Every finding on record at Dover Center for Health & Rehabilitation

Based on observation, interview, and record review, it was determined that the facility failed to determine if self-administration of medications was clinically appropriate for 1 of 4 residents reviewed for choices in a final sample of 20 residents. (Resident identifier is #68.) Findings include: Observation on 4/30/25 at approximately 8:35 a.m. of Resident #68's bedside table revealed a bottle of Refresh tears and Fluticasone nasal spray. Interview on 4/30/25 at approximately 8:35 a.m. with Resident #68 revealed that the medication has been on his/her bedside table since he/she was admitted about a month ago. Further interview revealed that he/she self-administers the medications 1-2 times a day. Observation on 4/30/25 at approximately 11:15 a.m. of Resident #68's bedside table revealed a bottle of Refresh tears and Fluticasone nasal spray. Review on 5/1/25 of Resident #68's medical record revealed that there was no assessment completed to determine if self-administration of medications is clinically appropriate for Resident #68. There was no physician orders for Refresh tears or Fluticasone nasal spray Interview on 5/1/25 at approximately 10:15 a.m. with Staff D (Licensed Practical Nurse) confirmed the above findings. Review on 5/1/25 of the facility policy titled Clinical Services, revision Date 10/2024 revealed: To maintain the residents' right to maintain a high level of independence, residents who request to self-administer medications are permitted to do so if the center's self-evaluation has determined that the practice would be safe for the resident and there is a health care provider's order to self-administer medication(s)/treatments. Procedure, 1. If the resident requests to self-administer medications, a Self-Administration Evaluation is completed by the licensed nurse to evaluate the resident's safety and understanding of their medication/treatments. 3. Upon obtaining the order for the medication/treatment the licensed nurse will instruct the resident in the process of storing the medications safely which should include a locked box .

Based on interview and record review, it was determined that the facility failed to develop and implement a comphrensive care plan for 1 of of 3 residents reviewed for accidents in a final sample of 20 residents (Resident Identifier is #6). Findings include: Review on 5/1/25 of Resident #6's progress notes revealed the following notes: On 3/19/25 at 11:34 a.m., Resident noted to have scissors in [pronoun omitted ] room. Resident states [pronoun omitted] got them from [pronoun] niece. [Name omitted] and ADON [Assistant Director of Nursing] attempted to retrieve scissors from resident but [pronoun omitted] refused multiple times. On 3/19/25 at 12:14 a.m., Scissors and stapler obtained from Resident's room and kept in UM [unit manager] office for safety . On 4/12/25 at 10:58 a.m., This writer was notified by MNA [Medication Nursing Assistant] that resident took [pronoun omitted] scissors and an ensure from med cart when [pronoun omitted] stepped away. Scissors were found hiding inside resident's pillowcase. When staff removed scissors from resident's room, [pronoun omitted] began to threaten the staff. On 4/24/25 at 10:16 a.m., Resident found attempting to get into staff offices and locked cabinets and room . Interview on 4/30/25 at 8:45 a.m. with Staff J (Licensed Nursing Assistant) that Resident #6 wanders in and out of resident's room and takes things from other residents. Interview further revieaed that Resident #6 had a history of being physically threatening to residents and staff. Staff J stated that he/she was not assigned to care for Resident #6 anymore because Resident #6 threatened to stab him/her. Observation on 5/2/25 between 9:00 a.m. and 9:10 a.m. of the medication cart #4 on the TCU unit revealed that there were scissors left unattended on the medication cart while Staff K (Registered Nurse) was in a resident's room administering medication. Interview on 5/2/25 at 9:11 a.m. with Staff K confirmed that he/she left the scissors on top of medication cart #4 and the scissors were not secured. Review on 5/2/25 of Resident #6's comprehensive care plan revealed that there was no focus, goals, or interventions in place for Resident #6's behaviors of taking items that can pose a safety risk to themself or others or physically threatening residents and staff. Interciew on 5/2/25 at approximately 11:00 a.m. with Staff E (Director of Nursing) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards for medication storage and administration for 1 of 3 medication carts observed. (Resident identifier is #69.) Findings include: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 608 . Right Medication . Because the nurse who administers the medication is responsible for any errors related to it, nurses administer only the medications they prepare. You cannot delegate preperation of medication to another person and then administer the medication to a patient . Observation on 4/30/25 at approximately 7:30 a.m. of the medication cart TCU #4 with Staff B (Registered Nurse) revealed an unlabeled medication cup with pills in the top drawer. Further observation revealed that the medication cup was tipped on it's side and 3 unidentifiable pills were on the side of the medication cup on the bottom of the medication cart drawer. Interview on 4/30/25 at approximately 7:30 a.m. with Staff B confirmed the above findings and that the unlabeled medication cup with pills were for Resident #69. Review on 4/30/25 of Resident #69's April 2025's MAR (Medication Administration Record) revealed the following 6:00 a.m. medications signed as administered on 4/30/25: Bactrim DS (Double Strength) tablet 800-160 mg (milligrams) Cholecalciferol Tablet 50 mcg (micrograms) Ferrous Sulfate Tablet 325 mg Furosemide Tablet 20 mg Loratidine Tablet 10 mg Multivitamin Tablet Omeprazole Capsule Delayed Release 40 mg Oxycodone Tablet 5 mg Prednisone Tablet 20 mg Reglan Tablet 5 mg Interview on 4/30/25 at approximately 12:00 p.m. with Staff B confirmed the medication in the medicine cup was for Resident #69 and that Staff B was not the nurse who prepared the medications. Further interview with Staff B revealed that the night nurse prepared the medications for Resident #69 and asked him/her to administer the medications to the resident. Staff B administered them to Resident #69. Interview on 4/30/25 at approximately 1:45 p.m. with Staff C (Licensed Practical Nurse) night nurse confirmed that they had prepared Resident #69's morning medications and left them in the top drawer of the medication cart to be administered by Staff B on day shift. Further interview with Staff C confirmed that Resident #69's Oxycodone was in the medication cup and was not double locked. Review on 4/30/25 of the facility policy titled, Clinical Services, revision date 9/23/24, revealed the following . Do not pre-pour medications: administer them as they are prepared. Administration of medications must be documented at the time of the medication pass .

Based on observation, interview, and record review, it was determined that the facility failed to maintain an environment free of accident hazards by not securing scissors when not in use for 1 of 3 residents reviewed for accidents in a final sample of 20 residents (Resident Identifier is #6). Findings include: Observation on 4/30/25 at 9:30 a.m. on the Transitional Care Unit (TCU) revealed that Resident #6 was ambulating with a rolling walker around the TCU unit going in and out of other resident's rooms. Review on 5/1/25 of Resident #6's progress notes revealed the following notes: On 3/19/25 at 11:34 a.m., Resident noted to have scissors in [pronoun omitted ] room. Resident states [pronoun omitted] got them from [pronoun] niece. [Name omitted] and ADON [Assistant Director of Nursing] attempted to retrieve scissors from resident but [pronoun omitted] refused multiple times. On 3/19/25 at 12:14 a.m., Scissors and stapler obtained from Resident's room and kept in UM [unit manager] office for safety . On 4/12/25 at 10:58 a.m., This writer was notified by MNA [Medication Nursing Assistant] that resident took [pronoun omitted] scissors and an ensure from med cart when [pronoun omitted] stepped away. Scissors were found hiding inside resident's pillowcase. When staff removed scissors from resident's room, [pronoun omitted] began to threaten the staff. On 4/24/25 at 10:16 a.m., Resident found attempting to get into staff offices and locked cabinets and room. Resident redirected and educated on staying in resident areas. Resident states I don't care, I'll find the code. Interview on 4/30/25 at 8:45 a.m. with Staff J (Licensed Nursing Assistant) that Resident #6 wanders in and out of resident's room and takes things from other residents. Interview further revieaed that Resident #6 had a history of being physically threatening to residents and staff. Staff J stated that he/she was not assigned to care for Resident #6 anymore because Resident #6 threatened to stab him/her. Observation on 5/2/25 between 9:00 a.m. and 9:10 a.m. of the medication cart #4 on the TCU unit revealed that there were scissors left unattended on the medication cart while Staff K (Registered Nurse) was in a resident's room administering medication. Interview on 5/2/25 at 9:11 a.m. with Staff K confirmed that he/she left the scissors on top of medication cart #4 and the scissors were not secured.

Based on interview and record review, it was determined that the facility failed to ensure that the provider reviewed irregularities identified by the pharmacist during the monthly Pharmacy Medication Regimen Review (MRR) timely for 3 of 5 residents reviewed for unnecessary medications (Resident Identifiers are #1, #51, and #55). Findings include: Resident #1 Review on 5/2/25 of Resident # 1's Pharmacy MRR, dated 3/4/25, revealed the following recommendation: Resident has an order for Gabapentin 200 mg (milligrams), twice daily for, 'post herpetic neuralgia'. This order was initiated 9-16-2024. Please review if this scheduled medication for pain remains necessary for the resident. Further review of the MRR revealed that the physician did not address the recommendation until 5/1/25. Resident #51 Review on 5/2/25 of Resident #51's Pharmacy MRR, dated 3/4/2025, revealed the following recommendation: Resident is receiving Lipitor 40 mg. Please consider lipid panel with next resident lab draw and at least annually thereafter. Further review revealed that the physician did not address the recommendation until 5/1/25. Interview on 5/2/25 at approximately 10:30 a.m. with Staff E (Director of Nursing) confirmed the above findings for Resident #1 and #51. 40522 Resident #55 Review on 5/1/25 of Resident #55's monthly Medication Regimen Review, dated 1/6/25, revealed that Resident #55 was receiving Protonix since 8/2023 and a pharmacist recommendation to consider tapering to discontinue the Protonix medication or if no change to the Protonix medication to indicate medical necessity of current therapy and potential risk versus current therapeutic benefit in the progress note. Further review of the MRR revealed that there was no documentation that the provider reviewed and/or addressed this recommendation. Review on 5/1/25 of Resident #55's active physician's orders revealed an order for Protonix delayed release 40 milligrams by mouth once a day for acid reflux with a start date of 8/19/23. Review on 5/1/25 of Resident #55's progress notes revealed no documentation from the provider of the medical necessity and potential risk versus current therapeutic benefit for the continued use of the Protonix medication. Interview on 5/1/25 at approximately 2:13 p.m. with Staff E (Director of Nursing) confirmed that Resident #55's MRR, dated 1/6/25, was not reviewed or addressed by the provider. Review on 5/2/25 of the facility policy titled, Documentation and Communication of Consultant Pharmacist Recommendations, revision date of 12/2019, revealed .Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review .Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendations directed to him/her [within 30 days], the Director of Nursing and/or the consultant pharmacist may contact the Medical Director .

Based on interview and record review, it was determined that the facility failed to ensure that a resident receiving antipsychotic medication had an adequate indication for use for 1 of 5 residents reviewed for unnecessary medications in a final sample of 20 residents (Resident identifier is #1). Findings include: Review on 5/2/25 of Resident #1's physician orders revealed the following order: Seroquel (Antipsychotic Medication) Oral Tablet 25 mg (milligrams) Give 25 mg by mouth one time a day for confusion, agitation with a start date of 9/16/24. Review on 5/2/25 of Resident #1's medical record revealed that he/she was admitted to the facility on [DATE]. Review on 5/2/25 of Resident #1's diagnosis list revealed a diagnosis of Vascular Dementia, mild, with anxiety. Review on 5/2/25 of Resident #1's medical record for monitoring behavior symptoms revealed that Resident #1 did not exhibit any behaviors from 4/3/25 thru 5/2/25. Review on 5/2/25 of Resident #1's Psychiatric Evaluation and Consultation note, dated 1/24/25, revealed the following: [Name omitted] is a [AGE] year old [pronoun omitted] with no significant past psychiatric history. [Pronoun removed] he was hospitalized on [DATE] for UTI [urinary tract infection], and was started on Seroquel same day per chart review . Family refused GDR [gradual dose reduction]. Review on 5/2/25 of Resident #1's most recent Psychiatric Evaluation and Consultation note. dated 3/7/25. revealed the following: [Name omitted] is a [AGE] year old [gender removed] with no significant past psychiatric history. Further review revealed a diagnosis of Unspecified Dementia without behavioral disturbance- Severity: Low. Interview on 5/2/25 with Staff G (Nurse Practitioner/Psychiatric Provider) revealed that Resident #1 has no significant psychiatric diagnosis. Review on 5/2/25 of facility policy titled Clinical Services Subject: Psychotropic Medications, dated 5/2023, revealed the following: .Guidelines: 2. When the psychoactive medications are prescribed, a specific condition or targeted behavior that warrants the use of psychoactive medications shall be documented in the clinical record .

Based on interview and record review, it was determined that the facility failed to ensure residents remained free from significant medication errors for 1 of 3 residents reviewed for accidents and hazards in a final sample of 20 residents. (Resident identifiers is #9.) Findings include: Review on 5/1/25 of Resident #9's medical record revealed a nursing note, written by Staff L (Registered Nurse), dated 4/23/25, at 7:51 p.m.: Med error reported to on call physician and DPOA (Durable Power of Attorney). Resident given 30 units of Lantus, 75 mg (milligrams) of Lyrica. 5 mg of oxy. Interview on 5/2/25 at approximately 1:00 p.m. with Staff E (Director of Nursing) confirmed that Resident #9 had received Resident #18's evening medications. Review on 5/2/25 of Resident #9's medical provider note dated 4/23/25 at 4:23 p.m. revealed that .Patient was given Lantus 30 units, Lyrica 75 mg, Oxycodone 5 mg with his usual nightly 4 ounces of scotch. Patient is a diabetic who takes 10 units of long acting typically . Review on 5/2/25 of Resident #9's active physician orders revealed the following: Lantus Solar Subcutaneous Solution 100 Unit/ML (milliliter) (Insulin Glargine), Inject 10 units subcutaneously one time a day for DM (Diabetes Mellitus), (Resident #9 received 30 units); No physician orders for Lyrica Oral Capsule 75 MG (Pregabalin); No physician orders Oxycodone HCI Oral Tablet 5 MG (Oxycodone HCI). Review on 5/2/25 of the facility's policy titled Medication Pass Policy dated 9/24 revealed, .Identify each resident PRIOR to administration of medication (picture, ID bracelet, ect.) .

Based on observation, interview, and record review, it was determined that the facility failed to label and store medications in accordance with professional standards for 2 of 3 medication carts observed. Findings include: Observation on 4/30/25 at approximately 7:20 a.m. of the medication cart [NAME] Cart 2 and 4 with Staff A (Registered Nurse) revealed: Resident #59's Incruse Inhaler, opened without a date of opening; Resident #32's Fluticasone Propionate and Salemetrol inhaler opened with a labeled date of expiration of 4/24; Resident #29's Incruse inhaler opened, without a date of opening; Resident #5's Anoro inhaler opened, without a date of opening. Interview on 4/30/25 at approximately 7:20 a.m. with Staff A confirmed the above findings. Observation on 4/30/25 at approximately 7:30 a.m. of the medication cart TCU #4 with Staff B (Registered Nurse) revealed an unlabeled medication cup with pills in it in the top drawer for Resident #69. Resident #9's Lispro insulin opened labeled with a date of expiration of 4/28/25. Interview on 4/30/25 at approximately 7:30 a.m. with Staff B confirmed the above findings. Further interview revealed that Resident #9 received his/her a.m. dose of Lispro on 4/30/25. Review on 4/30/25 of Resident #9's April 2025's MAR (Medication Administration Record) revealed: On 4/30/25 at 6:00 a.m. Resident #9 received 8 units of Lispro. Review on 4/30/25 of Resident #69's April 2025's MAR (Medication Administration Record) revealed the following 6:00 a.m. medications signed as administered on 4/30/25: Bactrim DS (Double Strength) tablet 800-160 mg (milligrams) Cholecalciferol Tablet 50 mcg (micrograms) Ferrous Sulfate Tablet 325 mg Furosemide Tablet 20 mg Loratidine Tablet 10 mg Multivitamin Tablet Omeprazole Capsule Delayed Release 40 mg Oxycodone Tablet 5 mg Prednisone Tablet 20 mg Reglan Tablet 5 mg Interview on 4/30/25 at approximately 12:00 p.m. with Staff B confirmed the medication in the medicine cup was for Resident #69. Interview on 4/30/25 at approximately 1:45 p.m. with Staff C (Licensed Practical Nurse) night nurse confirmed that they had prepared Resident #69's morning medications and left them in the top drawer of the medication cart to be administered by Staff B on day shift. Further interview with Staff C confirmed that Resident #69's Oxycodone was in the medication cup and was not double locked. Review on 4/30/25 of the manufacturer's instructions for Insulin Lispro Cartridges and Pens, undated revealed: . Store opened cartridges and pens at room temperature. Throw away any part not used after 28 days Review on 4/30/25 of the manufacturer's instructions for Fluticasone and Salmetrol Inhalation Powder, undated revealed . Throw away the inhaler when the dose counter reaches 0', 1 month after opening foil pouch, or after the expiration date, whichever comes first . Review on 4/30/25 of the manufacturer's instructions for Umeclidinium and Vilanterol (Anoro Ellipta), undated revealed . Throw away the inhaler when the dose counter reaches 0', 6 weeks after opening foil pouch, or after the expiration date, whichever comes first . Review on 4/30/25 of the manufacturer's instructions for Umeclidinium (Incruse Ellipta), undated revealed .Throw away the inhaler when the dose counter reaches 0', 6 weeks after opening foil pouch, or after the expiration date, whichever comes first . Review on 4/30/25 of the facility policy titled, ID1: Storage of Medications, Revision Date December 2019, revealed . Procedures . C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label H. Outdated, contaminated, or deteriorated medications . are immediately removed from inventory, . Expiration Dating .D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration E. The nurse will check the expiration date of each medication before administering it ID2: Controlled Substances .B. Schedule [II-V] medications and other medications subject to abuse or diversion are stored in a permanently affixed, [double-locked] compartment separate from all other medications .

Based on interview and record review, it was determined that the facility failed to report an allegation of neglect to the State Survey Agency (SSA) for 1 out of 3 grievances reviewed for alleged neglect (Resident Identifier #4). Findings include: Review on 4/10/24 of the facility grievance form filed on 3/14/24 by Resident #4 revealed the following allegation: The resident reports [pronoun omitted] waited 30 minutes for [pronoun omitted] call light to be answered and ultimately self-ambulated to the bathroom and fell . [pronoun omitted] reports the nurse on overnight was not helpful and said it was the resident's fault that [pronoun omitted] fell . Interview on 4/10/24 at approximately 12:00 p.m. with Staff A (Administrator) revealed that the above allegation was not reported to the SSA. Review on 4/10/24 of the facility's policy titled Clinical Services, Abuse Policy and Procedure, Procedure for Abuse Investigation revised on 1/23 revealed: .Procedure Guidelines .5. The facility will notify Department of Public Health and Local Law Enforcement immediately but no later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse .

Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 of 2 newly admitted residents reviewed for medications in a final sample of 20 residents (Resident Identifier is #346). Findings include: Review on 4/9/24 of professional nursing standard: Fundamentals of Nursing, [NAME], [NAME] A., and [NAME]. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009 revealed: Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician ' s orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Interview on 4/9/24 at approximately 10:45 a.m. with Resident #346 revealed that he/she was admitted to the facility in April 2024 in the afternoon and the facility did not administer his/her medications that evening. Review on 4/10/24 of Resident #346's April 2024 Medication Administration Record (MAR) revealed the following medications ordered for administration: 1. Atorvastatin Calcium (antilipemic) 40 milligram (mg) - 1 tablet at bedtime 2. Finasteride (5-alpha reductase inhibitors) 5 mg - 1 tablet at bedtime 3. Oxcarbazepine (anticonvulsant) 300 mg - 1 tablet twice a day 4. Tamsulosin HCL (alpha blocker) (Hydrochloride) 0.4 mg - 1 tablet twice a day 5. Apixaban (anticoagulant) 5 mg - 1 tablet twice a day. Upon further review, the above medications were not administered and documented as not available. Review on 4/10/24 of the Omnicell (automated dispensing machine) revealed that the following medications were available: 1. Atorvastatin Calcium 2. Oxcarbazepine 3. Tamsulosin 4. Apixaban Interview on 4/10/24 at approximately 10:30 a.m. with Staff C (Unit Manager) confirmed the above findings. Staff C stated that Resident #346 was admitted to the facility around 12:30 p.m. and that medications, as mentioned above, were available in the Omnicell for administration. Review on 4/10/24 of the facility's policy titled Unavailable Medication revision date 5/23 revealed: .Policy If a medication is unavailable, for any reason, the facility shall act promptly to notify the pharmacy and the appropriate practitioners to obtain a new medication supply/order .Procedure .2. The Nursing Supervisor and/or Charge Nurse will check all possible areas where medications are stored to check if medication is available (E-box [emergency box]), Automatic Dispensing Machine .3. If medication is not available, notify the Physician/NP [Nurse Practitioner] if there is a comparable medication available that can be given as an alternate .4. Obtain order for alternate or to hold medication and administer at time of delivery .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents' environment remained as free as possible of accident hazards to prevent injury in regards to the application of seizure pads on the bed for 1 of 3 residents reviewed for accidents in a final sample of 20 residents (Resident Identifier #67). Findings include: Observation on 4/9/24 at approximately 11:15 a.m. of Resident #67 lying in bed with seizure pads attached to the outside of the quarter rails, with no padding between the bed rails and the resident's body. Observation on 4/9/24 at approximately 2:10 p.m. of Resident #67 lying in bed with seizure pads attached to the outside of the quarter rails, with no padding between the bed rails and the resident's body. Review on 4/9/24 of Resident #67's medical record showed diagnosis of epilepsy present on admission. Further review revealed the following physician's order for seizure pads: Seizure pads, every shift, order date 1/31/24. Interview on 4/10/24 at approximately 10:30 a.m. with Staff C (Unit Manager) confirmed the above findings. Staff C stated that the seizure pads should be attached to the inside of the quarter rails towards the resident. Review on 4/9/24 of professional nursing standard: Lippincott Manual of Nursing Practice, Nettina, 11th Edition, Philadelphia, Wolters Kluwer, 2019 revealed: Page 419 Seizure Disorders .Nursing Interventions .Preventing injury 1. Provide a safe environment by padding side rails .

Based on record review, observation, and interview, it was determined that the facility failed to maintain infection prevention related to catheter care for 1 of 3 residents reviewed for catheters (Resident Identifier #153). Findings include: Review on 4/9/24 of Resident #153's medical record revealed they had a Foley catheter since admission in April 2024. Further review of Resident #153's catheter care plan dated April 2024 revealed: .Keep urinary collection bag off the floor . Observation on 4/9/24 at approximately 12:30 p.m. revealed Resident #153 in a wheelchair with their Foley catheter drainage bag and catheter tubing resting on the floor. Interview on 4/9/24 at approximately 12:30 p.m. with Resident #153 revealed they did not place their Foley catheter drainage bag and catheter tubing on the floor. Observation on 4/10/24 at approximately 12:15 p.m. revealed Resident #153 in their wheelchair self-propelling with the bottom of their Foley catheter drainage bag dragging on the floor. Interview on 4/10/24 at approximately 12:35 p.m. with Staff B (Unit Manager) confirmed the above finding. Review on 4/15/24 of Catheter-Associated Urinary Tract Infections (CAUTI) guidelines on the Centers for Disease Control and Prevention (CDC) website, found at https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html revealed: .III. Proper Techniques for Urinary Catheter Maintenance .III.B.2 - Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that resident records were complete and accurate for 3 residents in a final sample of 20 residents (Resident Identifiers #24, #34, and #67). Findings include: Resident #34 Review on 4/10/24 of Resident #34's April 2024 Medication Administration Record (MAR) revealed an order for HumaLOG Solution (Insulin Lispro) 100 unit/milliliter (mL) inject as per sliding scale: 0 - 149 = 0 units if blood sugar (BS) less than 70 after initiating protocol call Doctor of Medicine (MD): 150 - 199 = 2 units 200 - 249 = 4 units 250 - 299 = 6 units 300 - 349 = 8 units 350 - 399 = 10 units 400 plus = notify MD for directions, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM) with a start date of 12/12/23. Further review of the MAR revealed that on 4/7/24 at 6:30 a.m. there was no documentation that Resident #34's blood sugar was taken and no documentation that sliding scale insulin was administered. Review on 4/10/24 of Resident #34's nursing notes revealed that there was no documentation of why the insulin had not been given. Interview on 4/10/24 at approximately 1:30 p.m. with Staff C (Unit Manager) confirmed the above findings. 50163 Resident #24 Review on 4/9/24 of Resident #24's April 2024 MAR revealed the following physician order: 1. Insulin Glargine solution 100 UNIT/mL, inject 6 units subcutaneously one time a day with a start date of 1/23/24, scheduled for bedtime. 2. Humalog solution (Insulin Lispro) 100 UNIT/mL, inject as per sliding scale: 0 - 59 = Notify MD and initiate hypoglycemic protocol; 60 - 150 = 0 units; 151- 200 = 4 units; 201 - 250 = 8 units; 251 - 300 = 12 units; 301 - 350 = 14 units; 351 - 400 = 16 units; 401 plus = 18 units call provider to verify dose prior to administration, subcutaneously before meals and at bedtime with a start date of 1/16/24. Review on 4/10/24 of Resident #24's MAR revealed no documentation of Resident #24's blood sugar value or administration of insulin on the following dates: Insulin Glargine 4/4/24 at bedtime Insulin Lispro 4/4/24 at 8:00 p.m. 4/7/24 at 6:30 a.m. 4/8/24 at 6:30 a.m. Interview on 4/10/24 at approximately 1:40 p.m. with Staff C confirmed the above findings. Resident #67 Review on 4/9/24 of Resident #67's April 2024 MAR revealed the following physician order : 1. Basaglar KwikPen (Insulin Glargine) subcutaneous solution pen - injector 100 UNIT/mL, inject 10 units subcutaneously one time a day with start date of 2/1/24, scheduled at 6:00 a.m. Review on 4/10/24 of Resident #67's MAR revealed no documentation of Resident #67's blood sugar value and administration of insulin on the following dates: Insulin Glargine 4/7/24 at 6:00 a.m. 4/8/24 at 6:00 a.m. Interview on 4/10/24 at approximately 1:40 p.m. with Staff C confirmed the above findings. Review on 4/10/24 of facility's policy titled Diabetes Management Protocol revised 3/23, revealed: .Procedure: Insulin Dependent Diabetic with Routine Insulin Orders and Sliding Scale .3. Administers short acting insulin per sliding scale order .5. Documents result of finger stick dose of insulin administered and site .

Based on observation, interview, and record review it was determine that the facility failed to ensure that opened medications were labeled with an open date or open expiration date on 1 of 3 medication carts observed, failed to ensure that expired supplements were removed from the medication room, and failed to ensure that medications were kept secured on 1 of 3 units observed (Resident Identifiers are #41, #52, and #7). Findings include: Passport Medication Room Observation on [DATE] at approximately 8:45 a.m. of the Passport Medication Room revealed: 13 Apple Ensure clear therapeutic drinks, expiration date [DATE] 10 Berry Ensure clear therapeutic drinks, expiration date [DATE] Interview on [DATE] at approximately 8:45 a.m. with Staff D (Licensed Practical Nurse (LPN)) confirmed the above findings and that the expired drinks should have been removed from the medication room. [NAME] Medication Carts 2 and 4 Observation on [DATE] at approximately 9:00 a.m. of the [NAME] Medication Carts 2 and 4 revealed the following medications for Resident #7: A Victoza Pen labeled with an opened date of [DATE] and a Levemir Insulin Pen with no opened date or open expiration date. Interview on [DATE] at approximately 9:00 a.m. with Staff E (LPN) confirmed the above findings. Review on [DATE] of the manufacturer's instructions for Levemir insulin, dated ,d+[DATE] revealed: .After vials have been opened: . Throw away all opened Levemir vials after 42 days, even if they still have insulin left in them Review on [DATE] of the manufacturer's instructions for Victoza insulin, dated ,d+[DATE] revealed: . Use a Victoza pen for only 30 days. Throw away a used Victoza pen 30 days after you start using it, even if some medicine is left in the pen Transitional Care Unit (TCU) Observation on [DATE] at 9:30 a.m. of the mediation administration pass on TCU with Staff C (Registered Nurse) revealed that Staff C entered room [ROOM NUMBER] and left the medication cart unlocked. Staff C was not within sight of the unsecured medication cart for approximately 2 minutes while in room [ROOM NUMBER]. Interview on [DATE] at 09:35 a.m. with Staff C confirmed that the cart was unlocked. Transitional Care Unit - Treatment Cart Observation on [DATE] at approximately 1:45 p.m. of the treatment cart on the TCU revealed the treatment cart was unlocked. Further observation revealed the following treatments that were not secured: 1 bottle of Acetic Acid 0.25 percent (%) irrigation solution (Resident #52) 1 syringe of Glydo 2% Jelly syringe (Resident #71) Interview on [DATE] at approximately 1:48 p.m. with Staff F (LPN) confirmed the above findings and revealed that the treatment cart should be locked. Review on [DATE] of the facility policy titled, Medication Ordering and Receiving From Pharmacy Provider, Medication and Medication Labels, dated ,d+[DATE] revealed: .2. Multi-dose vials shall be labeled to assure product integrity, considering the manufacturers, specifications. (Example: Modified expiration dates upon opening the multi-dose vial.) Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label. Review on [DATE] of the facility policy titled, Medication Storage, Storage of Medication, dated ,d+[DATE] revealed: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access . 45419 46654

Based on observation, interview, and record review it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 of 3 residents reviewed for choices in a final sample of 23 residents (Resident identifier is #41). Findings include: Observation on 3/8/23 at approximately 8:53 a.m. of Resident # 41's room revealed the resident administering his/her medication without any staff present. The resident had already begun taking his/her medication and it appeared that there were approximately 5-6 pills left in the medication cup. The resident stated that some nurses will leave them for him/her to take unsupervised while others will administer them. Interview at 12:01 p.m. on 3/8/23 with Staff A (Unit Manager) revealed that it is facility policy to not give residents Medication unsupervised and that the nurse should stay with him/her. Staff A also stated that the resident was not assessed to self-administer medications and that there was not a physician order for self-administration in the resident's chart. Interview at 12:02 p.m. on 3/8/23 with Staff B (Registered Nurse) confirmed that he/she left the medications with Resident #41 and then left the room. Staff B confirmed that he/she gave the resident the following medications: Keppra 750 Tablet Gabapentin Capsule Irbesartan Tablet Metoprolol Tablet Omeprazole Capsule Oxcarbazepine Tablet Oxcarbazepine Tablet Potassium Chloride Tablet Record Review of the Medication Administration Review (MAR) on 3/9/23 revealed that the above medications were administered by Staff B on 3/8/23.

Based on observation and interview, the facility failed to conduct testing in a safe environement that is consistent with current standards of practice for resident COVID- 19 testing. (Resident identifiers are #7 and #42.) Findings include: Observation on 4/12/22 at approximately 10:10 a.m. of the carpeted Central Unit common area revealed Staff A (Respiratory Therapist) to be wearing an N95 mask, eye protection, gloves and an isolation gown and perform a nasal swab on Resident #7 and then conduct a rapid antigen COVID-19 test, in the center of the common area. Further observation revealed a total of 3 other residents to be sitting in the common area watching television. Interview on 4/12/22 at approximately 10:12 a.m. with Staff A confirmed they had collected a nasal swab in the common area for Resident #7 and then conduct a rapid antigen COVID-19 test. Staff A stated that they could perform sample collection and testing this procedure in the common area as long as they themselves had appropriate personal protective equipment on. Observation on 4/12/22 at approximately 10:50 a.m. of Resident #42 revealed Staff A conducting a nasal swab for a COVID-19 test with the room door open and mobile testing cart to be just inside dorrway of room. Further observation revealed 4 Binax now COVID tests to be processing on the top of the mobile testing cart. Interview on 4/12/22 at approximately 10:50 a.m. with Staff A confirmed the mobile testing cart was just inside the doorway of Resident #42's room and also had 4 other resident's rapid antigen COVID-19 tests processing on the top of the cart. Review on 4/12/22 of the CDC (Centers for Disease Control and Prevention) website titled, Performing Broad-Based Testing for [CONDITION(S)]-CoV-2 in Congregate Settings, updated March 29,2021, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/broad-based-testing.html revealed the following: .Physical space .For indoor specimen collection activities, designate separate spaces for each specimen collection testing station, either rooms with doors that close fully or protected spaces removed from other stations by distance and physical barriers, such as privacy curtains and plexiglass. To prevent inducing coughing/sneezing in an environment where multiple people are present and could be exposed, avoid collecting specimens in open-style housing spaces with current residents or in multi-use areas where other activities are occurring .Do not keep testing and other supplies in the immediate specimen collection area to avoid the possibility of contamination test materials. Consider having each person carry their prefilled specimen bag (containing a swab and labeled sterile [CONDITION(S)] transport media container) from the check-in area to the specimen collection area. Clean and disinfect all surfaces often using an Environmental Protection Agency-registered disinfectant from List Nexternal icon?: -At least hourly for surfaces within 6 feet of where specimen collection was performed; Anytime the surface is visibly soiled or within 6 feet of an uncovered cough or sneeze; At the end of shift for all surfaces and equipment in the specimen collection area .

Based on observation, interview, and record review the facility failed to ensure nursing staff understood the process to determining a resident's code status in an event of an emergency for 2 out of 3 staff interviewed. (Staff Identifier's are Staff C and Staff D.) Findings include: Interview on 4/13/22 at 8:20 a.m. with Staff C (Licensed Practical Nurse) revealed that he/she would identify a residents' code status by looking at the colored label on the binder of the paper medical record. A blue label would identify a DNR (Do Not Resuscitate). Interview on 4/13/22 at 10:55 a.m. with Staff D (Registered Nurse) revealed that he/she would identify a resident's code status by looking at the blue dot/star label on the resident doorway. A blue dot/star would identify a DNR. Interview on 4/13/22 at 3:00 p.m. with Staff B (Director of Nursing) revealed that colored labels on the binder of the paper medical record identifies the resident's physician/provider and a residents' code status would be found in the medical record. Review on 4/14/22 at 12:56 p.m. of Staff C's education and competencies provided at orientation, dated 12/30/21, revealed no documented education on the facility process for identifying the code status of a resident. Review on 4/14/22 at 1:30 p.m. of Staff D's education and competencies provided at orientation, dated 3/17/22, revealed no documented education on the facility process for identifying the code status of a resident. Interview on 4/14/22 at 1:35 p.m. with Staff B revealed the facility was unable to provide documented staff education on the facility's process for identifying a resident's code status prior to caring for a resident.

Based on observation, staff interview and record review, it was determined that the facility failed to label prepared food following manufacture's instruction in 2 out of 2 kitchenettes observed. Findings include: Review on 4/14/22 of the manufacturer's recommendation for thickened liquid products dated 4/14/21, read in part: .Shelf Life: 7 months from date of manufacturer. Refrigerate after opening and use within 7 days. [NAME] Unit Kitchenette Observation on 4/12/22 at 9:05 a.m. revealed one opened carton of thickened cranberry juice, use by date 4/30/22, no opened date; one opened carton of thickened orange juice, use by date 4/30/22, no open date and one opened carton of thickened water, use by date 4/30/22, no open date in the refrigerator. Interview on 4/12/22 at 9:07 a.m. with Staff E (Food Service Director) confirmed the above finding. Transitional Care Unit Kitchenette Observation on 4/12/22 at 9:10 a.m. revealed one opened carton of thickened water, use by date 4/30/22, no open date; one opened carton of thickened lemon flavored water, use by date 4/17/22, no open date and one opened carton of thickened cranberry juice, use by date 4/30/22, no open date in the refrigerator. Interview on 4/12/22 at 9:12 a.m. with Staff E revealed cartons of thickened water/juice were good for 30 days once opened and confirmed the above finding.

Based on observation, interview, and medical record review, it was determined that the facility failed to assess the safety and clinical appropriateness for self-administration of medications for 1 resident of 1 residents reviewed for self administation of medications in a final survey sample size of 21 residents. (Resident identifier is #67.) Findings include: Observation on 04/07/21 at 11 a.m. of Resident #67's bedside tray table revealed that there were lubricant eye drops and saline nasal spray on the top of the table. Interview on 4/7/21 at 11 a.m. with Resident #67's revealed that the resident takes the eye drops and nasal spray on his/her own and that he/she took them once or twice a day. Observation on 4/9/21 at 11:15 a.m. of Resident #67's bedside tray table revealed that there was lubricant eye drops, saline nasal spray, and a bottle of vitamin pills on the top of the table. Interview on 4/9/21 at approximately 11:20 a.m. with Staff D (Registered Nurse) revealed that there were no residents on the Glennwood unit (where Resident #67 resided) who were self-administering medications. Review on 4/9/21 of Resident #67's medical record revealed that there was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 4/9/21 at 11:25 a.m. with Staff C confirmed that Resident #67 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Self-Administration by Resident dated 10/07 read, in part, .Residents who desire to self-administer medications are permitted to do so with a presciber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe. Procedures 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skilled assessment conducted as part of the care plan process 3. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. 4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safely of bedside medication storage is conducted . 6. At least once during each shift, the nursing staff checks for usage of the medications by the resident . Review of the facility's policy titled Bedside Medication Storage dated 5/16 read, in part, .Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the presciber and when it is deemed appropriate in the judgement of the nursing care center's interdisciplinary resident assessment team 1. The interdisciplinary team (IDT) will review and approve resident competencies and understanding prior to permission of bedside storage of medications . 2. A written order for the bedside storage of medication is present in the resident's medical record 5. All nurses and nursing aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage .

1. Based on interview and medical record review, it was determined that the facility failed to follow physician's orders related to blood pressure and pulse parameters for 1 resident out of a final sample size of 21 residents. (Resident identifiers is #62.) Findings include: Professional reference: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 708 The prescriber often gives specific instructions about when to administer a medication . Resident #62 Review on 4/8/21 of facility's policy titled, Medication Pass, dated 10/2018, revealed .Acceptable medication pass time is 1 hour before and 1 hour after scheduled time for most medications .Medications requiring monitoring of vital signs (e.g. pulse, B/P [blood pressure], temp. [temperature]) are to be given AFTER vitals are obtained . Review on 4/8/21 of Resident #62's active physician's orders revealed physician's orders for [MEDICATION(S)] (diuretic) 25 mg (milligram) give 1 tablet by mouth one time a day hold if SBP (Systolic Blood Pressure) less than 100 with a start date of 3/19/21, and [MEDICATION(S)] (antihypertensive) 50 mg give 1 tablet by mouth twice a day hold if SBP less than 100, HR (Heart Rate) less than 60. Review on 4/8/21 of Resident #62's March 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #62 received the [MEDICATION(S)] 25 mg and [MEDICATION(S)] 50 mg 8:00 a.m. dose on 3/19/21 to 3/25/21, 3/27/21, 3/29/21 to 3/31/21. Further review also revealed that Resident #62 received [MEDICATION(S)] 8:00 p.m. dose on 3/19/21 to 3/31/21. Review on 4/8/21 of Resident #62's April 2021 EMAR revealed that Resident #62 received [MEDICATION(S)] 25 mg and [MEDICATION(S)] 50 mg on 4/1/21 to 4/8/21. Review on 4/9/21 of Resident #62's blood pressure record revealed that there were no documented blood pressure between 7:00 a.m. to 9:00 a.m. on 3/21/21, 3/22/21, 3/26/21, 4/2/21, 4/4/21, 4/6/21, 4/7/21 and 4/8/21. Further review also revealed that there were no documented blood pressure between 7:00 p.m. to 9:00 p.m. on 3/18/21, 3/19/21, 3/20/21, 3/21/21, 3/22/21, 3/24/21, 3/25/21, 3/27/21, 3/28/21, 3/29/21, 3/30/21, 3/31/21, 4/1/21, 4/2/21, 4/4/21, 4/6/21, 4/7/21, and 4/8/21. There were no SBP below 100 on Resident #62's blood pressure record. Review on 4/8/21 of Resident #62's pulse (heart rate) record revealed that there were no documented heart rate between 7:00 a.m. yo 9:00 a.m. on 3/21/21, 3/22/21, 3/26/21, 4/2/21, 4/4/21, 4/6/21, 4/7/21 and 4/8/21. Further review also revealed that there were no documented heart rate between 7:00 p.m. to 9:00 p.m. on 3/18/21, 3/19/21, 3/20/21, 3/21/21, 3/22/21, 3/24/21, 3/25/21, 3/27/21, 3/28/21, 3/29/21, 3/30/21, 3/31/21, 4/1/21, 4/2/21, 4/4/21, 4/6/21, 4/7/21, and 4/8/21. There were no heart rate below 60 on Resident #62's blood pressure record. Interview on 4/8/21 at 1:52 p.m. with Staff E (Licensed Practical Nurse) revealed that Staff E would obtain vital signs prior to administering physician's ordered medications with parameters. Staff E also stated that he/she obtains vital signs and document the results in the resident medical record. Interview on 4/9/21 at approximately 8:50 a.m. with Staff F (Registered Nurse) and Staff G (Licensed Practical Nurse) revealed that Staff F and Staff G would obtain vital signs prior to administering physician's ordered medications with parameters. Staff F and Staff G also stated that they obtain vital signs prior to medication administration per facility's policy and documents results in the resident medical record. Interview on 4/9/21 at 2:13 p.m. with Staff A (Director of Nursing) confirmed above findings on Resident #62's physician's orders, EMAR, blood pressure and pulse record. Staff A stated that nurses should document vital signs prior to administering physician's ordered medications with parameters within the medication pass time per the facility's policy. 2. Based on observation, interview, and medical record review, it was determined that the facility failed to follow physician's orders for 1 observation out of 25 medication administration opportunities observed. (Resident identifier is #50.) Findings include: Professional reference: Potter, Patricia A., and Perry, Anne Griffin . Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #50 Observation on 4/9/21 at 8:25 a.m. of Staff B (Registered Nurse) during medication pass revealed Staff B preparing medications for Resident #50. Staff B pulled a blister pack (a card that packages doses of medication) of [MEDICATION(S)] [MEDICATION(S)] extended release 50 mg (milligram) tablet (a medication for hypertension) and was observed administering one tablet of this medication to Resident #50. Review on 4/9/21 at 8:25 a.m. of Resident #50's blister pack revealed the medication that was administered was [MEDICATION(S)] [MEDICATION(S)] extended release 50 milligram tablets. The directions on the blister pack read 3 tabs [tablets] by mouth once daily for hypertension (150 mg). Review on 4/9/21 at approximately 8:45 a.m. of Resident #50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date for this order was 9/27/20 and it was signed of by Staff B as being administered on 4/9/21 for the morning medication pass. Interview on 4/9/21 at 8:55 a.m. with Staff B confirmed Resident #50 did not receive the correct dosage of [MEDICATION(S)] [MEDICATION(S)] extended release. Staff B confirmed that the directions were to administer three 50 mg tablets to equal 150 mg. Interview on 4/9/21 at 10:05 a.m. with Staff A (Director of Nursing) confirmed that Resident #50 should have received 3 tablets of the [MEDICATION(S)] [MEDICATION(S)] extended release based on the physician's order. Review of the facility's policy and procedure titled Medication Pass Policy issued 10/2018 read, in part, .It is the policy of this facility that mediations are administered safely and timely per the physician's orders Remember the six (6) rights of medication pass: . right dose .

Based on record review, interview, and review of facility policy and procedure it was determined that the facility failed to render the bilateral hand mobility treatments, failed to implement the application of the bilateral hand/finger strapping daily, failed to implement the occupational therapy hand exercises, ten repetitions twice a day for each hand, failed to assess bilateral hands to prevent the development of a Stage IV ulcer to the left hand with exposed tendon and bone and failed to prevent the development of an unstageable ulcer to the right hand for 1 resident in a survey sample of 18 residents. (Resident identifier is #1.) Findings include: Review of the facility policy and procedure titled "Prevention and treatment of [REDACTED]. "POLICY A skin and wound care program is designed and implemented to identify and reduce the risk of patients acquiring pressure ulcers and provides standards of care for patients with pressure ulcers and non-pressure related wounds to promote healing, reduce the risk of infections and prevent further development of pressure ulcers... Braden Scale ... Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category which is rated on a 1-3 scale. This combined for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa... Stage III Full Thickness Skin Loss: Full thickness tissue loss.... May include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location.... Bone/tendon is not visible or directly palpable... Stage IV Full Thickness Tissue Loss: Full thickness tissue loss with exposed bone, tendon or muscle... Exposed bone/tendon is visible or directly palpable... COMPONENTS:... 8. For stage III and stage IV pressure ulcers and Non-pressure related wounds interventions and treatment is based on Wound Care Coordinator (WCC)/Skin Champion/Designee/team. 9. Patients are assessed and identified for support surface intervention to mitigate further breakdown and support healing... 12. Interventions are initiated on patients who score less than or equal to 18 on the Braden Risk Scale or less than or equal to 14 on the Norton Scale... 19. Attending physician is notified when wounds/ulcers show no signs of healing within 2 weeks of initiating a treatment plan. New treatment strategies are discussed with the physician and new orders are obtained... c. Wound care for stage III or IV pressure ulcers, non-pressure related, full thickness wounds and atypical or complex wounds require a physician's order... 21. Pain management of wounds: a. Assessment and documentation b. Non-pharmacological and pharmacological c. Collaboration with physician d. Hand-off communication 22. Consultation and communication with ancillary services such as physical therapy, occupational therapy, nutritional services and speech and are documented in the patient record.....". Record review on 3/18/13 of the "RESIDENT PROGRESS NOTES" for Resident #1 dated "3/13" revealed "... wound bilateral his fingers which has discharges he has pain, difficulty to open bilateral fingers...". Review of the Braden Scale for Resident #2 revealed a score of "4", indicating "Very High Risk- 9 or below". Review of the "RESIDENT WEEKLY SKIN CHECK SHEET" for Resident #1 dated January 2013 revealed no documented evidence of bilateral hand skin integrity and showed skin intact with no open areas. Further review of this document revealed no documented evidence of a skin assessment done on week #3 (1/15/13) or on week #5 (1/28/13). Review of the "RESIDENT WEEKLY SKIN CHECK SHEET" for Resident #1 dated February 2013 revealed no documentation of a skin assessment done for week #1 (1/28/13 through 2/2/13) and none for week #4 (2/25/13). No documented evidence of the April 2013 "RESIDENT WEEKLY SKIN CHECK SHEET" could be found for Resident #1. Review of the "OCCUPATIONAL THERAPY DISCHARGE SUMMARY" for Resident #1 with a discharge date of "3/27/13" revealed "upon evaluation pt. with B (bilateral) hand contractures L (left) worse than R (right) pain with ... ROM (range of motion) 9/10, wounds between lateral PIP joint of left & middle PIP, right ring finger PIP joint lateral; right finger wound improved left tunneling of index finger, pain at 8/10 level with abduction for wound care. Pt (patient) tolerating ... (range of motion) with ^ abduction of left hand ^ tolerance for placement of soft strapping intertwined between fingers for light stretch... Pt. trained on need for ... (range of motion)- opening/closing fist & abd fingers; caregiver training for encouraging hand exercises & staff to apply soft strapping daily.... staff education for strap placement between fingers ...(bilateral) hands." Record review of the "OCCUPATIONAL THERAPY DISCHARGE SUMMARY" for Resident #1 with a discharge date of "9/6/12" revealed in the section titled "Reason for Discharge... Pt (patient) has reached max level of improvement, staff & family educated in exercises... Trained staff in strategies for hygiene care with hands, how to put soft strapping between fingers to maintain abduction and in basic hand ROM (range of motion) ex. (example) to maintain ... functional range." During interview with Staff K (Occupational Therapist) on 4/18/13 at approximately 2:30 p.m. , Staff K reviewed the above listed rehabilitation notes and showed a copy of the occupational therapy instructions and diagram of "... hand exercises" to be repeated ten times twice a day located at Resident #1's bedside following the discharge from therapy on 9/6/12. Review of the "Wound Healing Institute Nursing Home Visit Physician Initial Visit Notes" for Resident #1 dated "3/20/13" revealed the following documentation: "Chief Complaint: pressure ulcers - fingers ... Musculoskeletal contractures to both hands Skin Ulcers to L (left) index finger medial aspect ... granulation tissue to ulcer bed ... purulent drainage ... palpable bone/joint... DIAGNOSIS/IMPRESSION: Stage 4 pressure ulcer medial ... L index finger and unstageable pressure ulcer lateral ... R (right) 4th finger PLAN: 1. conservative sharp debridement as needed 2. x-ray of L hand suggested to ... for osteo[DIAGNOSES REDACTED] of L index finger given the finding of palpable bone/joint...". Review of the "Wound Healing Institute Nursing Home Visit physician progress notes [REDACTED]. "IMPRESSION: Stage 4 pressure ulcer - L 2nd finger, medial side NARRATIVE NOTES/PLAN: x-ray L hand done 3/22/13 Difuse [MEDICAL CONDITION], [MEDICAL CONDITIONS] changes. No fracture or bone erosion evident..." Review of the "WOUND HEALING INSTITUTE" documentation for Resident #1 dated "3/20/13" revealed the following: "Wound Location: L hand 2nd finger medial... Pressure Ulcers Stage IV exposed tendon ... ORDERS: Recommend x-ray L 2nd finger to rule out osteomyleitis... continue ... separate fingers using OT (occupational therapy) device (.. straps) weave in between fingers...". "Wound Location: R hand 4th lateral finger Pressure Ulcers Unstageable covered with necrotic/slough tissue ORDERS: ... continue ... separate fingers using OT device (soft strap) weave in between fingers, continue ROM per OT..." Review of the "WOUND HEALING INSTITUTE" documentation for Resident #1 dated "4/2/13" revealed the following: "Wound Location: L hand 2nd finger medial ... Pressure Ulcers Stage IV exposed bone, tendon ..palpable bone ... ORDERS: ... wrap/weave band strap between fingers per OT to (decrease) pressure." "Wound Location: R hand 4th finger lateral Pressure Ulcers: Unstageable covered with necrotic tissue ORDERS: Wrap/weave band strap between fingers per OT to (decrease) pressure." Review of the facility "NON-PRESSURE ULCER WEEKLY SKIN LOG " for Resident #1 dated "3/13/13" revealed the following: "Date 3/13/13, Facility Acquired 3/13, L index finger, LxWxD 1 x 1 Date 3/13/13, Facility Acquired 3/13, R fourth finger, LxWxD [MEDICAL CONDITION]" The sections of this form titled Nutritional Intervention, Preventative Equipment, CP (care plan) Intervention" were not completed and the section of this form titled "Status/Progress Healing/S/S (signs and symptoms) of Infection" was not completed for the L finger and the R finger showed the note "redden sm (small) area." Review of the facility "NON -PRESSURE ULCER WEEKLY SKIN LOG" for Resident #1 dated 3/20/13 and 3/27/13 revealed no documentation in the sections titled "Nutritional Intervention, Preventative Equipment, CP Intervention and Status/Progress Healing/S?S of Infection" for the L and R finger. Further review of these logs revealed on 4/3/13, showed no documentation in the following sections, "Nutritional Intervention blank, Status/Progress Healing/S/S of Infection blank." for Resident #1. Review of the Interdisciplinary Care Plan for Resident #1 titled "Contractures Potential and Actual" dated "3/1/13" in the section titled "Approach" revealed the following: "Report and document any declines in ability. Refer to therapy as necessary Apply devices to affected joints as ordered, observe for redness/irritation...". Review of the individual Interdisciplinary Care Plan for Resident #1 titled "Non Pressure' Alteration in Skin Integrity" dated "3/20/13", one for the "L medial index finger" and one for the "R hand 4th finger" revealed the following: "Weekly documented skin check Institute Weekly Non Pressure Ulcer condition report Follow MD Orders for skin care and treatments..." Further Care Plan review for Resident #1 revealed a "Self Care Deficit/ADL Function" with a problem date of "4/3/08" and a review date of "12/20/12, 1/10/13, 3/13/13" revealed "Self care deficit / alteration in ADL function r/t (related to) Hx. (history) recent falls, recent status / condition change ...." showed no documented evidence of adaptive treatment and restorative exercises from OT to bilateral hands. Review of "Self Care Deficit/ADL Function" care plan with a problem date of "3/13/13" revealed the following: "Self care deficit/alteration in ADL function r/t decrease ROM (range of motion), ^ pain (secondary to) arthritic deformities of B (bilateral) hands... GOAL ... Pt will (decrease) hand pain with PROM (passive range of motion) & (decrease) breakdown areas & improve hygiene... with a goal date of "3/27/13". Review of the Interdisciplinary Care Plan for Resident #1 revealed no documented evidence of restorative exercises to be done twice a day and no documented evidence of the adaptive equipment straps to be intertwined between bilateral hand fingers. Review of the physician progress notes [REDACTED]. During interview on 4/18/13 with Staff I (Director of Nursing) at approximately 3:30 p.m., after Staff I reviewed the above listed wound center/visit sheets, the non-pressure skin condition reports, the weekly non-pressure skin condition reports , the interdisciplinary care plans, the occupational therapy notes & discharge summary with the hand diagram, hand exercises and preventative hand device straps, the nursing progress notes, the physician progress notes [REDACTED]./13/13.

Based on record review and interview it was determined that the facility failed to provide preventative care, treatment , assessment and care planning for 1 resident that developed a Stage IV right hand ulcer and an unstageable left hand ulcer with pain on range of motion to the bilateral hands in a survey sample of 18 residents. (Resident identifier is #1.) Findings include: Record review of the "OCCUPATIONAL THERAPY DISCHARGE SUMMARY" for Resident #1 with a discharge date of "9/6/12" revealed in the section titled "Reason for Discharge... Pt (patient) has reached max level of improvement, staff & family educated in exercises... Trained staff in strategies for hygiene care with hands, how to put soft strapping between fingers to maintain abduction and in basic hand ROM (range of motion) ex. (example) to maintain ... functional range." Review of the "OCCUPATIONAL THERAPY DISCHARGE SUMMARY" for Resident #1 with a discharge date of "3/27/13" revealed "upon evaluation pt. with B ((bilateral) hand contractures L (left) worse than R (right) pain with ... ROM (range of motion) 9/10, wounds between lateral PIP joint of left & middle PIP, right ring finger PIP joint lateral; right finger wound improved left tunneling of index finger, pain at 8/10 level with abduction for wound care. Pt (patient) tolerating ... (range of motion) with ^ abduction of left hand ^ tolerance for placement of soft strapping intertwined between fingers for light stretch... Pt. trained on need for ... (range of motion)- opening/closing fist & ... fingers; caregiver training for encouraging hand exercises & staff to apply soft strapping daily.... staff education for strap placement between fingers ... (bilateral) hands." During interview with Staff K (Occupational Therapist) on 4/18/13 at approximately 2:30 p.m, Staff K reviewed the above listed rehabilitation notes and showed a copy of the occupational therapy instructions and diagram of "... hand exercises" to be repeated ten times twice a day located at Resident #1's bedside following the discharge from therapy on 9/6/12. Review of the "Wound Healing Institute Nursing Home Visit Physician Initial Visit Notes" for Resident #1 dated "3/20/13" revealed the following documentation: "Chief Complaint: pressure ulcers - fingers ... Musculoskeletal contractures to both hands Skin Ulcers to L (left) index finger medial aspect ... granulation tissue to ulcer bed ... purulent drainage ... palpable bone/joint... DIAGNOSIS/IMPRESSION: Stage 4 pressure ulcer medial ... L index finger and unstageable pressure ulcer lateral ... R (right) 4th finger PLAN: 1. conservative sharp debridement as needed 2. x-ray of L hand suggested to ... for osteo[DIAGNOSES REDACTED] of L index finger given the finding of palpable bone/joint...". Review of the "Wound Healing Institute Nursing Home Visit physician progress notes [REDACTED]. "IMPRESSION: Stage 4 pressure ulcer - L 2nd finger, medial side NARRATIVE NOTES/PLAN: x-ray L hand done 3/22/13 Difuse [MEDICAL CONDITION], [MEDICAL CONDITIONS] changes. No fracture or bone erosion evident..." Review of the "WOUND HEALING INSTITUTE" documentation for Resident #1 dated "3/20/13" revealed the following: "Wound Location: L hand 2nd finger medial... Pressure Ulcers Stage IV exposed tendon ... ORDERS: Recommend x-ray L 2nd finger to rule out osteomyleitis... continue ... separate fingers using OT (occupational therapy) device (.. straps) weave in between fingers...". "Wound Location: R hand 4th lateral finger Pressure Ulcers Unstageable covered with necrotic/slough tissue ORDERS: ... continue ... separate fingers using OT device (soft strap) weave in between fingers, continue ROM per OT..." Review of the "WOUND HEALING INSTITUTE" documentation for Resident #1 dated "4/2/13" revealed the following: "Wound Location: L hand 2nd finger medial ... Pressure Ulcers Stage IV exposed bone, tendon ..palpable bone ... ORDERS: ... wrap/weave band strap between fingers per OT to (decrease) pressure." "Wound Location: R hand 4th finger lateral Pressure Ulcers: Unstageable covered with necrotic tissue ORDERS: Wrap/weave band strap between fingers per OT to (decrease) pressure." Review of the facility "NON-PRESSURE ULCER WEEKLY SKIN LOG " for Resident #1 dated "3/13/13" revealed the following: "Date 3/13/13, Facility Acquired 3/13, L index finger, LxWxD 1 x 1 Date 3/13/13, Facility Acquired 3/13, R fourth finger, LxWxD .3x2..." The sections of this form titled Nutritional Intervention, Preventative Equipment, CP (care plan) Intervention" were not completed and the section of this form titled "Status/Progress Healing/S/S (signs and symptoms) of Infection" was not completed for the L finger and the R finger showed the note "redden sm (small) area." Review of the facility "NON -PRESSURE ULCER WEEKLY SKIN LOG" for Resident #1 dated 3/20/13 and 3/27/13 revealed no documentation in the sections titled "Nutritional Intervention, Preventative Equipment, CP Intervention and Status/Progress Healing/S?S of Infection" for the L and R finger. Further review of these logs revealed on 4/3/13, showed no documentation in the following sections, "Nutritional Intervention blank, Status/Progress Healing/S/S of Infection blank." for Resident #1. Review of the Interdisciplinary Care Plan for Resident #1 titled "Contractures Potential and Actual" dated "3/1/13" in the section titled "Approach" revealed the following: "Report and document any declines in ability. Refer to therapy as necessary Apply devices to affected joints as ordered, observe for redness/irritation...". Review of the individual Interdisciplinary Care Plan for Resident #1 titled "Non Pressure' Alteration in Skin Integrity" dated "3/20/13", one for the "L medial index finger" and one for the "R hand 4th finger" revealed the following: "Weekly documented skin check Institute Weekly Non Pressure Ulcer condition report Follow MD Orders for skin care and treatments..." Further Care Plan review for Resident #1 revealed a "Self Care Deficit/ADL Function" with a problem date of "4/3/08" and a review date of "12/20/12, 1/10/13, 3/13/13" revealed "Self care deficit / alteration in ADL function r/t (related to) Hx. (history) recent falls, recent status / condition change ...." showed no documented evidence of adaptive treatment and restorative exercises from OT to bilateral hands. Review of "Self Care Deficit/ADL Function" care plan with a problem date of "3/13/13" revealed the following: "Self care deficit/alteration in ADL function r/t decrease ROM (range of motion), ^ pain (secondary to) arthritic deformities of B (bilateral) hands... GOAL ... Pt will (decrease) hand pain with PROM (passive range of motion) & (decrease) breakdown areas & improve hygiene... with a goal date of "3/27/13". Review of the Interdisciplinary Care Plan for Resident #1 revealed no documented evidence of restorative exercises to be done twice a day and no documented evidence of the adaptive equipment straps to be intertwined between bilateral hand fingers. Review of the physician progress notes [REDACTED]. During interview on 4/18/13 with Staff I (Director of Nursing) at approximately 3:30 p.m., after Staff I reviewed the above listed wound center/visit sheets, the non-pressure skin condition reports, the weekly non-pressure skin condition reports , the interdisciplinary care plans, the occupational therapy notes & discharge summary with the hand diagram, hand exercises and preventative hand device straps, the nursing progress notes, the physician progress notes [REDACTED]./13/13.