Every finding on record at Coos County Nursing Hospital

Based on observation, interview, and policies, it was determined that the facility failed to ensure that expired medications were removed from the emergency kit (E-kit) stored in the medication storage room on the first floor in 1 of 2 storage rooms observed. Findings include: Observation on 11/16/23 of the medication storage room on the first floor revealed an E-kit with a sticker on the top indicating an expiration date of 9/23; within the E-kit revealed six individual boxes with different medications. Review on 11/16/23 of Box 1 review the following expired medications: (6) Citalopram 10 milligrams (mg) expired 9/23 (6) Allopurinol 100 mg expired 8/23 (6) Clopindogrel 75 mg expired 8/26/23 (6) Carbidopa-levodaopa expired 9/23 (6) Carvedilol 3.125 mg expired 8/1/23 Review on 11/16/23 of Box 2 revealed the following instructions EMERGENCY KIT-BOX 2 Drugs Dip to [NAME] ** RECORD ALL MEDS [Medications] REMOVED FROM KIT WITH PATIENTS FULL NAME AND DATE OF REMOVAL** . Review revealed that on 11/4/23 Eliquis 2.5 mg was removed from Box 2 for Resident #30. Further review of Box 2 the following expired medications were noted: (1) Gabapentin expired 9/10/23 Review on 11/16/23 of Box 3 review the following expired medications: (2) Omeprazole Dr 20 mg expired 9/7/23 (6) Metformin HCL expired 8/5/23 (1) Olanzapine expired 11/3/23 (2) Olanzapine expired 8/25/23 Review on 11/16/23 of Box 4 review the following expired medications: (6) Prednisone 1 mg expired 9/7/23 (1) Risperidone 0.25 mg expired 9/10/23 Review on 11/16/23 of Box 5 review the following expired medications: (25) Nitro 0.4 mg expired 10/23 Review on 11/16/23 of Box 6 review the following expired medications: Glucagon Emergency Kit for low Blood sugar expired 10/27/23 Interview on 11/16/23 at 3:00 PM with Staff C (Director Of Nursing) indicated that the pharmacy has not been monitoring the E-kit because the facility was using a new automated medication storage and inventory system. Review of the facility's policy not dated, titled Disposal of Dropped, Refused, Expired or Discontinued Medications revealed, Risk Category 2 Policy .3. Methods of disposition of pharmaceutical hazardous and non-hazardous waste are consistent with applicable state and federal requirements, local ordinances, and standards of practice. The nursing home will use an approved vendor for pharmaceutical waste disposal needs. PharmMerica provides this service . 2. return of Non-Controlled Medication: b. Expired or Discontinued medications which have been at the facility for over 45 days shall not be returned to the pharmacy-PLEASE CHECK -LABEL for date DISPENSED NOT DR Issue date) and follow the procedure for Bulk Destruction. Review of the Pharmacy Service Agreement on 11/17/23 signed on 7/7/30/21 by Staff F (Administrator) and continues until 6/30/24, revealed 2. Obligations of the Pharmacy . C. Pharmacy shall provide. maintain and replenish emergency drug supply kits (Emergency Kits) as permitted by Applicable Law. Emergency Kits are property of Pharmacy as required by Applicable Law. Pharmacy shall deliver Products on a Stat basis when the contents of Emergency Kits cannot satisfy the needs of Customer . E. Pharmacy shall label all dispensed Medications in accordance with Applicable Law and currently accepted professional standards. Obligations of the Client revealed the Client shall, or require the Customer to, as the case may be: .K. Store and handle all Medications in accordance with Applicable Law.

Based on interview and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflect the resident's status for 4 of 16 residents reviewed for MDS in a final sample of 16 residents. (Resident identifiers are #5, #19, #48, and #51). Findings include: Resident #5 Interview on 11/15/23 at 2:10 p.m. with Resident #5 revealed that he/she has not had a fall with any major injury. Review on 11/17/23 of Resident #5's quarterly MDS with an Assessment Reference Date (ARD) of 11/3/23 revealed that Item J1900C Number of falls since Admission or Prior Assessment - Major injury was coded as 1 or One. Review on 11/17/23 of Resident #5's medical record revealed that there had not been a fall with a major injury documented. Interview on 11/17/23 at 10:08 a.m. with Staff B (MDS Coordinator) revealed that Resident #5's did not have a fall with a major injury and the above MDS had been incorrectly coded. Review on 11/17/23 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 updated October 2023, page J-36, revealed, . Definitions . Major Injury includes bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma . Resident #48 Review on 11/17/23 of Resident #48's quarterly MDS with an ARD of 10/13/23 revealed under item N0415E Anticoagulant was coded Yes. Review on 11/17/23 of Resident #48's physician's orders revealed no order for an anticoagulant. Review on 11/17/23 of Resident #48's October 2023 Medication Administrator Record revealed no documentation that an anticoagulant medication was administered. Interview on 11/17/23 at 10:08 a.m. with Staff B confirmed the above finding. Review on 11/17/23 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 updated October 2023, page N-7 revealed, .N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . Resident #51 Review on 11/17/23 of Resident #51's Admission MDS with an ARD of 9/18/23 revealed under Section O Special Treatment, Procedures, and Programs the following items were coded as Yes; -Intravenous Medication (IV) While a Resident; -Transfusions While a Resident and While Not a Resident; -Dialysis while a resident and while not a resident; -Hospice care while a resident and while not a resident; -Isolation/quarantine while a resident and while not a resident. Review on 11/17/23 of Resident #51's medical record, including progress notes, hospital discharge notes and physician's orders revealed no documentation that Resident #51 received the above treatments, procedures or programs while a resident and while not a resident. Interview on 11/17/23 at 10:08 a.m. with Staff B confirmed the above findings for Resident #51. 37488 Resident #19 Review on 11/17/23 Of Resident #19's quarterly MDS with an ARD of 10/13/23 revealed under section K was coded yes for parenteral/IV feeding while a resident, and yes for feeding tube. Review on 11/17/23 of Resident #19's physician's orders revealed no orders for parenteral/IV feeding or for a feeding tube. Interview on 11/17/23 at 10:08 a.m. with Staff B confirmed the above finding.

Based on interview and record review, it was determined that the facility failed to ensure that the posted daily nurse staffing data included the daily census and the actual hours worked by registered nurses and licensed practical nurses for 33 of the 33 days reviewed. Findings include: Review on 11/16/23 of the Report of Nursing Staff Directly Responsible for Resident Care posting on the first floor bulletin board near the front entrance revealed that the daily census was not included on the form. Further review revealed that the form listed how many licensed nursing staff were scheduled, but did not differentiate how many actual hours were scheduled for registered nurses (RN) versus licensed practical nurses (LPN). Review on 11/16/23 of the facility's Report of Nursing Staff Directly Responsible for Resident Care postings from October 15, 2023 to November 15, 2023 (32 days) revealed no daily census and did not differentiate how many actual hours were scheduled for registered nurses (RN) versus licensed practical nurses (LPN). Interview on 11/16/23 at 2:44 p.m. with Staff A (Staffing Coordinator) confirmed the above findings. Review on 11/16/23 of the facility's undated policy titled Posting Direct Care Daily Staffing Numbers revealed, .3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following . d. Type (RN, LPN . and category of nursing staff working during that shift .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that staff demonstrated proper use of gloves and hand hygiene during a dressing change for 1 out of 1 resident observed (Resident identifier is #14). Findings include: Observation on 11/15/22 at 2:49 p.m. of Resident #14's dressing change on right foot #5 metatarsal head with Staff B (Registered Nurse) revealed Staff B donned gloves, moved a urinal on the nightstand, gave Resident #14 a cup of pills then proceeded to clean Resident #14's wound with wound wash on a gauze pad. Staff B removed foam dressing from the package and with the same gloves, prepared the dressing by cutting with scissors, placed a small piece of foam dressing onto the wound, and covered with another foam dressing. Staff B had not performed any hand hygiene or changed his/her gloves during this procedure. Interview on 11/15/22 at 3:00 p.m. with Staff B confirmed that he/she did not change gloves. Interview on 11/15/22 at 2:55 p.m. with Staff F (Registered Nurse Wound Care Certified) confirmed the above observation. Review on 11/16/22 of the facility's policy titled Hand Hygiene (not dated) Risk Category 2 Standard: Hand Hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare setting When To Wash Your Hands at a Minimum * Before and after each resident contact * After touching a resident or handling his or her belongings or food * After contact with any body fluids * After handling any contaminated items * Before and after removal of PPE Review on 11/16/22 of the facility's policy titled Dressing Change Procedure (not dated) Risk Category 1 Procedure 3. Establish clean field in resident room for supplies. 4. Using aseptic technique, open dressings supplies Review on 11/17/22 of the Centers for Disease Control and Prevention Hand Hygiene in Healthcare Settings retrieved from https://www.cdc.gov/handhygiene/providers/index.html read, in part, . Introduction to Hand Hygiene . Why Practice Hand Hygiene? Cleaning your hands reduces: the spread of potentially deadly germs .use an alcohol-based hand sanitizer . before moving from work on a soiled body site to a clean body site on the same patient . After contact with blood, body fluids, or contaminated surfaces . Glove Use . Change gloves and perform hand hygiene during patient care, if . gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body sited on the same patient . Review on 11/17/22 of Potter, Patricia A., and Anne Griffin Perry. Clinical Nursing Skills & Techniques. 10th edition St. Louis, Missouri: Mosby Elsevier, 2022. pg. 1127; Performing a Wound Assessment .7. Perform hand hygiene. 8. Explain procedure of wound assessment to patient . 10. Apply clean gloves and remove soiled dressings; remove gauze one layer at a time. 11. Examine dressing for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressing were saturated, slightly moist, or had no drainage). Discard dressing in waterproof biohazard bag. Remove and discard gloves. 12. Perform hand hygiene and apply clean gloves.

Based on interview, observation, and review of manufacturer's instructions, the facility failed to ensure the mechanical lift slings were in safe working order for 1 of 1 residents reviewed for falls. (Resident identifier is #2.) Findings include: Review on 11/4/21 at approximately 10:00 a.m. of Resident #2's nurses note dated 10/24/21 revealed mechanical lift sling strap broke during a transfer causing Resident #2 to fall to the floor. Interview on 11/4/21 at approximately 11:00 a.m. of Staff C (Licensed Nursing Assistant) revealed that Resident #2 used a sit stand for transfers, but due to falling a mechanical hoyer lift was used to get Resident #2 off the floor on 10/24/21. Staff C stated that Staff C was unaware how to determine which mechanical hoyer sling should be used on which residents. Interview on 11/4/21 at approximately 11:20 a.m. with Staff B (Director of Nursing) that monthly inspections of lift pads were not conducted prior to incident. Interview on 11/4/21 at approximately 11:35 a.m. with Staff D (Registered Nurse) stated that after the fall he/she noted that the 2 lower straps of the mechanical lift sling had broken during the transfer. Staff stated that he/she did not inspect the lift sling prior to the transfer. Review on 11/4/21 of the manufacturer's instructions for the lift sling, revealed .Before each patient transfer, the sling must also be inspected for damage, for loose and missing stitching, and for tears and excessive wear that might cause it to fail. If a sling is damaged or overly worn, it must be thrown away and replaced with an undamaged sling .It is also required that a nurse or professional rehabilitation staff member inspect all VANDER-LIFT slings for the above types of damage at least monthly. A permanent record of each of these inspections and actions taken should be kept by the facility

Based on observations, interview and manufacturer's instruction review, it was determined that the facility failed to follow manufacturer's instructions for the thermometer used when screening visitors for COVID-19 upon entrance to the facility for 4 out of 4 visitors observed. Findings include: Observation on 10/19/21 at approximately 10:50 a.m. of Staff B (office staff) revealed that at the entrance of the facility Staff B took temperatures with the infrared thermometer on 4 out of 4 visitors observed by measuring the skin temperature on their neck and at their inner elbow. Interview on 10/19/21 at approximately 10:50 a.m. with Staff B confirmed the above observation. Staff B stated that they do Covid-19 screening for visitors on a routine basis. Staff B also stated they take the temperature at the side of neck or at the inner elbow. Observation on 10/20/21 at approximately 8:00 a.m. of Staff C (office staff) revealed that at the entrance of the facility Staff C took temperatures with the infrared thermometer on 4 out of 4 visitors observed by measuring the skin temperature on their neck and at their inner elbow. Interview on 10/20/21 at approximately 8:00 a.m. with Staff C confirmed the above observation on 10/20/21. Staff C stated that they do Covid-19 screening for visitors on a routine basis. Staff C also stated if the temperature is too low on the forehead then they check temperature behind the ear or at the inner elbow. Review on 10/20/21 at approximately 11:00 of Honggao Electronic Non-Contact Infrared Thermometer manufacturer's instructions, that Staff B and Staff C used to measure the visitors temperature, revealed .If the ambient temperature changes so significantly that the forehead temperature is affected, please measure the temperature by aligning the thermometer probe with the position behind the earlobe .

1. Based on observation, interview, and record review, it was determined that the facility failed to ensure that the resident's care plan reflected the appropriateness of the utilization of paid feeding assistant for 4 residents out of 4 residents reviewed for paid feeding assistant in a final sample size of 13 residents. (Resident identifiers are #6, #11, #42 and #50.) Findings include: Resident #50 Observation on 10/19/21 at approximately 12:00 p.m. revealed that Staff A (Paid Feeding Assistant/Activity Aide) was assisting Resident #50 with their lunch. Interview on 10/19/21 at approximately 12:00 p.m. with Staff A confirmed above observation. Staff A states that they do 1 on 1 assist with Resident #50 during meals. Review on 10/19/21 of the facility's list of residents utilizing paid feeding assistant's dated 10/4/21 revealed that Resident #50 was on the list for assist and queuing. Review on 10/20/21 of Resident #50's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 10/20/21 of Resident #50's diagnoses list revealed a diagnoses of dementia. There were no dysphagia diagnoses in Resident #50's medical record. Review on 10/20/21 of Resident #50's care plan revealed no documentation that Resident #50 utilizing paid feeding assistant for meals. Interview on 10/21/21 at approximately 10:00 a.m. with Staff F (Registered Nurse) confirmed above findings on Resident #50's care plan. Staff F stated that resident's on the paid feeding assistant list get reviewed by the nurse manager for appropriateness. Staff F was unable to explain if the review was documented in the resident care plan. Resident #11 Review on 10/19/21 of the facility's list of residents utilizing paid feeding assistants dated 10/4/21 revealed that Resident #11 was on the list for assist as needed. Review on 10/19/21 at approximately 1:15 p.m. of Resident #11's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 10/20/21 at approximately 2:00 p.m. of Resident #11's diagnoses revealed that Resident #11 had a diagnoses of dementia. There were no diagnoses of dysphagia in Resident #11's medical record. Review on 10/20/21 at approximately 2:00 p.m. of Resident #11's care plan revealed no documentation that Resident #11 was utilizing a paid feeding assistant during meals. Interview on 10/21/21 at approximately 10:00 a.m. with Staff F confirmed above findings on Resident #11's care plan. Resident #6 Review on 10/19/21 at 10:00 a.m. of the facility's list of residents utilizing paid feeding assistants dated 10/4/21 revealed that Resident #6 was on the list for assist as needed. Review on 10/19/21 at approximately 1:15 p.m. of Resident #6's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 10/19/21 at approximately 1:30 p.m. of Resident #6's diagnoses revealed that Resident #6 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 10/20/21 at approximately 10:00 a.m. of Resident #6's care plan revealed no documentation that Resident #6 was utilizing a paid feeding assistant during meals. Interview on 10/21/21 at approximately 10:00 a.m. with Staff F confirmed above findings on Resident #6's care plan. Resident #42 Review on 10/19/21 at 10:00 a.m. of the facility's list of residents utilizing paid feeding assistants dated 10/4/21 revealed that Resident #42 was on the list for assist as needed. Review on 10/19/21 at approximately 1:15 p.m. of Resident #42's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 10/19/21 at approximately 1:30 p.m. of Resident #42's diagnoses revealed active diagnoses of cognitive decline and [CONDITION(S)] disease. There were no diagnoses of dysphagia in Resident #6's medical record. Review on 10/20/21 at approximately 10:00 a.m. of Resident #42's care plan revealed no documentation that Resident #42 was utilizing a paid feeding assistant during meals. Interview on 10/21/21 at approximately 10:00 a.m. with Staff F confirmed above findings on Resident #42's care plan. 2. Based on interview and record review, it was determined that the facility failed to ensure that the resident's care plan was updated to reflect falls interventions after a fall for 1 residents out of 4 residents reviewed for falls in a final sample size of 13 residents. (Resident identifier is #7.) Findings include: Resident #7 Review on 10/20/21 at approximately 12:30 p.m. of Resident #7's progress notes revealed falls on the following dates: 9/3/21 9/5/21 9/10/21 9/16/21 9/19/21 x 2 9/27/21 9/29/21 10/8/21 10/9/21 10/12/21 Review on 10/20/21 at approximately 12:40 p.m. of Resident #7's care plan revealed no new interventions had been initiated for falls in September 2021 and October 2021 in an effort to prevent future falls. Review on 10/20/21 at approximately 2:00 p.m. of facility incident investigation reports revealed missing investigation for the following falls: 9/19/21 9/16/21 9/5/21 Interview on 10/20/21 at 2:10 p.m. with Staff F (Director of Nursing) revealed that only when a new intervention is implemented will it be added to the care plan. Interview on 10/21/21 at approximately 8:15 a.m. with Staff F confirmed the above findings.

Based on observation, interview, record review and facility policy review, it was determined that the facility failed to appropriately store Insulin on 1 out of 5 observed medication carts. (Resident identifier is #37.) Findings include: Observation on 11/14/18 at approximately 10:00 a.m. of the 3rd Floor North medication cart, which contained medications that were available and being used for residents, revealed a multidose vial of [MEDICATION NAME] Insulin for Resident #37. The vial had a sticker attached to it that read date open (the date of 10/1 was hand written in) and it also read discard (42 was hand written in) days after open. The vial was located in a box and the box also had a sticker on it that read Date open (10/1 was hand written in) Refrigerate until opened. If room temp. (temperature) expires (11/11 was hand written in.) Review on 11/14/18 of Resident #37's (MONTH) Medication Administration Record [REDACTED]. Interview on 11/14/18 at approximately 10:05 a.m. with Staff A (Registered Nurse) confirmed that the expiration date of the medication was 11/11/18, because it had been out of the refrigerator for 42 days. Staff A confirmed that medications stored in the medication cart are available for resident use. Staff A also confirmed that there were no other opened vials of [MEDICATION NAME] Insulin in the medication cart and that after looking at Resident #37's Medication Administration Record [REDACTED]. Review on 11/15/18 of the Facility policy titled, Medications With Special Expiration Date Requirements dated 12/12, revealed that .The beyond use date after initially entering or opening multiple dose vials is 28 days unless otherwise specified by the manufacturer . It also read .[MEDICATION NAME] vial .in use, not refrigerated 42 days .The end of use expiration date begins after opening/puncturing the product or after removing from refrigerator.

Based on interview and observation the facility failed to have 6 resident bedrooms with the minimum required 80 square feet per resident. Findings include: Observations during survey on 10/18/16-10/20/16, revealed that residents' rooms #230, #304, #305, #312, #314, and #321 had limited space available and did not meet the regulatory requirement for square footage in a bedroom. Interview with Staff A (Administrator) and Staff B (Director of Nursing) on 10/18/16 at 11:45 a.m., confirmed that the aforementioned rooms do not meet the minimum requirement of 80 square feet per resident in a multiple resident room. The State Survey Agency has granted a waiver for the aforementioned rooms.

Based on review of the resident trust fund and interview it was determined that the facility failed to convey resident funds within 30 days to the estate of the individual probate jurisdiction administering the resident estate for 7 out of sample residents. (Resident identifiers are #17, #18, #19, #20, #21, #22 and #23). Findings include: Review of deceased resident's accounts on [DATE] at approximately 12:30 p.m. revealed that Resident's #17, #18, #19, #21, #22, and# 23's probate paperwork had been filed after the 30 day limit. Review of accounts revealed the following: Resident #17 had expired on [DATE] with a balance of $40.97 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #18 had expired on [DATE] with a balance of $25.12 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #19 had expired on [DATE] with a balance of $419.43 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #20 had expired on [DATE] with a balance of $94.34 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #21 had expired on [DATE] with a balance of $581.68 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #22 had expired on [DATE] with a balance of $1433.66 remaining in this resident's account. Probate paperwork was filed on [DATE]. Resident #23 had expired on [DATE] with a balance of $94.34 remaining in this resident's account. Probate paperwork was filed on [DATE]. Interview with Staff D (Business Office Manager) on [DATE] at approximately 12:45 p.m., verbally confirmed the facility failed to convey resident funds within 30 days of demise.

Based on interview and observation the facility failed to have 6 resident bedrooms with the minimum required 80 square feet per resident. Findings include: Observations during survey on 10/27/15-10/29/15, revealed that residents' rooms #230, #304, #305, #312, #314, and #321 had limited space available and did not meet the regulatory requirement for square footage in a bedroom. Interview with Staff A (Administrator) on 10/27/15 at 11:00 a.m., confirmed that the aforementioned rooms do not meet the minimum requirement of 80 square feet per resident in a multiple resident room. The State Survey Agency has granted a waiver for the aforementioned rooms.

Based on observation, and interview, it was determined that the facility failed to store a vial of Novolog insulin correctly. Findings include: Tour of the 200 floor's medication cabinet with Staff A, LPN (Licensed Practical Nurse) on 11/19/14, revealed a vial of Novolog that had been unopened. Interview with Staff A at this time indicated that it should be refrigerated and not stored in the cabinet. Only opened vials can be stored in the mediation carts for 28 days and then discarded.

Based on observation, interview and facility's policy the facility failed to use appropriate cleaning solution to clean the glucomenters between patients on 2 of 3 floors. Findings include: Interview with Staff A (LPN) at 10:40 a.m. on 11/19/14, revealed the glucometer is cleaned with an alcohol wipe between patients. Interview with Staff B (LPN) at 10:45 a.m. on 11/19/14 revealed the glucometer is cleaned with an alcohol wipe between patients. Review of the facility's "Glucomter Blood Sugar Test" under the section called "Blood Sugar Test procedure...2. Clean glucometer with disinfectant wipe. Dispose of wipe and gloves in waste receptacle..." Resident #5 During observation of medication pass on 11/18/14 at 4 p.m. Staff C, Registered Nurse, administered prescribed oral medication and then proceeded to check Resident #5's blood sugar. After Staff C had finished with the glucometer, Staff C returned to the medication cart. Staff C cleaned the glucometer and returned it to the drawer. Interview with Staff C at 4:20 pm revealed that Staff C had used an alcohol wipe to clean the glucometer. Staff C went on to say "I know I am supposed to use bleach but I used alcohol." At this time Staff C confirmed the use of alcohol to clean the glucometer and not the designated cleaner. Interview with Staff D, Unit manager, revealed the wrong cleanser was used to clean the glucometer. At this time, Staff D showed this surveyor the appropriate wipe to clean the glucometer. Staff E, Infection Preventionalist, also confirmed the wrong cleaner was used by Staff C.

Based on interview and record review it was determine that the facility failed to follow accepted professional standards for not having parameters physicians orders for 4 of 15 sample residents. (Residents identifiers are: #2, #9, #11, and #12.) . Findings include: Resident #2 Review of Resident #2's medical record revealed an order written [REDACTED]. This is a potential for 3500 MG. Resident #11 Review of Resident #11's medical record revealed an order written [REDACTED]. This is a potential for 3900 MG. Resident#12 Review of Resident #12's medical record revealed an order written [REDACTED]. A order written on 6/14/14 with a start date of 7/1/13 for [MEDICATION NAME] Tablet 325 MG Give 2 tablet by mouth two times a day for Pain or elevated temp related to OTHER CHRONIC PAIN.. This is a potential for 5200 MG. Resident #9 Review of Resident #9's medical record revealed an order written [REDACTED]. This order did not include parameters to not exceed 4 gm. Resident #9 had the potential to received 5,000 mg in a day. Interview on 11/19/14 with nurse manager confirmed that the order lacked parameters to not exceed 4 mg of Tylenol per day.

Based on interview and observation the facility failed to have 6 resident bedrooms with the minimum required 80 square feet per resident. Findings include: Interview with Staff A (Administrator) on 11/20/14 at 11:00 a.m. and observations of surveyors revealed that rooms #230, #304, #305, #312, #314, and #321 do not meet the minimum requirement of 80 square feet per resident in a multiple resident room. Observations made on survey from 11/18/14-11/20/14 revealed that the aforementioned residents' rooms were confined with limited space available amd did not meet the regulatory requirement for square footage in a bedroom. The State Survey Agency has granted a waiver for the aforementioned rooms.

Based on report review and interview the facility failed to ensure that all residents were free of verbal abuse and mistreatment for one sampled resident. (Resident identifier #1) and one out of sample resident (Resident identifier #2) Findings include: During review of facility generated report dated 11/13/13, it was identified that an incident had occurred on 11/11/13 where Staff A (LNA) had used expletives in responding to a derogatory statement from Resident #1 who had a cognitive deficit. This incident continued as the Resident #1 "spit" at Staff A, who responded "with a lot of force" pushed a towel against the mouth of the resident. It was also identified earlier in the same shift that Staff B (LNA) had witnessed Staff A "being very rough" and "ripping" Resident #2 hands off the bar of a sit/stand lift while toileting the resident. During review of the facility investigation completed 11/14/13, other past occurrences involving Staff A had been identified by Staff C (LNA) and Staff D (Charge nurse). The past occurences could be allegations that may have been investigated to rule out abuse or mistreatment but they were not communicated to the facility so as to intervene with additional monitoring, education or other interventions. Interview with Staff E (DON) on 1/14/14 confirmed the above findings.

Based upon review of facility generated investigation and interview, the facility failed to ensure that policies and procedures for reporting all allegations of potential abuse were reported within the timeframes required by regulation. Findings include: Review of the facility generated report dated 11/13/13 identified that an incident had occurred on 11/11/13, the incident was not reported to facility Administrator or designee until 11/13/13. The Facility investigation completed 11/14/13, also identifies other occurrences that could be allegations that may have been investigated to rule out any issues i.e. "lacks patience", "not thorough with care" and needing a better ability to work with dementia residents. Interview with Staff E and Staff F (Administrator) on 1/14/14 confirmed the above findings.

Based on interview and observation the facility failed to have 6 resident bedrooms with the minimum required 80 square feet per resident. Findings include: Interview with Staff A (Administrator) on 10/1/10 at 11:00 a.m. and observations of surveyors revealed that rooms #230, #304, #305, #312, #314, and #321 do not meet the minimum requirement of 80 square feet per resident in a multiple resident room. Observations made on survey from 10/01/13-10/03/13 revealed that the aforementioned residents' rooms were confined with limited space available amd did not meet the regulatory requirement for square footage in a bedroom. The State Survey Agency has granted a waiver for the aforementioned rooms.

Based on record review and interview the facility has failed to offer established contracted hospice services to residents being placed on comfort care. (Resident identifiers are #2 and #6) Findings include: Based on review of the facility's contracts on 8/29/12 it was found that a Hospice contract was signed and activated on June 2011. Resident #2. Resident #2's record has a nurses note dated 8/28/12 that states "...Son updated on recent decline in intake (and) elevated temps noted recently. MD (medical doctor) spoke (with) son (and new order for comfort measures only)..." Resident #6. Resident #6's medical record has a physician's progress note dated 8/21/12 that states "...Discussion (with) (daughter) and we will (change) to more comfort measures (and) less aggressive (treatment)." On 8/28/12 a nurses note is written that states "MD (medical doctor) updated status N.O. (new order) CMO (Comfort Measures Ordered)..." On 8/29/12 it was confirmed through interview with Staff A (Medical Director) that when patients are in the end of life phase hospice services are not being offered. Staff A stated that the staff provide so great care to the residents that an outside agency would not be fair to the staff or resident. Review of both records revealed no documentation offering Resident #2 and #6 hospice services.

Based on resident record review the facility failed to update the comprehensive care plan for 1 of 16 sampled residents (Resident Identifier is #4). Findings include: Resident #4 was admitted to the facility on [DATE] with an admission weight of 245 lbs. Resident #4's comprehensive care plan has a current goal that Resident #4 will maintain their weight at between "240-250 lbs." A review of this resident's record revealed that Resident #4 has gained weight and as of 8/30/12 weighed 317 lbs making the current goal of keeping Resident #4's weight between 240-250 Ibs. outdated. The facility failed to update Resident #4's comprehensive care plan with an attainable goal for their weight.