Every finding on record at Crestview Healthcare and Rehabilitation

S483.80 Infection Control Based on observation, interview, record review, and facility policy review, the facility failed to 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 for 1 of 5 residents sampled for transmission-based precautions, Resident (R) 38. The findings include: Review of the facility policy, Infection Prevention and Control Program, revised 03/14/2024, revealed the facility was to maintain an environment that prevented transmission of infections. Further review revealed residents with an infection were to be placed in transmission-based precautions. Review of the facility sign Contact Precautions, not dated, revealed staff were required to wear protective gowns and gloves prior to entering the resident's room. Review of R38's Resident Face Sheet revealed the facility admitted the resident on 08/05/2022 and R38's diagnoses included Alzheimer's disease and extended spectrum beta lactamase (ESBL) resistance (an antibiotic resistant infection). Review of R38's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/2024 revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) of three out of 15, indicating the resident was severely cognitively impaired. Further review revealed the facility assessed the resident as having a multi-drug resistant organism (MDRO). Review of R38's Care Plan, dated 09/29/2024, revealed the facility identified R38 as requiring contact isolation for ESBL in her urine and included the intervention for nursing staff to follow isolation precautions. Observation on 10/01/2024 at 9:12 AM revealed R38 was lying in bed, yelling for staff to help her get up for the day. Per observation, Certified Nurse Aide (CNA) 2 and CNA3 entered R38's room without donning gowns that were hanging in a container on the resident's door. Further observation revealed the CNAs closed R38's door, and again failed to don (put on) gowns. Continued observation at 9:21 AM revealed CNA3 exited R38's room with a bag of soiled linens and trash, but no personal protective equipment (PPE) in the trash bag. Additional observation revealed signage for contact precautions hanging on the resident's door that described the need for staff to don gowns and gloves prior to entering the resident's room. In an immediate interview on 10/01/2024 at 9:21 AM, CNA3 stated she did not notice the transmission-based precautions sign on R38's door and was not familiar with the resident, since she normally did not work this hallway. In further interview, CNA3 stated staff did not need to wear PPE in R38's room unless they touched the resident. CNA3 continued to state that she should have worn a gown because getting a resident up and changing dirty linens was a high contact care activity. In an interview on 10/03/2024 at 12:30 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated R38 was in contact precautions due to a urinary tract infection with ESBL (extended-spectrum beta-lactamase, an antibiotic resistant organism). The ADON/IP further stated staff should have worn gowns and gloves when assisting R38 to get out of bed. In continued interview, the ADON/IP stated she educated staff upon hire and at least annually about what PPE they needed to wear with each type of transmission-based precautions. In an interview on 10/03/2024 at 1:32 PM, the Director of Nursing (DON) stated her expectations were for staff to wear PPE including gowns and gloves when providing any care for a resident in contact precautions. She stated CNAs should have worn gowns and gloves when assisting R38 to get out of bed for the day. In an interview on 10/03/2024 at 2:43 PM, the Administrator stated he expected staff to follow signage on resident doors for transmission-based precautions.

Based on observation, interview, record review and policy review it was determined the facility failed to ensure resident's smoking care plan interventions were implemented for one (1) of thirty-two (32) sampled residents, Resident #44. The findings include: Review of the facility policy titled, Smoking, revised 07/24/18, revealed the facility advocated for a smoke free facility. However, at the same time recognized that smoking was prevalent among certain populations and geographic areas they served. For those centers that allowed smoking, smoking would only be allowed in designated areas. Residents who smoked and were in the center before the effective date would be permitted to continue to smoke in designated areas only. The admissions staff would explain the smoke free policy to residents and their families. Failure to comply with the policy could result in initiation of a discharge plan. Residents would be assessed for safe smoking and re-evaluated quarterly and with a change in condition. A resident's smoking status such as independent, supervised, or not permitted would be documented on the care plan. The care plan would be updated as necessary. Smoking supplies including but not limited to tobacco, matches, lighters, lighter fluid, etc. would be labeled with the resident's name, room number, maintained by staff and stored in a suitable cabinet kept at the nursing station. If the resident was cognitively and physically able to secure all smoking materials, the center may allow him/her to maintain his/her own tobacco products in a locked compartment. Residents would not be allowed to maintain their own lighter, lighter fluid or matches. It may be necessary to counsel residents or responsible parties who violate the smoking policy. Such action would be documented in the medical record. Review of clinical record revealed the facility admitted Resident #44 on 03/18/18 with [DIAGNOSES REDACTED]. Review of Resident #44's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility conducted a Brief Interview for Mental Status and the resident scored a ten (10) out of fifteen (15) indicating the resident was interviewable. Review of Resident #44's Comprehensive Care Plan related to Smoking Independently, dated 05/16/18, revealed the Goal was for the resident to smoke safely through the target date of 09/12/19. The interventions directed the staff to educate the resident on the facility's smoking policy, to ensure the resident returned their smoking material to the nurse upon re-entry to the building and to monitor resident's compliance with smoking policy. Interview with Resident #44, on 09/17/19 at 11:49 AM, revealed he/she smoked unsupervised whenever he/she desired. Resident #44 showed this surveyor a lighter and cigarettes that he/she kept on their person and stated his/her son provided them. Observation of Resident #44, on 09/17/19 at 3:25 PM, revealed the resident outside the building, near the 100 Unit Hall door with no staff present. The resident was smoking a cigarette then extinguished it into a receptacle. Observation of Resident #44, on 09/18/19 at 10:03 AM, revealed the resident exited through the backdoor of the facility, which led to courtyard area. Observation of the courtyard area revealed no staff present. Resident #44 obtained a pack of cigarettes and a lighter from his/her belongings and lit the cigarette. Observation of Resident #44, on 09/20/19 at 9:29 AM, revealed the resident smoking in the courtyard. Interview with Registered Nurse (RN) #2, on 09/20/19 at 9:34 AM, revealed the facility was a non-smoking facility, but some resident's were grandfathered in and allowed to smoke. She stated nursing staff conducted quarterly smoking evaluations, for those that smoked and the evaluation directed staff to educate the resident on the smoking policy. She stated the resident was required to sign the evaluation acknowledging they would abide by the policy. Review of Resident #44's clinical record with RN #2, revealed Resident #44's smoking evaluations dated, 01/29/19 and 04/29/19, were not signed by the resident. Continued interview revealed residents were not allowed to keep their smoking materials on their person, but at the nurses station, per the plan of care and policy. However, the smoking materials were not locked/secured at the nurses station and resident's could obtain at their leisure. She stated the facility did not have a mechanism in place to ensure Resident #44's smoking care plan interventions and facility policy was implemented consistently by staff. She stated if residents smoking care plan interventions were not followed other resident's could obtain items,[MEDICAL CONDITION] harm could occur. Interview with the Front Hall Unit Manager (UM), at 9:59 AM on 09/20/19, revealed Resident #44 was the only smoking resident in the facility, due to being grandfathered in, after the facility went smoke-free. She stated residents that smoked were assessed quarterly to determine if they were safe to smoke unsupervised. The UM stated the smoking materials were to be kept at the nursing station, however they were not locked up to ensure resident safety. She stated the smoking care plan directed staff to educate the resident on the smoking policy. She stated Resident #44's smoking care plan was not being followed in regards to the securing of the resident's smoking material. The Unit Manager also stated no audits were being conducted nor a system put in place to ensure the implementation of the care plan or policy. She stated the smoking care plan and policy should be followed to ensure resident safety. Interview with the Center Nurse Executive (CNE), 09/20/19 at 11:23 AM, revealed she expected staff to implement the smoking policy and care plan interventions for residents. She stated she expected staff to keep smoking materials secured per the policy and care plan to ensure resident safety. She stated staff should monitor residents to ensure they smoked safely and in the designated smoking area. However, she did not nor did she have others conduct audits to determine if care plan interventions or the smoking policy was being followed. The CNE stated if staff did not follow the policy or care plan interventions residents could be harmed. Interview with the Center Executive, on 09/20/19 at 11:49 AM, revealed residents were not to have smoking material on their person and he was not aware Resident #44 had a lighter and cigarettes on their person. He stated he did not have audits to validate staff implementing smoking care plan or the policy. He stated his responsibility was to ensure resident safety and staff followed facility policy and procedure.

Based on observation, interview, record review and review of the policy it was determine the facility failed to ensure the smoking policy was implemented to prevent accidents or hazards for one (1) of thirty-two (32) sampled residents, Resident #44. The findings include: Review of the facility policy titled, Smoking, revised 07/24/18, revealed the facility advocated for a smoke free facility. However, at the same time recognized that smoking was prevalent among certain populations and geographic areas they served. For those centers that allowed smoking, smoking would only be allowed in designated areas. Residents who smoked and were in the center before the effective date would be permitted to continue to smoke in designated areas only. The admissions staff would explain the smoke free policy to residents and their families. Failure to comply with the policy could result in initiation of a discharge plan. A resident's smoking status such as independent, supervised, or not permitted would be documented on the care plan. Smoking supplies including but not limited to tobacco, matches, lighters, lighter fluid, etc. would be labeled with the resident's name, room number, maintained by staff and stored in a suitable cabinet kept at the nursing station. If the resident was cognitively and physically able to secure all smoking materials, the center may allow him/her to maintain his/her own tobacco products in a locked compartment. Residents would not be allowed to maintain their own lighter, lighter fluid or matches. It may be necessary to counsel residents or responsible parties who violate the smoking policy. Such action would be documented in the medical record. Review of clinical record revealed the facility admitted Resident #44 on 03/18/18 with [DIAGNOSES REDACTED]. Review of Resident #44's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility conducted a Brief Interview for Mental Status and the resident scored a ten (10) out of fifteen (15) indicating the resident was interviewable. Review of Resident #44's Comprehensive Care Plan related to Smoking Independently, dated 05/16/18, revealed the Goal was for the resident to smoke safely through the target date of 09/12/19. The interventions directed the staff to educate the resident on the facility's smoking policy, to ensure the resident returned their smoking material to the nurse upon re-entry to the building and to monitor resident's compliance with smoking policy. Interview on 09/17/19 at 11:49 AM, with Resident #44, revealed he/she smoked unsupervised whenever he/she desired. Resident #44 showed this surveyor a lighter and cigarettes that he/she kept on their person and stated his/her son provided them. Observation of Resident #44, on 09/17/19 at 3:25 PM, revealed the resident was outside smoking a cigarette then extinguished it into a receptacle. Observation on 09/18/19 at 10:03 AM, of Resident #44, revealed the resident exited through the backdoor of the facility, which led to courtyard area. Observation of the courtyard area revealed no staff present. Resident #44 obtained a pack of cigarettes and a lighter from his/her belongings and lit the cigarette. On 09/20/19 at 9:29 AM, Resident #44 was observed smoking in the courtyard. Interview on 09/20/19 at 9:34 AM, with Registered Nurse (RN) #2, revealed the facility was a non-smoking facility and Resident #44 was grandfathered in and allowed to smoke. She stated nursing staff assessed Resident #44 quarterly for smoking safety and to educate the resident on the facility smoking policy. She stated the resident was required to sign the evaluation acknowledging they would abide by the policy. Review of Resident #44's clinical record with RN #2, revealed Resident #44's smoking evaluations dated, 01/29/19 and 04/29/19, were not signed by the resident. Continued interview with RN #2, revealed Resident #44 was not allowed to keep smoking materials on their person. Instead the smoking material were to be secured at the nurses station, per the facility policy. However, the smoking materials were not locked/secured at the nurses station and the resident could obtain at their leisure. She stated the facility did not have a mechanism in place to ensure the facility policy was implemented consistently by staff. She stated if the smoking policy was not followed other resident's could obtain items,[MEDICAL CONDITION] harm could occur. Interview at 9:59 AM on 09/20/19, with the Front Hall Unit Manager (UM), revealed Resident #44 was the only smoking resident in the facility, due to being grandfathered in, after the facility went smoke-free. She stated residents that smoked were assessed quarterly and at that time educated on the facility's smoking policy. The UM stated the smoking materials were to be kept at the nursing station, however they were not locked up to ensure resident safety. The Unit Manager stated no audits were being conducted nor a system put in place to ensure the smoking policy was implemented by staff. She stated the smoking policy should be followed to ensure resident safety. Interview on 09/20/19 at 11:23 AM, with the Center Nurse Executive (CNE), revealed she expected staff to implement the smoking policy. She stated she expected staff to keep smoking materials secured per the policy to ensure resident safety. She stated staff should monitor residents to ensure they smoked safely and in the designated smoking area. However, she did not nor did she have others conduct audits to determine if the smoking policy was being followed. The CNE stated if staff did not follow the policy residents could be harmed. Interview on 09/20/19 at 11:49 AM, with the Center Executive, revealed residents were not to have smoking material on their person and he was not aware Resident #44 had a lighter and cigarettes on their person. He stated he did not have audits to validate staff implementing smoking policy. He stated his responsibility was to ensure resident safety and staff followed facility policy and procedure.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to store, distribute, and serve food in a sanitary manner. Observations revealed undated food in the refrigerator and staff did not perform hand hygiene or change contaminated gloves during meal service. In addition, trashcans located in the kitchen did not have lids. The findings include: Review of the facility's policy, Handwashing, revised 03/16/15, revealed the purpose of handwashing was to minimize the spread of disease. Handwashing was performed after touching hair, ears, nose, or mouth, and when moving from one task to another. Furthermore, use of disposable gloves did not replace proper handwashing. Review of the facility's policy, Food Handling, revised 05/07/17, revealed food was prepped with minimum handling. No bare hand contact with food was allowed. Employees were to wash hands frequently and wear disposable gloves when handling food. Disposable gloves were considered a single use item and changed after each use. All temperatures for safe food must be maintained. An internal temperature of cold foods was forty-one (41) degrees or lower and must be used or discarded at a maximum of seven (7) days. Foods in dry storage were in closed, labeled, and dated containers. For products that had been opened but not fully used, a use by date was included on the label. Observation of the kitchen, on 05/08/17 at 6:05 PM, revealed the refrigerator contained a metal bin with a lettuce type mix. The bin was uncovered, the mix was wilted, and no date was on the bin. There was an open plastic container marked sour cream that did not have an open date. In addition, there was a plastic container the Dietary Cook identified as ham salad partially covered with clear wrap with brown liquid splattered on the ham salad and on the clear wrap. The ham salad did not have a prepared and use by date label. Further observation of the kitchen revealed a metal round tray on a table the Dietary Cook identified as tuna fish sandwiches that were wrapped and not labeled with a prepared date and time. Observation of the kitchen, on 05/08/17 at 6:15 PM, revealed seventeen (17) of twenty-three (23) spice containers opened and not dated. Some spice containers had dark brown and greasy sediment on the sides of the containers. Observation of the 100 Hall, on 05/09/17 at 11:29 AM, revealed Certified Nursing Assistant (CNA) #2 exited resident room 103 and entered resident room 104 and assisted in opening the resident's ice cream and moved an over the bed table. Without performing hand hygiene, CNA #2 served a plate of food to the resident in room 105, moved the resident's walker, and then delivered a plate of food to the resident in room 106 without first performing hand hygiene. CNA #2 obtained a plate of food, with the CNA's thumb wrapped around onto the top of the plate, and delivered it to resident room 109. CNA #2 delivered a plate of food to resident room 110, placed it on an over the bed table, repositioned the resident with bare hands, retrieved a white towel from the sink and placed it under the resident's chin, and repositioned the resident again. CNA #2 left the room without washing or sanitizing hands and delivered a plate of food to resident room 112. CNA #2 continued with delivering plates of food to residents without performing hand hygiene between residents. Observation, on 05/09/17 at 11:56 AM, revealed CNA #2 delivered a plate of food to a resident in the restorative dining room by the front hall nurses' station. CNA #2 picked up the resident's sandwich and cut the sandwich in half with bare hands. CNA #2 did not sanitize or wash hands prior to touching the resident's food. Interview with CNA #2, on 05/09/17 at 2:00 PM, revealed the CNA assisted with passing meals daily. CNA #2 stated staff should use hand sanitizer after passing each tray or plate of food. According to CNA #2, staff should never handle food with bare hands. CNA #2 revealed residents could catch germs and become sick if staff did not clean hands. Interview with the Dietary Aide (DA), on 05/10/17 at 9:41 AM, revealed when passing trays, staff were to remove gloves, sanitize hands, and don new gloves. The DA further stated staff never handled food with bare hands. The DA stated staff sanitized hands frequently to prevent spreading infection to the residents. Observation, on 05/11/17 at 8:21 AM, revealed the Nutritional Services Director (NSD) handing out plates of food from the mobile steam table. A resident pointed to the NSD beard restraint and asked him what he was wearing. The NSD pulled off the beard restraint with his gloved hands, touched his beard and face, and stated he wore it to cover up his beard. He put the beard restraint back in place, did not change his gloves, grabbed a plate from the mobile steam cart, plated food, and handed it to a CNA who delivered it to a resident's room. Further observation, on 05/11/17 at 11:19 AM, revealed the NSD obtaining the temperature of food items for the lunch meal with gloved hands. The NSD went to the employee sink, turned the faucet on and off, touching the handles with gloved hands. The NSD resumed taking food temperatures without removing gloves or sanitizing hands after touching the faucet handles. Review of the facility's manual, Mobile Steam Table Training Manual, not dated, revealed the cook follows the mobile steam table down the hall, careful not to contaminate their hands by only touching serving utensils and properly handling plates. The manual suggested a CNA or designee push the steam table down the hall and to the next destination, plugging and unplugging the steam table to the electrical outlet. Observation, on 05/09/17 at 11:29 AM, revealed the NSD pushing a mobile steam table down the 100 hallway while wearing gloves. He grabbed the cord to the mobile steam table, which had dust visibly on it, and plugged the cord into the wall outlet. Without changing gloves, he opened a loaf of bread, took a plate off the steam table shelf, took a slice of bread from the bag, and placed it on the plate. He scooped meat out of the warmer, placed it onto the slice of bread, and handed the plate to Certified Nursing Assistant (CNA) #2. While wearing the same pair of gloves, he served two (2) additional residents. Observation, on 05/09/17 at 12:18 PM, revealed the NSD pushed a mobile steam table down the 300 hallway while wearing gloves. He grabbed the cord to the mobile steam table and plugged the cord into the wall outlet. Without changing gloves, he reached into a steam table drawer containing ice and ice cream cups, put his hand in the ice, pulled out an ice cream cup, took the lid off the ice cream, and handed it to a CNA. He grabbed a plate out of the steam table cart, reached into the bread bag and pulled out a slice of bread, and placed in on the plate. While wearing the same gloves, he served four (4) additional residents. Observation of the kitchen, on 05/10/17 at 8:50 AM, revealed a large metal mixing bowl facing upward and multiple other open containers placed under the area of the metal receiving table. On top of the receiving table sat washed dishes from the dishwasher dripping water onto the table. The metal table had water and white/dark sediment pooled on it and the large metal mixing bowl contained water and floating white material in the bottom of the bowl. Interview with the Dietary Aide, on 5/11/17 at 9:04 AM, revealed the mixing bowls under the wet receiving table for washed dishes had always been the storage place for the large mixing bowls and other large containers. Observation, on 05/11/17 at 12:45 PM, revealed the temperature of coleslaw on a test tray, after completion of meal pass for residents, was forty-five (45) degrees. Interview with the Nutritional Services Director (NSD), on 05/11/17 at 12:45 PM, revealed the mobile steam table did not have a cold drawer to keep temperatures forty-one (41) degrees or below for cold foods. The NSD stated he had two (2) weeks of training at another facility. He was also required to review video training, which he had not completed. The NSD stated he was aware and had read the Infection Control policy for Dietary Services. The NSD stated he had not read or reviewed the Mobile Steam Table Training Manual. The NSD further stated changing gloves and washing hands was a must and the most important aspect for kitchen staff to follow. NSD further stated dating was important for open or prepared foods so a food borne illness did not occur in the facility. Interview with the Senior Regional Float Dietary Director (SRFDD), on 05/11/17 at 2:05 PM, revealed staff was to change gloves if tasks changed or if a surface was touched outside the area of the steam table during food service. The SRFDD stated staff preparing food at the mobile steam table only handled food and plates and did not leave the cart. The food assistant or the CNA handled all other activities; including plugging and unplugging the electrical cord into the wall. The SRFDD stated cross contamination could cause a food borne illness causing a resident to get sick and pass away. The SRFDD stated the residents were at higher risk of infection due to their immune systems being weak. Interview with the Director of Nursing (DON), on 05/11/17 at 2:50 PM, revealed sanitary conditions were important in dietary because of the chance of [MEDICAL CONDITION] spreading to the residents that could make the residents sick. The DON stated proper gloving and hand cleaning was important for the facility for the prevention of infection. The DON further stated foods opened or prepared were to have a date open and use by date so the facility knew when to discard the food. She revealed discarding the food by the use by date prevented food illnesses. Review of the facility's policy, Department Sanitation, dated 10/01/15, revealed trashcans were covered with a lid. Observation of the kitchen, on 05/08/17 at 6:01 PM, revealed two (2) garbage cans in the kitchen. One (1) can was at the door entrance from the dining hall. A second can was in the dishwashing area next to the rinse tub. Both garbage cans did not have lids. Interview with the Nutritional Services Director (NSD), on 05/11/17 at 12:45 PM, revealed lids were to stay on the garbage cans so flies/insects and rodents did not come into the facility.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to notify the physician when the resident had a change in condition for one (1) of fourteen (14) sampled residents, Resident #1. The findings include: Review of the facility's policy, Physician/Advanced Practice Nurse (APRN)/Physician Assistant (PA) Notification, dated 03/15/16, revealed when a patient had a change of condition or abnormal lab values, a licensed nurse would perform appropriate clinical observations and data collection, and report to the physician/mid-level provider. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/17/16, with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, revised 11/21/16, revealed the facility managed the resident's [MEDICAL CONDITION] by staff notifying the physician of a temperature greater than 99.0 degrees Fahrenheit. The facility monitored for risk of dehydration by staff monitoring for signs/symptoms of dehydration including increased temperature, decreased urine output, mental status changes, dry mucous membranes, orthostatic [MEDICAL CONDITION] (low blood pressure), and [MEDICAL CONDITION](fast heart rate). Revision of the Care Plan on 02/22/17, revealed the resident [MEDICAL CONDITION] of the coccyx with treatment of [REDACTED]. Review of Resident #1's Progress Notes, dated 03/17/17 at 12:00 AM, revealed Resident #1 had complained of being cold and was shivering. Resident #1's oral temperature was 102.3 degrees Fahrenheit with a heart rate of 118. Tylenol was administered and Resident #1 would be monitored. Staff documented that a note would be left for the doctor in the morning. Further review revealed at 3:13 AM, Resident #1 stated he/she felt better and Resident #1's temperature was down one (1) degree at 101.3. On 03/17/17 at 1:34 PM, the Nurse Practitioner assessed Resident #1. Further review revealed on 03/18/17 at 1:34 PM, the facility sent Resident #1 to the hospital for evaluation and the resident returned to the facility with a [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #1, on 05/10/17 at 2:20 PM, revealed staff notified the provider when a resident had a change in condition including an increase in temperature or when there was a medical or mental change, whether it was daytime or nighttime. The RN further stated if the resident took a turn for the worse and it could have been prevented, then the nurse was not doing his/her job. Interview with RN #3, on 05/10/17 10:45 AM, revealed a temperature over 99.0 degrees should be reported to the provider. RN #3 stated a spike in temperature meant an underlying condition could exist. RN #3 further stated a provider was on call day and night and leaving a message for the provider when he/she arrived to the unit was not appropriate. Interview with the Director of Nursing, on 05/11/17 at 11:10 AM, revealed a resident temperature over 99.0 degrees should be called to the provider immediately after a full assessment was completed. She stated not notifying the provider could cause the resident to decline and cause the resident to have to go to the emergency room for evaluation.

Based on interview, record review, and facility policy review, it was determined the facility failed to follow the comprehensive care plan for one (1) of fourteen (14) sampled residents, Resident #1, when staff failed to notify the resident's physician when the resident had a change in condition as stated on the care plan. The findings include: Review of the facility's policy, Person-Centered Care Plan, dated 11/28/16, revealed the purpose of the care plan was to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan promoted positive communication between the team to optimize the residents' clinical outcomes. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/17/16, with [DIAGNOSES REDACTED]. The facility readmitted the resident on 02/22/17, with a [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan, dated 11/20/16, revealed the resident was monitored for [MEDICAL CONDITION] and interventions included staff notifying the physician of a temperature greater than ninety-nine (99) degrees Fahrenheit. The facility monitored for risk of dehydration by staff monitoring for signs/symptoms of dehydration including increased temperature, decreased urine output, mental status changes, dry mucous membranes, orthostatic [MEDICAL CONDITION] (low blood pressure), and [MEDICAL CONDITION](fast heart rate). Revision of the Care Plan on 02/22/17, revealed the resident [MEDICAL CONDITION] of the coccyx with treatment of [REDACTED]. Continued review of Resident #1's clinical record revealed on 03/17/17 at 12:10 AM, staff documented an oral temperature of 102.3 degree Fahrenheit. Further review revealed at 1:05 AM, staff documented the resident's temperature was 101.3 degree Fahrenheit. Review of Resident #1's Progress Notes, dated 03/17/17 at 12:10 AM, revealed Resident #1 complained of shivering. Staff obtained vital signs with a noted temperature of 102.3 degrees orally and a heart rate of 118 beats per minute. Further review revealed staff administered Tylenol and documented a note would be left for the physician in the morning. Continued review revealed at 3:13 AM, the resident felt better, no shivering noted, and the resident's temperature had gone down one (1) degree to 101.3. At 1:34 PM, the Nurse Practitioner assessed the resident. On 03/18/17, the facility sent the resident to the emergency room for evaluation and treatment and the resident returned to the facility with a [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #3, on 05/10/17 at 10:45 AM, revealed the facility implemented care plans for each resident in order to achieve the highest level of function for the resident. RN #3 stated any time a resident had a change in condition, including a temperature, staff needed to notify the physician. RN #3 stated care plans were completed with interventions to follow standards of care. RN #3 further stated late notification to a physician was unacceptable and leaving a message for in the morning was an inappropriate practice. Interview with RN #1, on 05/10/17 at 2:20 PM, revealed if the care plan stated to call the physician for a condition change or a temperature, then staff should call the physician. Interview with the Director of Nursing, on 05/10/17 at 11:10 AM, revealed staff did not follow the care plan if the intervention was to notify the physician if the resident's temperature was 99.0 degrees and staff did not notify the physician at the time of the change in condition. She further stated not following the care plan when there were set parameters on the care plan could lead to death.

Based on observation, interview, and record review, it was determined the facility failed to maintain effective infection control practices for two (2) of the fourteen (14) sampled residents, Resident #1 and #2, and one (1) unsampled resident, Unsampled Resident A. Observations revealed staff failed to perform hand hygiene during Resident #1's wound care, failed to clean the table used to hold supplies for Resident #2's dressing change, and Unsampled Resident A walked about the facility with a visibly soiled dressing. The findings include: Review of the facility's Infection Prevention and Control Program Description policy, revised 11/28/16, revealed it was a comprehensive process that addressed preventing, identifying, reporting, investigating, and controlling infections. The implementing of control measures and precautions included such basics as hand hygiene, standard and transmission based precautions, and cleaning/disinfecting equipment. Review of the facility's policy, Wound Dressings, reviewed 03/01/16, revealed wound dressings were performed using aseptic techniques to decrease the risk of wound contamination and cross-contamination during dressing changes. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/17/16, with the [DIAGNOSES REDACTED]. Review of Resident #1's Physician Orders, dated 04/21/17, revealed the physician ordered the coccyx cleaned with wound cleanser, packed with [MEDICATION NAME] AG, and then covered with [MEDICATION NAME]/dry dressing daily. In addition, the left hip wound cleaned with wound cleanser, apply [MEDICATION NAME], and then cover with dry dressing daily. Observation of Resident #1's wound care to the coccyx and hip, on 05/11/17 at 10:24 AM, revealed Registered Nurse (RN) #2 gathered supplies and placed them on a table, touched underneath the table with gloved hands, and then measured the resident's coccyx wound. RN #2 removed her gloves, left the area to gather more supplies, and without performing hand hygiene, donned new gloves and proceeded with cleansing the wound. After RN #2 completed wound care to the coccyx, she changed gloves and removed the dressing on the left hip; however, RN #2 did not perform hand hygiene prior to donning new gloves. After completing wound care to the hip, RN #2 completed the resident's skin assessment without changing gloves and performing hand hygiene. Using the same gloves, RN #2 applied a skin prep to the resident's left heel. In addition, RN #2 disposed the soiled wound dressings in Resident #1's bedside trash bag and did not remove the bag after wound care was completed. Further observation revealed after the wound care, RN #2 exited the room without washing her hands and pushed the treatment cart to the nurses' station and washed her hands at the nurses' station sink. Interview with RN #2, on 05/11/17 at 11:02 AM, revealed during wound care, staff washed or sanitized hands after each glove change to prevent the spread of bacteria. RN #2 stated residents with poor immune systems may not be able to fight off an infection and were at a higher risk of becoming septic. RN #2 further stated staff should place soiled wound dressings in a red biohazard bag and take the bag to the biohazard room for disposal after completion of wound care. According to RN #2, leaving soiled dressings in Resident #1's room was an infection control issue because other residents and staff had an increased potential for getting the germs from the soiled dressing and becoming ill. RN #2 stated not washing hands properly and touching surfaces could cause surfaces to become infected with Resident #1's bacteria and cause other residents and staff to become sick. Interview with the Director of Nursing (DON), on 05/11/17 at 2:40 PM, revealed staff took soiled wound dressings to the biohazard room and disposed immediately after wound care was completed. The DON stated gloves were placed at the bedside during wound care to prevent placing germs on other surfaces in the facility. The DON further stated staff was to sanitize hands after every glove change. The DON further stated staff washed hands in the resident's room after completion of wound care to prevent the spread of infection. The DON revealed infection control provided good care for the residents. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 08/12/16, with [DIAGNOSES REDACTED]. Observation of Resident #2's dressing change, on 05/09/17 at 3:30 PM, revealed License Practical Nurse (LPN) #1 did not clean the table before laying the dressing supplies on it. After the dressing change was completed, LPN #1 did not clean the table. Interview with LPN #1, on 05/09/17 at 3:45 PM, revealed the table should have been cleaned before and after Resident #2's dressing change, but she was nervous and did not clean it. She further revealed it posed a risk for infection control. Interview with the DON, on 05/11/17 at 2:40 PM, revealed the table that supplies were placed upon should be cleaned before and after a dressing change to prevent cross contamination. 3. Observation of Unsampled Resident A, on 05/11/17 at 11:00 AM, revealed the resident ambulated to the receptionist desk, down the 200 Hall, and on to his/her room in the 300 Hall. The resident's left leg had a Kerlix bandage wrapped around the lower leg with yellowish brownish drainage visible. Unsampled Resident A stopped to converse with several residents and passed other residents and staff on the way back to his/her room. Review of Unsampled Resident A's clinical record revealed the facility admitted the resident on 02/17/15, with [DIAGNOSES REDACTED]. Review of Unsampled Resident A's Physician Order, dated 02/13/17, revealed an order to cleanse bilateral lower extremity wounds with wound cleaner, apply Vaseline gauze, and wrap with Kerlix. The dressing was to be done every three (3) days. Review of Unsampled Resident A's Care Plan, revised 02/23/17, revealed a focus area for complications of infection related to cellulitis to bilateral lower extremities. Review of Unsampled Resident A's skin integrity report, dated 05/05/17, revealed serosanguinous drainage present. Interview with RN #4, on 05/11/17 at 11:45 AM, revealed Unsampled Resident A's dressing was to be changed every three (3) days and was due to be changed that day (05/11/17). She stated she was not the usual nurse to do the dressing change but she changed his/her bandage because she saw it was visibly soiled. RN #4 revealed it was an infection control problem because the drainage was exposed on the bandage. She revealed there was no infection but the resident had cellulitis. She revealed the soiled bandage put other residents and staff at risk in coming in contact with the drainage on the bandage. Interview with the DON, on 05/11/17 at 2:40 PM, revealed if a bandage had drainage it could expose staff and other residents to possible infection and spread the infection.

Based on observation, interview and record review, it was determined the facility failed to ensure it was free of medication error rates of five percent or greater. Medication pass observations conducted on the morning of 02/25/15 resulted in the assessment of three (3) medication errors out of thirty-eight (38) opportunities, reflecting a medication error rate of 7.9 percent. The findings included: 1. Observation during the morning medication pass on the 300 Unit, on 02/25/15 at 8:20 AM, for Unsampled Resident A with [DIAGNOSES REDACTED]. Immediately following the observation of the administration of the six medications, a review of Unsampled Resident A's Medication Administration Record [REDACTED]. RN #1 stated she was sure she administered the medication (i..e., [MEDICATION NAME]); it was the second packet she removed from the resident's drawer. Following the observation, review of Unsampled Resident A's medication orders revealed the resident's order for the [MEDICATION NAME] 10 mg. had been initiated on 01/18/15. Observation, at 2:50 PM on 02/25/15, during inspection of the medication cart for Unit 300 revealed Resident A's medication supply included a blister pack of [MEDICATION NAME] 10 mg., designated as Rx 287, dated 02/18/15 and which had originally contained a total of 30 tablets. Further inspection of the pack revealed seven (7) tablets had thusfar been removed from the pack. However, further review of the resident's MAR indicated [REDACTED].e., one tablet each day from 02/18/15 through 02/25/15). An additional interview with RN #1 at that time pertaining to the additional findings revealed the nurse continued to insist that the [MEDICATION NAME] had been administered to the resident that day during the morning medication pass. As a result of the findings, one medication error was assessed. 2. Observation during the morning medication pass, on 020/25/15 at 9:00 AM, on the 100 Unit for a second unsampled resident (Unsampled Resident B) diagnosed with [REDACTED]. The resident currently had an order of "NPO" (i.e., nothing by mouth). Each medication was prepared individually to be administered via the resident's feeding tube. All medications were tablet formulations, were separately crushed, were each mixed in approximately 5-10 milliliters of water, and then individually administered via the feeding tube. Prior to administration, RN #3 checked the tube's placement and residual. However, there was no effort made to pre-flush the tube prior to administering the medications. Subsequently, the nurse's attempt to administer the first medication revealed the resident's tube was significantly clogged. After continued efforts by the nurse to unclog the tube (resulting in some slight spillage of medication), the tube became unclogged, resulting in no further problems with the flow of the medication. RN #3 proceeded to administer each medication separately, flushed the tube between each medication, and concluded the administration with a post-flush. Immediately following the observation, RN #3 was interviewed and acknowledged the pre-flush should have been performed with the resident's feeding tube. However, because RN #3 failed to perform the tube pre-flush, a second medication error was assessed. Following the observation of Unsampled Resident B's morning medication administration, review of the medication orders revealed that one of Resident B's medications ([MEDICATION NAME] 30 mg.) stated to be given "by mouth". Moreover, the package as received from the pharmacy (Rx 506) dated 02/19/15 also stated to be given "by mouth". The package contained no additional instructions from pharmacy regarding the proper methods to use when administering by mouth (e.g., warnings not to chew, split, or crush the tablet), nor any instructions regarding the proper method for administering the medication via a feeding tube. Review of the manufacturer's literature regarding administration of the [MEDICATION NAME] revealed the tablet could be administered via a feeding tube if mixed in a small amount of water (approximately 10 milliliters), and then infusing through the tube within 15 minutes. The manufacturer specified the tablet should not be chewed, cut, or crushed. Interview at about 12 noon on 02/25/15, with RN #3 regarding the discrepancy regarding the [MEDICATION NAME] revealed the nurse expressed being unaware the [MEDICATION NAME] should not be crushed prior to administering via Unsampled Resident B's feeding tube. The manufacturer's specification regarding administering the medication via a feeding tube was explained to the nurse, and it was further suggested the facility check with its pharmacy provider for further clarification. Interview, at 9:00 AM on 02/26/15, with RN #4 regarding administration of Unsampled Resident B's medications via the feeding tube revealed the administration of the [MEDICATION NAME], the nurse explained they mixed the tablet in a small amount of water and give that through the tube. They know it's not supposed to be crushed. Thus, because the [MEDICATION NAME] was observed not being administered via the resident's feeding tube in accordance with manufacturer specifications, a third medication error was assessed.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the resident's legal representative was notified of a significant weight loss for one (1) of thirteen (13) sampled residents (Resident #9). The facility assessed Resident #9 with a significant loss of 6.5% in one (1) month and 8.6% in three (3) months from the day of admission on 11/28/14 to day of discharge to an acute care facility on 01/18/15 and the resident's legal representative was not informed of the weight loss. The findings include: Review of the facility's policy regarding Communication of Health Status, revised 10/01/12, revealed the resident and/or health care decision maker would be provided with information regarding the patient's total health status. This included functional status; medical care; nutritional status; rehabilitation and restorative potential; activities potential; cognitive status; oral health status; psychosocial status; and, sensory and physical impairment. Information would be communicated in a way that the resident/health care decision maker could understand. Review of Resident #9's closed clinical record revealed the facility admitted the resident on 11/03/14 with [DIAGNOSES REDACTED]. Review of Resident #9 Plan of Care (POC) revealed a focused area that Resident #9 had a Do Not Resituate, with a goal that the healthcare decision maker would participate in decisions regarding medical care and treatment. Review of Resident #9's weekly weights revealed on 11/16/14 the facility weighed Resident #9 at 118.8 pounds and on 12/14/14 at 111.1 lbs. which idicated a 6.5 % significant weight loss for one month. On 01/11/15 the facility weighed Resident #9 at 103.1 lbs for a significant weight loss of 8.6 % in less than three (3) months. Interview with the Registered Nurse Educator, on 02/26/15 at 8:05 AM, revealed the facility utilized a Change of condition assessment form that required seventy-two (72) hours of follow up charting. He stated the nurse was to fax the form to the Physician and when it returned with orders, the nurse would document the order and notify the responsible party. He stated if the resident was his or her own responsible party, then the resident was notified. Interview with the Registered Dietitian, on 02/26/15 at 10:00 AM, revealed she never talked to the family about weight loss, that it was nursing's responsibility. Interview with the Director of Nursing, on 02/26/15 at 5:40 PM, revealed the Power of Attorney should be notified when there was a change in status.

Based on interview, record review and review of the facility's policy,it was determined the facility failed to afforded the opportunity to be consulted about care and a treatment change with the initial care plan or with the significant change care plan for one (1) of thirteen (13) sampled residents. (Resident #9) The facility did not have an initial care plan meeting with the resident/legal representative. The findings include: Review of the facility's policy regarding Care Plans, revised 02/02/14, revealed residents and/or the health care decision makers would be invited to participate in care plan meetings. Review of Resident #9's closed clinical record revealed the facility admitted the resident on 11/03/14 with [DIAGNOSES REDACTED]. Review of Resident #9's Plan of Care (POC) revealed a focused area that Resident #9 had a Do Not Resituate, with a goal that the healthcare decision maker would participate in decisions regarding medical care and treatment. Phone interview with Resident #9's legal representative, on 02/23/15 at 12:30 PM, revealed he/she routinely visited the resident. The representative stated he/she was not notified of the resident's care plan conference or invited to participate. Interview with the Social Services Director, on 02/26/15 at 10:25 AM, revealed the Minimum Data Set (MDS) nurse would give her a list of the Care Plans due for the month, she then invited the legal representatives by letter and documented the letter was sent in a log she kept in her office. Review of the log revealed no entry for Resident #9's legal representative. Review during the interview of the Social Services progress notes from Resident #9's admission until discharge, revealed no note that a care plan conference had occurred. The Social Services Director stated she talked to Resident #9's legal representative all the time. Interview with the MDS nurse, on 02/26/15 at 10:35 AM, revealed she did not remember having a care plan conference for Resident #9. Interview with the Administrator, on 02/26/15 at 5:00 PM, revealed his expectation was for staff to follow the RAI (Resident Assessment Instrument) guidelines and if a care plan conference was needed beyond the guidelines they would have one. The Administrator stated the Social Worker was always talking with the responsible party.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure staff floated the heels of one (1) of thirteen (13) sampled residents (Resident #2) in accordance with the residents written Plan of Care (POC). The findings include: Review of the facility's policy regarding Care Plans, revised 02/02/14, revealed a comprehensive, individualized care plan would be developed by the interdisciplinary team for each patient. The care plan would include measurable objectives to meet patient needs and goals as identified by the assessment process, to promote necessary care and services to attain or maintain the patients's highest practicable physical, mental and psychosocial well being. However, the policy did not reference staff responsibility to follow the care plan. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 05/09/13 with [DIAGNOSES REDACTED]. Review of the Resident #2 Comprehensive Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as being at risk for development of pressure ulcers. Per the MDS the risk was secondary to Resident #2 requiring staff assistance to move sufficiently to relieve pressure over any one site and being confined to bed or chair all or most of the time. Review of the POC revealed a focused area of risk for skin breakdown as evidenced by decreased mobility and incontinence. One intervention was for the staff to float the resident's heels while in bed. Observation of Resident #2, on 02/24/15 at 3:25 PM, revealed Resident #2 was laying in bed without his/her heels being floated. Interview with SRNA #1, on 02/24/15 at 3:25 PM, revealed SRNA #1 worked the second shift and had just gotten to work. she was aware Resident #2 should have his/her feet floated while in bed. She stated the SRNA's get report on their residents and there was a cardex with each residents care plan. SRNA #1 then obtained a pillow, folded it and placed it under Resident #1 ankles. Interview with the Registered Nurse Educator, on 02/26/15 at 8:05 AM, revealed all the nurses had been working at the facility for a while; he stated they discussed supervision responsibilities upon hire. He stated the nurses were to observe the residents as they do the medication pass and treatments, that they should do spot checks, to make sure residents are getting the assistance they need and getting turned as needed. Interview with Registered Nurse #3, on 02/26/15 at 3:02 PM, revealed she supervised the SRNA's by ensuring they were aware of anything new going on with a resident, making rounds, following up, keeping an eye on them and ensuring they are answering the call lights. Interview with SRNA #6, on 02/26/15 at 5:10 PM, via telephone revealed she had been assigned to Resident #1, she stated she was aware that Resident #1 required his/her heels to be floated. She stated everybody makes mistakes. During an interview with the Director of Nursing (DON), on 02/26/15 at 5:40 PM, revealed the nurses were expected to do rounds and spot checks to ensure care was provided per the POC.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility staff failed to change indwelling catheters per physician order [REDACTED].#2. Registered Nurse (RN) #1 changed Resident #2's indwelling catheter and increased the catheter gauge (diameter) without a Physicians order. In addition, staff failed to ensure Resident #2's indwelling catheter bag was not touching the floor. The findings include: Review of the facility's policy regarding Care of the Indwelling Urinary Catheter, revised 01/02/14, revealed it did not address changing the indwelling catheter, obtaining an order to increase the size of the catheter or keeping the catheter bag off the floor. Review of the clinical record for Resident #2 revealed the facility admitted the resident on 05/09/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/14, revealed the facility assessed the resident as dependent on staff for all care. Review of the physician's orders [REDACTED]. Review of a nurses note, dated 01/12/15, revealed a nurse changed the indwelling catheter without an order and increased the size from a sixteen French (16 fr) to a twenty-four french (24 fr) without an order. Observation of Resident #2, on 02/24/15 at 3:25 PM, revealed him/her laying on the bed with the catheter bag on the floor and without a dignity bag. On 02/25/15 at 11:44 AM while Resident #2 was up in a wheelchair in the living room the catheter bag and tubing were observed touching the floor. Interview with State Registered Nursing Assistant (SRNA) #1, on 02/24/15 at 3:25 PM, revealed she worked the second shift and had just gotten to work. She was aware Resident #2 should not have his/her catheter bag on the floor due to risk of infection and should have a dignity bag covering the catheter bag. Interview with Registered Nurse #1, on 02/24/15 at 4:15 PM, revealed she had just changed the indwelling catheter at 3:00 PM and that could be why the catheter bag was on the floor and without a dignity bag. She also stated she had received a Physicians order to change the catheter due to minimal output and to increase the size, but had not written the order yet. Interview with SRNA #6, on 02/26/15 at 5:10 PM, via the telephone revealed she had been assigned to Resident #2 and she stated she was aware Resident #2's indwelling catheter bag needed to be off the floor and the indwelling catheter bag needed a dignity bag. She stated everybody makes mistakes. Interview with the Unit Manager, on 02/26/15 at 3:04 PM, revealed it was nursing judgement as to when the catheter needed to be changed, but stated a Physicians order was required to change the indwelling catheter and to increase the size of the catheter. She stated usually there was an as needed (PRN) order to change a catheter. The Unit Manager also stated the SRNA's were required to do change of shift rounds and the catheter on the floor without a dignity bag should have been caught during those rounds.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure staff transcribed physician orders [REDACTED]. (Resident #9) The facility staff wrote physician orders [REDACTED]. In addition, the staff failed to monitor the consumption of the house supplement. The findings include: Review of the facility's policy regarding Weights and Heights, under Significant Weight Change Management, revised 01/02/14, revealed a significant weight change was defined as 5% in one month and 10% in six months. The licensed nurse would notify the Physician/mid-level provider and Dietitian of the significant weight change, notify the Physician /mid-level provider of the Dietitian recommendations, and notify family/health care decision maker of the weight change and Dietitian recommendation. Family notification would be documented. Review of the facility's policy regarding Reordering, Changing and Discontinuing Medication Orders, dated 08/01/02, revealed the facility would communicate any medication reorders, changes or discontinuations to the pharmacy in accordance with pharmacy guidelines and state/federal regulations. Review of Resident #9's closed clinical record revealed the facility admitted the resident on 11/03/14 with [DIAGNOSES REDACTED]. Review of the weekly weights for Resident #9 revealed on 11/16/14 the facility weighed the resident at 118.8 pounds and on 12/14/14 the resident weighed 111.1 lbs. This was a 6.5 % significant weight loss for one month. On 01/11/15 the facility weighed Resident #9 at 103.1 lbs for a significant weight loss of 8.6 % in less than three (3) months. Review of the Physicians telephone order sheet revealed an order, dated 12/31/14, for [MEDICATION NAME] (used as an appetite stimulate) 4 milligrams twice a day. Review of the MAR for December 2014 and January 2015 revealed the resident never received the [MEDICATION NAME]. Continued review of the Physicians orders revealed an order dated 12/12/14 for a house supplement every day that was increased to three (3) times a day on 01/14/15. Interview with State Registered Nursing Assistant (SRNA) #2, revealed she had taken care of Resident #9 and she had assisted Resident #9 with eating, but did not remember for sure if Resident #9 had received a supplement. She stated there was no place to document if the house supplements were taken by the resident, but the fluid amount would be counted in with the meals or snacks. Interview with the Registered Dietitian, on 02/26/15 at 10:00 AM, revealed she had requested an appetite stimulate and had recommended [MEDICATION NAME] or [MEDICATION NAME]. She stated she had thought the resident was receiving one of those. The RD stated she had seen positive results with [MEDICATION NAME]. She stated as far monitoring; if a resident was consuming their supplement, she would usually ask a nurse how the resident was accepting/tolerating the supplement. Interview with the Registered Nurse Unit Manager, on 02/26/15 at 3:04 PM, revealed when the Physicians did rounds a nurse had to be consistently with them. The Physician would usually leave the chart open to the page the order was written, and the nurse would take the order off when the Physician left. She had no explaination how the [MEDICATION NAME] had been missed. Interview with the Director of Nursing (DON), on 02/25/15 at 10:10 AM, revealed the order for the [MEDICATION NAME] was noted in the nurse's notes, but no one took the order off. She stated a nurse or the Unit Manager usually took the orders off. On 02/26/15 at 5:45 PM, the DON stated at one time the facility had documented the amount of the supplements the residents consumed and documented it on the Medication Administration Record, [REDACTED].

Based on record review, interview and review of the facility's policy, it was determined the facility failed to ensure the drug regimen for one (1) of thirteen (13) sampled residents (Resident #3) was free from unnecessary drugs. The staff failed to transcribe a physician's orders [REDACTED]. The findings include: Review of the facility's policy regarding Reordering, Changing and Discontinuing Medication Orders, dated 08/01/02, revealed the Center would communicate any medication reorders, changes or discontinuation to the pharmacy in accordance with pharmacy guidelines and state/federal regulations. Review of the job description for the Registered Nurse, with a revision date of 10/22/12, revealed the Registered Nurse was responsible for coordinating and delegating care as appropriate, verifying the medical orders were accurately transcribed and collaborating with physicians in rounds and examination of patients as needed. Review of the Clinical record for Resident #3 revealed the facility admitted the resident on 01/23/13 with [DIAGNOSES REDACTED]. Review of the Plan of Care (POC) revealed a focused area that stated the resident was at risk for complications due to [MEDICAL CONDITION] drugs with a goal for the resident to have the smallest most effective dose without side effect. Continued review of the clinical record revealed a signed Physician order, dated 01/28/15, to decrease [MEDICATION NAME] one (1) milligram (mg) twice a day to [MEDICATION NAME] one-half (1/2) mg three times a day per the Pharmacist drug regimen review. Review of the February MAR indicated [REDACTED]. Interview with the Registered Nurse Unit Manager on 02/26/15 at 3:04 PM revealed when the Physicians to do rounds a nurse has to be consistently with them. The Physician will usually leave the chart open to the page the order was written, and the nurse will take the order off when the Physician leaves. Interview with the Administrator on 02/26/15 at 5:00 PM revealed his expectation was that the nurse take off the physician's orders [REDACTED].

Based on observation, interview and facility policy review, it was determined the facility failed to ensure the correct scoops were utilized to measure the servings for six (6) of ten (10) therapeutic diets served. The findings include: Review of the facility's policy regarding Menu Standards, revision date 10/06/13, revealed the policy was to ensure nutritional adequacy, regulatory compliance, operational efficiencies and resident quality of life. Review of the Menu Guide Report for 12/03/13 revealed the Dysphagia advanced marinated vegetable salad was to be dispensed at 1/2 cup and the Dysphagia pureed zesty cucumber salad was to be dispensed at 1/2 cup. The Dysphagia pureed zesty cucumber salad specified a #10 scoop. Review of Food and Nutrition Services Scoop Sizes revealed a #10 scoop measured 3/8 cup with a three (3) ounce volume and was to be used for meat patties. The #12 scoop measured 1/3 cup with a volume of 2-3/4 ounces to be used with salads. The #6 scoop measured 2/3 cup and was to be used with lunch-type salads. The #8 scoop measured 1/2 cup with a four (4) ounce volume to be used with casseroles, potatoes, vegetables, pudding, etc. Observation during the supper tray line, on 12/03/13 at 5:55 PM, revealed four (4) servings of the dysphagia advanced marinated vegetable salad and two (2) servings of the dysphagia pureed zesty cucumber were served with ladles that were not designated as a scoop and not labeled as to the size, ounces or volume being dispensed. Interview with Dietary Staff #1, on 12/03/13 at 5:55 PM, revealed the ladle used did not match the menu guide. She reported the guide was used to ensure the correct amount was served to the residents. She reported the ladle size should have been checked with the menu guide to ensure the correct ladle was used during meal service. She stated she was to ensure the residents received the correct serving sizes.

Based on observation, interview, record review and review of the facility's policy Activity Assessment and Documentation, it was determined the facility failed to provide activities based on the comprehensive assessment and interest of one (1) of fifteen (15) sampled residents (Resident #1). The findings include: Review of the facility's policy regarding Activity Assessment and Documentation, dated April 2010, revealed each resident would be assessed for physical, mental, spiritual, psychosocial, and leisure interests, as well as preferences for engagement in activities based on past and present patterns and interests. The facility did not provide a policy as to how it would meet the assessed activity needs and preferences. Review of the medical record for Resident #1 revealed the facility admitted the resident on 01/23/13. The facility assessed the resident utilizing the Minimum Data Set (MDS), on 09/16/13, as having a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the Activity/Recreation Assessment, dated 09/19/13, revealed Resident #1 preferred to be involved in spiritual services/programs. Review of the comprehensive plan of care revealed the resident would be assisted and encouraged to listen to gospel music. Observation of Resident #1, on 12/04/13 at 10:07 AM, revealed Resident #1 was sitting in a wheelchair, parked in the 100 living room with head down and staring at the floor. The resident occasionally looked up at television. Christmas carols and trumpet music could be heard coming from the Bible study activity in the main dining room. The resident looked up and around when singing started, then again looked back down at the floor. Observations of Resident #1, on 12/04/13 at 10:24 AM, 10:48 AM, 11:00 AM, 11:30 AM, 1:02 PM, and 3:05 PM, reveal the resident was still sitting in the living room, not engaged in any activity. Interview with Resident #1's family member, on 12/05/13 at 11:01 AM, revealed the resident was very active in the church and often provided food for the church pot lucks. The family member stated the resident attended church regularly and appeared to still enjoy church services. The family member relayed he/she used to see the resident in Bible studies, but noted as of late, the resident was not in attendance and did not know why the facility did not take the resident to participate in the activity. Review of the Residents Program Participation Record revealed the resident did not attend any religious activities in the month of November or December 2013. Interview with Certified Nursing Assistant (CNA) #6, on 12/05/13 at 12:50 PM, revealed they were not given a list as to which residents should attend which activity. The CNA revealed staff pretty much knew who to take to certain activities. The CNA revealed she did not transport the resident to the Bible study because she thought the resident was busy doing something else. Interview with the Activities Director, on 12/05/13 at 12:55 PM, revealed the resident liked to read, work puzzles, and did actively listen to anyone reading in a group activity. The Activities Director stated the living room was to be a quiet area and activities were no longer held in the space. The Activities Director indicated about a month ago the facility started to hold all group activities in the dining room to ensure the living room was kept a quiet space. However, the Activities Director felt this change had made it very difficult and felt a lot of residents were being left out and she had noticed a decline in attendance from residents who were cognitively impaired. The Activities Director further stated cognitively impaired residents tend to be in the Living Room area, so when activities were held in there, they were automatically included and could participate. The Activities Director felt it was out of habit that the residents were placed in the living room and not brought down to the dining room. The Activities Director also indicated she did not provide the nursing staff with a list of residents or verbally tell the staff which residents to bring over to activities. Interview with the Administrator, on 12/05/13 at 1:47 PM, revealed the purpose of activities was to provide stimulation, provide something for residents to do, and enhance the residents quality of life. The administrator stated small group activities at the facility are not as stimulating and had been held in the living room. The Administrator further stated he did observe activities, but was not aware of a decline in activity attendance since moving them to the dining room.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure an opportunity to explore and participate in alternative care was provided during the care plan conference of one (1) of fifteen (15) sampled residents. The facility removed Resident #2's electric wheelchair (w/c) from use. The findings include: Review of the facility's policy, Care Plan, revised 12/15/10, revealed the purpose was to guide therapeutic interventions to meet the resident's needs and achieve expected outcomes. The facility would promote participation of the resident in planning care. The standards of practice were to ensure the resident's care plan were updated, if unable to attend, and document in the resident's progress notes. Review of the facility's Admission Packet, page 13, Rights Related to Your Care, revealed the resident had the right to be fully informed in advance about care and treatment, and about any changes in treatment that may affect the well-being; and the right to participate in the care and treatment plan. Review of Resident #2's clinical record revealed the facility readmitted the resident on 10/21/13 after an acute hospital stay, with a [DIAGNOSES REDACTED]. The record revealed the resident used an electric wheelchair for locomotion. The facility utilized, the Minimum Data Set (MDS) on 10/28/13, to assess the resident's Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was cognitively intact. Review of the Mood and Behavior section of the MDS revealed the resident had no Mood or Behaviors. The facility assessed the resident's functional status as independent with locomotion on and off the unit. Review of the resident care plan conference notes revealed the resident was in attendance. Further review of the care conference notes dated 02/02/13, 08/07/13 and 09/27/13 revealed no evidence the facility was concerned with the resident's use of the electric wheelchair, safety or the resident's behavior. Review of the care conference note, dated 11/04/13 revealed the facility had made an administrative decision based on Resident #2 and Resident #6's safety, to discontinue the use of the motorized w/c. Review of the resident's event reports, dated 01/09/13 thru 11/04/13, revealed on 03/01/13 the resident fell from the electric w/c. The facility assessed the root cause as [MEDICATION NAME] due to a syncopal episode. Continued review of the resident's event report revealed, on 07/08/13, the resident was assessed with [REDACTED]. in place. Further review of the event reports for Resident #2, from 01/09/13-11/04/13, revealed the facility had no investigative reports of the resident's electric w/c safety concerns. The record revealed the resident was involved in activities, resident council and independent with the use of the electric w/c throughtout the facility. Interview with Resident #2, on 11/03/13 at 9:45 AM, revealed the resident had been in the electric w/c since admission. The resident said the electric w/c was the only means to maintain his/her independent mobiltiy. The resident indicated being involved in many activities throughout the facility and the resident was involved in his/her care plan conferences. The resident stated the facility hadn't discussed saftey or possible discontinuation of the electric w/c during any care plan conferences. The conference held on 11/04/13 informed him/her the electric w/c would be discontinued. The resident indicated the facility would have the hallway cluttered at times which made it difficult to navigate the electric w/c. The resident relayed the facility would not discuss opportunities to afford him/her the ability to remain independent with the electric w/c. The resident felt depressed and would leave this facility for another facility if he/she could. Interview with Certified Nursing Assistant (CNA) #3, on 11/03/13 at 3:40 PM, revealed Resident #2 was active and independent in the electric w/c. She revealed no concerns with the resident's safe use of the electric w/c. Review of an Occupational Therapy (OT) Evaluation, dated 10/17/21-10/21/13, revealed the resident was independent with the electric w/c. Review of the OT progress notes, dated 10/22/13-11/4/13, revealed the resident was assessed as being independent with the electric w/c. Further review of the record revealed OT cancelled the electric w/c assessment due to an administrative decision to discontinue the resident's use of it. The record revealed that OT felt the consequences to discontinuing the electric w/c was a decrease in overall quality of life and risk of a functional decline. Interview with the Occupational Therapist (OT), on 11/04/13 at 4:20 PM, revealed the resident was evaluated for generalized weakness after a recent hospitalization . She revealed the goal was the resident would operate the electric w/c with safe technique. She revealed the electric w/c evaluation was cancelled due to the facility's decision related to safety. The OT revealed the resident would be able to maneuver the manual w/c for short distance and the loss of the electric w/c would have a negative affect on the resident's quality of life. Interview with the Social Worker (SW), on 12/04/13 at 4:40 PM, revealed the resident regularly attended care plan conference. The SW the resident's safety, behavior or use of the electric w/c were not care planned because the facility had not identified it as a concern. She further stated the facility had not involved the resident in the removal of the electric w/c, because the electric w/c was not identified as a concern.

Based on interview, and review of the facility's policy, it was determined the facility failed to investigate the root cause of a resident to resident incident for two (2) of fifteen (15) sampled residents to prevent accidents/incidents (Residents #2 and #6). On 10/30/13, Resident #2 was in an electric wheelchair (w/c) and Resident #6 was in the hallway when the Resident #6's right (rt) foot was injured. The findings include: Review of the facility's policy regarding Accidents, Incidents, and Adverse Events, revised 0/01/13, revealed the facility would review, report and investigate all resident to resident accident/incidents. The incident could involve an observation of a situation that posed a threat to safety. The policy continued to reveal a patient to patient incident would require the investigation be initiated immediately by the Administrator, Director of Nursing, Charge Nurse or Supervisor. Review of Resident #6's clinical record revealed the facility admitted the resident on 12/27/10, with [DIAGNOSES REDACTED]. The facility utilized, The Minimum Data Set (MDS) on 11/15/13, to assess the resident's Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident had a severe cognitive impairment. Review of the MDS functional section revealed the resident required total care with the activities of daily living (ADL). Review of the nurse's note dated, 10/30/13 at 10:30 AM, revealed the resident's right foot was injured by Resident #2's electric w/c. The nurse's note revealed the incident was reported to the Director of Nursing (DON), that the resident's right toes (digit 1, 2, and 3) were injured. Interview with Registered Nurse (RN) #2, on 12/03/13 at 2:20 PM, revealed she was the nurse who cared for both residents' the day of the incident. She had not witnessed the resident to resident incident, but did hear Resident #6 yell out. She stated Resident #2 had at times exhibited verbal behaviors toward other residents. Continued interview revealed the DON was notified of the incident. She stated the DON was responsible for accident/incident investigation. Interview in the Social Worker's office with the Assistant Director of Nursing (ADON), on 12/04/13 at 4:30 PM, revealed any accident/incident that occurred to a resident outside of the normal care and services should be investigated. She stated the Interdisciplinary Team (IDT), Unit Manager or DON were responsible for the investigation. The UM stated the root cause of the incident was determined by Resident #2's history of reckless use of the electric w/c and behaviors. She revealed the facility had not assessed, care planned or had any evidence of the resident's careless use of the electric w/c. She revealed the IDT was not involved in the investigation. Interview in the Social Worker's office with the Social Worker, on 12/4/13 at 4:40 PM, in the presence of the ADON revealed she was unaware of Resident #2's careless use of the electric w/c or verbal behavior to other residents until the resident to resident incident occurred. Review of the Event Reports for Resident #2, dated 01/09/13 thru 11/04/13, revealed on 03/01/13 the resident fell from electric w/c, the facility assessed the root cause as intrinsic due to a syncopal episode. Review of the event report, dated 07/08/13, revealed the resident was assessed with [REDACTED]. The facility had no evidence an investigation was completed regarding the resident to resident incident that occurred on 10/30/13. Interview with the DON, on 12/04/13 at 5:30 PM, revealed a resident to resident incident was anything that occurred out of the normal care and services. She had knowledge of the accident/incident, but did not initiate an investigation. The DON stated an accident/incident investigation was not initiated because Resident #2 had no injury. She continued to state the root cause was assumed to be Resident #2's careless use of the electric w/c. She indicated the purpose of an accident/incident investigation was to establish the root cause and implement interventions to prevent further incidents. The DON had no evidence that established Resident #2's careless use of the electric w/c was the root cause of the accident/incident. Interview with Administrator, on 12/04/13 at 5:50 PM, revealed he was aware of the incident between Resident #2 and Resident #6. He stated the IDT determined through the investigation the root cause of the incident was Resident #2's inattentiveness to surroundings while operating the electric w/c. The administrator was unaware the incident had not been investigated to determine the root cause.

Based on observation, interview and facility policy review, it was determined the facility failed to ensure one (1) of two (2) medications rooms were accessed by authorized staff only. The authorized staff allowed housekeeping staff access to the medication room unattended. The findings include: Review of the facility's policy regarding Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 05/01/10, revealed the facility should ensure only authorized facility staff have possession of open medication storage areas. Observation of the Front Hall medication room, on 12/04/13 at 9:50 AM, revealed the Intravenous (IV) E (Emergency) Kit was unlocked and contained IV fluids and IV medications. Observation of the Front Hall medication room, while standing in front of the nurses station near the 100 Hall, on 12/04/13 at 1:25 PM, revealed the medication room door was propped open with a staff member moving items on the floor and cleaning the floor. Interview with Registered Nurse (RN) #1, on 12/04/13 at 1:25 PM, identified the staff member as a housekeeping staff cleaning the medication room. She reported she did not provide access to the medication room for the housekeeping staff. Observation and interview of RN #4, upon return to the nurses station, on 12/04/13 at 1:40 PM, revealed she provided access to the medication room for housekeeping to clean the medication room. She stated, the medications were locked up and there was not any medications accessible in the room. Upon review of the IV E-box, she stated there was IV fluids with the medication, Potassium Chloride in the fluids. She reported the box did contain medications. Interview with the Director of Nursing, on 12/05/13 at 2:39 PM, revealed the medication room should not be left unlocked, and unattended with housekeeping in the medication room. She reported the nurses had the keys and should remain in the room for supervision of the area.

Based on observation, interview and facility policy review, it was determined the facility failed to provide an emergency call light system in one (1) of one (1) unlocked bathrooms, identified as the visitor bathroom. The visitor bathroom located on the resident unit remained unlocked and resident accessible. The findings include: Review of the facility's policy, identified as 2.1 Call Lights, revised 10/01/12, revealed all residents would have a call light device within their reach at all times when unattended to ensure safety and communication between staff and residents. Observation of the bathroom, identified as the visitor bathroom, on 12/03/13 at 8:50 AM and 12/04/13 at 10:49 AM revealed the bathroom door ajar and accessible. The bathroom did not have an emergency call light. Observation, on 12/05/13 at 9:10 AM, revealed Unsampled Resident A was observed to exit the visitors bathroom across from the reception area. Resident A was using a walker as he/she came out of the bathroom. Resident A stated, " I did not know which bathroom to go to." Interview with the Administrator, on 12/05/13 at 11:20 AM, revealed the bathroom remained unlocked after the slide locks were removed from the doors as the result of a previous survey. He stated the staff kept an eye on the bathroom for residents who attempt to use this bathroom. He reported there had only been one (1) male resident that had attempted to use the bathroom in the past and the staff re-directed him when he attempted to use that bathroom.

Based on observation, record review and interview the facility failed to ensure one (1) resident of the nineteen (19) sampled residents, Resident #2, remained free of accidents. Resident #2 had a fall on 07/01/10 and then sustained a second fall that resulted in a clavicle (collar bone) fracture on 07/04/10. The findings included: Record review of the facility's Accident/Incident Policy dated 01/08 revealed it is the center's policy to provide an environment that is free from hazards over which the center has control. The intent of this policy is that the center identifies each resident at risk for accident and/or falls, and adequately plans care and implements procedures to prevent accidents. Review of Resident #2 's record revealed the facility admitted the resident on 11/06/09 with the [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) of 05/04/10 revealed the facility assessed the Resident as having no cognitive impairment and was able to be understood and did understand. Review of the falls risk care plan dated 05/11/10 revealed the resident had an unsteady gait, weakness and a history of two (2) previous falls. The care plan dated 11/18/09, detailed the follow interventions: 1) Encourage Resident to rest when necessary. 2) Standby assist with walker for ambulation, 3) Monitor and document for changes in behavior, such as increased agitation, decline in mental status, etc. 4) Keep call bell within reach of resident. 5) Provide Resident with clean glasses daily. 6) Complete fall assessment per protocol. 7) Explain care/activities prior to initiating. 8) Provide well lit, clutter free environment. 9) Keep frequently used objects within reach. 10) Stargazer. 11) Prefers to use left half side rail as an enabler. Review of the care plan interventions review date was on 02/11/10 and on 05/06/10 and no additional interventions were added or deleted. The resident's care plan dated 11/18/09, and reviewed on 02/11/10 and 05/06/10 did have the resident care planned as a fall risk related to a history of two (2) falls with injury while in the hospital. Factors to the resident's fall included the use of trazodone, weakness, and an unsteady gait. Educate the resident and the continuation of therapy for strengthening were the only interventions added to the care plan on 07/01/10 by the floor nurse. Record review of the nurses note dated 07/01/10 revealed the Resident was educated by RN #3 on purse lip breathing techniques and to receive assistance with transfers. The nurses notes on 07/01/10 at 2:30pm when the nurse was called to the sunroom with the resident in the floor documented the Resident had generalized weakness and increased fatigue with activities. Resident #2 had a second fall, which occurred on 07/04/10 in his/her room. The facility transferred the resident to the emergency room for treatment on 07/04/10 for a laceration to head, which required nine (9) sutures and pain to the right shoulder. The resident sustained [REDACTED]. The nurses notes dated 07/04/10, after resident returned from the Emergency Department, revealed the clip alarm was now on the resident. The care plan was updated but had no date identified for Resident #2's use of a clip alarm while in bed related to an unsteady gait and assistance is needed with ambulation. The clip alarm use was first documented in the nurses notes on 07/04/10 after the resident returned from the emergency room visit. The care plan dated 07/12/10 for Resident #2 revealed the clip alarm and assistance with ambulation was discontinued on 07/12/10 and revised on 07/12/10 to use a pressure alarm to the bed and wheelchair related to decreased safety awareness. Interview with the Certified Nurse Assistant #7 on 09/02/10 at 6:32pm revealed she/he as a caregiver did not receive any new or additional updates regarding Resident #2's fall or any additional intervention to meet his care needs. Interview with the Registered Nurse (RN) #3 on 09/02/10 at 5:30pm revealed he/she educated and reminded the resident to use their call light and to ask for help after his/her fall on 07/01/10 (first fall). The RN reported he/she had documented everything in the nurses notes. The RN reported the Resident had been spending time in the sunroom. Interview with the Director of Nursing on 09/02/10 at 7:10pm revealed that Resident #2's fall that occurred on 07/01/10 was not reviewed by the Interdisciplinary Team (IDT) until the following Tuesday, 07/06/10, due to the weekend and the 07/04/10 holiday. She did reveal the fall on 07/04/10 potentially could have been prevented if the IDT team had met and reviewed the care plan and interventions that were in place at the time the fall occurred on 07/01/10 and identified the root causes of that fall. Then additional interventions such as alarms for the bed and wheelchair could have been put into use prior to the second fall on 07/04/10. Record review of the physician orders [REDACTED]. The physician documented a decline in the residents condition and the family requested comfort measures. The facility assessed Resident #2 for a significant change MDS dated on 07/22/10 as having cognition impairment.