Every finding on record at Eagle Point Nursing and Rehabilitation

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food served at a palatable temperature and texture. The facility reported a census of 58 residents.Findings Include:During an interview on 04/20/2026 at 10:30 AM Resident #40 stated the facility only had one choice for some meals. The resident stated he cannot stand the pork chops as they are tough. Resident #40 stated the food could use improvement, and explained food had been service cold, overcooked and chewy making it difficult to eat. Resident #40 stated he had brought up his concerns to multiple staff but it continued to be a problem. During an interview on 04/20/2026 at 11:05 AM, Resident #18 stated the food can be cold at times. She stated she did not ask them to reheat and having food rewarmed in a microwave is not the same as getting food freshly cooked. Resident #18 added sometimes with dentures the food can be kind of hard to chew, and the meat can be dry and tough. During an interview on 04/20/2026 at 1:43 PM, Resident #4 stated the food is often dry or chewy like it was overcooked. She pointed at the food left on her tray and said I can't eat that, just look at it. Approximately 50% of the resident's meal left on her tray. During on observation 04/21/2026 at 12:04 PM, Resident #9, Resident #28 and Resident #55 at a table in the main dining room. The residents attempted to cut chicken breast with a knife. They reported the chicken is difficult to cut and is very dry and tough. During an observation on 04/21/2026 at 12:20PM, Resident #3 heard to say to other residents that the chicken is dry. During an observation on 04/22/2026 at 11:56 AM. Staff A, Dietary Manager took the temperatures of a test tray that had been delivered on a food cart. Temperature of Patty melt: 135 F (degrees Fahrenheit), sweet potato puffs: 127 F, and buttered peas 133 F. During an interview on 04/22/2026 at 11:58 Staff A, Dietary Manager stated if a resident complained of cold food, they would warm it back up or offer an alternative. She stated every once in a blue moon they would have a complaint of temperatures being too cold. When asked what temperature she would like the test tray food at she stated temperatures should be around 135 F to140 F. Staff A acknowledged the sweet potato puffs did not meet the standard. During an interview on 04/22/2026 at 1:35 PM, Resident #3 stated steaks are tough and hard to chew. Resident #3 stated that the chicken from the day before [4/21/26] was very dry and that meal quality was inconsistent. Resident #3 reported residents had voiced concerns during resident council meetings. A review of Resident Council minutes revealed: a. From the 1/30/26 minutes.complaints potatoes were not cooked enough, soups were scorched, and they were missing silverware. b. From the 2/3/26 minutes.residents would like more variety of foods, and they want their eggs warmer. c. Form the 3/3/26 minutes. meat tough lately. The soup was still scorched and sandwich bread was tough. Also, the minutes documented complaints of overcooked pasta, and residents wanting a variety of eggs in the morning. Alternate request sheets? A review of Grievance forms revealed: a. On 3/3/26, Resident #61 reported food is often served cold. b. On 4/1/26, a report several employees were concerned about cold food on room trays that had been delivered to residents. During an interview on 04/22/2026 at 2:48 PM, Resident #4 reported the chicken served on Tuesday [4/21/26] was dry, hard, and didn't have any taste to it. Resident #4 stated she could not eat the carrots as they were chewy. Resident #4 stated the facility too often served eggs for breakfast and the only alternative they gave were two pieces of toast and oatmeal, which she didn't like. She thought meals had been a little better lately but felt there was still work to do, especially with serving dry and overcooked food. Review of an undated facility policy, titled Food Temp Policy revealed a Policy statement which declared: Foods will be maintained at proper temperatures to ensure food safety. The Procedure section directed, in part: Hot foods much be serviced at a minimum of 1356 F, preferably at 160 F or higher. Reheated items and pureed items must be heated to 165 F or above. Test trays will be made up periodically and the Food Service Supervisor will record the food items temperature as the items are served to the resident.

Based on observation, clinical record review, facility policy review and staff interviews,he facility failed to repair peeling paint in a resident's room in an effort to provide a comfortable environment for 1 of 2 residents (Resident #11) reviewed for homelike environment. The facility reported a census of 58 residents. Findings include: Review of Resident #11's Minimum Data Set (MDS) assessment, dated 4/09/26, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. During an interview on 4/21/26 at 12:37 PM, Resident #11 stated there were areas of the paint on the walls peeling off in her room. Resident #11 stated that a friend brought in a framed picture to hang on the wall in an attempt to cover an area of paint peeling. Resident #11 reported that in the bathroom of her room was a plastic strainer kept on the floor for months. The resident explained the strainer had been used when she passed kidney stones in November of 2025. During an observation in Resident #11's room on 4/21/26 at 12:37 PM, the East had 10 to 12 half dollar size areas of bubbled paint on the wall. The paint had peeled off the wall in some areas and attached but hanging off the wall in the other areas. Resident #11 placed her bed along the north wall. The framed picture Resident #11 stated a friend gave her was placed on the north wall to cover an area of peeled paint. Also on the north wall, approximately 6 inches up from the floor the wall noted to be discolored, damaged and the paint peeled from the wall. A plastic strainer labeled with the date 11/23/25, observed to be on the floor of Resident #11's bathroom. The strainer appeared soiled with a red/brown colored substance. During an interview on 4/22/26 at 4:15 PM, Staff D, Maintenance Director, stated that at the beginning of the year he and the Administrator went throughout the resident rooms and made a list of areas that required repair and continued to work on completing these repairs.During an interview on 4/23/26 at 1:54 PM, the Administrator stated that Resident #11's room was on the list to be fixed and she would move the room higher on the list so it could be repaired sooner. Review of the undated facility policy titled, Homelike Environment, revealed a Policy Statement which declared residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.The Policy Interpretation and Implementation section, directed, in part:2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting; c. Inviting colors and decor; d. Personalized furniture and room arrangements; e. Clean bed and bath linens that are in good condition; f. Pleasant, neutral scents; g. Plants and flowers, where appropriate; h. Comfortable and safe temperatures (71 degrees Fahrenheit to 81 degrees Fahrenheit); and i. Comfortable noise levels.

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to ensure staff used infection control techniques during wound care (Resident #10) and preparation of a dose of insulin when drawn up from a multiuse vial (Resident #57) for 2 of 5 residents reviewed for infection control. The facility reported a census of 58 residents.Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 2/20/26, revealed that Resident #10 had one unhealed Stage 3 pressure ulcer. The list of diagnoses included cutaneous abscess of buttocks, diabetes mellitus, and renal insufficiency.Review of the Care Plan, revised on 3/20/26, revealed a Focus area for Resident #10's potential/actual impairment to skin integrity started as an abscess, now pressure ulcer with the goal that Resident #10 will have complications related to area on buttocks through the review date. Interventions instructed the following, in part:a. Enhanced Barrier Precautions per Centers for Disease Control (CDC) recommendations. Date initiated: 9/09/25.b. Follow facility protocols for treatment of injury. Date initiated: 12/05/22.c. Provide dressing change per physician's order. Date initiated 3/18/26.d. Report any signs and symptoms of skin breakdown to physician. Date initiated: 12/05/22.Review of the Care Plan, initiated 4/21/26, revealed a Focus are for Resident #10 having Methicillin Resistance Staphylococcus Aureus (MRSA) in wound with the goal that Resident #10's infection will resolve with minimal complications as evidenced by negative culture, vital signs within normal limits, and no signs or symptoms of acute infection by the review date. Interventions instructed the following, in part:a. Contact isolation: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Date initiated: 4/21/26.b. Use antibacterial soap and disposable towels. Wash hands immediately after Activities of Daily Living (ADLs), care tasks, and activities. Date initiated: 4/21/26.c. Instruct family/visitors/caregivers to wear disposable gown and gloves during physical contact with resident. Discard in appropriate receptacle and wash hands before leaving room. Date initiated: 4/21/26.d. Resident areas to be thoroughly cleaned using disinfectants. Date initiated: 4/21/26.e. Resident care equipment to be appropriately cleaned, disinfected, or sterilized according to facility protocol. Date initiated: 4/21/26.Review of the April 2026 Treatment Administration Record (TAR) revealed an order for: Coccyx wound, clean with wound cleanser, Vashe (solution used to clean, irrigate, moisten, and debride acute and chronic wounds) dampened gauze to wound bed, cover with rolled 4x4 gauze, secure with tape two times a day. On 4/22/26, the TAR documented the treatment completed by Staff C, Licensed Practical Nurse (LPN).During an observation on 4/22/26 at 8:58 AM, Staff C, LPN donned gown, gloves, a mask and googles prior to entering Resident 10's room. Staff C prepared the supplies needed for wound care. She placed a barrier on the over the bed table, and then set gauze, a padded dressing and tape on the barrier. Staff C removed the old dressing from Resident #10's coccyx, reported a scant amount of drainage on to the old dressing and put the dressing in the waste can. Staff C next sprayed wound cleanser onto the pressure wound and dabbed it dry with gauze. Without changing gloves or performing hand hygiene, Staff C then opened the bottle of Vashe and poured the solution over clean gauze. Staff C then placed the soaked gauze into the wound bed, and covered the area with clean, dry gauze. Staff C then placed the padded dressing over the area, and secured the dressing with tape. Without a change of gloves, or completion of hand hygiene, Staff C, LPN moved her gown away from her clothing, reached into her pocket for a pen, and used to the pen to date the new dressing. Staff C, then returned the pen to her pocket. Without a change of gloves, or completion of hand hygiene, Staff C removed the goggles from her face, then removed gloves, gown, goggles and mask. Staff C then completed hand hygiene prior to exiting Resident #10's room. During an interview on 4/23/26 at 8:49 AM, Staff C, LPN stated that hand hygiene should be completed before and after going into a resident's room and gloves to be changed when soiled and between patients. Staff C reported that Resident #10 had a MRSA infection in the wound and took an antibiotic related to the infection.2. Review of the MDS assessment, dated 2/20/26, revealed Resident #57 received daily insulin injections and had a diagnosis of diabetes mellitus.Review of the Care Plan, revised on 11/23/23, revealed a Focus area for Resident #57's diagnosis of diabetes mellitus with neuropathy, receiving insulin and oral anti-diabetic therapy with a goal that Resident #10 would experience no medical complications related to diabetes through the next review date. Interventions instructed the following, in part:a. Administer medications as ordered by physician. Date initiated: 5/15/17.b. Observe for open areas, signs and symptoms of infections and report to MD if noted Date Initiated: 05/15/17.Review of the April 2026 Medication Administration Record (MAR), revealed an order for Humalog Injection Solution (Insulin Lispro), with instructions to inject 12 units subcutaneously before meals related to type 2 diabetes mellitus with diabetic neuropathy, hold for blood sugar reading less than 100. On 4/22/26, the TAR documented the 11:30 AM dose administered by Staff C, LPN.During an observation of insulin administration on 4/22/26 at 11:36 AM, Staff C applied a pair of gloves, removed an insulin syringe from the sterile packaging, then without cleaning the stopper on the top of the bottle, inserted the needle into the multiuse vial of Humalog (Insulin Lispro). Staff C drew up 12 units of insulin into the syringe, cleaned Resident #57's right upper arm with an alcohol wipe, and injected the medication subcutaneously into Resident #57's right upper arm.During an interview on 4/22/26 at 11:40 AM, Staff C, LPN stated she did not clean the stopper of Resident #57's multiple use insulin vial because Resident #57 is the only resident who uses it.During an interview on 4/23/26 at 1:05 PM, the Director of Nursing (DON) stated she expected nurses to change gloves and perform hand hygiene when moving between soiled and clean items or tasks during wound care. The DON added she also expected the top (stopper) of an insulin vial would be cleaned prior to the insertion of the syringe to draw up the medication to prevent infections. Review of the facility policy titled, Dressing Change, revised 2/2026, Procedure section instructed staff to, in part: f8. Perform hand hygiene and apply gloves.9. Remove soiled dressing and discard in waste receptable.10. Inspect wound and peri-wound for appearance, color, size, drainage, edema, approximation (wound edges are together), presence/existence of drains if applicable, tissue, and odor.11. Remove soiled gloves, discard. Perform hand hygiene.12. Prepare clean field: Arrange supplies on table and open supplies.13. If dressings need to be cut to size, use clean scissors (disinfect scissors before and after using).14. Perform hand hygiene and apply gloves.15. Cleanse wound per physician's orders. Follow manufacturer's guidelines for product use. Clean from least to most contaminated area.16. Clean around any drain if present (starting near the drain and moving outward).17. Remove soiled gloves, discard. Perform hand hygiene and apply gloves.18. Apply dressing per physician's orders. If orders require topical application of ointment or cream, apply with applicator if available or clean glove.19. Label with initials and date of dressing change.20. Remove procedure towel (wound drape) or clean towel from under patient and discard.21. Dispose of soiled and used disposable equipment and supplies in waste receptacles (blood discarded in biohazard trash/red bag)22. Remove soiled gloves, discard. Perform hand hygiene.23. Disinfect over bed table.

Based on the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1st December 31), facility record review, and staff interviews the facility failed to submit accurate staffing data for the PBJ Staffing Data Report. The facility reported a census of 53 residents. Findings include: The PBJ report from the first fiscal year (FY) 2025, triggered for Excessively Low Weekend Staffing. The Daily Roster (nursing assignment) dated 12/28/24, identified the Minimum Data Set (MDS) nurse worked the 2-10 shift due to a call off for for the 2-10 shift. The Daily Roster dated 12/29/24, showed the Assistant Director of Nursing (ADON) worked the day shift and the MDS nurse worked the 2-10 shift due to a nurse called off for a double shift. The Facility assessment dated ,d+[DATE], reflected the Staffing Plan, other nursing personal (those with administrative duties that are not part of direct care like the Director of Nursing (DON), ADON and MDS. On 4/02/25 at 1:01 PM, the DON reported on 12/29/24 (Sunday) the ADON worked due to a call off for a double shift, and the MDS nurse worked the 2-10 shift. The DON revealed the ADON and the MDS nurses's hours failed to show up as nursing on the floor and were in management hours. She reported that's why the Trigger for Low Weekend Staffing. On 4/02/25 at 1:12 PM, the Human Recourses (HR) reported she gets the payroll completed and then it's sent to the Administrator who sends the information to the Corporate office and they do the PBJ. She stated the ADON and the MDS nurse's hours lacked inclusion in the nursing hours on the floor. The facility provided a policy titled Reporting Direct Care Staffing Information (Payroll-Based Journal) dated 8/2022. The policy directed complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS.

Based on observation, record review, staff interview, and policy review the facility failed to specify and maintain appropriate water temperatures in order to prevent legionella growth or use appropriate personal protective equipment (PPE) when laundering contaminated items. In addition, the facility failed to use a barrier when emptying the catheter bag for 2 of 2 residents reviewed (Residents #13 and Res #32). The facility failed to utilize enhanced barrier precautions when completing wound care on 1 out 3 wound cares observed (Resident #44). The facility reported a census of 52 residents. Findings include: 1. On 6/5/24 at 9:03 AM watched Staff B, Laundry/Housekeeping, wear gloves, failed to wear a gown when transferring soiled linens from a red bin (contaminated items) to the washing machine. On 6/5/24 at 9:07 AM Staff B confirmed she only wore gloves for handling linens, she didn't wear a gown or mask with contaminated linens. They used to do that during the Covid 19 pandemic but not anymore. On 6/5/24 at 9:18 AM Staff C, Housekeeping Supervisor explained laundry staff only wear gloves to process contaminated linens or those from residents on isolation precautions. They do not wear a gown or mask. The facility policy titled Laundry Manual, undated, instructed staff to store, handle, and transport linens in a way that precludes cross contamination. 2. A review of the weekly water temperature logs dated 5/2/24 6/3/24 revealed the hallway boiler tested less than 140 degrees Fahrenheit ( F) every week. On 6/5/24 at 9:32 AM the Administrator noted he couldn't answer what they do to prevent legionella in the facility. He explained the old maintenance man didn't leave anything behind and they could not find any documentation of testing. He reported they added filters to the ice making machine and did hot water testing weekly. They try to keep the outcoming water below 110 F to prevent burns. He verbalized he did not know why the boilers tested so high (138 F). Before the new maintenance man started he kept them at 120 F, the temperature before the water reached the mixing valve. The Legionella Water Management Plan policy, dated 2017 instructed staff to make sure hot water temperatures reach the right degree, but, failed to indicate what the right degrees are. 37072 3. Resident #32 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #32 required substantial/maximal staff assistance with dressing and total assistance from staff with toilet use, and showers. The MDS also identified Resident #32 had an indwelling catheter. The MDS included diagnoses of hypertension (high blood pressure), diabetes mellitus and renal insufficiency (poor kidney function). The Care Plan initiated 2/25/23 identified Resident #32 had a urinary catheter due to pressure ulcer on buttock. The Care Plan intervention directed staff to provide catheter care and treatment per physician orders. On 6/5/24 at 8:24 AM observed Staff E, Certified Nurse Aide (CNA), empty Resident #32's catheter. She placed the cylinder on the floor without a barrier under it prior to draining the urinary catheter bag. 4. Resident #44 Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. Resident #44 required substantial/maximal staff assistance with dressing and total assistance from staff with toilet use and showers. The MDS included diagnoses of atrial fibrillation (a type of irregular heart rhythm), hypertension, heart failure and diabetes mellitus. The MDS indicated Resident #44 had an unhealed pressure ulcer. The Care Plan initiated 4/12/24 reflected Resident #44 had a pressure ulcer to their sacrum. The Care Plan directed staff to follow facility policies/protocols for the prevention/treatment of skin breakdown. On 6/5/24 at 10:10 AM watched Staff I, Registered Nurse (RN)/ Infection Preventionist, provide wound care to Resident # 44. Prior to entering room and during the entire wound care she failed to utilize any personal protective equipment or enhanced barrier precautions. On 6/6/24 at 9:23 AM Staff I stated they utilized enhanced barrier precautions (EBP) for open wounds, catheters, and anyone who had a history of multi resistant staph aureus (MRSA) or multi drug resistant organism (MDRO). The precautions staff should use catheters, gowns, gloves, and glasses. With open wounds, the staff need to wear a gown and gloves. Resident #44 should have when they provided their wound care. Staff I explained they removed the EBP for dressing changes because his wound healed, then he ended up in the hospital, and they reinstated his wound care. At the time he readmitted back to the facility, he should have had EBP, but they we didn't restart it. On 6/6/24 at 09:48 AM the Director of Nursing (DON) reported when a resident has a wound or catheter, that required care, expect with a chronic open wound, the staff need to gown up when providing wound care for EBP. The undated policy titled Enhanced Barrier Precautions instructed the facility to implement EBP for the prevention of transmission of multi-drug resistant organisms. The policy directed the staff to obtain an order for EBP for residents with the following: wounds, (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) even if the resident if the infection status is unknown or if they are colonized with a MDRO. 25855 5. Resident #13's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. Resident #13 required substantial/maximal staff assistance with dressing and required total assistance from staff with toilet use, showers, putting on and taking off footwear. In addition, the MDS also identified Resident #13 had an indwelling catheter and colostomy. The MDS included diagnoses of diabetes mellitus, paraplegia (paralysis of one half of the body), and arthritis. Observations of Resident #13 revealed the following: a. 6/4/24 at 8:08 AM Resident #13 sat up in bed eating breakfast. The urine collection bag and tubing laid on the floor. b. 6/4/24 at 8:15 AM assessment unchanged c. 6/4/24 at 8:30 AM assessment unchanged d. 6/4/24 at 8:45 AM assessment unchanged e. 6/4/24 at 9:00 AM the urine collection bag and tubing remained on the floor. f. 6/24/24 at 9:07 AM the Assistant Director of Nursing (ADON) entered the room to complete wound care and did not pick up the bag off the floor. g. 6/4/24 at 9:07 AM the ADON, Staff H, CNA, and Staff E, CNA, applied isolation gowns, gloves, and masks then entered the room. h. 6/4/24 at 9:09 AM Staff H, CNA, picked up the urine collection bag off the floor and hung it on to the bed frame. On 6/4/24 at 1:30 PM, witnessed Staff E, CNA, put on an isolation gown, gloves, and mask. Resident #13 sat in his wheelchair. Staff E failed to place a proper barrier underneath the graduate before she placed it directly on the floor and drained the urine collection bag. Additional observations: a. 6/5/24 at 7:16 AM Resident #13 sat eating breakfast. The urinary collection bag and tubing didn't touch the floor. b. 6/5/24 at 8:00 AM the urinary collection bag and tubing now on the floor. c. 6/5/24 at 8:15 AM Assessment unchanged d. 6/5/24 at 8:30 AM Assessment unchanged e. 6/5/21 at 9:07 AM Assessment unchanged The Care Plan Focus revised 2/26/24 indicated Resident #13 had a risk for medical complications due to the use of a colostomy (surgically made area in the stomach to allow the passage of stool) and urostomy (surgically made area in the stomach to allow the passage of urine). The Care Plan failed to address the need to keep the collection bag and tubing off the floor to prevent urinary tract infections. Resident #13's last collected Urinalysis dated 3/31/24 listed the white blood cell (WBC) count as TNTC too many to count. The results reflected they had a large amount of leucocyte esterase (which tests if a urinary tract infection is present) and many bacteria. The Microbiology Report on the Urine dated 3/31/24 didn't identify the organism, only identified two antibiotics Trimethoprim/Sulfa as resistant and Tobramycin as susceptible. In an interview on 6/6/24 at 8:36 AM, Staff D, CNA, reported when they empty a urinary collection bag, they should put on all the personal protective equipment (PPE), put the barrier (such as a disposable chux or plastic bag) under the cylinder, then drain the urine into the cylinder. Staff D added the bag and tubing should never be on the floor. During her 5-day orientation at the facility, they explained the staff showed them how to empty catheter bags and completed a return demonstration afterward. In an interview on 6/6/24 8:51 AM, Staff E, CNA, explained when emptying a urinary collection bag, she should apply all the PPE, drain the bag into a graduate, wipe of the spout with an alcohol wipe, and return it to the holder. The bag and tubing should never be on the floor. She couldn't recall receiving infection control training from the facility. In an interview on 6/6/24 at 9:58 AM, Staff F, CNA, reported to empty a urinary collection bag, she should put on gloves, place a barrier such as a chux or plastic bag under the graduate, and drain the urine into the graduate. She only needed to wear the other PPE only if the resident has an infection. The bag and tubing should never be on the floor. The Infection Preventionist spent 3 days teaching her how to properly wash hands. She didn't receive any instruction about the enhanced barrier precautions. In an interview on 6/6/24 at 10:32 AM, Staff G, Licensed Practical Nurse (LPN), reported when emptying a urinary drainage bag, you should place a barrier such as a plastic bag or chux underneath the graduate and drain the urine into the graduate. The bag or tubing should never be on the floor. In an interview on 6/6/24 at 11:01 AM, the DON said when emptying a urinary drainage bag, they should place a barrier such as a plastic bag underneath the graduate and drain the urine into the graduate. The bag or tubing should never touch the floor.

Based on observation, record review, resident and staff interview, the facility failed to maintain a homelike environment for resident rooms for six out of six rooms reviewed. (Residents #5, #6, #31, #40, #45). The facility reported a census of 52 residents. Findings include: Observations of residents' rooms revealed the following: a. On 6/3/24 10:31 AM, Resident #5's bathroom door had approximately 40% of the paint missing from the bottom. Resident #5 reported the door to her bathroom looked that way since she moved in 3 years ago. In addition, the wall outside the door on the left side didn't have a baseboard. b. On 6/4/24 at 7:29 AM, Resident #40's bathroom door had splintering noted to bottom portion of the door. c. On 6/4/24 at 8:04 AM, Resident #45's bathroom door had paint missing to the lower portion, a baseboard missing to left side of the door, and corner covers peeled off with exposed plaster which measured approximately 4 feet in length. d. On 6/5/24 at 8:12 AM, Resident #6's bathroom door had paint missing to top portion of the door and the wall to right side of the bathroom door had an area without plaster which measured approximately 8 inches long and 2 inches wide with exposed metal. e. On 6/5/24 8:23 AM, Resident #31's wall to the right side of the bathroom door had approximately 6 inches of the baseboard peeling away from the wall. In an interview on 6/6/24 at 8:24 AM, the Maintenance Supervisor verbalized being the only staff member who worked in the Maintenance Department. He received problems that needed addressed through the company's software application. At the time of the interview, he explained he didn't have any repairs needed as everything is up to date. In addition, he made rounds around the facility rooms on a daily basis to see if any rooms needed repairs. In an interview on 6/6/24 at 12:09 PM, the Administrator explained the facility didn't have a policy related to informing Maintenance of room repair needs. He added, the facility used a software system to identify work tasks. The staff could enter the tasks requested through their electronic resident charting software. From there, the requested tasks go to the maintenance software system. At morning standup meetings, they give repair requests to the Maintenance Director. Sometimes, repair requests go through the use of text messages to the Maintenance Director. The Maintenance Director uses company software to complete weekly tasks and monthly maintenance.

Based on observation, record review, and staff interview, the facility failed to identify resident problems and implement appropriate interventions on the Care Plans for four of four residents reviewed (Residents #13, #21, #31, and #34). The facility reported a census of 52 residents. Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #13 required substantial/maximal staff assistance with dressing and required total assistance from staff with toilet use, showers, putting on and taking off footwear. In addition, the MDS also identified Resident #13 had an indwelling catheter and colostomy. The MDS included diagnoses of diabetes mellitus, paraplegia (paralysis of one half of the body) and arthritis. The Order Summary Report dated 6/4/24 included an order dated 12/28/22 for Ozempic (0.25 or 0.5 milligrams MG/dose) Solution Pen injector 2 MG/1.5 ml. Inject 0.25 MG subcutaneously in the evening every 7 day(s) for diabetes mellitus. The Care Plan lacked information related to Resident #13's diagnosis of diabetes mellitus and interventions. On 6/3/24 at 1:27 PM observed Resident #13 sit in his wheelchair in his room. He reported he lived at the facility for 6 years. He explained he had problems with diabetes and pressure ulcers. Resident #13 appeared well groomed, wearing clean clothing, wore gripper socks, appeared comfortable and looked properly positioned. On 6/4/24 at 2:40 PM, the Assistant Director of Nursing (ADON) reported Resident #13 had orders for Ozempic since 2022, however used Metformin (a medication also used to treat diabetes mellitus) long before 2022. 2. Resident #31's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive deficit. Resident #31 required substantial/maximal staff assistance with showers, lower body dressing and help with walking. The MDS also identified Resident #31 as totally dependent on staff to assist with toilet use, putting on footwear, taking off footwear, personal hygiene, and transfers. The MDS included diagnoses of coronary artery disease, diabetes mellitus and hip fracture. Resident #31's June 2024 Physician Orders and Medication Administration Record (MAR) included the following orders: a. 2/6/24: Eliquis Oral Tablet 5 MG. Give 5 MG by mouth two times a day for anticoagulant (blood thinner). b. 6/1/24: Metformin HCl ER Oral Tablet Extended Release 24-hour 500 MG. Give 1 tablet by mouth in the evening related to type 2 diabetes mellitus. Resident #31's Diagnoses Report reviewed 6/7/24 identified diagnoses of diabetes mellitus and atrial fibrillation (an abnormal heart rhythm which requires treatment with anticoagulants) with an onset date of 9/9/22. The Care Plan initiated 2/13/24 lacked the diagnosis of diabetes mellitus, the use of an anticoagulant, and interventions related to both. In an interview on 6/6/24 at 10:32 AM, Staff G, Licensed Practical Nurse (LPN), reported any nurse could update the Care Plans, however, the MDS Coordinator usually takes care of it. If a resident is Diabetic, she expected the Care Plan to address it and common interventions she expected to see on the Care Plan included: the use of parameters, the use of protein drinks, interventions to address low or high blood sugars, and the use of sliding scale. If a resident has orders for an anticoagulant, she expected the Care Plan to include that and interventions of an International Normalized Ratio (INR measures how long it takes the blood to clot), check for bruising, and bleeding. On 6/6/24 at 11:01 AM, the Director of Nursing reported any nurse can update the Care Plan, however, the MDS Coordinator is responsible for developing and updating the Care Plans. If a resident is Diabetic, she expected the Care Plan address their diagnosis and interventions related to the diagnosis such as accuchecks (blood glucose checks) according to orders, proper diet, skin assessments, and actions to take if signs of hypoglycemia or hyperglycemia. If a resident has orders for an anticoagulant, she expected the Care Plan to address it and common interventions such as monitor for bleeding, INR, and Prothrombin Time Test (PT measures how fast a blood sample can form a clot). 37072 3. Resident #34 Minimum Data Set (MDS) assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. Resident #34 required partial/moderate staff assistance with showers, lower body dressing, and walking. The MDS included diagnoses of coronary artery disease, peripheral vascular disease and diabetes mellitus. A review of the June 2024 Physician Orders and Medication Administration Records revealed the following: a. 2/7/24 Eliquis Oral Tablet 5 MG Give 1/2 tab by mouth two times a day for Anticoagulant. b. 4/23/24 Glipizide (diabetic medication) 5 MG by mouth two times a day related to Type 2 diabetes mellitus. Resident #34 also has a physician order from 2/17/24 for Lispro Insulin to inject subcutaneous three times a day dependent on results of blood sugar. A review of the Facility Diagnoses Report identified Resident #34 with diagnoses of diabetes mellitus and Atrial Fibrillation (an abnormal heart rhythm which requires treatment with anticoagulants) on 2/7/24. The Care Plan initiated 12/26/23 failed to identify Resident #34 with the diagnosis of diabetes mellitus and the order for the anticoagulant and the appropriate interventions for both. 49976 4. Resident #21 Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 had a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of end stage renal disease, anemia, and diabetes mellitus. The MDS indicated Resident #21 received dialysis as a resident at the facility. The Dialysis Agreement form dated 6/5/22 reflected Resident #21 received dialysis 3 days per week. Resident #21's Care Plan dated 11/2/23 lacked information related to his dialysis.

F 698 Dialysis SS=D Based on record review, resident and staff interview, and policy review the facility failed to conduct assessments of the dialysis access site and conduct post dialysis vitals for 1 of 1 resident reviewed (Res #21). The facility reported a census of 52 residents. Findings include: Resident #21 Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 had a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of end stage renal disease, anemia, and diabetes mellitus. The MDS indicated Resident #21 received dialysis as a resident at the facility. Resident #21's Care Plan dated 11/2/23 lacked information related to his dialysis. The Dialysis Agreement form dated 6/5/22 with the local health center documented the resident receives dialysis three days per week. Resident #21's electronic medical record lacked documentation of assessments of the access site pre and post dialysis or post dialysis vitals. The Dialysis Communication notes from 3/4/24 to 6/3/24 revealed no completion of Post Dialysis Vital Signs line on the facility section of the document. Resident #21's June 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked dialysis interventions for post dialysis vitals, access site assessment, pre-dialysis and post dialysis assessments. On 6/4/24 at 8:51 AM Resident #21 stated he received dialysis on Mondays, Wednesdays, and Fridays. He explained the dialysis center checked his vitals when he's there. The dialysis staff assess his access site, but not staff at the facility. On 6/4/24 at 3:15 PM Staff A, Licensed Practical Nurse (LPN), reported the two dialysis residents leave at 6 AM and come back around lunchtime. A communication book goes with the residents that have their name, morning vitals, and medications given. After they return, nursing checks Resident #21's blood sugars. The dialysis staff do the post vitals after dialysis and assess the access site; the facility staff didn't. On 6/4/24 at 3:29 PM the Director of Nursing (DON) explained the nurses at the facility didn't do the post dialysis vitals unless the dialysis center directs it on the form or via phone upon the resident's return. The Peritoneal Dialysis (Continuous Ambulatory) policy revised October 2010 failed to address the need for the facility to complete post dialysis vitals and to assess the access site pre and post dialysis.

Based on observation, record review, family, and staff interview, the facility failed to document an assessment of a resident prior to their transfer to the hospital for 1 of 2 residents reviewed (Resident #6). The facility reported a census of 52 residents. Findings include: Resident #6 Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. Resident #6 required total assistance from staff with most activities of daily living. The MDS included diagnoses of renal insufficiency (kidney failure), diabetes mellitus and non Alzheimer's dementia. On 6/3/24 at 10:03 AM witnessed Resident #6 sit in her recliner, awake, alert, and able to converse with the staff. Resident #6 denied pain, discomfort, or problems with cares. She looked properly positioned and comfortable. On 6/3/24 at 1:05 PM, Resident #6's family member reported Resident #6 got hospitalized in January 2024 due to influenza A. The Nurses Note dated 1/3/24 at 7:52 PM indicated the nurse spoke with Resident 6's son and informed him of Resident #6's decline that day with her poor fluid and meal intakes. The nurse could arouse Resident #6 with verbal and physical stimuli, but appeared sleepy that shift. Informed Resident #6's son of her urinary catheter placement related to urinary retention. In addition, the nurse collected a urine specimen, sent it to the lab, and received a new order for Levaquin 500 milligrams (MG) by mouth (PO) daily for 10 days. The Progress Note dated 1/4/24 at 5:08 AM reflected the emergency room (ER) nurse called to inform facility about Resident #6's admission to the hospital due to influenza A, pneumonia, and dehydration. The Daily Skilled Charting Note dated 1/7/24 at 9:38 PM indicated Resident #6 returned to the facility by ambulance following her hospitalization for influenza A, pneumonia, and minor urinary tract infection (UTI). The orders directed to continue the oral antibiotics at the facility for 4 days. The progress notes failed to document the assessment of Resident #6, when and why she went to the ER, mode of transportation, and physician orders to transfer to the emergency room . On 6/6/24 at 10:32 AM, Staff G, Licensed Practical Nurse (LPN), reported when a resident goes to the hospital, the nurse charts an assessment of when the resident began to show signs of any distress, actions I have taken, call to the doctor, mode of transportation to the hospital, notification of family. The nurse should chart the assessment within 24 hours. In addition, Staff G verified Resident #6's chart didn't have documentation to show an assessment, notification of physician, and family. The nurse should complete a transfer form in the computer on the face sheet page. Staff G verified Resident #6's clinical record had documentation of Resident #6's transfer to theER on [DATE], however, the clinical record didn't have documentation of an assessment. In an interview on 6/6/24 at 11:01 AM, the Director of Nursing reported when a resident goes to the hospital, she expected the nurse to chart in the progress notes the status change, notification of doctor, family, report, mode of transportation to the hospital, and a complete assessment. The nurse should document the assessment in the progress notes immediately. A form that documents Situation, Background, Assessment and Recommendation(SBAR) should also be completed and verified Resident #6's record did not have an SBAR prior to her hospitalization in January 2024.

Based on clinical record review, staff interviews and facility policy review, the facility failed to develop a Comprehensive Person-Centered Care Plan for three of 27 sampled residents (Resident #7, #19, and #22) whose Care Plans were reviewed. Specifically, Resident #7 did not have a Care Plan for use of antipsychotic medications or a schizophrenia diagnosis. Resident #19 did not have a Care Plan for Hospice Care that included pain management, skin integrity, or disease management services provided by Hospice and Resident #22 did not have a Care Plan for hyperlipidemia, hypotension, gastroesophageal reflux, bowel and bladder status, constipation, or code status. Findings Include: 1. Review of Resident #7's Admission Record in the Electronic Medical Record (EMR) under the Demographic Tab revealed the resident admitted to the facility on [DATE] with diagnosis of schizophrenia. Review of Resident #7's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/23/22 in the EMR and under the MDS tab, revealed the resident with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating no cognitive impairment. Review of Resident #7's current medication orders in the EMR under the Orders Tab, revealed an order dated 9/22/22 for Olanzapine Tablet 10 milligrams](mg) (an antipsychotic medication for the treatment of Schizophrenia), give 0.5 tablet by mouth two times a day related to Schizophrenia, Unspecified. Review of Resident #7's Care Plan, dated 12/8/22 in the EMR and under the Care Plan Tab, revealed the resident did not have a Care Plan for Schizophrenia or use of an antipsychotic medication. In an interview with the Director of Nursing (DON) on 02/09/23 at 9:32 AM, the DON stated, Schizophrenia and antipsychotic medications should be addressed in the Care Plans because behaviors and side effects should be monitored as well as behavior health management. 2. Review of Resident #19's Admission Record located in the EMR under the Profile Tab documented the resident admitted to the facility on [DATE] with a primary diagnosis of acute kidney failure. Review of Resident #19's Quarterly MDS, with an ARD on 12/28/22 located in the EMR under the MDS Tab revealed a BIMS score of 15 out of 15 indicating the resident cognitively intact. The MDS was completed prior to admission to Hospice Services which was on 01/09/23. Review of Resident #19's Physician Orders located in the EMR under the Orders Tab failed to include an order for Hospice Services but did include pain and wound management interventions. Additionally, under the Census Tab in the EMR indicated Resident #19 began Hospice Services on 01/09/23. Review of Resident #19's Hospice and Facility Coordinated Plan of Care dated 01/09/23, and provided by the facility, did not distinguish which days wound care would be provided, symptom management, nutrition/hydration needs, psychosocial needs, or any measurable goals and interventions to ensure continuity of care. Review of Resident #19's Care Plan located in the EMR under the Care Plan Tab included Hospice status and interventions for nutrition. The Care Plan did not include pain management, skin integrity, or disease management services provided by Hospice. 3. Review of Resident #22's Admission Record located in the EMR under the Profile Tab revealed she was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and hypothyroidism. Review of Resident #22's Care Plan located in the EMR under the Care Plan Tab revealed she had hypothyroidism but did not include thyroid medication administration or monitoring for adverse effects. The Care Plan failed to include interventions for COPD, for pain, constipation, fluid overload, or wound management which she was being treated for with medications. Review of Resident #22's Admission MDS with an ARD of 12/06/22 located in the EMR under the MDS tab revealed she had a BIMS score of 14 out of 15 indicating she was cognitively intact and had a metabolic disorder. During an interview on 02/09/23 at 3:26 PM, the MDS Coordinator (MDSC) confirmed that Resident #19 was admitted to Hospice Services after the Quarterly MDS had been submitted. Additionally, the MDSC confirmed that Resident #22's Care Plan did not include management of admitting diagnosis of COPD but should have, and should also have included interventions for hyperlipidemia, hypotension, reflux, bowl and bladder status, and cardiac status with interventions. Review of the facility's policy titled F656, F657, F658 Comprehensive Care Plans, revised date 8/2022 indicated the following: a. Under Point #2 - The Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to, the MDS and physician orders. Assessments of residents are ongoing and Care Plans are revised as information about the resident and the resident's condition change. b. Under Point #7 - The Care Plan should describe the resident's nursing, medical, physical, mental and psychosocial preferences. They should include person specific, measurable objectives and time frames with a goal to measure their progress towards meeting such.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure residents' medication labels indicated the Physician Orders for two of nine residents (Resident #3 and #22) reviewed for medication labeling. Findings Include: 1. Review of Resident #3's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile Tab documented the resident admitted to the facility on [DATE]. Review of Resident #3's Physician Order located in the EMR under the Orders Tab revealed an order for Novolog solution 100 unit/milliliter (ml) (insulin aspart) inject 6 units subcutaneously with meals, Hold if Blood Sugar (BS) less than 100 with an order date of 11/30/22. Observation on 02/08/23 at 8:47 AM, revealed Licensed Practical Nurse (LPN1) administering medications for Resident #3. The medication label dated 01/30/23 on the box indicated Novolog sliding scale should be given prior to meals (blood glucose <151= 0 units, , 151-200= 2 units; 20-250= 4 units, 251-300= 6 units; 301-350= 8 units, 351-400 = 10 units; greater than 400 call MD. 2. Review of Resident #22's Admission Record located in the EMR under the Profile Tab revealed she was admitted to the facility on [DATE]. Review of Resident #22's Physician Order located in the EMR under the Orders Tab included an order dated 02/09/23 for Levothyroxine Sodium Tablet 112 micrograms (MCG). Give 1 tablet by mouth one time a day related to hypothyroidism. Additional instructions included medication to be given on an empty stomach at 6:00 AM. Observation on 02/08/23 at 9:44 AM, LPN2 administered Resident #22's Levothyroxine Sodium Tablet 112 MCG. The resident had already finished her breakfast. Interview on 02/08/23 at 8:47 AM, LPN1 stated she hadn't noticed that the instructions on the box containing the bottle of Novolog read differently than what was in the computer's Physician Order. LPN1 confirmed that there was an order discrepancy and that it had not been reported to the Director of Nursing (DON). Interview on 02/08/23 at 9:44 AM, LPN2 stated she hadn't noticed that the medication instructions for Resident #22's Levothyroxine Sodium Tablet 112 MCG read to be given at 6:00 AM but had noticed that on the Medication Administration Record (MAR), the medication was marked to be given between 6:00 AM and 10:00 AM. LPN2 did not know why the medication hadn't been given at or before 6:00 AM on an empty stomach. Interview on 02/09/23 at 3:00 PM, the DON stated it was her expectation that the nurses verify the medication label against the Physicians' Orders prior to administering medications. The DON stated that LPN2 had mentioned to her after the medication pass that the Levothyroxine label and the Physician Order did not match. The DON confirmed that all Physician Orders and medication labels should match to avoid medication errors. Additionally, the DON stated that the facility's EMR interfaces with the Pharmacy and automatically sends any new orders to the Pharmacy immediately; DON was not sure why the error occurred. Review of the facility's policy titled, Medication Orders and Receipt Record, dated 04/2007 stated, Policy Interpretation and Implementation under the following points: a. At Point #3 - The Director of Nursing Services will designate individuals to be responsible for completing medication order/receipt forms. b. Under Point #4 - Medications should be ordered in advance, based on the dispensing Pharmacy's required lead time. c. Under Point #6 - The receiving nurse shall record medication orders received on the receipt record. The receiving nurse shall verify each delivered medication and check off the order form. d. Under Point #7 - Noted discrepancies shall be reported to the dispensing Pharmacy.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure a coordinated Plan of Care was completed between the facility and the Hospice Provider for two of two residents reviewed for Hospice Services (Resident #19 and #24). Findings Include: 1. Review of Resident #19's Hospice and Facility Coordinated Plan of Care dated 01/09/23, and provided by the facility, did not distinguish which days wound care would be provided, symptom management, nutrition/hydration needs, psychosocial needs, or any measurable goals and interventions to ensure continuity of care. Review of Resident #19's Admission Record located in the Electronic Medical Record (EMR) under the Profile Tab stated the resident admitted to the facility on [DATE] with a primary diagnosis of acute kidney failure. Review of Resident #19's Care Plan located in the EMR under the Care Plan tab included Hospice status and interventions for nutrition. The Care Plan did not include pain management, skin integrity, or disease management provided by hospice services. Review of Resident #19's Physician Orders located in the EMR under the Orders Tab did not include an order for Hospice Service. Review of the Hospice Binder at the Nurses' Stations indicated Hospice Services stated on 01/09/23. During an interview on 02/09/23 at 1:30 PM, the Director of Nurses (DON) stated the Hospice Case Manager was responsible for filling out the Coordinated Plan of Care (POC) within 24 hours of the resident's admission to Hospice Services. The POC is usually given to the Assistant DON, who then educates the Floor Nurses on the POC between the facility and the Hospice Agency. The DON confirmed that the POC should have been completed on day one of Hospice Services but was not. During a phone interview on 02/09/23 at 1:54 PM, the Director of Clinical Services (DCS) for the Hospice Agency stated that the Hospice Admissions Nurse should be filling out completely the Hospice and Facility Coordinated Plan of Care before leaving the facility after the resident was admitted into Hospice Services. 2. During the initial tour on 02/06/23 at approximately 2:05 PM, Resident #24 stated that he went on Hospice as of 01/31/23 due to health reasons. Review of facility's Nursing Facility Hospice and Respite Care Services Agreement dated March 22, 2018, revealed in Part II, Section A 2: The Plan of Care will be established by the Attending Physician, the Medical Director, or Physician-In-Charge and the Interdisciplinary Team prior to the provision of Hospice Services and will be established and maintained in consultation with Facility's representatives. The Plan of Care will identify the care and services that are needed and will specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. Review of Resident #24's Hospice and Coordinated Plan of Care dated 01/26/23, revealed no times or dates for services performed. The sheet had all blanks for routine care interventions. Wound Care (per Physician's Order) was to be coordinated by the Hospice Nurse and the Facility Nurse. During an interview on 02/09/2023 at approximately 1:36 PM, the DON reviewed the Hospice and Facility Coordination Plan of Care and agreed that the areas in question were blank, and it should have been completed in the first 24 hours after Resident #24 being placed on Hospice. Review of the facility's policy titled, Hospice Program, dated 06/2021, and provided by the facility stated - A Nursing Progress Note stating Hospice saw the resident and notes to follow etc. should be documented in the Progress Notes and include the most recent Hospice Plan of Care. Also directed at the following Points: a. At point #9 - The community retains the ultimate responsibility for the Care Plan. Coordinate the Plan of Care with the Hospice Provider, community staff and resident/family. The Care Plan may be in two portions, each maintaining their own but changes should be discussed. Suggestions for inclusion in the Care Plan: a. oral care; b. skin integrity c. medical diagnostic testing d. symptom management e. nutrition and hydration and f. activities/psychosocial needs b. At Point #10 - To promote continuity of care, collaborate with the Hospice, Nursing Home and resident/representative on a Coordinated Care Plan noted in the medical record to include, but not limited to: a. Resident/representative choices regarding care; b. The Hospice Philosophy of Care and all services needed for palliation and management of terminal illness and related conditions; c. Measurable goals and interventions based upon comprehensive and ongoing assessments; d. Interventions that address, as appropriate the identification of timely, pertinent non-pharmacological and pharmacological interventions to manage pain and other symptoms of discomfort; e. Identification of services the nursing home will continue to provide; and f. The identification of the provider responsible for performing specific services/ functions that have been agreed upon. Review of the undated Hospice and Facility Coordinated Plan of Care .Instructions for use, and provided by the facility indicated at Point #4 - The Coordinated Plan of Care is the foundation for care collaboration in the nursing facility and contains the agreed upon delineation of responsibilities for care delivery for each patient.

Based on the observation, record review and staff interviews the facility failed to complete proper assessments for 2 out of 2 resident's reviewed who received [CONDITION(S)] (Resident # 41 and # 19). The facility reported a census of 49 resident. Findings Include: 1. The Minimum Data Set (MDS) assessment dated for Resident # 41 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 3/25/21, directed the resident receives [CONDITION(S)] at the hospital 3 times a week. Monitor arteriovenous (AV) fistula for bruit (a rumbling sound that you can hear) and thrill (a rumbling sensation that you can feel). Obtain vital signs and weight per protocol. Observation on 7/28/21 at 8:06 AM, Resident # 41 sat at the breakfast table and ate 7/28/21 eggs, toast, sausage, and oatmeal. Review of the Order Summary dated 7/7/21, directed Nursing Staff to check access site for bruit and thrill daily on return shift. Vitals on return from [CONDITION(S)]. Review of the Order Summary dated 7/7/21, directed Nursing Staff to inspect the [CONDITION(S)] access site for infection daily in the left upper arm. Access for localized pain, [CONDITION(S)], warmth, [CONDITION(S)] to site, bleeding or abnormal drainage, caps secure, shortness of breath (SOB)/generalized [CONDITION(S)]. Access for thrill/bruit. Complete evening shift every Tuesday, Thursday, and Saturday for [CONDITION(S)]. Review of the Treatment Administration Sheet (TAR) for the months of June and July 2021, lacked documentation of pre [CONDITION(S)] assessments and lack every shift checking the bruit and thrill. Interview on 7/28/21 at 8:46 AM, Staff A, Licensee Practical Nurse (LPN) reported we are expected to check the weight of a resident before they go to [CONDITION(S)]. Staff A reported checked the access site before and after [CONDITION(S)], but only do vitals after [CONDITION(S)]. Interview on 7/28/21 8:48 AM, Staff B, Assistant Director of Nursing (ADON) reported the expectation is every shift assess the bruit and thrill. Staff B continued to explain staff should access vitals before the resident goes to [CONDITION(S)] and upon return and document on the TAR. Interview on 7/28/21 at 10:12 AM, the Director of Nursing (DON) reported the standard of care is staff complete pre and post [CONDITION(S)] assessments, vitals, check bruit and thrill every shirt. The facility provided a form titled Care of the Resident Receiving [CONDITION(S)] treatment undated, directed to monitor for infection or clotting at the access area , monitor bruit as ordered. and monitor for bleeding from the site. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 19 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 7/27/21, directed the resident receives [CONDITION(S)] at the hospital 3 times a week. Monitor/document/report any signs or symptoms as needed (PRN) of infection to access site: Redness, swelling, warmth or drainage. Observation on 7/27/21 at 10:20 AM, Resident # 19 in private room area visiting with a family member. Review of the Order Summary dated 7/7/21, directed Nursing Staff to check access site for bruit and thrill daily on return shift. Vitals on return from [CONDITION(S)]. Review of the Order Summary dated 7/7/21, directed monitor left wrist fistula every shift for redness, swelling, pain or bleeding. Review of the Treatment Administration Sheet (TAR) for the months of June and July 2021, lacked documentation of pre [CONDITION(S)] assessments and lack of every shift checking the bruit and thrill.

Based on clinical record review and staff interviews, the facility failed to perform inventory count of narcotics as required. The facility census was 75 residents. Findings include: The facility's Medication Orders policy, dated April, (YEAR), directed: 1. A controlled drug administration record used to maintain perpetual inventories of controlled substance medications, in addition to documentation on the Medication Administration Record [REDACTED] 2. Schedule II and III narcotics stored under double lock. 3. Only authorized staff, RN, LPN, or CMA permitted access to controlled medications. 4. The inventory of narcotics are verified at the end of each shift. 1. Physician orders [REDACTED].#1's [MEDICATION NAME] 1 milligram (mg) sublingually (under the tongue) every 6 hours as needed for anxiety and [MEDICATION NAME] concentrate solution (a Schedule II narcotic [MEDICATION NAME]), 5 mg or 10 mg sublingual every 2 hours as needed for pain. A delivery manifest dated 9/12/19 revealed [MEDICATION NAME] (a liquid form of the medication that required refrigeration) and [MEDICATION NAME] were delivered to the facility on [DATE] at 7:12 p.m., and confirmed by the signature of Staff A, registered nurse (RN). The center hall's narcotic medication ledger book revealed a control log for the [MEDICATION NAME] initiated on 9/12/19, and a notation on the page that stated the medication was located in the east hall medication room refrigerator. Staff failed to initiated a control log for the [MEDICATION NAME] in the east hall narcotic ledger book and did not account for refrigerated narcotics when narcotic counts completed. 2. Physician orders [REDACTED].#2's [MEDICATION NAME] 1 mg injected intramuscularly as needed for [MEDICAL CONDITION] more than 5 minutes, may repeat as needed in 5 minutes, the order discontinued on 7/1/19. A delivery manifest revealed 10 vials of [MEDICATION NAME] 2 mg per milliliter concentration delivered on 7/3/19 at 7:41 p.m., and confirmed by the signature of Staff F, LPN. The narcotic inventory page for the resident's [MEDICATION NAME], maintained in the east hall narcotic ledger book revealed 10 [MEDICATION NAME] vials added to the resident's inventory on 7/5/19, that made a total of 12 vials on hand. The next entry on the page, dated 9/20/19 at 10:00 p.m. revealed 7 [MEDICATION NAME] vials on hand. On 11/19/19 at 1:25 p.m., Staff G, RN, stated prior to 9/20/19, nurses counted narcotics at the beginning and end of each shift, refrigerated narcotics should have been counted, sometimes they were, sometimes they weren't. On 11/19/19 at 11:00 a.m., the director of nursing (DON), stated the facility initiated an investigation when notified of the missing [MEDICATION NAME], returned the resident's [MEDICATION NAME] to the pharmacy and staff would obtain the [MEDICATION NAME] from a secured, computer operated dispensary utilized by the facility since July, 2019.

Based on observation, document review, menu review and staff interviews the facility failed to follow the planned menu for 4 of 5 meals observed . The facility identified a census of 76 residents. Findings include: 1. Review of the facility's Week 3 Menu, approved by the Corporate Dietitian on 4/17/19, identified lemon pepper tilapia, wild rice, carrots and triple berry buckle as part of the noon meal on 9/9/19. Observation on 9/9/19, 11:32 a.m. to 12:30 p.m., revealed applesauce served to residents for dessert in place of the planned triple berry buckle, for all diet types. 2. Review of the facility's Week 3 Menu, approved by the Corporate Dietitian on 4/17/19, identified Swiss steak, mashed potatoes, beef gravy, corn and french silk dessert as part of the noon meal on 9/10/19. The planned menu identified a #8 scoop of mashed potatoes for all diet types (equivalent to 1/2 cup). Observation on 09/10/19, at 7:20 a.m., revealed the menus posted outside of the main dining room, and at the east and west halls identified Swiss steak, mashed potatoes, beef gravy, corn, fresh baked bread and French silk dessert for the noon meal . Observation on 9/10/19, from 11:20 a.m. to 12:35 p.m., revealed green beans served to in place of the planned corn and ice cream served in place of the planned french silk dessert to residents for all diet types. Staff F, Cook, served the mashed potatoes with a #12 scoop (equivalent to approximately 1/3 cup) to residents for all diet types. 3. Review of the facility's Week 3 Menu, approved by the corporate Dietitian on 4/17/19, identified egg drop soup, egg roll casserole, mandarin oranges and rainbow cake a la mode served as part of the evening meal on 9/10/19. During random resident interviews on 9/10/19, at 8:00 a.m., two residents shared positive comments about the breakfast mean and reported they were looking forward to the evening meal menu of egg roll casserole and egg drop soup. Observation on 9/10/19, at 8:40 a.m., revealed the menu posted outside the main dining room and at the east and west halls identified egg drop soup, egg roll casserole, mandarin oranges and rainbow cake a la mode for the evening meal. Observation at 9/10/19, at 3:28 p.m., revealed the menu posted for the evening meal had been changed to identify pizza burger, potato chips and black forest cake. Observation on 9/10/19, at 5:15 p.m., revealed pizza burger and potato chips served to residents in place of egg drop soup and egg roll casserole and black forest cake served to residents in place of rainbow cake a la mode. Observation at the beginning of evening meal service on 9/10/19, at 5:15 p.m., revealed a pizza burger, potato chips and black forest cake available for meal service in place of the planned menu items. 4. Review of the facility's Week 3 Menu, approved by the Corporate Dietitian on 4/17/19, identified Chicken Kiev, stuffing and Malibu blend vegetables as part of the noon meal on 9/11/19. Observation on 9/11/19, at 8:30 a.m., revealed the menu posted outside of the dining room and in the east and west hall identified chicken Kiev, stuffing, Malibu blend vegetables and seasonal fresh fruit for the noon meal, with a handwritten addition of mashed potatoes. Observation on 9/11/19, at 12:00 p.m. revealed mashed potatoes served to residents in place of stuffing. During an interview at Resident Council meeting on 9/9/19, beginning at 1:00 p.m., 5 of 5 residents agreed the menus posted don't always match what is on their plate. They reported in some cases, the original menu posted has a hand written change or is replaced with a new menu on a hand written sheet. Resident #28 reported the menu posted that day identified the dessert would be triple berry buckle and they got applesauce. Review of the past three months on the Resident Council Minutes revealed the following: 1. (MONTH) 12, 2019 . Menus are not always posted correctly. (Dietary Manager) explained that sometimes they have a missing ingredient or something didn't come in so they have to change the menu. (Dietary Manager) will remind cooks that they need to update the posted menus when that happens . 2. (MONTH) 10, 2019 . Residents expressed concern that meals served do not always match the posted menu. (Dietary Manager) explained that currently they are down a freezer, therefore they are using items as they need to before they spoil. (Dietary Manager) explained that the menus should still match when there are changes and she will talk with her staff . 3. (MONTH) 14, 2019 . There continues to be an issue with the menu served not matching what is posted on the menu boards. Residents understand that sometimes changes have to be made, but the boards need to reflect that change . During an interview on 9/11/19, at 1:50 p.m., the Dietary Manager acknowledged some of the menu changes observed resulted because of the lack of freezer space, when one of two freezers quit working about 4 months ago. She reported they do not have room to store everything they need and is unable to order some items if there's no room to store it. She confirmed the replacement of the triple berry buckle at the noon meal on 9/9/19, corn and french silk dessert at the noon meal on 9/10/19, occurred due to either lack of freezer space or needing to use items up to make room. She acknowledged some of the menu changes occurred due to resident preferences as some of these items residents do not care for. She acknowledged she has not revised the menus, in consultation with the Corporate Dietitian, to ensure the current menu items meet resident preferences. She confirmed she changed the evening meal on 9/11/19 because the residents don't care for the egg drop soup and egg roll casserole. She reported she made a menu change at the noon meal on 9/11/19 (mashed potatoes instead of stuffing) because they did not have stuffing mix on hand. The Dietary Manager reported when menu changes occur, staff are to pick a similar item (example: vegetable for vegetable, starch for starch, etc.) and are supposed to record the change on the menu substitution form, located in the menu book, to ensure there is record of what is served. During the interview, the Dietary Manager retrieved the menu book to display the form used to record substitutions and found none recorded. The form identified the opportunity to record the date, scheduled food item, substituted with, reason for substitution, employee and supervisor initials and RD signature. The Dietary Manager confirmed the menu specified a #8 scoop for the mashed potatoes and Staff F, Cook, should have served the mashed potatoes with a #8. She reported a #8 scoop is the standard serving size for the potatoes/starch items. During an interview on 9/11/19, at 4:15 p.m., the Administrator acknowledged one of the two kitchen freezers quit working a couple months ago and he planned to replace it. He acknowledged he had obtained 2 bids for corporate approval. He confirmed a new freezer had not been ordered at the time of the survey. During a telephone interview on 9/11/19, at 4:30 p.m., the Corporate Dietitian reported she works at the facility monthly and her last visit occurred in August. She acknowledged the kitchen had limited freezer space due to a freezer that quit working a couple months ago, which contributed to the Dietary Manager needing to make some menu substitutions. She reported the menu should be followed but confirmed if substitutions became necessary, they should be recorded on the substitution form which she would review on her visits.

Based on observations, policy review and staff interview, the facility Dietary staff failed to store and serve food under sanitary conditions in order to maintain food quality and reduce the risk of food-borne illness. The facility identified a census of 76 residents. Findings include: 1. Observations during the initial kitchen tour with the Dietary Manager on 9/9/19, beginning at 10:20 AM, revealed the following concerns: a. The Turbo Air refrigerator stored 3 partially used, undated pre-thickened liquids, including one 32 ounce (oz.) Hormel Thick & Easy nectar thick dairy beverage, a 46 oz Hormel Thick & Easy honey thick kiwi strawberry beverage and 46 oz. Hormel Thick & Easy honey thick orange beverage. The manufacturer product label identified the dairy beverage to be used within 4 days after opening and the juice beverages used within 10 days. During an interview at the time, Staff G, Dietary Aide, reported she opened them this morning but forgot to label with the open date and acknowledged she should have. b. The Heindel refrigerator stored 12 - 6 oz Yoplait blueberry yogurt with a best buy date of 9/7/19 and 2 - 5# containers of sour cream with a best by date of 7/12/19. One of the containers had not been opened but stored for use, and the other was about 1/2 full. The Dietary Manager acknowledged the best buy dates and discarded the products. c. The cooks area had one 8 oz can of Hormel Thick & Easy instant food and beverage thickener, about half full, with a scoop stored in the can and in contact with the product. Observation during the noon meal service on 9/10/19, at 12:20 p.m. revealed Staff F, Cook, opened the can of Hormel food thickener, removed the scoop from the can, added 1 scoop to a serving of pureed green beans and returned the scoop to the can. 2. Observation at the beginning of meal service on 9/10/19, at 11:20 a.m., revealed the gallons of milk, available for meal service, placed on top of ice in a large steam table pan. The gallons of milk remained on top of the ice for the entire meal service. Upon the conclusion of the noon meal service at 12:35 p.m., requested Staff G, dietary aide, measure the temperature of the milk. Observation showed the skim milk measured 46 degrees Fahrenheit (F.) and the 2% milk measured 44 degrees F. During an interview at the time, Staff G acknowledged it should be colder. During an interview on 9/11/19, at 1:50 p.m., the Dietary Manager, confirmed the pre-thickened beverages should be dated when opened so they can be used in the timeframe specified by the manufacturer and confirmed the manufacturer specifies the dairy beverage be used in 4 days after opening and the juices 10 days after opening. The Dietary Manager acknowledged the thickener scoop is generally kept in the can and recognized the practice of using the scoop and placing it back in the can could lead to cross contamination. She reported Staff G, Dietary Aide, had informed her of the post meal milk temperatures being too warm at the noon meal on 9/10/19. The Dietary Manager reported the milk temperature needed to be 40 degrees or lower. Review of an undated facility policy titled Food Temperatures, revealed in part . cold food temperatures should be below 41 Fahrenheit at the time during meal service.

Based on observation, record review, resident, family and staff interviews, the facility failed to revise the Comprehensive Care Plan for 2 of 18 residents reviewed (Resident #26, #7) for Activities of Daily Living (ADL's) and Restorative Nursing. The facility also failed to allow residents and/or resident representatives to participate in the Care Plan Conferences for 2 of 18 residents reviewed (Resident #56, #77) . The facility identified a census of 76 residents. Findings include: 1. Resident # 26's Minimum Data Set (MDS) assessment, dated 7/15/19, showed the resident with a Brief Interview of Mental Status (BIMS) of 15 indicating an intact memory. The resident required extensive assist with cares. The MDS showed the resident with [DIAGNOSES REDACTED]. The resident's Care Plan identified the resident with an ADL self care performance deficit related to a spinal cord injury. An intervention on the care plan showed the resident required 2 staff participation and the Hoyer (total) lift with transfers. Another intervention on the care plan showed to encourage the resident to participate to the fullest extent possible with each interaction. An observation on 9/9/19 at 12:02 p.m. revealed the resident sitting up in the electric wheelchair at the foot of the bed. The resident observed to have a white gait belt secured around the legs above the knees. An observation on 9/10/19 at 8:21 a.m. Staff P, Certified Nursing Assistant (CNA) and Staff H, CNA, used the Hoyer lift to transfer the resident from the bed to the electric wheelchair. After the resident verbalized appropriate positioning the resident requested to have the white gait belt secured around the legs above the knees. Staff P placed the gait belt around the legs above the knees as requested by the resident. During an observation on 9/11/19 at 1:13 p.m., noted the resident sitting up in the electric wheelchair at the foot of the bed with the white gait belt secured around the legs above the knees. During an interview on 9/10/19 at 9:22 a.m., the resident reported a preference to secure the gait belt around his legs to help ensure the legs do not bow outward while sitting in the wheelchair. The resident reported in the past the wheelchair had left a mark on the outside of the leg and the resident noted increased swelling in the legs. The resident reported the electric wheelchair equipped to prevent the resident from developing a mark on the leg, but the preference is to keep the legs together with the gait belt. During an interview on 9/11/19 at 11:17 a.m., Staff J, CNA, reported every resident needs to have routine cares provided each day. She reported if there is more specific care needs for the resident she would look under the Task section of the resident's electronic medical record. During an interview on 9/11/19 at 1:16 p.m., Staff K, CNA, reported she provides care for residents based off of the Set Sheets (a form that provides a reference for the resident care needs). She reported if she needed further information to provide care she would look at the care areas in the electronic medical record to determine the resident's needs. Staff K reported each morning at the start of the shift she reviews the Set Sheets to determine if there had been any changes in the resident's care. She reported the oncoming and off going shifts complete a report and verbally provide any change in the resident's care as well. During an interview on 9/11/19 at 1:28 p.m., Staff O , Registered Nurse (RN), reported staff are to use the Set Sheets to determine the care needs of the residents. She reported if she is unable to find the information on the Set Sheets, she would use the Care Plan to determine the care needs. Staff O reported if unable to find the care needs of the resident on the Set Sheet or the Care Plan she would verbally consult with Therapy, Social Services or the Director of Nursing (DON). During an interview on 9/11/19 at 2:20 p.m., the Director of Nursing (DON), reported staff are able to use the Set Sheets to provide guidance for the resident care needs. She reported staff are also able to use the Kardex on the electronic medical record as the information placed on the Care Plan is what is seen on the Kardex. The DON reported resident care requests should go on the Care Plan. Record review of the undated Set Sheets failed to show an intervention as requested by the resident to place a gait belt around the legs to prevent the legs from bowing outward. Record review of the resident's Care Plan, revised on 9/3/19, failed to show an intervention for staff to secure a gait belt around the resident's legs while up in the wheelchair as requested by the resident. Record review of the resident's undated Kardex failed to show an intervention for staff to place a gait belt around the resident's legs while up in the wheelchair as requested by the resident. Record review of the Care Planning Policy and Procedure, dated 11/28/16, revealed the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized Comprehensive Care Plan for each resident accordance with professional standards of practice, comprehensive person centered care and resident choices. The procedure section of the Care Planning Policy and Procedure showed the following: a. The Comprehensive Care Plan will include the resident needs, strengths and weaknesses, goals, personal and cultural preferences. The Care Plan will include measurable objectives, goals and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. b. Each resident's Care Plan shall be reviewed at least quarterly and will include the resident's strengths and weaknesses and incorporate personal and cultural preferences in developing goals. 2. Resident #7's MDS assessment, dated 6/9/19 showed the resident with a BIMS of 12 showing the resident with intact memory. The resident required extensive assist with cares. The MDS also documented the resident with end stage [MEDICAL CONDITION], unspecified abnormalities of gait and mobility and weakness. The MDS showed the resident had received 7 days of active range of motion (AROM) and 7 days of eating and/or swallowing with Restorative Nursing Programs. During an interview on 9/11/19 at 9:42 a.m., the DON reported the CNA's put the restorative documentation into the electronic medical record (EMR). She reported the Restorative Nurse is in charge of completing monthly Restorative Progress Notes. The DON reported the facility currently does not have a Restorative Nurse since (MONTH) 2019 and she has taken the responsibility for ensuring the monthly Progress Notes are placed in the EMR. The DON reported she had not placed the Restorative Progress Notes for (MONTH) or (MONTH) in the EMR yet but she had them to put in as a late entry. During an interview on 9/11/19 at 2:25 p.m., the DON reported when a resident is discharged from therapy the therapist provides a copy of the Therapy Communication/In-Service to Nursing to the DON. She reported she enters the resident's Restorative Program under the Task section of the electronic medical record followed by placing the resident's Restorative Program on the resident's Care Plan. The DON reported she communicates with the therapy department if there are concerns or suggestions in regards to the resident's Restorative Program. The DON reported if a resident goes to the hospital and returns with therapy needs the original restorative program should be discontinued then when therapy discharges the resident the DON places a new restorative program in the Task section of the electronic medical record and the care plan. The DON reported she expected the Care Plan should be updated immediately after the resident discharges from therapy. During an interview on 9/12/19 at 7:27 a.m., Staff H, CNA, reported not aware of Resident #7 being on a Restorative Program. During an interview on 9/12/19 at 7:29 a.m., Staff P, CNA, reported the resident does have a Restorative Program but unaware of the current programs. She reported when a resident is on a Restorative Program the Restorative Aides would complete the documentation. During an interview on 9/12/19 at 7:38 a.m., Staff Q, CNA reported the resident is currently on a Restorative Program for upper extremities, lower extremities and eating. She is unaware of how long the Restorative Programs had been in place. She reported the resident completes the Restorative Programs 6 times per week. Staff Q reported the Restorative Aides complete the documentation for the Restorative Programs in the electronic medical record. Record review of the Therapy Communication/In-Service to Nursing dated 3/13/19, showed the resident to start a Restorative Program on 3/14/19 for APT bicycle (stationary lower extremity bicycle) for 15 minutes and the arm bike for 15 minutes. The goal of the Restorative Program is to maintain/attain bilateral lower extremity strength and bilateral upper extremity strength and activity tolerance. Record review of the Therapy Communication/In-service to Nursing dated 2/18/19 showed the resident to start a Restorative Program and provide the patient with small amounts of liquid and small spoonfuls of mechanical soft consistency foods. The goal of the Restorative Program is the patient will independently take small bites and small cup sips. The patient will also go slow and switch between bites and sips showing no signs or symptoms of aspiration (no coughing or clearing throat). Record review of the Restorative Nursing Program Evaluation dated 3/11/19 showed the resident receiving a Restorative Program for eating and swallowing. The Restorative Nursing Program Evaluation showed the Care Plan reviewed (no changes). Record review of the Restorative Nursing Program Evaluation dated 9/11/9 showed the resident receiving AROM and Eating/Swallowing restorative programs. The Restorative Nursing Program Evaluation showed the Care Plan reviewed (no changes). Record review of the daily Restorative documentation showed the resident receiving an eating/swallowing and AROM restorative programs. Record review of the Care Plan, revised on 11/6/18, showed Nurse Rehab sitting balance activity related to weakness related to [DIAGNOSES REDACTED]. The Care Plan failed to address the restorative programs for AROM and eating/swallowing. Record review of the Principles and Considerations Applicable to Every Procedure from the Restorative Manual, dated 8/2009, showed the purpose of the policy promote the restorative nursing philosophy. The Guidelines for Documentation showed the following in the Implementing section of the policy: a. New program initiated for designated Restorative Certified Nursing Assistants (RCNA's). b. Add the resident's name to the master list in the RCNA's notebook. c. Add/write in the program on the CNA Kardex/Care Plan. d. Start the flow sheet and add to the RCNA notebook. e. Implement the program according to the prescription. The Care Planning Restorative Programs section of the policy showed all restorative problems, goals, and programs will be care planned by nursing. The problem or restorative need will be written showing the reason for the deficit. The Care Planning Restorative Programs also showed the following: a. Address the deficit, goals and program approaches on the care plan. b. The goals will be written in measurable terms, with a target date that is realistic to what the resident is trying to accomplish. 3. Resident #56's MDS assessment, dated 8/14/19, documented the resident with a BIMS of 15 indicating an intact memory. The MDS showed the resident required limited assist for cares. The MDS identified the resident with [DIAGNOSES REDACTED]. During initial tour on 9/9/19 at 4:11 p.m. the resident's daughter reported she had received a letter in the mail which indicated a Care Plan Conference to occur on a specific date and time. The daughter reported she arrived to the facility and staff never came to the resident or the resident's daughter to conduct the Care Plan Conference Meeting. The daughter reported she approached facility staff to discuss when the Care Plan Conference Meeting would be held and she reported it took another 2 days to set up the Care Plan Conference Meeting. During an interview on 9/11/19 at 1:55 p.m. the Social Worker reported she completes Care Plan Conferences every quarter with the residents. She reported previously she had not been completing the Care Plan Conferences appropriately at 48 hours and then again on day 21 of the resident's stay. In an interview on 9/11/19 at 4:21 p.m., the Social Worker reported she was only able to find one documented Care Plan Conference since the previous survey. She reported the facility should be conducting the Care Conferences every quarter. The Social Worker reported they have Resident #56's Care Plan Conferences more sporadically due to other concerns the resident would like to discuss. The Social Worker reported if the documentation is not available then the the Care Plan Conference not completed. In an interview on 9/12/19 at 9:44 a.m., the DON reported Care Plan Conferences should be held within the first 48 hours of admission and then quarterly thereafter. The DON reported the Social Worker sends out invitations to the family and sets up the Care Plan Conference meetings. She reported when the family confirms a time for the Care Plan Conference the Social Worker will send an email to the Interdisciplinary Team to make them aware of the conference time. She reported the Assistant Director of Nursing (ADON) and the DON attempt to attend as many Care Plan Conferences as possible. The DON reported the Care Plan Conference is interdisciplinary. The DON explained the Social Worker attempts to do Care Plan Conferences on Wednesdays, but the day and time is dependent upon the resident and family needs. The DON reported there is a Care Plan Sheet the Interdisciplinary team signs along with the resident and/or the resident representative to sign at the Care Plan Conference. The DON reported the Social Worker puts a note on the Care Plan form and it is scanned into the resident's electronic medical record. The DON acknowledged the Care Plan Conference summary should be completed every time a care conference is held. During an interview on 9/12/19 at 10:04 a.m., the DON reported the resident had a Care Plan Conference in (MONTH) and to have another one in June. The DON reported unable to find the documentation of the Care Plan Conference in June. Record review of the Resident/Resident Representation Care Plan Conference Review for 3/27/19 showed the form reviewed the resident's care and concerns the resident had during that Care Plan Conference. Record review of the resident's Care Plan showed the last revision on 8/6/19. Record review of the Care Planning Policy and Procedure, dated 11/28/16, instructed the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized Comprehensive Care Plan for each resident in accordance with professional standards of practice, comprehensive person centered care and resident choices. The procedure section of the policy showed the following: a. A Comprehensive Care Plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). The Comprehensive Care Plan will include the resident's needs, strengths, weakness, goals, personal and cultural preferences. The Care Plan will also include measurable objectives, goals and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. b. The resident, the resident's family and/or the resident's representative are encouraged to participate in the development of and revisions to the resident's Care Plan. The resident, the resident's family and/or the resident representative will be invited to participate in the resident's overall plan of care. Record of this invitation will be maintained in the resident's clinical record and written justification if the resident, the resident's family and/or the resident's representative does not participate. c. Every effort will be made to schedule Care Plan meetings at the best time of the day for the resident, the resident's family and/or the resident's representative. d. Each resident's Care Plan shall be reviewed at least quarterly and will include the resident's strengths and weaknesses and incorporate personal and cultural preferences in developing goals. 4. According to the quarterly Minimum Data Set (MDS) Assessment Tool dated 8/31/19 for Resident #77 [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #77 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident to be moderately impaired cognitively. During an interview with Resident #77's daughter on 9/11/19 at 12:28 p.m., she reported she has not attended a Care Conference and is not aware of family being invited to attend Care Conferences, and stated she would attend if invited. Her sister is also very involved with Resident #77's care and she is not aware of her attending any Care Conferences either. During an interview on 9/11/19 at 4:55 p.m., the Social Worker stated the facility does not have any documentation of family attending Care Conference or notification of a Care Plan date for resident #77.

Based on observation, staff interviews and record review, the facility failed to remove an expired emergency drug kit and maintain appropriate refrigerator temperature for storage of Pneumoccocal vaccine. The facility failed to provide quality control checks on individual resident blood glucose meters for 16 out of 16 residents. The facility census was 76 residents. Findings include: 1. During an observation on 9/11/19 at 11:07 a.m. revealed the medication room refrigerator had a temperature of 50 degrees Fahrenheit, frost build up in the freezer compartment and a half inch of water in the shelf tray. A plastic emergency drug kit was sitting in a half inch of water on the tray in the refrigerator. The emergency drug kit was labeled with F38 on the lid of the box and was sealed with a red zip lock tie number 72. The label on the emergency drug kit documented the expiration date of the kit as (MONTH) (YEAR). The emergency drug kit label documented the contents of the kit as: [MEDICATION NAME] N U100 - 1 vial [MEDICATION NAME] R U100 - 1 vial [MEDICATION NAME] 70/30 - 1 vial. [MEDICATION NAME] 25mg suppositories. Quantity 4. [MEDICATION NAME] - 1 vial Humalog - 1 vial [MEDICATION NAME] - 1 vial [MEDICATION NAME] Mix 70/30 - 1 vial. The emergency drug kit was a clear plastic box. Visible through the plastic box was one vial of [MEDICATION NAME] 70/30 insulin with an expiration date of 12/2018 and one vial of [MEDICATION NAME] Mix 70/30 with an expiration date of 11/2018. During an observation on 9/11/19 at 11:09 a.m., Staff V, Registered Nurse (RN) removed the emergency drug kit from the refrigerator. She verified the expiration date on the emergency drug kit was (MONTH) (YEAR). She proceeded to dump the half inch of water off the shelf tray and put the emergency drug kit F38 back in the refrigerator. An observation on 9/11/19 at 11:11 a.m. revealed the refrigerator contained twelve single dose Pneumococcal 13 talent conjugate vaccine (Prevnar 13) boxes on the upper shelf. The manufacturer directions on the box and insert stated upon receipt store refrigerated at 2 to 8 degrees Celsius (36 degrees to 46 degrees Fahrenheit). On 9/11/19 at 11:23 a.m., the Assistant Director of Nursing (ADON) stated she didn't know why the emergency drug box had not been removed. She stated the Pharmacy would have the records on the drug kit. The facility would not have the emergency drug kit records. The ADON stated the nurses should be documenting the refrigerator temperature twice a day. She confirmed the refrigerator temperature for 9/11/19 had not been documented. On 9/11/19 11:41 a.m., The Director of Nursing (DON) stated she didn't know where the records for the emergency drug kit would be. She stated the central wing had only been open a few months and she didn't know where the emergency drug kit had been prior to the central wing being opened. An observations on 9/11/19 at 12:01 p.m. revealed the central medication room refrigerator with a temperature of 52 degrees Fahrenheit. The expired emergency drug kit labeled F38 and twelve boxes of Prevnar 13 vaccine remained in the refrigerator. An observation on 9/11/19 at 12:55 p.m. revealed the central medication room refrigerator with a temperature of 48 degrees Fahrenheit. The expired emergency drug kit labeled F38 and twelve boxes of Prevnar 13 vaccine remained in the refrigerator. An observation on 9/11/19 at 2:13 p.m. revealed the central medication room refrigerator with a temperature of 48 degrees Fahrenheit. The expired emergency drug kit labeled F38 and twelve boxes of Prevnar 13 vaccine remained in the refrigerator. An observation on 9/12/19 at 7:25 a.m. of the Central medication room refrigerator revealed a temperature reading of 48 degrees Fahrenheit. The 12 doses of Prevnar 13 vaccine remained in the refrigerator. During an interview on 9/11/19 at 2:10 p.m., Staff T, RN stated she wasn't sure where the emergency drug box came from. She remembered there was a box on East wing of insulin but doesn't remember if the box was marked with a number. She stated the boxes came from the pharmacy with a red plastic zip tie and the nurses would sign medications removed from the emergency drug box on a pharmacy log that was duplicate copy. A copy went to the pharmacy and the facility kept a copy. During an interview 9/12/19 at 8:03 a.m., Staff O, RN stated the medication room refrigerators are to be checked and documented daily on third shift. During an interview on 9/12/19 at 8:10 a.m., the ADON stated that the night nurse is to check the medication room refrigerator temperatures and document daily. A Pharmacy Quality Improvement Consultation Summary Report for the period of (MONTH) (YEAR) documented the refrigerator box (insulin) F38 had a green lock in place. The report did not state the F38 box expiration date. The Pharmacy Quality Improvement Consultation Summary Report for (MONTH) 2019 documented no irregularities observed regarding drug storage, labeling or security. The Pharmacy Quality Improvement Consultation Summary Report for (MONTH) 2019 documented there were isolated issues observed regarding drug storage, labeling or security. The emergency drug kit F38 was not addressed in the summary report. A Pharmacy Quality Improvement Consultation Summary Report for the period of (MONTH) 2019 documented refrigerator box (insulin) number F38 was reordered. The report does not contain documentation the refrigerator box number F38 was removed from the facility. The (MONTH) 2019 Central medication room refrigerator temperature log was missing documentation of temperature reading for (MONTH) 5, 19, 26, 28, 29. The (MONTH) 2019 Central medication room refrigerator temperature log was missing documentation of temperature reading for (MONTH) 1, 2, 3, 5, 11. On 9/12/19 at 9:48 a.m., the ADON stated the emergency drug kits came from pharmacy with green tags indicating the kits were ready. When nurses sign medications out of the kit, a red numbered lock tag is applied. She confirmed that the emergency drug kit F38 with expiration date 12/2018 had been opened. On 9/12/19 at 10:08 a.m., the DON stated the emergency drug kits came from the pharmacy with green tags and the nurses would apply a red tag zip lock if they opened the kit to remove medications. The DON stated she would expect nurses to call her if the medication refrigerators were not maintaining the appropriate temperature so medications could be moved to appropriate storage. She stated she would expect nurses to remove expired medications and destroy per their policy or return the medications to the pharmacy. A facsimile received by the facility on 9/12/19 at 8:57 a.m. from the pharmacy provider of the emergency drug kit stated the boxes leave the pharmacy with a green tab and only red (tags) are inside. The Medication, Receipt, Storage and Destruction Policy and Procedure dated (MONTH) 28, (YEAR) documented medications requiring refrigeration are kept at temperatures from 36 degrees Fahrenheit to 46 degrees Fahrenheit. Refrigerated temperatures will be checked daily to assure that medications are kept under proper temperatures. The Pharmacy will maintain an emergency drug kit (EDK) box within the facility. Any items that may be included in the EDK that require refrigeration will be kept in separate containers in the refrigerator. The EDK box will be replaced at routine intervals by the pharmacy to assure it does not contain expired medications. It is the nurse's responsibility to assure medication is not expired. If there is an expired medication the nurse should immediately contact the Pharmacy and the EDK box will need to be replaced immediately. 2. During an observation on 9/11/19 at 10:34 a.m. of the Central wing medication cart revealed an undated bottle of Evencare Preview blood glucose strips. The box directions stated to discard the remaining strips after three months. There were five strips remaining in the fifty count bottle. During an observation on 9/11/19 at 1:10 p.m. of the East wing medication cart revealed an undated bottle of Evencare Preview blood glucose strips. The box directions stated to discard remaining strips after three months. There were eight strips remaining in the fifty count bottle. The East wing cart contained one undated bottle of Evencare ProView Level 3 glucose solution and one undated bottle of Evencare Pro View Level 2 glucose solution. The Evencare ProView manufacturer directions for control solution test procedure include: Evencare Pro View Glucose Control Solution are for use with Evencare Pro View Blood Glucose Meter and Blood Glucose Test Strips to check that the meter and test strips are working together properly. Newly opened bottles of control solutions must be marked with the date opened on the space provided on the control solution labels. Check the expiration date of the control solutions to make sure they have not expired. Discard any unused control solutions 90 days after opening or after expiration date, whichever comes first. The Evencare Pro View manufacturer directions state control solutions should be used at least once per week to verify that the meter and test strips are working properly. An observation of the East medication room on 9/11/19 at 1:15 p.m. revealed the glucometer calibration and quality control log book hanging in a large plastic bag with a undated bottles of Microdot high and low glucose test solutions. The manufacturer direction for Microdot glucose test solution directs use only for 90 days after opening. A review of the East wing glucometer calibration and quality control logs from 5/22/19 to 9/23/19 revealed the facility had not completed control checks since 8/23/19. The West wing glucometer calibration and quality control logs from 5/27/19 to 8/17/19 revealed the facility had not completed control check since 8/17/19. The facility failed to have documentation that the control testing on the residents' individual blood glucose meters was completed. During an interview on 9/11/19 at 1:26 p.m., the ADON reviewed the facility glucometer calibration and quality control log. She stated she did not know which control solutions the nurses were using for the control testing and could not tell from the control records which blood glucose meters the nurses had tested . The DON was present and stated she was not sure which meters had been tested from the documentation but would have the control record updated with individual resident names. During an interview on 9/11/19 at 1:40 p.m., the ADON stated she talked with Staff U, Licensed Practical Nurse (LPN) and she stated it has always been confusing and they have never been directed on what to do for the control checks on the blood sugar meters. During a telephone interview on 9/12/19 at 7:33 a.m., Staff U, LPN stated the facility's stock blood glucose meters were being tested every day. She stated the facility had changed to the Evencare ProView meters for individual residents toward the last week in August. She stated none of the resident individual blood glucose meters had received any control checks. The blood glucose meter testing had stopped and the nurses were waiting for more direction on what to do. During an interview on 9/12/19 at 9:12 a.m., the DON stated there is no policy in place for the resident blood glucose meters. She stated the meters had just been put out to use the past few weeks. She confirmed the resident meters had not had control checks completed.

Based on observation, record review and staff interview, the facility failed to utilize the proper infection control techniques while providing wound care for the only resident reviewed with pressure ulcers (Resident #31), and while emptying a catheter drainage bag for one resident (Resident #26) reviewed. The facility also failed to properly cover laundry being transported in the hallways. The facility reported a census of 76 residents. Findings include: 1. Resident #31's Minimum Data Set quarterly assessment completed 7/13/19 documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15, required extensive staff assistance with all activities of daily living and had one unhealed pressure ulcer. The Care Plan with the target date of 11/5/19 identified the resident with the following problem: the resident has a stage IV pressure ulcer related to immobility, incontinence and [MEDICAL CONDITION] and directed staff to: a. Administer treatments as ordered and monitor for effectiveness. b. Communication with physician on wound status. c. Dietitian consult to determine protein need to help with wound healing. d. Juven to promote wound healing. e. Offload pressure ulcer site as much as possible during day and night. f. Regularly scheduled wound clinic visits. g. ROHO cushion to wheelchair. h. Weekly skin checks per nursing. i. Wound treatment as ordered per wound clinic. A review of the physician orders dated 9/10/19 stated to cleanse area to right ischial with sound cleanser, pat dry. Pack wound with calcium alginate with silver cut into a strip, cover with foam type 4 x 4 dressing daily and as needed for when soiled or dislodged and every evening shift for wound care. Observations of wound care on 9/10/19 revealed the following: a. At 11:39 a.m., Staff T, Registered Nurse (RN), Staff D, Licensed Practical Nurse (LPN) and Staff E, LPN (observing) - all entered the room and closed the door. Staff T and Staff D washed their hands and donned gloves b. At 11:41 a.m., Staff T disinfected the scissors with an alcohol wipe. Then both pulled down blankets and turned the resident to her left side. Staff T removed the foam dressing and wound packing to right ischial tuberosity pressure ulcer, placed it beside the resident's body with the soiled side up. The wound appeared clean without signs of infection to surrounding skin. c. At 11:43 a.m., Staff T removed her gloves, used alcohol hand sanitizer and donned new gloves, opened up foam dressing, opened up packet with calcium alginate with silver. She then placed the tip of the nozzle into the wound and sprayed wound cleanser into the wound with the tip of the nozzle touching the wound. She removed the foam dressing from the coccyx area (which was placed for protection, no open area noted), removed her gloves and used her bare hands to pick up the soiled dressings she had removed from the pressure ulcer earlier. d. At 11:46 a.m., Staff T donned new gloves and used a cotton tipped applicator to pack calcium alginate with silver into the wound, then applied new foam dressing to wound, changed her gloves and applied new foam dressing to coccyx area. During an interview on 9/11/19 8:26 a.m., Staff D, LPN reported when using the wound spray to cleanse a tunneling wound, she would not place the tip of the sprayer directly into the wound and verified when Staff T performed wound care earlier, she observed Staff T place the tip directly into the wound. She also reported after removing a dressing from the wound, she would don gloves to pick up the dressing and immediately place it in a plastic bag. She also verified she observed Staff T pick up the soiled dressings with her bare hands and reported the facility had staff complete an annual skills fair to renew skills with return demonstrations on a mannequin. In an interview on 9/11/19 at 9:28 a.m., Staff E, LPN reported when using the wound spray to cleanse a tunneling wound, she would not place the spray nozzle directly into the wound and would hold it several inches away from the wound. She also reported when removing a soiled dressing from the wound, she would don gloves to pick it up and dispose of it in a plastic bag. She also verified she observed Staff T place the spray nozzle directly into the wound and pick up the soiled dressings with her bare hands. During an interview on 9/11/19 10:01 a.m., the Director of Nursing (DON) reported when using the wound spray to cleanse a tunneling wound, she would expect the nurse to hold the tip of the sprayer a few inches away from the wound and after removing a soiled dressing from a wound, she would expect the nurse to wear gloves and dispose of it in a plastic bag. A review of the facility policy titled: Pressure Ulcer and Wound Treatment Policy dated as effective (MONTH) 2009 did not have documentation on the proper technique expected to follow for wound care. 2. Observations on the following dates and times revealed a Laundry Aide pushed a metal rolling frame with clothes on hangers uncovered on: 9/9/19 at 1:30 p.m. and 9/11/19 at 7:52 a.m., on the East hallway and on 9/12/19 at 6:15 a.m. on the Central hallway. 3. Resident # 26's Minimum Data Set (MDS) assessment dated [DATE], showed the resident with a Brief Interview for Mental Status (BIMS) of 15 indicating an intact memory. The resident required extensive assistance for cares and required an indwelling catheter for bladder functions. The MDS also showed the [DIAGNOSES REDACTED]. The Care Plan, revised on 9/3/19, showed the resident with a suprapubic catheter for [MEDICAL CONDITION] bladder due to [MEDICAL CONDITION]. The Care Plan also showed the resident at risk for an urinary tract infection [MEDICAL CONDITION]. An intervention on the Care Plan included care of the suprapubic catheter per physician orders and nursing professional standards. Record review of the urine culture dated 7/6/19 showed the resident with the organisms Providencia stuartii (a gram negative bacillus commonly found in soil, water and sewage) and [NAME]ella morganii (a gram negative bacteria and has a commensal relationship within intestinal tracts of humans as normal flora). Review of the Nurse Progress Notes dated 7/6/19 showed the physician ordered an antibiotic (Bactrim Double Strength DS) 1 tablet twice daily for 10 days. Record review of the urine culture dated 9/21/18 showed the resident with the organisms [MEDICAL CONDITION][MEDICATION NAME] (an opportunistic pathogenic yeast that is a common member of the human stomach flora), and Acinetobacter baumannii (a gram negative bacillus affecting individuals with an compromised immune system). Review of the Nurse Progress Notes dated 9/24/19 showed the physician ordered an antifungal ([MEDICATION NAME]) daily for 5 days and to change the suprapubic catheter on day 4 of the medication administration. During an observation on 9/11/19 at 8:24 a.m., Staff H, Certified Nursing Assistant (CNA) used gloved hands to remove the heel protectors from the resident's feet. Staff H placed the heel protectors on the floor. She then walked around the resident's bed and with the same gloved hands placed a brown paper towel on the floor and a graduated cylinder on top of the paper towel. Staff H then lifted the dignity bag covering the resident's Foley catheter bag to expose the side of the bag and the tubing used to empty the catheter bag. Staff H used the same gloved hands to remove the tubing used to empty the catheter from the holder. Staff H opened the tubing to empty the contents of the catheter bag into the graduated cylinder. Observation of Staff H stopped the flow of urine part of the way through emptying the bag and took the full graduated cylinder to the bathroom and empty the contents. Staff H returned with the empty graduated cylinder and with the same gloved hands continued to empty the remainder of the urine from the Foley bag. Staff H observed to use alcohol wipes to clean the end of the catheter tubing and place the tubing back in the holder located on the side of the catheter bag. Staff H spilled a small amount of urine on the floor. She used the paper cloth under the graduated cylinder to wipe up the remaining urine. Staff I, Registered Nurse (RN), brought a container of disposable cleaning wipes and gave Staff H 2 of the wipes to clean the floor where the urine had previously spilled. Staff H removed the soiled gloves and without washing her hands placed a new pair of gloves on and continued to provide care to the resident. During an interview on 9/11/19 at 12:57 p.m., Staff J, CNA, reported to empty a catheter bag she would apply gloves, place paper towels down on the floor and place the cup used to empty the urine on top of it. She reported she would then remove the catheter tubing from the bag and wipe with alcohol. Staff J stated she would empty the urine into the cup, measure if needed, then wipe the tubing with alcohol and place back in the holder on the bag. She reported she would empty the cup of urine, clean out the cup, and clean up the mess and sanitize the floor. During an interview on 9/11/19 at 1:07 p.m., Staff I reported to empty a catheter bag staff must place a paper towel on the floor and place the graduated cylinder on top of the paper towels. She reported staff should use alcohol to wipe the catheter tubing and empty the urine into the cylinder. She reported staff should measure the urine if needed. Staff I reported if there is too much urine staff must empty the graduated cylinder and come back to finish emptying the urine in the catheter bag into the cylinder. She reported after the catheter bag is empty the tubing must be wiped with alcohol and placed back in the holder on the catheter bag. During an interview on 9/11/19 at 2:19 p.m., the Director of Nursing (DON), reported she expected staff to place a barrier on the ground, then place the graduated cylinder on top of the paper towel to empty a catheter bag. She reported staff are to use an alcohol wipe on the tubing used to empty the catheter before emptying the urine into the graduated cylinder. The DON reported after the urine had been emptied staff are to wipe the catheter tubing with an alcohol wipe. The DON reported staff need to wash their hands and put on gloves before emptying the catheter bag. The DON reported she expected staff to remove their gloves and wash their hands before they leave the room as well. Record review of the undated Urinary Catheter Care Procedure documented the purpose of the procedure is to prevent infection of the resident's urinary tract. The General Guidelines section of the procedure showed the following: a. Maintain an accurate record of the resident's daily output, per facility policy and procedure. b. Empty the collection bag at least every eight (8) hours. Record review of the undated Procedure to Empty a Urinary Drainage Bag instructed staff on the following: 1. Do initial steps. 2. Put on gloves. 3. Place paper towel on floor beneath bag and graduated cylinder on paper towel. 4. Detach spout (if bag has one) and point the drainage tube into center of graduated cylinder without letting tube touch sides. 5. Unclamp spout and drain urine. 6. Clamp spout. 7. Replace spout in holder. 8. Check urine for color, odor, amount and characteristics and report unusual findings to the nurse. 9. Measure and accurately record amount of urine. 10. Dispose of urine, rinse, sanitize and return graduated cylinder according to facility policies. 11. Remove gloves. 23. Do final steps. Record review of the undated Hand Washing Policy explained hand washing should be performed: a. As promptly as possible after contact with blood, bodily fluids, secretions, excretions and equipment or articles contaminated by them, whether or not gloves are worn. b. After gloves are removed. c. When indicated between tasks and procedures on the same resident to prevent cross contamination. 4. During random observations the following observed with Staff S, Laundry/Housekeeping staff: a. On 9/10/19 at 7:09 a.m., Staff S pushed a hanging laundry cart in the North East hall with a white sheet over the top of the hanging clothes, leaving the sides of the clothes exposed. b. On 9/10/19 at 7:11 a.m., Staff S pushed an over 1/4 full hanging laundry cart uncovered from the North East to the South East hall. c. On 9/10/19 at 7:17 a.m., Staff S uncovered the entire cart and went 1/2 way down the South East hall exposing all but one item of clothing on the cart. d. On 9/11/19 at 7:36 a.m., Staff S pushed a laundry basket on wheels containing folded laundry through the dining room while residents are eating and being served. The cart noted with a white cover over the top with the sides exposed. e. On 9/11/19 at 7:45 a.m., 24 residents sat eating in the dining room (DR) while Staff S pushed a 5 foot long hanging laundry cart through the center of the DR with a white cover over 7/8 of the top, leaving the sides of the hanging personal clothes exposed. Staff S then pushed the hanging laundry cart down to the East halls. f. On 9/11/19 at 7:52 a.m., Staff S noted down the North East hall delivering personal clothes from the hanging laundry cart with a white cover over the top, leaving the sides exposed as residents and staff went by the cart. g. On 9/11/19 at 8:13 a.m., the hanging laundry cart on the South East hall is completely uncovered with 4 hanging outfits remaining. h. On 9/12/19 at 7:39 a.m., Staff S pushed the laundry baskets on wheels through the DR with white cover over the top with the sides exposed to the central hall. During an interview on 9/12/19 at 7:59 a.m., the Director of Nursing (DON) reported expected that the laundry covered during delivery. During an interview on 9/12/19 8:06 a.m., the Laundry/Housekeeping Supervisor reported expected that the clean laundry covered during transportation. Review of the undated facility policy titled Infection Prevention and Control Program, directed at point number 4. Linens. Personal laundry must be handled, stored, processed, and linens transported so as to prevent the spread of infection.

Based on record reviews, staff and resident interviews the facility failed to provide a written summary of the Baseline Care Plan containing the information to properly care for the needs of the resident to the resident or the resident representative for 1 of 2 residents reviewed (Residents #27). The facility reported a census of 76 residents. The findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #27 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS revealed [DIAGNOSES REDACTED]. Review of the resident admission record indicated Resident #27 admitted to the facility on [DATE]. During an interview on 9/10/19 at 7:30 a.m., resident #27 reports the facility failed to invite him to attend his Care Conference meeting since admitted or given a copy of his Care Plan. During an interview on 9/10/19 at 2:11 p.m., the Director of Nursing (DON) stated the Care Plan is developed from the Baseline Care Plan in the electronic health record. Staff then document Care Conference attendance and copy of Baseline Care Plan given to resident and this would be in the miscellaneous section of the electronic health record. Review of the clinical record on 9/10/19 lacked documentation of any Care Conference attendance notes or any documentation the Care Plan was discussed with resident or a copy provided to the resident. During an interview on 9/10/19 at 2:17 p.m., the Social Worker states there is not an Admission Care Plan meeting being done with the Interdisciplinary Care Plan Team and the resident, we do not do this until after the first quarter. During an interview on 09/10/19 at 3:00 p.m., the Assistant Director of Nursing (ADON) stated the facility unable to print the Baseline Care Plan from the electronic health record. During an interview on 9/12/19 at 9:28 a.m., the DON verified the Social Worker is the one responsible for notifying family and the resident to meet with them and give them copies of the Baseline Care Plan and document attendance at the Care Plan meeting with the Interdisciplinary Team. The Care Planning Policy and Procedure dated (MONTH) 28,2016 provided by the facility directed staff to provide the Resident, the Resident's family and/or the Resident's representative with a summary of the Baseline Care Plan to be signed by Resident or Resident Representative that includes: a. Initial goals of the Resident. b. A summary of the Resident's medication and dietary instructions. c. Any services an treatments to be administered by the facility and the person delivering those services credentials. d. Any update information based on the details of the comprehensive plan as necessary.

Based on review of the facility transfer policy/procedures, record review and staff interviews, the facility failed to provide Resident #4 adequate supervision and failed to use a gait (transfer) belt when transferring the resident. The sample consisted of 14 residents and the facility reported a census of 75 residents. Findings Include: 1. Resident #4 had a MDS (Minimum Data Set) quarterly assessment with a reference date of 3/8/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance of 1 staff person with all activities of daily living skills, which included transfers of how the resident moves between surfaces including to or from the bed, chair, wheelchair or standing position. Resident #4 had a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 represented no cognitive problems. The Care Plan with a date initiated on11/4/15 identified a problem with self-care deficit. The resident needed maximum assistance with activities of daily living due to weakness. The interventions directed the nursing staff to transfer and ambulate the resident with the assistance of one staff member. The Care Plan with a date initiated on 11/4/15, identified a problem with the resident to be at high risk for falls due to gait/balance problems and incontinent issues, The approaches directed the staff to anticipate and meet the resident ' s needs and the certified nursing staff are to provide assistance as needed and follow the facility fall protocol. The Care Plan dated 3/10/16 identified the resident at risk for falls and injuries related to medications: psychotropic, diuretic, cardiovascular, pain and medical factors. The approached directed the nursing staff to avoid sudden position changes with the resident and observe the resident for an unsteady gait and balance. On 3/10/16, the Care Plan indicated the resident had an actual fall with a serious injury and to continue interventions on the at-risk plan. The revised Care Plan identified on 3/18/16, the resident needed 2 person physical assistance for transfers and ambulation after the fall. Review of the facility policy titled Transfer Activities, dated 2006, identified the purpose of the policy is to transfer the resident from bed to chair, toilet, or tub safely. The policy identified the equipment needed included a transfer belt. The procedure directed specific steps to be taken. One of the steps directed the staff to apply a transfer belt (prior to transfer). On 3/21/16 at 12:30 p.m., Staff E, Licensed Practical Nurse (LPN) was interviewed and stated she worked the third shift on 3/9/16 into 3/10/16 on the east hall. Staff E stated she was paged by Staff F (LPN) asked Staff E come to the assist with getting Resident #4 up off the floor. Staff E stated Resident #4 is a larger sized resident and so Staff F needed another person to help her. Staff E stated when she entered the resident ' s room, she noted the resident on the floor with back near the foot of the bed angled towards the wall/closet area next to the wheelchair. Staff E and Staff f tried to get the resident to lie still. Staff E instructed Staff G to hold the resident in a C-spine hold (keeping the head aligned with the neck) and told Staff F to call 911. Staff E reported seeing blood but did not turn the resident's head to see where the injury as trying to keep the resident's neck and head in line. While in the resident ' s room, Staff J said she was just going to take the resident to the bathroom. Staff E reported she did not see a transfer (gait) belt on the resident. The resident ' s shoes were next to the resident. Staff E stated the resident changes with the amount of staff assisted needed. Staff E stated she would use 2 staff persons to transfer the resident with a gait belt and a wheelchair to transfer. Staff E reported she did see the resident's walker near the bed. Staff E stated there should always be a gait belt utilized when transferring a resident who needed assistance. On 3/22/16 at 2:00 p.m., Staff F was interviewed and stated she worked 10:00 p.m. to 6:00 a.m. on 3/9/16 into 3/10/16, and working the west hall where Resident #4 resides on. Staff F reported it was about 5:15 a.m. when she heard a name called and looked down the hall and saw no one present., then did hear name again and saw Staff J in the hallway and then Staff J just said Resident #4's name. Staff F thought maybe Staff J needed help to get the resident up as he/she can be a 1-2 person transfer depending on the resident's equilibrium. As Staff F got closer to the doorway Staff J stated she was sorry and just tried to stop the resident but he/she fell . When walked into the room, Staff F saw the resident on the floor on his/her back at the foot of the bed at an angle with his/her head towards the closet, on one side of the resident was a sitting chair and on the other side was the wheel chair closer to the closet and had feet nearly under the bed. Staff F reported the resident awake when she arrived to the room and asked Staff J if the resident lost consciousness. Staff J answered no. Staff F reported the walker on the resident's bed; the resident did not have a gait belt on, and had slipper socks on but no shoes. The resident was transported to the hospital and she learned transferred to another hospital for care. The resident returned to the facility on [DATE]. On 3/21/16 at 4:36 p.m., Staff G, CNA was interviewed and reported she worked the 6:00 p.m. (3/9/16) to 6:00 a.m. (3/10/16) shift when Resident #4 fell . Staff G stated she saw the resident on the floor on his/her back at an angle near the foot of the bed. Staff G stated the resident was wedged between a setting chair at the end of the bed and the wheel chair near the closet. The resident was awake when Staff G got there, but he/she was not talking and Staff G did not see much for blood until the pillow removed from under the resident's head. When Staff G saw the blood he/she put a hold on the resident's head/neck for a C-spine hold. There was a towel under the resident's head for the blood as the resident lifting his/her head. Staff J stated she felt so bad; no one has ever fallen on me before. Staff G stated when she approached the resident; the resident was in a hospital gown, barefoot and no gait belt around the resident. Staff J explained she got the resident up first from the bed, looked at the staff and just went over backwards, straight back. Staff G stated the rule is when transferring a resident at any time; a gait belt is put on the resident. The exception would be if the resident is transferred with a Hoyer (mechanical) lift or for those residents that are independent. Staff G stated the Staff Development Nurse and herself have put gait belts in all the resident rooms to be utilized. This was done prior to Resident #4's fall. Staff G stated after Resident #4 fall, there was a facility in-service with all CNA's about gait belt usage when transferring a resident. On 3/22/16 at 7:50 a.m., Staff H, CNA was interviewed and stated while assisting Resident #4 to get out of bed, the CNA always was to use a gait belt with the resident. The gait belt is to be used at all times of assisting with standing or ambulating. On 3/22/16 at 7:50 a.m., Staff I, CNA reported she worked with Resident #4 prior to the fall. Staff I described the resident needed extensive assistance of 1 staff person and the use of a gait belt and front wheeled walker. Staff I stated that with the resident's Parkinson's, some days, she would get a 2nd CNA to help if the resident seemed unsteady. Staff I stated Resident #4 now requires 2 person assistance and always to use a gait belt with a front wheeled walker to transfer or ambulate. On 3/22/16 at 9:33 a.m., the Director of Nursing (DON) was interviewed and stated Resident #4 fell and hit head and then went to the emergency room . The DON did not recall any gait belt issues with Staff J prior to Resident #4's fall. The DON stated to use a gait belt in nursing or as a CNA is basic 101. The DON said to not use a gait belt is taking your job in your own hand and it (gait belt) needed to be used. The DON identified Resident #4 as a one person assist prior to the fall and personally had assisted the resident, who is slow with the Parkinson's Disease, but does ambulate with a front wheeled walker. The Care Plan was changed to a two person assist now after the fall with a front wheeled walker and gait belt. On 3/22/16 at 10:55 a.m., the Staff Development Nurse was interviewed and stated was the on-call nurse the morning of 3/10/16 when she got the call about Resident #4's fall around 5:30 a.m. - 5:40 a.m. from Staff F, LPN. The Staff Development Nurse stated she asked how the resident fell and Staff F reported Staff J had gone to respond to the call light in the resident's room. It wasn't long and Staff J put the call light back on, but called out for Staff F to come to the room. After the resident's fall, the Staff Development Nurse retrained all staff regarding falls and Parkinson's Disease. On 3/22/16 at 11:21 a.m., Staff J, CNA was interviewed and stated she asked the resident if he/she wanted to use the front wheeled walker (FWW) or a wheelchair to go to the bathroom. The resident asked for the front wheeled walker. Staff J stated she lowered the resident's bed, head of bed up, assisted to get the resident to sit on the edge of the bed, put on shoes and then got the FWW. Put the FWW in front of the resident and stood to the right hand side of the resident and said 1-2-3 and the resident stood up while Staff J held the FWW on the first try. Staff J had his/her hand on the resident's waist and right hand over the resident's hand while holding the walker, and did take a few steps from the middle of the bed to the end. Then all of a sudden the resident stiffened up and eyes were rolling back as the resident fell straight back stiffened, did not bend and hit head on the floor. Staff J reported she did ask the resident if alright and the resident responded yes. The resident's head was between a chair at the end of the bed and the wheelchair. Staff J admitted she did not place a gait belt on the resident prior to transferring. Staff J stated she could recall if a gait belt was in the room to be used, and reported she did not have a facility assigned belt. Staff J stated she may have signed for one, but never given one. Staff J stated she had own gait belt and had the belt that night, but in a bag at the CNA desk. Staff J stated she had not observed other CNAs use gait belts. Staff J did report she had transferred the resident before without a gait belt, and what she could recall, never used a gait belt when transferring Resident #4. The resident needed to go to the bathroom when walking with him/her and have walked to the bathroom and back to the bed always with no gait belt and no problems. Since hired have attended trainings and 2 meetings that can recall where talked about gait belt usage and all meetings told to follow what the CNAs and nurses do. Resident #4 was a 1 person transfer before the fall. Staff J stated she knew it was not the right choice to not use a gait belt, but was only doing how trained to transfer the resident

Based on observation, interview, and record review the facility failed to provide provisions and appropriate care to prevent pressure ulcers for one (1) of four (4) residents reviewed (Resident # 1). The facility reported a census of seventy-eight (78) residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a BIMS (Brief Interview for Mental Status) score of 11 out of 15, which revealed moderate cognitive impairments. The MDS identified the resident had medical [DIAGNOSES REDACTED]. The assessment noted the resident had been admitted on [DATE], and required assistance of two staff members for bed mobility, transfers, toilet use and one staff to assist with dressing, eating, and personal hygiene. The MDS documented the resident used a catheter/ostomy for urine output and bowel output. The MDS indicated the resident at risk of pressure ulcer, but documents no pressure ulcers present on admission or history of past unhealed pressure prior to admission. The MDS further identified the resident had no skin integrity issues present on admission. The MDS indicated the facility applied a pressure reducing device for the resident's chair and bed. Review of Nurse's Notes dated 4/3/14 at 6 p.m., indicated Resident #1 admitted to the facility from another facility; and received orders from the physician to continue with current medications. Review of the Treatment Administration Record (TAR) and Medication Administration Record [REDACTED] - Pressure reducing mattress to bed and wheelchair cushion. - Baza Antifungal 2 % topical cream to apply to affected area(s) two times a day in the morning and the evening. Review of the resident's Nurse's Notes dated 4/3/14 at 10 p.m. to 6 a.m. revealed the resident needed preventive skin interventions implemented that included pressure relief devices on bed/chair, repositioning, barrier creams or pads protector to maintain skin integrity. Review of the Facility Skin Condition Report dated 4/4/14, revealed the resident noted with a [MEDICAL CONDITION] site and a urinary catheter in place, reddened area noted to right abdominal area, scarring noted to coccyx/buttock area. The skin report indicated no pressure areas noted on the resident's skin. The Nursing Admission assessment dated [DATE] documented the resident had no initial skin interventions such as reposition program, heel elevation, foot cradle, specialty mattress, or any other intervention. A.) Review of the Documentation Flow Sheet dated 4/8/14 at 10:00 a.m., indicated during morning cares the staff noted a 6 cm X 6 cm (centimeter) blister to resident's left heel. The staff contacted the wound Nurse and received an order for [REDACTED]. Clinical record review of the next documentation of the resident's blister area on the left heel noted on 4/19/14 at 7:30 a.m., revealed the dressing to the left heel done this a.m., showing improvement. The clinical record lacked indications of skin or pressure assessment completed. Review of the Documentation Flow Sheet review the next documentation of the resident's left heel wound dated 4/21/14 at 9:00 p.m. that indicated the left heel dressing change. Record review showed no further assessment of wound documented. The resident ' s clinical record lacked indications of pressure log assessment or any documentation for skin assessment completed for the left heel wound. B). Record review of the SBAR (situation, background, assessment, and request) form dated 4/11/14 showed the resident had a 1 (cm) by 1 cm red area on the buttocks. The wound Nurse contacted and recommended A & D ointment for the resident ' s buttocks. Staff documented they notified the resident's physician and family. Review of Documentation Flow Sheet dated 4/11/14 at 1:00 p.m., revealed the area to the resident's buttock that measured 1 x 1 cm. The resident ' s clinical record lacked indications of pressure log assessment or skin assessment completed. Record review of the next documentation of the left buttocks wound dated 4/22/14 at 9:15 p.m., indicated the Certified Nurse Aide (CNA) reported to the nurse the area and the nurse documented she notified the facility wound Nurse/ADON of wound area and requested an evaluation and to initiate treatment. Review of the Wound Nurse Notes written by the ADON (Assisted Director of Nursing) dated 4/22/14 revealed the following: The resident's wounds assessed today and noted on 4/08/14 with a clear blister to left heel. The wound is now a deep tissue injury (DTI) and 100% eschar. The area measured 7 cm x 7 cm. No signs or symptoms of infection with dressing changes. The wound nurse also documented the resident had an area to buttock that was noted first on 4/22/14, and the wound Nurse was unable to determine the Stage or depth of buttock wound due to 90 % yellow slough and 10 % granulation. The wound Nurse documented the wound had a small amount of drainage which was serosanguineous (thin, watery, and pale red to pink in color drainage.) Resident already taking a multivitamin with minerals daily, high protein foods with all meals, pressure reducing mattress, moon boots on at all times, and to reposition frequently. The wounds Nurse identified the wounds should be cleaned with wound cleanser, santyl and cover with gauze daily and as needed. Resident's family and physician notified of current plan and nurse to monitor weekly until healed. (According to the nursing home Skin Condition Report, a DTI is an area of purple or maroon discoloration/intact skin or blood filled blister. The area may be preceded by painful, firm, mushy boggy or warmer or cooler tissue (than adjacent area).) Review of the resident's Skin Integrity Care Plan dated 4/18/14 revealed the resident required two staff assist with turning and reposition with the following interventions: 1) Pressures reducing mattress and bed and wheelchair cushion. 2) Apply lotion to skin following bathing. 3) Observe skin integrity during am/pm cares. 4) Maintain head of bed in lowest possible position. 5) Notify physician promptly of skin break down. 6) Refer to dietician to evaluate diet and needs. 7) Bathe/shower per schedule. 8) Encourage fluid intakes. 9) Provide diet as ordered. 10) Provide peri care and monitor incontinence. 11) Evaluate skin weekly. 12) Provide medications as ordered. 13) Encourage to reposition as able. 14) Reposition every two hours in bed. The Episodic Pressure Ulcer Care Plan dated 4/22/14, included the following interventions: a. [MEDICATION NAME] to heel and gauze to buttock. b. 4/22/14 PRAFO boot (moon boots). c. 4/22/14 Santyl and gauze daily and as needed. d. 5/08/14 Resident to be in bed after meals. e. 5/13/14 [MEDICATION NAME] to heel daily. f. 5/22/14 low air mattress. g. 5/27/[MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) precautions due to wounds Review of the resident's Flow Sheet from 4/4/14 to 4/30/14 the resident had not been repositioned during 13 shifts during that time. Review of the first skin sheet dated 4/23/14, revealed moon boots to feet, left heel eschar remains and ulcer on buttocks healing slowly. Review of the Wound Nurse Assessment written by the ADON dated 5/7/14 revealed the left heel wound measured 6 cm x 6 cm and 100 % eschar; and the buttock wound measured 6.5 x 3.5 cm and unable to determine Stage or depth due to 90 % of wound yellow slough and 10 % granulation and small amount of serosanguineous drainage noted. Request wound consult for heel wound since no improvement. Continue with daily dressing changes to wounds and reposition frequently. Review of the Wound Clinic Center Progress Note dated 5/21/14, revealed the resident alert and good memory, with a [DIAGNOSES REDACTED]. The buttock wound was now necrotic tissue (unstageable) and initial encounter measured at 5 cm length x 4.5 cm in width x 3.5 cm depth and presently showed signs and symptoms of infection. The left heel wound had been noticed by the facility on 4/8/14 and developed dark eschar, which now had an odor and drainage from edges. The posterior heel wound was now necrotic tissue (unstageable). Initial encounter measurements are 5 cm length x 5 cm width x 0.3 cm depth, and presents with signs and symptoms of infection. Both wounds required surgical debridement and wound culture done. The wound culture report collected 5/21/14 identified the results of [MEDICAL CONDITION]. Review of Skilled Documentation Flow Sheet dated 5/23 14 at 1:35 p.m. revealed the facility received a telephone order from the wound clinic for antibiotic for 10 days due to resident [MEDICAL CONDITION] in foot and buttock wounds. Review of the May 2014 Flow Sheet revealed the resident not being repositioned during 13 shifts. Interview on 10/31/14 at 12:07 p.m. (& also re-interviewed on 11/21 14) the ADON/wound Nurse, indicated that the resident's heel wound and buttock wound occurred at the facility after admission of 4/3/14. The ADON reported she thinks the heel wound started from friction and the facility could have done more to prevent the wounds from occurring, or been more proactive. The ADON stated she did not assess the resident when he/she first came into the nursing home. The ADON stated he/she did not know about the heel wound or the buttock wound until 4/22/14 when he/she first assessed the resident. The ADON stated at that time the resident did not have moon boots on as the care plan identified and the ADON implemented the boots on 4/22/14. The ADON stated the resident's family brought in a low air loss mattress sometime around 5/22/14, as the resident did have this in place prior to coming to the facility. The ADON stated reposition should be done at least every two hours or sooner if needed. The Wound Clinic progress note dated 6/4/14 documented the resident had Stage IV wound on his/her right buttocks area and left heel. The current treatment was to help with removing non-viable tissue and offloading. The resident lives in a nursing home and the care giver accompanied the resident today. The caregiver was informed the importance of offloading wound, and the resident was [MEDICAL CONDITION] for both wounds. Review of Wound Nurse Assessment Notes dated 6/3/14 indicated the resident went to the wound clinic last week and areas were assessed and derided. Wound clinic recommending wound vac to buttock wound, will apply once supplies are received. Review of Wound Nurse assessment dated [DATE] indicated the wound vac placed on 6/6/14 to resident's buttock wound. A review of the June 2014 Flow Sheet revealed the resident not being repositioned during 12 shifts. Review of the Wound Nurse assessment Note dated 10/7/14 indicated the heel wound measured .9 cm x 1 cm x 1 cm with scant amount of bloody drainage. The area to the buttock wound remains healed. Staff are to continue to monitor resident due to history of frequent pressure areas to buttock, and staff are to reposition frequently. Interview on 10/30/14 at 4:00 p.m., Resident #1 stated he/she depended on staff assistance for repositioning and his/her buttock wound healed up. Resident #1 stated staff assisted him/her with reposition but he/she does not like to get woke up every 2 hours at night. Resident #1 reported he/she had waited 3 hours for staff to reposition him/her.

Based on record review and staff interviews, the facility failed to provide adequate supervision and implement Resident #20 ' s care plan intervention to prevent accidents. Resident #20's care plan dated 3/6/14 directed staff to not leave the resident unattended on the toilet. On 3/30/14, Resident #20 sustained fractures to his/her arm and nose when the facility staff left him/her unattended on the toilet. Resident #3 care plan lacked revisions to address his/her safety needs. The facility identified a census of 70 residents, with nine (9) residents reviewed. Findings include: 1. Resident #20's Minimum Data Set (MDS) assessment dated [DATE] identified the resident with the following Diagnoses: [REDACTED]. The MDS assessment determined Resident #20 required two staff to assist with transfers, bed mobility and toilet use; and he/she required one staff to assist with walking in his/her room. The test for balance identified Resident #20 was not steady and only able to stabilize his/her balance with staff assistance when moving from seated to standing position. The assessment identified the resident had one fall without injury. The fall risk assessment form showed completion on 3/13/13 and 6/12/13 with scores of 20, on 9/10/13 with score of 16 and on 3/6/14 with a score of 17. Scores above 10 identified the resident at high risk for falls. In an interview on 4/9/14 at 7:40 a.m., Staff Y, LPN, reported fall risk assessments should be completed quarterly. The activities of living plan of care in vocollect (the facility's system for CNAs to access and dictate notes into regarding residents) had documentation of being last updated on 3/6/14 and directed staff to not leave unattended in the bathroom as he/she had been at high risk fir falls and required the assist of two more to transfer. The care plan dated as last reviewed 3/6/14 identified the resident at risk for falls and injuries and the following interventions added on 3/19/14 motion detector at all times, 4/1/14 moved to high traffic area and provided recliner for comfort and sling to left arm at all times. The care plan identified the resident with self-care deficit and directed staff to transfer with assist of one or two and extensive assistance needed for toileting. The change of condition SBAR form dated 3/30/14 at 4:30 p.m. had documentation the resident fell and landed face first and on left arm outside the shower room. A CNA placed the resident on the toilet in the shower room, left the resident on the toilet to obtain a clean incontinent brief. The resident ambulated without assist into the hallway and fell to the floor landing face down, breaking his/her eyeglasses causing a laceration to the bridge of the nose, complained of left arm pain with immediate edema to the shoulder. The resident had been sent to the emergency room per ambulance. The major injury determination form signed by the physician on 3/31/14 a5 3:30 p.m. revealed the resident fractured his/her nose and two fractures to the left arm when left unattended briefly in the bathroom. The resident required the assist of one to two staff for transfers or ambulation (walking). The hospital physician's history and physical report dated 3/30/14 identified the resident had a soft tissue hematoma, bilateral nasal bone fractures and left shoulder fracture, urinary tract infection and dehydration. The consultant physician's report dated 3/30/14 identified the resident with a 3 part fracture to the left arm. A CT (computed tomography) scan of the head dated 3/30/14 identified the resident with left nasal fracture, soft tissue hematoma adjacent to the left frontal bone. There was no indication of an intracranial hemorrhage. A CT scan of the maxillofacial region dated 3/30/14 identified the resident with bilateral nasal bone fractures. An x-ray of the left shoulder dated 3/30/14 identified the resident with an acute transverse of the left humeral neck with extension to the humeral head and significant fracture displacement of the humeral head (the top of the upper arm bone). A review of the Interdisciplinary Team (IDT) post occurrence assessment and plan review form dated 4/3/14 identified the resident fell on [DATE] when the CNA left the resident in the bathroom to obtain a clean brief, the resident walked out of the bathroom, fell and broke his/her glasses. The IDT made the recommendations to prevent recurrence by directing staff to: Use the Hoyer (mechanical) lift Sling to the left arm at all times Pain medication as needed Use recliner for resident comfort In an interview on 4/9/14 at 9:42 a.m., Staff T, RN, reported on 3/30/14 Staff X, CNA assisted the resident away from the nurse's station when she later heard a noise and found the resident lying on the floor face down by the shower room, blood everywhere, and wheelchair beside her. Staff T reported the resident had been transferred from the wheelchair to the toilet therefore the alarms were turned off. Staff X left the resident on the toilet without informing Staff T. The resident's right arm appeared deformed, the bridge of the nose had a laceration, probably from the eyeglasses which had broken and had a hematoma the size of a golf ball above the left eyebrow. Prior to that, the resident required the assist of one with use of a gait belt to transfer and had not been allowed to be left alone while on the toilet. Staff T also verified the care plan in the chart did not address this. In an interview in 4/9/14 at 10:17 a.m., the DON reported the MDS coordinator had been in charge of the care plans, however, any staff from the interdisciplinary team could add to the care plans. On 3/30/14 the staff were not to leave the resident unattended, the resident had been care planned to be transferred with the assistance of one using the gait belt and that if residents were alarmed, they should not be left alone. In an interview on 4/9/14 at 12:40 p.m., Staff U, CNA, reported the resident had been care planned to be transferred with the assist of one using a gait belt and walker and should not be left unattended on the toilet. In an interview on 4/9/14 at 12:49 p.m., Staff V, CNA, reported the resident had been care planned to transfer with the assist of one using the gait belt, sometimes it took two staff members. She also reported she had left the resident unattended on the toilet as the resident would not get up without assist. In an interview on 4/9/14 at 1:02 p.m., Staff W, CNA, reported the resident had been care planned to transfer with the assist of one with gait belt, sometimes it took two staff members. She also reported she had left the resident unattended in the past as the resident did not try to get up without assist and that CNAs could access the care plan on vocollect regarding resident needs. In an interview on 4/9/14 at 1:12 p.m., Staff Y, LPN, reported prior to the fall on 3/30/14 the resident should not have been left unattended on the toilet as there was a history of falls and the resident had cognitive deficits and could not understand that he/she could not get up and walk on his/her own. Staff Y verified she had been responsible for developing care plans for the residents and any nurse can update the activities of daily living plan of care in vocollect. When asked why the resident was identified on 3/6/14 on vocollect to not be left unattended in the bathroom and why the care plan in the chart did not address this, Staff Y could not explain. When new interventions were added into vocollect, the nurse should also add to the care plan in the chart or communicate this with Staff Y through a note or in the 24 hour report. In an interview on 4/10/14 at 11:21 a.m., Staff X, CNA, reported on 3/30/14 she had assisted the resident to sit on the toilet in the shower room by holding on to the back of the resident's pants as the facility did not provide CNAs with their own gait belts and there was no gait belt in the shower room. She left the resident unattended to get a new incontinent brief from the resident's room at the other end of the hall. She did not report this to Staff T, RN, as the nurse was sitting at the nurse's station right beside the shower room. When she reached the resident's room, she heard a noise and saw that the resident got up alone and out into the hallway without the walker and found the resident lying on the floor. The resident had been bleeding from the nose, had a hematoma on the forehead and left shoulder appeared very swollen. Staff T and Staff X cleaned the resident and used a Hoyer lift to transfer the resident back to bed. The resident was later sent to the emergency room . Staff X reported other aides have told her that the resident could be left alone in the past, however, had not been informed of the update in vocollect on 3/6/14 that the resident should not be left unattended on the toilet. She reported the vocollect system was supposed to make the staff listen to new updates and she had never received the update for 3/6/14. She also reported that the first shift aide left an hour earlier than usual and did not leave any report for her on the resident on 3/30/14. 2. Resident #3's MDS dated [DATE] identified the resident with the following Diagnoses: [REDACTED]. Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS) cognitive test. A score of 15 established Resident #3 with no cognitive impairments. The assessment identified the resident had no signs and symptoms of delirium (no inattention, no disorganized thinking, or no altered level of consciousness). The MDS assessment determined Resident #3 required two staff to assist with transfers, and toilet use; and he/she required one staff to assist with walking in his/her room and bed mobility. The test for balance identified Resident #3 was not steady and only able to stabilize his/her balance with staff assistance when moving from seated to standing position. A physical therapy treatment note dated 6/8/13 to 7/22/13, identified Resident #3 had been working on endurance during wheelchair transfers, safe ambulation with wheeled walker, and safety transferring from supine to sitting. FALL 7/1/13 7/1/13 an entry in nurse's notes revealed the resident fell during an attempt to self-transfer off the commode. The resident required staff assistance for transfers prior to the fall. 7/1/13 a radiology report had documentation x-rays of the right shoulder, right hip and right elbow showed no fractures. 7/2/13 an entry in the nurse's notes revealed the family reported the resident had a choking episode while eating in his/her room. 7/3/13 A orthopedic surgeon progress note revealed the resident had a non-displaced fracture to the right elbow. 7/11/13 an entry in the nurse's notes revealed after a visit from the physician, new orders received for x-rays of the right hip and pelvis, however, no documentation of the reason why. 7/11/13 A radiology report had documentation the indication had been for complaint of joint pain to the pelvis and revealed a non-displaced fracture through the right acetabulum (the socket of the hip bone where the head of the femur fits) A review of the July 2013 MARs revealed the resident requested Morphine 15 milligram (mg) tablets on 7/1/13 at 10:01 a.m., at 7:40 p.m., at 11:00 p.m., on 7/8/13 at 10:59 a.m., on 7/12/13 at 12:30 a.m. and on 7/15/13 at 10:58 a.m.. In an interview on 4/1/14 at 3:00 p.m., Staff L, CNA, reported prior to the fall on 7/1/13, the resident had a history of [REDACTED]. FALL 7/23/13 7/23/13 an entry in the nurse's notes revealed the resident fell during an attempt to self-transfer off the commode, found on the floor with deformity noted to right arm. The resident required staff assistance for transfers prior to the fall. The incident sbar form dated 7/23/13 noted a checkmark for fall from toilet/commode. 7/23/13 radiology reports revealed a fracture of the right elbow, some fractures to the right pubic bone, and fracture to the right arm. In an interview on 4/1/14 at 12:36 p.m. Staff D, CNA, reported the resident had a history of [REDACTED]. In an interview on 4/1/14 at 4:15 p.m., Staff M, RN, reported on7/23/13 the resident did not have a commode chair and tried to go to the bathroom without assistance and had been care planned to transfer with the assist of one staff member using a gait belt and walker. The resident had been found on the floor with a deformity to the left arm and taken to the hospital by ambulance that day. FALL 10/9/13 10/9/13 an entry in the nurse's notes revealed the resident fell when the resident rolled out of bed. The resident had been identified as dependent on staff for transfers. 10/10/13 the clinical interdisciplinary assessment and progress note identified the resident fell out of bed reaching for an item. The interdisciplinary team decided to add a winged mattress after the fall (this was not added to the care plan) FALL 1/14/14 1/14/14 when the resident lost his/her balance when attempting to stand on own. The resident had been identified as dependent on staff for transfers. Observations revealed the resident ate meals in his/her room on 3/31/14 for breakfast and on 4/1/14 for breakfast. A review of the care plan review dates of 8/26/13, 11/14/13, 11/26/13, 2/14/14 and 3/6/14 showed no new interventions added until 12/13 for self-locking brakes and on 1/15/14 encourage resident to eat in the lounge or dining room. Fall risk evaluations had been completed on 8/15/13 and 11/13/13 with scores of 20 (scores above 10 indicates the resident at high risk for falls). An interview on 4/9/14 at 7:40 a.m., Staff Y, LPN, reported fall risk evaluations should be completed quarterly. In an interview on 3/25/14 at 1:00 p.m., the resident reported he/she fell , fractured the right knee and left shoulder while up in the wheelchair, choked on food, tried to reach the call light and fell backwards in the process. The resident stated he/she continued to have pain to the left elbow and later discovered the elbow also had a fracture. When he/she turns on the call light, it can take as long as 30 minutes to an hour to get assistance, that this happened a couple of times a week, usually on second shift. On several occasions has had incontinence in bed waiting for help to the bathroom and did not want to have that happen again and would get up without help. In an interview on 4/3/14 at 7:30 a.m., Staff N, physical therapist reported the resident was treated by physical therapy during the following time frames: 6/8/13 through 7/22/13 after a pelvic fracture 9/26/13 through 11/13/13 after a fracture to the humerus and discontinued services due to achieving goal of ambulating 250 to 350 feet. 2/18/14 through 3/7/14 after a fracture to the hip or knee and discontinued services due to failure to progress and order for no ambulation In an interview on 4/3/14 at 8:36 a.m., the DON reported after a resident has a fall, the interdisciplinary team (IDT) will review within 24 hours after the fall, make changes to the care plan where interventions should be dated. Upon review of the current care plan, she verified the resident required assistance of two to transfer and no new interventions were added after the falls on 7/1/13, 7/23/13 and 10/9/13. A review of the facility policy titled: falls management dated October 2010, directed the staff to: a. Evaluate risk factors for sustaining falls upon admission with comprehensive assessments and while conducting interdisciplinary care plan reviews. b. Initiate a fall prevention care plan when appropriate with strategies to minimize risk and potential for injuries. c. Regularly review, revise, and evaluate care plan effectiveness at minimizing falls and injuries.

Based on observation, record review and staff interview, the facility failed to ensure residents were free of significant medication errors for 1 of 15 residents reviewed (Resident # 12). The facility reported a census of 95 residents. Finding include: 1. According to the facility Admission and Discharge Summary form dated 2/15/11, Resident #12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool with a reference date of 2/21/11 reflected Resident #12 scored a 13 of 15 on the Brief Interview for Mental Status (BIMS). The BIMS identified the resident as cognitively intact. The resident required extensive assistance of 2 staff for bed mobility, transfers, and toileting, and required extensive assist of 1 staff for dressing, personal hygiene, and bathing. Review of the resident's Care Plan dated 2/14/11 directed the nursing staff to assist the resident with 1 staff for bathing/hygiene, dressing/grooming, and assist with 2 staff for toileting, ambulation and transfers. Record review revealed Staff M, Licensed Practical Nurse (LPN), documented in the Narrative Nurses Notes/Additional Observations and Assessment form dated 2/15/11, 6:00 a.m. to 2:00 p.m. shift that Resident #12 received several incorrect medications. Vital signs taken at 9:30 a.m. were blood pressure - 96/64, pulse - 61 and respirations - 18. The resident was working with therapy and complained of feeling nauseated and dizzy. A telephone call was placed to the resident's doctor and a new order received to start normal saline at 50 milliliters (ml) per hour per intravenous (IV) route. The resident's family member was notified when he/she arrived at the facility. The doctor called and ordered the resident be sent to the emergency room (ER) for an evaluation and treatment. At 10:30 a.m., a local ambulance arrived and transported the resident to the ER. The Patient Transfer Form dated 2/15/11, revealed Staff M indicated Resident #12 received some wrong medications in the morning and complained of feeling nauseated and weak. Documentation indicated the resident ' s color as pale and normal blood pressure as 130/90 and heart rate in the 80's. Today after the wrong administration of medications was given to the resident, the blood pressure measured 90/56 with a heart rate of 56. The resident received [MEDICATION NAME] (antihypertensive)100 milligrams (mg) twice a day, [MEDICATION NAME] (to lower cholesterol) 80 mg,[MEDICATION NAME](used to prevent [MEDICAL CONDITION]) 120 mg, and [MEDICATION NAME] (antihypertensive) 25 mg which were not the resident's medications. Record review of the Medication Administration Record (MAR) Sheets for Resident #12 dated 2/01/11 to 2/28/11 revealed on 2/14/11, Staff L Registered Nurse (RN), administered the medications [MEDICATION NAME] 100 mg 1 tablet by mouth every 12 hours, and [MEDICATION NAME] 80 mg 1 tablet by mouth at bedtime on the bedtime shift. On 2/15/11, Staff M administered the medications aspirin 325 mg 1 tablet by mouth once daily, [MEDICATION NAME] mg 1 tablet by mouth once daily, [MEDICATION NAME] 25 mg 1 tablet by mouth once daily, [MEDICATION NAME] 100 mg 1 tablet by mouth every 12 hours, and [MEDICATION NAME] (used to prevent blood clots) 75 mg 1 tablet by mouth once daily on the 8:00 a.m. shift. Also noted [MEDICATION NAME] (dialates coronary arteries) 0.4 mg tablet sublingual dissolve 1 tablet under the tongue every 5 minutes up to 3 doses as needed for chest pain was on the resident's as needed medications. Record review of the Transfer Orders/Instructions from the local hospital dated 2/14/11 and noted by Staff L on 2/14/11, indicated the medications to be continued after discharge from the hospital did not include the following medications for Resident #12: a. Aspirin 325 mg 1 tablet by mouth once daily. b.[MEDICATION NAME] mg 1 tablet by mouth once daily. c. [MEDICATION NAME] 25 mg 1 tablet by mouth once daily. d. [MEDICATION NAME] 100 mg 1 tablet by mouth every 12 hours. e. [MEDICATION NAME] 75 mg 1 tablet by mouth once daily. f. [MEDICATION NAME] 80 mg 1 tablet by mouth at bedtime. g. [MEDICATION NAME] 0.4 mg tablet sublingual dissolve 1 tablet under the tongue every 5 minutes up to 3 doses as needed for chest pain. Record review of Resident #12's closed record revealed in the Narrative Nurses Notes/Additional Observations and assessment dated [DATE] that Resident #12 returned to the facility at 6:00 p.m. from the local ER. New order received if systolic blood pressure drops below 90 two times, run IV [MEDICATION NAME] normal saline at 500 ml. Documentation noted the resident complained of no pain or discomfort. Transferred with assist of two, gait belt and walker. Record review of Resident #12's closed record revealed in the Narrative Nurses Notes/Additional Observations and assessment dated [DATE] timed at 12:00 noon, that Resident #12 was discharged home at 11:40 a.m. home with wife and personal belongings taken and medications returned to pharmacy and the narcotics were destroyed. Record review of Resident #12's Drug Disposition Form revealed the following medications were returned to the pharmacy with a reason code of #6 indicating wrong medications for the resident: a. [MEDICATION NAME] 25 mg 1 tablet by mouth once daily, 14 quantity. b. [MEDICATION NAME] 75 mg 1 tablet by mouth once daily, 14 quantity. c. [MEDICATION NAME] 100 mg 1 tablet by mouth every 12 hours, 14 quantity. d.[MEDICATION NAME] mg 1 tablet by mouth once daily, 14 quantity. e. [MEDICATION NAME] 80 mg 1 tablet by mouth at bedtime, 14 quantity. f. [MEDICATION NAME] 100 mg 1 tablet by mouth every 12 hours, 14 quantity. Review of the explanation on the form revealed the medication cards as not full with 1 pill gone from each card. Review of the discharge orders for Resident #12 dated 2/21/11 did not include any of the medications that were returned to the pharmacy. During an interview on 3/17/11 at 12:58 p.m., Staff N, Pharmacist stated a facility will fax the initial admission sheet or a physician order [REDACTED]. The pharmacy will look to see what type of form it is, a new order, admit, or transfer. Staff N stated when Resident #12's paperwork came to the pharmacy in a facsimile (fax) there was another page not identified as not Resident #12's. The faxed paperwork was the Transfer Order/Instructions from the local hospital. The other resident's was not split out and identified as not Resident #12's. Staff N reported the facility called and notified the pharmacy on 2/15/11 of the medication error for Resident #12. Staff N reported the admits come in a packet usually identified for each resident if a facility sends multiple admits at one time, there are individual packets sent. Staff N explained there has been re-education of our staff here to be more thorough in looking at packets sent to make sure all information sent pertains to one certain resident per packet. Request made to Staff N for the original faxed packet for Resident #12 be sent. At 4:15 p.m., a 22 page fax received from Staff N. Record review of the faxed packet for Resident #12 from Staff N revealed the first 2 pages of the fax sent to the pharmacy on 2/14/11 from the facility did contain pages for another resident admitted to the facility the same day as Resident #12. The pages had a Current Discharge Medication List, instructing to start these medications: a. Aspirin 325 mg, take 1 tablet by mouth daily. b. [MEDICATION NAME] 75 mg, take 1 tablet by mouth daily. c. Atrovent 0.5 mg/2.5 ml nebulizer solution use, 2.5 ml by inhalation 3 times daily. d.[MEDICATION NAME] mg, take 1 tablet by mouth daily. e. [MEDICATION NAME] 0.5 mg, take 1 tablet by mouth at bedtime as needed for anxiety. f. [MEDICATION NAME] 25 mg, take 1 tablet by mouth daily. g. [MEDICATION NAME] 100 mg, take 1 tablet by mouth daily. h. [MEDICATION NAME] 0.4 mg sublingual tablet, place 1 tablet under the tongue every 5 minutes as needed for chest pain. i. [MEDICATION NAME] 80 mg, take 1 tablet by mouth daily. Review of a handwritten admission orders [REDACTED]. During an interview on 3/17/11 at 2:16 p.m., the Director of Nursing (DON) indicated Resident #12 was in a local hospital for a broken clavicle and sent to the facility for rehab and IV therapy. Resident #12 was admitted on [DATE] and another resident was admitted around the same time. The nursing staff prepared both packets to be sent to the pharmacy. The DON reported the packet included discharge orders from the hospital with medications, Face Sheet from the hospital if available. The transcribed orders from the discharging facility for the resident is written by the facility nursing staff. The packet is faxed to the pharmacy unless after hours, then it is called to the on-call pharmacist. Once faxed to the pharmacy it is processed and the bubble packs are filled with medication according to the orders (POS). The Medication Administration forms, Treatment Administration sheets (TAR) and the physician's order [REDACTED]. It is expected to have all delivered that day. The exception is late or weekends for the forms if on a Saturday would not get until Monday, if late night will get the forms next morning. If there are no forms the Nursing staff utilize the green copy of the transcribed orders to sign off medications till the hard copies arrive. The DON continued to state that on the morning of 2/15/2011 she/he was approached that the resident admitted at the same time as Resident #12 had not received medications yet from the pharmacy. The DON reported had assumed the facility had tried to contact the pharmacy even call on-call pharmacist as the medications had not come. The DON immediately called the head pharmacist to inquire about the other resident's medications and had a family member upset the medications were not at the facility yet. Not sure what nurse took a call from the pharmacy that they called and stated they had sent the correct medications for the other resident. The pharmacist telephoned and stated the pharmacy had identified the problem and the other resident ' s medication had Resident #12 name on the packaging and Resident ' #12 ' s correct medication were not at the facility.. The DON indicated the nurse who received the medications form the pharmacy for the admits, new orders, etc is responsible to check the bubble packs to the transcribed orders. The nurse, Staff L (RN) worked on t 2/14/11 and received the pills and would be responsible to check the bubble packs to the transcribed admission orders [REDACTED]. Staff L (RN) reported to the DON that she did not check the bubble packs to the transcribed admit orders and put the MAR's in the book and the medications on the cart. The bubble packs and the MAR ' s were the same, but not Resident #12's medications, but had Resident #12's name on them from the pharmacy. Resident #12 did receive some medications but not all and most medications came and were given at the PM doses 2/14/11 and AM doses 2/15/11. The morning of 2/15/11 was when the problem was found, and Resident #12 had already been given. Resident #12 had breakfast as usual and was in therapy when knew there was a problem and went to check on the resident's status. While in therapy the resident complained of nausea, but was talking to the DON and was not diaphoretic and doing usual activities. Staff M (LPN) gave the physical therapist a heads-up about the medication error and to monitor Resident #12 while doing therapy. Staff M (LPN) had taken vitals signs prior therapy as best as the DON can remember and while in therapy Staff M (LPN) kept the blood pressure monitor on the resident to do 15 minute checks. The DON reported wanted a set of vitals for a baseline to give to Resident #12's doctor when contacted. The timeframe of 30 minutes this was all done and the blood pressure taken at 9:30 a.m. and the doctor was called. The doctor ordered a Normal Saline IV at 50 ml per hour started and monitor the blood pressure and call with a report back by 11:00 a.m.. The DON indicated the resident never appeared in acute distress and was in the room in a wheel chair alert and talking to the friend.. The DON reported even when Resident #12's blood pressure was low at 96/64, there was no physical changes for the resident. The DON then informed the family member of what had happened with the medication error. The family member called the doctor's office and did verbalize wanted the resident to go to the ER to be checked out. The DON reported that after the family member called the doctor, the doctor called back to the facility with new orders to send the resident to the ER for evaluation. The DON reported the resident was transported per ambulance to the ER for evaluation and possible treatment at approximately 11:30 a.m. and returned back to the facility at approximately 6:00 p.m. The resident remained at the facility with no further problems until going home with the family member and discharged on [DATE]. During an interview on 3/17/11 at 4:44 p.m., Staff K, Licensed Practical Nurse (LPN) reported had worked only day shift 2/15/11 and was aware of a resident who had been admitted [DATE] and had not received medications yet from the pharmacy. Staff K reported another nurse, Staff M was communicating with the pharmacy. After Staff M received notification of the medication error with Resident #12 per the pharmacy, Staff M notified the DON. The DON came to Staff K and asked the staff to check the vital signs for Resident #12 while in therapy. Staff K indicated could not remember the exact blood pressure numbers, but remembered the resident made a comment about the blood pressure being lower than was in the hospital. Staff K reported had left therapy but kept the blood pressure cuff on Resident #12 as was an automatic blood pressure machine and instructed the physical therapist to push the machine to check the resident's blood pressure every 5 minutes. Staff K then went to the DON and Staff M and decision was made to pull the resident out of therapy and take to the resident's room for further monitoring and Staff K reported went back to work the west end of the north hall. During an interview on 3/17/11 at 4:54 p.m., Staff O, Medical Assistant for Resident #12's doctor reported taking the call from the facility and the family member in regards to medication error for Resident #12 on 2/15/11. Staff O did not remember the name of the staff who called from the facility but was told that Resident #12's medications came but were for another resident and were cardiac medications and Resident #12's name was on the bubble pack. The staff calling expressed anger that the nurse didn't check out the medications and Resident #12 received these cardiac medications in error. Staff O reported being informed the residents blood pressure went down and the resident became light headed and nauseous. Staff O reported went to tell the doctor and the family member called the doctor just after Staff O reported to the doctor. The family member requested the resident go to the ER. Staff O indicated the doctor wanted to run the normal saline IV first and after Staff O called the facility with the order the family called the doctor and requested the resident be sent to the ER. The ER report dated 2/15/11 indicated the resident presented to the hospital after given wrong medications last evening and this morning. The resident had been given cardiac medications not prescribed. The resident's pulse registered 63 (normal 60-80 beats per minute), and blood pressure was 95/62 (normal 120/80). The report indicated at 3:30 p.m. the resident was discharged . The resident was instructed to follow up with the regular physician in 1 to 2 days. During an interview on 3/17/11 at 5:26 p.m., Staff L, RN indicated Resident #12 arrived on 2/14/11 around 12:30 p.m. from the hospital for rehabilitation and IV therapy and the resident was weak with a broken clavicle (collar bone). Staff L stated could not remember if Staff M or themselves transcribed the admit orders, and then both of them have to check the transcribed order to the discharge orders from the hospital. Staff L could not remember if faxed the information on Resident #12 to the pharmacy or if Staff M did for the pharmacy to prepare the medications, MAR's, TAR's, and POS. Staff L indicated she/he worked the west hall south end which didn't work that very often. Staff L reported the medications were delivered by the pharmacy later in the shift on 2/14/11. The central hall nurse checked in all medications delivered and brought Staff L the medications for the west hall. Staff L reported checked Resident #12's bubble pack medications with the MAR supplied by the pharmacy but not the transcribed discharge orders from the hospital. Staff L indicated usually do the following of the MAR is checked to the transcribed discharge orders, then check the bubble packs to the MAR's to make sure all match. Staff L admitted just checked the MAR's with the bubble packs and that was not the usual protocol. Staff L realized it was incorrect and could have been prevented by me if had checked the medications correctly that night the medications were delivered. During an interview on 3/18/11 at 7:02 a.m., Staff M, LPN revealed had worked the west hall south end on 2/15/11 and learned about Resident #12 getting the wrong medications after giving them to the resident. Staff M indicated had received report from 3rd shift and learned another resident hadn't gotten their medications last night (2/14). Staff M reported passing medications the morning of 2/15/11 and gave the resident all medications ordered that were on the MAR and the bubble packs matched. Staff M went to the DON about the other resident's missing medications that was admitted at the time Resident #12 was admitted . Staff M called the pharmacy about the missing medications and was first told the pharmacy sent the medications already. Staff M double checked but the pharmacy called back and stated the medications had Resident #12's name on it. Staff M went to the DON about this and checked on Resident #12 after learning about the medication error. The resident was in therapy with no distress only complained of nausea. Staff M informed the resident staff needed to check on the resident and took the resident to the resident's room, but the resident wanted to stay in therapy. Staff M indicated the blood pressure for Resident #12 was approximately 96/50 and usual is 140/90. Staff M called the doctor and reported the error and the medications given to the resident. Staff M reported tried to explain what had happened as did the DON. New order for normal saline IV 50 ml per hour and the DON got that started. The DON was to call the family member and attempted and tried again and the family member came to the facility. The DON explained what had happened and what the doctor ordered and were to call the office by 11:00 a.m. with a report. While the family member was in the facility, personally called the doctor and requested Resident #12 to go to the ER for evaluation and possible treatment. The doctor's office called back to the facility before the facility called the office with an update and requested the resident be sent to the ER per the family member's wishes. Staff M reported Resident #12 never questioned about the extra medications given to him from Staff M. Staff M explained the nurse who received the delivered medications is the one responsible to check in the medications to make sure they are correct. The nurse needs to check the bubble packs to the order whether admit or new, check the MAR sent with the bubble packs to the order also to make sure all 3 match (discharge/admit orders, bubble packs, and MAR's). During an interview on 3/18/11 at 7:58 a.m., the DON revealed the expectations of the nurse when medications are delivered and how they are checked in. The DON stated the pharmacy delivers the medications to the central hall nurse who verifies the medications delivered. The central hall nurse delivers the medications to the appropriate hall nurse the medications for that hall. The hall nurse is responsible to do a complete check of the medications, check the bubble packs to the MAR's and all to to the chart to compare doctor orders whether new or admit. The DON indicated all has to match and then the medications can be put in the medication cart to be given and the MAR's and TAR's are put in the respective books to be signed off on. Review of the policy 5.1 Delivery and Receipt of Routine Deliveries dated may 2010, indicated the pharmacy and facility should coordinate to determine delivery day (s) and time (s) as soon as possible after the execution of the Pharmacy Services Agreement or Pharmacy Consultant Agreement. Review of the policy 5.2 Receipt of Interim/Stat/emergency Deliveries revised on May 1, 2010, directed the facility staff should immediately notify the Pharmacy when the facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery. Upon delivery of the interim/stat/emergency medication (s), a facility nurse or other authorized representative should sign the delivery manifest and note the time of arrival. A facility designee should inspect the package for damage errors and notify the pharmacy within 24 hours of any damage or other discrepancies found. If any item ordered is not received and the reason for missing the item is not evident, the facility should contact the pharmacy. The facility should document any delivery discrepancies. After taking delivery, the facility should place the medications in the appropriate location for use. Review of the policy 10.2 Medication-Related Errors revised May 1, 2010, directed if a medication reaches a resident in error the facility should: 1.1 Notify the pharmacy of any possible dispensing occurrence; and 1.2 Notify the physician/prescriber and obtain further instructions and/or orders. The facility staff should monitor the resident in accordance with the physician's/prescriber's instructions. During an interview on 3/18/11 at 10:15 a.m., the DON stated the facility did not have a procedure/policy for checking medications when received from the pharmacy. The DON stated it was considered standard nursing practice of what is expected of the check-in process for the nurse receiving the medications.