Every finding on record at Eckerd Living Center

Based on record review and staff interviews, the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications prior to initiation for 3 of 5 residents reviewed for unnecessary medications (Residents #36, #24, and #6).Findings Included: 1. Resident #36 was admitted to the facility on [DATE] with cumulative diagnoses that included unspecified dementia, anxiety disorder, depression and delusional disorder. A physician order dated 08/16/25 read quetiapine (anti-psychotic medication) 25 milligram (mg) tablet 1 tablet three times per day for anxiety and agitation. A physician order dated 12/10/25 read divalproex (anti-convulsant medication used for mood stabilization) 125 mg capsule 1 capsule three times per day for dementia with aggression and agitation. The order had a stop date of 04/09/26. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had moderate cognitive impairment. She received anti-psychotic, anti-depressant and anti-convulsant medications and displayed physical and verbal behavioral symptoms directed towards others and rejection of care for 4-6 days during the lookback period. A physician order dated 04/09/26 read divalproex 125 mg capsule 2 capsules three times per day for dementia with aggression and agitation. Review of the April 2026 Medication Administration Record (MAR) for Resident #36 revealed quetiapine and divalproex were administered as ordered. Review of Resident #36's electronic medical record revealed no documentation that Resident #36's Responsible Party was informed in advance of the risks and benefits of initiating or increasing the dose of quetiapine or divalproex and consented to the treatment. During an interview on 04/10/26 at 11:50 AM the Nurse Team Lead revealed she was responsible for obtaining psychotropic medication consents. She explained when a provider had a new order they gave it to the Nurse Team Lead. She explained when there was a new psychotropic medication ordered a consent form was obtained from the resident or their Responsible Party. The Nurse Team Lead confirmed they were unable to find psychotropic medication consent forms for Resident #36 and could not recall if she had called Resident #36's Responsible Party or not. During an interview on 04/10/26 at 2:11 PM with the Director of Nursing (DON), she explained that the process for handling new orders including new or changed psychotropic medication orders was that the provider communicated all new or changed orders to the Nurse Team Lead, who was then responsible for calling the resident's Responsible Party. The DON stated she expected the Nurse Team Lead to document when they call the family in the resident's medical record. The DON stated she believed Resident #36's Responsible Party was called but acknowledged that this was not documented and that the required form had not been completed. During an interview on 04/10/26 at 3:15 PM, the Administrator revealed that she believed this problem occurred because there was no second check in place and once it fell through the cracks it was unknown that the consent form was missing. The Administrator stated the psychotropic medication consent form for Resident #36 was forgotten and should have been documented. 2. Resident #24 was admitted to the facility on [DATE] with cumulative diagnoses that included anxiety disorder and depression. A physician order dated 03/18/26 read duloxetine (antidepressant medication) 30 milligrams (mg) capsule one capsule two times a day for depression. The 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had severe cognitive impairment. She displayed behavioral symptoms not directed toward others that significantly interfered with Resident #24's social interactions and disrupted care. She received anti-anxiety and anti-depressant medications during the MDS assessment look back period. A physician order dated 04/01/26 read; lorazepam 0.5 mg tablet 0.25 mg every 24 hours as needed for daytime anxiety with agitation and lorazepam 0.5 mg tablet 0.5 mg every 24 hours as needed for bedtime anxiety with agitation. Both orders had a stop date of 04/14/26. Review of the April 2026 Medication Administration Record (MAR) for Resident #24 revealed the duloxetine was given as ordered. Further review of the MAR revealed the Lorazepam was given on 04/01/26, 04/02/26, 04/03/26, 04/04/26, 04/06/26, 04/07/26 and 04/09/26. Review of Resident #24's electronic medical record revealed no documentation that Resident #24's Responsible Party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam and consented to the treatment. During an interview on 04/10/26 at 11:50 AM the Nurse Team Lead revealed she was responsible for obtaining psychotropic medication consents. She explained when a provider had a new order they gave it to the Team Nurse Lead. She explained when there was a new psychotropic medication ordered a consent form was obtained from the resident or their Responsible Party. The Nurse Team Lead confirmed they were unable to find psychotropic medication consent forms for Resident #24 and could not recall if she had called Resident #24's Responsible Party or not. During an interview on 04/10/26 at 2:11 PM with the Director of Nursing (DON), she explained that the process for handling new orders including new or changed psychotropic medication orders was that the provider communicated all new or changed orders to the Nurse Team Lead, who was then responsible for calling the resident's Responsible Party. The DON stated she expected the Nurse Team Lead to document when they call the family in the resident's medical record. Regarding Resident #24, the DON reported that she believed all consents were obtained verbally over the phone at admission; however, the psychotropic medication consent form was not documented. The DON stated the documentation just fell through the cracks. During an interview on 04/10/26 at 3:15 PM, the Administrator revealed that she believed this problem occurred because there was no second check in place and once it fell through the cracks it was unknown that the consent form was missing. The Administrator stated the psychotropic medication consent form for Resident #24 was forgotten and should have been documented. 3. Resident #6 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition. She displayed no behavioral symptoms and received antidepressant medication during the MDS assessment look-back period. Review of the March 2026 Medication Administration Record for Resident #6 revealed an active physician order dated 09/23/25 for escitalopram oxalate (antidepressant medication) 20 milligrams (mg) one time a day for depression/anxiety. Review of Resident #6's electronic medical record revealed no documentation that Resident #6 was informed in advance of the risks and benefits of initiating escitalopram oxalate 20 mg and consented to the treatment. During interviews on 04/10/26 at 11:50 AM and 04/10/26 at 2:05 PM, the Nurse Team Lead revealed she was responsible for obtaining psychotropic medication consents. She explained when a provider had a new order they gave it to the Nurse Team Lead and if the order was for a new psychotropic medication, the Nurse Team Lead obtained a consent form from the resident or their Responsible Party. The Nurse Team Lead stated she was not sure what had happened and confirmed they were unable to find a psychotropic medication consent form for Resident #6. During an interview on 04/10/26 at 3:04 PM, the Director of Nursing (DON) explained that new orders, including orders for psychotropic medications, were communicated by the provider to the Nurse Team Lead, who was responsible for notifying the resident or their Responsible Party (RP). The DON stated she expected the Nurse Team Lead to document the notification in the resident's medical record. The DON stated she believed Resident #6 was aware of the risks and benefits of the medication because she was followed by the Psychiatric Nurse Practitioner who discussed that information with her. The DON acknowledged they were unable to find a psychotropic medication consent form for Resident #6 and stated it was an oversight. During an interview on 04/10/26 at 3:15 PM, the Administrator revealed that she believed this problem occurred because there was no second check in place and once it fell through the cracks it was unknown that the consent form was missing. The Administrator stated the psychotropic medication consent form for Resident #6 was overlooked and should have been completed.

Based on record review and staff interviews, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay for 1 of 1 sampled resident reviewed for discharge (Resident #47).Findings included:Resident #47 was admitted to the facility on [DATE].The 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition and active discharge planning was in place.The discharge-return not anticipated MDS assessment dated [DATE] revealed Resident #47 discharged to the community.Review of Resident #47's electronic medical record on 04/10/26 revealed an undated, Transfer/Discharge Report containing the resident's demographic and clinical information including date of birth , date of admission to the facility, age, insurance details, allergies, primary contact information, primary physician information, medical diagnoses, most recent vital signs, and immunization history. It was noted under the section for current medications to refer to the medication administration record. The following sections of the report were left blank:*Advanced directive*Diet type/texture/fluid consistency*Resident-specific information related to behavior(s), ambulation, bladder/bowel status, feeding, and usual level of functioning.*Signature and date indicating the resident or representative received a copy of the Transfer/Discharge Report.During an interview on 04/10/26 at 11:14 PM, the Social Worker (SW) revealed she was responsible for long-term resident discharges and the Discharge Planner/Case Manger handled short-term resident discharges. The SW explained that the discharge process included arranging post-discharge needs, such as follow-up appointments, home health or equipment, and providing the resident or their representative with a satisfaction survey and list of the resident's medications with administration times. She also documented a progress note in the resident's medical record outlining the discharge arrangements. The SW stated if a follow-up appointment was arranged prior to the resident's discharge, the resident's medical records were faxed to the provider that included provider notes, therapy notes, and list of medications. The SW indicated she was not aware that a discharge summary that included a recapitulation of the resident's course of treatment while residing in the facility was also required.The Discharge Planner/Case Manager responsible for short-term resident discharges was unavailable for an interview.During an interview on 04/10/26 at 3:15 PM, the Administrator acknowledged that although the Transfer/Discharge Report they utilized contained some of the required discharge summary components, it did not summarize the resident's course of treatment while at the facility. The Administrator stated a discharge summary that included a recapitulation of Resident 47's stay with input from all disciplines should have been completed per the regulatory guidelines.

Based on record review and staff interviews, the facility failed to submit a request for a Level II PASRR (Preadmission Screening and Resident Review) evaluation for a resident with a serious mental health diagnosis for 1 of 2 residents reviewed for PASRR (Resident #3).Findings included:Review of Resident #3's medical records revealed the only evidence of a PASRR was a snapshot of the most recent evaluation completed on 07/28/22 and Resident #3 was determined as a Level I PASRR. Resident #3 was admitted to the facility on [DATE] with diagnosis which included bipolar disorder.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS revealed Resident #3 had an active bipolar disorder diagnosis and received antipsychotic medication on a routine basis only. Review of the physician's order dated 04/11/24 was for a psychiatric referral made for antipsychotic medication management. Review of Mental Health Psychiatric Nurse Practitioner (NP) medication management progress note dated 05/12/24 revealed Resident #3 was evaluated to have an active bipolar disorder diagnosis.Review of a Mental Health NP medication management progress note dated 03/17/26 revealed Resident #3 was evaluated for an active psychiatric diagnosis of bipolar disorder and recommended to continue the current treatment that included aripiprazole (antipsychotic) 7.5 milligrams (mg) at bedtime and bupropion (antidepressant) 300 mg extended release 24 hours.Review of the annual MDS assessment dated [DATE] revealed Resident #3 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS revealed Resident #3 was taking antipsychotic medications on a routine basis only and an antidepressant medication.Resident #3's comprehensive care plan revised on 04/06/26 included the use of psychotropic medications related to a bipolar disorder diagnosis with the goal to be free from psychotropic drug related complications through the review date. Interventions included to monitor, document, and report any adverse reactions of psychotropic medications. During an interview on 04/08/26 at 4:40 PM, the Social Worker (SW) revealed she had been in her position for five years and was responsible for ensuring newly admitted residents had a PASRR prior to their admission. She was aware Resident #3 had an active bipolar disorder diagnosis and was referred to psychiatric services. She explained no request for a Level II PASRR evaluation was made when Resident #3 was admitted on [DATE] because the resident did not demonstrate behaviors. She stated it was her understanding when a resident demonstrated behaviors, she needed to request an evaluation for Level II PASRR. The SW revealed she was not aware an evaluation for a Level II PASRR was needed when a resident was admitted with a mental health diagnosis and had a Level I PASRR. The SW confirmed on 02/28/24 she checked the North Carolina PASRR website prior to Resident #3's admission to ensure the resident had a PASRR but after 02/28/24 no request for a Level II PASRR evaluation had been made. During an interview on 04/10/26 at 3:12 PM, the Administrator confirmed no request was made for a Level II PASRR evaluation when Resident #3 was admitted on [DATE] with a mental health diagnosis. The Administrator stated going forward mental health diagnoses would be reviewed for newly admitted residents and if present a request would be made for a Level II PASRR evaluation.

Based on record review and staff interviews, the facility failed to ensure a resident was seen by the physician within 30 days from admission for 1 of 1 sampled resident (Resident #2).Findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with agitation, diabetes, severe-protein calorie malnutrition, chronic kidney disease, and hypertension.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had severe cognitive impairment.Review of Resident #2's electronic medical record (EMR) revealed no evidence he was seen by the physician.Review of Resident #2's EMR revealed he was seen by the Physician Assistant (PA) on 02/10/26 and the Nurse Practitioner (NP) on 03/05/26. During an interview on 04/10/26 at 11:33 AM, the Nurse Team Lead revealed she was responsible for keeping track of when physician regulatory visits were due. The Nurse Team Lead explained she ran a report from the computer system that listed the date residents were last seen by a provider (NP, PA or Physician,) manually marked the provider who conducted the visit on the report and then let the provider know what residents needed to be seen the next time the provider was at the facility. She stated once the resident was seen by the provider, she entered the date in the computer system. The Nurse Team Lead explained that typically the physician saw a resident for the initial admission visit; however, when the physician was at the facility on 02/25/26, Resident #2 did not show up on the list to be seen because the NP and PA had already seen him. She confirmed Resident #2 had not yet been seen by the physician and acknowledged it was an oversight.During an interview on 04/10/26 at 3:15 PM, the Administrator revealed the Nurse Team Lead was responsible for tracking when physician visits were due. The Administrator confirmed that although Resident #2 had been seen by both the NP and PA, he had not yet been seen by the physician. She explained the Nurse Team Lead was typically very good with keeping track of physician visits that were due but since Resident #2 was seen by both the NP and PA shortly after his admission, he did not appear on the physician-visit list and was inadvertently overlooked.

Based on observations and staff interviews, the facility failed to ensure dishware was air dried prior to stacking for use and free from dried debris. Additionally, the facility failed to ensure the double oven and stove were free of food and grease debris, the floors were free from built-up dark debris, and the high temperature dish-machine reached the manufacturer's recommended temperatures for dish sanitation. The facility failed to utilize the 3-compartment sink according to manufacturer's recommendations for the amount of time dishware was required to soak in the chemical solution for sanitizing dishware and the facility also failed to remove expired food stored for use, date leftover foods and ensure foods were sealed in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents. Findings included: a. During the initial tour of the kitchen with Dietary Staff #2 on [DATE] at 10:12 AM the following areas of concern were observed. Five plastic food preparation containers located on a shelf ready for use were stacked wet, one of five observed dinner plates contained dried dark debris located on the tray line ready for use, five divided plates and one cold plate lid contained dark yellow debris located on the tray line ready for use, the double oven and stove had dark dried grease and food debris on the cooking surfaces, and the floors had built up dark debris under storage racks, around the edges of the floor and wall and in corners. On [DATE] at 10:32 AM an interview was conducted with Dietary Staff #1 that revealed the process for cleaning dishes was to check for cleanliness and return the dishes to the dirty area for reprocessing if found dirty. He reported the process for drying dishware was once dishes were cleaned, they were placed on the drying rack to air dry the dishes. b. An observation of the walk-in cooler on [DATE] at 10:38 AM revealed one 3-pound bag of opened broccoli with no date and one block of [NAME] cheese that expired on [DATE]. An observation of the walk-in freezer on [DATE] at 10:42 AM revealed a package of opened fried chicken without a seal or date, seven premade puree country style chicken single serve packages. without dates, eight premade puree country style pork single serve packages without dates, nine premade puree sausage single serve packages without dates, and 22 premade puree macaroni and cheese single serve packages without dates. On [DATE] at 11:00AM with Dietary Staff #2 revealed he was not sure when premade puree products expired and that generally they went through the premade puree products quickly. He stated that Monday through Friday he was responsible for the cleanliness of the kitchen and ensuring opened food items were dated. On the weekends, the Sous Chef was responsible for kitchen cleanliness and ensured that open food items were dated. c. During a continued kitchen tour on [DATE] at 11:00 AM, the following concerns were identified: 6 plastic plate lids located on the tray line ready for use were stacked wet, the plate warmer had dark crumbly debris, and 3 dinner plates located on the tray line ready for use had dark brown debris and red staining. d. An observation was completed on [DATE] at 11:00 AM. Dietary Staff #2 tested the high temperature dish machine at the request of the surveyor and the wash temperature came to 159 degrees Fahrenheit (F) and the rinse cycle came to 141 F. There was a placard observed on the dish machine that indicated the wash temperature was to reach 160 degrees F and the rinse cycle was to reach 180 degrees F. An interview and observation with Dietary Staff #2 was conducted on [DATE] at 11:00 AM and revealed dietary staff had been working on repairing the dish machine with facility operations. Dietary staff were utilizing the 3 compartment sink to sanitize dishes or an added sodium hypochlorite chemical in the dish machine during the repair. Observation of the chemical container secured to the wall to the right of the dish machine revealed it was empty. Dietary Staff #2 stated they had gotten the chemical from their supervisor. He explained the chemical container had been empty for a while and were utilizing the 3 compartment sink to sanitize dishware until the chemical could be ordered. Observation of the 3 compartment sink process revealed Dietary Staff #2 allowed the dishes to dwell within the sanitizer for an estimated 5 seconds. Observation of a sign above the 3-compartment sink directed staff to dwell for a minimum of 60 seconds in the sanitizer. Dietary Staff #2 stated no one had ever told him how long the dishes needed to be in the sanitized water. Observation of Dietary Staff #2 revealed the tested parts per million (PPM) of the sanitizer were at 300. According to the manufacturer for the sanitizer, the required PPM range is ,d+[DATE]. An interview was completed with Facility Operations Staff #1 and Facility Operations Staff #2 on [DATE] at 12:21 PM revealed that they were aware that the dish machine was not coming up to the required water temperatures. They replaced the booster heater on [DATE] and were not aware that there was a concern with dish machine water temperatures on [DATE]. Facility Operations Staff #1 stated they also had a regulator on order to correct the water temperature concern with the dish machine. They also stated they were unaware that the kitchen staff had run out of the sanitizing chemicals. An interview with the Administrator on [DATE] at 12:27 PM revealed that the Dietary Manager was responsible for kitchen sanitation, however she was out on leave. The Administrator was aware that Facility Operations was working on repairing the dish machine.

Based on observation and staff interview the facility failed to contain trash when the dumpster doors were not closed and failed to keep the area around the trash compactor free from accumulated trash and debris for 2 of 2 dumpsters observed and 1 of 1 trash compactor observed. The findings included: An observation was completed on 2/17/25 at 11:45am. The observation revealed 2 dumpsters, the first dumpster door was completely open, and the second dumpster door was completely open with cardboard visible in both dumpsters. The area around the trash compactor had a soiled plastic bag, a tarp, and a box on the ground. An interview on 2/17/25 at 12:10 pm with Dietary Staff #2 revealed central supply staff use the dumpsters for cardboard and verified that the doors were left open. Dietary Staff #2 also explained that everyone used the trash compactor, and he was not sure who was responsible for keeping the area clean.

Based on record review and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) for the 3rd quarter in the fiscal year (FY) 2023. The findings included: Review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing data report Certification and Survey Provider Enhanced Reports (CASPER Report 1705D) dated 9/21/23 revealed no data was submitted for: April 1 - June 30 (FY Quarter 3 2023) An interview with the Administrator on 9/28/23 at 11:55 AM revealed she was aware that the data had not been submitted. She stated that she was the only staff member submitting this data and currently did not have another staff person to assist with the process. The Administrator explained the cut-off for PBJ data submission was the 15th of the month. The Administrator communicated once she was aware she had not submitted the PBJ data she contacted CMS but was unable to submit the PBJ data after the cut- off date of the 15th.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 2 residents (Resident #17) reviewed for hospice services. The findings included: Resident #17 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice progress notes were reviewed and revealed Resident #17's hospices started on 11/25/2019 and was visited routinely by hospice staff. The Hospice progress notes included notes dated 1/11/2022 and 1/25/2022. Both progress notes indicated Resident #17 was receiving hospice services with weekly visits from the home health aide and nurse. An annual MDS assessment dated [DATE] was reviewed and revealed Resident #17 was severely cognitively impaired and hospice services was coded as being received. A quarterly MDS assessment dated [DATE] was reviewed and revealed Resident #17 was severely cognitively impaired and hospice services was not coded as being received. A care plan dated 10/3/2021 and updated on 12/26/2021, 1/17/2022, 1/23/2022, and 3/28/2022 for Resident #17 showed a focus area for a terminal prognosis related to effects of a cerebral infarction with a goal stating resident's comfort will be maintained through the review date. Interventions included to consult with physician and social worker to have hospice care for resident in the facility and to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. During an interview with the MDS coordinator on 3/31/2022 at 10:17 AM, the MDS coordinator indicated Resident #17 was on hospice and had been receiving hospice services for as long as the MDS coordinator had worked there which was a little over 2 years. The MDS coordinator stated it was an oversight that she had not coded hospice services for Resident #17 on the quarterly MDS dated [DATE]. An interview with the Director of Nursing (DON) on 3/31/2022 at 12:18 PM revealed the quarterly MDS assessment dated [DATE] for Resident #17 should have been coded for hospice services.

Based on record review and staff interviews the facility failed to refer a resident to screen for a Level II Preadmission Screening and Resident Review (PASARR) after the new mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of Resident #24's PASARR documentation revealed a Level I screening was completed on 07/31/2015. Resident #24 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Both diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The annual Minimum Data Set (MDS) dated [DATE] coded Resident #24 with moderate impairment in cognition and required supervision for activities of daily living (ADL). Further review of the MDS revealed Resident #24 had not been referred to the appropriate state-designated authority for Level II PASARR evaluation and determination after she was diagnosed with [CONDITION(S)] disorder and delusional disorder. The comprehensive care plan dated 01/17/2022 indicated Resident #24 had mood problems related to depression. She was at risk for adverse reactions and side effects due to receiving multiple [CONDITION(S)] medications. The goal was to have improved mood state without signs and symptoms of depression, anxiety, or sadness through the next review date. Interventions included educated Resident #24 and family regarding expectations of treatment and concerns related to potential adverse effects of medications. Monitored, documented, and reported as needed when signs and symptoms of self-harming occurred. The March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the MDS Coordinator on 03/29/2022 at 2:17 PM, she stated Resident #24 was diagnosed with [CONDITION(S)] disorder and delusional disorder after she admitted to the facility. She confirmed Resident #24 had not been evaluated for Level II PASARR and explained the error was caused by her oversight. A joint interview with the Director of Nursing (DON) and the Administrator was conducted on 03/29/2022 at 2:28 PM. Both stated whenever a resident's level of care had changed, such as new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and staff interviews, the facility failed to develop a care plan for a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #192 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #192 was severely cognitively impaired and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Care plan review revealed there were no care plans in place for DM. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Solution 100 unit/milliliter (mL)- inject as per sliding scale subcutaneously (SQ) before meals and at bedtime for diabetes dated 12/21/2021 -[MEDICATION(S)] Solution 100 unit/mL- inject 12 units SQ at bedtime for diabetes dated 12/21/2021 An interview with the MDS coordinator on 3/31/2022 at 10:35 AM revealed there was not a care plan in place for diabetes for Resident #192. The MDS coordinator indicated she was responsible for implementing the diabetes care plan for Resident #192 and it should have been caught during record reviews for the previous MDS assessment on 1/5/2022. An interview with the Director of Nursing (DON) on 3/31/2022 at 12:18 PM revealed Resident #192 should have had a care plan in place for DM.

Based on observations, record reviews and staff interviews, the facility failed to administer oxygen therapy (O2) at 2 liters per minute (l/min), as prescribed by the physician for 1 of 1 resident reviewed for respiratory care (Resident #3). The findings included: Resident #3 was admitted to the facility 1/24/2019 with a [DIAGNOSES REDACTED]. Resident #3 was readmitted to the facility 4/3/2019. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was cognitively intact and required minimal assist with activities of daily living. Further review of the MDS revealed Resident #3 required oxygen therapy during the assessment period. A care plan dated 5/14/2019, revealed Resident #3 had an impaired gas exchange for [MEDICAL CONDITION] with goals to maintain optimal gas exchanges with oxygen saturation greater than 88% during vital sign checks. Interventions included: to ensure adequate oxygen and delivery system as needed, administer O2 and breathing treatment and check signs and symptoms of decreased oxygen saturation, abnormal breathing and respiratory function, positioning for optimal breathing, adequate hydration and strict oral hygiene practice. Review of a physician's orders [REDACTED]. An observation was made of Resident #3 on 8/19/2019 at 10:40 AM ambulating from the bathroom to the bed with O2 via NC at 3.5 l/min. An observation was made of Resident #3 on 8/19/2019 at 11:45 AM, 2:08 PM, and 4:33 PM of Resident #3 with O2 via NC at 3.5 l/min. An observation was made of resident #3 on 8/20/2019 at 10:53 AM was resting in the bed in no distress with O2 via NC at 3.5 l/min. An observation was made of Resident #3 on 8/20/2019 at 04:25 PM. Resident #3 was resting in the bed in no distress with a NC in her nose and attached to an oxygen concentrator, which read 3.5 l/min, per the regulator flow indicator. An interview was conducted with Medication Technician #1 (Med Tech), who was covering Resident #3's hall, on 8/20/2019 at 4:25 PM, stated Resident #3's O2 should be set at 2 l/min per the physician order. An observation was made with Med Tech #1 on 8/20/2019 at 4:30 PM of Resident #3 with O2 via NC at 3.5 l/min. Med Tech #1 asked Resident #3 if she had turned up the O2, which Resident #3 replied, no. An interview was conducted with Nurse #1 and Med Tech #1 on 8/20/2019 at 5:07 PM. Nurse #1 stated the physician orders [REDACTED]. Med Tech #1 then informed Nurse #1 the O2 was currently set at 3.5 l/min. Nurse #1 stated that adjustments to the O2 were made based on the O2 saturation (SAT) and if the resident needed more oxygen, and that was probably why the O2 setting was at 3.5 l/min. Nurse #1 directed Med Tech #1 to check the O2 SAT, turn down the O2 to 2 LPM and in 30 minutes, re-check the O2 SAT. Nurse #1 stated the assessments were done by the Med Tech and if there were changes needed the NA would inform the nurse. An interview was conducted on 08/22/2019, at 11:45 AM, with the facility's Director of Nursing (DON). She stated Resident #3's O2 should have been set at 2 l/min per the physician order. The DON further stated it was the responsibility of the nurse/Med Tech on the hall to make sure the O2 was at the correct setting.

Based on observations, record review, and staff interviews the facility failed to date an opened bottle of Latanoprost 0.005% eye drops in 1 of 2 medication carts checked for medication storage in the facility. Findings included: Per facility's expired medication removal policy that was last updated on [DATE], pharmacy products should not be kept in stock beyond the expiration date shown on the label and no contaminated or deteriorated drugs should be available for use. Per manufacturer's package insert for the storage of Latanoprost eye drops: Protect from light. Store unopened bottle(s) under refrigeration at 36 to 46 degree Fahrenheit. Once bottle is opened for use, it may be stored at room temperature up to 77 degree Fahrenheit for 6 weeks. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a medication storage check on [DATE] at 02:48 PM, one opened bottle of Latanoprost 0.005% eye drops for Resident #15 that was opened on [DATE] was found in the medication cart for Dogwood Hall. On [DATE] at 03:12 PM an interview was conducted with Nurse #1. She acknowledged that the Latanoprost that was opened on [DATE] and stored in the medication cart since then was expired on [DATE]. According to the nurse, she checked the expiration date for each medication each time before administering to residents and checked her entire medication cart each shift to ensure it was free of expired medication. She missed the expired Latanoprost when she checked the medication cart today. She attributed the error as an oversight and indicated it was an isolated incident. On [DATE] at 03:19 PM an interview was conducted with the Director of Nursing (DON). She stated that the facility had a system in place to ensure all medications were properly stored and free of expired medication. The nurses were instructed to check each medication before administration. Each month, the consultant pharmacist would send her a list of medication that needed to be checked in respective medication carts. The DON would order the third shift nurses to check all the medication carts thoroughly at least once monthly. It was her expectation for all the nurses to follow manufacturer's guidelines with respect to expiration date for opened medications to ensure the facility was free of expired medication. On [DATE] at 01:55 PM an interview was conducted with the Administrator. She expected the nurses to write the opening date and expiration date clearly on the label in order to minimize confusions. It was her expectation for the facility to remain free of expired medication.

Based on record review, staff, and family interviews the facility failed to provide supervision to prevent a resident who was cognitively impaired from exiting the facility unaccompanied for 1 of 6 residents reviewed for accidents (Resident #87). Findings included: Resident #87 was admitted to the facility from home on 07/18/17 with a [DIAGNOSES REDACTED]. A review of the Nursing Evaluation/Data Collection form dated 07/18/17 indicated Resident #87 was admitted to the facility from home with a [DIAGNOSES REDACTED].#87 was alert and confused with poor recall upon admission. A record review of Resident #87's initial care plan dated 07/18/17 revealed an identified problem of wandering and staff were to allow safe wandering and were to provide frequent checks on Resident #87's whereabouts in the facility. Other interventions included apply code alert bracelet and check code alert every shift and redirect as indicated. Documentation on the care plan specified the code alert bracelet was applied 07/18/17. A record review of the Wandering Evaluation dated 07/18/17 revealed Resident #87 was a new admission with a [DIAGNOSES REDACTED]. A review of the physician's admission history and physical dated 07/18/17 indicated Resident #87 had Alzheimer's dementia, memory loss, confusion, and was pleasantly demented with no history of violence and was seemingly happy. A nurse's note written 07/18/17 at 8:00 PM by Nurse #3 indicated Resident #87 was exit seeking after eating supper in the dining room and stated I am going to get my car and going home, back home to Florida. A nurse's note written 07/19/17 at 6:40 PM by Nurse #2 indicated Resident #87 was found walking outside of the facility at Cherry Hall and was easily directed back into the facility. A record review of the facility's Safety and Security Event dated 07/19/17 at 6:40 PM indicated Resident #87 had been admitted to the facility on [DATE] and had cognitive impairment, was confused and disoriented, and was seen walking out side of the facility at Cherry Hall and was easily directed back into the facility. An interview was conducted with Nurse #1 on 10/17/2017 at 11:02 AM. She stated on 07/19/17 Resident #87 had finished eating supper in the main dining room and then was noticed walking outside of the facility by Nurse Aide (NA) #1 who alerted Nurse #1. Nurse #1 stated she immediately ran outside of the facility to approach Resident #87. The resident stated he was going to his car. Nurse #1 described Resident #87 as being easily redirected back into the facility. Nurse #1 explained Resident #87 was a new admission to the facility and was adjusting to the facility and had wandering behaviors. Nurse #1 stated Resident #87 used to be a salesman by trade and thought he was staying in a hotel. Nurse #1 stated the resident was not observed leaving the building. The nurse thought after eating supper in the main dining room and was ambulating back to his room, Resident #87 exited the building through the sliding glass doors to the garden. Nurse #1 further explained the garden gate located in the back of the garden was not locked with a secure lock due to fire codes. A telephone interview was conducted with NA #1 on 10/17/17 at 3:06 PM. NA #1 stated as she was charting in the computer around supper time on Cherry Hall. Through the glass exit doors at the end of Cherry Hall she observed Resident #87 walking outside of the facility on the sidewalk. NA #1 stated she immediately called for staff assistance and went out of the facility to assist Resident #87 back into the facility. NA #1 stated Resident #87 stated he was looking for his car and was easily directed back into the facility. An interview was conducted with the Director of Nursing (DON) on 10/17/17 at 4:29 PM. The DON explained the sliding glass doors located on the Main Street hallway remained unlocked during the day when the weather was nice. The facility wanted the residents to enjoy being in the garden if they wanted. The door could be opened by standing in front of it. At night and on bad weather days, the door was locked. It could be opened by pushing a button next to the door. The button set off an alarm to alert staff someone had exited through the sliding glass door. A gate at the back of the garden had a latch but it was not a secure lock. Fire codes prohibited the garden gate to be locked since this was considered a fire exit. The DON stated after Resident #87 exited the facility through the garden gate, a motion sensor had been installed by the gate. The sensor was installed so that a person walking by or propelling in a wheelchair would set off an alarm. The DON added no resident had ever gone out that garden gate until Resident #87's exit. A telephone interview was conducted with Resident #87's Responsible Party (RP) on 10/18/17 at 9:52 AM. The RP stated Resident #87 was up frequently during the night to use the toilet. The RP stated she needed surgery and could no longer care for him at home because he had dementia and he made frequent trips to the bathroom all night. The RP explained before Resident #87 was admitted to the facility she sometimes took him during the day to a Senior Center. The RP stated while at the Senior Center Resident #87 would go to the door of the Senior Center and tell staff he was going to get his car so that he could pick her up. The RP stated he never exited the Senior Center. The RP added he had not wandered while at home and would go to the mail box daily to get the mail and come back inside the house. The RP stated she was informed by staff that Resident #87 had exited the facility and was redirected back into the facility. The wife further explained she had informed Resident #87 that he was staying in a hotel and had not informed him he was staying in a long term care facility. The RP stated she had no concerns whatsoever that staff were not keeping Resident #87 safe and he was immediately directed by staff back into the facility. An interview was conducted with Nurse #2 on 10/18/17 at 10:18 AM. The nurse stated she was on duty when Resident #87 exited the facility on 07/19/17. Nurse #2 stated Resident #87 had ambulated to and from the dining room unaccompanied by a staff member. Nurse #2 stated Resident #87 had been assessed on admission as being a wanderer. Nurse #2 added she had been informed by Resident #87's RP that when she took Resident #87 to the Senior Center, he had tried to look for his car. Nurse #2 stated she was completing end of shift charting around 6:40 PM at the nurses station when NA #1 informed her Resident #87 was outside of the facility at Cherry Hall. Nurse #2 stated she and Nurse#1 immediately went outside of the facility along with NA #1 and easily redirected Resident #87 back into the facility. An additional interview was conducted with the DON on 10/19/17 at 8:46 AM. The DON stated her expectation was that after Resident #87 finished eating supper in the dining room a staff member would have accompanied Resident #87 back to his hall and handed him over to a staff member. The DON stated Resident #87 was a new admission with wandering behaviors and should not have been left unaccompanied when exiting the dining room to return to his hallway and room. An interview was conducted with the Administrator on 10/19/17 at 10:31 AM who stated her expectation was that staff would have kept Resident #87 in visual range. The Administrator stated her expectation was that staff would have monitored Resident #87 when leaving the dining room until he was back on the hallway on which he resided.

Based on observations, work order review and staff interviews, the facility failed to maintain doors, walls, and furnishings on 2 of 3 hallways with issues in 6 rooms (Rooms 109, 110, 112, 123 and the shared bathroom for Room 124 and 125) and 1 hallway (Rosewood Court) reviewed for environmental concerns. Findings included: An observation on 08/09/16 at 1:23 PM of room 123 revealed the metal lever used for opening and shutting the door was loose from the door and had the screws adhering it to the door exposed between the door and the lever. This caused a half inch gap to be present on each side of the door, between the door and the lever. An observation on 08/09/16 at 4:09 PM of the hinged side of the wooden door facing the hallway for rooms 109, 110 and 112 revealed multiple areas where small pieces of the wood on the door edge were missing. The missing small wooden pieces resulted in a sharp exterior edge of the door for all 3 rooms. The common area on the Rosewood Court hallway had a wooden storage compartment at one entryway into the common area. The wooden storage unit had a strip of cabinet molding missing on the side, revealing a jagged edge. An observation on 08/09/16 at 4:52 PM of the bathroom shared by residents in rooms 124 and 125 revealed a large hole behind the toilet extending two feet in length and up to 4 inches in height where the baseboard and drywall were missing from the wall. During an interview with the Maintenance Technician (MT) on 08/12/16 at 3:25 PM, the MT stated work orders are put in the computer by the Health Care Unit Coordinator or Administrative Staff. He was able to access all work orders on the computer currently pending. Review of the work orders for the past six months revealed no requests for repairs regarding the concerns for rooms 109, 110, 112, 123 and the shared bathroom for room 124 and 125 had been reported. During a walking tour with the Director of Facility Services (DFS) and the Maintenance Technician (MT) on 08/12/16 at 3:34 PM, the MT stated he was unaware of the issues noted in rooms 109, 110, 112, 123 and the shared bathroom for room 124 and 125 and there was no work order for these issues. During an interview with Nurse #1 (N #1) on 08/12/16 at 3:49 PM, she stated if something was wrong in a room she would let maintenance know by telling the ward clerk directly or she could go on the computer herself and enter the concern. N #1 also stated she had also called maintenance in the past and let them know about the repair or concern that needed to be addressed. During an interview with Nurse Aide #1 (NA #1) on 08/12/16 at 3:55 PM, NA #1 stated she has never needed to contact maintenance for anything, but if she did she would let the charge nurse know and she thought the charge nurse would tell her who she needed to notify. During an interview with the Administrator on 08/12/16 at 4:27 PM, she indicated her expectation was for a safe, homelike, aesthetically pleasing environment for the residents. She further acknowledged her expectation was for concerns to be reported and resolved in a timely manner.

Based on observations and staff interviews the facility failed to ensure perishable foods were dated with their expiration date and labeled in 2 of 2 reach in refrigerators, failed to ensure perishable foods were dated with their expiration date in 2 of 2 iced beverage holding containers, and in 1 of 2 nourishment refrigerators. The findings included: 1 a. An initial tour of the satellite kitchen was conducted on 08/9/16 at 10:45 AM with the Patient Services Supervisor (PSS). Observation of reach in refrigerator #1 revealed 1 square plastic container with a mixed light brown food substance that was covered with plastic wrap and was unlabeled and undated, 1 small silver metal bowl of a green leafy vegetable which was covered in clear plastic wrap and was unlabeled and undated, and 1 large silver metal bowl of green leafy vegetable which was covered in clear plastic wrap and was undated and unlabeled, approximately 20 hardboiled eggs in a plastic container with a lid which was undated, and 7 clear plastic 4 ounce containers which were undated and unlabeled and contained a white thick substance. On 08/09/16 at 10:45 AM an interview was conducted with the PSS who stated any leftover food in refrigerator #1 was required to have a label, a date when the food was prepared, and a date when the food would expire. The PSS stated the mixed light brown food substance was tuna salad and had not been dated or labeled and stated the thick white food substance was yogurt and had not been dated or labeled. The PSS stated the green leafy vegetable in the 2 silver bowls was a salad and had not been dated or labeled and stated the hard boiled eggs in the plastic container had not been dated. The PSS stated the tuna fish, yogurt, and green leafy vegetable should have been labeled and dated when prepared and should have contained an expiration date and further indicated the hardboiled eggs should have been dated. The PSS stated the hardboiled eggs were good for 7 days when they were removed from the original packaging. The PSS stated the hardboiled eggs had not been dated when taken out of the original packaging and placed in refrigerator #1. The PSS stated because the hardboiled eggs were not dated then it could not be determined if the hardboiled eggs had expired. The PSS stated he had no tracking system in place for checking refrigerator #1 for unlabeled and undated leftover foods. On 08/09/16 at 3:28 PM an interview was conducted with the Dietary Aide from the main kitchen who stated any leftover food which was stored in refrigerator #1 required a label, a date when the food was prepared, and a date when the food would expire. The dietary aide stated leftover food was good for 3 days from when it was prepared and then should be discarded. The dietary aide stated yogurt was good for 7 days once it was removed from the original packaging but was required to be labeled and dated with an expiration date. The dietary aide stated the yogurt, tuna salad, and green leafy vegetable in refrigerator #1 should have been labeled and dated when prepared, and should have included an expiration date. The Dietary Aide stated the hardboiled eggs should have been dated when they were brought from the main kitchen and placed in refrigerator #1. On 08/10/16 at 5:34 PM an interview was conducted with the Director of Food Service (DFS) who stated his expectation was that the dietary staff would have labeled and dated the tuna salad, yogurt, green leafy vegetable, and dated the hardboiled eggs in refrigerator #1 as per facility policy. The DFS stated his expectation would have been for the PSS to have checked refrigerator #1 daily to assure all leftover foods were dated and labeled. The DFS stated the unlabeled and undated foods should have been discarded and should not have been in refrigerator #1. The DFS stated he felt the dietary staff were aware of the facility policy for labeling and dating leftover foods but the unlabeled and undated leftover foods just got missed. 1 b. An initial tour of the satellite kitchen was conducted on 08/09/16 at 10:45 AM with the Patient Services Supervisor (PSS). Observation of reach in refrigerator #2 revealed 9 chocolate 4 ounce mighty shakes, and 5 strawberry plus 8 ounce mighty shakes were not dated when thawed. Manufacturer specifications on the mighty shake container indicated mighty shakes were good for 14 days after being thawed. On 08/09/16 at 10:45 AM an interview was conducted with the Patient Services Supervisor (PSS) who stated he believed once the mighty shakes were thawed they were good for 7 days. The PSS stated the 9 chocolate 4 ounce and the 5 strawberry 8 ounce mighty shakes were not dated when they were taken out of the freezer to thaw. The PSS stated the mighty shakes were available for resident use and he could not determine if the mighty shakes had expired because they had not been dated when they were removed from the freezer to thaw. The PSS stated the process that was currently being used was that when the new mighty shakes were removed from the freezer the dietary staff rotated them without dating them to the back of the remaining mighty shakes in refrigerator #2. The PSS stated the oldest mighty shakes were rotated to the front of refrigerator #2 every 2 weeks by the dietary staff. The PSS stated there was no tracking system that the dietary staff actually rotated the mighty shakes in refrigerator #2. The PSS stated the dietary staff did not date any mighty shakes when they were removed from the freezer and he had no tracking system in place to determine when the mighty shakes would expire once thawed. On 08/09/16 at 3:28 PM an interview was conducted with the Dietary Aide from the main kitchen who stated that the 9 chocolate 4 ounce and the 5 strawberry 8 ounce mighty shakes should have been dated when removed from the freezer. The Dietary aide stated the mighty shakes per facility policy would expire 7 days from removal from the freezer. On 08/10/16 at 5:34 PM an interview was conducted with the Director of Food Service (DFS) who stated his expectation was that the dietary staff would have dated the mighty shakes when they were removed from the freezer. 1 c. On 08/09/16 at 12:31 PM an observation was made in the main dining room of 1 chocolate 4 ounce undated mighty shake that was available for resident use and was located in an iced beverage holding container. An observation was made in the restorative dining room of 1 vanilla 4 ounce mighty shake, 1 chocolate 4 ounce mighty shake, and 1strawberry 8 ounce mighty shake that were undated and available for resident use and were located in an iced beverage holding container. On 08/09/16 at 1:08 PM an interview was conducted with the Patient Services Supervisor (PSS) who stated he believed once the mighty shakes were thawed they were good for 7 days. The PSS stated the mighty shakes were available for resident use in the main dining room and the restorative dining room and he could not determine if the mighty shakes had expired because they had not been dated when they were removed from the freezer to thaw. The PSS stated the dietary staff did not date any mighty shakes when they were removed from the freezer and he had no tracking system in place to determine when the mighty shakes would expire once thawed. 08/10/16 at 5:34 PM an interview was conducted with the Director of Food Service (DFS) who stated his expectation was that the dietary staff would have dated the mighty shakes when they were removed from the freezer. 1 d. On 08/09/16 at 1:06 PM an observation was made of the Dogwood nourishment refrigerator and revealed 1 banana/strawberry 4 ounce mighty shake that was undated. On 08/09/16 at 1:08 PM an interview was conducted with the Patient Services Supervisor (PSS) who stated he believed once the mighty shake was thawed then it was good for 7 days. The PSS stated he could not determine if the 4 ounce banana/strawberry mighty shake in the Dogwood nourishment refrigerator had expired because the mighty shake had not been dated when it was removed from the freezer to thaw. The PSS stated the dietary staff did not date any mighty shakes when they were removed from the freezer and he had no tracking system in place to determine when the mighty shake would have expired once thawed and placed in the Dogwood nourishment refrigerator. On 08/10/16 at 5:34 PM an interview was conducted with the Director of Food Service (DFS) who stated his expectation was that the dietary staff would have dated the mighty shakes when they were removed from the freezer.

Based on record review and staff interviews the facility failed to accurately code 2 of 16 sampled residents utilizing the Minimum Data Set (MDS) to reflect hospice care for (Resident #49) and active [DIAGNOSES REDACTED].#56). Findings included: 1 a. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change Minimum Data Set ((MDS) dated [DATE] indicated Resident #49 was coded under Section O-Special Treatments and Programs as receiving hospice care. A review of an Interdisciplinary Data Collection Form dated 05/25/16 indicated Resident #49 appeared comfortable with hospice care. An MDS progress note dated 06/01/16 indicated Resident #49 was on hospice caseload. A record review of the quarterly MDS dated [DATE] indicated Resident #49 was not coded under Section O-Special Treatments and Programs as receiving hospice care. A review of the facility's list of hospice residents revealed that Resident #49 was included among the residents named on the list. The MDS Coordinator was interviewed on 08/11/16 at 8:33 AM, regarding the accuracy of Resident #49's quarterly MDS. The MDS did not reflect hospice care for Resident #49. The MDS Coordinator stated the MDS should have been coded to reflect Resident #49 was receiving hospice care and was missed for coding. The MDS Coordinator stated the Quarterly MDS would require a correction to reflect Resident #49 was receiving hospice care. On 08/11/16 at 10:08 AM an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that the quarterly MDS would have been coded accurately to reflect Resident #49 was receiving hospice care. On 08/11/16 at 10:24 AM an interview was conducted with the Administrator. The Administrator stated it was her expectation that the quarterly MDS would have been coded accurately to reflect Resident #49 was receiving hospice care. 1 b. A physician's orders [REDACTED].#49 had [DIAGNOSES REDACTED]. A care plan dated 03/16/16 indicated Resident #49 had an indwelling urinary catheter for a [DIAGNOSES REDACTED]. A record review of the quarterly MDS dated [DATE] indicated Resident #49 was not coded under Section I-Active [DIAGNOSES REDACTED]. On 08/11/16 at 5:09 PM an interview was conducted with the Minimum Data Set (MDS) Coordinator who stated she was responsible for coding the [DIAGNOSES REDACTED]. The quarterly MDS did not reflect an active [DIAGNOSES REDACTED].#49. The MDS Coordinator stated the MDS should have been coded to reflect Resident #49's active [DIAGNOSES REDACTED]. On 08/11/16 at 5:17 PM an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that the quarterly MDS dated [DATE] would have been coded accurately to reflect Resident #49 had an active [DIAGNOSES REDACTED]. On 08/11/16 at 05:20 PM an interview was conducted with the Administrator. The Administrator stated it was her expectation that the quarterly MDS would have been coded accurately to reflect Resident #49 had an active [DIAGNOSES REDACTED]. 2. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Care Area Assessment (CAA) for visual function dated 07/06/16 indicated Resident #56 had a [DIAGNOSES REDACTED]. A record review of the annual Minimum (MDS) data set [DATE] indicated under Section B-Hearing, Speech, and Vision that Resident #56 was coded as visually impaired. Resident #56 was not coded under Section I-Active [DIAGNOSES REDACTED]. On 08/11/16 at 3:30 PM an interview was conducted with the Minimum Data Set (MDS) Coordinator who stated she was responsible for coding the [DIAGNOSES REDACTED]. The annual MDS did not reflect an active [DIAGNOSES REDACTED].#56. The MDS Coordinator stated the MDS should have been coded to reflect Resident #56's active [DIAGNOSES REDACTED]. On 08/11/16 at 3:56 PM an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation that the annual MDS dated [DATE] would have been coded accurately to reflect Resident #56 had an active [DIAGNOSES REDACTED]. On 08/11/16 at 04:13 PM an interview was conducted with the Administrator. The Administrator stated it was her expectation that the annual MDS would have been coded accurately to reflect Resident #56 had an active [DIAGNOSES REDACTED].

Based on observations, record review and staff interview, the facility failed to remove expired or out of date medications from 2 of 3 medication carts. Review of manufacturer recommendations for Xalatan eye drops revealed the ophthalmic solution should not be used more than 42 days after opening. 1. A. Observation on 06/30/15 at 3:39 PM of the Cherry Trail Medication Cart revealed it contained 4 vials of Albuterol 0.83% 2.5 milligrams (mg)/3 milliliters (ml) which were labeled for a specific resident. 1 vial had an expiration date of March 2015. 1. B. Also, in the medication cart was a bottle of Xalatan eye drops which were labeled for a specific resident with a date opened sticker of 02/26/15. The manufacturer expiration date was December 2016. An interview with Nurse #1 on 06/30/15 at 3:50 PM about the facility process for checking for expired medications revealed all nurses were responsible for checking for expired medications and the night shift nurses were also supposed to check each cart. Nurse #1 stated the expired Albuterol should have been returned to the pharmacy. Nurse #1 stated she thought the Xalatan eye drops were good for 28 - 30 days after opening and should have been discarded. Nurse #1 stated the resident for whom the Albuterol was ordered received the medication on an as needed basis and had not received a dose in June 2015. Nurse #1 stated the resident for whom the Xalatan was ordered received it every night and the last dose was given on 06/29/15. An interview on 06/30/15 at 4:18 PM with the Director of Nursing (DON) about the storage guidelines for Xalatan eye drops revealed the facility policy for eye drops was that they could remain in use for 6 months after opening or until the expiration date, whichever came first. An interview on 06/30/15 at 4:30 PM with the DON revealed she had spoken with Pharmacy staff and confirmed that Xalatan eye drops could only remain in use for 6 weeks after opening. An interview on 07/01/15 at 4:12 PM with the DON revealed the Pharmacy sent a checklist each month that the night nurse on each medication cart completed that indicated expired meds were removed from the cart and refrigerator temperatures were checked. The DON stated she didn't know why there was an expired Albuterol in with 3 other Albuterol that weren't expired. The DON stated all multi-dose containers came with a sticker to indicate the date they were opened but the eye drops did not have instructions on the label to discard 6 weeks after opening. When asked about her expectation for expired medications, she stated she expected expired meds or out of date meds to be removed from the cart by the expiration date. 2. A. Observation on 06/30/15 at 4:22 PM of the Dogwood Medication Cart revealed a bottle of Q-Tussin cough syrup which was almost full labeled for a specific resident. The pharmacy dispense label indicated it was dispensed on 08/29/14. The manufacturer expiration date on the bottle was February 2015. 2. B. Also in the medication cart was a tube of Extra Protective Cream (EPC), a barrier protective cream used to protect the skin from incontinence, with a manufacturer expiration date of May 2013. The EPC cream was not labeled for a specific resident. An interview on 06/30/15 at 4:36 PM with Nurse #2 about who was responsible for checking expiration dates on medications revealed the night nurse was assigned to check the medication carts once a month. Nurse #2 stated the resident for whom the Q-Tussin was ordered had not received a dose in a long time and whenever she administered the medication to him she used the floor stock of Q-Tussin cough syrup. An interview on 07/01/15 at 4:12 PM with the DON revealed the Pharmacy sent a checklist each month that the night nurse on each medication cart completed that indicated expired meds were removed from the cart and refrigerator temperatures were checked. The DON was asked about expired medications being in the medication cart and she stated the containers of Q-Tussin labeled for specific residents weren't used any longer and EPC cream wasn't used in the facility so she didn't know why they were in the medication cart. When asked about her expectation for expired medications, she stated she expected expired meds or out of date meds to be removed from the cart by the expiration date.

Based on observations, record review and staff interviews, the facility failed to maintain 1 of 8 residents who were fed in the restorative dining room in a position to prevent possible aspiration. (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE]. She was hosptalized on [DATE] for pneumonia. Resident #27 had been discharged from Physical Therapy on 01/11/13. Therapy progress notes dated 01/12/13, noted that Resident #27 sat through 3 sessions for alignment in her wheelchair with her neck, head, and pelvis at center midline with adaptive positioning devices to increase participation in out of bed activities. At time of discharge, Physical Therapy stated the resident was successfully and appropriately positioned in a wheelchair with adaptive devices for midline spine and cervical. The notes stated registered nursing staff were educated on proper outfitting of this resident in her wheelchair. Remaining impairments included cognition, decreased strength and balance, decreased posture and motor control and decreased trunk control. Other than a new wheelchair, the report did not state any specific devices to be used while Resident #27 was in the wheelchair. On 01/22/13 Resident #27 was readmitted to the facility with the [DIAGNOSES REDACTED]. A Speech Therapy screening report dated 01/23/13 stated this screen was for a re-admission for status [REDACTED].#27 had a long standing [DIAGNOSES REDACTED]. Nursing notes dated 11/14/13 at 6:50 PM stated the nurse brought Resident #27 back from the dining room at 5:30 PM relaying she had 3 bites of food and a drink and had "aspirated." She did not need to be suctioned. Nursing notes dated 12/14/13 at 12:10 PM stated that this morning at breakfast, Resident #27 "Possibly aspirated." Resident was brought back to the hall and suctioned twice. Nursing notes dated 12/15/13 (7 PM - 7 AM) stated it was reported by off going nurse that Resident #27 "again possibly aspirated" at supper. Nursing notes dated 12/18/13 noted Resident #27 continued to eat pureed foods with honey thick liquids. Resident needed head elevated to 90 degrees and assist to tuck chin as best as possible with intake. The resident tended to hold her head back increasing the risk of aspiration. The most recent Minimum Data Set, an annual dated 01/27/14, coded her with long and short term memory deficits, severely impaired decision making skills, requiring extensive assistance with eating and receiving a mechanically altered diet. She was not checked as having signs or symptoms of a possible swallowing disorder. A Care Plan was developed 01/28/14 for being at risk for aspiration related to difficulty swallowing. The interventions to meet the goals for Resident #27 to not have any aspiration episodes included: diet and fluids as ordered; allow resident time to eat and drink; document and report any aspiration symptoms to nurse/MD (doctor); sit resident upright for at least 30 minutes after meals; and restorative dining if indicated. Nursing notes dated 02/19/14 at 3:35 PM stated Resident #27 "got choked on puree lunch today, brought back to hall, required suctioning". Observations made over two meals revealed the following positioning of Resident #27: *On 03/31/14 at 12:26 PM, Resident #27 had her neck roll moved to behind her back. During the entire meal, Resident #27's neck was hyperextended, causing her to be fed the pureed food and honey thickened milk while looking towards the ceiling. *On 04/02/14 at 8:47 AM, Resident #27 was observed during the breakfast meal. She was seated with 3 other residents at a moon shaped table. NA #1 would feed one resident then go around the table and give each of the other residents a bite of food or drink of liquid. Although there was a neck roll in place, Resident #27's neck was hyperextended causing her to look at the ceiling while Nurse Aide (NA) #1 fed her the pureed food and honey thickened milk. At 8:50 AM after NA #1 fed Resident #27 a spoon full of honey thickened milk, NA #1 told the resident to swallow. NA #1 continued to feed Resident #27 with the resident's neck hyperextended with no verbal cues to swallow or look down tor forward through 8:57 AM. At 8:59 AM the nurse aide fed her a large spoon of eggs. At 9:00 AM the resident was fed a large spoon of meat, followed by 2 more bites of pureed food. Her next bite at 9:05 AM was a bite of egg, followed by a bite of meat and a spoon of milk. Resident #27 remained looking up at the ceiling, with her neck hyperextended and at no time did the nurse aide give cues for head position or cues about swallowing. At 9:07 AM, Resident #27 began coughing. At 9:08 AM, when she continued to cough, NA #1 got up and went to the resident's side and held her head forward so that her eyes were now straight ahead and her face forward. Resident #27 continued to cough as the nurse aide held her head straight forward. At 9:10 AM, NA #1 returned to her seat at which time, Resident #27's neck returned to the hyperextended position. She coughed one more time and at 9:11 AM, staff gave the resident a spoon of milk. At 9:12 AM, the resident coughed again. The NA did not cue the resident to lift her head or swallow. NA #1 continued to feed Resident #27 for the remainder of the meal with the resident's neck hyperextended. She was noted to cough again at 9:31 AM while being fed desert with her neck hyperextended. On 04/02/14 at 9:37 AM, NA #1 was asked about Resident #27's position at meals. NA #1 stated in the past she had been given a neck pillow due to her hyperextension her neck. NA #1 stated she gave this resident small bites and made sure she swallowed between bites. She stated that sometimes she held her head forward/straight. She was unaware of any special instructions or devices to assist with head positioning except for the neck pillow. On 04/02/14 at 1:42 PM, Nurse #2 (the restorative nurse) stated Resident #27 was not in a restorative program at the present time. She stated there was no specific method used to feed Resident #27 except for small bites and alternating food and fluids as she could tolerate. Over the past year, Nurse #2 stated Resident #27 seemed to be more comfortable with her head back, looking upward. She further stated that the resident was referred to therapy several times for positioning and staff never got feed back about any positioning device other than a special wheelchair for her. On 04/02/14 at 2:07 PM, an interview was conducted with the Rehabilitation Manager (RM). RM stated she was unaware of any issues with Resident #27 having an extended neck. She was last seen in therapy to assist with sitting straight in a wheelchair. When asked about the treatment note related to devices in use for cervical extension on the therapy form dated 01/12/13, RM stated upon discharge she was positioned in a way "we consider neutral." She explained further that that would mean facing forward. She further added that she thought a rolled up towel was added for cervical support. RM stated that the resident should not be fed while her neck was hyperextended. Per the RM, she has not seen Resident #27 eat in a while and no one had mentioned concerns with the resident's position during meals. Interview with the Director of Nursing (DON) on 04/03/14 at 11:24 AM, revealed that she expected the discharge summary to explain what intervention, if any, was needed. She stated there was no specific device for her neck mentioned on the discharge summary of 01/12/13. Interview with the Speech Therapist (ST) who saw Resident #27 on 01/23/13 revealed that, at that time, Resident #27 needed cues to hold her head upright and straight which she deemed was due to fatigue and weakness. ST no longer worked in this facility. The Physical Therapist who wrote the note which referred to adaptive devices in the discharge summary dated 01/12/13, no longer worked for the facility and the facility was unable to provide a phone number to contact her.

Based on observations, staff interviews and review of the Material Safety Data Sheet, the facility failed to safely handle a portable oxygen cylinder when replacing 1 of 1 sampled resident's empty oxygen cylinder. (Resident #22). The findings included: The Material Safety Data Sheet (MSDS) related to oxygen provided by the facility was reviewed. "Section 7. Handling and storage" included instructions to "Use a suitable hand truck for cylinder movement." On 04/01/14 at 2:09 PM, Resident #22 was observed using oxygen at 2.5 liters per minute via a nasal cannula. On 04/02/14 at 8:27 AM, Nurse #1 was observed assisting Resident #22 from a recliner into a wheelchair. When staff went to change Resident #22's oxygen from the oxygen concentrator to the portable oxygen cylinder located on the back of her wheelchair, Nurse #1 noticed the portable oxygen cylinder was empty. Nurse #1 proceeded to hand carry the empty oxygen cylinder, by the gauge, down a hall and a half to where the full cylinders were stored. Nurse #1 retrieved a full oxygen cylinder and proceeded to hand carry the full oxygen cylinder back down the hall and a half by the gauge to the resident. Nurse #1 then proceeded to connect the resident's nasal cannula to the new full oxygen cylinder which she had placed on the back of her wheelchair. During an interview with Nurse #1 on 04/02/14 at 12:01 PM, the nurse stated she normally carried the oxygen cylinders by the gauge or under her arm as they were light weight. Nurse #1 further stated the facility had rolling carriers for the oxygen cylinders, however, once you used the carrier and replaced the new oxygen on the back of a wheelchair, the carrier wasn't needed anymore and would have to be returned to storage. She also stated that sometimes, the resident would be transported in the wheelchair down to the location of the oxygen cylinders and the change would take place there. Interview with the Director of Nursing on 04/02/14 at 4:00 PM revealed the staff should never leave a oxygen cylinder standing unsecured, however, she was not aware that oxygen cylinders could not be hand carried.

Based on record review and staff interviews, the facility failed to provide an alternative intervention to address a protein deficit for 1 of 3 sampled residents reviewed for nutrition, who refused the original intervention of liquid protein. (Resident #22). The findings included: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician orders dated 01/21/14 included a regular diet with no added salt. The Nutritional History dated 01/28/14 included the Registered Dietician's (RD) assessment which stated Resident #22's intake was fair to good with her intake varying from meal to meal. The note continued to state the nutritional status was "poor" with her [MEDICATION NAME] level being low at 2.3 milliequivalent/liter (meq/L) (normal range 3.4 -5.0 meq/L), her total protein level being low at 5.8 gram/deciliter (G/DL) (normal range 6.4 - 8.2 G/DL) and her calcium level being low at 8.3 milligram/deciliter (MG/DL) (normal range being 8.5 - 10.1 MG/DL). The note stated "Will order Healthy shot (a liquid protein supplement) daily to improve nutri. (nutrition) status." The Minimum Data Set, the admitted d 01/28/14, coded Resident #22 as being cognitively intact, having no behaviors, requiring supervision with eating, and having no swallowing or chewing issues. The Care Area assessment dated [DATE] for nutrition stated the resident was not currently at nutritional risk and no care care plan would be developed but monitoring would occur. There was no nutritional care plan found in the medical record. A physician's telephone order was written by the RD on 02/06/14 for the Healthy Shot one time per day for low [MEDICATION NAME]. Review of the February Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no physician's order or nursing note indicating that the physician and RD were notified of the refusal. On 04/02/14 at 10:53 AM the Dietetic Technician (DT) stated that Resident #22 was above her ideal body weight but was nutritionally at risk due to her low protein and that was dealt with by providing the Healthy Shot. Upon further interview on 04/02/14 at 11:44 AM, DT stated that he was unaware she had refused the Healthy Shot since it's initiation. He was not sure there was a system to alert the dietary department that an intervention such as the Healthy Shot was discontinued. He stated the RD came to the facility 2 - 3 times per week. He also stated he was not sure when the next laboratory test for [MEDICATION NAME] would be obtained for Resident #22. On 04/02/14 at 11:11 AM Nurse #3 stated she could not locate a physician's order discontinuing the Healthy Shot and there should be one. The Dietary Manager (DM) was interviewed on 04/02/14 at 3:15 PM. DM stated any lab results and dietary changes were faxed to the dietary department. She further stated that sometimes the Healthy Shot information would not be faxed but passed on by word of mouth to DT. DM stated the RD or nurse were responsible to determine if an alternative to the refused Healthy Shot was necessary. She stated she was not sure of the system to alert the RD and that she herself did not know the Healthy Shot was ordered, refused, and/or discontinued. On 04/02/14 at 3:34 PM the RD stated she expected to be notified of refusal for interventions, i.e. the Healthy Shot so that she could order something else in its place. She stated that if staff had notified DT, he could have followed up on the refusal of the protein supplement. She stated she was unaware of Resident #22's refusal of the Healthy Shot and could have ordered another type of protein that may have been more acceptable to Resident #22. The Director of Nursing (DON) stated during interveiw on 04/02/14 at 3:49 PM that Resdient #22 would not have been a candidate for the addition of a lot more calories but more protein could have been added to her diet as an alternative. She further stated on 04/02/14 at 4:26 PM there should have been an order for [REDACTED]. On 04/03/14 at 10:27 AM, Nurse #1, who wrote the note on the MAR indicated [REDACTED]. She stated the original order was not a physician's order as it was written by the RD and therefore she did not write a discontinued order for the physician. She stated she could not recall if she notified the RD of the refusal and would have to refer to the nursing notes.