Every finding on record at Bradley Creek Health Center

Based on observations, record review, Physician Assistant and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication (a medication that affects brain activities associated with mental processes and behavior) was limited to 14 days or document the continued use with a rationale and duration for 1 of 5 residents (Resident #10) reviewed for unnecessary medications. Findings included: Resident #10 was admitted to the facility on [DATE]. Diagnoses included, in part, fracture of left humerus, metabolic encephalopathy, Parkinson's, and anxiety. A review of the physician orders written on 03/12/24 revealed an order for Alprazolam 0.5 milligrams (mg) one tablet every 8 hours as needed for anxiety. There was no stop date indicated on this order. The Minimum Data Set admission assessment dated [DATE] revealed Resident #10 was cognitively impaired and exhibited hallucinations and refusal of care. Resident #10 received antianxiety, antidepressants, anticoagulant (blood thinner) and opioids during this assessment. Review of the Pharmacy Consultants medication regimen review dated 03/13/24 indicated, in part, PRN psychotropic medications are limited to 14 days. If you would like to extend Alprazolam 0.5 mg one tablet every 8 hours PRN for anxiety past 14 days, please document a rationale and indicate a duration. This was reviewed and signed by the Physician Assistant dated 03/14/24 with a rationale stating, working to wean off Alprazolam and hopefully will only need this one 14 dose package. Review of March 2024 Medication Administration Record revealed Resident #10 received Alprazolam 0.5 milligrams daily from 03/16/24 through 03/31/24. Review of the April 2024 Medication Administration Record revealed Resident #10 received Alprazolam 0.5 milligrams daily from 04/01/24 through 04/10/24. An interview with the Physician Assistant on 04/11/24 at 4:15 PM revealed when she reviewed this recommendation from the pharmacist, she did not include the end date along with her rationale and should have. The Physician Assistant added, when the nurse's put orders in for a PRN psychotropic medication, they should be putting an end date. She stated nursing did not make her aware that she was taking this regularly and she would reevaluate to see if the resident needed this medication scheduled instead of as needed. An interview was conducted with Nurse #3 on 04/11/24 at 4:20 PM. Nurse #3 reported anytime a resident was on a PRN psychotropic medication it should have a stop date at 14 days. She stated she entered the order as it was listed on the hospital discharge summary and she forgot to the put the 14 day stop date on the order. An interview with the Director of Nursing (DON) on 04/11/24 at 5:30 PM revealed he would have expected the PRN stop date to be applied. The DON stated the monthly Pharmacy medication recommendations regarding as needed orders with stop dates were given directly to the Physician or the Physician Assistant for review. Once the Physician reviewed and signed the recommendation, he would implement the order. The DON stated his nursing staff were aware of the regulation to have a stop date for as needed psychotropic medications and should have identified this when transcribing the order and during their medication pass.

Based on record review, Nurse Practitioner, Physician, Responsible Party, and staff interviews, the facility failed to notify the responsible party of a change in medication for 1 of 1 residents (Resident #85). Findings included: Resident #85 was admitted to the facility on [DATE]. Diagnoses included, in part, fracture of left femur, presence of left artificial hip joint, fall, and epilepsy. The Minimum Data Set admission assessment dated [DATE] revealed Resident #85 was moderately cognitively impaired and was coded as receiving scheduled pain medication and as needed pain medication. Resident #85's pain was assessed and noted to be frequent with difficulty sleeping at night and limited day to day activities. Pain described at severe. Resident #85 was coded as having major surgery prior to admission and required active skilled nursing care due to recent surgery. Resident #85 received 2 days of opioid medication during this assessment period. A review of the physician orders revealed Keppra (medication to treat seizures) 500 milligrams (mg) twice daily written on 07/10/23, Tramadol (an opioid pain medication) 50 mg one tablet every 6 hours as needed for pain written on 07/10/25 and discontinued on 07/25/23, Acetaminophen (pain relieving medication) 325 mg give 2 tablets every 6 hours as needed for pain written on 7/10/23 and changed to every 6 hours scheduled on 07/25/23. A review of a nursing progress note written on 07/25/23 at 7:25 AM written by Nurse #1 revealed nurse spoke with resident's responsible party (RP) in facility. RP expressed some concerns regarding orders she was not aware about. Writer apologized that RP was not notified and explained that in the future she would be notified of any new orders. A review of a provider note written by the previous Nurse Practitioner (NP) on 07/25/23 at 8:58 AM revealed, in part, reviewed resident's medications. Resident had a past medical history of subarachnoid hemorrhage (bleeding in the brain) from 04/19/23 with hospitalization , history of seizures, Dementia, and frequent falls. Current medications included Keppra (antiseizure medication) 500 mg twice daily, Tramadol 50 mg every 6 hours as needed for pain, Acetaminophen 650 mg every 6 hours as needed for pain. Current rehabilitation for left hip fracture surgery on 07/06/23. Tramadol and Keppra together have risk of lowering seizure threshold, increasing dizziness, drowsiness, confusion and decreasing motor coordination. Will discontinue Tramadol for these risks. The following medication changes have been ordered: discontinue Tramadol, change Acetaminophen 650 mg from every 6 hours as needed to three times daily for pain, and consider Oxycodone 2.5 mg three times daily as needed for pain if needed. Discussed plan with physician. Review of new physician orders written on 08/02/23 revealed an order for Oxycodone (an opioid pain medication) 5 mg give 0.5 mg tablet 4 times a day for pain. This order was discontinued on 08/07/23. A review of the medication administration record (MAR) revealed Resident #85 received Oxycodone 2.5 mg from 08/03/23 through 08/06/23 at a total of 14 doses. The MAR revealed the order was discontinued on 08/07/23. A nursing progress note written on 08/07/2023 at 12:56 PM revealed, in part, Nurse #1 spoke with RP regarding her concerns. Nurse discussed pain medication and told the RP that she would look into her concerns. A late entry nursing note written by Nurse #2 on 08/18/23 at 3:23 PM revealed, in part, that this nurse and Nurse #1 spoke to RP on 08/18/23 as a follow up call. Nurse #2 explained that after following up on why changes to resident's medication of oxycodone had been changed the following occurred: 1) Resident was given Tramadol by NP #1. NP #1 reviewed medications for resident's pain with the physician. Discussed seizure threshold of medications. Resident currently on Keppra so Tramadol was discontinued due to lowering seizure threshold on 07/25/23. Oxycodone 2.5 mg 4 times daily scheduled was ordered and nursing was to notify RP of changes. 3) Resident received Oxycodone 2.5mg from 08/03/23 through 08/06/23 for a total of 14 doses. 4) Nurse #2 discussed education was given to staff on notification communication. A phone interview with the Responsible Party on 04/09/24 at 11:59 AM revealed she was not notified the facility had ordered the Tramadol for Resident #85 until it was discontinued nor was she made aware that Oxycodone was started as a new order. The RP stated she was visiting the resident on 08/06/24 and observed the nurse administering the Oxycodone and questioned when the resident started receiving that medication. Interview with Nurse #2 on 04/10/24 at 1:50 PM revealed she recalled Resident #85 and remembered writing the note regarding the Tramadol and the Oxycodone orders. Nurse #2 stated normally whenever the NP put a new order in place, the NP would notify the family. She stated she did not know what happened and why the NP did not notify the family, but that it then initiated the facility to do a complete in-service with all nursing staff to make sure any new changes or orders were being communicated to the family by the nurse. A phone interview with Nurse #1 on 04/10/24 at 2:10 PM revealed she recalled the day the RP was inquiring about the Oxycodone and she stated she did not notify the family regarding the change of medication with the Tramadol or the Oxycodone because she thought the NP was notifying the family. An interview with the Physician on 04/10/24 at 4:10 PM revealed she would have expected the nursing staff to notify the family of the medication changes. The Physician stated notifying the family was not the sole responsibility of the NP when she initiated an order, but she knew that the NP would notify family at times. The Physician stated communication of who notified the family should be documented at the time of the notification to avoid confusion. A phone interview was conducted with the previous Nurse Practitioner (NP #1) on 04/11/24 at 5:10 PM. NP #1 stated she was not responsible for notifying the families of any medication changes. She stated it was the nursing staff's responsibility. An interview with the Director of Nursing on 04/11/24 at 5:30 PM revealed the expectation was that the nursing staff was to notify the RP of any medication changes. He stated after this incident occurred he did a full in service with all nursing staff to ensure they understood it was their responsibility to notify the family and document the notification in a nursing note. He did not complete a full plan of correction.

Based on record review, staff and the Physician Assistant interviews the facility failed to administer an as needed antihypertensive medication as prescribed by the physician for blood pressure greater than 150/90 millimeters of mercury (mm Hg) resulting in 3 missed doses. This occurred for 1 of 1 resident (Resident # 7) reviewed for medication administration. Findings included. Resident #7 was admitted to the facility on [DATE] with diagnoses including hypertension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #7 was cognitively intact. She had no rejection of care. A care plan dated 03/21/24 for Resident #7 revealed to administer antihypertensive medications as ordered. A physicians order dated 03/22/24 for Resident #7 revealed Clonidine (antihypertensive) oral tablet 0.1 milligram. Give 1 tablet by mouth every 24 hours as needed for hypertension. Give if systolic blood pressure is greater than 150 mm Hg and diastolic blood pressure is greater than 90 mm Hg. Review of the progress notes for Resident #7 from 03/21/24 through 03/31/24 revealed a blood pressure reading recorded on 03/23/24 at 9:33 AM of 168/98 mm Hg. The progress note revealed no documentation that Clonidine 0.1 mg as needed for blood pressure greater than 150/90 was administered to Resident #7. Review of the Medication Administration Record (MAR) dated March 2024 for Resident #7 revealed Clonidine 0.1 mg as needed for blood pressure greater than 150/90 mm Hg was not administered to Resident #7 on 03/23/24. Further review of the Medication Administration Record (MAR) dated March 2024 for Resident #7 revealed blood pressure readings less than 150/90 and the as needed Clonidine 0.1 mg was not needed and was not administered. Review of the Medication Administration Record (MAR) dated April 2024 for Resident #7 revealed blood pressure readings greater than 150/90 on the following dates: 04/01/24 the blood pressure reading was 179/98 mm Hg. 04/09/24 the blood pressure reading was 155/95 mm Hg. Review of the Medication Administration Record (MAR) dated April 2024 for Resident #7 revealed no documentation that Clonidine 0.1mg as needed for blood pressure greater than 150/90 mm Hg was administered to Resident #7 on 04/01/24 or 04/09/24. Review of the progress notes for Resident #7 from 04/01/24 through 04/09/24 revealed no documentation that Clonidine 0.1 mg was administered. During an interview on 04/11/24 at 6:10 PM the Physician Assistant stated Resident #7 had orders for scheduled Clonidine 0.1 mg daily and an as needed dose was ordered to be given once every 24 hours if her blood pressure was greater than 150/90 mm Hg. She indicated Resident #7 should have received the as needed dose on the days her blood pressure was elevated above 150/90 mm Hg. She stated she evaluated Resident #7 today and she was at her baseline and her vital signs were stable. She stated Resident #7 did not have any adverse effects by not receiving the 3 missed doses of the medication. During an interview on 04/11/24 at 6:35 PM Nurse #7 stated he was the assigned Nurse for Resident #7 on 04/01/24. He stated he did not give the as needed dose of Clonidine to Resident #7 because he gave the 9:00 AM scheduled dose and didn't want to give her 2 doses. He indicated he was uncertain of when exactly the blood pressure reading was taken on 04/01/24. He indicated with an elevated blood pressure of 179/98 he should have clarified the order with the physician. During an interview on 04/11/24 at 7:33 PM Nurse #4 stated the vital signs recorded on 04/09/24 for Resident #7 were taken by another staff member. She stated when she documented the blood pressure reading of 155/95 for Resident #7, she did not think to look at her medications to detrmine if any as needed medications for increased blood pressure should be given. She stated she did not administer as needed Clonidine to Resident #7 on 04/09/24. Nurse #8 who was assigned to Resident #7 on 03/23/24 when the blood pressure reading was 168/98 was not available for an interview. During an interview on 04/11/24 at 6:47 PM the Director of Nursing stated Resident #7 should have received the Clonidine 0.1 mg as needed for increased blood pressure when the blood pressure was greater than 150/90 mm Hg. He stated that did not occur and education would be provided.

Based on observations and staff interviews the facility failed to remove expired food items stored for use in the walk-in refrigerator. This practice had the potential to affect the foods served to the residents. The findings included: Initial observation of the kitchen walk-in refrigerator occurred on [DATE] at 10:15 AM with the Director of Dining Services and revealed a plastic container of mandarin oranges with a discard date of [DATE]. A follow-up observation of the kitchen walk-in refrigerator on [DATE] at 11:25 AM revealed a plastic container of yellow sliced cheese with a discard date of [DATE] and a plastic container of chocolate mousse with a discard date of [DATE]. An interview with the Chef was completed on [DATE] at 11:25 AM. The Chef stated that the expired food items observed on [DATE] and [DATE] should have been discarded. He further stated that all the Dining Services staff were responsible for removing expired food items from the walk-in refrigerator. An interview with the Administrator occurred on [DATE] at 3:45 AM. The Administrator stated that she expected the Dining Services staff to follow safe food handling practices when labeling and storing food items.

Based on observations and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of [DATE]. This was for 1 deficiency cited in the area of Food and Nutrition Services (F812). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F 812: Based on observations and staff interviews the facility failed to remove expired food items stored for use in the walk-in refrigerator. This practice had the potential to affect the foods served to the residents. During the recertification and complaint survey completed [DATE] the facility failed to maintain safe food temperatures for potentially hazardous foods. Hot foods should be maintained at a temperature of 135 degrees or higher and cold foods should be maintained at a temperature of 41 degrees or lower. A telephone interview was completed with the Administrator on [DATE] at 09:31 AM. The Administrator stated that she didn't think the facility's QA program for the kitchen had failed. She further stated that the facility was previously cited for failing to maintain safe food temperatures and that was not an issue during the current survey. The Administrator indicated that the facility would focus on developing a QA specific for safe food handling and storage practices.

Based on observations, manufacturer's instructions, staff interviews and Consultant Pharmacist interviews, the facility failed to store an unopened bottle of eye drops in the refrigerator specified by the manufacturer's instructions for 1 of 3 medication carts and failed to record an opened date on two opened bottles of eye drops for 1 of 3 medications carts observed for medication storage. Findings included: 1. During an observation with Nurse #1 on medication cart #1 on 12/20/22 at 9:30 AM an unopened bottle of Travoprost Solution 0.004% eye drops was not refrigerated as indicated on the manufacturer's instructions which stated, store unopened bottle in refrigerator, once opened store at room temperature and discard remaining amount not used after 6 weeks. An interview was conducted with Nurse #1 on 12/20/22 at 9:38 AM. Nurse #1 confirmed the label indicated the unopened eye drop solution should be refrigerated. Nurse #1 reported she did not know the eye drop solution was supposed to be refrigerated until it was opened. A phone interview was conducted with the Consultant Pharmacist on 12/22/22 at 10:55 AM. The Consultant Pharmacist stated the manufacturer's instructions should always be followed to ensure the medication maintains its efficacy. An interview was conducted with the Director of Nursing (DON) on 12/22/22 at 3:00 PM. The DON reported she expected her nursing staff to be following the manufacturer's instructions and labels as it pertained to medications. 2. During an observation with Nurse #1 on medication cart #1 on 12/20/22 at 9:30 AM revealed 2 bottles of Latanoprost Solution 0.005% eye drops were noted to be opened with no opened date indicated. Review of the manufacturer's instructions revealed store unopened bottle in refrigerator, once opened store at room temperature and discard remaining amount not used after 6 weeks. An interview with Nurse #1 revealed after opening the Latanoprost bottles, they should have been labeled with the date they were opened. Nurse #1 added, she did not know the eye drops were only good for 6 weeks after opening. A phone interview was conducted with the Consultant Pharmacist on 12/22/22 at 10:55 AM. The Consultant Pharmacist stated the manufacturer's instructions should always be followed to ensure the medication maintains its efficacy. The Pharmacist added, the medication should be discarded after 6 weeks from opening and without the date recorded when it was opened, staff would not know when to discard the medication. An interview was conducted with the Director of Nursing (DON) on 12/22/22 at 3:00 PM. The DON reported she expected her nursing staff to be following the manufacturer's instructions and labels as it pertained to medications.

Based on observations and staff interviews the facility failed to: 1) maintain broccoli at 135 degrees Fahrenheit (F.) or higher on the lunch meal tray line, and 2) maintain chicken salad, at 41 (F.) or below on the lunch meal tray line. Both of these items could be potentially hazardous if not served at the appropriate temperatures. The findings include: 1. An observation of the lunch meal tray line on 10/04/21 at 12:15 PM revealed a large stainless-steel serving tray of broccoli on the serving line (with the warming tray's switch off). Temperature monitoring, by the Chef on 10/04/21 at 12:30 PM revealed the following temperatures: broccoli - 80 degrees F. and chicken salad 53 degrees F. During an interview with the Chef on 10/04/21/21 at 12:35 PM, he stated that he expected dietary staff to serve hot foods 135 degrees F. or higher, and cold foods 41 degrees F. or below. and if temperatures of hot food were below 135-degree F. or cold foods were higher than 41-degree F., the food items should be discarded or re-heated prior to serving. He visually confirmed that the warming switch for the broccoli was not turned on, which resulted in the broccoli cooling down on the tray line to 80 degrees F. He also stated the chicken salad should have been kept cool below 41 degrees F. just prior to serving and was not. During an interview with the cook in the satellite kitchen on 10/04/21 at 12:45 PM she revealed when she took the temperatures of the food being served from the kitchens' tray line, they had to have hot food temperatures 135 degrees F. or higher, and the cold foods needed to be 35 degrees F. or colder. Cook said the kitchen staff should have checked both the broccoli and the chicken salad's temperatures to ensure all hot food items were above 135 degrees F. and that all cold foods were below 41 degrees F. before serving them on the lunch tray line. During an interview with the Director of Dietary Services on 10/07/21 at 8:52 AM, he revealed hot food temperatures were required to be at least 135 degrees F., and cold food temperatures were required to be below 41 degrees F. when served from the tray line. During an interview with the Administrator and Director of Nursing (DON) on 10/07/21 at 4:30 PM, they both reported it was their expectation the facility's kitchens follow all regulatory guidelines for food and kitchen sanitation safety

Based on observation, record review, and staff interviews the facility failed to provide a diet as ordered for 1 of 1 sampled residents (Resident #2) who should have received large protein portion meals. Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was moderately cognitively impaired and did not reject care. Resident #2 needed supervision and set up help with meals. Review of Resident #2's meal card revealed a large protein portion was to be included with all meals. In an observation on 06/04/19 at 12:30 PM Resident #2 was seated at a table in the dining room. A staff member was seen removing the meal plate. The plate contained vegetable lasagna and brussels sprouts. There was no protein seen with Resident #2's meal. In an interview on 06/04/19 at 12:35 PM the Dietary Manager stated that Resident #2 received a large portion of vegetable lasagna. She indicated that the vegetable lasagna did not contain any protein and that Resident #2 should have received a large portion of chicken with the meal and had not. In an interview on 06/05/19 at 3:05 PM Nursing Assistant (NA) #1 stated that Resident #2 was supposed to receive double protein meals. She indicated that she had been instructed to encourage Resident #2 to eat the protein that was provided with the meals. In an interview on 06/06/19 at 9:24 AM the Administrator indicated the Dietary Manager worked closely with the residents to choose their diets. She indicated that if a special diet, such as large protein portions, was ordered then that was to be included in addition to their regular diet order.

Based on record review and staff interviews the facility's quality assurance (QA) program failed to prevent the reoccurrence of deficient practice related to the maintenance of complete and accurately documented medical records which resulted in a repeat deficiency at F842. The re-citing of F842 during the last year of federal survey history showed a pattern of the facility's inability to sustain an effective QA program. Findings included: This tag is cross-referenced to: F842: Resident Records - Identifiable Information: Based on record review and staff interviews the facility failed to maintain complete and accurately documented medical records for 3 of 14 Residents (Resident #2, Resident #11, and Resident #9) whose medical records were reviewed. Findings included: Review of the facility's survey history revealed F842 was cited during the facility's 06/08/18 annual recertification/complaint investigation survey for incomplete and inaccurately documented medical records. The facility was re-cited during the current 06/06/19 annual recertification/complaint investigation survey for the same issue of incomplete and inaccurately documented medical records. In an interview on 06/06/19 at 3:22 PM the Administrator indicated that there had been a large staff turn-over and this may have contributed to a decreased focus on documentation. She indicated that a longer period in QA may have allowed the facility to monitor and audit documentation and provide education to the nurses as needed.

Based on record review and staff interviews the facility failed to maintain complete and accurately documented medical records for 3 of 14 Residents (Resident #2, Resident #11, and Resident #9) whose medical records were reviewed. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was moderately cognitively impaired and did not reject care. Review of the physician orders revealed daily weights had been ordered every night shift for Resident #2 on 04/15/19 for [MEDICAL CONDITION] monitoring. Review of the Weight Summary sheet for 04/26/19 revealed no weight documentation for Resident #2. Review of the Medication Administration Record (MAR) for 04/26/19 revealed the daily weight order was coded as a 7 which indicated Resident #2 was sleeping. There was no current weight recorded in Resident #2's 04/26/19 nursing notes. Review of the Weight Summary sheet for 04/29/19 revealed no weight documented for Resident #2. Review of the MAR for 04/29/19 revealed the daily weight order was coded as a 9 which indicated other/see nurse notes. There was no nursing note for 04/29/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/07/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/07/19 revealed no documentation of a weight for Resident #2. There was no nursing note for 05/07/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/10/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/10/19 revealed no documentation of a weight for Resident #2. There was no nursing note for 05/10/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/11/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/11/19 revealed no documentation of a weight for Resident #2. There was no nursing note for 05/11/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/12/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/12/19 revealed no documentation of a weight for Resident #2. There was no nursing note for 05/12/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/13/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/13/19 revealed no documentation of a weight for Resident #2. There was no nursing note for 05/13/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/17/19 revealed no weight documented for Resident #2. Review of the MAR for 05/17/19 revealed the daily weight order was coded as a 2 which indicated that Resident #2 had refused to be weighed at that time. There was no nursing note for 05/17/19 to indicate that a weight had been attempted at any other time during the day. Review of the Weight Summary sheet for 05/20/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/20/19 revealed no documentation of a weight for Resident #2. There was no nursing note for 05/20/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/21/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/21/19 revealed no documentation of a weight for Resident #2. There was no nursing note for 05/21/19 to indicate a weight or why the weight was not obtained for Resident #2. Review of the Weight Summary sheet for 05/27/19 revealed no weight documentation for Resident #2. Review of the MAR for 05/27/19 revealed no documentation of a weight for Resident #2. There was a nursing note for 05/27/19 that the daily weight was attempted on night shift but had not been obtained. Review of the Weight Summary sheet for 06/01/19 revealed no weight documented for Resident #2. Review of the MAR for 06/01/19 revealed the daily weight order was coded as a 9 which indicated other/see nurse notes. There was no nursing note for 06/01/19 to indicate a weight or why the weight was not obtained for Resident #2. In an interview on 06/06/19 at 8:40 AM Nurse #1 indicated that the order for daily weights would pop up on the computer screen for the night shift nurse to obtain. Once the weight was obtained the weight would be recorded on the MAR. She stated that unless the night shift nurse informed her that the weight was not obtained she would not know it was still needed. In a telephone interview on 06/06/19 at 9:01 AM Nurse #2 stated he provided a list of residents needing weights to the aides. He indicated it was their responsibility to obtain the weights and to inform him of the results and then he would enter the information on the MAR. In an interview on 06/06/19 at 9:24 AM the Director of Nursing (DON) indicated that if a resident had an order for [REDACTED]. 2. A. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #11 was cognitively intact and received opioid pain medication. Resident #11 did not reject care. Review of the physician orders revealed Resident #11's [DEVICE] had been discontinued on 05/30/19 and that [MEDICATION NAME] 5 mg (milligrams) by mouth as needed for pain every six hours had been discontinued on 05/31/19. Review of Resident #11's (MONTH) 2019 MAR revealed an order to give a prn (as needed) dose of [MEDICATION NAME] one hour prior to the [DEVICE] dressing changes on Monday, Wednesday, and Friday. The order was checked off as completed on 06/03/19 and 06/05/19. Review of the Narcotic Count Sheet revealed no [MEDICATION NAME] had been given to Resident #11 on 06/03/19 or 06/05/19. In an interview on 06/06/19 at 11:00 AM Nurse #1, who was assigned to Resident #11 on 06/05/19, stated that a check mark on the MAR meant the order had been completed. She indicated that although she had placed a checkmark on the order she had not given any [MEDICATION NAME] to Resident #11. Nurse #1 stated she had placed the checkmark to indicate that Resident #11 could have received [MEDICATION NAME] and not that she gave [MEDICATION NAME]. Nurse #1 indicated that the order to administer [MEDICATION NAME] prior to the [DEVICE] dressing changes should have been discontinued when the [DEVICE] treatment was discontinued to avoid confusion. In an interview on 06/06/19 at 3:02 PM the DON indicated that the nurses should discontinue orders that were no longer applicable and that they should not check them as completed when they were not done. 2. B. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed Resident #11 was cognitively intact and received opioid pain medication. Resident #11 did not reject care. Review of Resident #11's Narcotic Count Sheet revealed two tablets of [MEDICATION NAME] 5 mg were removed on 05/05/19 at 12:25 PM. Review of the 05/05/19 MAR revealed no documentation that the medication had been administered. Review of Resident #11's Narcotic Count Sheet revealed two tablets of [MEDICATION NAME] 5 mg were removed on 05/06/19 at 9:30 AM. Review of the 05/06/19 MAR revealed no documentation that the medication had been administered. Review of Resident #11's Narcotic Count Sheet revealed one tablet of 5 mg [MEDICATION NAME] was removed on 05/18/19 at 10:00 AM. Review of the 05/18/19 MAR revealed no documentation that the medication had been administered. Review of Resident #11's Narcotic Count Sheet revealed one tablet of 5 mg [MEDICATION NAME] was removed on 05/20/19 at 9:15 AM. Review of the 05/20/19 MAR revealed no documentation that the medication had been administered. Review of Resident #11's Narcotic Count Sheet revealed one tablet of 5 mg [MEDICATION NAME] was removed on 05/21/19 at 1:00 PM. Review of the 05/21/19 MAR revealed no documentation that the medication had been administered. Review of Resident #11's Narcotic Count Sheet revealed 2 tablets of 5 mg [MEDICATION NAME] were removed on 05/25/19 at 9:45 PM. Review of the 05/25/19 MAR revealed no documentation that the medication had been administered. Review of Resident #11's Narcotic Count Sheet revealed 2 tablets of 5 mg [MEDICATION NAME] were removed on 05/26/19 at 5:45 AM. Review of the 05/26/19 MAR revealed no documentation that the medication had been administered. In an interview on 06/06/19 at 2:05 PM Nurse #2, who was assigned to Resident #11 on 05/25/19, stated he administered [MEDICATION NAME] to Resident #11. He verified that he had not documented the administration of the medication on the MAR. In an interview on 06/06/19 at 2:06 PM Nurse #3, who was assigned to Resident #11 on 05/18/19, stated she administered the medication to Resident #11. She verified that she had not documented the administration of the [MEDICATION NAME] on the MAR. In an interview on 06/06/19 at 2:22 PM Nurse #4, who was assigned to Resident #11 on 05/06/19, stated she had signed out and administered the [MEDICATION NAME] to Resident #11. She verified that she did not document the administration of the medication on the MAR. In an interview on 06/06/19 at 2:27 PM Nurse #5, who was assigned to Resident #11 on 05/26/19, verified that she had not documented the administration of the [MEDICATION NAME] on the MAR but that she had administered the medication. In an interview on 06/06/19 at 2:33 PM Nurse #6, who was assigned to Resident #11 on 05/22/19 (not on 05/21/19), stated that she had written the incorrect date of 05/21/19 instead of 05/22/19 when she removed the [MEDICATION NAME] for administration to Resident #11 at 1:00 PM. Nurse #6 verified that she did not document the administration of the [MEDICATION NAME] on the 05/22/19 MAR. In an interview on 06/06/19 at 2:45 PM Nurse #7, who was assigned to Resident #11 on 05/20/19, indicated that she had administered [MEDICATION NAME] to Resident #11 on that date. She verified that she had not documented the administration on the MAR. In an interview on 06/06/19 at 3:02 PM the DON stated that any medication that was administered to a resident needed to be documented on the MAR. 3. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders for (MONTH) and (MONTH) 2019 revealed an order for [REDACTED]. Review of the MAR's for (MONTH) and (MONTH) 2019 revealed the above order was duplicated on the MAR's in error and signed off as given twice at the same time each day on 5/24/19, 5/25, 5/26, 5/27, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/3, and 6/4/19 at 9:00 AM. In an interview conducted on 06/05/19 at 8:40 AM with Nurse #6 she revealed that she had signed the MAR twice by mistake for the same dose of [MEDICATION NAME] Acid 500 mg. She stated when she administered medication she double checked the medication when she pulled the bubble pack and then poured the medication in the cup, administered it, then returned to the cart to sign off the medications taken by a resident. She commented that she had not noticed that she had been signing off the [MEDICATION NAME] Acid order twice when she had only given it once. She corrected the medical record to reflect only one [MEDICATION NAME] Acid order for 9:00 AM as ordered. In an interview with Nurse #4 on 06/05/19 at 10:45 AM she stated she had started doing wound care at the facility about a month previous. She commented she initiated the wound care protocol for residents who had wounds which included [MEDICATION NAME] Acid 500 mg daily. She thought she had checked the MAR's to be sure none of the orders had been duplicated but apparently missed it on the MAR for Resident #9 and two orders for [MEDICATION NAME] Acid were then recorded on the MAR. She explained Resident #9 already had an order for [REDACTED]. She confirmed the resident was to only receive one dose of [MEDICATION NAME] Acid 500 mg daily. In an interview with Nurse #8 on 06/05/19 at 11:00 AM she revealed that she cared for Resident #9. She confirmed that she had not noticed that she had signed the MAR for two doses of [MEDICATION NAME] Acid daily. She stated she had only ever given the resident one dose of [MEDICATION NAME] Acid each morning but signed it off twice in error. She stated she poured the medications, administered them, then returned to the MAR and signed them off as given. She had not noticed the [MEDICATION NAME] Acid was on the MAR twice, she simply clicked off the 0900 medications on the screen. She reported that she had been taking care of Resident #9 for a while and was certain she had only given her one tablet each morning. In an interview with the Director of Nurse on 06/05/19 at 11:30 AM she revealed that she expected the physician orders to be transcribed into the MAR correctly and administered as ordered. She confirmed this order duplication had occurred due to the initiation of the standing physician orders for wound care that included an order that was already present on the resident's MAR.

Based on observation and staff interviews the facility failed to keep unattended medications secured by leaving them out on an overbed table for 1 of 14 resident rooms (room [ROOM NUMBER]). Findings included: In an observation on 06/03/19 at 12:30 PM a round, dark pink tablet was seen in a medication cup on the overbed table in room [ROOM NUMBER]. In an interview on 06/06/19 at 12:42 PM Nurse #7 stated she had provided medications to the resident in room [ROOM NUMBER] at about 10:30 AM. She stated she thought the resident had taken all the medications and did not realize that she had left a medication in the cup on the overbed table. Nurse #7 indicated it was her responsibility to make sure medications were not left unsecured in resident's rooms. In an observation on 06/04/19 at 4:21 PM a round, dark pink tablet was again seen in a medication cup on the overbed table in room [ROOM NUMBER]. In an interview on 06/04/19 at 4:25 PM Nurse #4 stated that medications should never be left on a resident's overbed table. She indicated that anyone could take medications that were left out. In an interview on 06/04/19 at 2:16 PM the Director of Nursing (DON) stated that medications should not be left out on resident overbed tables. She indicated that medications should always be secured and not left where other residents, staff, or visitors could get them.

Based on staff interview and record review the facility failed to complete an accurate Minimum Data Set (MDS) assessment for 2 of 14 residents (#6 and #9) whose medical records were reviewed. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] completed for Resident #6 documented her weight as 64 pounds and indicated she had a qualifying weight gain during the assessment time frame indicated. Review of the weights recorded by the facility for Resident #6 revealed on 10/19/18 the resident weighed 149.1 pounds and on 04/02/19 she weighed 144.6 pounds. She had not weighed 64 pounds and had not gained weight. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment for Resident #9 dated 04/24/19 documented she had a weight loss during the assessment period. Review of weights recorded for Resident #9 revealed that she had not had a qualifying weight loss in the preceding six months. In an interview conducted with Nurse #9, MDS Coordinator, on 06/05/19 at 4:00 PM she stated Resident #6 had not weighed 64 pounds and had not gained weight as documented in the assessment. Nor had Resident #9 had a qualifying weight loss during the assessment time frame of her assessment. She confirmed the MDS assessments had been coded in error. She commented she would create and transmit assessment modifications to correct the errors. In an interview with the Director of Nursing on 06/05/19 at 4:45 PM she commented that she expected all residents to have an accurate MDS assessment completed.

Based on observation, Nurse Practitioner interview and staff interview the facility failed to maintain infection control for 1 of 2 residents observed for wound care (Resident #9) whose Stage 2 pressure ulcer on her left foot, 5th digit, was cleansed with a 4 x 4 that had been used to cleanse a wound on her shin that was infected with and being treated for [REDACTED]. Findings included: During an observation of wound care on 06/06/19 at 9:45 AM, Nurse #4 used a saline soaked 4 x 4 gauze pad to cleanse a Staphylococcus Aureus infected wound on Resident #9's left shin then immediately used the same 4 x 4 gauze pad to cleanse the Stage 2 pressure ulcer on her left foot 5th digit. In an interview with the facility Nurse Practitioner #1 on 06/06/19 at 11:40 AM he commented that the same gauze pad used to cleanse an infected wound on the resident's shin should not have been used to cleanse the wound on her toe that was not infected. In an interview with the Director of Nursing on 06/06/19 at 11:45 AM she stated that she intended to re-educate Nurse #4 concerning wound care. She stated that she would not expect a nurse to use the same cleansing gauze pad between wounds especially if one wound was infected.

Based on observation and staff interview the facility failed to keep cold salads made with mayonnaise at or below 41 degrees Fahrenheit prior to their leaving the kitchen. The facility also failed to air dry kitchenware before stacking it in storage, and failed to label and date opened food items. Findings included: 1. At 11:45 AM on 06/06/18 plastic wrap was placed over a cold plate containing three types of salads made with mayonnaise. At 11:47 AM on 06/06/18 the salad cold plate was placed on a tray, a tray slip was placed on the tray, and the tray was placed inside the meal cart. At 11:48 AM on 06/06/18 a calibrated thermometer used to check the temperature of the cold salads registered 51.4 degrees Fahrenheit for the tuna salad, 49.6 degrees Fahrenheit for the egg salad, and 48.7 degrees Fahrenheit for the chicken salad. At 11:50 AM on 06/06/18 a dietary employee reported when she checked the temperatures of the cold salads about an hour and half ago in the reach-in refrigerator they were at 40 degrees Fahrenheit. At 10:41 AM on 06/08/18 a dietary employee stated the facility made all its cold salads from scratch, and they could be held in refrigeration for 3 days (including the day they were made) before they were disposed of. She reported cold salads should be stored and leave the kitchen below 40 degrees Fahrenheit. She commented this practice helped reduce the chance that residents got sick from eating food served in the facility. At 10:50 AM on 06/08/18 the Food Service Director (FSD) stated the cold salads served on 06/06/18 contained a protein source (tuna, egg, or chicken), mayonnaise, and house seasonings. He reported these salads should be kept below 40 degrees Fahrenheit while they were stored in the kitchen. He commented cold salads made with mayonnaise were stored in the reach-in or walk-in refrigerators if they were made a day or so before serving, and they were placed in the walk-in freezer for a short time if they were made and served on the same day. 2. During initial tour of the kitchen, beginning at 11:37 AM on 06/04/18, 11 of 16 tray pans were stacked flush on top of one another with moisture trapped between them. During a follow-up tour of the kitchen, at 9:45 AM on 06/06/18 2 of 6 tray pans were stacked on top of one another with moisture trapped between them. At 10:41 AM on 06/08/18 a dietary employee stated she had received training about the storage of kitchenware. She reported the dietary staff was instructed to turn kitchenware upside down so it could drain and dry before stacking it on top of another in storage units. She commented trapped moisture could cause bacteria to grow. At 10:50 AM on 06/08/18 the Food Service Director (FSD) stated the dietary staff received training on storing kitchenware about two weeks ago, and at that time, staff were instructed that kitchenware had to be completely air dried before placing it in storage. 3. During initial tour of the kitchen and storage areas, beginning at 11:37 AM on 06/04/18, a box of pancake mix, a bag of rotini pasta, two bags of spaghetti noodles, 1 bag of ziti pasta, two bags of macaroni pasta, a package of creamy buttermilk dressing mix, and a 5-pound box of spice cake mix in the dry storage room were opened, but without a label and date on them. In the walk-in freezer a bag of chicken fingers and a bag of diced chicken were opened, but were without a label and date on them. During a follow-up tour of the kitchen and storage areas, at 9:56 AM on 06/06/18, two fish filets, two bags of French fries, a bag of raspberries, and an angel food cake which were opened and found in the walk-in freezer were without labels and dates. At 10:41 AM on 06/08/18 a dietary employee stated it was the responsibility of all dietary employees to monitor storage areas daily as they went in and out of them to make sure that opened food items had labels and dates on them, and foods past their use-by dates were discarded. She reported this practice helped to avoid food spoilage, and ensured the quality of the food remained exceptional. At 10:50 AM on 06/08/18 the Food Service Director (FSD) stated all food items in storage should have a receive and open date on them. He reported the labeling and dating policy was posted in all storage areas. He commented all employees were expected to place labels and dates on food items when they opened them, but were unable to use them all, and had to place the remainder in storage. According to the FSD, this FIFO (first in, first out) policy helped make sure the freshest food possible was served to the residents.

Based on record review, observation, and staff interview the facility failed to follow professional standards of nursing practice during dressing changes for 1 of 3 residents (Resident #26). The findings included: Resident #26 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #26's Minimum Data Set ((MDS) dated [DATE] revealed resident had severe cognitive impairments. The resident needed extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. Review of the Treatment Administration Record (TAR) revealed nursing did not initial off that Resident #26's dressing to his sacral pressure ulcer was changed on 06/05/18. A pressure ulcer dressing change observation for Resident #26 was conducted on 06/06/18 at 3:05 PM with Nurse #1 and the Director of Nursing (DON). The resident's existing stage 3 sacral pressure ulcer dressing was removed and observed not to be dated or initialed. In addition Nurse #1 did not date and initial the new dressing which she applied to the resident's sacrum. She also failed to check to initial the 06/6/18 dressing change on the resident's TAR. An interview was conducted on 06/06/18 at 3:10 PM with Nurse #1 who stated that before she worked for the facility she always dated and initialed all her dressing changes, which was good nursing practice. She said when she started at the facility, she was told that it was not the facility's policy to date and initial dressings, and was told to discontinue dating and initialing on dressings, and to only check off and initial on the TAR that a dressing was done. An interview was conducted on 06/07/18 at 4:30 PM with the Director of Nursing (DON), she confirmed that sacral dressing changes for Resident #26 were not checked off or initialed as completed on the resident's TAR for 06/5/18 and 06/6/18 per facility policy. However, after reviewing the facility's policy and procedure on dressing changes dated (MONTH) 2014, she stated moving forward it was her expectation (per professional clinical practice) that all dressings were required to be dated and initialed when placed or changed, and that they were also to be documented on the residents' TAR's. An interview was conducted on 06/08/18 at 10:30 AM, and the facility's Administrator revealed it was her expectation per facility's policy and procedure on dressing changes dated (MONTH) 2014, and per professional clinical practice, that all dressing changes were required to be dated and initialed when first placed or changed, as well as to also documented on the residents' TAR's.

Based on record review and staff interview the facility failed to keep complete and accurate medical records for 2 of 4 sampled residents (Resident #21 and #29) who had pressure ulcers. Findings included: 1. Resident #29 was admitted to the facility on [DATE]. His documented [DIAGNOSES REDACTED]. A 04/19/18 Nursing Admission Review documented, Pressure ulcer on top of right foot is 1/2 inch x 1 1/2 inches. Side of right foot if 2 inches x l inch. On 4/19/18 three electronic Weekly Wound Reviews were created. One documented, no wounds noted. The other two reviews documented Resident #29 had pressure ulcers to the right heel, side of the right foot, left heel, and top of the left foot. The resident's 04/26/18 admission minimum data set (MDS) documented his cognition was moderately impaired, he exhibited no behaviors including resistance to care, he required anywhere from minimal to extensive assistance from staff with his activities of daily living, he was always continent of bladder and occasionally incontinent of bowel, his weight was stable, and he had 3 unstageable ulcers present on admission. The 04/27/18 Weekly Clinical handwritten assessment for Resident #29's four ulcers included measurements and type of tissue in the wound bed. However, this assessment did not include information about the percentage of different types of tissue in the wound bed, exudate, odor, or pain. The 05/02/18 handwritten Weekly Clinical assessment and the 05/02/18 electronic Weekly Pressure Ulcer Review were the first documents to capture measurements, wound tissue and the percent of that tissue, exudate, odor, and pain on all four of Resident #29's wounds. There was no 05/09/19 assessment of Resident's 29's wounds either in a handwritten or electronic format. At 12:20 PM on 06/07/18 the Director of Nursing (DON) stated Nurse #2 measured and assessed resident wounds on 05/09/18, but forgot to document the information. The resident's treatment administration record (TAR) documented on 05/25/16 the resident began receiving the sacral wound treatment of [REDACTED]. A 05/26/18 Skilled Nursing Review progress note documented Resident #29 now had a pressure ulcer to his sacrum as well as pre-existing ulcers to his right heel, the top and side of his right foot, and his left heel. Air mattress ordered, awaiting delivery. A 06/01/18 handwritten Weekly Clinical assessment included the first measurements and wound bed description of Resident #29's sacral ulcer. There was no 06/01/19 electronic Weekly Pressure Ulcer Review completed on the resident's sacral ulcer so there was still no information provided about the percent of different types of tissue in the wound bed, exudate, odor, or pain associated with the ulcer. Observation on 06/06/18 at 8:38 AM revealed there was only a regular/standard mattress on Resident #29's bed. However, starting on 05/25/18 on the Medication Administration Record [REDACTED]. On 06/06/18 at 4:55 PM Nurse #2 stated Resident #2 felt the air mattress was uncomfortable, and did not want it to remain in place. She reported the resident made this decision after sleeping on it for two night. Resident #29's care plan, last revised on 06/06/18, identified, I currently have (pressure ulcers) and potential for (future) pressure ulcer development r/t (in regard to) immobility as a problem. On 06/07/18 at 5:00 PM the DON stated weekly wound assessments should include type of wounds, location of wounds, stage of pressure wounds, type and percent of tissue in wound beds, drainage/exudate information, and information about odor and pain associated with the wounds. She reported official assessment and measurement of wounds took place every Wednesday, but she still expected the nurses who initially viewed a newly emerged pressure ulcer to document approximate size, location, general description of wound bed, and presence of any drainage and odor. On 06/08/18 at 10:56 AM the Administrator stated an air mattress did not have to be ordered for Resident #29 because there was one already in the facility that was not in use. She reported two staff members told her the resident allowed it on his bed two nights before requesting that it be removed. She commented staff should observe or administer something before initialing off on the MAR indicated [REDACTED]. According to the Administrator, corrective action was being taken against the nurses who had been incorrectly initialing off that Resident #29's air mattress was inflated correctly. 2. Resident #21 was admitted to skilled nursing on 03/30/18, discharged to assisted living on 05/22/18, and readmitted to skilled nursing on 06/01/18. The resident's documented [DIAGNOSES REDACTED]. A 04/20/18 Weekly Skin Check documented Resident #21 had a new pressure ulcer. It was not until completion of the 04/23/18 electronic Weekly Pressure Ulcer Review that the location and complete description of the wound was captured in an assessment. An electronic Weekly Pressure Ulcer Review was completed for Resident #21's sacral pressure ulcer on 05/02/18. The resident's 05/8/18 significant change minimum data set (MDS) documented her cognition was intact, she exhibited no behaviors including resistance to care, she required anywhere from minimal to extensive assistance with her activities of daily living, she was occasionally incontinent of bowel and bladder, she experienced significant weight loss, and she had one unstageable pressue ulcer which presented with slough or eschar in the wound bed. There was no 05/09/19 assessment of Resident's 21's ulcer either in a handwritten or electronic format. At 12:20 PM on 06/07/18 the Director of Nursing (DON) stated Nurse #2 measured and assessed resident wounds on 05/09/18, but forgot to document the information. The resident's care plan, last updated 6/1/18, identified, I currently have a pressure ulcer to my sacrum /potential for (future) pressure ulcer development as a problem. On 06/07/18 at 5:00 PM the DON stated weekly wound assessments should include type of wounds, location of wounds, stage of pressure wounds, type and percent of tissue in wound beds, drainage/exudate information, and information about odor and pain associated with the wounds. She reported official assessment and measurement of wounds took place every Wednesday, but she still expected the nurses who initially viewed a newly emerged pressure ulcer to document approximate size, location, general description of wound bed, and presence of any drainage and odor.

Based on observations, record review, and staff interviews, the facility staff failed to dispose of a gown and gloves properly for one of two residents on contact isolation (Resident #17). Findings included: A review of the facility's in-service records revealed the housekeeping staff were in-serviced on infection control on 04/18/18 at 12:00 PM. Resident #17 was admitted to the facility on [DATE]. Resident #17's [DIAGNOSES REDACTED]. A review of Resident #17's care plan dated 06/5/18 revealed the resident was on antibiotic therapy with risk of adverse therapy related to E-coli, and had ESBL UTI and required contact isolation. Interventions included: wear gloves and mask when changing contaminated linen, place soiled linens in bags marked biohazard, bag linens, and close bag tightly before taking to laundry. An observation of Resident #17's room on 06/06/18 at 9:08 AM revealed PPE (Personal Protective Equipment) was available outside Resident #17's door in a closed cart, there were two red hazardous waste cans located just inside the resident's room next to the door, and a contact precaution sign was posted on the resident's door. An observation on 06/06/18 at 9:10 AM revealed Housekeeper #1 exiting Resident #17's room gowned and gloved. The housekeeper stood outside the resident's room with the gown balled up in her hands. She went to a large black garbage can located in the hall and disposed of the gown and gloves. In an interview on 06/06/18 at 09:15 AM Housekeeper #1 stated she did not know why she disposed of her gown and gloves in the black garbage can in the hallway rather than in the red hazardous waste bins located inside the resident's room. An interview on 06/6/18 at 9:20 AM Nurse #2 stated Resident #17 was on contact precautions for ESBL in her urine. She said it was her expectation that PPE should be removed prior to exiting the resident's room and disposed of in the red hazardous waste bins located just inside the resident's room. She stated the staff just had an in-service on isolation precautions months ago. An interview with the Director of Nursing (DON) was conducted on 06/06/18 at 9:40 AM. The DON reported that it was her expectation when a resident was on contact precautions that the staff would place a precaution sign on the door and have a PPE cart outside the resident's room. The DON reported it was her expectation that all staff would glove and gown when providing care to the resident prior to entering the room. She reported it was her expectation that when the staff was finished providing care that they would remove the gown and gloves and dispose of them in the red hazardous bins located in the room and wash hands with soap and water prior to leaving the room. The DON reported it was her expectation that the staff follow any precautions that the residents were on. The DON reported all staff were in-serviced on infection control practices during orientation and yearly. An interview with the Administrator was conducted on 06/08/18 at 10:56 AM. The Administrator reported it was her expectation that if a resident was on infection precautions, the staff would follow those precautions.

Based on record review, family, staff and physician interviews, the facility failed to secure an alternate physician when the resident declined the admitting physician and agreed upon any other facility physician which resulted in the resident's discharge to another facility within 6 hours of admission for 1 of 3 residents reviewed (Resident #23). Findings included: Record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes revealed an Admissions Summary Note dated 11/29/2017 at 2:09 PM. The note was signed by Nurse #1 and revealed Resident #23 could make her needs known, required assistance with transfers and activities of daily living (ADLs) and was in no distress. There were no further Progress Notes in Resident #23's medical record upon the initial review. Review of the Admission Minimum Data Set (MDS) revealed an Admission entry dated 11/29/2017 which indicated Resident #23 was admitted to the facility from an acute care hospital for a short-term stay. There was a Discharge MDS dated [DATE] which indicated the resident was discharged from the facility on 11/29/2017. The discharge MDS revealed the discharge was unplanned, and the resident's return to the facility was not anticipated. Review of the Admission Nursing Facility Agreement signed by Resident #23's responsible party (RP) on 11/29/2017 included the following statement: -The Facility shall obtain the services of a licensed Physician of the residents' choosing whenever necessary, or the services of another licensed Physician if Resident's personal Physician is not available. Resident #23 was unavailable for interview. A telephone interview was conducted with Resident #23's RP on 2/6/2018 at 12:30 PM. The RP revealed the resident was admitted to the facility from the hospital on [DATE] at approximately 1:30 PM for short-term rehabilitation due to lower back fractures. The RP revealed she signed the Admission paperwork shortly after the resident arrived at the facility. The RP revealed after the initial paperwork was signed, the person assisting with the paperwork informed her of the Physician who would be assigned to the resident's care during the facility stay. The RP stated she informed the person the resident was familiar with the Physician named and would prefer another Physician. The RP stated the admissions person indicated there were other Physicians in the named Physician's group as well as a Physician's Assistant (PA) and asked if they would agree to anyone else in the named Physician's group. The RP stated she informed the admissions person any of the other Physicians or the PA would be fine. The RP indicated she did not think there was an issue after the paper work was signed, and the decision was made to assign the resident to another Physician. The RP stated they were not informed of the attending Physician until after the resident was admitted to the facility. The RP stated after she signed all the papers, she checked on the resident and then left the facility to retrieve some items for the resident's stay. The RP stated it was approximately 4:30 PM when she left the facility. The RP further stated she received a call from the resident who was upset and indicated the Physician who they declined was in the resident's room and wanted to speak to the RP. The RP indicated she spoke with the Physician and informed her they desired for another Physician to care for the resident while she was at the facility and stated she informed the Physician they were agreeable to any other Physician in the group. The RP stated the Physician said ok, thanked the RP, and there was no further conversation. The RP indicated when she returned to the facility at approximately 5:30 PM, she was informed the resident would have to return to the hospital, because the named Physician would not allow anyone in the group to follow the resident. The RP stated she told the staff she would not agree for the resident to be sent back to the hospital and asked if there was anything that could be done to secure a physician. The RP indicated the Administration staff informed her since the resident did not have a Physician, she could not remain in the facility, as there was no one to treat her. The RP stated the staff told her another facility agreed to take the resident, and transportation would be arranged as soon as possible. The RP indicated she could not remember if they asked if the facility was acceptable, and although she and the resident were upset about the move, they felt it was better than returning to the hospital. A telephone interview was conducted with Nurse #1 on 2/6/2018 at 4:40 PM. Nurse #1 indicated she recalled Resident #23 and verified she was the admitting nurse. Nurse #1 reported she spoke with the named Physician the evening of 11/29/2017 and informed her the resident and the RP agreed to another Physician in the practice group. Nurse #1 revealed the named Physician was in the facility and spoke with the resident. After speaking with the resident, the named Physician informed the nurse no one in the practice group would follow the resident in the facility. Nurse #1 reported she contacted the Administrator (Adm), they tried to talk to the Physician again, and the Physician adamantly refused. Nurse #1 reported the Adm called the hospital liaison who contacted another facility, and the resident was transferred. Nurse #1 reported the resident and the RP were upset and did not understand why the resident could not be seen by another physician. An interview was conducted with the Administrator (Adm) 2/6/2018 at 5:05 PM. The Adm indicated she recalled the evening of 11/29/2017 and Resident #23. The Adm revealed the named Physician informed her no one in the practice group would follow the resident during her stay at the facility. The Adm indicated the situation arose late in the evening, and the resident could not stay in the facility without an attending Physician. The Adm reported she spoke with the RP, and the RP agreed to another Physician. The Adm further reported due to the time and the circumstances, the decision was made to transfer the resident to another facility. The Adm indicated if the situation had occurred earlier in the day, an alternate Physician possibly could have been secured. The Adm indicated there was no discussion with the named Physician, resident or the RP of the possibility of the named Physician or one of Physicians in the practice group to follow the resident until the next day to enable the facility to secure an alternate Physician. The Adm stated the named Physician was the facility's Medical Director. The Adm stated awareness of the resident's right to choose a Physician and stated there was no choice offered the evening the resident was transferred. An interview was conducted with the named Physician on 2/7/2018 at 2:52 PM. The Physician indicated she remembered Resident #23. The Physician stated she went to the resident's room on the evening of 11/29/2018 to complete her assessment. The Physician reported while in the room the resident informed her she did not want her services. The Physician stated she left the room and spoke to the Adm and informed her the resident was in the facility without an assigned Physician, and the facility would not be able to secure another Physician due to the lateness of the day. The Physician stated she informed the Adm the resident would be unable to stay in the facility. The Physician indicated since the resident did not want her services and her practice group would not follow her, it was not her responsibility to secure a Physician for Resident #23.

Based on observation, record review and staff interviews the facility failed to post the correct Nurse Staffing Information sheet located in the lobby of the facility. Findings included: On entry into the facility on [DATE] at 10:35 AM the facility Nurse Staffing Information was observed in a plastic stand on a shelf near the Reception desk. The posted Nurse Staffing Information was dated 05/31/17 and showed a census of 23. In an observation on 06/04/17 at 12:21 PM the Nurse Staffing Information was observed in the same plastic stand on a shelf near the Reception desk. The posted Nurse Staffing Information was now dated 06/04/17 and showed a census of 21. In an interview on 06/04/17 at 1:25 PM Nurse #1 stated she had taken over the responsibility of posting the Nurse Staffing Information in May 2017. She indicated she was not in the facility on 06/01/17 or 06/02/17 and that the Director of Nursing (DON) was responsible for the task when she was not there on weekdays. Nurse #1 stated that on weekends it was the responsibility of the receptionist to post the Nurse Staffing Information. In an interview on 06/04/17 at 1:29 PM the Receptionist indicated she had attempted to post the correct Nurse Staffing Information on 06/03/17 and 06/04/17 but that the information was not available. She indicated she did not inform anyone that the correct Nurse Staffing Information was not posted. In an interview on 06/04/17 at 2:35 PM the DON stated Nurse #1 usually prepared the Nurse Staffing Information sheets and gave them to the receptionist. She indicated she did not notice on 06/01/17 or 06/02/17 that the incorrect information was posted. The DON stated she expected the Nurse Staffing Information be posted daily.