Every finding on record at Coos County Nursing Home

Based on observation, interview and record review it was determine that the facility failed to implement the facility's infection control policies for 1 of 1 residents reviewed for transmission based precautions (Resident identifier is #1) and hand hygiene for 1 of 4 residents observed for medication administration (Resident identifier is #74). The facility failed to implement monitoring measures in the a water management plan that has the potential to effect a census of 74 residents. Findings include: Resident #1 Observation on 2/24/26 at approximately 10:47 a.m. revealed a contact precautions sign outside Resident #1's room. Further observation revealed Staff H (Housekeeping) exiting Resident #1's room wearing gloves and surgical mask and no gown. Staff H did not remove his/her gloves when leaving Resident #1's room. Interview on 2/24/26 at approximately 10:50 a.m. with Staff H confirmed the above findings. Observation on 2/26/26 at approximately 8:25 a.m. of Staff I (LNA) entering Resident #1's room revealed Staff I wearing a surgical mask. Staff I was then observed adjusting Resident #1's privacy curtain without gloves or gown. Interview on 2/26/26 at approximately 8:28 a.m. with Staff I confirmed the above findings. Interview on 2/26/26 at approximately 9:30 a.m. with Staff G (Infection Preventionist) revealed that Resident #1 was on contact precautions. Further interview revealed it is the policy for staff to don gloves, gown, and surgical mask before entering the resident's room on contact precautions regardless of interventions to be performed. Review on 2/26/26 of the facilities Infection Control Policy for Contact Precautions, revised 7/25, revealed, Wear Personal Protective Equipment (PPE) when entering the room . Review on 2/26/26 of the posted CDC Contact Precautions signage revealed the following instructions: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry Resident #74 Observation on 2/25/26 at approximately 9:30 a.m. of Staff A during medication administration pass revealed Staff A applied gloves, administered insulin to Resident #74, removed gloves and then proceeded to the medication cart and began preparing another residents medications, without performing hand hygiene. Interview on 2/25/26 at approximately 9:30 a.m. of Staff A confirmed above findings. Interview on 2/25/26 at approximately 2:00 p.m. of Staff G (Infection Preventionist) revealed the expectation is for staff to perform hand hygiene after gloves are removed. Review on 2/25/26 of facility policy titled Handwashing/Hand Hygiene undated, revealed Procedure:.3. If hands are not visibly soiled, may use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all following situations:.j. After removing gloves. 4. The use of gloves does not replace handwashing/hygiene. Review on 2/24/26 of the facilities policy Legionella Water Management, no review date, revealed the following: 5.d. Specific temperature range used to control the introduction and/or spread of Legionella ; e. Water temperatures maintained at 140 degrees Fahrenheit (F) at all times. f. Water temperatures is monitored every 4 hours as it leaves the boiler room i. Water temperatures in the residents' rooms are tested weekly and recorded. j. A 5-minute flush of water is required in any room empty greater than 5 days . Further review revealed that the Policy did not establish control measures and interventions for out of range data. Interview on 2/25/26 at approximately 2:55 p.m. with Staff J (Maintenance Director) revealed the following: Hot water temperature monitoring of water temperatures as it leave the boiler had not met the 140-degree F expectation for the month of February and that Staff J had not met with the Legionella team or management about the issue. Staff J revealed that he/she has not put any new interventions in place to mitigate the temperature issue. Further interview with Staff J revealed that weekly temperatures are being taken in the facility dining rooms and not in resident rooms as per the policy. Staff J also revealed that he/she had no evidence or tracking of flushing for empty rooms. Review on 2/26/26 of the Facilities Incoming Temperatures for the Month of January revealed that the boiler temperature did not meet or exceed 140 degrees F on 9 of 31 days and further that in February the boiler temperature for February did not meet or exceed 140 degrees F for 23 of 25 days. Review of Facility Logbook Documentation revealed that the facility had not checked resident room temperatures since 2/28/25.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5 percent (%) for 3 of 29 medication administrations observed. (Resident identifier is #74).Findings include:Observation on 2/25/26 at approximately 9:10 a.m. of Staff A (Licensed Practical Nurse) revealed Staff A prepared the following 2 medications for Resident #74: Eliquis 2.5 milligrams (mg) tablet and Lantus Insulin 100unit/milliliters (ml) injector pen. During preparation Staff A set the unit dial on the insulin pen to 14 without performing a safety test on the pen first.Review on 2/25/26 of Resident #74 Medication Administration Record revealed the following medications were also scheduled for the morning medication pass: Vitamin B12 500 micrograms (mcg) tablet and Metoprolol Succinate ER 50mg tablet, which were not prepared.Observation on 2/25/26 at approximately 9:20 a.m. revealed Staff A administered the Lantus to Resident #74 and when Resident #74 looked at the med cup with just the Eliquis, he/she asked where the other medications were. At that time, Staff A went back to the medication cart and poured the missed medications (Vitamin B12 and Metoprolol) then administered them all to Resident #74.Interview on 2/25/26 at approximately 9:30 a.m. with Staff A confirmed the above findings.Review on 2/25/26 of Lantus Insulin pen manufacturer instructions revealed the following, .Instruction Leaflet.Important Information for use.Step 3. Perform a Safety test Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by:.A. Select a dose of 2 units by turning the dosage selector. B. Take off the outer needle cap and keep it to remove the used needle after injections. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards. D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen.Review on 2/25/26 of facility policy titled Medication Administration General Guidelines dated 1/25 revealed, .Policy Medications are administered as prescribed in accordance with manufacturers' specifications.Medications Preparation: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record.There were 3 medication errors out of a total of 29 medication administration opportunities resulting in a 10.34% error rate.

Based on observation, record review, and interview, it was determined that the facility failed to keep residents free from physical restraints for 1 of 1 residents reviewed for physical restraints in a final sample of 18 residents (Resident identifier is #72). Findings include: Observation on 12/16/24 at approximately 12:00 p.m. revealed Resident #72 in the unit dining room, sitting in his/her broda chair with the back wheels locked, and his/her feet on the ground. Resident #72 was attempting to push back away from the table and attempted to tip table over. Interview on 12/16/24 at approximately 12:00 p.m. with Staff J (Licensed Nursing Assistant) confirmed the back wheels of Resident #72's broda chair were locked and the resident was unable to move the broda chair back. Observation on 12/18/24 at approximately 8:00 a.m. revealed Resident #72 in the unit dining room, sitting in his/her broda chair with the back wheels locked, and his/her feet touching the ground. Interview on 12/18/24 at approximately 9:10 a.m. with Staff J revealed Staff J locked the back wheels of Resident #72's broda chair primarily at dining table so Resident #72 will stay at the table to eat. Review on 12/18/24 of Resident #72's physician orders, assessments and care plan revealed no orders, assessment or care plan in place for restraint the resident's wheel chair during dining. Review on 12/18/24 of facility policy title RESTRAINTS-PHYSICAL , dated 11/3/2006, revealed .IMPLEMENTATION 1. Restraints will only be used after alternatives have been tried unsuccessfully, .A physician order is required with associated diagnosis. A Pre-Restraining Assessment Form will be completed to determine if a restraint is needed because Medical symptom(s) warrant restraint use .2 .A restraint is any method or device which restricts freedom of movement .3. Physical restraints shall not be used to limit resident mobility or for the convenience of the staff .

Based on interview and record review, it was determined that the staff failed to report an alleged violation of abuse immediately to the Administrator and the facility failed to report to the State Survey Agency (SSA) for 1 of 1 resident reviewed for abuse in a final sample of 18 residents (Resident identifier is #57). Findings include: Review on 12/16/24 of Resident #57's provider progress notes, written by Staff B (Advanced Practice Registered Nurse), revealed the following: 12/10/24, .Resident states [pronoun omitted] R [right] shoulder is in increased pain. [pronoun omitted] says one of the LNA's [Licensed Nursing Assistant] pulled [pronoun omitted] and [pronoun omitted] has [pronoun omitted] right shoulder and upper arm hurts now . Interview on 12/17/24 at approximately 2:15 p.m. with Staff B revealed that Staff B did not report the allegation to the administrator. Review on 12/18/24 of the facility policy titled, Instructions For Reporting Alleged Resident Abuse, revision date 11/24, revealed .2. Notify NHA (Nursing Home Administrator) and DON (Director of Nursing) (or their designees) of all mistreatment, abuse, neglect and misappropriation of resident property incidents via home/cell phone as soon as possible . Review on 12/18/24 of the facility policy titled, Abuse Policy and Procedures, revision date 11/24, revealed .Reporting Resident Abuse or Neglect, Observation or suspicion of alleged resident abuse, neglect or misappropriation of resident property must be reported and investigated IMMEDIATELY .

Based on record review and interview, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorder and intellectual disability for a Level I Pre-Admission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed for PASARR in a final sample of 18 residents (Resident identifier is #1). Findings include: Review on 12/16/24 of Resident #1's most recent Level I PASARR screening completed on 7/23/13 for new admission, revealed no indication of mental illness or intellectual disability. Review on 12/16/24 of Resident #1's medical diagnosis list revealed a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 8/22/24 and Personal History of Traumatic Brain Injury (TBI) dated 8/3/17. Review on 12/16/24 of Resident #1's mental health provider note, dated 8/19/24, revealed Resident #1 had an episode of recent aggression with an aide when attempt was made to redirect from the elevator focus on military and past trauma related to this .h/o [history of] TBI .confused about immediate situation and conflates this with past events leading to aggression as response . Review on 12/16/24 of Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/3/24, revealed in Section I (Active Diagnosis) lists Traumatic Brain Dysfunction as primary reason for admission, it also revealed TBI and PTSD selected. Review on 12/16/24 of Resident #1's care plan revealed PTSD and TBI had interventions in place for cognition and behaviors At times I talk about past events as though they are current (or delusions as I believe happened in my past, but are not true/accurate) e.g. I have cockroaches in my room and the Communist (but did not) .I display verbal behaviors (yelling and cursing) I reject care @ x's [at times] . Interview on 12/17/24 at approximately 2:15 p.m. with Staff L (Social Services Director) confirmed above findings and further revealed they have no process for referring for Level I PASARR screening with newly identified mental/intellectual disabilities.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 1 resident out of 3 residents reviewed for pressure ulcers in a final sample of 18 residents (Resident identifier is #36). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 12/17/24 at approximately 1:45 p.m. of Staff C (Licensed Practical Nurse) changing Resident #36's dressing to his/her coccyx revealed a separate dressing that was applied to his/her left gluteal fold, dated 12/16. Staff C removed the dressing and there was a pinpoint area noted to Resident #36's gluteal fold with a thick layer of cream applied under the dressing. Interview on 12/17/24 at approximately 1:45 p.m. with Staff C revealed that Staff C was unaware of any other dressing orders for Resident #36. Review on 12/17/24 of Resident #36's December 2024's TAR (Treatment Administration Record) and physician's orders revealed that there were no physicians order for the dressing applied to Resident #36's left gluteal fold. Interview on 12/17/24 at approximately 2:30 p.m. with Staff D (Assistant Director of Nurses/Wound Nurse) revealed that Staff D would not expect a dressing to be applied without a physician's order.

Based on interview and record review, it was determined that the facility failed to ensure a resident does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 of 2 residents reviewed for pressure ulcers in a final sample of 18 residents (Resident identifier is #69). Findings include: Review on 12/17/24 of Resident #69's medical record revealed the following progress notes: 11/8/24 at 11:15 a.m.: Weekly skin check done. Pt [patient] currently has a bruise on the outer left heel.; 11/8/24 at 3:12 p.m.: .very lethargic today .Laid down in [pronoun omitted] bed and has been sleeping since noon; 11/10/24 at 7:32 a.m.: Resident has been in bed since yesterday .noticed a golf [sic] size blister on [pronoun omitted] left heel that is weeping .Pillows were placed under [pronoun omitted] legs in order to float [pronoun omitted] heels. supervisor [name omitted]was notified .; 11/10/24 at 9:46 a.m.: Golf ball size blister noted to be draining serous fluid. Will notify MD [Medical Doctor].; 11/10/24 at 11:47 a.m.: New order to flush left heel blister with normal saline, pat dry, apply vaseline and cover with foam border dressing, keep moist and change dressing as needed until healed; Review on 12/17/24 of Resident #69's Skin integrity care plan that was initiated on 11/7/23 revealed the following: Focus was updated on 11/27/24 to include Stage 3 pressure injury to left heel; Interventions updated on 11/21/24 to include Keep heels elevated at all times with heels off cushion when in bed, and Multiboot to left foot when out of bed to off-load heel. Interview on 12/17/24 at approximately 1:30 p.m. with Staff D (Assistant Director of Nursing/Wound Nurse) confirmed that their were no orders for treatment of Resident #69's left heel until 11/10/24 when the blister was discovered. Staff D confirmed that there were no new care plan interventions added to Resident #69's care plan until 11/21/24. Staff D stated that they were not aware of the finding of the bruise on 11/8/24 to Resident #69's left heel until after the development of the blister on 11/10/24. Review on 12/17/24 of Resident #69's Licensed Nursing Assistant task documentation revealed the following: Multiboot to left foot when out of bed to offload heel and Keep heels elevated at all times with heels off cushion when in bed were both initiated on 11/20/24, 12 days after the identification of the bruised area to left heel. Interview on 12/18/24 at approximately 9:30 a.m. with Staff F (Director of Nursing) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident with an order for a CPAP (continuous positive airway pressure) machine recieved treatment consistant with the providers orders for 1 of 2 residents reviewed for Respiratory Care in a final sample of 18 residents (Resident identifier is #18). Findings include: Interview on 12/17/24 at approximately 10:15 a.m. with Resident #18 revealed that they have not been able to use their CPAP at night due to the mask not sealing. Resident #18 stated that staff were aware and that this has been going on for at least a week. Review on 12/17/24 of Resident #18's medical record revealed an order for CPAP on at bedtime and remove in the morning related to obstructive sleep apnea, start date of 11/21/23. Further review of Resident #18's medical record revealed the following order administration notes: 12/8/24 at 9:02 a.m. did not wear CPAP last night; 12/8/24 at 11:52 p.m. CPAP mask has a tear; 12/10/24 at 12:25 a.m. CPAP is broken; 12/10/24 at 7:35 a.m. CPAP is broken; 12/14/24 at 12:33 a.m. CPAP is broken; 12/14/24 at 6:01 a.m. CPAP is broken; 12/15/24 at 4:41 a.m. CPAP mask has a tear at the top; 12/15/24 at 7:05 a.m. CPAP mask has a tear; 12/16/24 at 1:00 a.m. CPAP mask has a tear at the top; 12/16/24 at 6:06 a.m. CPAP is broken; 12/17/24 at 12:01 a.m. CPAP mask has a tear at the top; 12/17/24 at 6:23 a.m. CPAP has a tear. Interview on 12/17/24 at approximately 12:00 p.m. with Staff E (Registered Nurse) confirmed that Resident #18's CPAP was not functioning properly due to a tear in the mask and that no one had notified the provider of the CPAP not being used as ordered.

Based on record review and interview, it was determined the facility failed to ensure that medical records were accurate for 2 residents reviewed in a final sample of 18 residents (Resident identifiers are #17 and #81). Findings include: Resident #17 Interview on 12/16/24 at approximately 2:00 p.m. with Resident #17 revealed that he/she has been using a hoyer lift for transfers for a few weeks. Interview on 12/18/24 at approximately 8:30 a.m. with Staff I (Licensed Nursing Assistant (LNA)) revealed that LNA's use the Resident Profiles that are hanging in the residents closets for resident transfer statuses. Review on 12/18/24 of Resident #17's Resident Profile in Resident #17's closet in his/her room revealed .Transfers 2 assist mechanical stand lift, Instructions: [pronoun omitted] sling PRN (as needed) . Interview on 12/18/24 at approximately 9:10 a.m. with Staff H (Director of Rehabilititation) confirmed that Resident #17 was no longer safe using a stand lift and had transitioned to a hoyer lift a few weeks ago. Interview on 12/18/24 at approximately 9:15 a.m. with Staff A (Administrator) revealed that he/she expects the Resident Profiles to be updated when any changes are made with a residents care needs. Interview on 12/18/24 at approximately 9:30 a.m. with Staff F (Director of Nursing) confirmed that Resident Profiles are part of the residents medical record. Resident #81 Review on 12/18/24 of Resident #81's progress notes revealed an entry on 11/11/24, at 6:30 a.m., that stated This nurse was notified by resident's visiting POA [Power of Attorney] that [pronoun omitted] was not breathing. [name omitted] RN [Registered Nurse] notified to pronounce. Further review of Resident #81's progress notes revealed no documentation regarding pronouncement of death. Interview on 12/18/24 at approximately 9:30 a.m. with Staff F confirmed the above findings. Review on 12/18/24 of the facility policy titled Death of a Resident revised 7/15, revealed .5. The licensed nurse will make the following entries on the residents' chart: a. Time of death b. Pronouncement of death by physician or Registered Nurse . 38218

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident was assessed for restraints for 1 of 1 resident reviewed for restraints in a final sample of 22 residents (Resident Identifier is #69). Findings include: Observation on 12/7/23 at approximately 11:10 a.m. of Resident #69 revealed that they were in a reclining wheelchair with a fastened seatbelt. Resident #69 has a diagnosis of cerebral palsy and is unable to release the seat belt or to move the reclining wheelchair from a reclined position to an upright position. Review on 12/7/23 of Resident #69's medical record revealed that there was no assessment of the seat belt and no physician's order for the seat belt. Further review of the medical record revealed that there was no care plan for the usage of the seat belt and that Section P of the quarterly MDS (Minimum Data Set) dated 11/14/23 titled Restraints and Alarms was coded 0 for not used. Observation on 12/8/23 at approximately 1:06 p.m. of Resident #69 revealed they were seated in the reclining wheelchair with the fastened seat belt in place. Interview on 12/8/23 at approximately 1:10 p.m. with Staff F (Director of Nursing) confirmed that there was no care plan for Resident #69's seat belt and no physician's order. Interview on 12/8/23 at approximately 1:15 p.m. with Staff G (Licensed Nursing Assistant (LNA)) who revealed that the seat belt is removed when Resident #69 goes to bed. Interview on 12/8/23 at approximately 1:20 p.m. with Staff H (LNA) who confirmed that Resident #69 has the seat belt removed only at bedtime. Interview on 12/8/23 at approximately 1:25 p.m. with Staff C (LNA) confirmed that Resident #69 has the seat belt removed only at bedtime. Interview on 12/8/23 at approximately 1:30 p.m. with Staff I (Minimum Data Set Nurse) who confirmed that Section P is not coded for the use of a restraint. Review on 12/8/23 of the facility policy titled, Restraints-Physical Nursing Handbook/Safety, Security, Enabling 11/3/2006 revealed 1. A physician order is required with associated diagnosis, a Pre-Restraining Assessment form will be completed to determine if a restraint is needed .5. c. Restrained residents must be repositioned at least every two (2) hours on all shifts and recorded in the LNA Restraint Record .7. The need for restraints will be reevaluated on the Physical Restraint Elimination Review Form at least quarterly .8. The resident's Assessments (i.e. MDS, RAP Summary) and Care Plan will be evidence that the restraint has been re-evaluated.

Based on interviews and record reviews it was determined that the facility failed to follow physician's orders for 1 resident in a final sample of 22 residents (Resident Identifier is #8). Findings include: Professional references: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 706-709-Standards The prescriber often gives specific instructions about when to administer a medication Review on 12/8/23 of Resident #8's November 2023 Medication Administration Record (MAR) revealed the following orders: Acetaminophen tablet 500 mg [milligrams], give 2 tablets by mouth two times a day for pain related to other specified arthritis, multiple sites. See corresponding order. Wait 4 hours between scheduled and PRN [as needed] dose *** NTE [not to exceed] 3 gm [grams] every 24 hrs [hours] with a start date of 6/2/23. The scheduled dose is for 9:00 a.m. and 8:00 p.m. Acetaminophen tablet 500 mg, give 2 tablets by mouth as needed for pain. Pain 2 tabs [tablet] po [by mouth] 1 every 24 hours. NTE 3 gm in 24 period. Wait 4 hours between scheduled and PRN dose. With an order date of 6/2/2023. Acetaminophen was administered PRN on the following dates: on 11/20/23 at 4:15 a.m. for a pain level of 6, effective and on 11/20/23 at 1:52 p.m. for a pain level of 8, effective. The scheduled dose of Acetaminophen tablet was also administered on 11/20/23 totaling 4 grams, therefore, exceeding 3 grams. Interview on 12/8/23 with Staff F (Director of Nursing) at approximately 12:30 p.m. confirmed the above findings. Review on 12/8/23 of Resident #8's December 2023 MAR revealed the following orders: Acetaminophen tablet 500 mg. Give 2 tablets by mouth as needed for pain. Pain 2 tabs po x 1 every 24 hours. NTE 3 grams in 24 period. Wait 4 hours between scheduled and PRN dose. With an order date of 6/2/23. Further review of Resident #8's December 2023 MAR revealed the following order for tramadol HCL [hydrochloride] oral tablet 50 mg. Give 0.5 tablet by mouth every 24 hours as needed for pain. May give 4 hours after previous dose 0.5 tablet = 25mg with a start of 11/21/2023 and a discontinue date of 12/8/2023. Further review of the December 2023 MAR for PRN Acetaminophen tablet 500 mg and Tramadol 0.5 mg did not have written parameters or pain scale on when to administer them. Interview on 12/8/23 with Staff F at approximately 12:30 p.m. confirmed the above findings.

Based on interview, record review, and policy review, it was determined that the facility failed to ensure that as needed (PRN) [CONDITION(S)] medication did not extend beyond 14 days without a documented physician rationale for 1 out of 5 residents reviewed for unnecessary medications in a final sample size of 19 residents. (Resident identifier is #40.) Findings include: Review on 11/3/22 of the pharmacy review dated 6/30/22 revealed: Recommendation: Resident is on PRN [MEDICATION(S)] with no stop date on MAR [Medication Administration Record] entry--- Per facility policy, all PRN [CONDITION(S)] medications need to have a stop date on the MAR. Review on 11/3/22 of the pharmacy review dated 8/19/22 revealed: THIS IS A DUPLICATION OF A PREVIOUS MRR [Medication Regimen Review]. PLEASE ADDRESS THE ISSUE. Resident is on PRN [MEDICATION(S)] with no stop date on MAR entry---Per facility policy, all PRN [CONDITION(S)] medications need to have a stop date on the MAR. Review on 11/3/22 of Resident #40's July and August 2022 MAR revealed the following: [MEDICATION(S)] Tablet 0.5 milligrams (mg) Give 1 tablet by mouth as needed for for anxiety **[pronoun omitted] MAY NOT DRIVE for 6 HOURS if [pronoun omitted] takes it at hs [hour of sleep]. **[pronoun omitted] SHOULD NOT BE DRINKING WHILE TAKING THIS MEDICATION**), start date 6/2/22, D/C [discontinue] date 8/4/22. Further review of Resident #40's July 2022 MAR revealed that Resident #40 received 30 PRN doses in July 2022. Further review of Resident #40's August 2022 MAR's revealed that Resident #40 received 1 PRN dose in August 2022. Interview on 11/3/22 at approximately 12:10 p.m. with Staff D (Director of Nursing) revealed that pharmacy recommendations are expected to be addressed by the facility upon receiving them and that PRN [CONDITION(S)] medications should have a 14 day stop date. Review on 11/3/22 of the facility policy titled, Medication Monitoring, Medication Regimen Review, and Reporting, dated 9/18 revealed: .8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days .

Based on observation, interview, and policy review it was determined that the facility failed to label 2 insulin pens with an open date, an open expiration date, and failed to store medication in its original container on 1 of 2 med carts observed. Findings include: Observation on 11/1/22 at approximately 10:15 a.m. of 3 East Medication Cart revealed the following insulin pens opened and not labeled with an open date or open expiration date. Resident #5 [MEDICATION(S)] insulin pen Resident #13 [MEDICATION(S)] insulin pen Further review of the 3 East Medication Cart revealed 2 white pills in a medication cup without any identifying markers. Interview on 11/1/22 at approximately 10:15 a.m. with Staff C (Licensed Practical Nurse) confirmed that the above 2 insulin pens were opened and not labeled with an open date or open expiration date and that Staff A (Charge Nurse) put the 2 pills in a medication cup in the cart and was going to administer them to a resident. Review on 11/2/22 of the manufacturer's instructions for [MEDICATION(S)] insulin pen, revision date December 2020 revealed: .How should I store [MEDICATION(S)]? . The [MEDICATION(S)] vials you are using should be thrown away after 28 days, even if it still has insulin in it . Review on 11/2/22 of the manufacturer's instruction for [MEDICATION(S)] insulin pen, dated July 2021 revealed: .Storage .In-use Pen .Throw away the Pen you are using after 28 days, even if it still has insulin in it . Review on 11/2/22 of the facility policy titled, Medication Storage, Storage of Medication, dated 9/18 revealed: .12. Note the date on the label for insulin vials and pens when first used. Review on 11/2/22 of the facility policy titled, Medication Ordering and Receiving From Pharmacy Provider, Medications and Medication Labels, dated 5/16 revealed: .10. Floor stock medications kept in the original manufacturer's container must have the expiration date and lot numbers clearly evident. The manufacturer's or pharmacy's label shall include the following: a. Medication name b. Medication strength c. quantity d. Accessory information e. Lot number f. Expiration date

Based on record review and interview, it was determined that the facility failed to ensure that resident's records were complete and accurate for 1 of 2 residents reviewed for urinary catheter in a final sample of 19 residents (Resident identifier is #42). Findings include: Review on 11/3/22 at approximately 8:50 a.m. of Resident #42's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Irrigate and clamp for 30 minutes dwell time, then release to drain gravity, with a start date of 2/8/21. Review on 11/3/22 at approximately 9:00 a.m. of Resident #42's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/3/22 at approximately 9:15 a.m. with Staff A (Charge Nurse) revealed that Resident #42 was in the quarantine unit during October and that staff did perform the irrigation but did not document it on the MAR.

Based on observation, record review and interview, it was determined that the facility failed to develop a comprehensive care plan that included a resident's Urinary Tract Infection [MEDICAL CONDITION] with blood in the urine for 1 resident in a standard survey sample of 20 residents. (Resident identifier is #83.) Findings include: Observation on 6/27/18 at approximately 8:15 a.m. of Resident #83 revealed that Resident #83 ambulated out of the assisted dining room and ambulated into room [ROOM NUMBER], which was not Resident #83's room, to use the bathroom. Review on 6/27/18 of Resident #83's Progress Notes revealed the following notes dated; 6/17/18, at 17:15 (5:15 p.m.) that read .displays urgency, difficulty to start voiding, urine foul smelling . 6/18/18, at 14:51 (2:51 p.m.) that read .LNA (licensed nursing assistant) states urine foul . 6/19/18, at 14:15 (2:15 p.m.) that read .urine foul, no s/s (signs and symptoms) urinary discomfort, increased fluids encouraged . 6/20/18, at 14:11 (2:11 p.m.) that read .housekeeping notified nursing staff that resident voided in bathroom (Room #, not Resident #83's bathroom) and there was blood in the toilet. Toilet bowl noted to have multiple large clots and dark red stained water, blood noted to be driping (sic) .down (Resident #83's) leg. Noted foul urine odor. Noted lower abdomen to be rigid and notable discomfort. Resident walking around holding onto .(body part,) weeping. PCP (Primary Care Physician) faxed at this time. N/O (New order) start Bactrim DS (Double Strength) 800/160 BID (twice daily) x (for) 7 days and acidophilus TID (three times daily) x7 days . 6/20/18, at 18:19 (6:19 p.m.) that read .Resident is rushing to the toilet approx. (approximately) q 30 min. (every 30 minutes) Hematuria (blood in urine) with clots noted . 6/20/18, at 19:14 (7:14 p.m.) that read .Resident noted to be going from bathroom to bathroom, using garbage cans, incontinent of bloody urine deep red in color, at this time resident has been voiding bloody/cloty (sic) urine q (every) 15 minutes, unable to hold (pronoun omitted) urine, removed a pull up staff attempted, (sic) been changed x5. (5 times) Due to roaming to use bathrooms, and infection control resident placed 1 on 1 with staff assist as the need arises . 6/20/18, at 19:48 (7:48 p.m.) that read Resident voided 60cc (cubic centimeters) of dark thick syrup consistency urine with small amount of clots, foul odor to urine. Noted blood dripping from (genital area) . 6/20/18, at 20:09 (8:09 p.m.) that read Call placed to POA (Power of Attorney) regarding gross hematuria, (pronoun omitted) requests on call (physician on call) be notified . 6/20/18, at 20:10 (8:10 p.m.) that read Call placed to On call MD (Medical Doctor) regarding hematuria/clots and frequent voiding. T/O (Telephone Order (Physician name omitted) , obtain CBC w/diff (Complete blood count with differential) stat (immediately) and again tomorrow AM (morning) -- dx (diagnosis) gross hematuria, hold ASA (Aspirin) have PCP (Primary Care Physician) arrange bladder ultrasound . Review on 6/28/18 of Resident #83's current care plan revealed that there was no care plan for Resident #83's UTI, hematuria, or associated symptoms. Interview on 6/29/18 at approximately 10:00 a.m. with Staff A (Director of Nursing) confirmed that there was not a care plan for Resident #83's UTI, hematuria, and associated symptoms, and that these should have been addressed in their care plan.