Every finding on record at Diversicare of Martin

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found unsecured and unattended in 2 of 57 (Residents #23 and #47) resident occupied rooms. The findings include: 1. Review of the facility policy titled, MEDICATION STORAGE IN THE FACILITY POLICY, dated 4/2025, revealed .Medications and biologicals must be stored safely, securely, and properly .BEDSIDE MEDICATION STORAGE .Written order in the medical record .Document on MAR [Medication Administration Record] and care plan .store in original/pharmacy containers . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Depression and Anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident #23 was moderately cognitively impaired. Review of the Self Administration of Medications, evaluation dated 2/3/2025, revealed .Flonase .Storage .With staff .Resident may self administer medications WITH SUPERVISION .Medication will be stored on med-cart . Review of the care plan updated 3/31/3025, revealed .Medications will be stored in a secure location. Location: med cart . Observation on 3/31/2025 at 9:05 AM, revealed 1 bottle labeled Fluticasone (nasal spray used for allergies) was on the nightstand in Resident #23's room. During an interview on 3/31/2025 9:19 AM, LPN A was asked if medications should be stored at the bedside. Licensed Practical Nurse (LPN) A stated, No During an interview on 3/31/2025 at 2:51 PM, the Administrator was asked if medications should be stored at the bedside. She stated, .no, I heard about that . 3. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident was cognitively intact. An observation and interview on 4/2/2025 at 8:35 AM, revealed a clear medication cup with a white powder in it on a storage bin in Resident #47's room. The Resident was asked what the powder in the medication cup was. She stated, Nystatin [antifungal] powder that they put under my breast at night before bed. LPN B was asked if medication should be stored at the bedside. She stated, No. During an interview on 4/2/2025 at 9:02 AM, the Director of Nursing (DON) confirmed medication should not be stored at the bedside.

Based on the facility Infection Control Guide, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 nurse (Licensed Practical Nurse (LPN C) failed to wear Personal Protective Equipment (PPE) in an enhanced barrier precautions room. The findings include: 1. Review of the facility manual, [Named Facility] Infection Control Guide, on pages 7 and 8, dated 2025, revealed .Enhanced Barrier Precautions .refers to .the expanded use of PPE during high-contact resident activities .residents with wounds .are at especially high risk .the use of gown and gloves for high-contact resident care activities is indicated . 2. Review of the medical record review revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Pressure Ulcer, Cerebrovascular Disease with Hemiplegia (paralysis on one side of the body), Heart Failure, Peripheral Vascular Disease, Hypertension, and Cachexia (muscle wasting). Review of the Order Summary Report dated 1/15/2025, revealed .Front Left Lateral Leg Stage IV (4) Pressure Ulcer: Cleanse with wound cleanser, pat dry with gauze .apply Negative Pressure Wound Therapy Vac (vacuum) . Monday .Wednesday, Friday . An observation during pressure ulcer care on 4/2/2025 at 9:40 AM, revealed LPN C performed Resident #77's left lower leg ulcer treatment without a PPE gown on in an enhanced barrier room. During an interview on 4/2/2025 at 11:55 AM, (Registered Nurse (RN) D) was asked if a nurse was performing pressure ulcer care on a resident should they wear PPE in an enhanced barrier room. RN D stated, Yes, you should.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of physical restraints for 1 of 1 (Resident #29) sampled residents reviewed for restraints. The findings include: 1. Review of the facility policy titled, Physical Restraint Guideline, dated 6/2017, revealed .For each patient/resident to maintain his or her highest practical health or well being in an environment that prohibits the use of restraints .and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Upon determination a patient/resident presents with medical symptoms that may require a restraint, they are evaluated .The Care Plan .is reviewed .revised to include restraint use. 2. Review of the medical record review revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Repeated Falls, Dementia, and Anxiety. Review of an Order Summary Report dated 8/19/2022, revealed .self release alarm seat belt to wheelchair every day and night shift for preventative . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29 was rarely/never understood and severely cognitively impaired. She is dependent on staff for all activities of daily living. Resident #29 is not assessed for a trunk restraint. Review of the Care Plan dated 4/1/2025, revealed Resident #29 was at risk for falls, with an intervention in place dated 11/30/2022, with education regarding self release seatbelt. Observation on 3/31/2025 at 10:58 AM and 2:58 PM, 4/1/2025 at 7:54 AM and 1:37 PM, and 4/2/2025 at 7:49 AM, revealed Resident #29 was sitting up in her wheelchair with a self release waist belt intact. Observation and interview on 4/2/2025 at 9:02 AM, the DON and Unit Manager took Resident #29 to her room. Resident #29 was asked and encouraged to release her waist belt several times, she was pleasantly confused and unable to release the belt. The DON at this time confirmed Resident #29 has a restraint on and she should be monitored and assessed for a restraint. DON stated, I will call her daughter and probably remove it. During an interview on 4/5/2025 at 8:57 AM, the Director of Nursing (DON) was asked if Resident #29's self release belt was a restraint. The DON stated, No, because she can take it off depending on her mood .her daughter insists she has this on due to previous falls .

Based on the facility's Clinical Skills Fair Guide, observation, and interview, the facility failed to use proper supplies when 1 of 5 nurses (Licensed Practical Nurse (LPN) A) administered medication from a flex pen during medication administration. The findings include: 1. Review of the [Named Facility] Clinical Skills Fair Guide, page 32 FLEX PEN [a pre-filled insulin delivery device] COMPETENCY AUDIT AND ADMINISTRATION GUIDE . revealed .REQUIRED MATERIALS .FlexPen .FLexPen needles .Removes the cover from the syringe .Opens new needle .screws the needle onto the FlexPen .Dials the number of units needed to inject .1 click=[equals] 1 unit of insulin .injects insulin by pressing the push button all the way in .Leaves the needle under the skin for at least 10 second after injecting insulin .Keep the button fully depressed until withdrawing the needle .Removes the needle from the pen . 2. An observation and interview during medication administration on 4/1/2025 at 4:43 PM, revealed LPN A took a FlexPen from the medication cart drawer and used an insulin syringe to draw up the medication from the FlexPen into the insulin syringe. LPN A was asked why she drew the insulin out of the FlexPen and did not put a needle on the FlexPen and administer the medication that way. LPN A stated, .ran out of needles for the FlexPens a few days ago .this happened in January, and we were told to do it this way . During an interview on 4/1/2025 at 5:15 PM the Director of Nursing (DON) was asked if she knew they did not have needles for the FlexPens and the staff was using insulin syringes to draw the medication out of the FlexPen to administer insulin to the Residents. The DON stated, I was unaware they were out of needles for the insulin pens . She stated that this happened earlier in the year and the pharmacy said they could do that. When asked who she talked to she was unsure. During a telephone interview on 4/2/2025 at 12:40 PM, the Pharmacist stated that none of the pharmacists recall a conversation about drawing insulin from the FlexPen with an insulin syringe.

Based on policy review, medical record review, and interview, the facility failed to educate and provide written information to residents regarding a right to formulate an advanced directive for 4 of 24 residents (Residents #24, #36, #75, and #239) reviewed. The findings include: 1.Review of the facility's policy titled, Advance Directives, dated 11/1/2016, revealed .[Named facility] recognizes the right of each resident to issue Advance Directives regarding his or her health care .and a right to formulate, at the individual's option, an Advance Directive .will provide Residents with information regarding Advance Directives at admission .If a Resident is incapacitated .unable to receive information about Advanced Directives or articulate whether he/she has an Advance Directive .will provide information regarding Advance Directives to the Resident's family or Resident Representative .will document in the Resident's medical record whether or not the Resident has executed an Advance Directive . 2.a. Review of the medical records revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Diabetes, and Chronic Obstructive Pulmonary Disease. Review of the annual MDS assessment dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. b. Review of the medical records revealed Resident #36 was admitted to the facility on [DATE], with diagnoses of including Diabetes, Heart Failure, and Kidney Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #36 had BIMS score of 15, which indicated intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. c. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Dementia, Alzheimer's, and Bipolar Disorder. Review of the significant change in status MDS assessment dated [DATE], revealed Resident #75 BIMS score of 13, which indicated intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. d. Review of the medical record revealed Resident #239 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Kidney Failure, and Heart Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #239 had a BIMS score of 15, which indicates intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. During an interview on 4/2/2025 at 10:58 AM, the Administrator confirmed that she had provided everything she had related to advanced directives. The facility was unable to provide documentation that the residents were educated and provided written information regarding their right to formulate an advanced directive.

Based on policy review, medical record review, and interview, the facility failed to follow their policy to conduct the care plan meeting within 72 hours of admission for 1 of 3 residents (Resident #1) reviewed for care plan meetings. The findings include: Review of the facility's undated policy titled, 72 Hour Care Plan Meeting, revealed .Purpose .To engage, align and integrate patient, resident and family in care and discharge plans with that of the Care Coordination team .Expectations .Within 48 hours of the patient's/resident's admission to center, the Care Coordination team completes initial evaluation by function and meets and completes the Baseline Care Plan to prepare for and conduct the meeting within 72 hours of admission .Admissions/Designee to schedule the 72 Hour Care Plan Meeting upon admission with resident/family to occur within 72 hours on all admissions .Care Plan process-explain the importance of family involvement, review goals .Review Medication Routine . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Director of Nursing's (DON) November 2021 calendar revealed there was a 72-hour meeting scheduled with Resident #1 and her daughter on 11/19/2021 at 2:00 PM. Review of the DON's handwritten notes on the facility's Baseline Care Plan dated 11/10/2021, revealed the 72-hour Care Plan meeting was conducted on 11/19/2021 at 2:00 PM. During an interview conducted on 1/28/2022 at 10:09 AM, Resident #1's daughter stated, .She [Resident #1] admitted on the 10th [11/10/2021] and I was told within 72 hours we would have a family care plan meeting .never heard anything .called them .finally got it scheduled for Friday, the 19th [11/19/2021] .complaining about that because I think some of this confusion with her sugar [blood glucose] could have been straightened out at that meeting .don't know if it just got overlooked . During an interview conducted on 2/14/2022 at 3:03 PM, the DON confirmed there was no documentation in Resident #1's medical record related to the 72-Hour Care Plan meeting. The DON confirmed that the handwritten notes dated 11/19/2021 at 2:00 PM on Resident #1's Baseline Care Plan were documented during the 72-Hour Care Plan meeting. The DON stated, .take notes when I did the meetings .very informal .not in PCC [Point Click Care, the facility's electronic medical record] . During an interview conducted on 2/17/2022 at 11:18 AM, the Administrator confirmed the 72-Hour Care Plan was not conducted until 11/19/2021, 9 days after Resident #1 admitted to the facility.

Based on policy review, observation, and interview the facility failed to ensure food was stored and distributed in a manner to prevent the spread of infection when unlabeled and expired foods were found in a refrigerator in the Kitchen, and when 4 of 21 staff members (Certified Nursing Assistant (CNA) #1 and #3, Licensed Practical Nurse (LPN) #3 and Nursing Assistant (NA) #1) touched residents' food, failed to appropriately sanitize their hands, and failed to wear appropriate Personal Protective Equipment (PPE) during meal service. This had the potential to affect the 96 of the 97 residents who had received a tray from the Kitchen. The findings include: The facility's undated policy titled, Labeling and Dating, revealed .Food labels must include: The food item name .The date of preparation .The 'use by' date .Leftovers must be labeled and dated with the date they are prepared and the 'use by' date .foods that are held for more than 24 hours at a temperature of 40 [degrees] F [Fahrenheit] or less, will be labeled and dated with a 'prepared date' (Day 1) and a 'use by' date (Day 7) . The facility's undated policy titled, System of Isolation Precautions for Infection Control revealed .Contact .Gloves required upon entering room .Gown required if clothing may come into contact with patient/resident or environmental surfaces . Review of the facility's IN-SERVICE TRAINING RECORD, dated [DATE] revealed .Yellow Zone .You must DON [put on] your PPE [Personal Protective Equipment: gowns, gloves, face mask] (gowns), gloves, N95 [a filtering face piece respirator], eyewear when entering each room .Everyone, every time . Observation in the Kitchen during initial tour on [DATE] at 5:25 AM, revealed the following items stored in a refrigerator: a. 1 unlabeled, undated container of chicken and dumplings. b. 1 container of brown gravy labeled with a preparation date of [DATE], and a use by date of [DATE]. c. 1 container of meat sauce labeled with a use by date of [DATE]. d. 2 open bags of turkey sandwich meat with no opened dates. e. 1 container of chicken gravy labeled [DATE]/2021. f. 1 container of yellow cheese slices labeled with a preparation date of [DATE], and a use by date of [DATE]. g. 1 container of orange slices in juice labeled with a use by date of [DATE]. h. 1 unlabeled, undated container of brown meat chunks. During an interview on [DATE] at 5:30 AM, Dietary Aide #1 confirmed that the chicken gravy was not labeled appropriately, was prepared on [DATE] and should have been discarded. Dietary Aide #1 was asked if she could identify the brown meat chunks in the unlabeled container. Dietary Aide #1 stated, I'm not sure . Observation in the Kitchen on [DATE] at 1:08 PM, revealed the following items remained in the refrigerator: a. 2 open bags of turkey sandwich meat, not labeled with opened dates. b. 1 container of yellow cheese slices labeled with a preparation date of [DATE] and a use by date of [DATE]. During an interview on [DATE] at 1:10 PM, the Assistant Dietary Manager stated, .I don't think that date [on the container of cheese] is correct. I think they put food in containers, after they are washed, and don't change the labels . The Assistant Dietary Manager confirmed that opened items stored in the refrigerator should be labeled with an opened or prepared date. Observation in the Kitchen on [DATE] at 4:10 PM, revealed 1 container of yellow cheese slices dated with a prepared date of [DATE], and a use by [DATE] still in the refrigerator. During an interview on [DATE] at 4:11 PM, the District Dietary Manager confirmed the container of cheese was not properly labeled and that items should not be in the refrigerator after the use by date. Observation in the 600 Hall Dining Room on [DATE] at 7:50 AM, revealed CNA #1 picked up Resident #11's biscuit off of the plate, opened the biscuit with her bare hand, spread butter and jelly on the biscuit, closed it, and placed it back on the plate. Observation in the 600 Hall Dining Room on [DATE] at 7:52 AM, revealed CNA #1 touched Resident #18 on her shoulder, then picked up the biscuit off the tray, opened the biscuit with her bare hand, spread butter and jelly on the biscuit, closed it and placed it back on her plate. During an interview on [DATE] at 12:59 PM, CNA #1 confirmed that she should not handle the resident's food with bare hands during dining. Observation on the 100 Hall on [DATE] at 7:50 AM, revealed the doors were closed with a sign on the door indicating it was a Yellow Zone. Isolation signs posted on the outside of the hall doors and on the doors of all occupied rooms revealed, Contact Precautions everyone must: Clean their hands, including before entering and when leaving room. Providers and staff must also: put on gloves before entry .put on gown before entry . and Droplet Precautions everyone must .make sure eyes, nose and mouth are fully covered before entry . Observation on the 100 Hall on [DATE], beginning at 7:52 AM during dining, revealed NA #1 entered Resident #296's room wearing a surgical mask, but not wearing a gown, gloves, N95 mask or eye protection, NA #1 exited the room and failed to perform hand hygiene. NA #1 removed a tray from the cart and entered Resident #297's room, without donning proper PPE. NA #1 placed the tray on the bedside table, then exited the room, and failed to perform hand hygiene and exited the 100 Hall. NA #1 returned to the 100 hall with a cup of coffee and delivered it to Resident #297's room, without donning proper PPE. NA #1 then exited Resident #297's room, and failed to perform hand hygiene and exited the 100 Hall. NA #1 then returned to the 100 hall, and without donning proper PPE, entered Resident #297's room. Observation on the 100 Hall on [DATE] at 8:01 AM, revealed NA #1 was wearing a surgical mask, delivered a tray to Resident #347's room, without donning proper PPE, then exited the room and failed to perform hand hygiene. Observation in the 600 Hall Dining Room on [DATE] at 12:39 PM, revealed that LPN #3 served 4 resident trays without performing hand hygiene. Observation on the 100 Hall during meal service on [DATE] at 12:42 PM, revealed CNA #3 passing meal trays wearing an N95 mask. CNA #3 delivered trays to Resident #296 and Resident #347's rooms without donning eye wear, gown, or gloves. CNA #3 then proceeded down the hall with tray cart, stopped outside Resident #57's room, donned a gown and gloves, but no protective eye wear or face shield and entered Resident #57's room with a meal tray. Observation in the 600 Hall Dining Room on [DATE] at 12:43 PM, revealed that LPN #3 served 5 resident trays without performing hand hygiene. During an interview on [DATE] at 1:00 PM, LPN #3 confirmed that she should have used hand sanitizer between every third resident. During an interview on [DATE] at 9:21 AM, the Director of Nursing (DON) confirmed that the staff members should not touch resident's food with their bare hands. The DON confirmed that when serving trays in the Dining Room, the staff members should sanitize their hand after each resident. During an interview conducted on [DATE] at 9:24 AM, the DON confirmed that staff should wear N95 masks and full PPE, including gown, gloves and eye protection when entering resident rooms in the Yellow Zone of the 100 Hall.

Based on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure a resident was free from a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #2) failed to administer insulin within the proper time frame related to meals for Resident #24. The failure to provide a substantial meal or snack within 15 minutes of insulin administration resulted in a significant medication error. The findings include: Review of the Geriatric Medication Handbook, tenth edition, page 43 revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Rapid-Acting Insulin Analog .ONSET .15 min [minutes] .[administer] 5-[to]10 minutes .prior to meals . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Review History Report, dated 6/16/2021, revealed .NovoLOG Mix 70/30 [MEDICATION(S)] Suspension Pen-injector (70-30) 100 UNIT/ML [millimeter]15 unit subcutaneously two times a day for Blood glucose control . Observations in the resident ' s room on 6/14/2021 at 7:02 AM, revealed LPN #2 administered 15 units of Novolog insulin to Resident #24. Observations in the resident's room on 6/14/2021 at 7:52 AM, revealed Resident #24 took her first bite of a fudge snack cake which was 50 minutes after Resident #24 received the insulin. During an interview on 6/15/2021 at 7:45 AM, the Director of Nursing (DON) confirmed that the resident should receive a snack or tray within 15 minutes of administrating insulin .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure feeding syringes were properly labeled for 2 of 4 sampled residents (Resident #47 and #298) reviewed for tube feedings. The findings include: Review of the facility's undated policy titled, Medication Administration Competency Audit, revealed .Cleans feeding syringe and return to bedside stand. Syringes are replaced after 24 hours or by state regulation . Review of the medical record, revealed Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Enteral Feed Order three times a day Bolus 1 can (8 oz [ounce]) of [MEDICATION(S)] 1.5 Cal [calorie] if < [less than] 50% [percent] of meal consumed. Change feeding tubing and syringe every 24 hours and label with date/time/feeding and rate every night shift .Flush peg tube with 30 cc [cubic centimeters] water before and after medication administration and 10 cc of water between medications every shift . Review of the June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 6/14/2021 at 9:50 AM, revealed a feeding syringe in a plastic sleeve labeled with only Resident #47's last name, not dated or timed, laying on the nightstand. Observation in the resident's room on 6/16/2021 at 8:01 AM, revealed a feeding syringe in a plastic sleeve, labeled with Resident #47's last name and dated 6/15/2021, but not timed, laying on the nightstand. Review of the medical record, revealed Resident #298 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Enteral Feed every shift [MEDICATION(S)] 1.2 Cal at 55 cc/hr [hour] x [times] 22 hours with 25 cc auto flush water .Change Gastric tube feeding bottle, water flush tubing set, and flush syringe. Label with Resident's name, date, time, and feeding infusion rate one time a day every night shift. May administer crushed medications per gastric tube . Observation in Resident #298's room on 6/16/2021 at 7:57 AM, revealed a feeding syringe in a plastic sleeve, labeled with a date of 6/15/2021, no name or time, in a plastic sleeve laying on the bedside table. Observation in Resident #298's room on 6/16/2021 at 12:15 PM, revealed a feeding syringe in a plastic sleeve labeled with a date of 6/15/021, no name or time, laying on the bedside table. During an interview on 6/16/2021 at 12:11 PM, Licensed Practical Nurse (LPN) #3 confirmed that feeding syringes should be changed daily by night shift and replaced if not labeled correctly. During an interview on 6/16/2021 at 5:58 PM, the Director of Nursing (DON) confirmed the feeding tube syringes should be changed daily by the night shift and should be labeled with the resident's name, room number, and date and time. The DON was asked what staff should do if a syringe is in the room labeled with the previous day's date. The DON stated, Put a new one on [Get a new syringe].

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by outdated and unsealed food, dust in the walk-in cooler, dented can, unlabeled and undated food, and dust on the ice machine and the water filter. The facility had a census of 93 residents with 91 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's Refrigerated Storage policy dated (MONTH) 1, (YEAR) documented, .All foods should be covered, labeled, and dated. All foods should be checked to assure that foods .will be consumed by their safe use by dates . The facility's Dry Storage policy dated (MONTH) 1, 2012 documented, .Damaged can food containers will be stored together in the storeroom in a separate and distinct area away from other food items . 2. Observations in the kitchen on 4/1/19 at 9:05 AM revealed the following: a. 1 carton grape juice with a use by date of 3/28/19 and an opened date of 3/29/19 in the reach-in cooler b. 1 carton grape juice with a use by date of 3/28/19 and an opened date of 3/25/19 in the reach-in cooler c. 1 box of unsealed rolls in the walk-in freezer d. A large amount of a gray colored dusty substance above the exit door inside the walk-in cooler e. 1 dented can of pears stored on a rack with other canned foods in the dry storage area Interview with the Dietary Manager on 4/1/19 beginning at 9:05 AM, in the Kitchen, the Dietary Manager was asked if the 2 cartons of grape juice were outdated. The Dietary Manager stated, Yes. The Dietary Manager was asked if the rolls should be completely sealed. The Dietary Manager said, Yes. The Dietary Manager was asked if dust should be above the exit door inside the walk-in cooler. The Dietary Manager stated, No. The Dietary Manager was asked if dented cans should be stored with other canned food items. The Dietary Manager stated, No. Observations in the kitchen on 4/3/19 at 3:00 PM revealed the following: a. A gray colored dusty substance on the vents of the ice machine b. A gray colored dusty substance on top of the water filter next to the ice machine c. 4 plastic containers of cereal not labeled or dated in the walk-in cooler d. A gray colored dusty substance on the wall behind stored food items inside the walk-in cooler Interview with the Dietary Manager on 4/3/19 at 3:00 PM in the Kitchen, the Dietary Manager was asked what was on the vents of the ice machine and the water filter. The Dietary Manager confirmed there was dust on the ice machine and the water filter and should not be there. The Dietary Manager was asked if food items should be labeled and dated. The Dietary Manager confirmed they should be dated and labeled. The Dietary Manager was asked if there should be dust on the walls behind stored food items inside the walk-in cooler. The Dietary Manager stated, No.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the policy related to physical restraints for 2 of 3 (Resident #35 and 80) sampled residents reviewed for physical restraints. The findings included: 1. The facility's Physical Restraint Guideline policy dated (MONTH) (YEAR) documented, .For each patient/resident to maintain his or her highest practical health or well-being in an environment that prohibits the use of restraints for discipline or convenience, and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Upon determination .a patient/resident presents with medical symptoms that may require a restraint, they are evaluated using the applicable Pre-Restraint evaluation .If it is determined a restraint is needed the least restrictive device will be considered .A physicians order is required for any physical restraint, which will include the medical symptom(s) that warrant the restraint along with observation and release time parameters .Signed consent is obtained by the patient/resident representative after a review of the risks and benefits of using a restraint .The IDT (Interdisciplinary Team) care plan needs to address: When the restraint is to be used, plans for alternative measures, periodic and routine evaluation for reduction of the device and continued need .When a patient/resident is determined to need a restraint, the Physical Restraint Elimination evaluation .will be completed at least on a quarterly basis or with a significant change in the patients/residents condition. This evaluation will assist in determining continued need or possible reduction/elimination . 2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan documented, .requires staff assistance with ADL's (activities of daily living) .Approaches .3/13/18 Low air loss mattress .Full side rails x (times) 2 d/t (due to) low air loss mattress . Review of the signed physician's orders [REDACTED]. There was no documentation a consent for siderails was obtained until 5/30/18. Observations in Resident #35's room on 5/29/18 at 9:26 AM, 11:33 AM, 12:35 PM, 1:08 PM, 3:00 PM, and 4:42 PM; and on 5/30/18 at 7:25 AM, 11:10 AM, 3:25 PM, and 5:54 PM, revealed Resident #35 lying in bed with bilateral full siderails raised. Interview with the Director of Nursing (DON) on 5/31/18 at 1:26 PM, in the conference room, the DON was asked when he expected the consent for siderails to be obtained. The DON stated, Prior to use. The DON was asked if it was acceptable that the siderail assessment and consent were not completed prior to use of bilateral full siderails for Resident #35. The DON stated, No. 3. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #80 had severe cognitive impairment per staff assessment, required extensive to total staff assistance for all ADLs, and a trunk restraint was used. The care plan last reviewed and updated 5/10/18 documented, .at risk for injury due to need for trunk restraint .Approaches .Self Release Alarm Seatbelt while up in wheelchair check every 30 minutes . The signed physician's orders [REDACTED].SELF RELEASE ALARM SEATBELT WHILE UP IN WHEELCHAIR CHECK EVERY 30 MINUTES AND RELEASE EVERY 2 HOURS . The last completed RESTRAINT ELIMINATION REVIEW was dated 1/23/17. The Interdisciplinary Therapy Data Collection Form dated 4/24/18 documented, .No significant (changes) in positioning/seatbelt . The Interdisciplinary Therapy Data Collection Form dated 5/14/18 documented, .NSG (Nursing) referral to assess safety of removing self-release alarm seatbelt . Interview with the DON on 5/31/18 at 6:35 PM, in the conference room, the DON was asked if it was acceptable that the restraint elimination assessments were not completed quarterly per the facility policy. The DON stated, Only thing I can find is we missed one by a month . Interview with Certified Nursing Assistant (CNA) #2 on 5/31/18 at 6:30 PM, on the 300 hall, CNA #2 was asked how often she checked Resident #80's seatbelt. CNA #2 stated, Every hour and a half or 2 hours .I just check to see if it's too tight or not hurting her .

Based on review of the MEDICATIONS WITH SHORTENED EXPIRATION DATES guide provided by the American Society of Consultant Pharmacist, policy review, observation and interview, the facility failed to ensure medications and biologicals were stored safely when medications were found unattended at bedside in 1 of 76 (Resident #246's room) resident rooms; and when medications were stored past their expiration dates and stored with chemicals in 2 of 5 (400 hall medication cart #1 and 600 hall medication cart #2) medication carts. The findings included: 1. Observations in Resident #246's room on [DATE] at 10:40 AM and 10:50 AM, revealed 2 [MEDICATION NAME] lock flushes and 1 sodium chloride flush lying on the bedside table unattended. Interview with the Director of Nursing (DON) on [DATE] at 3:50 PM, in the DON office, the DON was asked if was acceptable for syringes of [MEDICATION NAME] flush and normal saline to be left unattended at the bed side. The DON stated, .They should not be. 2. The facility's MEDICATION STORAGE IN THE FACILITY policy documented .CLEANING SUPPLIES, DISINFECTANTS AND OTHER HARMFUL SUBSTANCES SHOULD BE KEPT SEPARATE . Observations on the 400 hall medication cart #1 on [DATE] at 11:02 AM, revealed one bottle of Polyethylene [MEDICATION NAME] (laxative) next to a container of bleach wipes. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:05 AM, on 400 hall, LPN #1 was asked if the Polyethylene [MEDICATION NAME] should be stored next to a container of bleach wipes. LPN #1 stated, No. 3. The MEDICATIONS WITH SHORTENED EXPIRATION DATES guide provided by the American Society of Consultant Pharmacist, .([MEDICATION NAME] insulin) product must be used within 28 days after opening or removing from refrigerator . Observations on the 600 hall medication cart #2 on [DATE] at 2:10 PM, revealed a [MEDICATION NAME] flex pen with an open date of [DATE] and expiration date of [DATE]. Interview with LPN #2 on [DATE] at 2:12 PM, in the 600 hall nurse's station, LPN #2 was shown the [MEDICATION NAME] flex pen and was asked what was the expiration date. LPN #2 stated, XXX[DATE] . LPN #2 was asked if the [MEDICATION NAME] flex pen should still be in the medication cart if it was expired. LPN #2 stated, .must have missed that one . Interview with the Director of Nursing (DON) on [DATE] at 8:31 AM, in the conference room, the DON was asked should Polyethylene [MEDICATION NAME] be stored next to a container of bleach wipes in the same compartment. The DON stated, .should be in a separate compartment . The DON was asked should there be expired medication on the medication cart. The DON stated, .it should not . The DON was asked if a [MEDICATION NAME] pen was opened on [DATE] how long was it good for. The DON stated, .twenty-eight days.

Based on medical record review, observation, and interview, the facility failed to assess 1 of 1 (Resident #91) resident for self-administration of medication. The findings included: Review of the medical record revealed Resident #91 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. a. .IPRAT-ALBUT ([MEDICATION NAME]/[MEDICATION NAME]) 0.5-3(2.5) MG (milligrams)/3ML (milliliters) INHALANT TWICE DAILY . b. .[MEDICATION NAME] SUL (SULFATE) 2.5 MG/3ML SOLN (SOLUTION) INHALANT EVERY 6 HOURS WHILE AWAKE . Observations in Resident #91's room on 5/29/18 at 9:44 AM and 5/30/18 at 4:15 PM, revealed Resident #91 lying in bed with a face mask over her binasal oxygen and receiving a nebulized breathing treatment, unattended by nursing staff. Interview with the Director of Nursing (DON) on 5/31/18 at 3:50 PM, in the DON office, the DON was asked if it was acceptable for a resident to self- administer or leave a resident unattended while receiving a nebulized breathing treatment. The DON stated, If they were safe. I don't think I have anyone to my knowledge. I don't have anyone safe to administer breathing treatments. The DON was asked if a resident should be left unattended while receiving a nebulized breathing treatment. The DON stated, No, unless she was assessed. The DON looked at medical record and confirmed there was no self- administration form on the chart and stated, I did not see (documentation) she was safe to administer in (Resident #91's) chart.

Based on policy review, medical record review, observation, and interview the facility failed to maintain residents' dignity for 1 of 19 (Resident #29) sampled residents. The findings included: The facility's Privacy policy documented, .Each patient/resident has the right to personal privacy of his/her physical body .Each patient/resident must be provided individualized care with dignity and respect . Medical record review revealed Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #29's room on 5/29/18 at 9:50 AM, and 5/30/18 at 8:03 AM, revealed Resident #29 with no shirt or gown on with brief and Percutaneous Endoscopic Gastrostomy (PEG) site exposed with the resident's door open. Observations in Resident #29's room on 5/30/18 at 10:40 AM, revealed Certified Nursing Assistant (CNA) #1 at bedside bathing Resident #29. Resident #29 was lying in bed, naked and completely exposed with the window blinds open. Interview with the Director of Nursing (DON) on 5/31/18 at 3:50 PM, in the DON office, the DON was asked if it was acceptable for a resident to be completely exposed from the hallway, and if a resident should be completely exposed during a bed bath with the blinds left open. The DON stated, If a resident is completely exposed, privacy should be ensured.

Based on medical record review and interview, the facility failed to ensure the physician and responsible party were notified of a new wound for 1 of 3 (Resident #30) sampled residents reviewed for pressure ulcers. The findings included: Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Wound Assessment Report dated 5/14/18 documented, .Wound Type .unspecified ulcer .Left Lateral Malleolus .Date wound identified .5/2/2018 .Date Physician notified .5/14/2018 .Date Responsible Party notified .5/14/2018 . Interview with the Director of Nursing (DON) on 5/31/18 at 1:28 PM, in the conference room, the DON was asked when he would expect the physician to be notified of a wound found on admission. The DON stated, On admission. The DON was asked if it was acceptable for the physician to be notified on 5/14/18 of a wound identified on 5/2/18. The DON stated, Not if that was the case .

Based on policy review, medical record review, review of the facility's investigation, and interview, the facility failed to follow the abuse policy and failed to thoroughly investigate misappropriation for 1 of 3 (Resident #69) residents reviewed for abuse. The findings included: 1. The facility's Abuse Policy documented, .Misappropriation of patient/resident property .means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/patient's belongings or money without the resident/patient's consent .all alleged violations .which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident/patient property .are reported immediately to the Administrator/Director of Nursing .Such violations will also be reported to state agencies and law enforcement in accordance with existing state law. The Administrator/Director of Nursing will direct a thorough investigation . 2. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 3. Review of the facility investigation revealed on 4/9/18 at 7:00 AM, during the morning narcotic count, it was reported a medication card containing [MEDICATION NAME] salts ([MEDICATION NAME]) 20 mg appeared to have been tampered with, and 5 pills had been removed and replaced with another medication ([MEDICATION NAME]). A total of 4 nurses (Licensed Practical Nurse (LPN) #3, LPN #5, LPN #7, and Registered Nurse (RN) #1) were sent for drug testing. Review of the working schedule revealed a total of 6 nurses (LPN #3, LPN#4, LPN #5, LPN#6, LPN #8, and RN #1) had access to the medication cart which contained the missing [MEDICATION NAME] during the time period of 4/4/18-4/9/18. No drug screens were performed on LPN #4, #6, or #8. Interview with the Director of Nursing (DON) on 5/31/18 at 2:56 PM, in the conference room, the DON was asked how they determined which nurses should be sent for drug screening. The DON stated, No other second shift or first shift nurses were tested .We determined that it most likely happened on third shift since that is the shift the medication is given on. The DON was asked if nurses working other shifts had access to the medications and knowledge of its presence on the cart. The DON stated, Yes . Interview with the Administrator on 5/31/18 at 4:53 PM, in the conference room, the Administrator was asked if she thought it was appropriate that only the third shift nurses were drug screened when nurses on other shifts also had access to the medication. The Administrator stated, .Corporate told us to test the nurses with the most access and opportunity. 4. Interview with RN #1 on 5/30/18 at 5:25 PM, in the conference room, RN #1 confirmed that on 4/9/18 at approximately 6:30 AM, she noticed that Resident #69's [MEDICATION NAME] appeared to have been tampered with. She reported this to the oncoming nurse and asked her to notify the DON. RN #1 was asked what the policy stated about notification of misappropriation. RN #1 stated, .Policy is probably to call immediately, but I had to take my child to school . Interview with the Administrator on 5/31/18 at 4:53 PM, in the conference room, the Administrator was asked if it was appropriate for the nurses to wait until Administration arrived in the building to report the medication misappropriation. The Administrator stated, Technically it should have been reported immediately. 5. Interview with the Administrator on 5/30/18 at 3:30 PM, in the Administrator's office, the Administrator asked if a police report was filed related to the misappropriation. The Administrator stated, No, I did not call the police . Interview with the Administrator on 5/31/18 at 4:53 PM, in the conference room, the Administrator was asked if she considered a staff member removing a controlled substance from the building a crime such as theft. The Administrator stated, I would consider it misappropriation. The Administrator was asked if she would consider misappropriation of other items such as cash belonging to a resident to be a theft or a crime. The Administrator stated, By definition, Yes

Based on medical record review, observation, and interview, the facility failed to accurately identify, assess, and provide treatment as ordered for pressure ulcers for 1 of 3 (Resident #30) sampled residents reviewed for pressure ulcers. The findings included: Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden Risk Assessment Report dated 5/2/18 revealed Resident #30 was at moderate risk for pressure ulcer development. The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 5/9/18 documented, .SKILLED NURSE TO PROVIDE INSTRUCTIONS RELATED TO DECUBITUS ULCER CARE . The care plan with a revision date of 5/24/18 documented, .at risk for pressure ulcers .Approaches .Treatment per Md (physician) orders (open area/left lateral ankle) .5/22/2018 . The physician's telephone order dated 5/15/18 documented, .Wound cleanser to open area on top of left .ankle, apply Santyl, cover (with) island dressing .(Change) daily et (and) PRN (as needed) .Repeat tx (treatment) to lateral aspect of (left) ankle . The physician's telephone order dated 5/22/18 documented, .D/C (discontinue) tx's to (left) ankle .Wound cleanser to (left) lat (lateral) malleolus apply [MEDICATION NAME] (and) cover (with) foam dressing .(Change) EOD (every other day) (and) PRN . The (MONTH) (YEAR) Treatment Administration Record (TAR) revealed no documentation the treatment for [REDACTED]. The Wound Assessment Report dated 5/14/18 documented, .Wound Type .unspecified ulcer .Left Lateral Malleolus .Date wound identified .5/2/2018 .Measurements .2.50 cm (centimeters) .2.50 cm .0.10 cm .Date Physician notified .5/14/2018 .Date Responsible Party notified .5/14/2018 . The facility was unable to provide an initial wound assessment or any other wound assessments for the ankle wounds from 5/2/18 - 5/13/18, or 5/15/18 - 5/31/18. The Departmental Notes documented, .5/2/2018 .Nursing .Assessment .left outer ankle half dollar size open area, top of left foot 1X1cm scabbed area .5/13/2018 .Nursing .While dressing resident CNA noticed some sores on resident;s (resident's) left foot .(2 inches by 1.5 inches) with some necrotic skin noted to ankle .(1 inch by 0.75 inches) on torsal (tarsal) bone .Made a (note in) treatment book for treatment nurse to evaluate and decide treatment .5/15/18 .Nursing .Late entry for 5/14/2018--Resident noted with 2 open areas to left lateral ankle and top of left ankle. New orders received to clean areas with wound cleanser, apply santyl and cover with island dressings .Change daily and as needed . Observations in Resident #30's room on 5/31/18 at 11:01 AM, revealed Resident #30 lying in bed. Resident #30 had a large open ulcer on the left ankle directly over the lateral malleolus, and a smaller open ulcer to the top/anterior area of the left ankle with yellow slough in the center of the wound bed. Interview with the Wound Care Nurse on 5/31/18 at 11:02 AM, in Resident #30's room, the Wound Care Nurse was asked what type of wound was on Resident #30's ankle. The Wound Care Nurse stated, Well, it's unspecified. She came back from the hospital with the area, and hospice is seeing her. She didn't have any kind of [DIAGNOSES REDACTED]. The Wound Care Nurse was asked whether he thought it was a pressure ulcer. The Wound Care Nurse stated, It could be . Interview with the Hospice Registered Nurse (RN) on 5/31/18 at 11:03 AM, in the conference room, the Hospice RN was asked if Resident #30 had the ankle wounds when she was admitted to hospice. The Hospice RN stated, Yes. The Hospice RN was asked if she had seen the wounds. The Hospice RN confirmed she had. The Hospice RN was asked what type of wounds they were. The Hospice RN stated, I personally think they are pressure . Interview with the Director of Nursing (DON) on 5/31/18 at 1:28 PM, in the conference room, the DON was asked if he had seen Resident #30's ankle wounds. The DON stated, I think I saw it one time. The DON was asked what type of wounds they were. The DON stated, I'd have to pull her wound notes .wound nurse .put abrasion to area .I would need to clarify with him what that is being documented as . The DON was asked when he would expect treatment to begin if the wound was identified on 5/2/18. The DON stated, On identification. The DON was asked when he would expect the physician to be notified of a wound found on admission. The DON stated, On admission. The DON was asked if it was acceptable for the physician to be notified on 5/14/18 of a wound identified on 5/2/18. The DON stated, Not if that was the case . Interview with the Wound Care Nurse on 5/31/18 at 1:48 PM, in the conference room, the Wound Care Nurse was asked when the wounds to Resident #30's ankle were identified. The Wound Care Nurse stated, She was admitted with the wound, but her wound on admission was not open. It was a scabby area. The Wound Care Nurse was asked if the physician should be notified. The Wound Care Nurse stated, Yes .I didn't initiate treatment until the 14th (5/14/18) because that was when it was brought to me that the scabby area had opened up . There was no documentation the physician was notified or that treatment orders had been obtained for the wound identified on 5/2/18 until 5/14/18.

Based on review of the Pharmacy Consultant Pharmacist Services Provider Requirements, medical record review and interview, the facility failed to ensure the pharmacist reported irregularities in the drug regimen in a timely manner for 1 of 5 (Resident #60) sampled residents and the pharmacist failed to report irregularities, including duplicative medication and a lack of indicators for use of medication, for 1 of 5 (Resident #80) sampled residents reviewed for unnecessary medications. The findings included: 1. The Pharmacy Consultant Pharmacist Services Provider Requirements regarding the expectation of the pharmacist documented, .review medication administration records and physician orders [REDACTED]. 2. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. On 12/09/16, an order to initiate Melatonin 3 milligrams every night was written, at the pharmacist's recommendation. Resident #60 received 9 milligrams of Melatonin from 12/9/16 through 12/12/16 (four doses). On 12/13/16, an order was written to discontinue the Melatonin 3 milligrams every night. Review of the psychiatry and pharmacy recommendations revealed the pharmacist conducted the medication review on 11/1/16 but did not send the recommendation for 3 milligrams of Melatonin to the facility until 11/27/16. The physician ordered 6 milligrams of Melatonin on 11/22/16 after the pharmacist reviewed the resident's medications but before the pharmacist sent the recommendation. The Physician's Assistant agreed to the pharmacist's recommendation based on a recommendation that was out of date. Interview with the Director of Nursing (DON) on 5/16/17 at 2:54 PM, at the nurse's station, the DON was asked to explain the order for 3 milligrams of Melatonin on 12/9/16 and why it was added to the 6 milligrams already given. The DON stated, .in reviewing the record, it appeared the order for 3 milligrams was recommended by the pharmacist after the monthly medication regimen review and because the physician had already ordered 6 milligrams, the two doses were combined. Interview with the Administrator on 5/16/17 at 3:10 PM, at the nurse's station, the Administrator reviewed the pharmacy recommendation and acknowledged it appeared the monthly medication regimen review was conducted almost a month prior to the facility receiving the recommendations from the pharmacist. Interview with the DON on 5/16/17 at 3:23 PM, at the nurse's station, the DON was asked to review the Pharmacy recommendation. The DON acknowledged the order for 3 milligrams of Melatonin was based on a pharmacy recommendation that was not current. The DON stated, he had not previously identified the pharmacist was conducting monthly medication regimens and not submitting them to the facility for up to a month after. The DON also stated, I have reviewed several other pharmacy recommendations and have identified that it is a common occurrence. We will talk to the pharmacist about that .they (the pharmacist) review throughout the month and send them all at once. When asked how long after the monthly medication regimen review was conducted the facility expected to receive the report, the DON stated, I would think within a week or two at the most. The facility's failure to ensure the pharmacist provided recommendations in a timely manner contributed to Resident #60 receiving a higher than recommended dose of Melatonin. 2. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The pharmacist conducted a monthly medication regimen review on 4/02/17. There was no indication the pharmacist identified the use of the Trazodone and Melatonin at night as a possible concern of duplicative therapy. Interview with the DON on 5/16/17 at 3:15 PM, at the nurse's station, the DON stated, I did not find any indication the pharmacist made any recommendations related to the use of the Trazodone and Melatonin.

Based on medical record review and interview, the facility failed to promptly notify the attending physician of abnormal lab results for 1 of 19 (Resident #40) sampled residents reviewed of the 31 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 2/2/17 documented, .Obtain UA (urinalysis) c (with) C & S (culture and sensitivity) . A nurse's note dated 2/3/17 documented, .Urine obtained for UA via sterile in and out cath (catheterization) . Review of the urinalysis results dated 2/3/17 revealed the following abnormal values: Glucose 50 MG/DL (milligrams per deciliter) High with reference range of Negative Blood Small with reference range of Negative Leukocytes Esterase Moderate with reference range of Negative White Blood Cell 5-15 with reference range of 0-4 Red Blood Cell 5-15 with reference range of 0-4 Squamous [MEDICATION NAME] 5-15 with reference range of 0-4 Bacteria Few with reference range of None Amorphous Crystal Rare with reference range of None The urinalysis results contained a handwritten note that documented, faxed MD (Medical Doctor) 2/3/17 . Review of the urine culture and sensitivity results dated 2/5/17 revealed greater than 100,000 CFU/ML (Colony Forming Units per milliliter) [MEDICATION NAME] species. The facility was unable to provide documentation that the physician had been notified of the results of the culture and sensitivity. Interview with the Director of Nursing (DON) on 5/16/17 at 4:01 PM, in the nursing office, the DON was asked to describe what happened regarding the urinalysis results for Resident #40. The DON stated, We got an order for [REDACTED]. The results of the CBC and CMP were faxed to him on the 13th. On the 15th, he went out to the hospital for an acute change in status per the family's request . The DON was asked if anyone followed up with the physician regarding the UA and C& S results. The DON stated, No .I don't know if he looked at the results when he was here on the 9th or not, but it was in the chart . Telephone interview with Resident #40's Primary Care Doctor (PCP) on 5/17/17 at 8:52 AM, the PCP was asked if he was notified of the UA and C& S results for Resident #40. The PCP stated, If I was it wasn't before he went in the hospital (2/15/17) The PCP was asked if he had been notified of the results, would he have treated Resident #40 for a Urinary Tract Infection. The PCP stated, I don't know if I would have treated him or not; he wasn't symptomatic . Interview with the DON on 5/17/17 at 3:24 PM, in the conference room, the DON was asked what the facility policy was regarding notifying a physician about abnormal lab results. The DON stated, We don't have a policy, but my expectation is that we notify them immediately to 72 hours depending on the symptoms .

Based on medical record review and interview, the facility failed to ensure 2 of 5 (Resident #60 and 80) sampled residents reviewed for unnecessary medications had adequate indicators for use of all medications, and received medications in appropriate doses. The findings included: 1. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. On 12/9/16, an order to initiate [MEDICATION NAME] 3 milligrams every night was written, at the pharmacist's recommendation. Resident #60 received 9 milligrams of [MEDICATION NAME] nightly from 12/9/16 through 12/12/16 (four doses). Review of the psychiatry and pharmacy recommendations revealed the pharmacist conducted the medication review on 11/1/16 but did not send the recommendation for 3 milligrams of [MEDICATION NAME] to the facility until 11/29/16. The physician ordered 6 milligrams of [MEDICATION NAME] on 11/22/16 after the pharmacist reviewed the resident's medications but before the pharmacist sent the recommendation. The Physician's Assistant agreed to the pharmacist's recommendation based on a recommendation that was out of date. Interview with the Director of Nursing (DON) on 5/16/17 at 2:54 PM, at the nurse's station, the DON was asked to explain the order for 3 milligrams of [MEDICATION NAME] on 12/9/16 and why it was added to the 6 milligrams already given. The DON stated, In reviewing the record, it appeared the order for 3 milligrams was recommended by the pharmacist after the monthly medication regimen review and because the physician had already ordered 6 milligrams, the two doses were combined .that isn't clear in the way the order was written, I can see why you were confused. I was too. We will work on clearing that up, will talk to the physician about how the orders were written. The DON confirmed Resident #60 had received [MEDICATION NAME] 9 milligrams nightly from 12/9/16 through 12/12/16. Interview with the Administrator on 5/16/17 at 3:10 PM, at the nurse's station, the Administrator confirmed the monthly medication regimen review was conducted almost a month prior to the facility receiving the recommendations from the pharmacist. Interview with the DON on 5/16/17 at 3:23 PM, at the nurse's station, the DON was asked to review the Pharmacy recommendation. The DON acknowledged the order for 3 milligrams of [MEDICATION NAME] was based on a pharmacy recommendation that was not current. He stated 9 milligrams of [MEDICATION NAME] was very high and would not be recommended for an elderly person such as Resident #60. The facility's failure to ensure the resident was not prescribed the same medication twice resulted in the administration of an unnecessary medication. 2. Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. None of these orders included the indication for use with the order. Interview with the DON on 5/16/17 at 3:15 PM, at the nurse's station, the DON was asked for justification for the newly ordered [MEDICATION NAME] in addition to the [MEDICATION NAME]. The DON stated. There was no indication noted for the [MEDICATION NAME] in the resident's record, so it might be giving it for depression and not [MEDICAL CONDITION] .it's not clear. When noted the resident also received the anti-depressants [MEDICATION NAME] and [MEDICATION NAME], the DON was unable to explain the use of the three anti-depressants. He was unable to state if the medications were duplicative since the indications for use of the medications were not clearly identified.

Based on policy review, medical record review, and interview, it was determined the facility failed to ensure that a resident at risk for falls had interventions implemented after each fall to prevent further falls for 1 of 14 (Resident #1) sampled residents identified with falls. The failure to develop interventions after each fall to prevent further falls, resulted in actual harm when Resident #1 had subsequent a fall on 10/11/10 with a laceration to the right eyebrow and a subsequent fall on 11/22/10 with a hematoma with a puncture wound to the back of her head. The findings included: 1. Review of the facility's "RESIDENT/VISITOR INCIDENT INVESTIGATION" policy documented, "...Policy Statement... It (incident investigation) will include what must be done to prevent recurrence..." Medical record review for Resident #1 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's notes documented Resident #1 had falls on 6/9/10, 8/3/10, 10/9/10, 10/11/10, 11/21/10, 11/22/10, 12/20/10 and 1/31/11 with no new interventions put in place after each fall to prevent further falls. Review of a nurse's note documented the following: a. 6/9/10 at 7:30 PM, "Notified per CNA (certified nursing assistant) that res. (resident) was found on floor ... Res. got up & (and) ambulated s (without) problem..." b. 8/3/10 at 4:30. "Resident noted lying in (on) floor on L (left) side. 0 (no) c/o (complaint) pain voiced 0 Bruising..." c. 10/9/10 655 PM, "Res (up) ad lib in hallway... Another res. was holding (Resident #1's) hand @ (at) the time ... kept her (Resident #1) from falling hard. Res. landed c (with) hands on floor..." d. 10/11/10 at 2:45 PM, "Resident noted lying on floor... Abrasion to R (right) eye noted. Cleaned it dressed c (with) steri-strips..." Review of the incident report dated 10/11/10 at 2:45 PM documented a fall in the dining room with laceration of the right eye. e. 11/21/10 at 6:45 AM, "...CNA states "She said she fell trying to go to bathroom... this nurse observed an abrasion 4 in (inch) x (by) 3 in on resident's lf (left) lower back. Area very red in color... felt a small raised area on the back left of resident's head..." f. 11/22/10 at 10:30 PM, "...Res (resident) noted standing in room c blood coming from head. Assessment reveals Lg (large) hematoma c sm (small) puncture wound to back of head..." g. 12/20/10 at 5:30 PM, "CNA (certified nursing assistant) observed resident sitting in floor of dayroom. Large 3 1/2" x 1 1/4" bruise noted to upper R inside arm..." h. 1/31/11 at 8:00 PM, "resident was bent over as to touch shoes... When standing back up resident lost her footing landing on her bottom. She hit her R arm on the wood rail causing a skin tear..." During an interview in the conference room on 4/6/11 at 9:45 AM, the Director of Nursing (DON) was asked where interventions to prevent further falls would be documented. The DON stated, "They should be on the care plan." The failure to develop interventions after each fall to prevent further falls, resulted in actual harm when Resident #1 had subsequent a fall on 10/11/10 with a laceration to the right eyebrow and a subsequent fall on 11/22/10 with a hematoma with a puncture wound to the back of her head.

Based on medical record review and interview, it was determined the facility failed to ensure care plans were revised to reflect interventions for falls for 6 of 23 (Residents #1, 10, 11, 17, 19 and 20) sampled residents. The failure to develop interventions after each fall to prevent further falls, resulted in actual harm when Resident #1 had subsequent a fall on 10/11/10 with a laceration to the right eyebrow and a subsequent fall on 11/22/10 with a hematoma with a puncture wound to the back of her head. The findings included: 1. Review of the facility's "RESIDENT/VISITOR INCIDENT INVESTIGATION" policy documented, "...Policy Statement... It (incident investigation) will include what must be done to prevent recurrence..." Medical record review for Resident #1 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurse's notes documented Resident #1 had falls on 6/9/10, 8/3/10, 10/9/10, 10/11/10, 11/21/10, 11/22/10, 12/20/10 and 1/31/11 with no new interventions put in place after each fall to prevent further falls. Review of a nurse's note documented the following: a. 6/9/10 at 7:30 PM, "Notified per CNA (certified nursing assistant) that res. (resident) was found on floor ... Res. got up & (and) ambulated s (without) problem..." b. 8/3/10 at 4:30. "Resident noted lying in (on) floor on L (left) side. 0 (no) c/o (complaint) pain voiced 0 Bruising..." c. 10/9/10 655 PM, "Res (up) ad lib in hallway... Another res. was holding (Resident #1's) hand @ (at) the time ... kept her (Resident #1) from falling hard. Res. landed c (with) hands on floor..." d. 10/11/10 at 2:45 PM, "Resident noted lying on floor... Abrasion to R (right) eye noted. Cleaned it dressed c (with) steri-strips..." Review of the incident report dated 10/11/10 at 2:45 PM documented a fall in the dining room with laceration of the right eye. e. 11/21/10 at 6:45 AM, "...CNA states "She said she fell trying to go to bathroom... this nurse observed an abrasion 4 in (inch) x (by) 3 in on resident's lf (left) lower back. Area very red in color... felt a small raised area on the back left of resident's head..." f. 11/22/10 at 10:30 PM, "...Res noted standing in room c blood coming from head. Assessment reveals Lg (large) hematoma c sm (small) puncture wound to back of head..." g. 12/20/10 at 5:30 PM, "CNA (certified nursing assistant) observed resident sitting in floor of dayroom. Large 3 1/2" x 1 1/4" bruise noted to upper R inside arm..." h. 1/31/11 at 8:00 PM, "resident was bent over as to touch shoes... When standing back up resident lost her footing landing on her bottom. She hit her R arm on the wood rail causing a skin tear..." During an interview in the conference room on 4/6/11 at 9:45 AM, the Director of Nursing (DON) was asked where interventions to prevent further falls would be documented. The DON stated, "They should be on the care plan." The failure to develop interventions after each fall to prevent further falls, resulted in actual harm when Resident #1 had subsequent a fall on 10/11/10 with a laceration to the right eyebrow and a subsequent fall on 11/22/10 with a hematoma with a puncture wound to the back of her head. 2. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the nurses notes dated 2/7/11 documented the resident had a fall with no injuries. Review of the care plan last updated 2/12/11 had no documentation of a fall on 2/7/11 nor were there any interventions put in place to prevent further falls. 3. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the investigation reports dated 1/16/11 and 1/23/11 documented Resident #11 had a fall with no injuries. Review of the care plan last updated 2/17/11 had no documentation of the falls nor were there any interventions put in place to prevent further falls. 4. Medical record review for Resident #17 documented an admitted 2/8/10 with [DIAGNOSES REDACTED]. Review of the "72-Hour Documentation for Incidents" dated 4/6/10 to 4/9/10 documented a fall on 4/6/10 with no injury. Review of the care plan dated 2/8/10 had no documentation of revision to include interventions for the fall on 4/6/10. 5. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "72-Hour Documentation for Incidents" and the nurses notes documented a fall on 12/20/10 with no injuries, a fall on 2/8/11 with no injuries, and a fall on 3/23/11 with no injuries. Review of the care plan with a problem onset date of 7/11/08 and updated 3/3/11 had no documented interventions for the falls on 12/20/10, 2/8/11 or 3/23/11. During an interview in the conference room on 4/6/11 at 10:15 AM, the Assistant Director of Nursing (ADON) confirmed there was no documentation of interventions for the falls on 12/20/10, 2/8/11 or 3/23/11. The ADON stated, "... (interventions) should be on the care plan." 6. Medical record review for Resident #20 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "72-Hour Documentation for Incidents" dated 6/25/10 through (-) 6/28/10 documented a fall on 6/25/10 with no injury. The "72-Hour Documentation for Incidents" dated 7/16/10-7/19/10 documented a fall on 7/16/10 with no injury. The "72-Hour Documentation for Incidents" dated 8/30/10-9/2/10 documented a fall on 8/30/10 with no injury. The "72-Hour Documentation for Incidents" dated 10/9/10-10/12/10 documented a fall on 10/9/10 with no injury. Review of the care plan dated 6/18/05 and updated 2/10/11 revealed Resident #20 had no revisions to include interventions for falls on 6/25/10, 7/16/10, 8/30/10 and 10/9/10.