Every finding on record at Coral Desert Rehabilitation and Care

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs and was provided adequate monitoring of those drugs. Specifically, for 1 out of 37 sampled residents, a resident taking a medication used as a hypnotic was not monitored for the number of hours of sleep each night. Resident Identifier: 46. Findings included: Resident 46 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, displaced midcervical fracture of right femur, depression, and chronic kidney disease. Resident 46's medical record was reviewed on 11/18/24 through 11/21/24. A physician's order dated 11/2/24, documented Hydroxyzine HCL [hydrochloride] Oral Tablet 25 MG [milligrams] Give 1 tablet by mouth at bedtime for Sleep. There were no physician's orders located for staff to monitor for the amount of sleep resident 46 obtained each night. The Medication Administration Record (MAR) and Treatment Administration Record were reviewed for the month of November 2024. There was no documentation of the amount of sleep resident 46 obtained each night. The progress notes were reviewed for the months of October 2024 and November 2024. There was no documentation of the amount of sleep resident 46 obtained each night. On 11/20/24 at 9:37 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 46 was prescribed Hydroxyzine for sleep. LPN 1 stated that the amount of sleep resident 46 obtained each night should be documented in the monitoring section of the resident's MAR. LPN 1 verified with her manager over the phone that hours of sleep would be documented in the monitoring section of the MAR. LPN 1 reviewed resident 46's MAR for the month of November 2024 and confirmed that resident 46's hours of sleep were not being documented. On 11/20/24 at 10:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 46's hours of sleep should have been documented on the resident's MAR. The DON stated that there should be an option on the MAR for staff to click and document the amount of sleep the resident obtained.

Based on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 out of 37 sampled residents, a resident had a medication stored on the bed side table and the resident had not been evaluated to determine if they were safe to self administer medications. Resident identifier: 108. Findings included: Resident 108 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spinal stenosis lumbar region, type two diabetes mellitus, cognitive communication deficit, anxiety disorder, mood affective disorder, scoliosis, and fall on same level. On 11/19/24 at 8:56 AM, an observation was conducted of resident 108's room. A bottle of AREDS 2 eye vitamin and mineral supplement was observed on resident 108's bedside table. Resident 108's medical record was reviewed on 11/19/24 through 11/21/24. An admission Minimum Data Set assessment dated [DATE], documented that resident 108 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 would suggest intact cognition. There were no current physician's orders indicating that resident 108 was to be administered AREDS 2 eye vitamin and mineral supplement. There were no assessments located indicating that resident 108 was safe for self administration of medications. On 11/20/24 at 11:01 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated if a resident requested to self administer their medications the staff had an assessment form they would complete. LPN 1 stated she would go over the medications with the resident if the resident was okay to self administer. LPN 1 stated there were no residents on her hall that self administered their medications. On 11/20/24 at 1:13 PM, an interview was conducted with resident 108. Resident 108 stated that she had not requested to self administer her medications. Resident 108 stated that she was legally blind and took the AREDS eye vitamin and mineral supplement twice a day. Resident 108 stated that the facility did not have the AREDS available. Resident 108 stated that her daughter brought the bottle of AREDS to the facility. On 11/20/24 at 1:40 PM, a follow up interview was conducted with LPN 1. LPN 1 stated if a resident was taking AREDS eye vitamin and mineral supplement there would need to be a physician's order and the okay from the physician to administer the medication. On 11/20/24 at 2:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident requested to self administer their medications the staff would need to complete the self medication administration assessment. The DON stated If the resident was competent the staff would get a physician's order and care plan the self administration

Based on observation, interview, and record review, it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not use hand hygiene (HH) during medication pass, a medication was touched with an ungloved hand and placed back in the medication pack for future use, and medication was touched after no HH was used and administered to a resident. Resident identifier: 9 Findings included: 1. On 12/14/22, an observation was made of Licensed Practical Nurse (LPN) 1. LPN 1 did not use HH prior to beginning medication pass. LPN 1 deposited 2 pills into the medication cup which held previously dispensed medications for resident 9. LPN 1 took her ungloved right hand and placed it into the medication cup to retrieve one of the medications. The medication was then placed back into the medication pack and placed back into the medication cart drawer. The medications were then administered to resident 9. No HH used on exiting the room after touching resident 9's personal belongings. 2. On 12/14/22, LPN 1 was observed to not use HH prior to administering medications to the resident in room [ROOM NUMBER]. The resident refused one of the medications. LPN 1 took her ungloved right hand and placed it into the medication cup to retrieve the medication, other medications remained in the cup. The other medications were then administered to the resident in room [ROOM NUMBER]. No HH was used on exiting room [ROOM NUMBER]. On 12/14/22 at 7:20 AM, an interview was conducted with LPN 1. LPN 1 stated HH should be done to keep things clean. LPN 1 stated it was okay to return medication to the pill packs if the medications were clean. On 12/14/22 at 10:19 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated the staff were expected to use HH before entering a room and after exiting a room. On 12/15/22 at 9:07 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses should use HH before, in between, and after each resident during medication pass. The DON stated the nurses should not touch the medications with bare hands and should pop the medications out of the card without touching the medication.

Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, observations were made of medications left unattended on top of the medication cart, the medication cart was left unlocked when unattended, and expired medications were administered. Resident identifiers: 9, 17, 100, and 148. Findings included: 1. On 12/14/22 at 7:09 AM, Licensed Practical Nurse (LPN) 1 was observed to enter resident 9's room and leave the medication cart for the 100 hallway unlocked with medications unattended on top of the medication cart. 2. On 12/14/22 at 7:34 AM, LPN 1 was observed to administer PreserVision AREDS 2 tablets with an expiration date of 3/31/22, and Centrum Adult Multivitamin 1 tablet with an expiration date of 4/30/22, to resident 148. LPN 1 was immediately interviewed and stated the medications came from the resident's hospice company. LPN 1 stated it was the responsibility of the admitting nurse to verify the medications were not expired and each nurse should check the expiration dates while they were passing the medications. [Note: Both medications were placed back into the medication cart for future use.] 3. On 12/14/22 at 7:43 AM, the medication cart in the 100 hall was observed with LPN 1. The insulin pen for resident 18 had an expiration date of 11/18/22, on the label and nothing written on the cap. LPN 1 stated the insulin pen was expired and that was why there was a second insulin pen in the drawer for resident 18. LPN 1 stated she would discard the expired insulin pen and took the pen out of the medication cart. LPN 1 stated the medications in the cart were the medications used for the residents and the medication room had more medications if needed. LPN 1 stated insulin was good for 30 days after being opened. 4. On 12/14/22 at 7:50 AM, an observation was made of the medication refrigerator in the medication room on the 100 hallway. It was observed to have a bottle of Omeprazole that expired on 12/12/22, for resident 17. LPN 1 was interviewed and stated resident 17's Omeprazole was refrigerated and the bottle in the refrigerator was the supply the staff used for resident 17. 5. On 12/14/22 at 8:25 AM, an observation was made of the medication cart on the 200 hallway. It was observed to have two insulin pens for resident 100 with no date written on the cap. Registered Nurse (RN) 1 was interviewed and stated the insulin pens came the night before and she forgot to put the date on the cap. RN 1 stated the insulin pens should have been marked with the date they were pulled out of the refrigerator. RN 1 stated insulin was good for 28 days after being open and 45 days out of the refrigerator if not opened. On 12/15/22 at 8:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurse on duty was responsible for verifying the medications when they came from the pharmacy. The staff were expected to write the date on the container when the medication was opened. The DON stated there may need to be some more education when told about the medication cart being left unlocked when unattended and medications being left on top of the medication cart when unattended.

Based on observation and interview, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 30 medication opportunities, on 12/14/22, revealed 2 medication errors which resulted in a 6.67% medication error rate. Specifically, for 1 out of 19 sampled residents, a resident received two expired medications. Resident identifier: 148. Findings included: Resident 148 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. On 12/14/22 at 7:34 AM, Licensed Practical Nurse (LPN) 1 was observed to administer PreserVision AREDS 2 tablets with an expiration date of 3/31/22 and Centrum Adult Multivitamin 1 tablet with an expiration date of 4/30/22 to resident 148. On 12/14/22 at 7:40 AM, an interview was conducted with LPN 1. LPN 1 stated the medications came from the resident's hospice company. LPN 1 stated it was the responsibility of the admitting nurse to verify that the medications were not expired and each nurse should check the expiration date on the medication before giving them to the residents. [Note: Both medications were placed back into the medication cart for future use.] On 12/15/22 at 8:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated medications came from the pharmacy and it was the on duty nurse to verify those medications and place them in the medication cart for use. The DON stated the nurses were expected to verify any medications that came in with the residents, this included the expiration dates, prior to use of the medications.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically, food items in the dry storage room, refrigerator, and freezer were open to air and food items in the refrigerator were past the use by date. Findings included: On 12/12/22 at 1:40 PM, an initial walk-through of the kitchen was conducted. In the walk-in refrigerator a container of cottage cheese was observed with a use by date of 12/7/22. The date written on the top of the container was 12/10/22. Additionally, in the walk-in freezer, a box of uncooked bacon strips was open to air. In the walk-in freezer, a box of pizza dough with a use by date of 12/7/22 was observed. A box with frozen tortillas and a box of sausage links were also observed to be open to air. In the dry food storage room, a package of spaghetti noodles was observed to be unsealed and open to air. On 12/15/22 at approximately 11:00 AM, a second walk-through of the kitchen was conducted. In the walk-in refrigerator, a container of cottage cheese was observed with a use by date of 12/7/22. The date written on the top of the container was 12/10/22. A box of uncooked bacon strips was also observed to be open to air. In the walk-in freezer, a box of Italian sausage was open to air. In the dry food storage room, a box of corn bread mix was not sealed and open to air. On 12/15/22 at approximately 11:30 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the Registered Dietitian did not do kitchen audits for sanitation or food safety. The DM stated she was responsible for ordering and accepting shipments of food with the help from her staff. The DM stated staff had been educated about proper food storage and handling. The DM stated she would review proper food storage and handling with her staff. During the interview, the DM spoke to the cook about the bacon that was open to air. The cook immediately went and packaged the bacon in sealed plastic bags and returned to show that it had been completed. The DM stated the cottage cheese with a use by date of 12/7/22, should not be used and should be thrown away.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident consistent with the resident's rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, for 3 out of 19 sampled residents, a resident who required one on one feeding assistance was not receiving that assistance, and two residents who required oxygen did not have the use of oxygen included in the comprehensive care plan. Resident identifiers: 91, 103, and 143. Findings included: 1. Resident 91 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, other intraarticular fracture of lower end of left radius, history of falling, chronic obstructive pulmonary disease, dehydration, nutritional anemia, hypertension, and hyperlipidemia. On 12/13/22 at 11:49 AM, an interview was conducted with Resident 91. Resident 91 was using oxygen via a nasal cannula. No label was observed on the oxygen tubing indicating when it had been changed. Resident 91 stated she did not know when the oxygen tubing was changed. On 12/13/22, Resident 91's medical record was reviewed. No oxygen orders were found in the physician's orders. No oxygen treatment instructions were found on the Treatment Administration records (TAR). Resident 91's care plan was reviewed, a respiratory focus area and intervention were not included. A Daily Skilled Note dated 12/10/22, documented, 12/10/2022 07:39 [AM] O2 [Oxygen] 94% [percent] - 12/10/2022 09:33 [AM] Method: Oxygen via Nasal Cannula. A Daily Skilled Note dated 12/11/22, documented, 12/11/2022 21:52 [9:52 PM] O2 90% - 12/11/2022 21:52 Method: Oxygen via Nasal Cannula. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, history of falling, moderate protein-calorie malnutrition, type 2 diabetes, chronic obstructive pulmonary disease, left bundle-branch block, hypertension, anemia, major depressive disorder, retention of urine, and urinary tract infection. On 12/13/22, resident 103's medical record was reviewed. No oxygen orders were found in the physician's orders. No oxygen treatment instructions were found on the TAR. Resident 103's care plan was reviewed, a respiratory care focus area or intervention were not included. A review of resident 103's admission Minimum Data Set assessment dated [DATE], revealed that resident 103 used oxygen before her admission and had used oxygen during her current admission. The hospital discharge summary dated 12/6/22, revealed in the discharge orders Unchanged DME [Durable Medical Equipment] RESP [Respiratory] Oxygen therapy. A progress note dated 12/7/22, revealed that resident 103 received respiratory treatment Oxygen therapy. Oxygen administered while a resident. Use is continuous oxygen. Set at 2L [liters] per NC [Nasal Cannula]. 44640 3. Resident 143 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemipareses affecting right dominant side, displaced supracondylar fracture of right humerus, and history of falling. On 12/12/22 at 3:30 PM, an interview was conducted with resident 143's family member. The family member stated the staff did not cut up resident 143's food. The family member stated resident 143 could only use her left arm, which was her non-dominant arm, since her stroke and broken right arm. The family member stated if he was not at the facility to help resident 143, she would not eat because she could not cut up the food by herself. The family member stated, They expect me to always be here so they just don't do it. They should take care of her whether I am here or not. On 12/13/22 at 12:24 PM, an observation was made of resident 143's meal ticket that was on the tray. The ticket documented, CUT UP ALL FOOD in bold capital letters. On 12/13/22 at 7:25 AM, an observation was made of Certified Nurses Assistant (CNA) 1. CNA 1 entered resident 143's room, resident 143 was reclined in bed. CNA 1 placed the breakfast tray on the bedside table in front of resident 143. CNA 1 cut up the food on resident 143's plate, then exited the room. CNA 1 did not assist resident 143 with eating. On 12/14/22 at 7:35 AM, an observation was made of resident 143 lying in bed leaning on her left side, the bedside table was across the bed in front of resident 143. Resident 143's breakfast was on the bedside table. No staff or family were in the room with the resident. Resident 143 was observed not eating. On 12/14/22 at 12:33 PM, an observation was made of resident 143 lying in bed, with the head of the bed elevated. Resident 143's lunch tray was on the bedside table in front of her. Resident 143's lunch tray had breaded chicken that was cut up, steamed vegetables that were not cut up, a buttered roll that was not cut up, and a dessert that was not cut up. No staff or family were in the room assisting Resident 143. Resident 143 could only reach the roll with her fork. Resident 143 held the fork in her left hand and tried to pick up the roll with her fork. Resident 143 tried to cut the roll with her fork. This surveyor observed resident 143 drop her fork after many failed attempts and stopped eating. On 12/15/22 at 7:15 AM, an observation was made of resident 143 sitting in bed, the bedside table was in front of the resident. Resident 143's breakfast tray was on the bedside table. Scrambled eggs, grapes, and cut up toast were on the plate in front of resident 143. No staff or family were in the room assisting resident 143 with eating. Resident 143 attempted to eat with her left hand but was unable to bring the fork to her mouth. On 12/15/22, resident 143's medical record was reviewed. An Initial Admission Record dated 12/8/22, revealed resident 143 had right arm weakness and paralysis. A Late Loss ADL (Activities of Daily Living) Form dated 12/11/22, revealed resident 143 required one person physical assistance and extensive assistance with eating. A care plan dated 12/9/22 with a revision on 12/11/22, revealed, [Resident 143] has a potential nutritional problem r/t [related to] hx [history] of CVA [cardiovascular accident] in adulthood with hemipareses/plegia, under weight, bone fx [fracture]. The goal revealed [Resident 143] will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx [sign/symptoms] of malnutrition through review date. The interventions included, provide, serve diet as ordered. Monitor and record q [every] meal. [Note: The care plan did not include the feeding assistance that resident 143 required.] A physician's order dated 12/8/22, revealed a regular diet with regular texture and thin liquids consistency for a one on one feed was ordered. On 12/14/22 at 7:30 AM, an interview was conducted with CNA 1. CNA 1 stated that a one on one feed meant that the resident needed someone in the room with them to help them eat or to feed them. CNA 1 stated if she were the only CNA working the floor then she would serve all the residents, then return to the resident who needed the one on one feeding, and would provide them with assistance. CNA 1 stated the information on whether a resident needed to be a one on one feed would be passed on in report, it would be documented on the report shift report sheet, and in the resident's medical record. CNA 1 stated she was unaware of any residents on the 100 hall who needed one on one feeding assistance. On 12/14/22 at 7:38 AM, an observation was made of CNA 1's report sheet. The report sheet did not reveal that resident 143 was a one on one feed. On 12/15/22 at 8:50 AM, a telephone interview was conducted with the Director of Nursing (DON). The DON stated the CNA's were expected to assist the residents with eating if it was needed. The CNA's and nurses had monthly inservices to go over areas of concern or that may need more education. The DON stated the expectation was the nurses and the CNA's would follow what was on the residents meal ticket and ordered by the physician. The DON stated the care that each resident needed was found on their care plan in their medical record.

Based on observation, interview, and record review, the facility did not provide a resident who was unable to carry out activities of daily living the necessary services to maintain good grooming and personal hygiene. Specifically, for 1 out of 19 sampled residents, a resident was not provided one on one feeding assistance. Resident identifier: 143. Findings included: Resident 143 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemipareses affecting right dominant side, displaced supracondylar fracture of right humerus, and history of falling. On 12/12/22 at 3:30 PM, an interview was conducted with resident 143's family member. The family member stated the staff did not cut up resident 143's food. The family member stated resident 143 could only use her left arm, which was her non-dominant arm, since her stroke and broken right arm. The family member stated if he was not at the facility to help resident 143, she would not eat because she could not cut up the food by herself. The family member stated, They expect me to always be here so they just don't do it. They should take care of her whether I am here or not. On 12/13/22 at 12:24 PM, an observation was made of resident 143's meal ticket that was on the tray. The ticket stated, CUT UP ALL FOOD in bold capital letters. On 12/14/22 at 7:25 AM, an observation was made of Certified Nurses Assistant (CNA) 1. CNA 1 entered resident 143's room, and placed the breakfast tray on the bedside table in front of resident 143. CNA 1 cut up the food on the plate, then left the room. CNA 1 did not assist resident 143 with eating. On 12/14/22 at 7:45 AM, an observation was made of resident 143 lying in bed leaning on her left side, the bedside table was in front of the resident. Resident 143's breakfast was on the bedside table. Waffles were on the plate that had been cut into squares. No staff or family were in the room with the resident. Resident 143 was observed not eating. On 12/14/22 at 12:33 PM, an observation was made of resident 143 lying in bed, the head of the bed was elevated. Resident 143's lunch tray was on the bedside table in front of her. Resident 143's lunch tray had breaded chicken that was cut up, steamed vegetables that were not cut up, a buttered roll that was not cut up, and a dessert that was not cut up. No staff or family were in the room assisting resident 143. Resident 143 could only reach the roll with her fork. Resident 143 held the fork in her left hand and tried to pick up the roll with her fork. Resident 143 tried to cut the roll with her fork. This surveyor observed resident 143 drop her fork after many failed attempts and stopped eating. On 12/15/22 at 7:15 AM, an observation was made of resident 143 sitting in bed, the bedside table was in front of the resident. Resident 143's breakfast tray was on the bedside table. Scrambled eggs, grapes, and cut up toast were on the plate in front of resident 143. No staff or family were in the room assisting resident 143 with eating. Resident 143 tried to eat with her left hand but was unable to bring the fork to her mouth. On 12/15/22, resident 143's medical record was reviewed. An Initial Admission Record dated 12/8/22, revealed resident 143 had right arm weakness and paralysis. A Functional Performance Evaluation dated 12/8/22, revealed resident 143 required partial/moderate assistance with eating. Partial/moderate assistance was defined as, Helper does less than half the effort. Helper lifts or holds trunk or limbs and provides less than half the effort. A Late Loss ADL (Activities of Daily Living) Form dated 12/11/22, revealed resident 143 required a one person physical assist and extensive assistance with eating. A care plan dated 12/9/22 with a revision on 12/11/22, revealed, [Resident 143] has potential nutritional problem r/t [related to] hx [history] of CVA [cardiovascular accident] in adulthood with hemipareses/plegia, under weight, bone fx [fracture]. The goal revealed [Resident 143] will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx [sign/symptoms] of malnutrition through review date. The interventions included, provide, serve diet as ordered. Monitor and record q [every] meal. [Note: The care plan did not include the feeding assistance that resident 143 required.] A physician's order dated 12/8/22, revealed a regular diet with regular texture and thin liquids consistency for a one on one feed was ordered. On 12/13/22 at 1:03 PM, an interview was conducted with CNA 2. CNA 2 stated resident 143 could eat by herself, she just needed to be sat up. CNA 2 stated resident 143's husband would cut up her food and if he was not here then resident 143 could do it by herself. CNA 2 stated the staff would go in and check on resident 143. CNA 2 stated that resident 143 was a slow eater but she could do it all by herself. CNA 2 stated the staff did help resident 143 if she wanted to get up, get dressed, or shower since resident 143 could only use one side from having a stroke. On 12/14/22 at 7:30 AM, an interview was conducted with CNA 1. CNA 1 stated that a one on one feed meant that the resident needed someone in the room with them to help them eat or to feed them. CNA 1 stated if she were the only CNA working the floor then she would serve all the residents, then return to the resident who needed the one on one feeding, and would provide them with assistance. CNA 1 stated the information on whether a resident needed to be a one on one feed would be passed on in report, it would be documented on the report shift report sheet, and in the resident's medical record. CNA 1 stated she was unaware of any residents on the 100 hall who needed one on one feeding assistance. On 12/14/22 at 7:38 AM, an observation was made of CNA 1's report sheet. The report sheet did not reveal that resident 143 was a one on one feed. On 12/15/22 at 8:50 AM, a telephone interview was conducted with the Director of Nursing (DON). The DON stated the CNA's were expected to assist the residents with eating if it was needed. The CNA's and nurses had monthly inservices to go over areas of concern or that may need more education. The DON stated the expectation was the nurses and the CNA's would follow what was on the residents meal ticket and ordered by the physician. The DON stated the care that each resident needed was found on their care plan in their medical record.

Based on observation, interview, and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status. Specifically, for 1 out of 19 sampled residents, a resident with weight loss did not receive timely and appropriate interventions. Resident identifier: 18. Findings included: Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dependence on ventilator, unspecified intracranial injury, epilepsy, type II diabetes hemiplegia and hemipareses on left non-dominant side, dysphagia, and anxiety. On 12/15/22, resident 18's medical record was reviewed. On 9/29/22, the Weight Summary revealed a weight of 181 pounds. On 12/14/22, the Weight Summary revealed a weight of 143.5 pounds. [Note: This was a 37.5 pound weight loss, 20.72 percent weight loss in 76 days.] A care plan dated 8/11/22 revealed, At risk for potential nutrition problem per inadequate oral intake, fluid deficit. A goal developed on 8/11/22 and revised on 11/11/22, revealed, [Resident 18] will maintain adequate nutritional status as evidenced by maintaining weight with no sign/symptom of malnutrition through review date of 1/24/23. An intervention to monitor and document intake and output as per facility policy was created on 12/2/22. No entries were made to the care plan that indicated resident 18's weight had decreased. A physician's order dated 8/29/22, revealed resident 18 was on a Consistent Carbohydrate (CCHO)mechanical soft diet with chopped texture and thin liquids. A Nutrition Note dated 10/6/22, revealed, No new weight recorded this week. Pt [Patient] continues to receive PO [by mouth] feedings, of which he is taking 65%. This intake is not adequate to meet his nutrition goals, and wt [weight] loss is expected .Provider notified. A Provider Visit Note dated 10/10/22, revealed, [Resident 18] states he is still eating and drinking really well with no issues. Weight at 175 lbs [pounds]. No changes to plan. On 10/12/22, the Weight Summary revealed a weight of 168.2 pounds. A Nutrition Note dated 10/15/22, revealed, Pt experienced a recent wt loss of 13# [pounds] (in 2 weeks). His PO intake is recorded at 67 %, which is shy of pt's nutrition goals. Pt expresses concern that he was previously gaining wt and wanted to return to his weight from a month ago. Also suspect fluid shift per diuretics. If wt loss continues, will suggest supplementation .Provider notified. It should be noted, the physician's order revealed resident 18 had been on Furosemide 20 milligrams one tablet every morning since admission to the facility on [DATE]. No new diuretics had been added to Resident 18's medication regimen. Resident 18's weight one month prior to the Nutrition Note dated 10/15/22, was 175 pounds. The care plan was not updated and no new interventions were put into place with resident 18's weight decrease. A Provider Visit Note dated 10/17/22, revealed, .[Resident 18] stated he is still eating and drinking better. He is tolerating more food than before. Weight 175 lbs. No changes to plan. On 11/2/22, the Weight Summary revealed a weight of 157 pounds. The care plan was not updated and no new interventions put into place with resident 18's weight decrease. On 11/9/22, the Weight Summary revealed a weight of 155.6 pounds. A Nutrition Note dated 11/11/22, revealed, Pt lost 2# this week (13# in one month). Provider notified .PO intake of CCHO averages 65%. Continue to monitor. Add supplement if wt loss continues. The care plan was not updated and no new interventions put into place with resident 18's weight decrease. On 11/16/22, the Weight Summary revealed a weight of 154 pounds. A Nutrition Note dated 11/19/22, revealed, Pt continues to lose wt .Provider notified .Add Boost Very High Calorie twice a day. Continue to monitor. A physician's order dated 11/19/22, revealed resident 18 was started on Boost Very High Calorie two times a day for inadequate intake to meet needs, weight loss. A Provider Note dated 11/21/22, had a weight noted of 154 lbs and revealed to, continue current treatment, no changes to current plan. On 11/23/22, the Weight Summary revealed a weight of 151.6 pounds. On 11/29/22, the Weight Summary revealed a weight of 146.6 pounds. A Nutrition Noted dated 12/2/22, revealed, Pt lost 5 # this week .PO intake not meeting nutritional goals .increase Boost to three times a day. If wt continues to trend downward, suggest considering replacing Percutaneous Endoscopic Gastrostomy for enteral nutrition support. A physician's order dated 12/2/22, revealed resident 18 was started on Boost Very High Calorie three times a day for inadequate intake to meet needs, weight loss. On 12/14/22, the Weight Summary revealed a weight of 143.5 pounds. On 12/15/22 at 10:54 AM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated resident 18 was losing weight because he wanted to lose weight and refused to have his Percutaneous Endoscopic Gastrostomy (PEG) tube replaced. The ADON stated she was unsure why no other interventions had been put in place to combat the weight loss other than the added Boost. The ADON stated there was a recall on a protein drink that had been used previously but she was unsure as to why no other supplementation or medication had been tried. On 12/15/22 at 11:33 AM, an interview with the Registered Dietician (RD) was conducted. The RD stated the residents were weighed every Wednesday, and the weights were reviewed by herself and the ADON in the weekly nutrition meeting. The RD stated she evaluated all the residents in the building on Thursdays, and would add supplements or fortification if it was needed based on the weight loss and her evaluation. The RD stated fortifying just means adding butter and more food to a resident's diet. The RD stated if a resident would not eat all of the food they were being given then there was no reason to fortify it or increase the amount. The RD stated resident 18 just needed to have his PEG tube replaced but resident 18 was resistant to it. The RD stated resident 18 was using Boost but did not drink all of it all of the time. The RD stated it may be worth it to try other supplements or measures to help stop resident 18's weight loss.

Based on observation, interview and record review, the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications. Specifically, for 1 out of 19 sampled residents, a resident's tube feeding was not infusing at the prescribed infusion rate. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, tracheostomy, dependence on ventilator, dysphagia, cognitive communication deficit, chronic diastolic congestive heart failure, essential hypertension, rheumatoid arthritis, major depressive disorder, and need for assistance with personal care. On 12/12/22 at 4:12 PM, an observation was made of resident 17 lying asleep in bed with a family member (FM) in the room. Resident 17's tube feeding (TF) was infusing at 75 milliliters an hour (ml/hr) with 40 ml/hr of water flush. On the TF bag a label revealed a date and time of 12/11/22 at 2000 (8:00 PM) and a run rate of 65 ml/hr. On 12/15/22, resident 17's medical record was reviewed. A physician's order dated 11/9/22, revealed, Enteral Feed Order, 1.5 kcal [kilocalorie]/ml [milliliter] 55 ml/hr with 25 ml of water flush every hour as tolerated. GOAL of 65 ml/hr. Increase appropriately. A Physician Progress Note dated 11/25/22, revealed, [Resident 17's] rate is now up to 55/hr [hour] due to family worried about her vomiting. The goal is still at 65ml/hr. Flush is now at 30 ml every hour. The following observations were made of resident 17's TF infusing at a rate of 75 ml/hr with 40 ml flush every hour: a. On 12/13/22 at 8:22 AM, no family was present in resident 17's room. No label observed on the TF bag. b. On 12/13/22 at 1:00 PM, a family member was present in resident 17's room. No label was observed on the TF bag. c. On 12/13/22 at 3:56 PM, a family member was present in the room. No label was observed on the TF bag. d. On 12/14/22 at 9:37 AM, a family member was present at resident 17's bedside. The TF bag was labeled with a date of 12/13/22, and an infusion rate of 75 ml/hr. e. On 12/14/22 at 2:05 PM, no family was present in resident 17's room. The TF bag was labeled with a date of 12/13/22, and an infusion rate of 75 ml/hr. f. On 12/14/22 at 4:16 PM, no family was present in resident 17's room. The TF bag was labeled with a date of 12/13/22, and an infusion rate of 75 ml/hr. g. On 12/15/22 at 7:30 AM, no family was present in resident 17's room. The TF bag label was not dated and had an infusion rate documented of 75 ml/hr. On 12/15/22 at 7:20 AM, an observation was made of Licensed Practical Nurse (LPN) 1 in the 100 hallway. LPN 1 asked the Respiratory Therapist (RT) to check that her feeding was going so she didn't have to get all dressed while the RT was in room [ROOM NUMBER]. It should be noted room [ROOM NUMBER] was an isolation room and full personal protective equipment was required to enter. An immediate interview was conducted with LPN 1. LPN 1 stated it was just easier if the RT checked it for her since the resident was in isolation. LPN 1 stated it was not the RT's job to verify feeding rates. LPN 1 stated she did check all other feedings and followed the physician's order as they were written. On 12/15/22 at 8:42 AM, a telephone interview was conducted with the Director of Nursing (DON). The DON stated the nurses were expected to follow the physician's order as they were wrote. The DON stated the night nurses changed the feeding supplies for those residents on tube feedings and each nurse was suppose to verify the feeding was running as it should. On 12/15/22 at 10:45 AM, an interview was conducted with LPN 1. LPN 1 stated orders for enteral feedings were found in the order section of the medical record. An observation was made of LPN 1 locating the enteral feeding order in resident 17's medical record. LPN 1 stated the feeding should be infusing at 65 ml/hr. LPN 1 located the order on the Medication Administration Record for resident 17 which revealed the rate to be 65 ml/hr with a 25 ml of flush every hour. LPN 1 stated the provider would come the next day and review resident 17's medical record and make any adjustments at that time. LPN 1 stated the night shift changed the tube feeding and would set the rate but it was every nurses job to verify the tube feeding was infusing as ordered. Additional information provided after survey exit. On 12/25/22 at 7:00 PM, a voicemail was received from Resident 17's FM. The FM stated he had caused the facility to get a bad mark and had increased resident 17's feeding rate from 70 ml/hr to 75 ml/hr on 12/7/22. The FM stated as a result of this the facility didn't know the rate had been changed. [Note: The tube feeding rate goal for Resident 17 was set at 65 ml/hr with a 25 ml hourly flush and it ran at 75 ml/hr with a 40 ml hourly flush the entire time the survey team was in the facility.]

Based on observation, interview and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 2 out of 19 sampled residents, residents who required oxygen did not have a physician's order for oxygen. Resident identifiers: 91 and 103. Findings included: 1. Resident 91 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, other intraarticular fracture of lower end of left radius, history of falling, chronic obstructive pulmonary disease, dehydration, nutritional anemia, hypertension, and hyperlipidemia. On 12/13/22 at 11:49 AM, an interview was conducted with resident 91. Resident 91 was observed wearing oxygen with the nasal cannula properly placed. An observation was made that the oxygen tubing had no information as to when it was last changed. Resident 91 stated she did not know how often the staff changed the tubing. Resident 91's Medical Record was reviewed. No physician's order for oxygen was found. No documentation was found on the Treatment Administration Record (TAR) for use of oxygen or oxygen tube changes. Resident 91's care plan was reviewed and there was no focus area or interventions for oxygen therapy. On 12/10/22, a Daily Skilled Note revealed, 12/10/2022 07:39 [AM] O2 [oxygen] 94% [percent]-12/10/2022 09:33 [AM] Method: Oxygen via Nasal Cannula. On 12/11/22, a Daily Skilled Note revealed, 12/11/2022 21:52 [9:52 PM] O2 90% - 12/11/2022 21:52 Method: Oxygen via Nasal Cannula. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, history of falling, moderate protein-calorie malnutrition, type 2 diabetes, chronic obstructive pulmonary disease, left bundle-branch block, hypertension, anemia, major depressive disorder, retention of urine, and urinary tract infection. Resident 103's Medical Record was reviewed: No physician's order for oxygen was found. No documentation was found on the TAR for use of oxygen or oxygen tube changes. The admission Minimum Data Set assessment dated [DATE], revealed that resident 103 was using oxygen before her admission and was using oxygen during her current admission. The hospital discharge summary dated 12/6/22, revealed in the discharge orders Unchanged DME [Durable Medical Equipment] RESP [Respiratory] Oxygen therapy. A progress note dated 12/7/22, revealed that resident 103 was receiving respiratory treatment oxygen therapy. Oxygen administered while a resident. Use is continuous oxygen. Set at 2L [liters] per NC [Nasal Cannula]. On 12/11/22, a Daily Skilled Note that included vital signs revealed, O2 90.0% - 12/11/2022 21:34 [9:34 PM] Method: Oxygen via Nasal Cannula. On 12/12/22, a Daily Skilled Note that included vital signs revealed, O2 92.0% - 12/12/2022 6:02 [AM] Method: Oxygen via Nasal Cannula. On 12/13/22, a Daily Skilled Note that included vital signs revealed,O2 96% - 12/13/2022 07:50 [AM Method: Room Air. Under the respiratory assessment the note revealed, Other observations and interventions include Pt [patient] tolerating O2 therapy well. On 12/14/22 at 9:21 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated she was unable to find a physician's order for oxygen in the physician's order and the TAR for resident 103. The CRN stated, it is what it is. On 12/15/22 at 9:23 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that a physician's order was required for a resident to receive oxygen. RN 1 stated when the oxygen order was put into the computer it would transfer over to the TAR with instructions. RN 1 stated oxygen tubing should be changed every week and labeled. RN 1 stated if the tubing was observed without a label, the tubing would be changed as soon as it was identified. A review of the facility Oxygen Administration Policy revealed that It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. Under procedures the document 1. Obtain appropriate physician's order, and 2. Identify the resident. A full list of procedures was provided. Included in the Instructions for tubing and humidifier changes were the following: 1. Label humidifier with the day. Change pre-filled humidifier per manufacturer's recommendations. Other humidifiers must be filled with distilled water replaced every 24 hours and replaced every 30 days. 2. Oxygen tubing is to be replaced every seven (7) days. Oxygen masks or nasal prongs are to be replaced every seven (7) days. 3. Store cannula/mask in bag when not in use. 4. Humidifiers are not required if flow of oxygen is two (2) liters or less per minute. 5. Re-fill non-disposable humidifiers with distilled water, as needed.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 19 sampled residents, the facility administered a narcotic within two hours of an antianxiety medication which was outside of the physician ordered parameters. Resident identifier: 18. Findings included: Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dependence on ventilator, unspecified intracranial injury, epilepsy, type II diabetes hemiplegia and hemiparesis on left non-dominant side, dysphagia, and anxiety. On 12/15/22, resident 18's medical record review was completed. A physician's order dated 9/24/22, documented an order for Oxycodone HCI [hydrochloride] 7.5mg [milligrams] tablet, give 1.5 tablet by mouth every 4 hours as needed for pain. A physician's order dated 11/23/22, documented an order for Alprazolam 0.5 mg tablet, give 1 tablet by mouth every 6 hours as needed for anxiety. DO NOT GIVE NARCOTICS WITHIN 2 HOURS OF THIS MED [medication]. A review of the October 2022 Medication Administration Record (MAR) documented the following entries when resident 18 received the Oxycodone within two hours of the Alprazolam. a. On 10/5/22, Oxycodone was administered at 5:42 AM, and Alprazolam was administered at 7:34 AM. b. On 10/6/22, Oxycodone was administered at 9:53 AM, and Alprazolam was administered at 11:39 AM. c. On 10/9/22, Oxycodone was administered at 7:55 PM, and Alprazolam was administered at 9:50 PM. d. On 10/25/22, Oxycodone was administered at 7:10 PM, and Alprazolam was administered at 8:57 PM. e. On 10/29/22, Oxycodone was administered at 8:25 PM, and Alprazolam was administered at 10:01 PM. A review of the December 2022 MAR documented the following entries when resident 18 received the Oxycodone within two hours of the Alprazolam. a. On 12/2/22, Oxycodone was administered at 9:11 PM, and Alprazolam was administered at 10:50 PM. b. On 12/8/22, Oxycodone was administered at 7:26 PM, and Alprazolam was administered at 7:24 PM. On 12/14/22 at 7:20 AM, an interview with a Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated parameters for medications were found in the physician's order section and/or the MAR of the medical record. LPN 1 stated parameters of a medication should be followed for the safety of the residents. On 12/15/22 at 8:30 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated it was the expectation of the facility for all the nurses to administer medications as they were prescribed and if there was a question to talk with the provider. The DON stated the nurses were expected to verify every medication given and give medications within the parameters set by the provider for the safety of the residents.

Based on interview and record review, the facility did not file laboratory reports that were dated and contained the name and address of the testing laboratory in the residents' clinical record. Specifically, for 2 out of 19 sampled residents, results of laboratory (lab) tests were not in the residents medical record and were not readily accessible. Resident identifiers: 97 and 103. Findings included: 1. Resident 97 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur, presence of artificial hip joint, abnormalities of gait, muscle weakness, acute kidney failure, thrombocytopenia, hypertension, rheumatoid arthritis, benign prostatic hyperplasia, and insomnia. Resident 97 was transferred to the hospital on 12/6/22, for altered mental status. A review of the hospital discharge documents revealed that resident 97 had a urinary tract infection (UTI). The discharge document also revealed that resident 97 had a urinalysis (UA) and urine culture. Resident 97 was given a written prescription for an antibiotic to be given three times each day for seven days. In reviewing resident 97's chart it was noted that there were no laboratory results for the UA and culture that was obtained at the hospital. On 12/7/22, a progress note revealed pt [patient] returned to [name of Long Term Care Facility removed] with dx [diagnosis] of UTI. On 12/8/22, a progress note revealed, Patient currently receiving Cephalexin for probable UTI (increased WBC [White Blood Cells] in urine). C&S [culture and sensitivity] results are currently pending (no growth at this time). Will monitor patient for efficacy of drug and for adverse reactions. On 12/14/22 at 11:13 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when a resident came back from the hospital with a new prescription a nurse put it into the computer and it would be checked by two people. RN 1 stated after the prescription was checked, it would be scanned into the resident's medical record. RN 1 stated medications were entered into the orders tab in the medical record. RN 1 stated the physician would be messaged to let them know there was a new prescription for the resident. RN 1 stated that the resident was re-assessed when the medication was completed. On 12/14/22 at 11:18 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that once lab results were received the staff would message the physician and complete antibiotic charting. The ADON stated antibiotic charting was in a progress note attached to the medication. The ADON stated the results for resident 97 may be in the medical records system used at the hospital, and they might be in the infection control book. The ADON stated resident 97 did not have a UTI, but had elevated WBC in his urine and she felt he responded well to the antibiotic. The ADON stated there was no growth on the urine culture so the antibiotic that had been prescribed had been continued because of the WBC in the urine. The ADON stated resident 97 had intermittent confusion. The ADON stated resident 97 did not have a diagnosis of dementia and she blamed resident 97's confusion on his post-surgical status. The DON stated if a resident had a change in condition the physician would be notified and if there were orders for labs the labs would be drawn. The ADON stated the physician came to the facility almost every day, especially for new admissions and quarterly assessments. 2. Resident 103 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, history of falling, moderate protein-calorie malnutrition, type 2 diabetes, chronic obstructive pulmonary disease, left bundle-branch block, hypertension, anemia, major depressive disorder, retention of urine, and urinary tract infection. On 12/13/22, resident 103's medical record was reviewed. On 12/6/22, a physician's order for ciprofloxacin for infection was entered. Resident 103's Medication Administration Record revealed that ciprofloxacin was administered for the designated seven day period. On 12/8/22, a progress note revealed, Patient is receiving ciprofloxacin for UTI which grew Enterococcus Faecalis and Pseudomonas Aeruginosa. Both bacteria are susceptible to this drug, and patient will be monitored for efficacy and adverse reactions. No laboratory results were found in resident 103's medical record. On 12/14/22 at 3:00 PM, an interview was conducted with the ADON. The ADON stated laboratory results were kept in the antibiotic stewardship binder. The ADON provided the antibiotic stewardship binder that contained lab results separated by month. A urinalysis result was found for resident 97 in the December section, however, there was no result from the urine culture. A urinalysis result and culture result were found in the December section of the binder for resident 103. The ADON stated the results could be found in the hospital records that were available to the facility. The ADON obtained and printed the urine culture results and emailed the UA and culture results for both resident 97 and resident 103 to the State surveyor.

Based on observation, interview, and record review it was determined, for 1 of 25 sample residents, that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, a toilet did not flush, trash cans were over flowing and the kitchens for each floor were dirty. Resident identifier: 3. Findings include: 1. On 10/28/19 at 1:28 PM an interview was conducted with resident 3. Resident 3 stated that her bathroom trash can was over flowing and the toilet did not flush. Resident 3 stated that she reported the trash and the problem with toilet not flushing to staff. Resident 3 stated that after reported the issues, the trash was still over flowing and the toilet was not flushing. On 10/28/19 at 1:30 PM, an observation was made of resident 3's bathroom. The trash was over flowing in the bathroom. The toilet was observed to have urine and used toilet paper in the bowl. The toilet was observed not to flush the toilet paper down. A review of the maintenance log on 10/28/19 at approximately 3:00 PM showed that there had not been a work order put into the system for resident 3's toilet. 2. On 10/28/19 at 12:45 PM, there was trash on the floor in room [ROOM NUMBER]. On 10/28/19 at approximately 2:45 PM, an interview was conducted with the Maintenance Executive (ME). The ME stated that maintenance issues were entered into an electronic system. The ME stated that resident rooms were cleaned daily and all trashes were emptied during the room cleaning. The ME stated that he was resident 3's Guardian Angel and he should have been visiting resident 3 daily to see if there were any concerns. On 10/28/19 an interview with the Administrator. The Administrator stated that the facility had a Guardian Angel program. The Administrator stated that the Guardian Angel program consisted of a staff member visiting each resident daily to ask if there were any concerns or issues. The Administrator stated that the staff member did not document concerns or issues that a resident had. 3. On 10/28/19 at 5:00 PM, an observation was made of the microwave. The microwave on the 2nd floor in the dining room and therapy gym, had food splattered inside, on turn plate, and on the door. 4. On 10/28/19 at 12:42 PM, an observation was made of the kitchen on the main level. There was a container labeled Applesauce on it's side without a lid in the door of the refrigerator. There was applesauce inside the refrigerator on the shelves, on the bottom of the refrigerator and on the floor in the kitchen. There were Beer N Brats dated 10/16 in the refrigerator. There was chicken stock with no open dated with room [ROOM NUMBER] on the container. There was an ice cream cone with ice cream that was not covered, not dated, with no no name in the freezer. There was black substance on the floor in the kitchen. There was a breakfast meal tray on the counter next to the sink. There was a white ice cooler with black substance on it. On 10/28/19 at 3:49 PM, an interview was conducted with ME. The ME stated that there was a housekeeping staff member assigned to the common area. On 10/28/19 at 4:30 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated Certified Nursing Assistant's (CNAs) and nurses were responsible for keeping the kitchen areas clean. RN 1 stated that housekeeping staff were responsible to deep clean the kitchen. RN 1 stated that CNAs were responsible for cleaning the refrigerator. RN 1 stated that night shift CNAs cleaned the refrigerator. On 10/28/19 at 4:39 PM, an interview was conducted with CNA 1. CNA 1 stated that housekeeping staff cleaned the kitchens. CNA 1 stated that the night shift CNAs were responsible for cleaning the refrigerator. On 10/28/19 at 4:40 PM, an interview was conducted with CNA 2. CNA 2 stated that housekeeping staff cleaned the kitchens on the main level and the second level. CNA 2 stated that night shift CNAs cleaned out the refrigerator. CNA 2 stated that he received a text from the night shift CNAs that they did not have time to clean out the refrigerator.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were expired food items, there was dirty equipement in the kitchen, and there dirty surfaces in the kitchen. Findings include: 1. On [DATE] at 11: 55 AM, an observation was made of the refrigerator on the first floor in the room labeled Serving Kitchen. In the freezer, there were 3 therapy packs labeled with resident names and room numbers. The therapy packs were with other food in the freezer. In the refrigerator there was a sandwich with no date and eggs with a sell by date of [DATE]. There was a container labeled Resource Thicken up with an expiration date of [DATE]. 2. On [DATE] at 11:55 AM, an initial tour of the kitchen was conducted. The following was observed: a. The oven was observed to have black build up in the bottom of both ovens and the doors were soiled. b. There were 2 drains by the double oven that had crumbs and debris in them. c. There was a white substance around the outside of the ice machine. d. There was a brown and white substance on the floor in the walk-in refrigerator. e. There was a container of peaches open to air in the walk-in refrigerator. f. There were 3 cantaloupes with a mold substance in the walk-in refrigerator. g. There were 3 containers of tomato paste with a best by date of [DATE]. h. The cream colored door to the dry storage was soiled with a black substance. i. The stove had a large black substance on the stove top. Under the stove top there was foil that was soiled with grease and debris. j. There were drains by the stove that had debris and crumbs in them. 3. On [DATE] at 2:00 PM, a follow up tour of the kitchen was conducted. The following was observed: a. The oven was observed to have black build up in the bottom of both ovens and the doors were soiled. b. There were 2 drains by the double oven that had crumbs and debris in them. c. There was white substance around the outside of the ice machine. d. There was a brown and white substance on the floor in the walk-in refrigerator. e. The cream colored door to the dry storage area was soiled with a black substance. f. The stove had a large black substance on the stove top. Under the stove top there was foil that was soiled with grease and debris. g. There were drains by the stove that had debris and crumbs in them. An interview was immediately conducted with the Dietary Manager (DM). The DM stated that the ovens were cleaned monthly but she did not know when the ovens were last cleaned. The DM stated that the drains were not on the cleaning schedule. The DM stated that the foil under the stove was pulled monthly when the stove was cleaned. The DM stated she did not know what to use to clean the stove. The DM stated that ice machine was cleaned monthly and wiped down. The DM stated that the substance on the floor in the walk-in was hard water build up from the ice machine. The DM stated that the refrigerator in the Serving Kitchen was for staff food.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, a small cup of pills was observed on a nurses' cart that were unlabelled. Findings include: On 4/24/19 at 8:05 AM, an observation was made of the Zion hall nurses' cart. The cart contained a small cup of unlabelled capsules. Registered Nurse (RN) 2 was observed to take one capsule and administer it to a resident. On 4/24/19 at 8:05 AM, RN 2 stated that she knew that the medication was [MEDICATION NAME]. RN 2 stated that the medication bottle had been to large to put on her medication cart. RN 2 stated that she did not need the cup labeled because I know what it is. On 4/24/19 at 11:36 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility had received a large bottle of 100 mg ducosate ([MEDICATION NAME]) from Central Supply. The DON stated that she told the purchasing staff to buy smaller bottles so nurses could have them labeled on the carts. The DON stated that nurses should not have unlabelled medications on the medication carts.

Based on interview, observation and record review it was determined, for 1 of 19 sample residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, one resident experienced pain without intervention by facility staff. Resident identifier: 140. Findings include: Resident 140 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 4/22/19 at 1:44 PM, resident 140 was moving repeatedly in his bed. Resident 140 appeared restless. On 4/24/19 at 12:35 PM, resident 140 was moving repeatedly in his bed. Resident 140 appeared restless. On 4/24/19 a record review was completed for resident 140. Resident 140's orders included the following: a. [MEDICATION NAME] Suppository 650 MG (milligrams), insert 1 suppository rectally every 4 hours as needed for mild pain was ordered on [DATE]. b. [MEDICATION NAME] (concentrate) solution, 20 mg/ml (milligrams per milliliter), give 0.25 ml by mouth every 2 hours as needed for mild pain. c. Monitor level of pain using 0-10 scale (0=no pain, 1-3=mild pain, 4-5=moderate pain, 6-9=severe pain, 10=excruciating pain) every shift. On 4/13/19, Resident 140's Hospice Care Plan revealed that the following intervention: Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Resident 140's care plan dated 4/23/19 revealed Terminal Prognosis r/t (related to) End Stage [MEDICAL CONDITION]. The following interventions were developed: a. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. b. Work with nursing staff to provide maximum comfort for the resident. Resident 140's care plan created on 4/13/19 revealed, potential for acute/chronic pain r/t risk for falls, weakness, impaired mobility. The following interventions were developed: a. Administer [MEDICATION NAME] medication ([MEDICATION NAME], [MEDICATION NAME] Suppository) per orders. b. Pain assessment every shift. The following pain levels were documented in resident 140's Medication Administration Record [REDACTED]. The level 0 was no pain and level 10 was excruciating pain.) a. On 4/12/19, 4/10 on PM shift b. On 4/16/19, 1/10 on AM shift c. On 4/16/19, 4/10 on PM shift d. On 4/17/19, 2/10 on AM shift e. On 4/17/19, 4/10 on PM shift f. On 4/21/19, 4/10 on PM shift g. On 4/22/19, 3/10 on PM shift Resident 140's pain monitoring was also recorded in the vital signs charting with the following pain level: a. On 4/19/19 at 1:18 AM, pain 5/10 Resident 140's MAR indicated [REDACTED]. On 4/24/19 at 1:01 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 140 did not regularly use his call light, and did not ask for help. CNA 1 stated that resident 140 was restless at times and moaned, but was unable to express a pain level verbally. On 4/24/19 at 1:10 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 140 was withdrawn the past few days, but occasionally woke up active and combative. RN 1 stated that resident 140 was non-verbal and did not ask for pain medication. On 4/24/19 at 1:20 PM, an interview was conducted with RN 2. RN 2 stated that resident 140 thrashed around in bed. RN 2 stated that she identified resident 140 as having discomfort when he showed signs of anxiety and believed that resident 140 had pain when he was moving around in his bed. RN 2 stated that resident 140 was not able to verbally express pain or discomfort. RN 2 stated that resident 140 had spoken a week ago, but he's not cognitive enough for communication. RN 2 stated that nurses utilized a PAINAID scale for pain for non-verbal residents. RN 2 stated that resident 140 had some grimacing, restlessness, and other signs of pain. On 4/24/19 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MAR indicated [REDACTED]. The DON checked the nurses' narcotic signed sheet which also revealed that resident 140 had not received narcotic pain medication.

Based on observation, interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 26 medication opportunities, on 4/24/19, revealed two medication errors which resulted in a 7% medication error rate. Specifically, one resident had the wrong dose of a medication that resulted in the medication not being administered and another medication was administered that was unlabelled. Resident identifier: 139. Findings include: Resident 139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/24/19 at 8:05 AM, Registered Nurse (RN) 2 was observed to administer medications to resident 139. RN 2 was observed to administer a medication from a small, unlabelled cup in the nurse's cart. RN 2 retrieved a card of [MEDICATION NAME], 25 mg (milligram) from the medication cart. RN 2 identified that resident 139 should have a card with 10 mg [MEDICATION NAME], so RN 2 did not administer the 25 mg tablet. On 4/24/19, resident 139's medical record was reviewed for the reconciliation of medications. Resident 139's systolic blood pressure on 4/24/19 was 156 mm Hg (millimeters of mercury). Normal systolic blood pressure would have been less than 140. According to physician's orders [REDACTED]. On 4/24/19 at 8:05 AM, RN 2 was interviewed. RN 2 stated that she knew that the unlabelled medication in the cup was 100 mg [MEDICATION NAME]. RN 2 stated that she did not have the bottle of medication because it was a very large bottle and RN 2 did not have room for it on her medication cart. RN 2 stated that the [MEDICATION NAME] was held because it was the wrong dose. A review of resident 139's physician's orders [REDACTED]. On 4/24/19 at 11:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 139's [MEDICATION NAME] was ordered for morning administration, and therefore should have been administered between 6:00 AM and 10:00 AM. The DON stated that the correct dose was ordered through the pharmacy but was not available during morning medication pass. The DON stated that the nurse should not have administered a medication that was unlabelled.

Based on interview and record review it was determined, for 2 of 19 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, resident experienced falls and the care plans were not updated. Resident identifiers: 5 and 89. Findings include: 1. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 4/24/19. On 4/10/19 at 12:47 PM a nursing progress note revealed, At 1130, he was found lying on floor calling loudly. Stated he had gotten up to go to the bathroom to have a BM (bowel movement) and did not use call bell to request for assistance. He was able to move all extremities while lying on the ground. Head examined and no lacerations or areas of swelling. Resident 5's care plan was created on 4/22/19 and revealed Has had an actual fall with No Injury r/t (related to) Poor Balance, Unsteady gait. The goal developed was, Will resume usual activities without further incident through the review date. The interventions developed were, Continue interventions on the at-risk plan. Remind patient to use call light to ask for help. On 4/24/19 at 12:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after each fall the care plan should be updated by the nurse. The DON stated that the care plans were not updated after the fall on 4/10/19. 2. Resident 89 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 89's medical record was reviewed on 4/24/19. Resident 89's nursing progress note dated 4/16/19 at 12:34 PM revealed, Fall Committee IDT (interdisciplinary team) . Follow-up from fall on 04/15/2019 1330 (1:30 PM)- Cna (Certified Nursing Assistant) observed resident on floor next to wardrobe when entering room. Cna called nurse to residents room. Upon entering room nurse observed resident on the floor at the foot of the bed next to the wardrobe. When asked what happened resident stated that she 'had gotten out of bed and was walking towards the wardrobe when her right knee gave out and she fell to the floor'. The resident upon assessment was leaning her left side against the bed and her left leg was facing the direction of the wardrobe with her right leg bent at the knee and her right foot under her left thigh. Resident stated that she did not hit her head but did hit her knee. She denied any pain to her knee, no redness, bruising or swelling noted to her right knee, but did think she twisted her right ankle. Resident denied any pain except for her right ankle. She had full ROM (range of motion) to all extremities. Resident was assisted back to bed by staff and further assessment of Right ankle done. Resident had full ROM in right ankle and no pain with flexion or extension of right foot. There was no bruising at the time of assessment but outer ankle did have slight swelling. MD (Medical Doctor) was notified and portable x-ray done at 1400 (2:00 PM). Therapy placed ace wrap to right ankle. Right ankle was elevated and continued to use ice packs. At 2145 (9:45 PM) X-Ray results back distal tib (Tibial)--fib (Fibula) fracture. N[NAME] (night) nurse notified Resident and NP (Nurse Practitioner) of X-Ray results. Resident was sent to ER (emergency room ) for further evaluation. Daughter stated that her mother was not a good candidate for surgical interventions due to she has 'brittle bones' Resident has osteopenia and had a bone density test last (MONTH) with results indicating 'High risk for insufficiency fracture.' A care plan dated 3/27/19 revealed, At risk for falls r/t (SPECIFY). The goal developed was, Will not sustain serious injury through the review date. The interventions developed on 3/27/19 included, Be sure the call light is within reach and encourage to use it to call for assistance as needed. Bed in lowest position. Ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c (wheelchair). Maintain a clear pathway, free of obstacles. Needs a safe environment: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. On 4/24/19 at 12:39 PM, an interview was conducted with the DON. The DON stated that fall care plan had not been updated after resident 89 sustained a fall on 4/15/19 or when resident 89 returned from the hospital on [DATE].

Based on interview and record review it was determined for 1 of 6 sample residents, that the facility did not provide services by qualified persons in accordance with each resident's written plan of care. Specifically, a nurses note revealed not to leave a resident alone in the bathroom and resident sustained [REDACTED]. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 6/14/18. Resident 1's progress notes revealed the following entries: a. 2/28/18, (Resident 1) is legally blind and can not see call light string in bathroom and do to her height she is unable to sit on the toilet and have her feet touch the ground. Put a note on pt (patient) door in bathroom not to leave alone in bathroom. Also got (Resident 1) a stool that goes around the toilet so she can rest her feet on there when using the toilet. b. 3/15/18 at 6:34 AM, Pt's son (name removed) was informed of his mothers stable condition s/p (status [REDACTED]. Pt is alert and oriented and has tenderness to her L (left) hand, with full ROM (range of motion). Pt states she will take pain meds (medications) with her other pills, .Pt continues to be monitored. c. On 3/15/18 at 8:04 PM, Patient appeared alert and oriented through out the day, but did not want to participate in therapy today because she had showed no acute abnormalities. We have all made clear to our co-workers that patient must not be left alone in the bathroom at any time. The goose egg on her L forehead is quite bruised down to her eye. Have been monitoring her pain and keeping her comfortable and monitoring call lights. An incident report dated 3/15/18 and revised on 3/26/18 revealed, Pt was assisted to the restroom by CNA (Certified Nursing Assistant). While sitting alone on the toilet the pt states she blacked out and ended up on the floor. The CNA herd the pt calling out for help and found pt on her L side in fetal position on the floor in front of the toilet. 3 PA (person assistance) helped pt to w/c (wheelchair) and then to bed. Further assessment displayed skin tear, 1 inch, to L knee. Skin tear, half inch, to L wrist lateral side. Hematoma (goose egg) (sic) to L forehead, above brow. Pt's neuros (neurological examination) checked out wnl (within normal limits) and pt stated she wanted to miss therapy today but didn't want to go to the hospital. She said her head hit the wall on the way to the floor and her wrist caught the garbage can and her L knee broke her fall on the floor. L hip appears to have no further injury noted.Neuro checks and VS (vital signs) as dir (directed). The Immediate Action Taken revealed, Pt was quickly assessed, then 3 persons assisted pt off floor to w/c and stand pivot to bed. Further assessment made, VS and neuro checks taken as dir. A care plan dated 2/24/18 revealed a Focus of At risk for falls r/t (related to) L THA (total hip arthroplasty) and hx (history) of falls at home. The goal developed was Will not sustain serious injury through the review date. A few interventions developed were, Be sure the call light is within reach and encourage to use it to call for assistance as needed and ensure resident is wearing appropriate footwear when ambulating or wheeling in w/c. On 6/14/18 at 11:10 AM, an interview was conducted with the Assistant Director of Nursing (ADON) and Assistant Administrator (AA). The ADON and AA stated that staff brought resident 1 a stool to put her feet on while using the toilet. The ADON stated resident was to not be alone on the toilet according to the nurses note. The ADON stated that maybe CNA figured resident 1 was fine to be left alone on the toilet since she had a stool for her feet. There was no additional information provided.