Every finding on record at Conover Nursing And Rehabilitation Center

Based on observations, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for oral/dental status (Resident #27) and the use of a hypoglycemic medication (a medication used to lower blood sugar in people diagnosed with diabetes) (Resident #71) for 2 of 20 residents whose MDS assessments were reviewed. Findings included: 1. Resident #27 was admitted to the facility 04/14/17. Review of a dentist's note dated 07/15/24 revealed Resident #27 had 6 teeth pulled and was now edentulous (lacking teeth). The annual MDS assessment dated [DATE] did not reflect Resident #27 was edentulous. Observations of Resident #27 on 02/18/25 at 11:25 AM, 02/19/25 at 8:17 AM, and 2/20/25 at 12:43 PM revealed she did not have any teeth. An interview with the MDS Coordinator on 02/20/25 at 4:49 PM revealed Resident #27's annual MDS assessment should have reflected that she was edentulous, and it was an oversight. An interview with the Director of Nursing on 02/21/25 at 11:26 AM revealed she expected the MDS assessment to be coded correctly. An interview with the Administrator on 02/21/25 at 12:38 PM revealed he expected the MDS assessment to be as accurate as possible. 2. Resident #71 was admitted to the facility 11/01/24 with a diagnosis including diabetes. Review of Resident #71's Physician orders revealed an order dated 11/02/24 for Insulin Glargine 5 units subcutaneously (under the skin) daily for diabetes. Review of Resident #71's November 2024, December 2024, and January 2025 Medication Administration Record revealed she received Insulin Glargine as ordered. Resident #71's quarterly MDS assessment dated [DATE] did not reflect that she received hypoglycemic medication. In an interview with the MDS Coordinator on 02/20/25 at 4:52 PM she confirmed Resident #71's quarterly MDS assessment should have reflected that she received hypoglycemic medication, and it was an oversight. An interview with the Director of Nursing on 02/21/25 at 11:26 AM revealed she expected the MDS assessment to be coded correctly. An interview with the Administrator on 02/21/25 at 12:38 PM revealed he expected the MDS assessment to be as accurate as possible.

Based on observations, record reviews and staff interviews, the facility failed to update the care plan to include oxygen therapy for 2 of 2 residents (Resident #16 and Resident #23) reviewed for respiratory therapy. The findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that included hypoxemia (low levels of oxygen in the blood). A review of Resident #16's physician orders dated 06/28/24 indicated oxygen at 1-3 liters per minute via nasal cannula every shift as needed for hypoxia. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supplemental oxygen. Review of Resident #16's revised care plan dated 12/30/24 revealed the Resident's oxygen use was not care planned. An interview was conducted with the MDS Coordinator on 02/20/25 at 5:33 PM. The MDS Coordinator explained that the purpose of the care plan was to guide the care of the residents and should be individualized for that resident. The MDS Coordinator stated that oxygen should be on Resident #16's care plan because she might have trouble breathing. The MDS Coordinator stated she was still fairly new and overlooked the oxygen care plan. During an interview with the Director of Nursing (DON) on 02/21/25 at 10:57 AM she explained that the care plan should identify the resident and guide the care of the resident. The DON stated her expectation was for oxygen to be on the care plan. On 02/21/25 at 11:50 AM an interview was conducted with the Administrator who indicated that oxygen needed to be on the care plan. 2. Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (blood flow to the brain is interrupted). A review of Resident #23's physician orders dated 06/28/24 revealed oxygen 1-3 liters per minute via nasal cannula for comfort/hypoxia (low oxygen levels in the blood) every shift. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was severely impaired and she received supplemental oxygen therapy. Review of Resident #23's revised care plan dated 12/06/24 revealed there was no oxygen care plan. An interview was conducted with the MDS Coordinator on 02/20/25 at 5:33 PM. The MDS Coordinator explained that the purpose of the care plan was to guide the care of the residents and should be individualized for that resident. The MDS Coordinator stated that oxygen should be on Resident #23's care plan because she might have trouble breathing. The MDS Coordinator stated she was still fairly new and overlooked the oxygen care plan. During an interview with the Director of Nursing (DON) on 02/21/25 at 10:57 AM she explained that the care plan should identify the resident and guide the care of the resident. The DON stated her expectation was for oxygen to be on the care plan. On 02/21/25 at 11:50 AM an interview was conducted with the Administrator who indicated that oxygen needed to be on the care plan.

Based on observations, record reviews, and Resident and staff interviews, the facility failed to ensure an oxygen concentrator filter was free of dust and failed to ensure a concentrator had an external filter for 1 of 2 residents (Resident #16) reviewed for respiratory care. The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses that included hypoxemia (low levels of oxygen in the blood). A review of Resident #16's physician orders dated 06/28/24 indicated oxygen at 1-3 liters per minute via nasal cannula as needed for hypoxia every shift and change oxygen tubing and clean filter every Thursday night. Review of Resident #16's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and received supplemental oxygen. Review of Resident #16's revised care plan dated 12/30/24 revealed the Resident's oxygen was not care planned. A review of Resident #16's Medication Administration Record (MAR) for 02/2025 revealed oxygen at 1-3 liters per minute was delivered every day and every shift since 02/01/25. The MAR also indicated the oxygen filter had been cleaned on Thursday 02/13/25 by Nurse #2 On 02/18/25 at 10:40 AM an observation and interview were conducted with Resident #16 who was sitting in her wheelchair watching TV. The Resident indicated the staff took care of her oxygen. Upon inspection of the oxygen concentrator the filter on the left side was covered with light gray dust build up, that fell to the floor when touched. The vent located on the right side of the concentrator revealed the filter was missing. An observation was made on 02/19/25 at 9:10 AM revealed the oxygen concentrator filter remained covered with dust. During an interview with Nurse #1 on 02/19/25 at 9:17 AM the Nurse explained the oxygen filters were cleaned on third shift every Thursday night by the nurse. The Nurse indicated that nurses should check the filters every so often to make sure they were clean. An observation was conducted in conjunction with an interview with Nurse #1 on 02/19/25 at 9:22 AM. Nurse #1 stated she was assigned to Resident #16. The Nurse observed Resident #16's oxygen concentrator and when she inspected the filter on the left side of the concentrator she stated Oh, it's dirty, and removed the filter. As the Nurse held the dusty filter up, dust particles were observed to fall to the floor. The Nurse then looked at the vent with the missing filter on the right side of the machine and stated there was not a filter there while pointing at the vent where the filter should have been. The Nurse indicated if the dust buildup accumulated that thick in one week, then the filters should be checked and or cleaned more often. Nurse #1 stated she would get a replacement filter right away for the vent and clean the dirty filter. An interview was conducted with Nurse #2 on 02/20/25 at 10:10 AM who explained the oxygen filters were checked and cleaned with water once a week on Thursday nights by the Nurse and the filters should be checked often for dust buildup. Nurse #2 confirmed she was Resident #16's Nurse on the night of 02/13/25 and stated she checked and cleaned Resident #16's oxygen concentrator filter on 02/13/25 but could not remember if the filter was missing. The Nurse stated if the filter was missing, she would have notified maintenance to provide a replacement. The Nurse stated if the filter was extremely dusty then the filters should be cleaned more often that weekly. During an interview with the Director of Nursing (DON) on 02/21/25 at 10:57 AM the DON explained that she had someone auditing the oxygen concentrators other than the nurses and there was nothing on the audits about Resident #16's oxygen concentrator filters being dirty or missing. The DON stated she may need to increase the filter cleaning to twice weekly. An interview was conducted with the Administrator on 02/21/25 at 11:50 AM who indicated his expectation was for the oxygen filters to be clean and in place on the concentrator.

Based on observations, record reviews, and resident and staff interviews, the facility failed to secure opened tubes of medicated ointment/skin protectant observed in residents' rooms for 2 of 2 residents reviewed for medication storage (Resident #49 and Resident #27). Findings included: 1. Resident #49 was admitted to the facility 09/13/21 with a diagnosis including non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. An observation of Resident #49's dresser on 02/18/25 at 11:12 AM revealed a 0.33-ounce tube of triple antibiotic ointment sitting on top. An interview with Resident #49 at the same date and time revealed Family Member #1 brought her the medication for some sores and Family Member #1 applied the medication, but she could not recall the last time the medication was used. Additional observations of Resident #49's dresser on 02/19/25 at 8:22 AM, 02/20/25 at 12:21 PM, and 02/21/25 at 9:40 AM revealed a 0.33-ounce tube of triple antibiotic ointment sitting on top. An interview with the Director of Nursing (DON) on 02/21/25 at 11:26 AM revealed no medication should be left at the bedside unless the resident had a physician order to leave the medication. The DON confirmed Resident #49 did not have a physician order to leave the triple antibiotic ointment in her room. 2. Resident #27 was admitted to the facility 04/14/17 with a diagnosis including Alzheimer's disease. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was moderately cognitively impaired. An observation of Resident #27's room on 02/19/25 at 12:47 PM revealed two 2-ounce tubes of skin protectant with an active ingredient of Zinc Oxide 20% in a bath basin sitting on top of her dresser. In an interview with Resident #27 at the same date and time she stated the staff applied the cream to her bottom sometimes, but she could not recall the last time the medication was used. Additional observations of Resident #27's room on 02/20/25 at 12:25 PM and 02/21/25 at 9:49 AM revealed two 2-ounce tubes of skin protectant with an active ingredient of Zinc Oxide 20% in a bath basin sitting on top of her dresser. An interview with the Director of Nursing (DON) on 02/21/25 at 11:26 AM revealed no medication should be left at the bedside unless the resident had a physician order to leave the medication. The DON confirmed Resident #27 did not have a physician order to leave the Zinc Oxide cream in her room.

Based on observations, record reviews, staff interviews and a Health Department nurse interview, the facility failed to implement their infection control measures for the use of Personal Protective Equipment (PPE) when 3 of 3 staff (Nurse #2, NA #3 and NA #4) on the Isolation/Quarantine hall failed to change their mask and isolation gowns between residents. This failure occurred during a COVID-19 pandemic. Findings included: The Centers for Disease Control and Prevention (CDC) guideline entitled Responding to Coronavirus (COVID-19) in Nursing Homes last reviewed and updated on 04/30/20 indicated the following statements: · Place signage at the entrance to the COVID-19 unit that instructs healthcare personnel (HCP) they must wear eye protection and an N95 or higher-level respirator (or facemask if respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. · All recommended COVID-19 Personal Protective Equipment (PPE) should be worn during care of residents under observation which includes use of an N95 or higher-level respirator (or facemask if respirator is not available), eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. · A single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted resident should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. The CDC guideline entitled Strategies for Optimizing the Supply of Isolation Gowns last reviewed and updated on 10/09/20 under the section Re-use of Isolation Gowns read: The risks to Health Care Personnel (HCP) and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risk for possible transmission among HCP and patients that likely outweigh any potential benefits. Similar to extended gown use, gown re-use has the potential to facilitate transmission of organisms among patients. However, unlike extended use, repeatedly donning and doffing a contaminated gown may increase risk for HCP self-contamination. If re-use is considered, gowns should be dedicated to care of individual patients. Any gown that becomes visibly soiled during patient care should be disposed of or, if reusable laundered. A review of the facility's COVID-19 Emergency Plan read in part The COVID-19 pandemic is a fluid event and changes to the plan may be made without notice based on guidance from the Centers for Medicare and Medicaid Services (CMS), CDC and the local Health Department. The Facility will adhere to the Core Principles of COVID-19 Infection Prevention: · Screening of all who enter the facility · Hand hygiene · Face covering or mask · Social distancing · Instrumental signage throughout the facility · Cleaning and disinfecting high frequency touched surfaces in the facility often · Appropriate staff use of PPE · Effective cohorting of residents. During the entrance conference on 01/11/21 at 9:15AM, the Administrator indicated the 100 hall was the COVID-19 positive hall and the 400 hall was the Isolation/Quarantine Hall for new admissions and readmissions. A review of the facility census revealed there were 10 residents on the COVID-19 positive hall and 10 residents on the Isolation/Quarantine hall. A continuous observation on 01/11/21 from 2:00PM to 2:20PM on the Isolation/Quarantine hall for the new admissions and readmissions revealed Nurse #2, NA (Nurse Aide) #3 and NA #4 were providing care on the unit. An interview on 01/11/21 at 2:20PM with NA #3 and NA #4 both dressed in a mask, goggles and gown revealed they worked on the Isolation/Quarantine unit and were assigned to the unit on 01/11/21. NA #3 and NA #4 stated they had worn the same mask, goggles and gown into resident's rooms. NA #3 and NA #4 both stated they had been told by the Infection Preventionist (IP) and Director of Nursing (DON) they could wear the same mask and gown all day in the Isolation/Quarantine Unit unless they got soiled. According to NA #3 and NA #4 this had been the practice every day they had worked in the unit. An interview with Nurse #2 on 01/11/21 at 3:00PM revealed she had worked on the Isolation/Quarantine unit and was assigned to the unit on 01/11/21. Nurse #2 stated she had worn the same gown, mask and goggles into all the resident rooms in the unit but stated she disinfected her goggles between residents but had not changed her mask or gown. Nurse #2 further stated that had been the practice of everyone working in the unit because they had been told by Administration they could wear the same mask and gown all day unless it was soiled. Nurse #2 indicated she, the NAs and therapy had all worn the same gown all day when working with the residents on the Isolation/Quarantine unit. An interview on 01/11/21 at 3:30PM with the Administrator and Director of Nursing (DON) revealed they had followed guidance they had been given by the local Health Department and another team of consultants. The Administrator stated no one had told them they were doing anything incorrectly on COVID-19 unit or the Isolation/Quarantine unit. He further stated they had been told they were doing everything correctly for the residents on the units. The Administrator and DON indicated they were not aware that staff were required to change masks and gowns between residents on the Isolation/Quarantine unit. They further indicated they were not aware the staff needed to sanitize their eye protection between residents. The Administrator stated they had had the Isolation/Quarantine hall since the beginning of COVID-19 and residents had been admitted or readmitted to the unit if they were negative for [MEDICAL CONDITION]. A phone interview on 01/11/21 at 4:35PM with the local health department nurse who was the liaison for the facility revealed she had worked closely with the facility administration to ensure they had all precautionary measures in place for COVID-19 for the protection of the residents and staff. The nurse stated she had worked closely with the Administrator in advising guidance for the COVID-19 positive residents and Isolation/Quarantine residents admitted to the facility. The health department nurse indicated she was not aware staff had to change PPE between the residents on the Isolation/Quarantine hall.

Based on staff interviews and record review, the facility failed to accurately code the Minimum Data Set (MDS) related to prognosis of life for 6 of 8 residents who received hospice care (Residents #3, #8, #12, #15, #58 and #59). Additionally, the facility failed to code 1 of 3 sampled residents (Resident #7) with a Level II Preadmission Screen Resident Review and having an intellectual disability. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Resident #3 was admitted to hospice services on 12/22/17. Review of Resident #3's hospice recertification signed and dated by a physician on 03/19/19, 05/06/19 and on 07/14/19 revealed the physician certified: Based on the patient's [DIAGNOSES REDACTED]. Review of Resident #3's annual Minimum Data Set ((MDS) dated [DATE] revealed the MDS indicated Resident #3 received hospice care. The MDS indicated Resident #3 did not have a prognosis of life expectancy of less than 6 months. Review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 received hospice care. The MDS indicated Resident #3 did not have a prognosis of life expectancy of less than 6 months. Review of Resident #3's quarterly MDS dated [DATE] revealed Resident #3 received hospice care. The MDS indicated Resident #3 did not have a prognosis of life expectancy of less than 6 months. Interview with the MDS Coordinator on 09/19/19 at 10:35 AM revealed Resident #3's prognosis should be marked less than 6 months. The MDS Coordinator explained the section for prognosis was coded in error. Interview with the Director of Nursing (DON) on 09/19/19 at 10:41 AM revealed the MDS should be accurate and reflect Resident #3's prognosis of life. 2. Resident #8 was admitted to the facility on [DATE] and began hospice care on 08/09/19. Review of Resident #8's significant change Minimum Data Set ((MDS) dated [DATE] revealed the MDS indicated Resident #8 received hospice care. The MDS indicated Resident #8 did not have a prognosis of life expectancy of less than 6 months. Interview with the MDS Coordinator on 09/19/19 at 10:35 AM revealed Resident #8's prognosis should be marked less than 6 months. The MDS Coordinator explained the section for prognosis was coded in error. Interview with the Director of Nursing (DON) on 09/19/19 at 10:41 AM revealed the MDS should be accurate and reflect Resident #8's prognosis of life. 3. Resident #12 was admitted to the facility on [DATE] and began hospice care on 08/16/19. Review of Resident #12's significant change Minimum Data Set ((MDS) dated [DATE] revealed the MDS indicated Resident #12 received hospice care. The MDS indicated Resident #12 did not have a prognosis of life expectancy of less than 6 months. Interview with the MDS Coordinator on 09/19/19 at 10:35 AM revealed Resident #12's prognosis should be marked less than 6 months. The MDS Coordinator explained the section for prognosis was coded in error. Interview with the Director of Nursing (DON) on 09/19/19 at 10:41 AM revealed the MDS should be accurate and reflect Resident #12's prognosis of life. 4. Resident #15 was admitted to the facility on [DATE] and began hospice care on 02/14/19. Review of Resident #15's hospice recertification signed and dated by a physician on hospice admission, 03/06/19 and on 05/28/19 revealed the physician certified: Based on the patient's [DIAGNOSES REDACTED]. Review of Resident #15's significant change Minimum Data Set ((MDS) dated [DATE] revealed the MDS indicated Resident #15 received hospice care. The MDS indicated Resident #15 did not have a prognosis of life expectancy of less than 6 months. Review of Resident #15's quarterly MDS dated [DATE] revealed Resident #3 received hospice care. The MDS indicated Resident #15 did not have a prognosis of life expectancy of less than 6 months. Review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 received hospice care. The MDS indicated Resident #15 did not have a prognosis of life expectancy of less than 6 months. Interview with the MDS Coordinator on 09/19/19 at 10:35 AM revealed Resident #15's prognosis should be marked less than 6 months. The MDS Coordinator explained the section for prognosis was coded in error. Interview with the Director of Nursing (DON) on 09/19/19 at 10:41 AM revealed the MDS should be accurate and reflect Resident #15's prognosis of life. 5. Resident #58 was admitted to the facility on [DATE] and began hospice care on 06/29/17. Review of Resident #58's hospice recertification signed and dated by a physician on 03/19/19 and on 07/14/19 revealed the physician certified: Based on the patient's [DIAGNOSES REDACTED]. Review of Resident #58's annual Minimum Data Set ((MDS) dated [DATE] revealed the MDS indicated Resident #58 received hospice care. The MDS indicated Resident #58 did not have a prognosis of life expectancy of less than 6 months. Review of Resident #58's quarterly MDS dated [DATE] revealed Resident #58 received hospice care. The MDS indicated Resident #58 did not have a prognosis of life expectancy of less than 6 months. Interview with the MDS Coordinator on 09/19/19 at 10:35 AM revealed Resident #58's prognosis should be marked less than 6 months. The MDS Coordinator explained the section for prognosis was coded in error. Interview with the Director of Nursing (DON) on 09/19/19 at 10:41 AM revealed the MDS should be accurate and reflect Resident #58's prognosis of life. 6. Resident #59 was admitted to the facility on [DATE] and admitted to hospice services on 08/02/18. Review of Resident #59's annual Minimum Data Set ((MDS) dated [DATE] revealed the MDS indicated Resident #59 received hospice care. The MDS indicated Resident #59 did not have a prognosis of life expectancy of less than 6 months. Interview with the MDS Coordinator on 09/19/19 at 10:35 AM revealed Resident #59's prognosis should be marked less than 6 months. The MDS Coordinator explained the section for prognosis was coded in error. Interview with the Director of Nursing (DON) on 09/19/19 at 10:41 AM revealed the MDS should be accurate and reflect Resident #59's prognosis of life. 7. Resident #7 was readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #7's annual Minimum Data Set ((MDS) dated [DATE] revealed he had severe cognitive impairments. Review of Section A1500 (Preadmission Screening and Resident Review- PASRR) was coded 0 which indicated Resident #7 was considered by the state level II PASRR process to not have a serious mental illness and/or intellectual disability or related condition. Continued review of Section A1510 (Level II Preadmission Screening and Resident Review (PASRR) Conditions) did not code Resident #7 as having an intellectual disability. Further review of Section A1550 (Conditions Related to ID/ DD Status) did not code Resident #7 as having Dow[DIAGNOSES REDACTED]. An interview was completed with the Social Worker on 9/19/2019 at 10:11 AM. The Social Worker revealed she was aware Resident #7 was a level II PASRR and had a [DIAGNOSES REDACTED]. An interview was completed with MDS Coordinator on 9/19/2019 at 10:15 AM. The MDS Coordinator stated she was aware of Resident #7 and his [DIAGNOSES REDACTED]. The MDS Coordinator expressed the coding for section A1500, A1510, and A1550 was an oversight and she would correct the assessment. An interview was completed with the Director of Nursing (DON) on 9/19/2019 at 10:22 AM. The DON expressed her expectation was for the MDS to be coded accurately.

Based on record review and staff interviews the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs for 1 of 3 residents investigated for medication errors (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] and discharged from the facility on 05/05/19. Resident #2's [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired for daily decision making and required extensive assistance with activities of daily living. Review of a laboratory test dated 04/03/19 revealed Resident #2's potassium level was 3.4 which was low. The normal parameters indicated by the laboratory were 3.5-5.1. Review of a physician order [REDACTED]. The order was signed off by Nurse #1. Review of the Medication Administration Record (MAR) dated 04/01/19 through 04/30/19 revealed that Resident #2 received [MEDICATION NAME] 15 gm on 04/05/19 from Nurse #2. Review of a physician order [REDACTED]. Review of a laboratory test dated 04/06/19 revealed that Resident #2's potassium level was 3.2 which was low. The normal parameter indicated by the laboratory were 3.5-5.1. Review of a physician order [REDACTED]. Give KDur (potassium) 20 milliequivalent (meq) by mouth x 3 days then recheck potassium level. An interview was conducted with the PA on 07/24/19 at 1:56 PM. The PA indicated she had examined Resident #2 on 04/04/19 for a chronic visit and according to her note there were no issues with his potassium level. She added that in (MONTH) 2019 Resident #2's potassium level was normal. The PA explained that [MEDICATION NAME] was used to treat [MEDICAL CONDITION] (high potassium) and not [DIAGNOSES REDACTED] and it was error on her part. The PA indicated she should have prescribed KDur and not [MEDICATION NAME]. She stated Resident #2's potassium level on 04/06/19 was low and the staff called the on-call provider who discontinued the [MEDICATION NAME] and ordered the KDur. The PA added that Resident #2 received one dose of the [MEDICATION NAME] and never displayed any signs or symptoms of [DIAGNOSES REDACTED] that included chest pain, shortness of breath, nausea etc. Again, the PA confirmed that it was an error on her part and she had prescribed the wrong medication and Resident #2 received one dose of [MEDICATION NAME] before it was discontinued. An attempt to speak to Nurse #1 was made on 07/24/19 at 2:37 PM and was unsuccessful. An interview was conducted with Nurse #2 on 07/24/19 at 3:18 PM. Nurse #2 stated that she did not recall giving Resident #2 the [MEDICATION NAME] but reviewed the MAR and confirmed that she administered the medication on 04/05/19 as ordered. She stated when she administered the medication, she did not question the order but if she would have signed the order off indicating the [MEDICATION NAME] was being ordered for [DIAGNOSES REDACTED] she would have questioned the PA about it. An interview was conducted with the Director of Nursing (DON) and the Administrator on 07/24/19 at 6:49 PM. The DON stated that she was aware of the medication error and indicated that the PA should have written for KDur and not [MEDICATION NAME]. The DON added that when Nurse #2 was administering the [MEDICATION NAME] she would not have seen the order with the [DIAGNOSES REDACTED].#1.

Based on observations, record reviews and interviews the facility failed to assist a resident dependent who required extensive assistance with personal hygiene to 1 of 4 residents reviewed for activities of daily living (Resident #65). The finding included: Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #65's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderately impaired cognition and required extensive assistance with most of her activities of daily living (ADLs). Review of Resident #65's Care Area Assessment for ADLs dated 04/30/18 revealed in part that she required extensive assistance of one to two staff for most of her ADLs (which included personal hygiene). Review of Resident #65's Care Plan dated 07/10/18 indicated the care she required exceeded the home care setting therefore her needs would be met by the facility staff on a daily basis. Observation on 08/20/18 at 2:21 PM noted Resident #65 sitting in her wheel chair next to her bed sleeping. On the seat of her wheel chair beside her left thigh were 2 pieces of meat (appeared to be beef) both approximately 1.5 inches () x 0.5. Also noted was a white food debris on the tips of her three middle fingers on her right hand. A subsequent observation on 08/20/18 at 3:57 PM noted Resident #65 sleeping in the same position as stated above and the 2 pieces of meat remained on her wheel chair seat by her left thigh. Resident #65's right hand was clinched into a fist therefore, her fingertips were not observed. Observation on 08/22/18 at 9:35 AM noted Resident #65 sitting in her wheel chair next to her bed sleeping. On the seat of her wheel chair beside her left thigh was an approximately quarter sized piece of scrambled egg. A subsequent observation at 11:07 AM noted her and the piece of scrambled egg were in the same position. Interview with Nurse Aides (NA) #4 and #5 on 08/22/18 at 12:00 PM revealed they made rounds on the residents every two hours for general ADL care which included toileting, bathing and personal hygiene. NA #4 explained they did not have specific resident assignments because they worked together as a team to get the work done. NA #4 stated that they kept a list at the kiosk with the residents' name on it and when a round was completed they would put a check mark next to the resident's name which indicated the resident's care had been completed. On 08/22/18 at 12:04 PM an observation was made of Resident #65 with both NAs #4 and #5 present and both stated that Resident #65 had already been checked this morning. The resident was awake sitting in her wheel chair next to her bed and the piece of scrambled egg remained on the wheel chair seat next to her left thigh. NA #5 picked the piece of scrambled egg off of the resident's seat and stated that (the egg) should have been removed before now. Neither NA could report who had checked Resident #65 after breakfast this morning or what care had been done for her. NA #4 indicated the check sheets were not kept from day to day therefore it could not be determined which NA had checked Resident #65 after lunch on 08/20/18. Interview with Nurse #1 on 08/22/18 at 12:08 PM revealed she expected the aides to provide personal hygiene for the residents on the first round after meals which included making sure excess food be removed from their persons. Interview with Interim Director of Nursing (IDON) on 08/23/18 at 1:38 PM revealed she would not expect the aides to wake Resident #65 up to provide personal care but felt that removing a piece of meat or scrambled egg would not have woke her up.

Based on observations, record review, resident and staff interviews, the facility failed to provide a safe transfer for a resident with [DIAGNOSES REDACTED]. During the transfer, Resident #172 sustained a skin tear when her arm scrapped against a bed rail for 1 of 4 sampled residents. The findings included: Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data ((MDS) dated [DATE] specified the resident's cognition was intact and she required 2 person assistance with bed mobility and transfers. The Care Area Assessment (CAA) for falls specified the resident needed extensive two person assistance with transfers. A care plan for ADL specified staff were to assist the resident as needed with help. Nurses' noted dated 07/21/17 made by Nurse #1 specified Resident #172 was alert and oriented times 2 and needed frequent reminders of left arm awareness due to risk of injury. The nurse also documented the resident required 2 person assistance for transfers. On 07/22/17 at 11:13 AM Nurse #2 documented nurse aide (NA) #1 reported Resident #172 had sustained a skin tear to her left forearm during a transfer. A physician's orders [REDACTED]. An incident report dated 07/22/17 specified the resident sustained [REDACTED]. On 07/23/17 Nurse #2 documented a late entry for 07/22/17 that specified Resident #172 continued to work with therapy 5 days a week for strengthening, gait training, safety awareness and the required 2 person assistance with all activities of daily living. On 07/25/17 at 8:58 AM an interview was conducted with Resident #172. The resident's forearm was noted to have steri strips. The Resident explained that she had a skin tear from a staff member that tried to get her out of bed but her arm got caught in the top assist bar attached to the bed. On 07/25/17 at 2:34 PM NA #1 was interviewed and explained that she worked in the facility part-time and as needed but recalled that she was assigned to Resident #172 on 07/22/17 during the 7 AM to 3 PM shift. The NA added that when transferring the resident from the bed to the wheelchair, the resident's left arm scrapped against the bed rail attached to the top of the bed. The NA reported that she failed to lower the head of bed. The NA also stated she was confused about the resident's transfer status because the kiosk (a computerized instruction system for each resident) said the resident could transfer with 1 person but the number magnet (a magnet placed over the resident's bed) specified 2 meaning two people were needed to transfer the resident. The NA also explained that she did not verify with the nurse but made the decision to transfer the resident without any assistance because she had done so in the past. The NA stated that she had been trained to rely on the number magnet to know a resident's transfer status. NA #1 described that when transferring the resident out of the bed, she had the resident stand and pivot and failed to protect the Resident's left side which caused her arm to scrape against the bed rail. The NA stated she had not been told she could transfer the resident with 1 person and was not aware to protect the resident's arm during a transfer. On 07/25/17 at 5:13 PM Nurse #2 was interviewed on the telephone and reported Resident #172 required two person assistance for transfers. The Nurse stated that when she was treating Resident #172's skin tear she observed the number magnet to be a 2 meaning the resident was to be transferred with two people. The nurse added she spoke to NA #1 to verify the resident was not transferred using two people. Nurse #2 stated that if the NA had lowered the head of the bed and used two people to transfer the resident, the skin tear would have not occurred. On 07/26/17 at 1:39 PM Nurse #1 was interviewed and reported that she worked Monday through Friday 7 AM to 3 PM on the rehab unit. The nurse explained that transfer status was determined upon admission by physical therapy and status was communicated to staff using a magnet system. She added that magnet was placed over the resident's bed for staff to reference before transferring a resident. The nurse stated that therapy would communicate changes in transfer status to nursing so they could update the magnet as needed. Nurse #1 sated that Resident #172 was able to be managed as one person assistance. On 07/27/17 at 9:17 AM the Physical Therapist (PT) was interviewed and explained that at admission transfer status was determined by the therapy department and communicated to nursing. He added that therapy and nursing communicated with each other when changes in a resident's ability changed. The PT described Resident #172 needing two person assistance with transfers after her admission but had recently been changed to one person assistance. The PT added that if one person was going to transfer the resident, the resident's left arm should be protected by tucking the affected arm underneath the armpit of the staff person. The PT also stated that for a safe transfer, the staff member would need to be on the left side of the resident and the head of the bed should be lowered. The PT stated he couldn't recall when Resident #172's transfer status changed from 2 to 1 but he stated he told staff, but could not recall who. The PT explained he did not document in therapy notes changes in transfer status and communicated changes to the nurse and nurse aide working with the resident that day. On 07/27/17 at 9:51 AM the Director of Nursing (DON) was interviewed and explained she had reviewed the incident report for Resident #172 and felt the injury could have been prevented if NA #1 had lowered the head of the bed and followed the safety guidelines described by the PT to protect Resident #172's left arm. The DON reported that the magnet system was updated when changes were made in a resident's transfer status by nursing; but Resident #172's magnet at the time of the incident on 07/22/17 had not been changed to reflect 1 person assistance with transfers.

Based on staff and family interviews and record review the facility failed to notify the family when the physician referred a resident to a specialist for treatment of [REDACTED].#3). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan created on 06/04/12 for Resident #3 specified the resident became agitated when his schedule was disrupted such as leaving the facility. Resident #3's care plan specified his schedule was to be kept consistent. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact and his skin was not impaired. Review of Resident #3's medical record revealed a physician's progress note dated 10/29/15 that specified the resident was reviewed for a [MEDICAL CONDITION] on his hand. The physician documented, neoplasm (abnormal growth of tissue) of uncertain behavior of skin. Referral to dermatology for biopsy. Possibility of this being [MEDICAL CONDITION] lesion. A physician's orders [REDACTED]. The order was noted by Nurse #1. The nurses' notes were reviewed and did not specify Resident #3's family was notified of the new order to refer Resident #3 to dermatology for the [MEDICAL CONDITION]. Nurse #1 was no longer employed at the facility and unable to be interviewed. The Director of Nursing (DON) was not present during the investigation. On 02/29/16 at 11:55 AM the Staff Development Coordinator (SDC) was interviewed and explained that it was customary for a nurse to notify families of changes in a resident's condition when the change was major and required immediate treatment. She gave an example such as [MEDICATION NAME] for chest pain or a fall with injury. She stated that in the case of an order written [REDACTED]. The SDC added that the medical record staff person was responsible for receiving the order for referrals, making the appointment and then would contact the family to notify them of the new appointment. The SDC stated that in the case of Resident #3 she was not aware if the family had been notified on 10/29/15 of the new referral to the dermatologist because the facility was trying to arrange to have the in-house physician biopsy the [MEDICAL CONDITION] to keep the resident from having to leave the facility due to psychiatric diagnoses. On 02/29/16 at 12:10 PM the medical record staff person was interviewed and explained that when she received orders for appointments it was her responsibility to make the appointment and contact the family to notify them of the appointment. She stated that she did not contact Resident #3 ' s family to notify them of the new dermatology referral because she did not make the appointment. She explained that when she received the order she alerted the SDC that Resident #3 did not handle leaving the facility well and asked the SDC if the biopsy could be performed in-house. The medical record staff person stated that the SDC told her she would discuss with the physician and let her know what the physician decided. On 02/29/16 at 1:38 PM a family member for Resident #3 was interviewed on the telephone she stated that the family visited the Resident on 11/08/15 and observed the resident's hand and had concerns about the lesion. She stated the family asked to review the medical record and learned that a referral had been made on 10/29/15. She stated that the facility had not notified the family of the referral. On 02/29/16 at 2:15 PM the physician was interviewed on the telephone and explained that she was asked to examine Resident #3 for a [MEDICAL CONDITION]. She added that normally she was able to remove [MEDICAL CONDITION] but because she felt this needed a biopsy the resident would require going out to a dermatologist. The physician stated that she saw skin tumors on the elderly all the time and that it was not acute and not an emergency but certainly needed to be addressed. She added that it usually took months to get a new dermatology appointment and waiting a few days to get the appointment did not have an impact on the resident.

Based on observations, record reviews, and staff and resident interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in May 2014. This was for one recited deficiency which was originally cited in February 2013 on a recertification survey, again on a recertification and complaint survey in April 2014 and again on the current recertification survey. The deficiency was in the area of medication labeling and storage. Two additional recited deficiencies were originally cited in April 2014 on a recertification and complaint survey and again on the current recertification and complaint survey. The deficiencies were in the areas of activities of daily living and Quality Assessment and Assurance Committee. The facility's continued failure to implement and maintain procedures from a Quality Assessment and Assurance Committee, during three federal surveys of record, show a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag is cross referred to: 1 a. F 312 Activities of Daily Living: Based on observation, record review and staff interviews the facility failed to clean stool off a resident during incontinence care for 1 of 1 resident observed for incontinence care. (Resident #29). F 312 was originally cited during the April 11, 2014 recertification survey for failure to provide oral care for residents who required extensive assistance for activities of daily living. On the current recertification and complaint survey the facility was again recited for failure to clean stool off a resident during incontinence care. b. F 431 Medication Labeling and Storage: Based on observations, nursing staff and pharmacist interviews the facility failed to securely store medications in 1 of 2 medication rooms (400 hall). F 431 was originally cited during the February 20, 2013 recertification survey for failure to discard expired medications in 2 of 4 medication carts. The facility was again recited for F 431 during the April 11, 2014 recertification and complaint survey for failure to discard an opened insulin medication vial that was expired for 4 days and was available for use in 1 of 4 medication carts. On the current recertification survey the facility was again recited for failure to securely store medications in 1 of 2 medication rooms. c. F 520 Quality Assessment and Assurance Committee: Based on observations, record reviews and staff and resident interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in May 2014. This was for one recited deficiency which was originally cited in February 2013 on a recertification survey, again on a recertification and complaint survey in April 2014 and again on the current recertification survey. The deficiency was in the area of medication labeling and storage. Two additional recited deficiencies were originally cited in April 2014 on a recertification and complaint survey and again on the current recertification and complaint survey. The deficiencies were in the areas of activities of daily living and Quality Assessment and Assurance Committee. The facility's continued failure to implement and maintain procedures from a Quality Assessment and Assurance Committee, during three federal surveys of record, show a pattern of the facility's inability to sustain an effective Quality Assurance Program. During the April 2014 recertification survey and complaint investigation, the facility was cited for failure to ensure there were no expired medications in 1 of 4 medication carts and for failure to provide oral care for residents who required extensive assistance for activities of daily living as part of the monitoring process for quality assurance. The facility was recited during the current recertification survey and complaint investigation for failure to implement and maintain an effective QA program regarding 3 repeat deficiencies in the areas of medication labeling and storage for 3 federal surveys of record and for 2 repeat deficiencies in the areas of activities of daily living, and QA during two federal surveys of record. During an interview on 07/02/15 at 5:42 PM with the facility Administrator, he confirmed the facility had a Quality Assessment and Assurance Program that met quarterly. He stated the committee had monitored the plans of correction for prior surveys. He further stated they had focused their efforts only on the specific issues that were cited previously and he was unaware of the current issues that were found during the current survey.

Based on record review and staff interview, the facility failed to accurately assess falls for 1 of 3 residents sampled for falls. (Resident #126). The findings included: Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] coded Resident #126 as having intact cognition (scoring a 9 out of 15 on the Brief Interview for Mental Status (BIMS)), being nonambulatory, requiring extensive assistance with bed mobility and transfers and having balance problems in which he needed human assistance to stabilize during transitions. He was also noted to have had a fall before admission to the facility. Review of the incident logs revealed on 03/16/15 at 10:43 PM, Resident #126 experienced a fall with no head injury. The incident report noted the resident slid from the wheelchair to the floor and was found sitting on his buttocks. This report was signed off as being reviewed by the first shift supervisor on 03/17/15 with the addition of dycems (nonskid pad) to be placed both under and over the chair cushion. There was no corresponding nursing note to this fall. A nursing note dated 03/17/15 at 3:11 AM noted there was no signs or symptoms of injury from the previous fall. The quarterly MDS dated [DATE] coded Resident #126 has having had no falls since the previous assessment. On 07/02/15 at 9:55 AM the MDS nurse was interviewed. She stated that she collected MDS information from the computer, nursing notes, looking and talking to the resident, and getting information from morning meetings. As she reviewed the MDS dated [DATE], she confirmed that she had not correctly coded Resident #126's fall on the MDS. She was unable to state how this information was missed when she completed the MDS. In the midst of this conversation, the MDS Coordinator joined in and stated there was nothing in the nursing notes related to the fall on 03/16/15. On 07/02/15 at 5:13 PM, the Director of Nursing stated during interview that she expected the MDS to be coded accurately.

Based on record review and staff interviews, the facility failed to initiate restorative services for 1 of 3 residents sampled for rehabilitation services. Resident #141 was not started on a restorative plan until over a month following a referral and subsequently not placed on the referred ambulation program. The findings included: Resident #141 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was hosptalized on [DATE] and readmitted to the facility on [DATE] with pneumonia. The admission Minimum Data Set ((MDS) dated [DATE] coded Resident #141 with severely impaired cognition, having no behaviors, requiring extensive assistance with bed mobility and transfers, being nonambulatory, needing human assistance with balance during transitions, and receiving occupational and physical therapies. Review of physical therapy (PT) notes revealed Resident #141 started PT on 03/27/15 due to difficulty walking. The last PT note dated 04/22/15 noted a plan to discontinue skilled services and refer to a functional maintenance program for gait analysis, safety training and standing balance activity. A Restorative Referral was completed on 04/24/15 by the physical therapist and stated that the start date of the restorative program was 04/25/15. Per this form, Resident #141's current functional status was gait training greater or equal to 100 feet with a rolling walker with care giver assistance and verbal cues. The program was for gait training and range of motion to bilateral lower extremities and bilateral upper extremities exercises. This restorative referral was signed by 2 restorative nursing aides (RNA #1 and #2) on 04/24/15 indicating they received training on Resident #141's restorative program. The quarterly MDS dated [DATE] coded Resident #141 with severely impaired cognition, having no behaviors, being nonambulatory, requiring extensive assistance with bed mobility and transfers, and receiving no skilled therapies or restorative services. A restorative plan of care was developed for transfers on 05/29/15 with a goal for her to perform at least 5 sit to stand transfer exercises at the rail with rest periods, verbal cues and limited assistance by 08/26/15. Interventions included sit to stand transfer exercises at least 6 times per week. A restorative plan of care was developed for active range of motion on 05/29/15 with a goal for Resident #141 to participate and perform 10 repetitions times 2 sets to all extremities with verbal cues by 08/26/15. Interventions were to provide active range of motion 6 times per week. There was no plan of care for ambulation or gait training. Review of restorative documentation revealed Resident #141 did not receive restorative services until 05/29/15. The documentation revealed she received range of motion exercises and transfer training but no ambulation. On 07/01/15 at 12:43 PM, RNA #3 stated Resident #141 received active range of motion and transfers. RNA #3 stated she needed assistance to stand. On 07/02/15 at 11:39 AM the Rehabilitation Director stated normally restorative services picked a resident up immediately upon skilled therapy discharge. On 07/02/15 at 12:29 PM the Rehabilitation Director provided the restorative referral which indicated PT trained restorative staff on 04/24/15 to take over Resident #141's care which included ambulation and range of motion exercises. On 07/02/15 at 12:38 PM the Restorative Director was interviewed. The Restorative Director stated that referrals for restorative services came from skilled therapy, sometimes verbally, however, she did not initiate the program until a written referral was received. After restorative aides signed they have been trained by therapy on the specific program, then she developed the written care plan. She stated that a restorative program and services did not begin until 05/29/15. She further stated that there was a lot going on in the facility at the time the referral came to her and when she found the referral on her desk, she developed the care plan and started services. Restorative Director further stated that because of the delay between skilled services ending and restorative services starting, she did not care plan an ambulation program as therapy had indicated because she wanted to be sure Resident #141 was strong enough to ambulate. On 07/02/15 at 12:57 PM RNA #2 stated she was trained on the restorative program on 04/24/15 but did not begin the program until the Restorative director puts it in the computer, i.e. the care plan. On 07/02/15 at 2:37 PM, nurse aide (NA) #3, who was providing care this date, stated Resident #141 did not walk. During interview on 07/02/15 at 5:16 PM, the Director of Nursing stated she expected restorative services to be implemented as soon as possible after a referral was made by therapy.

Based on observation, record review and staff interviews the facility failed to thoroughly clean stool off a resident during incontinence care for 1 of 1 resident observed for incontinence care. (Resident #29). The findings included: Resident #29 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change Minimum Data Set ((MDS) dated [DATE] indicated Resident #29 was moderately impaired in cognition for daily decision making, required extensive assistance for toileting and hygiene, was frequently incontinent of bladder, and was always incontinent of bowel. A care plan meeting was held reviewing the care plans on 05/01/15. A review of a care plan titled incontinence care indicated to give perineal care when Resident #29 was incontinent. During an observation of incontinence care on 07/01/15 at 11:11 AM Resident #29 was in bed and was turned on her right side by NA #1 and NA #2. Resident #29's brief was removed and she had a bowel movement. NA #1 used individual peri wipes to wipe stool from Resident #29's bottom. Resident #29 still had a small amount of brown stool on her bottom and NA #2 asked Resident #29 if she still needed to have a bowel movement and Resident #29 stated no. A clean brief was placed under Resident #29, she was turned to her back, then turned slightly to her left side to place a pillow at her back and the sheet was pulled up. NA #1 removed her gloves and stepped back from the side of the bed but was stopped by the surveyor and questioned if incontinence care was finished. NA #1 stated yes but when questioned if all of the stool had been cleaned from Resident #29's bottom, NA #1 and NA #2 put on gloves, turned Resident #29 on her right side, removed the brief, and at that time, Resident #29 was observed with stool on her bottom. NA #1 used individual peri wipes and cleaned the stool off Resident #29's bottom, placed a clean brief under Resident #29, turned her slightly to her right side, placed a pillow behind her back and covered her with a sheet. During an interview on 07/01/15 at 11:23 AM with NA #1, she confirmed she thought Resident #29 had finished having a bowel movement but when asked if she was clean she wasn't sure so they turned her again to check and found she still had stool on her. During an interview on 07/01/15 at 11:25 AM with NA #2 she stated they should have made sure Resident #29 was clean before they placed a pillow at her back and pulled the sheet up over the resident. NA #2 verified when Resident #29 was turned again and the brief was removed she still had a stool on her bottom. During an interview on 07/01/15 at 11:36 AM with the Director of Nursing (DON) she stated it was her expectation for incontinence care to be done after each incontinent episode and she expected for staff to get the resident clean. She explained Resident #29 had redness on her bottom and was at risk for skin breakdown and staff should have made sure she was clean so her skin didn't break down.

Based on observations, nursing staff and pharmacist interviews the facility failed to securely store medications in 1 of 2 medication rooms (400 hall). The findings included: The facility's storage medications policy was reviewed. The policy dated 04/2007 included the following statement, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The #9 Policy Interpretation and Implementation revealed, medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station or another secured location. On 07/01/15 at 4:05 PM, the 400 hall medication storage area had a small refrigerator located in the staff bathroom. The refrigerator, bathroom door and door to the outer hallway were not locked. Medications not secured in the refrigerator included Humalog insulin, Acetaminophen suppository 650 mg, Tuberculin 5 TU/0.1 ml and Bisacodyl 10 mg suppository. On 07/01/15 at 4:05 PM, the day shift Nurse #3 stated that medication refrigerator was in the staff bathroom. It did not have a lock on it. The hallway door to the bathroom was not locked and the bathroom door was not kept locked. On 07/01/15 at 4:05 PM, the Evening Nurse #2 stated that the room where the medication refrigerator was located was a staff bathroom which was used only by staff. The refrigerator was not locked. She stated the hallway door to the bathroom and the bathroom door were not kept locked. On 07/01/15 at 4:10 PM an interview with the consultant pharmacist was conducted. She stated that her expectation was that all medications were securely stored. On 07/02/15 at 3:30 PM an interview was conducted with the Director of Nursing. She stated her expectations were that all medications were stored securely and narcotics were secured and locked.

Based on observations, family interviews, staff interviews, and medical record review, the facility failed to provide oral care for 3 of 4 residents (Resident #50, #36, and #94) requiring extensive assistance for activities of daily living. The findings included: 1. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] assessed resident #50 as severely cognitively impaired, rarely understood and rarely able to understand others. The MDS assessed Resident #50 as requiring extensive assistance of at least two persons for personal hygiene. Interview with family member of Resident #50 on 04/08/14 at 10:39 AM revealed family was concerned because food and tartar were visible in mouth and on teeth of Resident #50 each day when they visited. The family member stated that she had provided care for Resident #50 for three years before moving her into the facility, and she had worked hard to keep Resident #50's teeth clean each day. The family member also stated earlier in Resident #50's life, Resident #50 had been extremely particular about keeping her teeth clean and her breath fresh. The family member stated Resident #50's dirty teeth had been the most difficult thing to adjust to since her admission to the facility. The family member stated she had reported Resident #50's need for oral care to the Nurse Aids who work with Resident #50, and she had been told because Resident #50's teeth were difficult to get to with a traditional toothbrush, they would look into having someone supply Resident #50 with mouth swabs to keep her mouth clean. The family member stated since that report, no swabs had been provided and Resident #50's mouth and teeth continued to be dirty and filled with tartar at each visit. Resident #50 was observed on 04/08/14 at 11:30 AM in the dining room, waiting for lunch. White debris and food particles were observed around the top of Resident #50's upper teeth. Also observed was a cloudy film across Resident #50's tongue and debris between her bottom teeth. Resident #50 had white matter at the top of each tooth, where it met the gum line. Observation of Resident #50 on 04/09/14 at 2:49 PM revealed dried food on corners of resident's mouth, on teeth, and on tongue, as well as foul odor detected around Resident #50's mouth. Interview with Nurse Aid (NA) #5 on 04/10/14 at 1:32 PM revealed all nurse aides assigned to hall worked on oral care with all residents. NA #5 stated Resident #50's teeth were very difficult to get to because Resident #50 did not like to open her mouth for staff. NA #5 stated that their system of documentation showed when an attempt at oral care had been made and did not show when the resident had refused or the staff was unable to complete the oral care. NA #5 stated as a result, staff marked off oral care for Resident #50 daily even though they were not usually able to get into her mouth to clean her teeth. Interview with Director of Nursing (DON) on 04/10/14 at 3:22 PM revealed her expectation was that nurse aides would provide oral care for residents who were non-verbal whenever it was needed by the resident. Interview with NA #6 and NA #7 on 04/10/14 at 3:55 PM revealed they attempted to brush the teeth of Resident #50 daily but Resident #50 frequently refused to open her mouth. NA #6 and NA #7 stated they had been asked by the DON ten minutes earlier to provide oral care for Resident #50 and had just done so. NA #6 and NA #7 demonstrated Resident #50's teeth and gums, which were observed clean with bleeding and swollen gums, especially just above each tooth. NA #6 stated she had not seen Resident #50's mouth bleed like that before but usually they were not able to get that far into her mouth. Interview with Nurse #4 on 04/10/14 at 3:52 PM revealed her expectation that nurse aides would assist all residents with tooth brushing and oral care after each meal, at bedtime, and as needed. Nurse #4 stated if a resident's teeth were difficult to clean or the resident refused care, the NA was to report to the nurse to make alternate arrangements for the oral care to be completed. Interview with Administrator on 04/11/14 at 9:40 AM revealed his expectation was that all residents would receive oral care at least twice daily and as needed. 2. Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] assessed resident #36 as cognitively intact, able to understand others and able to be understood. The MDS assessed Resident #36 as requiring extensive assistance of one person for personal hygiene. The MDS also specified the resident did not refuse care. Resident #36's care plan included a goal for Nurse Aides to assist Resident #36 with oral care daily, and that Resident #36 would be well groomed and odor free. Interview with Resident #36 on 04/08/14 at 12:04 PM revealed staff assisted him with oral care once weekly or less often. Resident #36 stated he couldn't brush his teeth or tongue without help from staff and they did not include tooth brushing in his care routine most of the time. Resident #36 stated at times a nurse aide would ask him about brushing his teeth when he was doing something and he would ask them to come back when he was finished but they never came back. Observation of Resident #36's mouth and teeth on 04/08/14 at 12:10 PM revealed food debris between teeth at front and back of mouth, a white film across tongue, and a line of dried debris across the top of teeth at gum line. Also observed was a foul odor around Resident #36's mouth. Observation of Resident #36 on 04/10/14 at 11:28 AM revealed a line of tartar above lip line on top of font teeth, foul odor from moth, and food debris on top back teeth on both sides. When asked when he had last received assistance with oral care, Resident #36 stated it had been several days. Interview with Nurse Aid (NA) #5 on 04/10/14 at 1:32 PM revealed all nurse aides assigned to hall worked on oral care with all residents. NA #5 stated Resident #36 did not always allow staff to brush his teeth, even when they needed brushing. NA #5 stated that their system of documentation showed when an attempt at oral care had been made and did not show when the resident had refused or the staff was unable to complete the oral care. NA #5 stated as a result, staff marked off oral care for Resident #36 daily even though they were often not able to clean his teeth. Interview with Director of Nursing (DON) on 04/10/14 at 3:22 PM revealed her expectation was that nurse aides would provide oral care for residents who were able to speak when the residents requested the oral care. The DON stated she did not expect residents who were able to verbalize their needs to receive oral care unless they requested the care. Interview with Nurse #4 on 04/10/14 at 3:52 PM revealed her expectation that nurse aides would assist all residents with tooth brushing and oral care after each meal, at bedtime, and as needed. Nurse #4 stated if a resident's teeth were difficult to clean or the resident refused care, the NA was to report to the nurse to make alternate arrangements for the oral care to be completed. Interview with Resident #36 on 04/11/14 at 8:45 AM revealed a nurse had met with him that morning, checked his teeth, and told him from now on he would receive oral care each day instead of every week or every month. Resident #36 stated he was very happy with the change and looked forward to having clean teeth every day. Interview with Administrator on 04/11/14 at 9:40 AM revealed his expectation was that all residents would receive oral care at least twice daily and as needed. 3. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #94 as cognitively intact, able to understand others and able to be understood. The MDS assessed Resident #94 as requiring extensive assistance of one person for personal hygiene. The MDS also specified the resident did not refuse care. Resident #94's care plan revealed a goal for nurse aide staff to assist Resident #94 with oral care daily. Interview with Resident #94 on 04/07/14 at 3:03 PM revealed Resident #94 had not received assistance with oral care since early January of 2014. Resident #94 stated she had been told by staff that it took too long for staff to assist her to brush her teeth. Resident #94 stated her daughter had been coming in nightly for a month to brush her teeth at night, but she didn't receive oral care any other time of day from any facility staff. Resident #94 stated she had always brushed her teeth at least twice daily before living in the facility. Observation of Resident #94 on 04/09/14 at 2:55 PM revealed particles of food between front teeth and on back teeth as well as white film on tongue. Resident #94 stated her mouth felt stale and she was very uncomfortable after meals when her teeth were not brushed. Interview with family member of Resident #94 on 04/09/14 at 3:15 PM revealed family member had coming in to the facility each night after dinner to brush Resident #94's teeth for about a month. Family member stated she and her brother had been called in to the facility a month ago and told by facility social worker that brushing Resident #94's teeth was taking too much time for the nurse aide staff and they didn't know what to do. Family member stated she felt they were not going to complete oral care for Resident #94 and so she started to come in each night to brush her teeth. Resident #94's family member stated her extensive need for assistance with oral care had been the main reason she had moved from assisted living to skilled nursing. The family member also stated it had been extremely difficult for her to come into the facility each night to brush Resident #94's teeth and she didn't understand why the facility staff were not able to provide that care for her family member. Observation of Resident #94 on 04/10/14 at 11:34 AM revealed Resident with food debris in her teeth, above her teeth, and a film across her tongue. Resident #94 stated her teeth had not been brushed since her family member brushed them the night before. Resident #94 stated again that facility staff had not assisted her with brushing her teeth in several months, and did not brush her teeth in the mornings, even though she had asked them for help repeatedly. Interview with Nurse Aid (NA) #5 on 04/10/14 at 1:32 PM revealed all nurse aides assigned to hall worked on oral care with all residents. NA #5 stated Resident #94's teeth were very difficult to keep clean because Resident #94 had [MEDICAL CONDITION], which caused Resident #94 to shake while she worked on her teeth and made the process take a very long time. NA #5 stated staff would make attempts to assist Resident #94 but she frequently took so long they were forced to leave and assist other residents. NA #5 stated that their system of documentation showed when an attempt at oral care had been made and did not show when the care had been initiated but not completed. NA #5 stated as a result, staff marked off oral care for Resident #50 daily even though they were not sure the care was completed. NA #5 stated she could not remember the last time she had assisted Resident #94 with oral care because Resident #94's family member had been providing that care. Interview with Director of Nursing (DON) on 04/10/14 at 3:22 PM revealed her expectation was that nurse aides would provide oral care for residents who were able to speak when the residents requested the oral care. The DON stated she did not expect residents who were able to verbalize their needs to receive oral care unless they requested the care. Interview with Nurse #4 on 04/10/14 at 3:52 PM revealed her expectation that nurse aides would assist all residents with tooth brushing and oral care after each meal, at bedtime, and as needed. Nurse #4 stated if a resident's teeth were difficult to clean or the resident refused care, the NA was to report to the nurse to make alternate arrangements for the oral care to be completed. Interview with Administrator on 04/11/14 at 9:40 AM revealed his expectation was that all residents would receive oral care at least twice daily and as needed.

Based on record review, facility policy and staff interviews, facility failed to submit a 24 hour report for 1 of 4 residents (Resident #159) reviewed with allegations of abuse. The findings included: 1. Resident #159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] assessed Resident #159 as cognitively intact, able to understand others and able to be understood. Resident #159 was no longer in the facility at the time of the recertification survey. Review of Resident Grievance/Complaint submitted by social worker (SW) on 12/12/13 revealed Resident #159 had reported to SW on morning of 12/12/13 that Nurse Aide (NA) #3 had come in to Resident #159's room around 3:00 AM, had spoken rudely and said to "shut up" to Resident #159. The report also revealed Resident #159 had reported to the SW NA #3 had refused to roll Resident #159's wheelchair over to her, and when NA #3 started to work with Resident #159's roommate, the roommate was screaming more than usual and yelling out "You're hurting me!" The Resident Grievance/Complaint revealed Resident #159 had reported to the SW on the morning of 12/12/13 that she was afraid of NA #3 and was so upset she could not eat her breakfast and had thrown it up. Finally, the report revealed Resident #159 had requested to not receive care by NA #3 again. Interview with Social Worker on 04/09/14 at 3:41 PM revealed Resident #159 had told her NA #3 had been very rude to her and Resident #159 had observed NA #3 hurting her roommate. SW reported that even though the roommate of Resident #159 frequently yelled when receiving care, Resident #159 had never before reported her roommate yelling "you're hurting me" or an observation of any NA hurting her roommate. The SW stated she did not submit a 24-hour report because there was no evidence of bodily harm to Resident #159 or her roommate. Interview with Director of Nursing (DON) on 04/09/14 at 5:13 PM revealed the facility process for handling allegations of mistreatment was when a resident reported an allegation to the SW, the SW was to complete a grievance form which she passed on to the nursing supervisor. The DON stated if the allegation involved possible harm to a resident, the DON got directly involved with the investigation. When asked the difference between an allegation that would warrant filing a 24-hour report and an allegation that was handled as a grievance, the DON stated that if the allegation included the potential for resident harm, it was handled as a grievance but if the allegation involved intent to do harm and direct observation of that intent by another staff person, it was handled as an abuse investigation. The DON stated when she heard the report regarding Resident #159 and NA #3 , she had sent NA #3 home and called the night supervisor to instruct her to not allow NA #3 to work around Resident #159 during the duration of her investigation. The DON stated anytime an allegation sounded suspicious, she took action to protect the resident's safety, but did not submit a 24-hour report until she had time to investigate the allegation more thoroughly. The DON stated no 24-hour report had been submitted regarding this incident. Interview with the Administrator on 04/10/14 at 10:04 AM revealed his expectation that any allegation by a resident is investigated and if anytime during the initial 24 hours abuse or neglect was suspected, a 24-hour report was to be submitted to the North Carolina Healthcare Registry.

Based on resident and staff interviews and record reviews, the facility failed to provide residents with the amount of baths/showers that they wanted each week for 2 of 3 residents sampled for choices (#32 and #36) and the time to go to bed at night for 1 of 3 residents sampled for choices (#32). The findings included: 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] assessed resident #32 as cognitively intact, able to understand others and able to be understood. The MDS assessment revealed Resident #32 required physical help with at least one part of bathing. Interview with Resident #32 on 04/07/14 at 3:20 PM revealed Resident #32 would choose to shower every other evening if given a choice about shower frequency. Resident #32 stated when living at home, she took a shower every other night, and liked that schedule very much. Resident #32 stated she hadn't asked to change her shower schedule of two showers weekly because she felt the staff would get mad if she asked for more. Resident #32 stated she had never been asked how often she would like to shower, and instead was told which two days weekly she would be offered a shower. Resident #32 also stated each evening the Nurse Aides came in between 7:00 PM and 8:00 PM and told her it was time to go to bed. Resident #32 stated she had never gone to bed before 9:00 PM in her life. When asked if she had told staff she preferred to stay up later, Resident #32 stated when she had told staff, they left her up but then had been rude to her and made her wait an hour or more to go to bed once she called them and told them she was ready and needed help to get into bed. Resident #32 stated she had decided it was better to allow them to put her to bed each night between 7:00 PM and 8:00 PM even though she wasn't tired, rather than have them treat her disrespectfully when she spoke up about her preferences. Interview with Nurse Aide (NA) #5 on 04/10/14 at 1:32 PM revealed residents are offered two showers weekly based on the location of their room. NA #5 stated residents were reminded of their set shower schedule if they asked for showers. Interview with MDS Coordinator on 04/10/14 at 2:30 PM revealed preferences were assessed through the MDS process. The MDS Coordinator stated she was not aware of any assessment that was done specifically to discover resident preferences of shower frequency or time to go to bed. Interview with Nurse #4 on 04/10/14 at 3:52 PM revealed each hall had a shower schedule stating which residents were scheduled for showers each day. Nurse #4 stated each resident was offered two showers weekly and the schedule was set up by room number. When asked about residents who request extra showers, Nurse #4 stated the Nurse Aides struggle with having enough time to provide the two showers per week each resident is given. Interview with NA #6 on 04/10/14 at 4:48 PM revealed the shower schedule was set for residents based on their room numbers and each resident was given two showers each week. NA #6 stated when residents asked for an extra shower she told them when their next shower day was. NA #6 stated Resident #32 had asked before to stay up later at night, but because Resident #32 got tired at night, the nurse aides all encouraged her to go to bed early. NA #6 stated the wait time for care at night could be longer than during the day, and it was easier to get residents to bed at an earlier time. Interview with NA #7 on 04/10/14 at 4:55 PM revealed all nurse aides started their routine of getting residents ready for and in bed just after supper. NA #7 stated the hall was very quiet by 7:30 or 8:00 PM and all the residents were in bed. NA #7 stated she did not ask residents what time they wanted to go to bed because they were all tired and needed their rest. NA#7 stated the showers are set for each resident to get two showers weekly, and Nurse Aides didn ' t have time to give more showers than that, unless there was an emergency. Interview with the Admissions Coordinator on 04/11/14 at 8:50 AM revealed during the admissions process, residents were not specifically asked about their shower frequency preference or their choice on time to go to bed. Interview with Social Worker on 04/11/14 at 9:27 AM revealed that preference assessment was completed by activities staff for the MDS, but the residents were not specifically asked about their choices in shower frequency or time to go to bed unless they came forward to complain about the set schedule. Interview with the Director of Nursing on 04/11/14 at 10:21 AM revealed the shower schedule was set for each resident to be offered two showers each week, based on the location of the resident's bedroom. The DON stated if a resident wanted an extra shower, they needed to request it, and her expectation was that staff would accommodate that need. The DON stated unless the resident requested, the staff would not be aware of a choice for more showers or a different bedtime. 2. Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] assessed resident #36 as cognitively intact, able to understand others and able to be understood. The MDS assessment revealed Resident #36 required extensive assistance to shower. Interview with Resident #36 on 04/08/14 at 8:27 AM revealed Resident #36 would prefer to have at least 3 showers weekly instead of the two weekly showers he was offered. Resident #36 stated he has told staff he'd prefer more showers, and has been told they don't have enough staff to offer more than two showers weekly. Resident #36 stated at home he had taken a shower daily, and although he could live without daily showers, he didn't like to feel dirty and unsanitary, which is how he felt with only two showers weekly. Resident #36 stated no staff had ever asked him about his preference for frequency of showers and he had been told each resident was offered two showers each week. Interview with Nurse Aide (NA) #5 on 04/10/14 at 1:32 PM revealed residents are offered two showers weekly based on the location of their room. NA #5 stated residents were reminded of their set shower schedule if they asked for showers. Interview with MDS Coordinator on 04/10/14 at 2:30 PM revealed preferences were assessed through the MDS process. The MDS Coordinator stated she was not aware of any assessment that was done specifically to discover preferences of residents' choices of shower frequency. Interview with Nurse #4 on 04/10/14 at 3:52 PM revealed each hall had a shower schedule stating which residents were scheduled for showers each day. Nurse #4 stated each resident was offered two showers weekly and the schedule was set up by room number. When asked about residents who request extra showers, Nurse #4 stated the Nurse Aides struggle with having enough time to provide the two showers per week each resident is given. Interview with NA #6 on 04/10/14 at 4:48 PM revealed the shower schedule was set for residents based on their room numbers and each resident was given two showers each week. NA #6 stated when residents asked for an extra shower she told them when their next shower day was. Interview with NA #7 on 04/10/14 at 4:55 PM revealed the showers are set for each resident to get two showers weekly, and Nurse Aides didn't have time to give more showers than that, unless there was an emergency. Interview with the Admissions Coordinator on 04/11/14 at 8:50 AM revealed during the admissions process, residents were not specifically asked about their shower frequency preference. Interview with Social Worker on 04/11/14 at 9:27 AM revealed that preference assessment was completed by activities staff for the MDS, but the residents were not specifically asked about their choices in shower frequency unless they came forward to complain about the set schedule. Interview with the Director of Nursing on 04/11/14 at 10:21 AM revealed the shower schedule was set for each resident to be offered two showers each week, based on the location of the resident's bedroom. The DON stated if a resident wanted an extra shower, they needed to request it, and her expectation was that staff would accommodate that need. The DON stated unless the resident requested, the staff would not be aware of a choice for more showers.

Based on observation, record review and staff interviews, the facility failed to discard an opened insulin medication vial that was expired for 4 days and was available for use in 1 of 4 medication carts. Findings included: A review of prescribing information for the use of Novolog insulin indicated after opening may be used for up to 28 days and then discarded. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #19 was severely cognitively impaired. Record review revealed an order dated 01/17/14 for Novolog 100 Unit/milliliter (ml) vial sliding scale for Resident #19 to be administered 4 times a day and a new order dated 03/20/14 for Novolog 100 units/ML vial for Resident #19 to be administered in the morning and evening. Review of the April Medication Administration Record [REDACTED]. On 04/10/14 at 11:42 AM, an open Novolog 100 unit/ML vial sliding scale insulin dated 03/09/14 was observed in the 300 hall medication cart. On 04/10/14 at 11:42 AM Nurse #1, who administered medications on the 300 hall, was interviewed and stated she had noted on the prescription label Novolog insulin and who was to receive the insulin but had not noted the expired date. On 04/10/14 at 12:04 PM Nurse #2 was interviewed and revealed the medication carts and medication room was checked every Monday for expired medications. She stated the insulin should have been checked also on Monday 04/07/14. On 04/10/14 at 5:18 PM, the Director of Nursing (DON) was interviewed. The DON stated the pharmacy consultant reviewed the medication carts and medication refrigerator monthly and the staff development nurse checked the medication carts and medication refrigerator every Monday. She revealed her expectation of nurses should be that they check the vials of insulin, noting the date of the 28th day, and if outdated they needed to discard the insulin before they administered it and should get a new insulin vial from the medication room refrigerator.

Based on observations, record reviews and staff interviews the facility failed to ensure there were no expired medications in 1 of 4 medication carts as part of the monitoring process for quality assurance. The findings included: The facility on the previous recertification survey dated 02/20/13 was cited for failure to discard expired medications in 2 of 4 medication carts at F 431. Cross reference to F 431 - the facility failed to discard an opened insulin medication vial that was expired for 4 days and was available for use in 1 of 4 medication carts. During an observation on 04/10/14 at 11:42 AM, an open [MEDICATION NAME] 100 unit/milliliter (ml) sliding scale insulin vial dated 03/09/14 was observed in the 300 hall medication cart. During an interview on 04/10/14 at 11:42 AM Nurse #1, who administered medication on the 300 hall stated she had not noted the expired date on the [MEDICATION NAME] 100 unit/ml vial and confirmed insulin from the expired vial had been given to Resident #19 for 4 days after the expiration date. During an interview on 04/11/14 at 11:35 AM the Administrator explained nursing staff was supposed to check for expired medications as part of the quality assurance monitoring of medications. He explained the regularly scheduled 300 hall nurse was on vacation and the nurse who was on duty was a nurse who was scheduled as needed (PRN) and missed seeing the expired insulin in the 300 hall medication cart. He stated he expected that the monitoring of medications for quality assurance should have caught the expired medication but since it didn't it would have to be fixed. During an interview on 04/11/14 at 11:55 AM the Director of Nursing (DON) explained quality assurance monitoring for medications included a pharmacy consultant checked medications on a monthly basis and the staff development nurse checked the medication carts and medication refrigerator weekly on Monday. She stated the monitoring process should have caught the expired medication in the 300 hall medication cart but she also expected for nurses to check medications for expiration dates before they gave the medication and if a nurse found an expired medication they were supposed to discard it right then.