Every finding on record at Excell Health Care Center

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, identified as a high risk for falls, was provided consistently close monitoring/supervision to minimize complications and prevent multiple falls.This resulted in Resident 1 sustaining fall injuries from a third unwitnessed fall. Resident 1 was transferred to the emergency department (ED) for evaluation and was found with multiple facial fractures (breaks in the facial bones such as the jaw, nose, or eye sockets, typically caused by accidents, falls, or assaults, and often required prompt medical attention).A review of Resident 1's admission Record, printed on 4/15/26, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in memory or thinking skills severe enough to reduce a person's ability to perform activities of daily living [ADL, the basic self-care tasks an individual does on a day-to-day basis]), abnormalities of gait and mobility, muscle weakness, and adult failure-to-thrive (AFTT, a rapid, progressive decline in physical, functional, or cognitive health in older adults). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 9/12/25, indicated, Resident 1's primary language was Vietnamese, and had severely impaired cognition. Resident 1 required substantial/maximal assistance (helper does more than half the effort) to dependent (helper does all the effort) or the assistance of two or more helpers was required for the resident to complete the activity. Resident 1 required substantial/maximal assistance from sitting to lying position, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfer. A review of Resident 1's Care Plans, initiated date of 9/9/25, indicated Resident 1 had impaired cognitive function/dementia or impaired thought processes related to dementia. A Care Plan, with initiated date of 10/13/25, indicated Resident 1 had actual or suspected history of personal trauma, associated behaviors include trying to get out of bed, involuntary movements, and calling out related to dementia. Further review of Resident 1's Care Plans, initiated date of 10/10/25, indicated Resident 1 with episodes of behavior, crawling from bed to mattress and floor, episode of slapping her face, and tapping her left arm constantly. Review of the Care Plan also indicated when sitting in the wheelchair (w/c), Resident 1 observed with behavior of putting her feet up when staff passing by. Interventions included: Bring the resident to dining room to enjoy activities, implement head-to-toe assessments with each behavior of crawling and tapping and, ensure no skin issue injuries all the time. Keep resident in visual sight, monitor behavior frequently, observe what triggered behavior and notify Medical Doctor (MD). Offer frequently ADLs and mobility, place bed in lowest position all the time, and ensure mattress next to bed. A review of Resident 1's Care Plan, initiated date 11/12/25, indicated Resident 1 with an unwitnessed fall. Assist in ADLs and anticipate needs promptly, assist in transfers, toileting, and mobility functioning. Frequent visual check and assist the resident in the front or dining area, implement head-to-toe assessment and range of motion (ROM, a measure of joint functionality and flexibility), notify MD for any skin issues or injuries if noted. Monitor vital signs for any changes and notify MD, neurological check per protocol, monitor level of consciousness (LOC) closely, and notify MD promptly for any changes. On 11/13/25, Resident 1's existing care plan, initiated on 11/12/25, was updated related to another unwitnessed fall incident. Resident 1 was found on the floor beside the wheelchair (w/c) on her right side, noted with skin cut below the eyebrow area with scant amount of bleeding, and with purplish skin discoloration around the right eye, more to the inner right eye area with swelling. Added interventions included: Transfer resident to emergency department for possible computed tomography (CT, uses special x-ray equipment to help assess head injuries, severe headaches, dizziness and other symptoms) scan of the head. A review of Resident 1's initial Fall Risk Observation/Assessment, dated 9/9/25, indicated Resident 1 had no falls in the past three months, was chair-bound and required assist in elimination, required use of an assistive device (example: w/c). A review of Resident 1's Fall Risk Observation/Assessment, dated 10/1/25, indicated resident had intermittent confusion, one to two falls in the past three months, chair-bound which required assistance in elimination, with balance problem while standing and walking, and required use of an assistive device. A Review of Resident 1's Fall Risk Observation/Assessment, dated 11/12/25, indicated Resident 1 had one to two falls in the past three months, chair-bound which required assist in elimination, and required use of an assistive device. Further review of Resident 1's Fall Risk Observation/Assessment, dated 11/19/25, indicated Resident 1 had three or more falls in the past three months, chair-bound which required assist in elimination, and required use of assistive device. A review of Resident 1's Situation Background Appearance Review and Notify (SBAR, a communication tool used to transfer critical patient information between members of the team) Communication Form, dated 10/1/25, at 3:15 p.m., indicated Resident 1 had an unwitnessed fall (first fall since admitted to the facility) in the hallway, was seen lying on the floor next to her w/c, alert and verbally responsive with confusion. Resident 1 pointed to her upper lip, upon assessment no injuries noted, no change in LOC. Resident 1 tried to stand by herself, denied head strike, skin intact, able to move all extremities without difficulty, vital signs stable. A review of Resident 1's SBAR Communication Form, dated 11/12/25, at 9:30 p.m., indicated Resident 1 had another unwitnessed fall (second fall) in the hallway, found seated on the floor beside her w/c, with both knees flexed near to chest, and both hands on the floor. No noted bump, no skin discoloration, no bleeding, skin intact, no signs of grimacing, or moaning. Able to move all extremities with no difficulty, noted no change in LOC. A review of Resident 1's SBAR Communication Form, dated 11/13/25, at 6:00 a.m., indicated Resident 1 had another unwitnessed fall (third fall), in resident's room, seated on the floor beside her w/c. Resident 1 was noted with a small cut on her right eyebrow, with scant bleeding, and discoloration (from previous fall on 11/12/25) noted. Able to move all extremities with no change in LOC. ROM to upper and lower extremities with no complaint of pain. A review of Resident 1's Skin and Wound Evaluation, dated 11/13/25, indicated Resident 1 sustained a laceration (a jagged, deep tear) to the right corner of eyebrow, 7.2 centimeters (cm) length by 5.2 cm width, with scant amount of bleeding, with black/blue skin discoloration, and swelling. A review of Resident 1's Neurological Flowsheet, dated 11/13/25, at 6:00 a.m., indicated a head-to-toe assessment was started, and at 10:00 a.m. Resident 1 was transferred to the hospital for evaluation. A review of Resident 1's Investigation Summary, dated 11/13/25, indicated Resident 1 had taken a fall on 11/13/25, at approximately 6:00 a.m., and was sent out to the hospital for further evaluation. A review of Resident 1's Hospital Emergency Department (ED) visit, dated 11/13/25, indicated an admission diagnosis of unspecified injury of head. Resident 1 was discharged from the hospital on [DATE], with final discharge diagnoses that included: Traumatic (an injury that causes severe and lasting physical damage) subarachnoid hemorrhage (bleeding into the space around the brain caused by head trauma) without loss of consciousness, initial encounter. Maxillary fracture (a break in the upper jawbone), right side, initial encounter for closed fracture (a broken bone that does not break through the skin). Fracture of orbital floor (bottom of the eye socket), right side, initial encounter for closed fracture. Zygomatic (cheekbone) fracture, right side, initial encounter for closed fracture. Laceration without foreign body of right eyelid and periocular (surrounding the eye) area, initial encounter and pain in the left elbow. Resident 1 also received a discharge order for follow up appointment on 11/20/25, at Oral and Maxillofacial Surgery (OMFS, a specialized dental surgical specialty focused on treating conditions, injuries, and defects of the mouth, teeth, jaws, face, head, and neck). During a telephone interview on 4/16/26, at 10:45 a.m., with Resident 1's Resident Representative (RR), RR stated although Resident 1's behavior remained the same at home, Resident 1 had not had any falls in the last four months since discharged from the facility on 12/19/25. During a telephone interview on 4/17/26, at 8:30 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 denied knowledge of Resident 1's fall and stated he was unable to recall the incident but remembered Resident 1 as frequently restless, unsettled, and fidgety, with frequent episodes of attempting to get out of bed. CNA 1 stated Resident 1 did not have a permanent 1:1 sitter (a healthcare worker who provides continuous, dedicated, one-on-one observation for a single patient to ensure their safety and prevent injuries), instead, whoever was the CNA assigned to that room assignment watched the resident. During a telephone interview on 4/23/26, at 6:45 a.m., with CNA 2, CNA 2 stated she did not take care of Resident 1 directly but knew the resident moved around a lot in bed when awake and was at a high risk for fall. CNA 2 stated Resident 1 did not have a dedicated 1:1 sitter, any of the nursing staff not currently busy shared in watching the resident. During a telephone interview on 4/23/26, at 6:55 a.m., with Registered Nurse 1 (RN 1), RN 1 stated on 11/13/25, at approximately 6:00 a.m., CNA 1 reported Resident 1 had an unwitnessed fall while CNA 1 assisted Resident 2 (Resident 1's roommate) with incontinent care (help provided to someone who cannot control their bladder or bowel), while Resident 1 was asleep in bed right inside the same room with privacy curtain pulled. RN 1 stated CNA 1 found Resident 1 seated on the floor mattress next to the resident's bed and w/c. Resident 1 was noted with a skin cut below the right eyebrow area, with scant amount of bleeding, and had a purplish skin discoloration with swelling around the right eye. During an interview on 5/13/26, at 11 a.m., with the Director of Nursing (DON), DON stated Resident 1 was a high risk for falls, had no safety awareness, and had no capacity to make medical decisions. Interventions to prevent further falls included putting the bed in the lowest position, mattress on floor, monitored and watched closely by staff, and/or taken to the Nurses' Station, Rehab Therapy, or Activities. DON stated Resident 1 did not have a dedicated 1:1 sitter who had no other responsibilities but to stay and keep the resident safe. A review of the facility's policy and procedure (P&P) titled, Fall Prevention Program, date reviewed/revised 9/2/22, indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level.The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere.Provide additional interventions as directed by the resident's assessment, including but not limited to.Sitter, if indicated.interventions will be monitored for effectiveness.

Based on observation and interview, the facility failed to prepare food in accordance with professional standards of food service safety when the Facility [NAME] (COOK) used a cleaning cloth instead of a potholder to remove an item from the oven. This failure had the potential to result in cross-contamination, resulting in the potential for food-borne illness for 83 out of 90 residents who receive food from the kitchen. Findings: During an observation on 11/19/24 at 10:33 a.m. in the kitchen, the Facility [NAME] (COOK) removed a tray of chicken from the oven using a pot holder on her left hand and a red cloth to cover her right hand. The red cloth was observed to come into contact with liquid on the tray. During an interview on 11/19/24 at 10:40 a.m., COOK stated she used the red cloth and the pot holder to remove the chicken from the oven. COOK stated the chicken was heavy and required two hands. During an interview on 11/19/24 at 10:42 a.m., with the Dietary Services Manager (DSM), DSM stated the red cloth should be used for cleaning and pot holders should be used for food. Dietary Manager stated sanitizer chemical could have been on cloth and it could have come in contact with food. During an interview on 11/21/24 at 9:21 a.m. with the Infection Preventionist (IP), IP stated a cloth used for cleaning counters should not also be used to handle items that contain food because of the risk for cross-contamination (potentially dangerous bacteria could be spread around the kitchen, which could lead to food poisoning). During a review of the 2022 Food Code by the U.S. Food and Drug Administration, dated 1/18/23, the Food Code section 3-304.14 indicated that cloths used for wiping food spills should be used for no other purpose.

Based on observation, interview and record review, the facility failed to ensure to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of five sample selected residents (Resident 84, 48 and 43) when: 1. The facility's staff left the disconnected feeding tube uncapped and exposed to the air on the pole (pole was holding feeding liquid bags and water) and then staff touched the feeding bag and put the cap on the tip of tube with bare hand (no gloves). 2. The facility's staff did not change the gloves between clean and dirty supplies during the wound care for 48. 3. The facility's staff touched the equipment and belonging with bare hand (no gloves) for Resident 43. Residents 84, 48 and 43 were on EBP care (Enhanced Barrier Precautions is an approach to the use of personal protective equipment (PPE) to reduce transmission of Multi-Resistant Organisms (MDROs) between residents in skilled nursing facilities). Findings: A review of Resident 43's Admission Record indicated, Resident 43 admitted to the facility with multiple diagnosis including Immunodeficiency (Inability to produce an adequate immune response because of an insufficiency or absence of antibodies, immune cells, or both). A review of Resident 43's Order summary report indicated . Resident on EBP, R/T (due to) upper abd (Abdomen) cholecystostomy (a surgical procedure that creates an opening in the gallbladder to drain bile and relieve symptoms) . A review of Resident 84's Admission Record indicated, Resident 64 admitted to the facility with multiple disease including Gastrectomy (surgical removal of a part or the whole of the stomach) . A review of Resident 84's Order summary report indicated . Resident on EBP, R/T long term use of indwelling medical device GTF (Gastric Tube Feeding) . A review of Resident 48's Admission Record indicated, Resident 48 admitted to the facility with multiple disease including pressure ulcers (damaged skin and tissue caused by constant pressure on the skin for a prolonged period). During a concurrent observation and interview on 11/18/24 at 11:25 a.m., with the Registered Nurse (RN)1 at Resident 84's room, observed the feeding tube connected to the formula bag was hang from the poll with no cap, RN1 confirmed and touched the formula bag and tube with bare hands while the resident was on EBP care. RN1 put the cap on the tip of the tube with bare hand and no gloves. RN1 stated she should have wear gloves before touching the supplies to prevent the infection, because Resident 84 is on EBP care due to having Gtube (Gastric Tube). During an observation and interview on 11/18/24 at 11:30 a.m., Infection Preventions (IP) entered to the room, IP had mask only, no gloves, IP touched the Resident 43's side table and moved it, then removed the communication board from the resident's bed which was touching the Resident 43's abdomen and then opened the board and started to talk to the resident with the board. IP confirmed that the Resident 43 is on EBP care and staff need to wear gloves, gown and mask when they are working with the residents on EBP care, and IP should have wear gloves when touched Resident 43's belonging specially when they were touched the Resident 43's body, due the infection prevention. During a consecutive observation and interview on 11/19/24 at 01:51 p.m., observed Licensed Vocational Nurse (LVN) changed the dressing on Resident 48's coccyx, (The small bone at the bottom of the spine). LVN removed the old dressing and with the same gloves opened new gauze and saline solution, cleaned the wound and dry pat with the same gloves, LVN confirmed that did not change gloves between old dressing and cleaning the wound and stated LVN was supposed to change gloves between dirty and clean supplies for the infection prevention matter. During an interview on 11/21/24 at 09:11 a.m., with IP, IP stated the nurses after disconnecting the tube from the Gtube they need to put the cap on the tip of tube for the infection control. If nurses, see the tube with no cap they should replace the tube and not recap it. Stated the nurses should change the gloves after removing the old dressing because the gloves can transfer the bacteria from old dressing to the wound when they clean the wound with the same gloves. A review of the facility's policy and procedure (P&P) Clean Dressing Change revised 12/19/2022, indicated .9. Loosen the tape and remove the existing dressing . 10. Remove gloves .11. Wash hands and put on clean gloves. 12. Cleans the wound as ordered . A review of the facility's policy and procedure Personal Protective Equipment revised 12/19/2022, indicated . 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious material is likely . A review of the facility's policy and procedure Enhanced Barrier Precautions revised 12/19/2022, indicated . PPE for enhanced barrier precautions is only necessary when high contact care activities .High-contact resident care activities include . g. Device care or use: central lines, urinary catheters, feeding tubes, . It may be acceptable to use gloves, alone, for some uses of a medical device that involve only limited physical contact between the healthcare worker and the resident . During an interview on 11/21/24 at 09:11 a.m., with IP, IP stated that the facility does not have any specific P&P for Tube Feeding connected to the feeding bag's set up and keep the tube clean.

Based on observation, interview, and record review, the facility failed to store and serve food in a sanitary manner when food items stored in the snack refrigerator were unlabeled and food items served during lunch did not have their temperatures checked before being served. These deficient practices had the potential to cause food borne illness that can affect all residents. The facility census was 99 and 95 residents were served food from the kitchen. Findings: During a concurrent observation and interview on 12/19/22 at 9:10 a.m. of the kitchen with Dietary Manager (DM) 1, three food items stored in the snack refrigerator were not labeled. DM 1 confirmed the three food items stored in the snack refrigerator were not labeled. DM 1 stated food items stored in the snack refrigerator should all have a label to identify what food items are stored in the container. During an observation and interview on 12/20/22 at 12:30 a.m. with Cook 1 during lunch service, two servings of rice, one serving of carrots and one serving of hot dog were served. Cook 1 stated the two servings of rice, one serving of carrots and one serving of hot dog were all prepared earlier in the kitchen. During a concurrent record review and interview on 12/20/22 at 12:45 p.m. of the 12/20/22 lunch temperature log, the temperatures of the rice, carrots and hot dog were not recorded. DM 1 acknowledged the temperatures of the rice, carrots and hot dog's temperatures were not recorded. DM 1 further stated the rice, carrots and hot dog were served to residents for lunch. A review of the facility document titled, Labeling and Dating of Foods, undated, indicated Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . All prepared foods need to be covered, labeled and dated . Leftovers will be covered, labeled and dated. A review of the facility document titled, Record of Food Temperatures, undated, indicated Policy: It is the policy of this facility to record food temperatures daily to ensure food that is at the proper serving temperature(s) before trays are assembled . 1. Food temperatures will be checked on all items prepared in the dietary department . 6. Measure and record the temperatures for each food product and mil at all meals. Record temperatures on temperature log.

Based on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. two insulin (a medication to maintain blood sugar in diabetics) pens (an insulin dispensing device with replaceable needles) and a vial of insulin were found without an open or expiration date in a drawer in Medication Cart (Med Cart) 3; 2. six loose pills were found in two drawers in Med Cart 3; 3. two expired glucagon (a medication to raise blood sugar) auto-injectors (a device that automatically injects medication) were found in a drawer in Med Cart 3, 4. a bottle of fluticasone propionate solution 50 mcg/act (nasal spray used to relieve nasal symptoms, such as stuffy nose, itching and sneezing) was stored on Resident 30's nightstand. These failures had the potential for administration of expired medications to residents and administration of medications to the wrong resident. Findings: 1.During a concurrent inspection of Med Cart 3 and interview on 12/20/22, at 10:08 a.m., with Licensed Vocational Nurse (LVN) 2, two insulin pens and one vial of insulin were found in a drawer in Med Cart 3. LVN 2 stated the two insulin pens and vial of insulin did not have an open or expiration date written on the appropriate label. LVN 2 stated whoever opened the pens and vial should have labeled them appropriately. LVN 2 stated she did not know when the open dates for the two insulin pens or insulin vials were. During a review of manufacturer's storage recommendation for insulin pens and vial, dated 11/2019, the recommendations indicated opened insulin pens and vials be discarded after 28 days. 2.During an observation and interview on 12/20/22, at 10:08 a.m., with LVN 2, Med Cart 3 was inspected. Six loose pills were found in two of Med Cart 3's drawer. LVN removed the six pills and stated those pills should not be found loose in the drawers. 3.During an observation and interview on 12/20/22, at 10:10 a.m., with LVN 2, two expired glucagon auto-injectors were found in a drawer in Med Cart 3. LVN 2 stated the expiration date of the two glucagon auto-injectors was 8/22. During an interview on 12/20/22, at 10:20 a.m., with the Director of Nursing (DON), the DON stated expired medications needed to be removed from medication carts as they are found. During a review of facility policy and procedure (P&P) titled, Medication Storage, dated 9/2/22, the P&P indicated medication carts are routinely inspected by the consulting pharmacist for .medications with worn, illegible, or missing labels. The P&P further indicated medications be stored according to the manufacturer's recommendations .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 39383 4. During a concurrent observation of Resident 30's room and interview with LVN 3, on 12/19/22 at 9:40 a.m., there was a bottle of fluticasone propionate suspension 50 mcg/act (nasal spray used to relieve nasal symptoms, such as stuffy nose, itching and sneezing) placed on Resident 30's nightstand. LVN 3 acknowledged the bottle of fluticasone propionate suspension 50 mcg/act at Resident 30's nightstand. LVN 3 stated Resident 30 has no current orders for this medication. LVN 3 stated this medication should not be at Resident 30's nightstand for the resident's safety. During an interview on 12/21/21 at 1:40 p.m. with DON, DON stated Resident 30 has no orders to self-medicate. DON stated there is no assessment done for Resident 30's self medication. DON further stated medication should never be left at bedside for the safety of the residents. A review of the facility P&P titled, Medication Storage in the Facility, dated April 2008, indicated, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deems appropriate in the judgment of the facility's interdisciplinary resident assessment team. The P&P Section A indicated, A written order for the bedside storage of medication is present in the resident's medical record and Section F further indicated, All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary.

Based on observations, interviews, and record review, the facility failed to ensure a medication error rate below five percent for two of nine sampled residents (Resident 23 and 32) when: 1. Resident 32 was administered sennosides (medication to induce bowel movement) 8.6 milligram (mg, a unit of weight measurement) instead of docusate (medication to induce bowel movement) 200 mg as prescribed by physician's order; and 2. Resident 23 did not receive vitamin d3 (a vitamin needed for various body function) 25 mcg (microgram, a unit of measurement) as prescribed. This failure resulted in two medication errors out of 30 opportunities during observation of medication administration which resulted in the facility having a medication error rate of 6.67% and resulted in residents not receiving the correct medication or receiving the medication as prescribed. Findings: 1. During a concurrent medication pass observation and interview on 12/19/22, at 9:40 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 administered to Resident 32, two tablets of sennosides 8.6 mg. LVN 1 stated the two tablets of sennosides 8.6 mg was for Resident 32's order for docusate 200 mg. Docusate 200 mg was not given to Resident 32. A record review of Resident 32's physician's orders, dated 12/19/22, indicated Resident 32 did not have an order for sennosides 8.6 mg. The physician's order indicated Resident 32 had an order for docusate 200 mg, twice a day. During an interview and record review on 12/19/22, at 12:10 p.m., with LVN 1, Resident 32's Medication Administration Record (MAR) was reviewed. LVN 1 identified a bottle of sennosides 8.6 mg which two tablets were removed for Resident 32's order for docusate 200 mg. When asked to verify on the MAR if Resident 32 had an order for sennosides 8.6 mg, LVN 1 stated Resident 32 did not have an order for sennosides 8.6 mg. During an interview on 12/20/22, at 11:52 a.m., with the Director of Nursing (DON), the DON stated nursing staff should check medications against physician's order and MAR before administration. 2. A review of Resident 23's admission record dated 12/20/22 indicated Resident 23 had a diagnosis of vitamin d3 deficiency. During a medication pass observation and interview on 12/20/22, at 9:15 a.m., with LVN 2, LVN 2 administered three medications to Resident 23. LVN 2 stated the medications in the cup were two Tylenol (a pain reliever) 325 mg tablets, two sennosides 8.6 mg tablets, and two vitamin B12 (vitamin needed for blood production) tablets. LVN 2 stated a total of six pills were in the medication cup. A review of Resident 23's physician's orders, dated 12/21/22, indicated Resident 23 had another order for vitamin d3 25 mcg, once a day. During an interview and record review on 12/20/22, at 12:22 p.m., with LVN 2, Resident 23's MAR was reviewed. Resident 23's MAR indicated LVN 2 administered vitamin d3 25 mcg at 9:21 a.m. The MAR further indicated at 9:21 a.m., Resident 23 received two tablets of Tylenol 325 mg, two tablets of sennosides 8.6 mg and two tablets of vitamin B12. LVN 2 stated she gave Resident 23 all his morning medications at the same time and did not administer other medications before or after the 9:15 a.m. medication pass observation. LVN 2 recalled again six pills were in the medication cup. Reviewing Resident 23's MAR, LVN 2 stated Resident 23 should have received seven pills and could not recall giving vitamin d3. During an interview on 12/20/22, at 11:52 a.m., with the DON, the DON stated nursing staff should administer medications according to the MAR and document the administration after giving the medication. A review of facility policy and procedure (P&P) titled, Medication Administration, dated 9/2/22, indicated staff review MAR to identify medication to be administered and compare medication source with MAR to verify .medication name, form, dose, route and time.

Based on interview and record review, the facility failed to ensure competency skills checks for three of five licensed nursing staff were completed. This failure had the potential for care to be provided by licensed nurses in an unsafe and incompetent manner. Findings: During an interview on 12/4/19, at 12:04 p.m., with the Director of Nursing (DON), DON acknowledged her role as the nursing supervisor included conducting competency skills checks for all licensed nurses. During an interview on 12/4/19, at 12:33 p.m., with Registered Nurse 1 (RN 1), RN 1 stated DON had never done a competency skills checklist with her. During a review of employee personnel files, the files indicated RN 1 was hired on 10/24/11, LVN 1 was hired on 8/21/17, and LVN 4 was re-hired on 10/3/18. No competency skills checklists for RN 1, LVN 1, and LVN 4 could be found in their employee personnel files. During a concurrent interview and record review on 12/4/19, at 12:49 p.m., with DON, DON could not show current and previous years' competency skills checklists for three licensed nurses.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (5%) when, during a medication pass observation, three medication errors out of 32 opportunities resulted in a 9.3% error rate because: 1. Licensed Vocational Nurse 2 (LVN 2) did not follow the manufacturer's specifications when administering a potassium chloride tablet without food to Resident 32. 2. Licensed Vocational Nurse 3 (LVN 3) incorrectly crushed and administered an [MEDICATION NAME]-coated aspirin to Resident 83 and also administered a potassium chloride tablet without food to Resident 83. These failures had the potential to result in undesired health outcomes for Residents 32 and 83, such as stomach irritation, [MEDICAL CONDITION], and gastric bleeding. Findings: 1. During a medication pass observation on 12/4/19 at 9 a.m., LVN 2 prepared and administered 13 medications to Resident 32, including potassium chloride ([MEDICATION NAME]). During a review of the Order Summary Report for Resident 32, the physician's orders [REDACTED]. Administer with meals. During a review of the [MEDICATION NAME] M20 medication label, the label stated, Give with food/meals. Take with plenty of water. During an interview on 12/4/19 at 1:16 p.m., with LVN 2, LVN 2 indicated she should have given the [MEDICATION NAME] with food, according to the physician's orders [REDACTED]. It has something to do with binding . LVN 2 also indicated the pharmacist told the licensed nurses to give the medications as instructed on the label. 2. During a medication pass observation on 12/4/19 at 9:50 a.m., LVN 3 prepared and administered seven tablets to Resident 83, including [MEDICATION NAME]-coated (EC) aspirin and [MEDICATION NAME] to Resident 83. ([MEDICATION NAME] coating is a delayed-release safety coating designed to allow the aspirin tablet to pass through the stomach to the small intestine before dissolving, thereby providing added stomach protection.) LVN 3 crushed all the tablets, including the [MEDICATION NAME]-coated aspirin, and mixed them in applesauce in a medicine cup. LVN 3 placed the [MEDICATION NAME] tablet in a separate medicine cup and administered it separately with apple sauce. During a review of the Order Summary Report for Resident 83, a physician's orders [REDACTED]. Give with food. During a review of the KCL ER medication label, the label stated, Take this medication with a meal. Take with plenty of water. During a review of the Order Summary Report for Resident 83, a physician's orders [REDACTED]. Fib ([MEDICAL CONDITION] fibrilation, a heart condition). During an interview on 12/4/19 at 1 p.m. with LVN 3, LVN 3 admitted crushing the [MEDICATION NAME]-coated aspirin, and stated, Coated medications should not be crushed. LVN 3 also indicated Resident 83 had eaten breakfast at 7:30 a.m., and the KCL tab should have been given with food. LVN 3 stated, It is for better absorption, with food. During a telephone interview on 12/4/19 at 1:26 p.m. with the facility's Registered Pharmacist (RPh), RPh stated, [MEDICATION NAME]-coated medications should not be crushed. It may be harmful to the patients. The crushed [MEDICATION NAME]-coated medications also loses the protective coating which could be harsh on the stomach. During a review of the manufacturer's instructions for the administration of potassium chloride, the instructions indicated [MEDICATION NAME] M tablets should be taken with meals and with a glass of water or other liquid. This product should not be taken on an empty stomach because of its potential for gastric irritation. During a review of the Institute for Safe Medication Practices (ISMP) guidelines titled, Oral Dosage Forms That Should Not Be Crushed, commonly referred to as the Do No Crush list, [MEDICATION NAME]-coated aspirin is listed as a medication that should not be crushed because it is coated and designed to be released slowly. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 06/08, the P&P indicated, Medications are administered in accordance with the written orders of the attending physician .The nurse is responsible to read and follow precautionary or instructions on prescription labels .Check the Do Not Crush list before crushing medications.

Based on observation, interview, and record review, the facility failed to provide personal hygiene assistance (combing hair, brushing, teeth, shaving, washing, and drying the face and hands) to one of 18 sampled residents (Resident 36) when Resident 36's facial hair was not shaved. This failure resulted in Resident 36, a female, having overgrown facial hair resembling a mustache and beard. Findings: During a review of Resident 36's Minimum Data Set (MDS, an assessment tool used to guide care) dated 10/2/19, indicated Resident 36 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 03, indicating Resident 36 was severely cognitive impaired. The MDS also indicated Resident 36 needed extensive assistance of one person with her Activities of Daily Living (ADLs). During a concurrent observation and interview on 12/2/19 at 12:20 p.m., with Resident 36 and the Director of Staff Development (DSD), in the main dining room, Resident 36 was observed to have overgrown facial hair (beard and mustache). Resident 36 stated, I don't like it but no one does it for me. The DSD stated, She used to refuse to be shaved, but they will do it today. When the DSD asked Resident 36 if she wanted to be shaved, Resident 36 indicated she did want to be shaved. During an interview on 12/4/19 at 1:31 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 indicated Resident 36 sometimes refused to be shaved, but not all the time. CNA 1 also indicated she was aware Resident 36 was not shaved on 12/2/19. During a review of the facility's policy and procedure (P&P) titled, Routine Resident Care, dated (MONTH) 2011, the P&P indicated, Residents receive the necessary assistance to maintain good grooming and personal hygiene .

Based on observation, interview, and record review, the facility failed to ensure safe storage of medications when a bottle of [MEDICATION NAME] eye drops (a medication used to lower pressure in the eyes) was stored in the medication refrigerator instead of at room temperature, as per the manufacturer's specifications. This failure had the potential for the effectiveness of the medication to be reduced and residents receiving the medication to not receive the full therapeutic benefit of the drug. Findings: During a concurrent observation and interview on 12/3/19, at 8 a.m., with Registered Nurse 1 (RN 1), in Medication Storage room [ROOM NUMBER], a bottle of [MEDICATION NAME] eye drops was seen in the medication refrigerator and the refrigerator's temperature was 40 degrees Fahrenheit. The medication instructions printed on the [MEDICATION NAME] box indicated Store at 25 degrees Celsius (77 degrees Fahrenheit). RN 1 stated, I don't know why this is here but it should not be stored in the refrigerator. We missed it. RN 1 indicated inappropriate storage of medications causes the medication to lose its efficacy. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication, dated 05/12, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. Medications requiring storage at 'room temperature' are kept at temperatures ranging from 15 degrees Celsius (59 degrees Fahrenheit) to 25 degrees Celsius (77 degrees Fahrenheit).

Based on observation, interview, and record review, the facility failed to follow the physician's order for oxygen administration for one of 18 sampled residents (Resident 29), when Resident 29's oxygen flow rate was not at the specific ordered rate. This failure had the potential to result in life threatening adverse effects for Resident 29, who had a medical history of [REDACTED]. Findings: During a review of Resident 29's face sheet dated 12/4/19, the face sheet showed Resident 29 was admitted with multiple diagnoses, including [MEDICAL CONDITION] and [MEDICAL CONDITION]. During a review of the Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in Resident 29's Annual Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/25/19, Resident 29's BIMS score was 15, meaning Resident 29 was cognitively intact. The MDS also indicated Resident 29 required oxygen therapy. During a concurrent observation and interview on 12/2/19, at 10:19 a.m., with Resident 29, in room [ROOM NUMBER]-2, Resident 29 was receiving oxygen via a nasal cannula (NC, a tube used to deliver supplemental oxygen) and set at a flow rate of 3.5 Liters (L, a unit of measurement). Resident 29 stated the flow rate is supposed to be 2 L NC. Resident 29 indicated that due to his medical conditions, he needs oxygen all the time. During a concurrent observation and interview on 12/2/19, at 11:58 a.m., with Licensed Vocational Nurse 2 (LVN 2), in room [ROOM NUMBER]-2, LVN 2 confirmed the oxygen administration rate was set at 3.5 L NC. LVN 2 stated Resident 29's flow rate was supposed to be at 2 L NC. LVN 2 indicated if Resident 29 felt short of breath and notified the licensed nurse, LVN 2 would assess the resident and provide the 'as needed' (PRN) inhaler or nebulizer as ordered. LVN 2 would then notify the physician. LVN 2 stated there is no order for the oxygen flow rate to be titrated (adjusting the concentration). During a review of Resident 29's Medication Administration Record [REDACTED]. During a subsequent interview with LVN 2, on 12/4/19, at 1:53 p.m., LVN 2 stated that with Resident 29's medical history of [REDACTED]. LVN 2 indicated Resident 29 should not be given more oxygen than what was ordered because it could cause a build up of carbon [MEDICATION NAME] (CO2) in the blood, and Resident 29 would not be able to expel CO2 properly from his lungs when feeling short of breath.

Based on observation, interview, and record review, the facility failed to ensure their infection control and prevention program was followed for two of 18 sampled residents when: 1. Licensed Vocational Nurse 1 (LVN 1) did not wash his hands between glove changes and after providing wound care to Resident 10. 2. The urinary drainage bag for Resident 58 was on the floor. These failures had the potential to spread infection to Resident 10 and Resident 58. Findings: 1. During a wound dressing change observation on 12/2/19 at 9:45 a.m. with LVN 1, LVN 1 donned gloves, removed the soiled dressing, removed the gloves, put a new pair of gloves on without washing his hands, cleansed the wound, applied an ordered medical treatment to the wound, and covered the wound wearing the same pair of gloves. LVN 1 gathered the soiled dressing materials, discarded them, then removed his gloves. LVN 1 used hand sanitizer, and then exited Resident 10's room without washing his hands During an interview on 12/2/19 at 9:55 a.m. with LVN 1, LVN 1 admitted he did not wash or sanitize his hands between glove changes, and after cleansing the wound but prior to applying treatment to the wound. LVN 1 indicated he was supposed to wash his hands after every glove change and stated, I am supposed to wash with soap and water after doing (the wound care) treatment. During an interview on 12/2/19 at 11:20 a.m. with the Director of Staff Development (DSD), DSD stated, Staff must wash their hands before and after a procedure and after use of gloves before donning a new pair. During a review of the facility's policy and procedure (P&P) titled, Clean Dressing Change, dated 12/09, the P&P indicated, Put on gloves Remove soiled dressing, place in bag for disposal. Remove/dispose of gloves, wash hands, don clean gloves. Clean wound as ordered Remove/dispose of gloves, wash hands, don clean gloves. Apply dressing and secure as ordered Remove gloves; place in bag for disposal. Wash hands. 2. During a review of Resident 58's Admission Record, dated 10/19/19, the Admission Record indicated Resident 58 was admitted with multiple diagnoses, including obstructive and reflux [MEDICAL CONDITION] (occurring when urine cannot drain through the urinary tract; urine then backs up into the kidneys and causes the kidneys to swell) and [MEDICAL CONDITION]. During an observation on 12/2/19 at 9:10 a.m. of room [ROOM NUMBER], Bed 2, Resident 58 was in bed with his urinary drainage bag hanging on the right side of his bed and touching the floor. During an interview on 12/2/19 at 9:15 a.m. with LVN 1, after LVN 1 checked the urinary drainage bag, LVN 1 stated, Yes, the catheter bag is touching the floor. How many inches should the catheter bag be off the floor? A review of the facility's policy and procedure titled, Infection Prevention Program Overview, dated 2/18, did not reveal any specific information regarding catheter maintenance for the prevention of catheter-associated urinary tract infections. During a review of the professional guidelines the facility indicated they followed, Lippincott Procedures on indwelling urinary catheter (Foley) care and management, dated 11/15/19, the Lippincott Procedures indicated, .don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI (catheter associated urinary tract infections). During a review of the Centers for Disease Control's (CDC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009, the CDC guidelines indicated at Proper Techniques for Urinary Catheter Maintenance, that the urine collection bag should not rest on the floor.

Based on observation, interview and record review, the facility failed to ensure one (Resident 298) of seven sampled residents' food brought by family was stored safely when Resident 298's food brought by family was left unlabeled/ undated in Refrigerator #1 and the temperature was above 41 degree Fahrenheit (F). This deficient practice had the potential for Resident 298 to consume the food that was potentially out of date and out of range which could cause avoidable food borne illnesses. Findings: Review of facility's policy and procedure titled Safe Handling for Foods from Visitors dated 9/2017 indicated, Ensure that the food is stored separate or easily distinguishable from the facility food. During an observation and interview with LVN 1 on 10/10/18 at 12:05 p.m., Resident 298's lunch box (clear plastic with green lid) brought from home was in Refrigerator (Ref#1). The lunch box had about 1 cup of white rice, half a cup of green beans and two hamburger patties with gravy. Lid had a purple sticker with Resident 298's name on it but no date or time denoting when the facility received that lunch box. Ref#1 thermometer read as 48 degrees F. In an interview with Administrator (Adm) on 10/10/18 at 12:13 p.m., Adm stated, Our staff labels the food brought from outside with residents' name, room number, date and the time the food was received by the facility. In an interview with Certified Nursing Assistant (CNA 3) on 10/10/18 at 12:53 p.m., CNA 3 stated Resident 298's family brought the food the same morning at 10:25 a.m. but she forgot to put date and time on it. During an interview on 10/10/18 at 12:55 p.m., Dietary Manager (DM) stated that she discovered that the refrigerator's regulator dial was turned to number 7 whereas it should have been at number 1. DM also stated that Ref#1 was not closed all the way which caused temperature to rise up to 50 degrees F. DM and DON were unable state for how long Ref#1's temperature was out of range, and who was the responsible staff member to log Ref#1's temperature. In another interview with DM on 10/11/18 at 8:00 a.m., DM stated that she misunderstood the question on 10/10/18 and that is was she who logged the temperature for Ref# 1 at 5:00 a.m. on 10/10/18. The facility's policy and procedure titled Food: Safe Handling for Foods from Visitors dated 9/2017 indicated, When food items are intended for later consumption, the responsible facility member will label foods with the resident name and the current date. Refrigerators will be maintained and have temperature monitored daily for refrigeration less than or equal to 41 degrees F

Based on observation, interview and record review, the facility failed to ensure one (Resident 40) of seven sampled residents was provided adequate personal care and hygiene. For Resident 40, he had long, dirty, and bent fingernails with black brown matter underneath them for both hands and feet. And Resident 40's Right hand was contracted (a condition of shortening and hardening of muscles, tendons, which leads to deformity and rigidity of joints) with white sticky matter on the palm. This failure to provide Activities of Daily Living (ADL) care to Resident 40 had the potential to affect his sense of self-worth, self-respect and possibly cause infection. Findings: Review of ADMISSION RECORD dated 10/11/18 showed Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Quarterly Minimal Data Set (MDS- An assessment tool) dated 8/2/18 showed Resident 40 requires Total assistance to maintain his personal hygiene. During an observation on 10/9/18 at 10:10 a.m., Resident 40 was lying in his bed. Resident 40 had long, dirty, bent fingernails with black brown matter underneath his nails on both hands and feet. During an observation and interview on 10/9/18 at 10:15 a.m., Certified Nursing Assistant (CNA 1), CNA 1 was unable to open Resident 40's right hand and was unable to state what was underneath the nails. Resident 40's right hand was balled into a fist with Resident 40's fingers embedded in his palm. Resident 40's right hand was moist with white sickly matter on his palm and in between all fingers. CNA 1 stated, It smells like cracked eggs. Review of Resident 40's shower sheet dated 10/4/18 showed Finger Nails section was marked as Clean and no indication if it needed clipping. Further review of shower sheet dated 10/8/18 had no information on Fingernails documented there. Further review of a plan of care with revision date on 2/9/18 identified a care need, as Resident 40 has an ADL self-care performance deficit, there were no indications of what approaches or interventions would be used to address Resident 40's personal hygiene needs.

Based on interview and record review, the facility failed to have accirate medical information for one (Resident 245) of seven (7) sampled residents in the clinical record. When Resident 245's physician orders did not match with the information on the Physician orders for Life Sustaining Treatment (POLST) form. This deficient practice had the potential for Resident 245 not being treated according to his wishes during an emergent life/death situation. Findings: Review of Resident 245's Admission Record dated [DATE] showed Resident 245 was admitted to the facility on [DATE] Record review of Resident 245's Physician orders dated [DATE] showed an active order to Do not Resuscitate- DNR (meaning Allow Natural Death if there was no pulse or he was not breathing). A review of Resident 245's POLST dated [DATE] revealed Attempt Resuscitation/ Cardiopulmonary Resuscitation (CPR) if Resident has no pulse and is not breathing. Both these contradicting orders were active in the record. MDSC 1 stated Care Conference Note dated [DATE] showed Resident 245 wished to be Full Code (meaning Attempt CPR), so physician order for [REDACTED]. The facility's policy and procedure titled Advance Directives dated (MONTH) (YEAR) indicated, Nursing notifies the physician of the resident's wishes, obtains orders as appropriate, and enters the information in the Electronic Health Record.

2. Review of Admission Record dated 10/1/18 showed Resident 21 was originally admitted to the facility on [DATE]. Review of SBAR communication sheet dated 9/29/18 showed Resident 21 fell at the facility. In an interview and concurrent record review on 10/10/18 at 10:26 a.m., Licensed Vocational Nurse (LVN 1) stated that Resident 21 had Right [MEDICAL CONDITION] from the fall and that Resident 21 was transferred to the Acute Care hospital on [DATE]. Review of Inter-Facility Transfer Report from Acute Care Hospital dated 10/1/18 indicated Resident 21 was diagnosed with [REDACTED]. Under Discharge Instructions it indicated continue to follow hip dislocation precautions. In an observation on 10/10/18 at 10:35 a.m., Resident 21 was lying in his bed with right leg externally rotated (leg in a position that made the toes point sideways), stated he was in pain and was not able to move his right leg because of the fracture. In an interview with Physical Therapist (PT) on 10/10/18 at 10:51 a.m., PT stated that he gave an Abductor Pillow (A soft triangular pillow to keep the hips in alignment after hip surgery) to Resident 21 on 10/09/18. In an observation and interview with Resident 21's attending Certified Nursing Assistant (CNA 5) and LVN 2 on 10/10/18 at 11:00 a.m., CNA 5 and LVN 2 stated, We have not seen an abductor pillow in Resident 21's room since he came back to the facility after hip surgery. CNA 5 and LVN 2 stated Resident 21 was lying in bed with right leg out of position (externally rotated) at that time. CNA 5 and LVN 2 checked Resident 21's room for an Abductor pillow, but did not find one. During an interview on 10/10/18 at 11:07 a.m., the PT stated the abductor pillow should be between Resident 21's legs while he was in bed. During another observation and interview on 10/11/18 at 7:38 a.m., Resident 21 was lying in the bed with right leg out of position and abductor pillow was incorrectly placed by his feet, covered under a sheet. CNA 4 at bedside stated that was the first time he saw Resident 21 with abductor pillow and it should be between his legs not by the feet. Based on observation, interview and record review, the facility failed to provide preventative devices or restorative range of motion exercises for two (Resident 40 and 21) of seven sampled residents. 1. For Resident 40, there was no intervention to address right hand contractures (a condition of shortening and hardening of muscles, tendons, which leads to deformity and rigidity of joints). 2. For Resident 21, a hip dislocation precautions (ways of moving around that help prevent hip dislocation or separation of the new joint until the joint has time to heal) after a hip surgery was not provided as ordered by the physician. This failure had the potential for Resident 40 and 21 to experience worsening of mobility status or range of motion. Findings: Review of Admission Record dated 10/11/18 showed Resident 40 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview with Certified Nursing Assistant (CNA 1) on 10/9/18 at 10:15 a.m., Resident 40 was lying in his bed. Resident 40's right hand was balled into a fist with Resident 40's fingers embedded in his palm. CNA 1 tried to open Resident 40's right hand but it was difficult to open. CNA 1 stated, Resident 40 goes to therapy once in a while. His right hand was contracted since his admission. He wears something in his hand, but he throws it away. a search on and around the bed revealed no hand roll or other contracture management device at bed side or on the floor at that time. In a follow up observation on 10/10/18 at 9:32 a.m., Resident 40 was seen with Right hand balled into a fist, with no contracture preventative measures in place. In an interview on 10/11/18 at 8:30 a.m., CNA 2, who was the facility Restorative Nurse Aide, stated Resident 40 has never received restorative range of motion. During a concurrent interview and record review of Minimal Data Set (MDS- An assessment tool) on 10/11/18 at 8:36 a.m., the MDS Coordinator (MDSC 1), stated, Resident 40 has limitation in range motion in his right hand since admission. MDSC 1 added that Resident 40 did not receive a Right hand contracture assessment and or therapy or restorative range of motion since he was admitted there.

Based on observation, interview and record review, facility failed to ensure that one (Resident 27) of seven sampled residents' hearing aides were being used. This failure had the potential to cause Resident 27 to be unable to meet his highest practicable physical and psychosocial wellbeing and feel isolated. Findings: Review of Admission Record dated 10/11/18 showed Resident 27 was originally admitted to the facility on [DATE]. Review of Significant change in status Minimal Data Set (MDS, An assessment tool used to guide care) dated 7/12/18 showed Resident 27, was hard of hearing and was using hearing aids as a corrective device. During an attempted interview on 10/9/18 at 10:57 a.m., Resident 27 could not answer any questions and repeatedly stated, I cannot hear you. In an interview on 10/9/18 at 11:00 a.m., the Certified Nursing Assistant (CNA 1) Stated, When I need to talk to him, I shout at him and he shouts back at me. CNA 1 added, Resident 27 had an amplifier (hearing Aid) but the family took it home about two months ago. In an observation on 10/9/18 at 11:07 a.m., CNA 1 was talking to Resident 27 in a loud voice, which was clearly audible from the hallway in a public area. In an interview on 10/9/18 at 11:24 a.m., Licensed Vocational Nurse (LVN 2) stated that she was Resident 27's nurse since (MONTH) of this year and she was not aware if Resident 27 ever had an amplifier (hearing aid). In another interview with Social Service Assistant (SSA) on 10/9/18 at 12:00 p.m., SSA stated that Resident 27's amplifier (hearing aid) was in his room. During an interview and document review on 10/9/18 at 12:43 p.m., in presence of LVN 2, Resident 27 turned on the amplifier and stated, People here do not have patience with me when I use my amplifier, so I stopped using it. And now I am here by myself- an introvert. Resident 27's Care plan review for Hearing Impairment revised on 10/26/17 indicated, Ensure appropriate hearing aides are available as necessary and ensure appropriate communication options are available as necessary.

Based on observation, interview, and record review, the facility failed to provide one (Resident 7), of seven sampled residents, a privacy bag for his Percutaneous Cholecystectomy (PC - drainage catheter placed into the gallbladder) tube drainage bag. This deficient practice resulted in Resident 7 feeling disrespected and ignored. Review of the medical record showed Resident 7 was admitted to the facility on [DATE]. Further review of Resident 7's last comprehensive Minimum Data Set (MDS - an assessment tool used to direct health care needs), dated 6/25/18, indicated Resident 7 had a Brief Interview for Mental Status (BIMS - screening tool to assess cognition) score of 11 (moderately impaired). During an observation on 10/09/18 at 9:20 a.m., Resident 7 was lying in bed, with his PC tube drainage bag hanging from the bottom bed rail, without a privacy bag, showing bile (fluid made by the liver, and stored in the gallbladder). During an interview on 10/9/18 at 9:22 a.m., Resident 7 stated the facility ignores him, and feels that staff does not care about him. Resident 7 further stated They disrespect me. During an observation on 10/9/18 at 9:36 a.m., with Licensed Vocational Nurse 1 (LVN1), Resident 7 did not have a privacy bag covering the PC tube drainage bag. During an interview on 10/9/18 at 9:37 a.m., LVN1 stated all drainage bags should have dignity bags covering them. Review of the facility policy and procedure titled, Resident Dignity and Personal Privacy dated (MONTH) 2007, showed, Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs.

Based on interview and record review the facility failed to act upon the pharmacist recommendation in a timely manner for one (Resident 32) of seven sampled residents when the physician was not notified of pharmacy recommendation to change the type of pain medication. This deficient practice resulted in Resident 32 being at risk for adverse effects of medications. Findings: Resident 32 was admitted to the facility on [DATE], according to his undated face sheet. Review of Pharmacy Consultation Report, dated 8/28/18 showed that the pharmacist recommended for Resident 32 to receive [MEDICATION NAME] (Tylenol) 650 mg every six hours as needed for mild or moderate pain or an alternative non-opioid (a non-narcotic medication) pain reliever. Also recommended to clarify the [MEDICATION NAME]/[MEDICATION NAME] (narcotic plus Tylenol medication) given PRN (as needed) for severe pain. Limit total daily dose of [MEDICATION NAME] to 4 grams from any source. Review of Resident 32's record showed no documentation the physician was notified of Pharmacist recommendation. During an interview with Director of Nursing (DON) on (MONTH) 11, (YEAR) at 10:05 a.m., she could not show in Resident 32's record where the doctor was informed of the pharmacist recommendation.

Based on observation and interview, the facility failed to maintain adequate housekeeping and maintenance services for one (shower room one) of two shower rooms and Residents rooms 114 and 117. 1. There was black colored substance in the tile grout of the floor and walls of both shower stalls and there was dirt on the floor of shower stall number 1. 2. Two of four shower chairs stored in shower stall number 2 had a brown colored substance on the seats. 3. A blue pad, which covered a Geri chair (designed to assist seniors with limited mobility), had brown colored stains on the front and back of the pad. 4. The bathroom sinks in rooms 114 and 117 were separating from the wall. Findings: 1. During the environmental tour observation, on 11/8/17 at 7:50 a.m., the Maintenance Supervisor (MS) and the Environmental Services Supervisor (EVS) there was black colored matter on the tile grout on the floor and walls of Shower Room one and the dirt on the floor of shower stall number one. The EVS stated the shower rooms were cleaned a couple of times a day. 2. There were four shower chairs stored in shower stall number two. The cushioned seats of two of the shower chairs were stained with a brown colored substance. The EVS stated it was powder and wiped the seat of one of the chairs with his hand, then wiped the seat with a towel. 3. A Geri chair, stored in the shower room, had a blue colored pad covering the top of the chair. The blue pad had brown stains on the top and bottom sides of the pad. In an interview, on 11/8/17 at 8 am, Restorative Aide (RA) stated the chair was used by all residents but she couldn't identify the stains on the pad. 4. An observation of the bathroom in room 114, on 11/8/17 at 8:15 a.m., the sink was separating from the wall. The MS stated the sink needed a new brace to hold the sink to the wall.

Based on observation, interview and record review, the facility staff failed to report an allegation of abuse immediately to the Administrator and to the State as stated in their policies and procedures on prohibiting mistreatment, neglect, and abuse for one of 3 sampled residents (1). The facility policy indicated that all allegations of abuse, mistreatment, neglect should be reported to the Director of Nurse and Administrator immediately and to the State. On 4/1/12, Resident 1 told 2 staff members that a certified nursing assistant (CNA 1) had handled her roughly, would not take her to the bathroom and told her to go in her "brief" (adult diaper). The staff members, Speech Therapist (ST) and the Payroll Coordinator who acted as an interpreter (Interpreter 1), delayed reporting the incident to the Director of Nurses for 2 days. The delay in reporting the incident resulted in CNA 1 continuing to be assigned to Resident 1 for the days after the incident, even though Resident 1 did not want CNA 1 to care for her and was upset by it. The incident was not reported to State until 4 days later. Findings: On 4/16/12 and 4/17/12, review of Resident 1''s medical record showed that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set (MDS) assessment dated [DATE], Resident 1 needed extensive assistance with the physical help of one person to transfer between surfaces including bed to chair, and was frequently incontinent of urine and needed physical help in moving on and off the toilet. The Care Area Assessment Review Report dated 4/2/12 revealed, Resident 1 experienced frequent urinary incontinence related to decline in her functional mobility and that she required assistance to the bathroom frequently. The MDS identified Resident 1 preferred to use her native language (not English). In a telephone interview on 4/17/12 at 11:50 a.m., the resident's medical doctor M.D. stated that he saw her last on 4/4/12 and her short term memory was intact. He stated he had not evaluated her long term memory but found her to be a reliable informant. He stated that she could go to the bathroom but needed assistance because she could not walk by herself. In an telephone interview on 4/20/12 at 9:03 a.m., Interpreter 1 stated that she was translating for Resident 1 during her Speech Therapy session on 4/2/12 and asked Resident 1 how she was doing. Resident 1 told her that she was feeling uncomfortable because one of the nurses pushed her, took her brand new sweater and put it in the dirty linen barrel against her wishes. Resident 1 told Interpreter I that the nurse took her to the bathroom and was pushing her to hurry and made her feel uncomfortable. Interpreter I stated that Resident 1 was really, really upset and her demeanor had changed from her usual quiet self, her tone of voice became stronger and her face was expressive when she relayed the incident. Interpreter I did not report the incident to the DON right away. Interpreter I said she and ST were discussing who should write the report, and she was doing her own investigation to find out who the CNA was before reporting. During an interview on 4/16/12 at 2 p.m., using CNA 2 as an interpreter, when asked about the incident, Resident 1 stated she was lying on her side in bed when a CNA 1 came into her room and roughly pushed her. CNA 1 spoke same language as Resident 1. Resident 1 asked CNA 1 if she could go to the bathroom and CNA 1 responded saying she was going to put a diaper on her and she (Resident 1) could go in the diaper because she "had 18 patients to take care of and didn't have time to take her to the bathroom." Resident 1 said that CNA 1 kept pushing her down and trying to put an alarm (motion detector) on her. When Licensed Vocational Nurse (LVN 1), came into the room, Resident I said she did not want that CNA 1 taking care of her anymore. She said later that night CNA 1 came to her and said " why did you report me?" When asked how how the incident made her feel she stated she was not afraid because now the CNA 1 was gone, but it "hurt her, her feelings and made her feel really really bad." The resident had tears in her eyes as she spoke. On 4/17/12 at 9:30 a.m., during a telephone interview, LVN 1 stated that during the evening on 4/1/12, CNA 1 said that Resident 1 had called her the "B" word. LVN 1 and CNA 1 entered Resident 1's room to give her medication on 4/1/12 around 9 p.m. Resident 1 seemed calm but was trying to tell him something but LVN 1 could not understand Resident 1. LVN1 asked CNA 1 to interpret but CNA 1 never replied. LVN 1 said he did not press CNA 1 to respond. When asked about the resident's bathroom abilities, LVN 1 responded that Resident 1 was both continent and incontinent at times but she did require assistance to go to the bathroom. During an interview on 4/17/12 at 2 p.m. Speech Therapist (ST) stated that on 4/2/12 she was providing therapy to Resident 1 with the assistance of Interpreter 1 when the resident told her that she was "handled toughly and quickly" by one of the nurses who took her sweater and put it in the laundry hamper against her wishes. ST did not report the allegation of "tough handling" to the Director of Nurses (DON) until 4/4/12 because she was trying to figure out who the nurse was that the resident was talking about. According to a review of the facility's Abuse and Neglect Prohibition policy and procedure dated September 2011, "Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing...Neglect means failure to provide goods and services necessary to avoid...mental anguish...Physical abuse includes, but is not limited to hitting, slapping pinching, and kicking...It also includes controlling behavior through corporal punishment..." "The facility will protect residents from harm during the investigation."

Based on observation, interview and record review, the facility failed to provide pain management for one (Resident 14) of one resident who received hospice care, in a sample of 18 residents reviewed. For Resident 14, the facility failed to administer pain medication as needed which resulted in unrelieved pain and distress. Findings: Record review on 4/12/12, showed Resident 14 was readmitted to the facility on [DATE]. On 2/17/12, she was placed on hospice care because of a decline in health related to heart and kidney failure. The hospice philosophy and care focuses on relieving pain and suffering of a terminally ill resident. The Minimum Data Set (MDS) screening and assessment tool, dated 3/1/12, indicated Resident 14 had memory problems, but was able to understand and make herself understood, needed extensive assistance with the activities of daily living, and had pain frequently. Resident 14's physician ordered on [DATE] [MEDICATION NAME]([MEDICATION NAME] sulfate is a narcotic [MEDICATION NAME] designed to release the medication slowly over a period of time) 15 mg (milligrams) by mouth twice a day for pain. The facility scheduled this pain medication to be given at 9 a.m. and 5 p.m. Further record review showed another physician order [REDACTED]. During an observation and interview on 4/12/12 at 9:45 a.m., with Resident 14 and her resident care specialist (RCA) 1, Resident 14 stated with a furrowed brow expression, her head hurt and had pain all over (her body). RCA 1 said she would tell the nurse about the pain and proceeded to assist Resident 14 with repositioning in bed. RCA 1 stated the resident (Resident 14) seemed in pain with any touch or movement. RCA 1 also stated that when a resident would tell her about being in pain, she would let the nurse know about it, and the nurse would then decide if the resident needed a pain pill. According to Resident 14's licensed vocational nurse (LVN 1), at 1:15 p.m., the same day, RCA 1 never told her about Resident 14's pain. LVN 1 checked the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Immediately following the interview LVN 1, when visited in her room, Resident 14 said she still had a lot of pain. LVN 1 was asked to assess Resident 14. Resident 14 rated her pain level at 10/10 (on a scale of 1-10, 10 is the worst pain), stating, "I'm in so much pain. I'm suffering... Oh God." LVN 1 gave Resident 14 a dose of 0.25 ml [MEDICATION NAME]. Resident 14's plan of care for Pain, dated 12/8/11, instructed the staff to, "Observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing..."), to monitor pain every shift and as needed, and to, "Administer [MEDICATION NAME] as ordered." In a second interview at 2:35 p.m., RCA 1 explained that she did not tell the charge nurse about Resident 14's pain because Resident 14 said she was ok after she gave her some water. In an observation and interview on 4/12/12 at 4:48 p.m., with the hospice registered nurse (HRN) at the resident's bed side, Resident 14 stated, with a relaxed facial expression, that she had just a little pain. HRN stated that, "when the resident says she's in pain, we have to give it ([MEDICATION NAME]) as ordered." Subsequent interview and MAR (last 24 hours) review with HRN and LVN 3, showed Resident 14 received during the prior 24 hours, one dose of liquid [MEDICATION NAME] on 4/11/12 at 7:45 p.m. According to LVN 3, he gave the liquid [MEDICATION NAME] yesterday because, "Resident 14's son asked me to." HRN stated she will revise the care plan to direct staff in consistency in documenting and assessing for pain, especially, nonverbal cues every two hours. Facility policy for Pain Management, with the revision date of February 2010, indicated, "The goal of the Pain Management Program is that pain is identified and treated effectively and consistently." The policy instructed the staff to, "Remember that pain is whatever the resident states that it is. Further the policy stated, "To be successful your team must be consistent; everyone must provide the same type of care to that resident everyday, and be proactive to make sure that the resident achieves relief and remains free from pain. Monitoring the resident and communicating with each and every team member regarding the pain management for your identified residents is crucial."

Based on interview and record review the facility failed to provide care necessary to prevent urinary tract infections in one of 2 sampled residents (1) who required the use of an Foley catheter (tube into urine bladder) because of a [MEDICAL CONDITION] bladder (dysfunction due to nerve damage, causes difficulty or full inability to pass urine) by not providing the necessary catheter care every shift, monitoring the urinary output or lack of output, which resulted in the resident becoming septic and needing emergency care and hospitalization for urosepsis (infection ranging from urinary tract infection to [MEDICAL CONDITION] which may result from such infection). Findings: On 2/9/12 at 8:05 a.m. review of the medical record revealed Resident 1 had a [MEDICAL CONDITION] bladder requiring a Foley catheter to drain his urine. physician's orders [REDACTED]. On 7/22/11, the physician ordered the Foley catheter to be changed every month. A care plan was written on 6/3/11 for the problem of Indwelling Catheter, Foley for the [DIAGNOSES REDACTED]. Some of the approaches for nursing were, "...Perineal care (washing of the genital and rectal areas) as indicated, notify nurse of any redness or irritation at insertion site...Observe urine odor, color, clarity and amount as needed..." According to the Treatment Administration Record (TAR) for July 2011, the resident did not receive catheter care on the night shift of the 7/4, 7/5, 7/6, and 7/15 or on the day shift for 7/27, 7/28, and 7/29. The TAR dated September 2011 revealed that catheter care was not provided on the night shift of the 9/1, 9/2 and the evening shift of 9/4 and 9/5. According to the August 2011 TAR the drainage bag was changed on 8/15. It was not changed two weeks later as ordered on [DATE] or at any time in September 2011. According to the August 2011 TAR, the Foley catheter was changed on 8/23/12. Resident 1 had a change of condition on 9/11/11. The "Change of Condition" form revealed that the resident had vomited once, had chills and a fever of 102.7, her pulse was 144 beats per minute and her respirations were 28. She was sent to the hospital for evaluation. The Foley catheter was not mentioned nor was there any assessment data of the resident's urine output. The emergency room nurse documented in the "Clinical Report" on 9/11/11 at 2:22 p.m. that the resident had "...abdominal distention (bladder distention)..." and they reinserted a Foley catheter and had a "return of greater than 1000 m. yellow-colored cloudy urine..." The hospital admitting nurse documented in a note on 9/11/11 at 10:00 p.m. that the emergency room nurse reported that the resident was admitted to the ER with a Foley catheter which was in place from the facility. The drainage bag however, "appears still new (no drainage in bag...). When the ER nurse changed the Foley, the urine from the new catheter was "thick and foul smelling". According to the Discharge Summary dated 9/18/11, the physician documented that Resident 1 arrived at the hospital and was found to be septic with probable urinary tract infection. She was admitted for treatment of [REDACTED]." A review of the facility's policy and procedure for Indwelling Catheter Care (daily cleansing) dated 2009 reflected that "...Urine retention or infection from [MEDICAL CONDITION] bladder paralysis...the patient's urine output must be monitored closely...For monitoring purposes, empty the collection bag at least every 8 hours..." and for documentation, "...Describe the amount, color, and other characteristics of urine emptied from the bladder..." A review of the medical record revealed there were no such documented notes regarding the resident's urine output. In an interview with the Director of Nurses (DON) on 2/14/12 at 1 p.m. at the facility, she stated that she reviewed the medical record and spoke with the nurses and there was no documentation regarding the urine output for Resident 1.