated he felt like he did everything he could and got the doctor involved, who escalated the concern. The APRN stated that the resident's right leg was an ongoing, chronic issue. Interview on 02/02/2023 at 2:21 p.m., the Director of Nursing (DON) stated that the resident was admitted to the facility with a mobility issue. The DON stated that the facility staff used the communication form depending on the resident concern. The DON stated that if the concern was something the APRN or MD could see the resident for later, staff completed a communication form and placed it in the APRN/MD box. When the APRN/MD arrived at the facility to see residents, they reviewed the communication forms. The DON stated that the APRN was at the facility twice a week, and the MD was at the facility once a week. The DON could not explain why she was not notified of the resident's concern until 08/15/2022. The DON stated it was a possibility that the nurse who wrote the communication form on 08/13/2022 should have contacted the APRN via telephone instead of the communication form. The DON stated there was a delay in treatment because the communication form was completed over the weekend, and she would have expected the nurse that completed the form to call the APRN. She stated if the pain was more severe, the nurse should have contacted the physician or contacted the on-call physician. She stated that if the nurse was unable to contact the physician or on-call physician, the nurse should have monitored the resident's pain and possibly sent the resident out to the hospital. Interview on 02/02/2023 at 4:52 p.m., the DON stated that if a resident voiced concerns about an issue with their leg, she would expect staff to assess the leg and determine how severe the concern was. She stated that if the level was different from the resident's normal, staff should notify the APRN or MD. Interview on 02/02/2023 at 3:40 p.m., the Medical Director (MD) stated the resident's leg pain was gradual, and the resident had chronic pain and complained of pain everywhere, including the hand, shoulder, foot, and jaw. The MD stated that the facility completed the communication forms and placed them in their folder, and the APRN or MD reviewed the forms once to twice a week. She stated it would be the nurse's perception of the resident if the communication form needed to be completed or if the concern warranted the need to notify someone immediately. Interview on 02/02/2023 at 5:09 p.m., the Administrator stated he expected staff to assess, evaluate, and follow up with the APRN and/or the MD if the resident voiced new concerns. He stated that the staff was allowed to complete communication forms and place them in the APRN or MD's box, but the staff should still call the APRN or MD regarding the concern.

Based on record review, review of facility policies titled COVID-19 Visitation Guidelines and Admission and Placement of Patients, and interviews, the facility failed to ensure one fully vaccinated resident (R) (#15) was allowed visitation after readmission to the facility. The sample size was 27 residents. Findings include: Review of facility policy titled Admission and Placement of Patients dated September 2021 revealed that patients may be placed in the general population (and not in the observation unit) if the following criteria are met: is fully vaccinated and has not had prolonged close contact with someone with COVID-19 infection in the past 14 days. Review of facility policy titled COVID-19 Visitation Guidelines revised April 2021 revealed guidelines for indoor visitation: fully vaccinated patients may engage in close contact while wearing a surgical or well-fitted mask with appropriate hand hygiene before and after contact. Responsible indoor visitation is allowed unless certain scenarios arise that would limit visitation. A review of county positive rate information revealed county positive rates for 7/1/21 - 7/14/21: green. Review of a Nurse's Note revealed R#15 was tested for COVID-19 on 7/7/21 and was negative. Interview with family of R#15 on 9/21/21 at 11:19 a.m. revealed that when resident returned to the facility from hospital visit (on 7/7/21) the resident was placed on quarantine for 14 days and the family was not allowed in the building to see resident. Continued interview revealed that family member voiced concern over why visitation was not allowed in the facility but was allowed in the hospital after the resident had been fully vaccinated and had no signs or symptoms of COVID exposure. Interview with DON (Director of Nursing) on 9/21/21 at 1:34 p.m. revealed that all residents that are re-admission from the hospital or any new admissions are placed on quarantine when they enter the building for 14 days even if the resident had been fully vaccinated and tested for COVID as a precaution. Further interview also revealed that 96% of staff and residents have been vaccinated and only two staff have not been vaccinated. There is no visitation during an outbreak in the facility except for window visits and there have not been any visits inside the facility except for on the porch with a plexiglass petition between the resident and the visitor. Further interview also revealed that there was not a designated area for in house visits because there was not an area in the facility that would accommodate the visit. Continued interview with the DON on 9/21/21 at 2:00 p.m. revealed there was a COVID outbreak that started on 8/16/21 and ended on 9/17/21. Interview with Administrator on 9/21/21 at 2:14 p.m. revealed that the facility currently does not have any positive COVID cases in house. The Administrator stated currently the facility is only allowing window visits but will start in house visit now that there are no COVID positive residents on site.

Based on observation, interview and record review the facility failed to provide nail care for one (1) resident ("F") of seven (7) residents sampled. Findings include: Review of the Patient Information Summary indicated that resident "F" was admitted into the facility in May of 2012. Review of the Client [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set for the resident dated 11/13/14 revealed that he/she was totally dependent on the assistance of two (2) persons for bed mobility and for transfers to or from the bed, chair or wheelchair. The resident's Brief Interview for Mental Status (BIMS) assessment was zero (0) on this assessment indicating the resident was severely cognitively impaired. Observation on 2/4/15 at 10:20 a.m. revealed the resident had very long fingernails. During an interview on 02/04/15 at 12:15 p.m., a family member of resident "F" said that he/she visited most Fridays and Sundays and that the staff was supposed to keep the resident's nails trimmed. The treatment nurse stated on 02/04/15 at 1:20 p.m. that either she, the activity aide or the weekend supervisor were responsible for providing nail care to the residents. The treatment nurse stated that the resident's nails were done as needed and that nail care was not scheduled. Interviews on 02/04/15 at 1:25 p.m. and 2:30 p.m. with the Director of Nursing (DON) and the Regional Nurse Consultant revealed there was no schedule for resident nail care. According to the DON, the treatment nurse was responsible for fingernail care. There were Spa Days that included nail care offered by the activity department. The weekend supervisor could also do nail care. The DON added that she had clipped the resident's nails in the past but had not done so lately. Further interview revealed that normally a certified nursing assistant (CNA) or the family would tell him/her if the resident's nails needed clipping. A review of the facility Procedural Guidelines for Personal Care of Fingernails and/or Toenails revealed the intent of the center was to provide appropriate nail care to all patients.

Based on observation, interview and record review the facility failed to provide indwelling urinary catheter care in a manner to prevent infection related to catheter changes for one (1) resident (#2) of seven (7) sampled residents. Findings include: Review of the Patient Information Summary for Resident #2 indicated that she was admitted into the facility in March of 2008. Review of the physician's orders [REDACTED]. A review of the physician's order [REDACTED]. A review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that resident #2 usually understood and was able to understand others with a Brief Interview for Mental Status (BIMS) score of 13. Review of Section H of the quarterly MDS dated [DATE] indicated that resident #2 had an indwelling catheter. A review of the Plan of Care dated 05/13/2014 for resident #2 revealed a plan for the indwelling catheter related to a [DIAGNOSES REDACTED]. A review of the Medication Administration Records (MARS), the Treatment Administration Records (TARS), the 24-hour report logs and the Interdisciplinary Team (IDT) notes for October 2014 through February 2015 revealed the indwelling urinary catheter was not changed every three weeks as the Physician ordered. The catheter was changed on October 05, 2014 per the twenty-four (24) hour report, November 11, 2014 according to the MAR and January 13, 2015 per the 24-hour report. Interviews with the Director of Nursing (DON) on 02/04/2015 at 1:10 p.m. and 3:15 p.m. revealed that scheduled Foley catheter changes were to be done on the 7 PM - 7 AM shift. The DON said that she was unable to verify that the Foley catheter had been changed according to the physician's orders [REDACTED].

Based on observation, interview and record review the facility failed to follow the resident's individualized Care Plan to change the indwelling urinary catheter as ordered by the physician for one (1) resident (#2) of seven (7) sampled residents. Findings include: Review of the Patient Information Summary for Resident #2 indicated that she was admitted into the facility in March of 2008. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Section H of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicated that resident #2 had an indwelling catheter. A review of the Plan of Care dated 05/13/2014 for resident #2 revealed a plan for the indwelling catheter related to a [DIAGNOSES REDACTED]. A review of the Medication Administration Records (MARS), the Treatment Administration Records (TARS), the 24-hour report logs and the Interdisciplinary Team (IDT) notes for October 2014 through February 2015 revealed the indwelling urinary catheter was not changed every three weeks as the Physician ordered. The catheter was changed on October 05, 2014 per the twenty-four (24) hour report, November 11, 2014 according to the MAR and January 13, 2015 per the 24-hour report. Interviews with the Director of Nursing (DON) on 02/04/2015 at 1:10 p.m. and 3:15 p.m. revealed that scheduled Foley catheter changes were to be done on the 7 PM - 7 AM shift. The DON said that she was unable to verify that the Foley catheter had been changed according to the physician's orders [REDACTED].

Based on observation, staff interview and record review the facility failed to revise the plan of care related to safety for one (1) resident (#6) from a sample of seven (7) residents. Findings include: Review of the Patient Information Summary indicated that resident #6 was admitted into the facility in May of 2012. Review of the Client [DIAGNOSES REDACTED].#6 had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set for resident #6 dated 11/13/14 revealed that she was totally dependent on the assistance of two persons for bed mobility and for transfers to or from the bed, chair or wheelchair. Resident #6 ' s brief interview for mental status score (BIM) was zero (0) on this assessment. Review of the Interdisciplinary Progress Notes for resident #6 dated 01/02/2015 indicated that while putting resident to bed she turned and hit her forehead on assist bar with small one-fourth inch hematoma noted and yellowish bruise noted and starting to form. A review of the Fax form for Physician Communication indicated on 01/02/2015 at 11:35 a.m. revealed that while putting the resident to bed, she hit her right forehead on the assist bar resulting in a small one-fourth inch hematoma noted and bruising starting to form. A review of the Plan of Care for Resident #6 revealed a problem dated 03/13/2014 for resident having thin, fragile skin with history of bruising and skin tears and remained at risk. The goal dated 03/19/2014 stated that the resident would have no infection related to bruising and skin tears during the review period. Interventions included 1) observing signs of abnormal bruising and skin tears and notifying the charge nurse and 2) using caution when transferring the resident as not to bruise or tear skin. An observation of resident #6 on 02/04/2015 at 11:05 a.m. revealed resident with hard light-colored assist rails up on both sides of the bed. Resident #6 was observed lying on her left side gripping left the assist rail with both hands and rocking. The rocking motion caused her head to bump the assist rails. Interviews with the treatment nurse on 02/04/2015 at 1:20 p.m. and 2:15 p.m. revealed that she, the MDS coordinator or the resident care coordinators would be responsible for updating interventions, if needed, on the plan of care for residents with incidents involving bruises. She would do it if she knew about its occurrence. She revealed she was unaware of the incident involving resident #6 hitting her head on the assist rail on 01/02/2014. It may have been discussed in the morning meeting if it had been put on the twenty-four (24) hour report and may have been discussed in the Interdisciplinary Team meeting. She was not sure why the plan of care for Resident #6 was not updated to reflect the injury on 01/02/15. Interviews with the Director of Nursing (DON) and regional nurse consultant on 02/04/2015 at 1:25 p.m. and 2:30 p.m. revealed the facility padded assist rails when needed. They said that an intervention was expected to be put in place for resident #6 ' s safety after the incident involving the assist rail on 01/02/2015. A review of the facility Procedural Guidelines for the Patient ' s Plan of Care indicated the intent of the center was to develop and maintain an individualized plan of care for each patient. It further indicated that the plan of care was to include identified problem areas and incorporate risk factors associated with the identified problems. The care plan was also to be revised as changes in the resident's condition dictated.

Based on resident interview, staff interview, and record review the facility failed to obtain a orthotic referral for one resident ("A"), from a total sample of thirty two (32) residents. Findings include: Review of the medical record for Resident "A" revealed that the resident had a [DIAGNOSES REDACTED]. An interview with the resident on 1/28/14 at 10:46 a.m., he/she stated that the therapist was supposed to be getting him/her a splint for his/her right leg. A review of the resident's medical record revealed [REDACTED]. The PT had written a recommendation to the nursing staff for the resident to be referred to an orthotic specialist for a device for the resident's right leg in order to continue with skilled physical therapy. The therapy note also listed that nursing education had been provided to the Minimum Data Set nurse (MDS) and nurse on duty for referral to orthotic specialist. Review of the physician order [REDACTED]. However, there was no evidence that the nursing staff had obtained the referral. An interview on 1/30/14 at 11:15 a.m., with the Resident Care Coordinator licensed nurse "CC" for the B wing, revealed that whenever a skilled therapist referred to nursing for an orthotic device for a resident the order should be taken off the chart by the nursing staff and a form should be left for the Restorative nurse to order the referral. An interview on 1/30/14 at 11:20 a.m. with the licensed restorative nurse, ("DD") revealed that she was not aware of a brace order for the resident but thought that the therapy department had ordered it and would obtain the information. An interview with the Physical Therapist on 1/30/14 at 11:39 a.m., revealed that she has spoken to licensed nurse "BB" about the brace and had informed the nurse that she (PT) could not treat the resident until the resident received an orthotic device for his/her right leg. An interview with the Licensed Practical Nurse "BB" on 1/30/14 at 11:45 a.m. revealed that an appointment should have been made for the resident to see an orthotic specialist but it had not been done.

Based on observations and staff interviews the facility failed to properly monitor for expired medications and to store medications properly on one(1) hall (A) of two (2) medication rooms (A and B Hall). Findings include: During observation of medication storage room on A hall on 1/29/13 at 2:15 p.m., three (3) Novolog 70/30 prefilled insulin syringes for resident #22 were found in medication refrigerator with an expiration date of 12/20/13 and one (1) unopened vial of Humalog for resident #65 with an expiration date of 10/20/13. An interview with Licensed Practical Nurse "EE", on 1/29/14 at 2:15 p.m. revealed that resident #22 was not being administered insulin with a prefilled flex pen and that resident #65 was not being administered the Humolog insulin. She confirmed that the both medications were out of date.

Based on resident interview and record review the facility failed to provide one resident ("A" ) with a referral for an orthotic device from a total sample of thirty two (32) residents. Findings include: An interview on 1/28/14 at 10:46 a.m., with Resident "A" revealed that the therapist was supposed to be getting him/her a splint for his/her right leg. The resident was assessed on the 10/9/14 Annual Minimum Data Set (MDS) as requiring extensive assistance with transfers. The 10/23/13 care plan, revised on 1/15/14, listed that the resident had a decreased weakness noted to the right side related to a [MEDICAL CONDITIONS] with [MEDICAL CONDITION]. The interventions included to follow up with skilled therapy as needed. A review of the resident's medical record revealed [REDACTED]. The PT wrote a recommendation to the nursing staff for the resident to be referred to an orthotic specialist for a device for the resident's right leg in order to continue with skilled physical therapy. However, there was no evidence that the nursing staff had made a referral for the device. Cross to F318

Based on observation, record review and staff interview, it was determined that the nursing staff failed to assess recurrent bruises on one resident (#18) and ensure that preventative measures were implemented from a total sample of 33 residents. Findings include: Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received 81 milligrams of Aspirin every day. He/She had a care plan since 3/01/11 for being at risk for skin impairment due to incontinence. However, staff had not developed a care plan with interventions to prevent the resident from bruising. According to the 1/25/12 nurses' note, licensed nursing staff observed numerous discolorations of small bruises and age spots on the resident. Licensed nursing staff documented on the 2/01/12 nurses' note that the resident had an old, dark blue bruise on his/her left hand. On 2/08/12, licensed nursing staff documented that the resident had a small discolored area on his/her right hand. According to the 4/11/12 nurses' note, the resident had a small bruise on the back of his/her left hand. On 4/30/12 at 3:16 p.m., the resident was wearing a short-sleeved shirt. There was an irregular purplish area on his/her right forearm near the elbow. The resident was observed using his/her arms to reposition himself/herself in the wheelchair on 5/02/12 at 1:55 p.m. On 5/02/12 at 2:10 p.m., certified nursing assistant (CNA) "CC" stated that she/he would immediately report any bruises on the residents to the charge nurse but, she was not aware that resident #18 had any bruises. On 5/02/12 at 2:15 p.m., supervisory nurse "DD" stated that the CNAs were supposed to immediately report any bruises on residents to a nurse. The nurse was then supposed to fill out a form and give it to the Resident Care Coordinator who would investigate the possible causes of the bruise in order to implement preventative measures. "DD" stated that nursing staff had not notified her/him about the bruises on resident #18 which had been documented in the 1/25/12, 2/01/12, 2/08/12 and 4/11/12 nurses' notes. There was not any evidence that facility staff had investigated the possible causes of those bruises or implemented any preventative measures.

Based on observation, record review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care for one resident (#18) to address his/her risk for bruising from a sample of 33 residents. Findings included: Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received 81 milligrams of Aspirin every day. Licensed nursing staff had documented the presence of bruises on the resident on 1/25/12, 2/01/12, 2/08/12 and 4/11/12. Although the resident's care plan since 3/01/11 addressed his/her risk for skin impairment due to incontinence, it did not address his/her potential for bruising. The staff had not developed any interventions to address the services needed to prevent bruising related to his/her medical condition, age and aspirin therapy. On 5/2/12 at 2:30 p.m., after surveyor inquiry, staff initiated a care plan to prevent the resident from developing bruises related to his/her use of his/her elbows to reposition him/herself in the wheelchair. See F323 for additional information regarding resident #18.

Based on record review , observation and staff interview, it was determined that the facility failed to maintain a complete and accurate record of incidents and corrective actions related to infections for two residents (#6 and #10), failed to implement appropriate precautions for one resident (#6) with Clostridium difficile infection in a total sample of 14 residents, and failed to ensure that one of 11 employees reviewed were free of communicable disease prior to employment. Findings include: According to the Centers for Disease Control (CDC) and Prevention,[DIAGNOSES REDACTED].-associated disease could be prevented in healthcare settings by: the use of Contact Precautions; and implementing an environmental cleaning and disinfection strategy. Patients were to be placed in private rooms. If private rooms were not available, those patients would be placed in rooms (cohorted) with other patients with [DIAGNOSES REDACTED]-associated disease. Gloves were to be used when entering patients' rooms and during patient care. Gowns were to be used if soiling of clothes was likely. Equipment was to be dedicated to that patient whenever possible. Those precautions were to continue until diarrhea ceased. The facility's Infection Control Surveillance Program included a "Organisms or Infections and Precautions Needed" form. It included a brief summary of room requirements and /or precautions to be observed with specific organisms or infections. Under the heading for Clostridium difficile infection, the room requirements included a private room or cohort with the same diagnosis/organism or discuss room placement with management/corporate. The duration for the private room was listed as "until the diarrhea ceases." The precautions were listed as "Contact Precautions". At the bottom of the form, there was a Summary of "Contact Precautions". The summary included the use of a Stop sign posted on the door; gloves to enter the room; gowns to enter the room; trash and linen containers in the room until the trash and linen could be placed in the soiled utility room or taken to the laundry. It also listed that no special bags were needed and that the linen should be washed separately. The Contact Precautions fact sheet listed that the Stop sign instructed staff and visitors that contact precautions were to be used and to see a nurse for instructions. During an interview on 8/19/10 at 10:45 a.m., the Director of Nurses explained that the facility's "Infection Patient List" form included where the infection was acquired. She said that if the resident was admitted with the infection, the infection was coded as a community acquired infection (CAI). If the resident acquired the infection at the nursing home then, it was coded as a nursing home infection (NI). She stated that when an infection was coded as a CAI, it was not included in the facility's "Monthly Infection Control" detail list or included in the facility's "Infection Rate Graph". 1. During the intial tour of the facility on 8/17/10 at 11:10 a.m. and 12:00 noon, licensed charge nurse "RR" stated that resident #6 had a colonoscopy completed on Friday. He/she stated that morning (8/17) the physician, who performed the colonoscopy, had called to inform them that the resident had Clostridium Difficile (C-Diff). Licensed nurse "RR" stated that the resident had a history of [REDACTED]. However, upon entering the resident's semi private room, it was observed that there were not any infection control precautions posted on the resident's door or inside the resident's room. There were not any gloves or gowns outside the resident's room for use by the staff. The nurse confirmed that the resident had a room mate who shared the same bathroom. A review of the room-mate's clinical record revealed no evidence that he/she had a[DIAGNOSES REDACTED]. associated disease. A review of the 8/17/10 nursing notes revealed documentation that licensed nurse "RR" had received a telephone call from the physician's office that morning informing him/her that resident #6 had[DIAGNOSES REDACTED]. Resident #6 was observed in his/her room on 8/17/10 at 12:45 p.m., 1:20 p.m., 3:30 p.m., and 4:40 p.m. However, there was no evidence that contact precautions had been implemented by nursing staff. There was not a Stop sign posted on the resident's door. On 8/18/10 at 8:10 a.m. and 11:00 a.m., the resident was observed in his/her room but, there were not any contact precautions in place. On 8/19/10 at 10:00 a.m., the resident was observed sitting in his/her wheelchair in his/her room visiting with another resident but, there were not any contact precautions in place. There was not a Stop sign posted on the door to instruct visitors to see a nurse prior to entering that room. During an interview on 8/19/10 at 10:45 a.m., the Director of Nurses stated that she was not aware that resident #6 had the[DIAGNOSES REDACTED] diagnosis. Nursing staff sent a fax to the attending physician on 6/2/109 that resident #6 was complaining about painful urination and frequent urination. A urinalysis with a culture and sensitivity was obtained on 6/4/10 . On 6/7/10, the culture and sensitivity report revealed that the resident had an infection of Escherichia Coli (E. Coli) bacteria of over 100,000 colony count. The resident was treated with 250 milligrams of [MEDICATION NAME] (an antibiotic), twice a day for 10 days. A repeat urinalysis with a culture and sensitivity was obtained on 6/23/10 with the results of E. Coli bacteria of over 100,000 units. The resident was treated with 100 milligrams of [MEDICATION NAME] (an antibiotic), twice a day for 10 days. However, a review of the June 2010 "Patient Infection List" recorded resident #6 as having an Urinary Tract infection on 6/4/10 and 6/21/10. The infections were listed as Community Acquired Infections (CAI) and therefore were not included on the Monthly Infection Control Detail report. This failure resulted in the facility having an inaccurate Infection Rate for the month of June. 2. Resident #10 had a urinalysis collected on 7/9/10 with a culture and sensitivity test completed on 7/12/10. The results of that culture revealed an infection of Proteus Mirabilis with over 100,0000 colony count. The resident was treated with 500 milligrams [MEDICATION NAME] a day for 10 days. A repeat urinalysis with a culture and sensitivity was obtained on 7/29/10 and revealed an infection of E.Coli with over 100,00 colony count. The resident was treated with one gram of [MEDICATION NAME] (an antibiotic) every day for 7 days. Although the facility's July "Patient Infection List" revealed that resident #10 had an urinary tract infection , nursing staff failed to list the results of the cultures and identify that the resident had two different infections. This failure caused the Monthly Infection Detail list and Infection Rate to be inaccurate for the month of July. 3. During a review of 11 employees' personnel records on 8/18/10, it was determined that one employee had been hired on 9/1/09. However, there was no evidence that the facility had obtained the results of his/her [DIAGNOSES REDACTED] screening test until 9/15/09. In an interview on 8/18/10 at approximately 4:30 p.m., the Administrator stated that, since this employee was transferred from another facility within the corporation, she was not aware that a new PPD was required before working at the facility.