Every finding on record at Fair Haven Home Inc

Based on observation, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy and procedure when Nurse Aide (NA) #1 did not doff her gloves, perform hand hygiene and don clean gloves after removing a dressing and before cleaning the wound during wound care to Resident #26. The deficient practice occurred for 1 of 8 staff members observed for infection control practices (NA #1). The findings included: Review of the facility's policy entitled Hand Hygiene last updated May 2025 read in part: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 3. Alcohol-based hand rub with 60% to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Hand Hygiene Table Use either soap and water or alcohol-based hand rub for the following conditions: - Before performing invasive procedures. - Before applying and after removing personal protective equipment (PPE) including gloves. - Before and after handling clean or soiled dressings, linens, etc. - After handling items potentially contaminated with blood, body fluids, secretions or excretions. An observation of NA #1 and Nurse #1 providing wound care to Resident #26's coccyx wound was made on 07/08/25 at 10:25 AM. Nurse #1 had gathered all her dressing supplies and placed them on a barrier on the overbed table. The dressing on the coccyx wound was removed by NA #1 who was assisting with wound care. NA #1 removed the dressing and without doffing her gloves, sanitizing her hands and donning clean gloves, proceeded to clean the wound with normal saline-soaked gauze and then dried the wound with a dry gauze pad. NA #1 doffed her gloves after cleaning and drying the wound, washed her hands with soap and water, donned clean gloves and assisted Nurse #1 in completing the wound care and application of wound vac to Resident #26's coccyx wound. After the wound care was completed, Nurse #1 and NA #1 gathered the supplies and trash, doffed their gowns and gloves, washed their hands with soap and water and left the room. An interview on 07/08/25 at 2:29 PM with Nurse #1 and NA #1 revealed they both thought the wound care had gone well. NA #1 stated she should have doffed her gloves, sanitized her hands, and donned clean gloves after removing the dressing and before cleaning and drying the wound in preparation for application of the wound vac. NA #1 stated it was an oversight and she knew that she should have doffed her gloves, sanitized her hands and donned clean gloves prior to cleansing Resident #26's wound. An interview on 07/08/25 at 4:09 PM with the Infection Preventionist (IP) revealed NA #1 should have doffed her gloves, sanitized her hands, and donned clean gloves after removing Resident #26's dressing and before cleaning the wound with normal saline. The IP stated they were constantly doing education on infection prevention practices and they would provide NA #1 with one-to-one education. An interview on 07/08/25 at 6:39 PM with the Administrator revealed it was her expectation for all staff to follow infection prevention procedures when providing resident care. The Administrator stated NA #1 should have removed her gloves, sanitized her hands and applied clean gloves prior to cleaning Resident #26's wound.

Based on observations, record review and staff interviews, the facility failed to: 1) ensure items stored ready for use were labeled and dated in the walk-in freezer; 2) remove expired food items in 1 of 2 coolers. These practices had the potential to affect food served to residents. Findings included: a An observation and interview conducted with the Dietary Manager (DM) on [DATE] at 10:00 AM revealed there were two bags of hash browns (20 each) that were not labeled or dated in the walk-in freezer. The DM could not recall when they had been placed in the freezer and indicated the bags should labeled and dated. b. An observation conducted on [DATE] at 10:05 AM revealed two packages of ten pounds of ground beef on a tray with thaw date [DATE]. The observation further revealed the ground beef to be turning a gray like color. An observation and interview conducted with the DM on [DATE] at 11:05 AM revealed the ground beef to be a gray color and thaw date labeled [DATE]. The DM stated the ground beef was planned for use on [DATE] for sloppy joes and [DATE] for meat loaf for resident meals. The DM indicated she had been educated from the prior DM ground beef could be thawed and used after 3 to 5 days. An interview with the DM on [DATE] at 1:25 PM revealed she had newer staff and felt like there was a need for education and training for labeling and guidelines for different type of meats. An interview conducted with the Administrator on [DATE] at 2:25 PM revealed he understood the concerns and believed the staff were newer and needed more education and training and expected staff to follow rules and regulations.

Based on observation, record review, resident interview, and staff interviews the facility failed to provide a safe transfer for 1 of 3 residents sampled for accidents (Resident #15). The findings included: Resident #15 was originally admitted on [DATE] with diagnoses that included hypertension and hyperlipidemia. Review of Resident #15's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance of two or more staff with transfers and toilet use. Review of Resident #15's care plan dated 10/31/22 revealed Resident #15 required assistance with activities of daily living (ADL) related to weakness and decreased mobility with admission to hospice services with diagnosis of cerebral atherosclerosis. Resident #15's goal was to be able to participate in ADL care through next review. Interventions included staff to assist with ADL care on a routine basis and as needed. Observation of the inside of Resident #15's closet door on 1/4/23 at 12:30 PM revealed a Transfer/ Mechanical Lift assessment dated [DATE] which indicated Resident #15 was a two person assist with no lift. Review of the facility incident report dated 12/4/22 at 6:43 PM revealed Nurse Aide (NA) #1 observed Resident #15 lose her balance and fell in the bathroom while trying to sit back into the wheelchair around 3:35 PM. The incident report further revealed NA #1 stated, I was trying to scoot the wheelchair behind her, and she fell and hit her head against the wall. The incident report indicated Resident #15 was assessed and no injuries were noted. An interview conducted with Resident #15 on 1/4/23 at 12:30 PM revealed NA #1 and NA #2 had assisted Resident #15 to the shower room to use the bathroom because Resident #15 preferred more room. Resident #15 further revealed NA #2 walked away while she was being transferred from her wheelchair to the toilet. Resident #15 indicated she became weak, and NA #1 was unable to hold her and assisted her to the floor. Resident #15 stated she usually had two person-assist for transfers and did not know why NA #2 had walked away. Resident #15 revealed she did not recall hitting her head or obtaining any injuries. Review of progress note dated 12/4/22 revealed Nurse Aide (NA) #1 observed Resident #15 lose her balance in the bathroom while trying to sit back in her wheelchair. The note further revealed vitals were taken and Resident #15 complained of a headache post fall and received Tylenol. An interview was unable to be conducted with Nurse Aide (NA) #1 during the investigation. An interview conducted with Nurse Aide (NA) #2 on 1/4/23 at 11:50 AM revealed he and NA #1 assisted Resident #15 to the restroom in the shower room to use the toilet. NA #2 further revealed NA #1 transferred Resident #15 from the wheelchair to the toilet while he had walked over to the linen cart an estimated 10 feet away from the toilet in the shower room. NA #2 stated he heard a thump and observed Resident #15 on the floor. NA #2 indicated he was aware and re-educated after the fall that Resident #15 was a two person assist for transfers. The interview further revealed residents in the facility had a Kardex located on their closet doors that disclosed required assistance needed for transfers. An interview conducted with Nurse #1 on 1/4/23 at 11:17 AM revealed on 12/4/22 she had walked by the shower room and heard a thump. Nurse #1 further revealed she entered the room and observed Resident #15 and NA #1 on the floor and NA #2 away from the resident at the linen cart. Nurse #1 indicated Resident #15 had fallen forward on her knees and was a two person assist for transfers and both NAs should have been with the resident during the transfer. Nurse #1 revealed Resident #15 was assessed and did not have any injuries and she had educated both NAs about safely transferring residents with appropriate assist. An interview conducted with the facility Rehabilitation Manager on 1/4/23 at 2:40 PM revealed Resident #15 was not participating in therapy during the incident on 12/4/22. The Rehabilitation manager further revealed Resident #15 was a two person assist for transfers due to Resident #15 sometimes being weak and knees buckling. The Rehabilitation Manager indicated both NAs should have been with Resident #15 during the transfer to prevent the fall. An interview conducted with the Director of Nursing (DON) on 1/4/23 at 3:15 PM revealed Resident #15 required two-person extensive assistance for transfers. The DON further revealed both NAs should have assisted Resident #15 during the transfer to prevent the fall.

Based on observations, record reviews, resident interviews and staff interviews, the facility failed to assess and monitor the ability of a resident to safely self-administer oral medications that were observed in the resident's room for 1 of 1 residents sampled for self-administration of medications (Resident #2). The findings included: Resident #2 was admitted to the facility 9/6/19 and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that Resident #2 was cognitively intact. Resident #2 had adequate hearing, clear speech, able to understand and make herself understood. Resident #2 required supervision and limited assistance with most activities of daily living (ADL). Review of the care plan updated 8/26/20 revealed Resident #2 was not care planned to self-administer oral medications. Review of Resident # 2's Medication Administration Record [REDACTED]. An observation in Resident #2's room with the Director of Nursing (DON) on 1/21/21 at 12:08pm revealed a white pill with the marking ABRS-123 found in a basket on her table located beside her bed. During this observation, the DON stated the white pill was potassium, should not have been within residents access and she removed the white pill from the basket. During an interview with Nurse #1 on 1/21/21 at 1:04PM, she stated she gave Resident #2 her potassium medication that morning at breakfast time for the resident to keep and take at her lunch meal. She further stated it was the resident's preference to keep the potassium to take at lunch and the nurses have just always done it this way. An additional observation of Resident #2's room on 1/21/21 at 1:14pm revealed a white pill in a medicine cup sitting on the table beside her bed. An interview was conducted with Resident #2 during this observation. During this interview, Resident #2 stated the white pill in the medicine cup on her table was potassium. She further stated she received it at breakfast from the nurse but kept it to take at lunch because it was too big to swallow with applesauce in the morning. Resident #2 also stated she forgot to take it at lunch but planned to take it with the dinner meal. An interview on 1/22/21 at 11:43am with the DON revealed there was not an assessment tool in place to monitor and evaluate Resident #2's ability to self-administer potassium. She stated a physician order, care plan, and an assessment of the resident's cognition and physical capabilities were required prior to self-administration of medications. The DON further stated she was unaware nurses were allowing Resident #2 to self-administer the morning potassium medication. An interview was conducted on 1/22/21 at 11:52am with the Administrator. During this interview she stated the administration time for Resident #2's potassium medication should have been changed to the afternoon rather than nurses leaving it in the morning for the resident to self-administer later in the day, and this was an incorrect procedure.

Based on observations and staff interviews, the facility failed to maintain the dumpster area free of debris. The findings included: Observations on 05/15/17 at 9:00 AM upon driving to facility revealed debris was noticed on the ground around the 3 dumpsters. During the kitchen tour on 05/15/17 at 9:25 AM with the Dietary Manager, observations revealed 3 disposable gloves, 5 plastic cup lids, 7 straws, salt packets, and papers and plastic wrap debris on the ground around the dumpsters. The Dietary Manager stated at this time that the dumpsters were emptied on Saturday and positioned differently in the space. She stated the debris was probably under where the other dumpsters were before they were moved. A follow up interview with the Dietary Manager on 05/18/17 at 2:34 PM revealed that she passed the dumpsters on the way into the facility and should have noticed the debris on the ground. She stated the dumpsters were emptied Saturday night. The Administrator who was present during this interview stated that the dumpsters were used daily and it was everyone's responsibility to keep the dumpster area clean and free of debris.

Based on observations and staff interviews the facility failed to repair chipped and splintered bedroom and/or bathroom doors, which had the potential to cause splinters or skin tears, in 8 of 19 resident rooms (#'s 105, 201, 202, 204, 209, 211, 213 and 215). The findings included: A. Observations on 05/15/17 at 2:12 PM revealed the bedroom door to room 105 was chipped and splintered on the side edge of the door. Subsequent observation on 05/18/17 at 2:50 PM remained unchanged. B. Observations on 05/15/17 at 2:56 PM revealed the bedroom door to room 201 was chipped and splintered on the side edge of the door. Subsequent observation on 05/18/17 at 2:50 PM remained unchanged. C. Observations on 05/15/17 at 2:49 PM revealed the bedroom door to room 202 was chipped and splintered on the side edge of the door. Subsequent observation on 05/18/17 at 2:50 PM remained unchanged. D. Observations on 05/15/17 at 10:51 AM revealed the bedroom door to room 204 was chipped and splintered on the side edge of the door. Subsequent observations on 05/16/17 at 8:32 AM and 05/18/17 at 2:50 PM remained unchanged. E. Observations on 05/16/17 at 8:46 AM revealed the bedroom and bathroom doors in room 209 were chipped and splintered on the side edges of the doors. The wood was chipped and splintered near the bathroom door handle. Subsequent observation on 05/18/17 at 2:50 PM remained unchanged. F. Observations on 05/15/17 at 1:55 PM revealed the bedroom door to room 211 was chipped and splintered on the side edges of the door. Subsequent observations on 05/16/17 at 9:53 AM and 05/18/17 2:50 PM remained unchanged. G. Observations on 05/15/17 at 1:56 PM revealed the bedroom and bathroom doors in room 213 were chipped and splintered on the side edges of the doors. Subsequent observations on 05/16/17 at 8:45 AM and 05/18/17 at 2:50 PM remained unchanged. H. Observations on 05/15/17 at 3:47 PM revealed the bedroom door to room 215 was chipped and splintered on the side edges of the door. Subsequent observation on 05/18/17 at 2:50 PM remained unchanged. Interview and tour with the Maintenance Director on 05/18/17 at 2:45 PM revealed, the staff were in-serviced upon hire how to identify maintenance issues, how to complete a maintenance requisition and where to put the requisitions for the Maintenance Director to collect them. The Maintenance Director stated he checked the skilled nursing desk, the Social Worker's office and a box outside of his office more than once a day for the repair requisitions. He explained that he was currently in the process of sanding and refinishing the handrails in the hallways as well as repairing, restaining and repainting the doors to the resident rooms of which he had already started on the Rest Home side of the facility and would continue with the nursing home side after he finished. The Maintenance Director added that he did not have a scheduled plan but that he worked on the doors when he could. After pointing out the concerned resident bedroom and bathroom doors to the Maintenance Director, he agreed the damaged doors were a hazard for the residents and stated he would continue with the damaged doors identified. Interview with the Administrator on 05/18/17 at 3:34 PM revealed, the Management Team identified environmental concerns by rounds made throughout the facility and a Quality Assurance Performance Improvement (QAPI) plan was developed. The Administrator stated a project of sanding and refinishing the handrails in the hallways began in March and the kitchen would undergo a renovation with the replacement of the heating and air system. Informed the Administrator of the concern of the condition of the resident bedroom and bathroom doors being a potential hazard because of the chipped and splintered areas. The Administrator stated that Maintenance would start on the resident rooms next.

Based on observations and staff interviews, the facility failed to maintain the kitchen ceilings free from hanging dust over the steam table and free from hanging dust and peeling paint over the dish machine. The findings included: Observations on 05/17/17 at 8:56 AM revealed the popcorn ceiling above the dish machine was spotted with rust colored spots. The metal pipe running along the ceiling over the dish machine had paint which was peeling away, leaving hanging peels of loose paint above the clean end of the dish machine. The Dietary Manger stated at this time that they were expecting a new air conditioning unit next week which would replace the peeling pipe. Observations of the popcorn ceiling above the steam table on 05/17/17 at 11:35 AM, on which food items were placed and plates of food were being prepared, was hanging dust. The Dietary Manger stated at this time that she had tried to use a duster to remove and even sticky tape but could not remove the hanging dust. Observations were made on 05/18/17 at 2:40 PM with the Administrator, Maintenance Director and Dietary Manager of the ceilings in the kitchen. Hanging dust was observed over the steam table and dish machine which were observed to move with the air circulation. The pipe over the dish machine had peeling paint hanging from it. The Dietary Manager stated that in April the Administrator pointed out the dust on the ceilings and asked her to clean it. She stated that she tried to use a duster and sticky tape which were unsuccessful. She then spoke to the Maintenance Director about how to remove the dust. At that time they developed a plan to replace the air conditioning unit which would remove the pipes and the plumbing lines running along the ceiling. Once this was completed, the ceiling would be easier to paint. The Administrator stated she was aware of this plan and was in agreement. The Maintenance Director stated that he ordered the new air conditioning unit two weeks ago for the kitchen and that company was due out next week. He stated they had not hired a painting company to come in yet to paint the ceiling, which was in their plans. The Dietary Manger stated it had been a couple of years since the ceiling was painted.

Based on observations and staff interviews, the facility failed to maintain securely fastened side rails to the bed and in a manner to alleviate any gaps between the mattress and the side rail for 1 of 3 residents sampled for side rail use (Resident #13). The findings included: Resident #13 was admitted to the facility most recently on 12/11/07. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded her with unclear speech, usually understanding and being understood, and having severely impaired cognition. She was coded as requiring extensive assistance with bed mobility and transfers and being nonambulatory. Review of the Re-evaluation for side rail use dated 11/30/16 revealed the rationale for side rail use as half side rails were used for bed mobility and repositioning. Resident #13 was able to hold self over while care was being given. The quarterly MDS dated [DATE] coded her again with severely impaired cognition and requiring extensive assistance with bed mobility, total assistance with transfers and requiring set up and limited assistance with eating. The Re-evaluation for side rail use dated 03/01/17 described the rationale for side rail use as half rails for bed mobility and repositioning. She was able to hold self over while care was being given. The care plan dated 03/01/17 addressed the problem that she required extensive assistance to total care with activities of daily living skills related to left sided hemiparesis and decreased range of motion secondary to a past cerebral vascular accident. One of the interventions listed was the use of half side rails to aid with assistance of activities of daily living skills during changing or repositioning. The intervention noted she was able to hold self over with use of side rails. Review of the monthly computerized physician orders [REDACTED]. There was no start date for this device. Resident #13 was observed during the initial tour, which began at 9:05 AM on 05/15/17, in bed with the right half side rail in the upright position that was loose and not securely fastened to the bed. The left side of the bed was against the wall. The side rails remained loose when observed on 05/15/17 at 11:03 AM with 4 to 5 inches of play noted towards and away from the mattress. Resident #13 remained in bed with the right top half rail upright, with inches of play and a gap between the mattress and the side rail large enough to fit a fist in during observations on 05/16/17 at 3:15 PM and on 05/17/17 at 8:53 AM. On 05/17/17 at 10:26 AM, Nurse Aide (NA) #1 checked Resident #13 for wetness and turned and repositioned her in bed. After care was given, NA #1 was asked if the resident was capable of using the side rail. NA #1 stated yes if you cued her to do so. At this point, NA #1 used the knob located at the base of the side rail to tighten the loose side rail. Nothing was done about the gap between the side rail and mattress. During the following observations, the side rail was observed with inches of play towards and away from the mattress and the fist size gap between the side rail and mattress as follows: *05/17/17 at 12:52 PM; *05/17/17 at 2:43 PM; and *05/17/17 at 3:56 PM. The resident remained in bed with the right top half rail loose and with a fist size gap between the mattress and side rail during observations on 05/18/17 at 9:43 AM, at 9:43 AM, at 10:22 AM, and at 10:51 AM. On 05/18/17 at 10:51 AM, NA #2 was observed repositioning Resident #13. Although NA #2 cued Resident #13 to hold the rail, she did not. NA #2 was observed leaning against the rail several times rendering care and the side rail moved easily towards the bed. NA #2 made no attempt to tighten the side rail or fill the gap between the mattress and side rail. On 05/18/17 at 11:50 AM, the resident was in bed with the top half side rail upright. Although the side rail appeared tighter with less movement, the fist size gap remained. On 05/18/17 at 2:11 PM the Maintenance Director stated he kept no documentation of routine preventative maintenance checks. He stated that he relied on staff to fill out a work order for items needing maintenance's attention. He further stated he did not routinely check side rails for tightness or fit. He stated he has had no recent requests to check any resident's side rail. The Maintenance Director and Director of Nursing accompanied the surveyor to Resident #13's room, where she was positioned in bed. At this time, the side rail was noted to be loose with several inches of play. The Maintenance Director then moved the side rail closer to the head of the bed and tightened. The DON stated that she expected staff to report loose side rails or accident hazards. She further stated the facility had been working on reducing the use of side rails, however, Resident #13 used her side rail for repositioning when turning.

Based on record review and resident and staff interviews the facility failed to assess a resident's [MEDICAL TREATMENT] port for patency for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 was cognitively intact and required [MEDICAL TREATMENT]. Review of the care plan dated 05/17/17 revealed Resident #24 required [MEDICAL TREATMENT] 3 times weekly related to end stage [MEDICAL CONDITION]. The goal was for Resident #24 to be free of complications related to [MEDICAL TREATMENT] throughout the review. The interventions included: transport to [MEDICAL TREATMENT] as needed, coordinate care with [MEDICAL TREATMENT] center pertaining to resident needs, assess resident pre and post [MEDICAL TREATMENT], weigh resident per facility protocol, review medications per pharmacy guidelines and policy, keep port/access clean and dry, bandage if needed, monitor vital signs, and assess port for patency. Review of the nurse's notes from 05/01/17 through present, the 05/2017 Medication Administration Record [REDACTED]. An interview conducted on 05/17/17 at 9:00 AM with Resident #24 revealed the nurses put cream on his arm before he went to [MEDICAL TREATMENT] but they had never listened to his fistula with a stethoscope. He stated he just started [MEDICAL TREATMENT] in May and he had been 5 times. An interview conducted on 05/17/17 at 4:00 PM with Nurse #1 revealed she did not check Resident #24's AVF for a thrill or bruit, she stated she assessed the area and put a numbing cream on it before sending him out to [MEDICAL TREATMENT]. An interview conducted on 05/17/17 at 4:22 PM with the Nursing Supervisor of the [MEDICAL TREATMENT] Center where Resident #24 received [MEDICAL TREATMENT] revealed it was very important for the facility staff to assess Resident #24's AVF by checking for a thrill and bruit at least daily. She stated if the AVF wasn't patent it should be reported to the [MEDICAL TREATMENT] Center immediately and surgery could possibly be required to repair the AVF. An interview conducted on 05/17/17 at 9:30 AM with the facility Nurse Practitioner revealed it was her expectation for staff to assess a thrill and bruit on [MEDICAL TREATMENT] residents with an AVF. She stated she was not aware it wasn't being done for Resident #24. An interview conducted on 05/18/17 at 10:04 AM with Nurse #3 revealed she assessed Resident #24's AVF for a thrill and bruit but had never documented it in the medical record, MAR indicated [REDACTED] An interview conducted on 05/18/17 at 10:07 AM with the Director of Nursing (DON) revealed it was her expectation for the nurses to check for a thrill and bruit on Resident #24 every shift and document on the MAR indicated [REDACTED].

Based on observation, record review and staff interviews the facility failed to properly store a medication per the manufacture's recommendation for a medication found in 1 of 1 medication cart. The findings included: Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/03/17 Resident #23 was prescribed Miacalcin Nasal Spray (generic name Calcitonin Salmon) 200 international units (IU), spray one spray intranasal alternating nostrils daily for the treatment of [REDACTED]. Observed on 05/17/17 at 2:50 PM an opened box of Calcitonin Salmon Nasal Spray dated 05/05/17 (which indicated the date the bottle was opened) that was lying in the top drawer of the medication cart. The instructions read for Resident #23 to spray one spray intranasal alternating nostrils daily. Also included on the label were directions to discard 35 days after opening and to refer to insert for more information which the insert was not in the box. Interview with Nurse #1 on 05/17/17 at 2:50 PM revealed, she was not aware the Calcitonin Salmon Nasal Spray had specific storage instructions to be positioned in an upright position after it was opened. Nurse #1 stated she had never been told that nor had there ever been a sticker on the medication from the Pharmacy with that specific instruction for the medication. Nurse #1 also reported she had given that nasal spray to Resident #23 at 9:00 AM that morning. Interview with the Director of Nursing (DON) on 05/17/17 at 2:55 PM revealed she was unaware the Calcitonin Salmon Nasal Spray had specific storage instructions to be positioned in an upright position after it was opened. The DON added she had not received instructions from the Pharmacist of special instructions of storage for the medication. During a telephone interview with the Pharmacist on 05/17/17 at 4:21 PM he stated the Calcitonin Salmon Nasal Spray should be stored in an upright position after it was opened. He further stated the medication should have come from the Pharmacy labeled with those instructions and if the bottle was not labeled then he should have instructed the facility to do it.

Based on record review and resident and staff interviews the facility failed to document the assessment of a resident before and after [MEDICAL TREATMENT] for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 was cognitively intact and required [MEDICAL TREATMENT]. Review of the care plan dated 05/17/17 revealed Resident #24 required [MEDICAL TREATMENT] 3 times weekly related to end stage [MEDICAL CONDITION]. The goal was for Resident #24 to be free of complications related to [MEDICAL TREATMENT] throughout the review. The interventions included: transport to [MEDICAL TREATMENT] as needed, coordinate care with [MEDICAL TREATMENT] center pertaining to resident needs, assess resident pre and post [MEDICAL TREATMENT], weigh resident per facility protocol, review medications per pharmacy guidelines and policy, keep port/access clean and dry, bandage if needed, monitor vital signs, and assess port for patency. Review of the nurse's notes from 05/01/17 through present, the 05/2017 Medication Administration Record (MAR) and the 05/2017 Treatment Administration Record (TAR) revealed no documentation of assessment of Resident #24 pre or post [MEDICAL TREATMENT], no communication between the [MEDICAL TREATMENT] center and the facility and no documentation of assessment of Resident #24's [MEDICAL TREATMENT] port for patency. An interview conducted on 05/17/17 at 4:00 PM with Nurse #1 revealed she did not check Resident #24's [MEDICAL TREATMENT] port for patency, she stated she assessed the area and put a numbing cream on it before sending him out to [MEDICAL TREATMENT]. She further stated she didn't document a resident assessment in the medical record pre and post [MEDICAL TREATMENT] for Resident #24. An interview conducted on 05/18/17 at 10:04 AM with Nurse #3 revealed she assessed Resident #24's [MEDICAL TREATMENT] port for patency but had never documented it in the medical record, MAR or TAR. An interview conducted on 05/18/17 at 10:07 AM with the Director of Nursing (DON) revealed it was her expectation for the nurses to assess the resident pre and post [MEDICAL TREATMENT] and document the assessment in the nurse's notes. She stated Resident #24's [MEDICAL TREATMENT] port should be assessed every shift and documented on the Medication Administration Record. She further stated there should be a communication form sent with Resident #24 to each [MEDICAL TREATMENT] appointment and received back with Resident #24 when he returned from [MEDICAL TREATMENT] for communication of orders from the [MEDICAL TREATMENT] center and kept in the medical record.

Based on record review and staff interview, the facility failed to follow physician orders [REDACTED].#2). The findings included: Resident #2 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Medical record review revealed during the monthly pharmacist review of medications dated 01/31/17, the pharmacist noted that the diabetic medication [MEDICATION NAME] was increased on 01/30/17 from 500 milligrams (mg) twice a day to 1000 mg twice a day. The note stated that the laboratory test for A1C was completed on 11/29/16 and was measured 7.0 %, which was high. The recommendation at this time was to repeat the A1C in 3 months due 02/28/17. The pharmacist review dated 02/28/17 noted that on 02/06/17 the A1C was still high at 6.0 %c. The pharmacist recommended a repeat A1C in 3 months due 05/06/17. A handwritten note next to this recommendation noted that an order was written on 03/24/17. Review of physician telephone orders revealed an order was written on 03/24/17 Per Pharmacy Recommendations A1C Due 5/6/17. This was signed by the physician on 03/27/17. Review of the medical record revealed no evidence that an A1C was drawn on 05/06/17. Review of laboratory tests revealed that on 05/08/17 CBC (complete blood count) with Differential/Platelets was drawn as the only ordered lab. Interview with Nurse #1 on 05/17/17 at 3:42 PM stated there was a lab book which logged all ordered pending laboratory tests. Review of this book revealed both the CBC and the A1C scheduled for 05/06/17. Nurse #2 stated on 05/17/17 at 3:50 PM during interview that the A1C was typically drawn every 3 months and she just wrote an order for [REDACTED]. Review of the 03/06/17 A1C revealed the reading was still high at 6.0 %. The Director of Nursing (DON) was interviewed on 05/18/17 at 12:04 PM. She stated that once a pharmacy recommendation was obtain, a telephone order was written and the date and lab was written in the lab book. The night before the lab draws, the nurse wrote a lab requisition, based on the lab book entries. which accompanied the lab draw. She further stated there was no copy of the requisition maintained by the facility. The DON then stated there was no system for follow up to ensure the laboratory tests were completed as ordered. She could not say if the facility missed requisitioning the A1C or the lab missed it.

Based on observation, record review, and staff interviews the facility failed to implement a care plan intervention for using total mechanical lift transfer for 1 of 3 residents sampled for accidents (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's most recent significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #7's care plan dated 03/09/16 revealed a problem for potential for injury related to history of falls with daily use of restraints for poor safety awareness and physical debility secondary to advanced dementia. An intervention to prevent falls was as follows: Staff were to use the sit to stand or total mechanical lift when transferring Resident #7. A new intervention was added to the care plan on 03/17/16 that indicated Resident #7 was required to have total mechanical lift for all transfers and the sit to stand lift was discontinued. A review of the current daily nurse aide care guide revealed Resident #7 was a fall risk and required transfers using the sit to stand lift or the total mechanical lift for safe transfers. The Resident Incident Report dated 03/14/16 indicated during transfer with the sit to stand lift Resident #7 let go of the bars and slid out of the sling and was lowered to the floor by staff. The Resident Incident Report indicated the staff were educated that Resident #7 was no longer able to use the sit to stand lift for transfers related to physical decline. The Resident Incident Report indicated staff were further educated to use the total mechanical lift for all transfers for Resident #7. On 04/05/16 at 3:16 PM an interview was conducted with the Director of Nursing (DON) who stated on 03/14/16 during a staff assisted transfer with the sit to stand lift Resident #7 became combative with staff during the transfer. The DON stated Resident #7 was slipping out of the sling of the sit to stand lift and was lowered to the floor by staff. The DON stated the total mechanical lift was implemented for all transfers on 03/17/16 and the sit to stand lift was discontinued. On 04/07/16 at 8:32 AM Resident #7 was observed out of bed and was sitting in a wheel chair at bedside eating breakfast. On 04/07/16 at 9:07 AM an interview was conducted with Nurse Aide (NA) #1 who stated she used the sit to stand lift to transfer Resident #7 out of bed to the wheel chair this morning and was not aware that Resident #7 required total mechanical lift for all transfers. NA #1 stated she had not received in report from the nurse or the off going nurse aide that Resident #7 required total mechanical lift for all transfers related to prior fall. NA #1 verified that the computer nurse aide care guide and the paper daily nurse aide care guide did not indicate Resident #7 required total mechanical lift for all transfers and both care guides indicated Resident #7 could be transferred by using sit to stand or total mechanical lift. On 04/07/16 at 9:24 AM an interview was conducted with the DON who stated the NA daily care guide was not updated on 03/17/16 to reflect Resident #7 required total mechanical lift for all transfers related to decline in cognition and physical ability. The DON stated her expectation was that the Minimum Data Set (MDS) nurse would have updated the NA daily care guide to reflect Resident #7 required total mechanical lift for all transfers. The DON stated NA #1 had no way of knowing that Resident #7 required total mechanical lift for all transfers because she had not received the information in report from the nurse and the intervention was not included on the NA daily care guide. The DON stated Resident #7 should not have been transferred using the sit to stand lift. On 04/07/16 at 9:45 AM an interview was conducted with Nurse #1 who stated Resident #7 required total mechanical lift for all transfers. Nurse #1 stated she had not provided NA #1 with information that Resident #7 required total mechanical lift for all transfers. On 04/07/16 at 9:44 AM an interview was conducted with the MDS Nurse who stated Resident #7 had a fall using the sit to stand lift and the nursing care plan was updated on 03/17/16 to reflect Resident #7 required total mechanical lift for all transfers related to decline in cognition and physical ability. The MDS nurse stated she forgot to update the NA daily care guide on 03/17/16 to reflect NA staff were to use total mechanical lift for all transfers for Resident #7. The MDS Nurse stated NA #1 would not have known that a total mechanical lift was required for all transfers for Resident #7 because the intervention was not indicated on the NA daily care guide. The MDS Nurse stated she was immediately going to update the NA daily care guide to reflect Resident #7 required total mechanical lift for all transfers.

Based on observations, staff and resident interviews and record review, the facility failed to secure a resident according to manufacturer's instructions which resulted in 1 of 4 residents reviewed for accidents turning over in his wheelchair during transport (Resident #40). The findings included: The facility provided an undated copy of instructions for use of the Q'Straint system for securing a resident in a wheelchair in a van equipped with four tiedown anchorage points in the van floor. The instructions indicated the following: The wheelchair should be centered squarely on all four corners of the tiedown anchorage points. Q'Straint belts should first be attached to a solid frame member of the wheelchair on both front corners and then attached to the front anchorage points in the floor. Belts should then be snugged and locked. The procedure should then be repeated for both back corners of the wheelchair and back anchorage points. Back belts should then be snugged and locked. The wheelchair should then be checked for any movement back and forth. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 01/06/14 and returned home. Review of Resident #40's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Resident #40 required extensive assistance with mobility and activities of daily living. Resident #40's care plan dated 10/30/13 specified he had a potential for falls related to recent history of falls with unsteady gait secondary to [DIAGNOSES REDACTED]. The care plan goal was as follows: "Lessen potential for fall related injury until 01/22/14." A review of an incident/accident report dated 12/16/13 at 8:30 AM revealed Resident #40 was involved in an incident in the facility's transport van. The incident report noted that on the way to an adult day care center, Transporter #1 made a turn and the wheelchair with Resident #40 in it turned over to the left. Transporter #1 stopped the van and noted that Resident #40 was responsive and did not appear to be seriously injured. Transporter |#1 noted in the incident report that Resident #40 was alert and denied any pain or injury several times. The report noted that Transporter #1 assisted Resident #40 back into his wheelchair. Review of Resident #40's closed medical record revealed a nurse's note written on 12/16/13 at 6:08 PM. This note described Resident #40 as being up in his wheelchair and the resident's responsible party was visiting. The resident had voiced no complaints. Resident #40 was placed on the head trauma protocol related to a fall in the facility's van earlier in the day. No problems were noted. Further review of Resident #40's medical record included head trauma protocol documentation. No abnormal assessment findings were noted as a result of the head trauma protocol assessments. On 04/15/14 at 3:38 PM the Director of Nursing (DON) was interviewed. The DON stated on 12/16/13 at 8:30 AM she was contacted by Transporter #1 and informed Resident #40 had fallen over in his wheelchair while being transported in the van. The DON asked Transporter #1 if the resident was injured. Transporter #1 reported that Resident #40 was alert, denied any pain or injury, and wanted to continue on to the adult day care center rather than return to the facility. The DON instructed the transporter to inform the nurse at the adult day care center about the accident and have her assess the resident on arrival. Resident #40 remained at the adult day care for the day and returned to the facility later that evening. The DON reported that Resident #40 was also assessed after returning to the facility by Nurse #1. The DON stated she notified Resident #40's responsible party of the accident in the van shortly after it occurred and she (responsible party) said she would go to the adult day care to check on the resident. The DON stated when Transporter #1 returned to the facility re-training was implemented immediately regarding how to secure a resident in a wheelchair according to manufacturer's instructions. On 04/15/14 at 4:34 PM an observation was conducted of Transporter #1 returning to the facility with a resident in the facility's transport van. The resident was secured with 4 tiedown straps connected to the van wheelchair restraint system according to manufacturer's instructions. On 04/15/14 at 4:42 PM Transporter #1 was interviewed. Transporter #1 explained she was transporting Resident #40 to adult day care and was turning on to the street from another street and his wheelchair went onto the left side. Transporter #1 stated Resident #40 was still buckled in and did not come out of the chair until she removed the buckle and removed him from the chair. Transporter #1 stopped the van and called the DON to inform her that Resident #40 had fallen in the van. Transporter #1 stated that the DON had her determine that the resident was conscious with no signs of injury. Resident #40 denied any pain or injuries and was placed back into the wheelchair. Transporter #1 asked Resident #40 if he wanted to return to the facility or continue to adult day care. Resident #40 replied he wanted to go to adult day care. Once they arrived at the adult day care Transporter #1 reported to the nurse Resident #40 had fallen in the van during transport. Transporter #1 returned to the facility and reported the incident to the Assistant Administrator. Transporter #1 stated she had knowledge and understanding of how to safely secure a resident in the wheelchair restraint system, but on 12/16/13 she had forgotten to attach the front 2 straps to ensure the residents wheelchair did not move while traveling in the van. On 04/16/14 at 2:52 PM a follow-up interview was conducted with the DON. The DON stated Resident #40 was assessed by Nurse #1 after returning to the facility. Resident #40 showed no signs of complications related to the fall in the facility's transport van. The DON further stated the facility continued monitoring Resident #40 for 2 days ensuring the resident had not suffered any internal injuries. On 04/16/14 at 3:53 PM Nurse #1 was interviewed about the assessment of Resident #40 after returning from adult day care on 12/16/13. Nurse #1 described checking Resident #40 from head to toe and he presented no signs of injury. Due to the accident being a fall Nurse #1 placed Resident #40 on the head trauma protocol. The head trauma protocol assessed vital signs, pupil response, temperature and pain. The head trauma protocol also included checking for dizziness and seizure activity to ensure no internal injuries. Nurse #1 stated that Resident #40 presented no signs of internal injury. On 04/16/14 at 4:53 PM the Assistant Administrator was interviewed. After Transporter #1 returned to the facility the DON informed the Assistant Administrator the van accident had occurred and Resident #40 had suffered no injuries. At this time the DON and the Assistant Administrator started the facility's investigation of Resident #40's fall in the facility's van during transport which occurred on 12/16/13. On 12/16/13 Transporter #1 was re-educated on how to secure wheelchairs in the facility's van using "Transit Operational Video" and the "Ride Safe" manual. A demonstration of how to properly secure the 4 tie down straps was reviewed and Transporter #1 performed a return demonstration. Transporter #1 explained to the Assistant Administrator she knew how to secure the 4 tie down straps, but she had just forgotten to secure the front 2 straps on 12/16/13. On 04/16/14 at 11:56 AM the facility Administrator stated since 12/16/13 the facility had implemented corrective actions to ensure residents were secured during transport on the facility's van according to manufacturer's instructions, indicating past non-compliance from 12/16/13 to 12/17/13. The Administrator specified these corrective actions included the implementation of the following measures: ? Transporter #1 was re-educated/re-trained on proper installation of straps on wheelchairs by Assistant Administrator on 12/16/13. ? Return demonstration was given by Transporter #1 of securing a wheelchair and resident in van on 12/16/13. ? In order to prevent re-occurrence, a new transportation log was created that required the transporte's initials for verification that all four tie down straps were connected securely and safety belt was properly fastened. ? Transporter #1 was retrained by watching "Transit Operational Video" and receiving another copy of "Ride Safe" manual, and was trained on the newly implemented "transporter safety check log," all on 12/16/13. ? Transporter #1 received a written warning for violating safety practices that may result in serious injury, as outlined in Employee Handbook ? Transporter #1 was monitored for competency by administrative staff on 12/16/13, 01/15/14, 01/22/14, 03/07/14, 03/20/14, 03/26/14 and 04/10/14. A. During the outing on 03/20/14 resident #939 (number assigned by facility) stated she felt securely fastened in the van B. During the outing on 03/26/14 resident #928 (number assigned by facility) stated she felt securely fastened in the van C. During the outing on 04/10/14 resident #928 (number assigned by facility) stated that she felt securely fastened in the van ? Transporter safety check logs are turned into Assistant Administrator as they are filled for review for ongoing compliance. The proper completion of these forms was discussed at the quarterly Quality Assurance Meetings on 01/21/14 and 04/08/14. Observations, review of facility documentation, and interviews with staff and residents during the 04/16/14 survey revealed the facility had implemented these corrective actions beginning on 12/16/13 to ensure resident safety when transported in the facility's van. Interviews with the facility's transporter revealed she was provided with instructions on the van's wheelchair restraint system and demonstrated she was knowledgeable on how to properly attach the 4 tie down straps to secure a resident during transport according to manufacturer's instructions. Additionally, observations of the van's wheelchair restraining system revealed it to be in good repair with all equipment in good working order. Review of facility documentation and interviews with the facility's Administrator on 04/16/14 revealed the facility implemented monitoring measures to ensure continued compliance beginning on 12/16/13 which included monitoring the facility transporter for competency by the Administrator and Assistant Administrator to ensure residents were secured according to manufacturer's instructions. Transporter #1 was responsible for documenting compliance on the transporter safety check log. The Assistant Administrator was responsible for ensuring compliance on the facility's Quality Assurance (QA) monitoring tool. The Assistant Administrator and Administrator stated they had monitored the facility's QA data information collected by staff since 12/16/13. The Administrator further stated that during the months since the incident in December 2013 no further van accidents had occurred.

Based on observations, interviews with staff and review of menus, the facility failed to provide 9 residents with a 4 ounce portion of oatmeal or grits according to the menu. (Residents #18, 23, 45, 2, 47, 44, 48, 32 and 26) The findings include: An observation of the breakfast tray line occurred on 04/25/13 at 07:10 AM. The breakfast menu included cereal of choice, egg, bacon, toast, juice, milk, coffee or hot tea. Cold cereal, grits and oatmeal were all available on the breakfast tray line. Review of the menu revealed 1 serving of cereal was to be provided to residents for breakfast. From 07:34 AM until 07:50 AM, the kitchen supervisor was observed to plate grits for Residents #18, 45, 2, 47, 44, 32 and oatmeal for Residents #23, and 26 using a 4 ounce serving utensil that was not completely full. The kitchen supervisor was observed to plate approximately 3/4 of the serving utensil of grits and oatmeal into a small bowl instead of a full 4 ounce portion. The kitchen supervisor stated during the observation when asked how she determined how much oatmeal or grits to provide "I fill it to the top of the bowl, but I don't want to overfill." On 04/25/13 at 08:20 AM the dietary manager was interviewed and stated that a serving of hot cereal should be a full 4 ounce portion. She further stated that she did not typically observe the breakfast meal and was not aware that a full 4 ounce portion of grits or oatmeal was not provided to residents. An interview with the consultant registered dietitian (RD) was conducted on 04/25/13 at 10:49 AM. During the interview the RD confirmed that residents should receive foods in portions according to the menu.

Based on observations, record reviews and staff interviews the provider pharmacy failed to label the strength of Vitamin D present in Calcium plus Vitamin D tablets dispensed to several active residents checked in 100 hall and 200 hall medication carts. The findings include: Medication storage areas including medication storage rooms, medication carts were observed for medication labeling requirements. A review of the provider pharmacy dispensed products of Calcium 600 mg with Vitamin D stock medication did not reveal the strength of Vitamin D present in those products, on the labels of the provider pharmacy: On 4/24/2013 at 3:27 PM observation of the 100/200 hall medication carts revealed several containers of Calcium with Vitamin D tablets packed by the pharmacy in which the strength of Calcium was disclosed but not the strength of Vitamin D on the pharmacy dispensing label. An interview with the medication nurse (Nurse #1) on 4/24/13 at 3:28 PM revealed that all over the counter and prescription pharmaceuticals were sent by the pharmacy with appropriate label to all the residents. Nurse #1 stated that the physician order [REDACTED]. She was not aware why the strength of Vitamin D was not disclosed on the pharmacy labels in the Calcium plus D products and was not sure how many international units of Vitamin D the residents were receiving. An interview with the consultant pharmacist on 4/24/13 at 3:35 PM revealed that all medications sent from the pharmacy should have the correct strength of medications and if there was any concern with the medication strength in the physician orders [REDACTED]. In case of Calcium with Vitamin D tablets labeling, the interview revealed that the pharmacy had several strength of Calcium 600 mg plus Vitamin D and the strength should have been disclosed on the label. If the physician order [REDACTED]. The pharmacist stated that it was a professional practice to indicate the strength of medication on repacked products on the labels. An interview with the Director of Nursing (DON) on 4/25/13 at 9:35 AM revealed that all stock medications were supplied by the provider pharmacy and was not aware why they were not accurately labeled with the correct Vitamin D content.

Based on observations and staff interviews the facility failed to discard expired milk, maintain a clean fan in the dish room, and store food properly under a sink in the nourishment room. The findings are: 1. An initial tour of the kitchen was conducted with the Dietary Manager (DM) on 05/21/12 at 9:50 AM. Observations of the milk refrigerator revealed twenty-one (21) 1/2 pint cartons of fat free milk with an expiration of 05/15/12 available for use. The crate of fat free milk was at the front left side of the milk refrigerator with other crates of milk adjacent to and behind it. The DM could not explain why the expired milk was still in the refrigerator and stated the cook and dietary aides were expected to check the milk refrigerator for expired milk cartons every morning. When the tour of the kitchen was completed the DM instructed one of the dietary aides to discard the expired fat free milk. During an interview on 05/23/12 at 10:40 AM the Kitchen Supervisor stated all dietary staff were responsible for checking the refrigerators daily for expired and outdated milk cartons and food items. The Kitchen Supervisor explained expired milk is not discarded because the facility can get credit for it the next delivery day. The Kitchen Supervisor further stated kitchen staff communicated with each other verbally when they noted expired milk cartons in the refrigerator. The interview further revealed the "milk man" checked the milk refrigerator for expired milk cartons when he delivered the milk order to the facility every Tuesday and Thursday. A follow-up interview was conducted with the DM on 05/23/12 at 12:50 PM. During the interview the DM confirmed she could not be certain the expired fat free milk had not been consumed by a resident after 05/15/12. The DM stated expired milk cartons were typically moved over to the side of the milk refrigerator and dietary staff communicated this information to each other by word of mouth. 2. Observations of the dish room on 05/23/12 at 10:50 AM revealed a large fan mounted on the wall directly behind the dish washing machine. The fan was operating at high speed and the air from the fan was blowing in the direction of the dish machine and a dish drying rack located against the wall opposite the dish washing machine. Large clumps of grey dust build up were noted clinging to the entire surface of both the front and back grills of the fan. An additional observation of the dish room on 05/23/15 at 12:40 PM revealed the fan was operating at high speed and the air from the fan was blowing in the direction of the dish machine and a dish drying rack located against the wall opposite the dish washing machine. Large clumps of grey dust build up were noted clinging to the entire surface of both the front and back grills of the fan. A dietary aide was observed removing a rack of plates from the dish washing machine and allow them to dry off completely before stacking them in the kitchen. A rack of dome lids were removed from the dish washing machine shortly thereafter and were immediately placed on the drying rack. During an interview on 05/23/12 at 12:50 PM the Dietary Manager (DM) stated she had noticed the fan in the dish room needed to be cleaned apporximately two (2) weeks ago and asked the Maintenance Director to see if he could take it down and clean it. The DM could not recall if the Maintenance Supervisor had attempted to clean the fan and confirmed she had not followed up with him regarding this matter. A kitchen cleaning schdule was reviewed during the interview was reviewed during the interview and did not include the dish room fan. An interview with the Maintenance Director on 05/23/12 at 2:10 PM revealed the DM first contacted him regarding cleaning the dish room fan approximately two (2) weeks ago. The Maintenance Director stated he had attempted to clean the fan using an industrial vaccum cleaner and this was not successful. The Maintenance Director further stated the dish room fan had slipped his mind and he should have cleaned it. 3. During the initial tour on 05/21/12 at 9:35 AM, the resident pantry was observed to have a salt shaker, an opened bag of coffee grounds and an undated open can of coffee. In the other lower cabinet was an opened undated container of instant powdered creamer. These items remained in place during observations made on 05/22/12 at 2:39 PM and on 05/23/12 at 9:03 AM. On 05/23/12 at 9:03 AM a large opened undated container of instant creamer was located on the counter top. On 05/23/12 at 2:13 PM the treatment nurse aide stated the pantry is maintained by the housekeeping department. On 05/23/12 at 2:16 PM housekeeper #1 stated that the housekeeper assigned to the nursing unit was responsible for checking the pantry for outdated items and cleanliness. Housekeeper #1 stated this was usually done in the morning. When she observed the pantry on 05/23/12 at 2:18 PM she confirmed the salt, coffee and creamers should not be stored in the lower cabinets and should have been removed by housekeeping. On 05/23/12 at 2:27PM, the director of Housekeeping stated the coffee pot and coffee and creamer were for nurses personal use. On 05/23/12 at 2:56 PM the charge nurse stated that the food in the pantry was for resident use only and that staff will make coffee for the residents as requested.

Based on observations and staff interviews, the facility failed to maintain a clean shower stall and store personal care equipment in sanitary manner. The findings are: 1. On 5/22/12 at 2:33 PM the shower room was observed. In the shower stall were five (5) wet pink wash basins, stacked on top of one another lying on the floor of the shower. Next to these stacked wash basins was a wet commode bucket. Observations on 5/23/12 at 9:00 AM and at 2:11 PM revealed five (5) stacked wash basins on the shower floor with the top one full of water, another pink wash basin with water on the shower floor beside the five basins, and the commode bucket on the shower floor. All were unlabeled and appeared clean but all were wet. On 5/23/12 at 2:20 PM, housekeeper #1 stated when she cleans the shower; she normally sees the wash basins and buckets on the shower floor but did not comment on their purpose. On 5/23/12 at 2:27 PM the Director of Housekeeping stated the housekeepers clean the shower room two to three times a day and use a disinfectant on the shower tiles. She stated the wash basins and the bucket are used under the shower chairs and should be cleaned after each shower. On 5/23/12 at 2:43 PM two second shift nurse aides were interviewed together and stated that all showers were given on first shift. Both nurse aides stated they did not know why the wash basins were in the shower room and on the floor. On 5/23/12 at 2:53 PM interview with the treatment nurse aide revealed she was not sure about the wash basins on the shower floor and guessed they were used under the shower chairs. On 5/23/12 at 3:03 PM interview with a first shift nurse aide #1 stated the wash basins were used under the shower chairs and disinfected and rinsed after each use. She further stated the wash basins were routinely left on the shower floor. On 5/23/12 at 3:13 PM the charge nurse stated the wash basins in the shower stall were used under the shower chairs and were to be disinfected and replaced under the shower chair after each use and not stored wet on the shower stall floor. 2. On 5/22/12 at 2:33 PM, the shower stall in the shower room was observed with reddish rust like stains on the tiles and on the dish soap. The grout on the wall with the shower head had black mold like residue around the soap dish and in multiple areas of the grout between the tiles. Some black residue was easily removed by rubbing with a paper towel. This remained the same during the observations made on 5/23/12 at 9:00 AM and 2:11 PM. On 5/23/12 at 2:20 PM, housekeeper #1 stated she cleans the shower stall daily using a disinfectant spray on the shower walls. She further stated that she had seen it but did not think it was mold. She then stated she would scrub it with a brush. On 5/23/12 at 2:27 PM the Director of Housekeeping stated the housekeepers clean the shower room two to three times a day and use a disinfectant on the shower tiles. She stated the discoloration on the grout was due to the grout coming off. The surveyor demonstrated with a paper towel that black residue came off when the grout was rubbed. She then stated that there should be no mold because staff was supposed to wipe the shower down daily with the disinfectant. On 5/24/12 at 1:45 PM the shower tiles were observed with clean grout and no black residue.

Based observations, record reviews, and staff interviews the facility failed to document the administration of laxatives for three (3) of ten (10) residents and to properly dispose of a narcotic patch for one (1) of one (1) resident. (Resident # 2, 7, #8, #19) The findings are: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED].#7 had moderately impaired cognition and required extensive assistance with toilet use. Constipation was not listed as a problem on the most recent MDS. Review of Resident #7's medical record revealed standing orders signed by the Physician on 02/15/12 which included [MEDICATION NAME] (laxative) 30 millimeters for constipation and if no bowel movement in 24 hours give Fleets (sodium [MEDICATION NAME]) enema and repeat A care plan dated 02/29/12 stated Resident #7 had the potential for constipation related to decreased mobility and daily use of pain medication. The goal was for Resident #7 to have a bowel movement every three (3) days. Interventions included: provide medication daily for constipation, document bowel movements every shift, provide laxatives as ordered per standing order if no BM (bowel movement) in three days. Review of Resident #7's bowel movement reports for April and May of 2012 revealed the following: - No BM from 04/12/12 through 04/15/12. (four (4) days) - No BM from 04/17/12 through 04/22/12. (six (6) days) - No BM from 05/10/12 through 05/13/12. (four (4) days) - No BM from 05/17/12 through 05/23/12. (seven (7) days) Review of Resident #7's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the MARs revealed no further interventions for constipation were documented as administered. In addition, nurse's notes did not reflect the administration of any standing orders for constipation from 04/12/12 through 05/23/12. Review of the 24 hour report sheets revealed Resident #7 was administered a laxative on 04/15/12, 04/19/12, 04/21/12, 05/0812, 05/13/12, 05/14/12, 05/15/12, and 05/21/12. The notation on the 24 hour report sheets did not include what laxative was administered or when it had been administered. During an interview the Charge Nurse on 05/24/12 at 10:45 AM revealed the days shift (7:00 AM to 3:00 PM) licensed nurse (LN #1) printed the list of residents with no BM in three days at least twice a week. The interview further revealed LN #1 reviewed the list, administered additional laxatives to residents without a BM for three days as needed, and shared this information with the LN on the oncoming shift. An interview with the Director of Nursing (DON) on 05/24/12 at 2:20 PM revealed she expected LNs to document all medications administered on the resident's MAR. The DON stated she had contacted direct care staff members prior to the interview and was able to confirm Resident #7 had a BM on 05/22/12 that had not been entered into the computer tracking system. On 05/24/12 at 3:08 PM LN #1 stated she had never transcribed a Physician's standing order for a laxative to residents' MARs and could not provide a reason. LN #1 further stated she typically passed on the information to the oncoming LN during shift to shift report and noted this information on the 24 hour report sheets. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #8's Physician's standing orders dated 03/09/07 included the medication [MEDICATION NAME] 30 milliliters to be given as needed for constipation. Her current physician orders [REDACTED]. Resident #8's most recent Minimum Data Set ((MDS) dated [DATE] as having intact cognition and being totally dependent on staff for toileting and being totally incontinent of bowel. Her current care plan updated 05/02/12 which addressed constipation included the goal to have a bowel movement every two to three days. Interventions included the use of the standing order laxative. Resident #8 stated during interview on 05/05/12 at 9:53 AM that she often only had a bowel movement once to twice a week and she started feeling bad after two to three days without a bowel movement. Review of the Bowel Movement Validation Reports revealed Resident #8 did not have a bowel movement on: *on 04/12/12, 04/13/12, 04/14/12, 04/15/12; *on 04/17/12, 04/18/12, 04/19/12, 04/20/12; *on 04/22/12, 04/23/12, 04/24/12, 04/25/12; *on 04/27/12, 04/28/12, 04/29/12, 04/30/12; *on 05/06/12, 05/07/12, 05/08/12, 05/09/12; *on 05/16/12, 05/17/12, 05/18/12, 05/19/12, 05/20/12, and 05/21/12. Review of the Medication Administration Records (MARs) revealed no documentation of the standing orders for any time in April or May of 2012. In addition, the nursing notes did not reflect the administration of any standing orders for constipation. During interview on 05/24/12 at 11:45 AM, the charge nurse stated Licensed Nurse (LN) #1 ran the bowel validation reports (submitted by the nurse aides) off the computer at least twice per week. Information from this report was shared with the oncoming shifts for ongoing monitoring and implementation of standing orders. On 05/24/12 at 2:20 PM the Director of Nursing (DON) provided the daily 24 hour sheets which indicated the interventions resulting from the bowel validation reports. Review of these 24 hours sheets reflected Resident #8 received a laxative on 04/15/12, 04/30/12, 05/01/12, 05/14/12, 05/15/12, 05/19/12 and 05/21/12. There was no indication on these sheets as to the type of laxative administered, the time of administration or who administered the medication. The DON stated that nurses should document medications they administer on the MAR. On 05/24/12 at 3:08 PM LN #1 stated she had never transcribed a Physician's standing order for a laxative to residents' MARs and could not provide a reason. LN #1 further stated she typically passed on the information to the oncoming LN during shift to shift report and noted this information on the 24 hour report sheets. 3. Resident #2 was admitted with [DIAGNOSES REDACTED]. Her current physician orders [REDACTED]. Resident #2's admission Minimum Data Set ((MDS) dated [DATE] coded her with cognitive impairment, requiring extensive assistance with toileting and always being incontinent of bowel. Resident #2's care plan dated 03/14/12 addressing her risk for constipation with the goal to have a bowel movement every two to three days. Interventions included the use of the standing order laxative. Review of the Bowel Movement Validation Reports revealed Resident #2 had no bowel movements documented on the bowel validation sheets on: *on 04/17/12, 04/18/12, 04/19/12, 04/20/12; *on 04/22/12, 04/23/12, 04/24/12, 04/25/12; *on 05/02/12, 05/03/12, 05/04/12; *on 05/06/12, 05/07/12, 05/08/12, 05/09/12; Review of the Medication Administration Records (MARs) revealed no documentation of the standing orders for any time in April or May of 2012. In addition, the nursing notes did not reflect the administration of any standing orders for constipation. During interview on 05/24/12 at 11:45 AM, the charge nurse stated Licensed Nurse (LN) #1 ran the bowel validation reports (submitted by the nurse aides) off the computer at least twice per week. Information from this report was shared with the oncoming shifts for ongoing monitoring and implementation of standing orders. On 05/24/12 at 2:20 PM the Director of Nursing (DON) provided the daily 24 hour sheets which indicated the interventions resulting from the bowel validation reports. Review of these 24 hours sheets reflected Resident #2 received a laxative on 04/19/12, 05/09/12 and 05/10/12. There was no indication on these sheets as to the type of laxative administered, the time of administration or who administered the medication. The DON stated that nurses should document medications they administer on the MAR. On 05/24/12 at 3:08 PM LN #1 stated she had never transcribed a Physician's standing order for a laxative to residents' MARs and could not provide a reason. LN #1 further stated she typically passed on the information to the oncoming LN during shift to shift report and noted this information on the 24 hour report sheets. 4. An undated policy regarding disposal of narcotics was provided by the facility. The policy noted that any controlled substance medication should be disposed of in a manner to prevent access by anyone else and the disposal should be witnessed by two licensed nurses. On 05/22/12 at 4:12 PM, Licensed Nurse (LN) #2 was observed to remove a narcotic pain patch ([MEDICATION NAME] 12 mcg/hour) from Resident #19. LN #2 folded the used pain patch in half, sealing it to itself, removed her latex gloves leaving the pain patch inside the gloves, and placed the gloves in the trash can in Resident #19's bathroom. LN #2 did not ask another LN to witness the disposal of the pain patch. In an interview with LN #2 at that time, she stated facility practice was to place discarded narcotic pain patches in the trash without a LN witness. The facility Pharmacist was interviewed on 05/23/12 at 3:56 PM. He stated that narcotic pain patches contained detectable levels of narcotic pain medication after use. The Pharmacist further stated that in order to prevent diversion, used narcotic pain patches should be folded in half and disposed of in a secured waste container and witnessed by another staff. On 05/24/12 at 8:37 AM the Director of Nursing (DON) was interviewed. She stated the facility had no specific policy regarding the safe disposal of used narcotic pain patches. She further stated staff disposed of used narcotic pain patches in unsecured waste containers and without a second witness. The DON stated that after consultation with the facility Pharmacist, she expected nursing staff to fold used narcotic pain patches in half and dispose of them in a secured waste container with a witness present.

Based on observations, staff interviews and medical record reviews, the facility failed to clarify medication orders for six of ten sampled residents. (Residents # 2, 3, 6, 7, 9, and 10) The findings are: 1. Resident #6 was admitted [DATE] with [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE] revealed severe cognitive impairment, dependence on staff for activities of daily living, and oxygen therapy. During Medication Pass on 3/30/11 at 8:55 a.m., Resident #6 was observed as she received her medications, which included a Pro Air HFA inhaler, from Licensed Nurse (LN) #1. The resident did not receive medication from a second inhaler. review of the resident's medical record revealed [REDACTED]." Further record review revealed a 3/11/11 Physician's Telephone Order to discontinue the [MEDICATION NAME] CFC free inhaler order. Review of the resident's March 2011 Medication Administration Record (MAR) revealed duplication of the inhaler order with the [MEDICATION NAME] CFC free inhaler listed as well as "Pro Air HFA (hydrofluoroalkane, a CFC free inhaler) 90 mcg inhaler take 2 puffs po (by mouth) 4x (times) /day." Continued review of the MAR revealed both medications were initialed as administered from 3/6/11-3/11/11. During an interview on 3/30/11 at 9:40 a.m., LN #1 was asked about the two inhaler medications listed on the MAR. The nurse said it took her until 3/11 to realize they were the same medication. She stated she reported it to the Nursing Supervisor and the Nursing Supervisor discontinued the one inhaler order. LN #1 was unable to give a reason why she initialed both medications as administered but she stated only one inhaler had been in use. Interview with the Nursing Supervisor on 3/30/11 at 10:05 a.m. revealed a second -shift nurse, who was unavailable during the survey, had added the Pro Air HFA medication on the MAR after the pharmacy sent the resident's medications because she thought she needed to write it that way. The Nursing Supervisor stated the nurse should have discontinued the other inhaler order at that time. Telephone interview on 3/30/11 at 10:20 a.m. with a pharmacist at the facility's pharmacy service revealed only one inhaler, the Pro Air HFA, had been sent for the resident. During an interview on 3/30/11 at 3:30 p.m., the Director of Nursing (DON) stated medication orders should be written correctly, and if there are inconsistencies with orders, the nurses should clarify the orders. The DON confirmed nurses should only sign for medications administered to the resident. 2. Resident #7 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] revealed the resident was cognitively intact and independent with most activities of daily living. Review of the physician's orders [REDACTED]. Review of the March 2011 Medication Administration (MAR) record revealed the same order for [MEDICATION NAME] 1110 mcg IM monthly was handwritten on the form, but there were no initialed entries indicating the medication was given. During an interview on 3/31/11 at 11:10 a.m., the Nursing Supervisor confirmed she wrote the order on the physician's orders [REDACTED]. She said the resident had not yet received the medication because it is given monthly and he was admitted mid-month and would not receive it until the beginning of next month. The Nursing Supervisor said the medication only comes in a 1000mcg dose and stated, "I was busy and just wrote 1110 but if there was a question, the dose would have been clarified." 3. Resident #10 was readmitted [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] moderately impaired cognition and dependence on staff for activities of daily living. Review of the resident's closed medical record revealed a Physician's Telephone Order dated 11/16/10 [MEDICATION NAME](antibiotic) 500 milligrams by mouth every other day for chronic/recurrent UTI. Review of the November 2010 Medication Administration Record (MAR) revealed the order was correctly transcribed. Review of the December 2010 physician's orders [REDACTED]." Review of the December 2010 and January 2011 MARs revealed the following: "Cipro 500 mg Take 1 tablet every other day." Initialed entries indicated the medication was administered during December 2010 until January 12, 2011. During an interview on 3/30/11 at 3:30 p.m., the Director of Nursing stated medication orders should specify the route, and if there are inconsistencies with orders, the nurses should clarify the orders. 4. Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum (MDS) data set [DATE] indicated no impairment of cognition and dependence on staff assistance for daily care. Review of the monthly physician's orders [REDACTED]. Review of the written physician orders [REDACTED]. Review of nursing documentation revealed nursing staff contacted the [MEDICAL TREATMENT] provider 3/2/11 to cancel the resident's appointment. The [MEDICAL TREATMENT] staff member instructed the nurse to monitor the resident's potassium and fluid intake, and the nurse wrote the physician's orders [REDACTED]. On 3/30/11 at 1:45 p.m., the order was reviewed with the Medical Director (the resident's physician) and the Nursing Supervisor. The physician stated the order was "vague." The Nursing Supervisor agreed the order was vague, and stated the order didn't specify what should be done for the resident. On 3/30/11 at 3:30 p.m., interview with the Director of Nursing (DON) revealed the 3/2/11 order should not have been written as a physician's orders [REDACTED]. The DON stated orders should be clarified with the physician when there are inconsistencies. 5. Resident #9 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the monthly physician's orders [REDACTED]. Review of the written physician orders [REDACTED]. (milligrams) per day. A written physician's orders [REDACTED]. per day. On 3/30/11 at 11:05 a.m., the [MEDICATION NAME] orders were reviewed with the Nursing Supervisor. The Nursing Supervisor stated she had written the order on 3/25/11 to continue [MEDICATION NAME] 5.5 mg, and the order was written incorrectly. The Nursing Supervisor stated the resident was receiving [MEDICATION NAME] 6 mg daily, and the errant order was not transcribed to the Medication Administration Record (MAR). 6. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum (MDS) data set [DATE] indicated severe impairment of cognition and total dependence on staff assistance for all daily care. Observation of the resident revealed all intake was provided by a [MEDICAL CONDITION] tube. Review of the physician's orders [REDACTED]. Review of the medication orders revealed the following: [MEDICATION NAME] 40 mg tablet by mouth at bedtime Actos 15 mg tablet by mouth before breakfast [MEDICATION NAME] 0.5 mg Take (1) tablet by mouth twice a day as needed for anxiety [MEDICATION NAME] S tablet Take 1 tablet by mouth twice daily [MEDICATION NAME] 100 mg Take 1 tablet by mouth twice daily [MEDICATION NAME] Liquid Give 5 cc by mouth daily Zinc Sulfate 220 mg Take one capsule by mouth every day On 3/30/11 at 3:30 p.m., the Director of Nursing stated the resident received all medications via tube, and the medication orders should direct administration via [DEVICE] ([MEDICAL CONDITION] tube). The DON stated medication orders should reflect the correct route for administration, and if there are inconsistencies with orders, the nurses should clarify the orders.