Every finding on record at Fairview University Trans Serv

Based on interview and document review, the facility failed to provide the resident and/or their representative a written bed hold notice for 2 of 3 residents (R7, R8) reviewed for hospitalization . Findings include: The facility's Summary of Epic (software) Encounters (EE) printed 1/17/19, indicated R7 was admitted to the hospital on [DATE], and returned to the facility on [DATE]; and again admitted to the hospital on [DATE], and returned to the facility on [DATE]. R7's electronic medical record (EMR) lacked documentation which would indicate R7 or her representative received a bed hold notification when she was transferred to the hospital on [DATE] or 12/14/18. The Summary of EE printed 1/17/19, indicated R8 was admitted to the hospital on [DATE], and returned to the facility on [DATE]. R8's EMR lacked documentation which would indicate R8 received a bed hold notification when he was transferred to the hospital on [DATE]. On 1/16/19, at 1:52 p.m. registered nurse (RN)-A stated R7 had been rehospitalized a couple of times since coming to the facility, and R8 had been rehospitalized at least one time since admission. RN-A stated most patients or families say no to bed holds as they have to pay. RN-A verified no bed hold forms or progress notes regarding bed holds for R7 and/or R8 had been completed for their transfers to the hospital. RN-B sitting nearby stated she could remember only one time a family had requested a bed hold upon a patient transfer to the hospital. At 2:20 p.m. the director of nursing (DON) stated bed hold information was given upon admission to patients and/or their representatives. DON stated bed holds were completed verbally at the time of transfer to hospital. The Administrator standing near stated the patients were always accepted back to the facility from the hospital and were not charged for bed holds. Facility's Bed Hold Notice-Transitional Care Unit dated 08/29/17, indicated patients could reserve their bed held, pay at their own expense or with Medicaid, and were to notify the social worker if wishing to hold their bed. Facility policy for Bed Holds requested but not made available.

Based on observation, interview and document review, the facility failed to ensure documentation of each resident's advance directive/code status was consistent throughout their records, and facility's systems to ensure the code status reflected the current resuscitation preferences and physician's orders [REDACTED]. Findings Include: R314 On 1/15/19, at 10:09 a.m. registered nurse (RN)-C stated patients' wrist bands should be marked for code status, match the physician order [REDACTED]. RN-C stated R314 was newly admitted to the facility on [DATE], early evening she went to apply the wrist band to R314 and discussed R314 being full code as the admission order had been written. RN-C stated R314 had told her that the full code status was wrong and that she wanted DNR (do not resuscitate). RN-C stated she marked DNR on the wrist band and said she would notify the physician. RN-C stated she notified the evening charge nurse and the oncoming night nurse of this, left a computer sticky note for the physician the following day, but had not documented it in a progress note or anywhere else. RN-C stated she would have normally documented this in a progress note but had not. RN-C stated upon coming back to work two days later she noticed the physician order [REDACTED]. RN-C stated normally code status was addressed with patients the same day of admission or the next day with the physician. RN-C stated she did not know why it had not been taken care of the day before as code status was very important. RN-C stated in the event of a code (respiratory or [MEDICAL CONDITION]) with R314's wrist band code status DNR not matching the admission order full code she would have followed the physician order [REDACTED]. RN-C verified on the discharge sheet from the hospital dated 1/12/19, the nurse practitioner had indicated R314 had discussed and wanted DNR/DNI code status but at the bottom of the discharge sheet had indicated Code Status Full Code. RN-C and surveyor went to R314's room and looked at R314's wrist band and it was checked twice, once for DNR and another check box marked DNI. At 10:33 a.m. the Interim Director of Nursing (IDON) stated the physician had seen R314 today and written a new order to change R314's code status from full code to DNR/DNI. IDON stated she had marked R314's wrist band DNI also as the band had only indicated DNR. IDON stated the wrist band should always match the physician order [REDACTED]. IDON stated if a wrist band did not match a physician order [REDACTED]. IDON stated in the event of a code where there was a discrepancy between the wrist band and the physician order [REDACTED]. physician progress notes [REDACTED]. The PN indicated R314's code status had been updated to DNR/DNI. Physician order [REDACTED]. R7 On 1/15/19, at 9:59 a.m. R7 was observed with a wrist band with code status left blank. R7's family member (FM)-A standing near stated she would have liked to have the code status indicated on the wrist band in case of an emergency and stated she was R7's conservator and R7 wanted full code. At 10:03 a.m. RN-A stated she had known some patients' wristbands in the facility were left blank and not marked, stated she thought some nurses did not mark the boxes for code status, and that the double checking for code status using the wrist bands had fallen through years back. RN-A walked up to R7 sitting by the nurse station and looked at her wrist band, verified no box for code status had been marked, and then checked the full code box on R7's wristband. RN-A stated in the event of a patient code where the wrist band was left blank or did not match the physician order [REDACTED]. At 10:07 a.m. RN-B stated she had known some patients' code status had not been marked on their wrist bands. RN-B stated in the event of a patient code she would go by the physician order [REDACTED]. RN-B stated she had not been trained to double check the wristbands with physician orders. R7's H & P (History and Physical) dated 1/3/19, indicated R7 was readmitted to the facility 1/2/19, and was Full Code status. R7's physician order [REDACTED]. The physician order [REDACTED]. R8 On 1/15/19, at 9:00 a.m. IDON stated R8 had been admitted to the facility on [DATE], readmitted to the hospital on [DATE], and came back from hospital on [DATE]. IDON verified in the EMR R8's physician order [REDACTED]. IDON stated the facility have had problems with the EPIC software with readmissions. At 9:32 a.m. IDON verified on R8's wrist band the code status had been left blank. R8 stated to IDON he did not not want tubes (intubation) like had happened once before. IDON told R8 she would have a new wrist band made for R8 with the correct code status indicated on it. At 10:38 a.m. IDON stated she had gotten R8 a new wrist band with the code status marked on it. physician progress notes [REDACTED]. to be full code and would like to remain full code until he could discuss with FM-B. The Admission (Current) in TR Transitional Care physician orders [REDACTED]. R8's POLST (Provider Orders for Life-Sustaining Treatment dated and signed 4/24/18, indicated DNR/Selective Treatment including No intubation. Facility policy DNR, DNI: Code Status and Decisions Regarding Life-Sustaining Interventions dated 1/16/19, indicated Code Status should be reviewed with the patient or authorized surrogate decision-maker at the time of admission and readmission. The policy indicated if code status was identified code status would be displayed in the header of the EMR. The policy also indicated Designation of Code status on identification armbands in those entities that use armbands: See system Patient Identification policy. Facility policy Patient Identification dated 1/16/19, indicated patients wore identification bands (wrist bands) that should include code status (DNR, DNI, Full Code or Special) to match the service or treatment to that patient.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R128) was assessed to safely self-administer a narcotic during a random observation. Findings include: On 11/13/17, at 2:55 p.m. during the initial interview with R128, the registered nurse (RN)-C entered the room. RN-C picked up a plastic medication cup with a white pill in it from the R128's lunch tray. RN-C handed the medication cup to R128. R128 took the cup and put the pill into her mouth and swallowed the pill without difficulty. After RN-C left the room R128 stated she did not know what the medication was in the cup. R128 stated that the nurse brought the pill to her earlier, but she had an urgent need to use the bathroom and could not wait to take the medication. R128's Admission Record dated 11/12/17, indicated that R128 had been diagnosed with [REDACTED]. R128's Physician Orders dated 11/12/17, included orders for medications including [MEDICATION NAME] 5 to 10 milligrams (mg). The Physician Orders did not include an order for [REDACTED].>R128's Initial Nursing assessment dated [DATE], included an assessment for pain but did not include an assessment for self-administration of medication. R128's Medication Administration Record [REDACTED]. R128's Progress Notes from admission and initial plan of care dated 11/15/17, were reviewed and did not address self-administration of medication. On 11/13/17, at 3:05 p.m. RN-C was interviewed and asked what the medication was that was left on the tray in the R128's room. RN-C stated the medication was [MEDICATION NAME] 5 mg. RN-C also stated when she first brought the medication to R128, R128 had an urgent need to use the bathroom and could not wait. RN-C stated that she told R128 to take the medication as soon as she finished in the bathroom. On 11/16/17, 9:44 a.m. during an interview the director of nursing (DON) stated that her expectation was the nurses witness the resident take their medication. In addition, the DON stated the nurse needed to see the resident take the medications and not leave them on the bedside table. The Medication Self Administration policy reviewed on 1/17, was for University of Minnesota Medical Center. The DON stated it was the policy the facility followed. Also reviewed was the facility's Assessment and Care Plan policy dated revised on 8/17. The Medication Self Administration policy indicated that self-administration of medication by a patient was prohibited unless the medication was a critical medication or the patient was in a special patient population.

Based on observation interview and document review, the facility failed to ensure glucometers (a machine for checking blood sugars) were sanitized after usage for 2 of 3 residents (R139, R130) observed for blood sugar checks. Findings include: During interview on 11/13/17, at 12:05 p.m. registered nurse (RN)-D stated R139 was on contact precautions for MRSA (methicillin resistive staphylococcus aureus) in his heel. During observation on 11/13/17, at 5:24 p.m. nursing assistant (NA)-A put on gown and gloves. NA-A put a plastic transparent cover over glucometer and entered R139's room. NA-A explained to R139 what he was going to do. NA-A wiped R139's finger with alcohol swab and obtained a drop of blood. After checking blood sugar NA-A went out to the isolation cart and wiped glucometer with a Super Sani cloth germicide wipes for 25 seconds and then let it dry in 45 seconds. After glucometer was dry NA-A put glucometer in its case. NA-A stated was taught to clean the glucometer by wiping the meter once and then it let it dry. NA-A verified the glucometer was dry immediately. NA-A verified the glucometer was used by multiple residents on the floor. NA-A verified the instructions on the wipes container was to have the glucometer surface remain wet for two full minutes. R139's Diabetes Consult Daily Progress note dated 11/15/17, identified R139 had [DIAGNOSES REDACTED]. R130's Diabetes Consult Daily Progress note dated 11/10/17, identified R130 was alert, had [DIAGNOSES REDACTED]. During interview on 11/13/17, at 12:05 p.m. registered nurse (RN)-D stated R130 was on contact precautions for ESBL (extended spectrum beta-lactamase) in blood and VRE ([MEDICATION NAME] resistive [MEDICATION NAME]) in urine. During observation on 11/15/17, at 9:58 a.m. NA-B put on gown and gloves. NA-B put a plastic transparent cover over glucometer and entered R130's room. NA-B explained what he was going to do and set glucometer on R130's bed. NA-B wiped R130's finger with alcohol swab and obtained a drop of blood. NA-B removed gown and gloves and entered R130's bathroom. NA-B set glucometer, without plastic cover, on the counter in R130's bathroom while NA-B washed hands. NA-B exited R130's room and went to an isolation cart. NA-B set the glucometer on the inside of case and put on gloves. NA-B wiped the glucometer with Super Sani cloth germicidal wipe for 17 seconds. NA-B wiped the inside of the glucometer case with germicidal wipe and then put glucometer in case. NA-B verified glucometer was dry at 42 seconds. NA-B took glucometer case to supply room and put in charging base. During interview on 11/15/17, at 10:06 a.m. NA-B stated he was to briefly wipe the glucometer with a sanitizer wipe. NA-B stated the glucometer would dry in about 15 to 30 seconds. NA-B stated staff had to be very careful to not saturate the meter or get the strip area wet. NA-B stated he had been told glucometers were to remain wet with sanitizer for about one to two minutes. NA-B verified used Super Sani cloth germicidal wipes and stated would normally have used the bleach wipes (PDI Sani Cloth Bleach germicidal wipe) but R130 was on contact precautions. NA-B verified instructions on Super Sani cloth germicidal wipes stated surface was to remain wet for a full two minutes. During interview on 11/15/17, at 10:35 a.m. RN-A infection preventionist, and RN-B infection preventionist stated that anything that came out of a patient's room was to be wiped down with a PDI wipe. RN-A stated staff were to use purple (PDI super Sani Cloth germicidal wipe) or orange (PDI Sani Cloth Bleach germicidal wipe) top wipes. The purple top wipes were to be used for any type of isolation except [MEDICATION NAME] precautions, then staff were to use the orange top. RN-A stated items wiped with purple top wipes had to remain visible wet for two minutes and items wiped with the orange top had to stay visible wet for four minutes. RN-B stated if staff set the glucometer down on a surface they would need to wipe the surface down. RN-A stated glucometer surface would not be fully disinfected if the glucometer did not remain visible wet for at least two minutes and microorganisms' pathogens would still be on the surface and potentially infectious. PDI Super Sani Wipes General Guidelines for Use dated 2016, instruct users to if present remove heavy soil loads prior to disinfecting. Unfold clean wipe and thoroughly treat surface. Allow surface to remain treated for [REDACTED].

Based on interview and document review, the facility failed to provide proper liability and appeal rights notices on a timely manner prior to termination of all Medicare skilled services for 1 of 3 residents (R53) reviewed for liability notice and beneficiary appeal rights. Findings include: R53 was admitted to the facility on [DATE], and discharged on [DATE]. A Notice of Medicare Non-Coverage indicated R53's skilled services ending date was 7/2/15, but had been signed on 7/1/15, which was one day to the end of skilled services. On 11/3/15, at 8:48 a.m. the Minimum Data Set (MDS) registered nurse (RN)-B verified and acknowledged the notice had not been given timely. When asked what the facility policy was for issuing notices, RN-B stated notice was supposed to be given within two calendar days. RN-B further indicated there was no documentation for why the notice had been given late and thought R53 had been cleared medically to be discharged to another setting. On 11/4/15, at 1:52 p.m. the director of nursing stated she was aware of the issue and would have expected the appropriate notices to be provided in a timely manner according to the regulatory requirements. Non-Coverage of Services: TCU policy revised 6/13, directed: I. Procedure for Medicare patients B. The discharge planning team anticipates when Medicare covered services will end based on the plan of care and patient program, and a probable discharge date is established. At least two calendar days before the covered services are expected to end, a staff member in either care management or business services will deliver to the patient the letter specifying the date services end.

Based on observation, interview and document review the facility failed to ensure 1 of 2 blanket warmers were maintained in a fully functional manner, which had the ability affect 1 of 2 residents (R46) reviewed who utilized the blanket warmer on the unit. However, this had the potential to affect 6 of the 11 residents. Findings include: On 9/29/14, at 11:55 a.m. in the clean utility room the blanket warmer in West clean supply room (425) was set at 155 degrees Fahrenheit (F), the digital display read 156 F. A sign posted on the face of the blanket warmer stated, "This blanket warmer can be used only for blankets. Maximum temperature is 130 F. If the temperature is set higher than 130 F. Reset to 130 F." The blanket warmer was opened; the temperature of the blankets to touch was minimally warm, but not hot. -At 12:00 p.m. nursing assistant (NA)-A entered the clean utility room, NA-A verified the digital display on the blanket warmer read 154 F. NA-A then took a Blanket to room 426 for R46, NA-A then returned to the clean supply room. -At 1:30 p.m. the director of nursing (DON) observed the blanket warmer in the West clean utility room blanket warmer had been set down to 130 F, the digital display indicated 130 F, when checked with the electronic thermometer the temperature registered 117 F. On 9/29/14, at 1:55 p.m. the regulatory compliance specialist for the University of Minnesota Medical Center (RC) stated there have not been any I-cares (incident and accident reports) [MEDICAL CONDITION] the blanket warmers. The RC provided the work orders related to the individual blanket warmers. A general work order dated 3/21/14, was reviewed for the blanket warmer in West clean utility room (425). The work order lacked notation of the equipment ID number, and identified issue: "Blanket warmer is too hot, at 160 F, supposed to be at 130 F." The report was called into the security office at 5:04 p.m. with a priority of 5 non-emergency/general work. The work order indicated the work was completed at 9:00 p.m., but the work order did not identify what the problem was or what was done to correct the problem. A general work order dated 4/2/13, at 12:47 p.m. and sent to facilities indicated: "Blanket warmer in East clean utility room was not warming, priority level 5 non-emergency general work." At 3:55 p.m. the problem code identified repair replace, with no further description or what was done to correct the problem. On 9/30/14, at 8:30 a.m. R46 was interviewed and stated the warm blankets are just barely warm, and have not caused any issues or discomfort for him. R46 indicated he was recovering from kidney surgery. R46 was alert and oriented at the time of the interview. On 9/30/14, at 9:28 a.m. a Preventative Maintenance (PM) work order indicated priority non-emergency patient care, completed 9/30/14, indicated blanket warmer Amsco asset # 2 (new red bar coded sticker) and Amsco asset # 3 (new red bar coded sticker) indicated procedures: "blanket warmer annual: check operation, check temp, check for proper signage, make sure set point is locked, check all working parts (lights/door hinges/latches/gaskets)." On 9/30/14, at 2:08 p.m. the director of facilities (FD), with the RC and administrator were given a summary of the observations on 9/29/14, for the blanket warmer(s) findings. The FD stated the equipment was checked when brought into the system and then things like blanket warmers were tabled exempt and only looked at when called to check repair them. The FD verified during a review of the work orders,the work orders lacked documentation of the equipment ID number, or a description of the service provided to repair the blanket warmer(s). The FD stated "They should be documenting what they did to repair it on the work order sheets." "The Blanket warmers were put back into the PM cycle today, calibrated and given new bar code stickers that say UMMC-W (for west bank)." The FD further stated, as equipment was located it was being brought back into the PM cycle, these (blanket warmers) were never part of an alternative maintenance program they were tabled exempt, with the thought that surveyors would see exempt and walk past. The FD stated the staff meeting would be that week, identifying equipment not in the cycle and documenting work done would be addressed. The Medical Equipment Maintenance Schedule-UMMC revised 1/11 noted, "To ensure that the equipment maintenance schedule is implemented and completed, as required by the Clinical Risk Assessment Plan. ...the PM technician and other technicians assigned to PM's are responsible for closing PM work orders, they are also responsible for any editing of the St Croix Systems database with regard to their assigned PM's for the month. This includes looking for duplicate pieces of equipment and requesting a 'merge' from the 'Change Manager' if needed, switching from B numbers to F numbers, filling in missing serial numbers, changing department owner and location information, adding new equipment to the database, and verifying manufacturer/model numbers of devices. ....when closing PM and safety inspection work orders, all template banks must be filled in. If an edit needs to occur to the PM template, send a request to the 'Change Manager.'" On 10/2/14, at 9:15 a.m. registered nurse (RN)-A, stated that "usually 60 to 70% of the patients are using warmed blankets at any time, although not 100% because some have orders not to use them (warmed blankets), depending on what has been done. We usually use them for transport to other services (through the tunnel system on campus)." The Amsco Blanket Warmer manufacturer's recommendations, provided by the facility, (section 5) indicated, "Each warming cabinet must be testing and inspected. A visual inspection of the cabinet and doors. A functional temperature checks should calibrate within 5 degrees F."

Based on observation, interview and document review the facility failed to ensure the staff posting was updated on a daily basis. This had the potential to affect all 11 residents and family/visitors. Findings include: On 9/29/14, at 11:50 a.m. during an initial tour of the facility, the staff posting dated 9/29/14, was located on the wall across from the nursing station, in a clear acrylic wall holder. For each shift, the staff posting listed the census of the unit, registered nurses (RN)'s on duty and nursing assistants (NA)'s on duty. The staff posting dated 9/29/14, indicated the 7:00 a.m. to 3:30 p.m. shift had a patient census of 11, with three RN's and one NA working. On 9/30/14, at 8:00 a.m. the staff posting had not been changed and indicated the date of 9/29/14, the 7:00 a.m. to 3:30 p.m. shift had a patient census of 11, with three RN's and one NA working. The evening shift did not have a census and listed three RN's and one NA scheduled. The night shift did not have a census and listed two RN's and one NA scheduled. On 9/30/14, at 12:10 p.m. the director of nursing (DON) verified the staff posting was still dated for 9/29/14, and had not been updated for the evening and night shift census. The DON stated the HUC was floated today and that was probably why it was not updated. The regulation requirements were reviewed with the DON, and included the staff posting should be updated at the start of every shift. -At 12:30 p.m. the DON provided the staff posting for 9/30/14, which indicated the day shift had a census of 11 with three RN's for 24 hours, two NA's for 16 hours. The evening shift had a census listed of 12 with three RN's for 24 hours, and two NA's for 16 hours. The night shift had a census listed of 12 with two RN's for 16 hours and one NA for eight hours. The DON verified an admission was expected to raise the census to 12.

Based on interview, observation and document review, the facility failed to ensure comfortable temperatures were maintained in resident's rooms for 2 of 3 residents (R214, R218). In addition, 2 refrigerators in the occupational therapy (OT) kitchen/Leisure room were not maintained in a clean manner when reviewed for environment which had the potential to affect up to 14 residents per week who participated in occupational therapy learning skills. Findings include: Comfortable Temperatures: On 11/12/13, 03:01 p.m. during interview R218 stated It gets cold and hot in here and has been hard to regulate the temperature." She was not sure if she had reported it but thought she had to one of the staff. On 11/12/13, 03:48 p.m. during interview R214 stated "It is hard to regulate temperature in this room it is either too hot or too cold." On 11/14/13, at 9:00 a.m. the environmental tour was conducted with the facility administrator (O)-A, the director of environmental services (O)-B, the director of facility services (O)-C, the regulatory compliance specialist (O)-E and the principle engineer. The following issues were noted: -At 9:06 a.m. R218 was observed lying in her bed with covers up to her neck and the induction unit vent area was covered with cloth tote bags and a pillow on top. R218 reported to surveyor and O-C the temperature was hard to regulate. O-C was observed reaching over the induction unit on the wall and stated "Feels a little cool here." R218 stated she used the tote bags and pillow to keep the cold air from blowing in the room. O-C assured R218 that the engineering staff would look into the issue as soon as possible. The temperature was reading 70 degrees Fahrenheit. -At 9:10 a.m. R214 reported to O-C the temperature in the room was hard to regulate and stated was a little cold right then and was shortly going to get a sweater. R214 further stated "When the sun comes up it gets hot and I am going home tomorrow but want the problem to be fixed for the next patient." O-C assured the R214 the issue would be resolved and temperature at the time was reading 75.9 degrees Fahrenheit. The Plant Operations and Maintenance Program policy revised 12/10, directed "The maintenance and operation of all hospital buildings, plant components, utilities (including electric, water systems, steam, air, gas, fuel, oil), sanitary systems, refrigerator units, ventilation and air conditioning systems, fire alarm systems, and internal lighting are the primary responsibilities essential in the Plant Operations and Maintenance Program." OT Kitchen/leisure room: On 11/12/13, at 4:05 p.m. R224 reported "The kitchen area to the right of the nursing station is dirty and there was mold in the coffee maker when I was in that kitchen and I had to clean it. The occupational therapist staff came and got me to fix a bag of popcorn but I told the staff I was not going to do so as the microwave was dirty and looking inside the drawers and fridges it was disgusting. I can clean the area even better than them here. And I can make a bag of popcorn myself." On 11/14/13, at 9:00 a.m. the environmental tour was conducted with the facility administrator (O)-A, the director of environmental services (O)-B, the director of facility services (O)-C, the regulatory compliance specialist (O)-E and the principle engineer. The following issues were noted: On 11/14/13, at 9:11 a.m. O-B verified both the refrigerators in the OT kitchen/Leisure room were not clean and stated food service was responsible for cleaning the refrigerators once a month and would check with the food service director (O)-F if the department needed assistance to clean the refrigerators. On 11/14/13, at 9:14 a.m. O-A stated one of the refrigerators used by OT was cleaned by the OT staff and her expectation was to have the area clean as that was resident space. On 11/14/13, at 12:57 p.m. the regulatory specialist provided a copy of "Refrigerators/ Freezers" a cleaning log stated the director of food service (O)-F had provided a blank copy of what the facility actually used to track the cleaning of the refrigerators on the unit and there were no completed cleaning log records which indicated when the refrigerators had been cleaned. Additionally, O-E stated the O-F had reported the food service manager was responsible to oversee the cleaning schedule for the refrigerators. On 11/15/13, at 8:18 a.m. via telephone the administrator stated that typically the OT kitchen area would be used by four to six residents or family members and the refrigerators were used as courteously for residents and families to store foods or some residents would use it to store ethnically preferred foods. On 11/15/13, at 8:24 a.m. via telephone the administrator stated per OT typically the OT kitchen area was used by one to two residents per day to practice kitchen skills and normally the residents are not invited to eat the food they are [MEDICATION NAME] to prepare but rather demonstrating kitchen skills. The facility Refrigerator Safety policy revised 9/7/2012, directed "E. Patient care staff as assigned by the unit is responsible for the: 4. Cleaning of any and all incidental spills." The policy lacked information on where staff was to document after cleaning the refrigerators, how often to clean them, and who was responsible to oversee the refrigerators used to store resident food were maintained clean.

Based on observation, interview, and document review, the facility failed to monitor for drug-induced side effects and efficacy for 1 of 5 residents (R80) in the sample reviewed for the use of anti-psychotic and anti-anxiety medications. Findings include: R80 was re-admitted on [DATE], with [DIAGNOSES REDACTED]. R80 was readmitted to the facility after a fall at home in which R80 sustained a left femoral neck fracture. R80 received [MEDICATION NAME] (an antipsychotic medication) - which potentially can be a risk factor for tardive dyskinesia often called extrapyramidal side effects (EPSE) (involuntary movements of the tongue, lips, face, trunk, and extremities and severe orthostatic [MEDICAL CONDITION] (when a person's blood pressure drops significantly when changing positions from lying down or sitting to standing up). [MEDICATION NAME] (a medication used for nausea/vomiting) which can potentially cause side effects of tardive dyskinesia and/or [MEDICAL CONDITION]. [MEDICATION NAME] (an anti-anxiety medication) which can potentially cause a side effect of [MEDICAL CONDITION]. R80 was not monitored for the potential side effects and indications for use of the medications. R80 was observed to be lying down in bed on 11/12/13, at 3:10 p.m. R80 stated they were not feeling well. On 11/13/13, at 7:30 a.m. R80 was observed lying on a gurney waiting for tests to be performed. The care plan dated 10/23/13, indicated: fall precautions, monitor for fall risk and follow safety measures, using a rolling walker provided from home. On [MEDICATION NAME] watch for EPSE. The care plan failed to identify target behaviors and what to monitor for the falls risk. A Pharmacy Medication Review Regimen dated 11/1/13, at 3:41 p.m., indicated a pharmacist had reviewed all medications, all medications had clear indications and recommended limiting Tylenol to 3 grams per day related to an elevated liver test, no hemoglobin (HGB) parameters for [MEDICATION NAME], to monitor platelets weekly related to blood thinning medications. Magnesium to be rechecked on an office visit and to monitor for excessive sedation and falls related to [MEDICATION NAME] and [MEDICATION NAME] (a pain control medication) ordered as needed. No additional pharmacy review notes were available. The recommendations lacked evidence of review of anti-psychotic medications, and lacked a warning for orthostatic blood pressure monitoring (even though it was listed in the detailed medication order), and lacked direction for a baseline Abnormal Involuntary Movement Scale (AIMS), or Dyskinesia Identification System: Condensed User Scales (DISCUS). The Care Area Assessment (CAA) dated 11/5/13, included: functional rehabilitation, falls, [MEDICAL CONDITION] drug use, and indicated care plan initiated. Physicians orders: indicated [MEDICATION NAME] (an antipsychotic medication) 2.5 milligrams (mg) was ordered on [DATE], [MEDICATION NAME] 5-10 mg tablets every six hours as needed was ordered 11/8/13, and [MEDICATION NAME] 0.5 mg for anxiety or nausea and vomiting was ordered 11/8/13. Nursing progress notes dated 11/8/13, indicated Behavioral assessment "not exhibited", mobility in bed, transfers, and ambulation "Independent, no help or oversight at anytime." The medical record lacked evidence of the monitoring of the side effects and target behvaior/mood monitoring. On 10/14/13, at 10:50 a.m. registered nurse (RN)-A charge nurse stated EPSE would be documented on the flow sheet, when the flow sheet was reviewed RN-A stated, there were areas for cognition, mood, behaviors, and speech, but no area to document side effects. RN-A stated EPSE monitoring may be put into nursing notes. On 11/14/13, at 10:55 a.m. the consultant pharmacist stated nursing staff recorded side effects of medications and would fill out any forms for DISCUS or AIMS assessments. On 11/1/4/13, at 10:58 a.m. the director of nursing (DON) stated antipsychotic charting would be under behavioral in the electronic medical record (e-MR) and would be exception charting. A review of the e-MR charting did not include any behavioral notes on behaviors or EPSE. The DON verified there was no orthostatic blood pressure (BP) assessment documented, but did note the order (in Epic e-mar). The DON was not aware orthostatic BP's were needed for [MEDICATION NAME], or that the DISCUS, AIMS or other method of assessing and monitoring EPSE is needed as baseline for anti-psychotic medications. The DON did verify that R80 was considered a high fall risk on assessment due to the fall at home, and [MEDICATION NAME] and [MEDICATION NAME] medications. On 11/14/13, at 10:45 a.m. MDS coordinator (MDS-J) reviewed the Epic e-MR and did not see any side effects or behavioral documentation, but stated she was not the expert on EPIC charting. MDS-J stated usually the resource nurse, does the admission, and sets up the initial care plan. The facility lacked baseline DISCUS/AIMS assessment, did not identify target behaviors and lacked side effect monitoring for [MEDICATION NAME] and [MEDICATION NAME]. The Policy Medication Management: TCU, dated as reviewed 1/24/11, indicated: I. "The interdisciplinary team reviews the resident's medication regiment (sic) for efficacy and actual or potential medication-related problems on an ongoing basis... B. The resident is evaluated before initiating, withdrawing or withholding medications, or using nonpharmacologic approaches. 1. The extent of the evaluation will vary according to the resident's current condition, but may include: a. An appropriately detailed evaluation of mental, physical, psychosocial, and functional status, including co-morbid conditions and pertinent psychiatric symptoms and diagnoses... C. Information gathered during the initial and ongoing evaluations are incorporated into a comprehensive care plan that reflects appropriate medication related goals and parameters for monitoring the resident's condition and ongoing need for the medications, including, but not limited to what is monitored, who will be responsible for monitoring, and how often and when a re-evaluation is necessary. 1. The care planning team defines quantitative and qualitative monitoring parameters using a variety of resources...Monitoring Medication in Long Term Care Residents, manufacturers' package inserts and black box warnings; facility policies and procedures; pharmacists; clinical practice guidelines or clinical standards of practice; medication references; and clinical studies or evidence based review articles that are published in medical and/or pharmacy journals. D. The resident medication regimen is evaluated when one or more of the following occur... 1. Admission or re-admission... I. When a resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, and or non-pharmacological interventions, including behavioral interventions have been effective in reducing the symptoms, the resident is evaluated for the appropriateness of a taper or gradual dose reduction (GDR) of the medication 1. Antipsychotic's. If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year. A GDR must be attempted annually, unless clinical contraindicated.... II. If a medication seems unnecessary or harmful to the resident, the consultant pharmacist requests the prescriber to evaluate the resident for the continued need for the medication and/or to consider tapering the medication. If the prescriber deems the medication necessary, a documented clinical rationale for the benefit of, or necessity for, the medication is documented in the resident's active record. III. When other organizations perform medication therapy management services, e.g., Medicare Prescription Drug Plans (PDPs), the consultant pharmacist evaluates the recommendation for applicability to the long-term care resident. Psychopharmacologic medication is defined by the centers for Medicare and Medicaid Services (42 CFR #483.25(1) Unnecessary Medications (F329)) as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders."

Based on observation, interview and document review, the consultant pharmacist failed to identify and report an irregularity regarding antipsychotic medications and/or document clinical indications for continued use and for monitoring of side effects for 1 of 5 residents (R80) whose medications were reviewed. Findings include: R80 was observed to be lying down in bed at 3:10 p.m. on 11/12/13, stated not feeling well. On 11/13/13, at 7:30 a.m. was observed on a gurney (rolling cart to transport patients) to transfer for ventilation perfusion scan (looking for blood clots in the lungs) testing and a biliary (gallbladder) drain change. The Admission Progress Note dated 10/23/13, indicated R80 was admitted with [DIAGNOSES REDACTED]. R80 had been hospitalized [DATE] through 10/5/13, for bacteremia (an overwhelming immune response to a bacterial infection) secondary to cholangitis (infection in the duct from the gallbladder to the liver). R80 was then in the facility from 10/5/13 through 10/17/13, and discharged home. On 10/18/13, R80 was readmitted to the hospital after a fall at home and was transferred to the facility again on 10/23/13, with acute left femoral neck fracture repair, complicated by acute delirium and acute on chronic anemia, with ongoing chemotherapy. Delirium now resolved, likely multifactorial, secondary to inpatient/post-operative status, chemotherapy, narcotics, infection and benzodiazepines. The care plan dated 10/23/13, indicated: on Zyprexa, Compazine watch for EPSE. The Care plan failed to identify target behaviors, and lacked direction to perform an orthostatic blood pressure check. The Care Area Assessment (CAA) dated 11/5/13, included: functional rehabilitation, falls, psychotropic drug use, and indicated care plan initiated. Physicians orders: indicated Zyprexa (an antipsychotic medication) 2.5 milligrams (mg) was ordered on [DATE], Compazine 5-10 mg tablets every six hours as needed was ordered 11/8/13, and Ativan 0.5 mg for anxiety or nausea and vomiting was ordered 11/8/13. Nursing progress notes dated 11/8/13, indicated Behavioral assessment "not exhibited", mobility in bed, transfers, and ambulation "Independent, no help or oversight at anytime." The medical record lacked evidence of the monitoring of the side effects and target behavior/mood monitoring for the medications ordered for R80. On 10/14/13, at 10:50 a.m. registered nurse (RN)-A charge nurse stated EPSE would be documented on the flowsheet, when the flowsheet was reviewed RN-A stated, there were areas for cognition, mood, behaviors, and speech, but no area to document side effects. RN-A stated EPSE monitoring may be put into nursing notes. On 11/14/13, at 10:55 a.m. the consultant pharmacist stated nursing records side effects of medications and would fill out any forms for DISCUS or AIMS assessments. The consultant pharmacist verified pharmacy was decentralized (on the unit every day reviewing medication orders). On 11/1/4/13, at 10:58 a.m. the director of nursing (DON) stated antipsychotic charting would be under behavioral in the electronic medical record (e-MR) and would be exception charting. A review of the e-MR charting did not reveal any behavioral notes on behaviors or EPSE. The DON verified there was no orthostatic blood pressure (BP) assessment documented, but did note the order did exist in Epic e-mar. The DON was not aware orthostatic BP's were needed for Zyprexa and Compazine, or that the DISCUS, AIMS or other method of assessing and monitoring EPSE was needed as baseline for anti-psychotic medications. The DON did verify that R80 was considered a high fall risk on assessment due to the fall at home, and Zyprexa and Compazine medications. The nursing notes lacked target behavior monitoring for specific identified behaviors for anti-psychotic and anti-anxiety medications. On 11/14/13, at 10:45 a.m. MDS coordinator (MDS-J) reviewed the Epic e-MR and did not see any side effects or behavioral documentation, but stated she was not the expert on EPIC charting. MDS-J stated usually the resource nurse, does the admission, and set up initial care plan. The facility lacked baseline Discus/Aims assessment, did not identify target behaviors and lacked side effect monitoring for Zyprexa and Compazine. The Policy Medication Management: TCU, dated as reviewed 1/24/11, indicated: I. "The interdisciplinary team reviews the resident's medication regiment (sic) for efficacy and actual or potential medication-related problems on an ongoing basis... B. The resident is evaluated before initiating, withdrawing or withholding medications, or using nonpharmacologic approaches. 1. The extent of the evaluation will vary according to the resident's current condition, but may include: a. An appropriately detailed evaluation of mental, physical, psychosocial, and functional status, including co-morbid conditions and pertinent psychiatric symptoms and diagnoses... C. Information gathered during the initial and ongoing evaluations are incorporated into a comprehensive care plan that reflects appropriate medication related goals and parameters for monitoring the resident's condition and ongoing need for the medications, including, but not limited to what is monitored, who will be responsible for monitoring, and how often and when a re-evaluation is necessary. 1. The care planning team defines quantitative and qualitative monitoring parameters using a variety of resources...Monitoring Medication in Long Term Care Residents, manufacturers' package inserts and black box warnings; facility policies and procedures; pharmacists; clinical practice guidelines or clinical standards of practice; medication references; and clinical studies or evidence based review articles that are published in medical and/or pharmacy journals. D. The resident medication regimen is evaluated when one or more of the following occur... 1. Admission or re-admission... I. When a resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, and or non-pharmacological interventions, including behavioral interventions have been effective in reducing the symptoms, the resident is evaluated for the appropriateness of a taper or gradual dose reduction (GDR) of the medication 1. Antipsychotic's. If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year. A GDR must be attempted annually, unless clinical contraindicated.... II. If a medication seems unnecessary or harmful to the resident, the consultant pharmacist requests the prescriber to evaluate the resident for the continued need for the medication and/or to consider tapering the medication. If the prescriber deems the medication necessary, a documented clinical rationale for the benefit of, or necessity for, the medication is documented in the resident's active record. III. When other organizations perform medication therapy management services, e.g., Medicare Prescription Drug Plans (PDPs), the consultant pharmacist evaluates the recommendation for applicability to the long-term care resident. Psychopharmacologic medication is defined by the centers for Medicare and Medicaid Services (42 CFR #483.25(1) Unnecessary Medications (F329)) as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders."

Based on interview and document review, the facility failed report and complete a thorough investigation to rule out abuse and neglect of care for 2 of 3 residents (R237, R241) in the sample records reviewed for allegation of maltreatment and fall with fracture. Findings include: R237 had informed staff of a possible maltreatment and that was not reported to the designated State agency (SA) until the next day. During interview on [DATE], at 5:33 p.m. R237 reported since she was admitted to the transitional care unit (TCU) she had been treated roughly by staff. R237 explained staff put lotion on her legs, than wrapped her legs with ACE (elastic) wraps. Per R237, the procedure was very painful, she started crying, and told staff at least ten times not to touch her feet, but staff proceeded to finish the treatment. R237 also stated that on another occasion another staff member grabbed her legs to assist her to bed, she have told staff that her legs were hurting, but staff member just continued to put her to bed. The allegation was reported to the administrator on [DATE], at 9:49 a.m. During the interview, the administrator stated in case of abuse the administrator or director of nursing (DON) interviewed the resident first, than investigated, and based on the results they made the decision to report or not to the SA. During interview on [DATE], at 9:49 a.m. the administrator stated she just reported R237's allegation in the morning. The administrator explained she wanted to report R237's allegation of maltreatment the day before, but she got busy. R241 had a fracture due to a fall from [DATE], and it was reported to the designated SA on [DATE] (11 days later). The Investigative Report submitted to the SA on [DATE], indicated R241 was admitted to the TCU on [DATE], with [DIAGNOSES REDACTED]. R241 was assessed upon admission as high risk for falls, and the recommendation was that "patient is monitored when out of bed, commode is at bedside, non-skid slippers are used and lighting adjusted for safety." The report also noted R241 was found on the floor on [DATE], at 6:45 a.m. R241 was transferred to the hospital at 9:06 a.m. where "[MEDICAL CONDITION] was identified after scan, and surgery completed to repair hip on ,[DATE]. The patient continued to decline, and expired on ,[DATE] of cardiac failure due to septic shock." The report also noted, "The RN {registered nurse} and nursing assistant {NA}were following the plan of care and rounding regularly on the patient." Review of R241's medical record did not contain evidence that a thorough investigation was completed to rule out potential neglect of care. The admission/discharge Minimum Data Set ((MDS) dated [DATE], indicated R241 transferred with one staff's extensive assistance, needed extensive assist with bed mobility, limited assist with toilet use and personal hygiene. The MDS also indicated R241 used a walker, and balance was not steady, but R241 was able to stabilize with human assistance. Per the MDS, R241 was occasionally incontinent with bladder (urine), continent of bowels, and was not on any toileting program. The MDS also indicated R241 had a fall in the last one month prior to admission, and did not contain information related to R241's cognition. The electronic care plan dated [DATE], indicated the problem "Fall/Trauma/Injury Risk (Adult)", but had no personalized interventions listed. There was no care plan related to R241's needs with transfers, bed mobility, toileting needs, and /or activities of daily living (ADL). The incident report dated [DATE], indicated R241 was "found on the floor @ (at) 6:45, lying on her R (right) hip, head resting on the bathroom door. Patient soaked with urine." Per the incident report R241 was alert and very confused. Review of the flow sheet data indicated, R241 was incontinent with bladder on [DATE] and on [DATE]. The RN progress notes dated [DATE], indicated R241 used the bedside commode four times with assist during that shift, and R241 was incontinent once due to urgency. There was no evidence that R241's bowel and bladder status was assessed and care planned to meet R241's toileting needs and the relationship to falls. The John Hopkins Falls assessment dated [DATE], indicated R241 had a score of 16 (high risk for falls). The safety precautions listed were "commode/urinal/ bedpan at bedside; lightning adjusted for task/ safety; low bed; non-skid shoes/ slippers when out of bed". The record lacked evidence that a personalized care plan was in place to minimize risk for falling. Review of the undated investigation indicated, the DON interviewed the RN who worked on [DATE]. The RN relayed the following information: - At 23:50 p.m. R241 was awake, stated she was OK, and just wanted to sleep, - At 2.00 a.m. R241 was asleep in bed, - At 4:30 a.m. R241 was asleep in bed, - At 6:45 a.m. staff went into the room to complete blood draw and found R241 on the floor, who laid on her right side with her head by the bathroom door, - The time of the fall was unknown, - The length of the time on the floor was unknown, - R241 usually called when needed to get up to use commode, and patient did use the commode earlier in the night, since as about 0100 a.m. the NA {nursing assistant} emptied the commode." There was no evidence a thorough fall scene investigation was completed to verify if the safety precautions listed on the fall risk assessment were in place or that the line staff were interviewed who worked that night. Review of the call light records indicated R241 called at 00:17 a.m. on [DATE]. There was no evidence in the investigation that staff were interviewed to find out what happened at that time. The medical record indicated an x-ray was taken and the result dated [DATE], indicated R241 sustained a [MEDICAL CONDITION] hip. On [DATE], on 2:30 p.m. the DON and administrator were interviewed. The DON stated R241 fell on Friday morning, and when she got to the facility at around 8:30 a.m. the staff gave her report and R241 was sent to the hospital at around 9:00 a.m. The DON also stated R241 used a bedside commode, was able to transfer independently to the commode while used a four-wheeled walker, and was continent of bowel and bladder. The DON also stated R241 was not on any special toileting program, R241 was alert and able to use the call light, and that staff assisted as needed. The DON further explained the hospital did not keep in touch with the TCU unit, and they learned on Monday (three days later) that R241 had a fracture. The administrator stated they did not report the fracture to the SA since the cause of the injury was known, and because staff ruled out neglect even before they knew about the fracture. The administrator also explained the hospitals root cause analysis (RCA) team reviewed cases like R241's monthly. The administrator also stated that after the RCA team had the first meeting, she felt she needed to report the incident. The report was made on [DATE], (11 days after the fall). On [DATE], at 9:30 a.m. the DON explained that during her investigation she ruled out neglect, since she felt R241 had a change in medical condition overnight. After reviewing the care plan the DON stated, she did not review R241's medical record after the fall and was not aware that there was no individualized fall risk care plan completed. The DON explained the Epic System (healthcare information systems) was set up in a way, that if someone was at risk for falls, staff was able to access the Clinical Practice Guidelines for Fall/Trauma, Injury Risk protocol through a link attached to the site. Per the DON, the resident assistants (RA's) had no access to the nurse's assessments. The DON provided two blank NA assignment sheet for review, and explained staff could use those to take notes relevant to patient care during the report, or while reviewing the record in the Epic System. The DON acknowledged she did not interview the resident assistant's to investigate if the fall precautions listed on the fall risk assessment (from [DATE]) were in place or not. The DON stated R241 supposed to have the night light on; however, per the staff, the room was dark when R241 was found on the floor. When the assessment/care planning policy was requested, the DON stated they did not have one, they followed the Epic System. Review of the facility's Vulnerable Adult-Maltreatment Prevention Plan: TCU policy with revision date ,[DATE], indicated "An online report to the Minnesota Department of Health (MDH) must be reported within 24 hours of the reported incident occurrence." The policy did not include immediate notification of the SA, did not have clear definition for injuries of unknown origin, and did not provide clear guidance regarding resident to resident altercation. During interview with the DON and administrator on [DATE], at 3:03 p.m. the DON stated if there was an allegation of abuse or mistreatment, they completed investigation, and if the allegation was substantiated, than they reported it to the SA and common entry point. The DON and administrator acknowledgedthe policy did not include: regulatory language for immediately reporting to the SA, clear definition for reportable injuries of injuries of unknown origin, and resident to resident altercation. On [DATE], at 8:20 a.m. the DON stated she was aware that a fall with fracture was reportable event, however, she called the risk assessment team on [DATE] (three days later), when she learned R241 sustained a fracture, and the team took over the case.

Based on interview and document review, the facility failed report allegation of maltreatment immediately to the state agency and /or to complete a thorough investigation to rule out neglect of care for 2 of 3 residents (R237, R241) in the sample records reviewed for the abuse protocol. In addition, the facility to ensure the abuse prohibition policies and procedures included the immediate reporting of potential abuse, neglect, and injuries of unknown origin to the State Agency (SA), and lacked clear guidance related to resident to resident altercation. Findings include: R237 had informed staff of a possible maltreatment and that was not reported to the designated SA until the next day. During interview on [DATE], at 5:33 p.m. R237 reported since she was admitted to the transitional care unit (TCU) she had been treated roughly by staff. R237 explained staff put lotion on her legs, than wrapped her legs with ACE (elastic) wrap. Per R237, the procedure was very painful, she started crying, and told staff at least ten times not to touch her feet, but staff proceeded to finish the treatment. R237 also stated that on another occasion another staff member grabbed her legs to assist her to bed, she have told staff that her legs were hurting, but staff member just continued to put her to bed. The allegation was reported to the administrator on [DATE], at 9:49 a.m. During interview the administrator stated when an abuse allegation was made, the administrator or director of nursing (DON) interviewed the resident first, than investigated, and based on the results they made the decision to report or not to the SA. During interview on [DATE], at 9:49 a.m. the administrator stated she just reported R237's allegation in the morning. The administrator explained she wanted to report R237's allegation of maltreatment the day before, but she got busy. R241 had a fracture due to a fall from [DATE], and it was reported to the designated SA on [DATE] (11 days later). The Investigative Report submitted to the SA on [DATE], indicated R241 was admitted to the TCU on [DATE], with [DIAGNOSES REDACTED]. R241 was assessed upon admission as high risk for falls, and the recommendation were that "patient is monitored when out of bed, commode is at bedside, non-skid slippers are used and lighting adjusted for safety." The report also noted that R241 was found on the floor on [DATE], at 6:45 a.m. R241 was transferred to the hospital at 9:06 a.m. where "[MEDICAL CONDITION] was identified after scan, and surgery completed to repair hip on ,[DATE]. The patient continued to decline, and expired on ,[DATE] of cardiac failure due to septic shock." The report also noted, "The RN {registered nurse} and nursing assistant {NA}were following the plan of care and rounding regularly on the patient." On [DATE], at 8:20 a.m. the DON stated she was aware that a fall with fracture was reportable event, however, she called the risk assessment team on [DATE] (three days later) when she learned R241 sustained a fracture, and the team took over the case. Review of the facility's Vulnerable Adult-Maltreatment Prevention Plan: TCU policy with revision date ,[DATE], indicated, "An online report to the Minnesota Department of Health (MDH) must be reported within 24 hours of the reported incident occurrence." The policy did not include immediate notification of the SA, did not have clear definition for injuries of unknown origin, and did not provide clear guidance regarding resident to resident altercation. During interview with the DON and administrator on [DATE], at 3:03 p.m. the DON stated if there was an allegation of abuse or mistreatment, they completed investigation, and if the allegation was substantiated, than they reported it to the SA and common entry point. The DON and administrator acknowledged that the policy did not include regulatory language for immediately reporting to the SA, clear definition for reportable injuries of injuries of unknown origin, and resident to resident altercation.

Based on interview and document review, the facility failed to develop care planning sufficient to meet the needs of newly admitted residents, prior to completion of the first comprehensive care plan, for 1 of 4 residents (R241) identified with falls. In addition, the facility failed to assess and develop interventions to promote continence status for 1 of 1 resident (R241) reviewed with urinary incontinence. Findings include: Falls: R241 was identified at high risk for falls upon admission and fell on [DATE]. The medical record lacked evidence of temporary care plan to minimize risk of falls. R241 sustained a [MEDICAL CONDITION] during fall on 8/11/12. R241 was admitted to the transitional care unit (TCU) on 8/4/12, and participated in physical and occupational therapy. The nurse practitioner (NP) progress notes dated 8/6/12, indicated R241's [DIAGNOSES REDACTED]. The physical therapist (PT) initial assessment dated [DATE], indicated R241 required assistance to stand, reported weakness in her legs and was "worried about falling". The Physical Therapy Progress note dated 8/5/12, indicated R241 was alert and oriented and R241 was able to follow commands and answers question 100% of the time. Personal safety and judgement and memory was intact. There was no evidence in the medical record R241 had a care plan to meet R241's mobility needs. The John Hopkins Falls assessment dated [DATE], indicated R241 had a score of 16 (high risk for falls). The safety precautions listed were "commode/urinal/ bedpan at bedside; lightning adjusted for task/safety; low bed; non-skid shoes/ slippers when out of bed." The record lacked evidence that a personalized care plan was in place to minimize risk for falling. The electronic care plan dated 8/5/12, indicated the problem Fall/Trauma/Injury Risk (Adult), but had no personalized interventions listed. There was no care plan related to R241's needs with transfers, bed mobility, toileting needs, and/or activities of daily living (ADL). The admission/discharge Minimum Data Set ((MDS) dated [DATE], indicated R241 transferred with one staff's extensive assistance and needed extensive assist with bed mobility. The MDS also indicated R241 used a walker, and balance was not steady, but R241 was able to stabilize with human assistance. The MDS also indicated R241 had a fall in the last one month prior to admission, and did not contain information related to R241's cognition. On 10/3/12, at 9:30 a.m. the director of nursing (DON) was interviewed. After reviewing the care plan the DON verified that no individualized fall risk care plan completed. The DON explained the Epic System was set up in a way, that if someone was at risk for falls, staff was able to access the Clinical Practice Guidelines for Fall/Trauma Injury Risk protocol through a link attached to the site. When the assessment/care planning policy were requested the DON stated they did not have one, they followed the Epic System. The facility's fall reduction policy revised 2/11, indicated transitional care unit residents identified at risk for falling based on Johns Hopkins Fall Risk Assessment Tool, would have appropriate interventions according to the residents risk category. The policy indicated that an interdisciplinary plan of care would identify specific fall precautions and safety interventions as well as documentation to reflect the appropriate interventions were implemented. It indicated, in the event of a call staff should objectively document in the medical record a description of the event, patient reaction to the event, the name of the physician notified and time notified, the name of the family member notified and time notified, actions taken as a result of the event and patient response to any actions taken. This was not done following R241's risk for falls. Urinary incontinence: The physician's orders [REDACTED]. Review of the flow sheet data indicated, R241 was incontinent with bladder on 8/4/12 and on 8/5/12. The registered nurse (RN) progress notes dated 8/9/12, indicated R241 used the bedside commode four times with assist during that shift, and R241 was incontinent once due to urgency. There was no evidence that R241's bladder status was assessed and care planned to meet R241's toileting needs. The electronic care plan dated 8/5/12, lacked interventions for R241's needs with transfers, bed mobility, toileting needs, and/or activities of daily living (ADL). The NP progress notes dated 8/6/12, indicated R241's [DIAGNOSES REDACTED]. The progress note also indicated R241 had low extremity [MEDICAL CONDITION] (+3 pitting), feet were cool to touch, and R241 had fluid increase in abdomen. The admission/discharge MDS dated [DATE], indicated R241 transferred with one staff's extensive assistance, needed limited assist with toilet use and personal hygiene. Per the MDS, R241 was occasionally incontinent with bladder (urine), and was not on any toileting program. The MDS did not contain information related to R241's cognition. On 10/3/12, at 9:30 a.m. the DON was interviewed. The DON confirmed R241's urinary status was not comprehensively assessed, and there were no individualized interventions listed to promote R241's continence status. The DON explained R241's bladder status was not comprehensively assessed since R241 was only two times incontinent on 8/4/12 and 8/5/12. The DON also stated R241 always called when needed assistants to transfer to the commode or toilet, and staff provided assistance as needed. When the assessment/care planning policy was requested, the DON stated they did not have one, and that staff followed the Epic System. On 10/4/12, at 8:15 a.m. the Administrator explained the TCU functioned more like a hospital instead of a nursing home and stated, "Our plan of care is diagnostic driven." The administrator stated that they did not have a policy for care planning. R241 was at risk for falls and was occasionally incontinent. R241 also was prescribed two different diuretic medications, and needed physical assist to transfer to the toilet/commode, there was no evidence that assessment and care plan was completed after R241 was admitted . R241 lacked the necessary care and services to minimize the risk falls and maintain bladder function.

Based on observation, interview and document review the facility the facility did not minimize the risk for falls for 1 of 4 residents (R225) reviewed for accidents. Findings include: R225 was admitted on [DATE], with [DIAGNOSES REDACTED]. R225 experienced a fall on 9/27/12, and the facility did not minimize the risk for further falls by removing identified causative factors, a blue falls mat with commode placed on top of it. The admission MDS dated [DATE], indicated a cognitive review for mental status should not be completed as R225 was rarely or never understood and there was no evidence of an acute change in mental status from her baseline. It identified R225 required extensive assistance of one staff for bed mobility and limited assistance of one staff for transferring, walking in her room, and toileting. It also noted R225 was not steady while moving form seated to standing position, moving on and off toilet and transferring from surface to surface (between bed and chair or wheelchair), but was able to stabilize herself without staff assistance. R225's Care Area assessment dated [DATE], indicated she was impulsive to toilet and required a one to one sitter for impulsive behavior related to her safety. It identified family (F)-A was at the facility most days at her bedside and one to ones were being utilized with a mat on the ground and the bed in a low position. A Johns Hopkins Total Score for Falls Assessment completed on 9/26/12, at 7:00 p.m. indicated R225 scored a 22 which identified her at high risk for falls. R225's Care Plan dated 9/27/12, at 1:56 p.m. indicated R225 was a high falls risk. There were standard interventions initiated for all residents identified at high risk which included: placed near nursing station, monitor when out of bed, bed alarm, door magnet, staff in attendance while toileting, nonskid shoes/slippers, low bed/mattress, and environment modifications with IV pole. The care plan did not indicate that staff should be using a blue falls mat for safety. An ICARE note, which was not part of R225's medical record, dated 9/28/12 at 2:41 a.m. identified R225 fell on [DATE], at 11:41 p.m. The note indicated, "Bed alarm goes off and staff immediately went to pt's {patient} room. RT {writer} is the first one who saw pt and described pt head is {as} leaning on wall with the BSC {bed side commode} tipped over next to the patient. Floor pad was in place but found pt off the floor pad. No bump and redness in the head noted. Pt denies hitting head and denies pain." It identified immediate action included, "VS {vital signs} were taken, Neuro checks done. Assessed for injury and MD {physician} notified." The recommendations for improvement included that R225 required a sitter for 24 hours. The DON reviewed the fall investigation and noted, "Reviewed. Pt has had a trial of no sitter and was doing well, BSC was placed on the floor pad and not sure if this was stable. 1:1 in place." The care plan was not updated at that time to reflect that staff should not utilize the falls mat or place the commode on the falls mat. physician progress notes [REDACTED]. Nursing progress note dated 9/29/12, at 12:09 p.m. indicated fall risk secondary to confusion, impulsive fall precautions, bed/chair alarm and one to one sitter. During observation on 10/1/12, at 4:40 p.m. R225 had a nursing assistant one to one in her room. At 4:45 p.m. MD had discussion with F-A and F-C about a procedure on 10/2/12. At that time R225 sat up to get out of bed and set off her bed alarm. NA-C assisted R225 to the commode. During observation on 10/2/12, at 12:15 p.m. R225 was lying in bed on her right side. F-A was at her bed side. R225 was sleeping quietly in the bed at this time. F-A stated R225 had frequent bladder infections and would get a little "goofy." F-A reported R225 was very impulsive with getting out of bed to use the commode. F-A stated R225 was too quick and last week she fell . F-A reported the blue mat that was leaning against the wall was slippery and likely contributed to her falling. F-A reported when he was there staff had not been using the blue mat. During interview on 10/2/12, at 12:43 p.m. the DON stated R225 did have a fall on 9/27/12. DON reported R225 had an intermittent sitter in the hospital due to impulsiveness. DON stated the facility completed a trial without a sitter and she did well for 36 to 48 hours, and then R225 had a fall. DON stated the investigation the facility completed concluded R225 was up to sit on commode that was placed unstably on top of the blue falls mat. DON stated F-A reported R225 had a history of [REDACTED]. During observation on 10/2/12, at 2:44 p.m. R225 had a blue falls pad folded and leaning against the far wall. During interview on 10/2/12, at 2:45 p.m. NA-B stated she worked with R225 all morning on a one to one basis. NA-B reported R225 had set off her bed alarm three times prior to her procedure at 10:00 a.m. NA-B reported staff get into the room as soon as possible because R225 was not steady on her feet. NA-B stated that she was not sure if other staff use that blue falls mat but she did not. During observation and interview on 10/2/12, at 7:24 a.m. R225 was lying in bed on her left side. The commode was at her bedside and call light was within reach. There was a blue falls mat leaning on the far wall on the other side of the room. NA-D was one to one with R225 overnights. NA-D stated R225 was very restless overnight and was up constantly to use the commode. NA-D reported she was very quick with her movements. Nursing note dated 10/3/12, at 5:59 a.m. indicated R225 was restless that shift and attempted to get out of bed almost every 20 minutes. It identified R225 had a bed alarm on and a nursing attendant at beside for safety. During observation on 10/3/12, at 9:30 a.m. R225 was in her room lying in bed. There was no one to one nursing attendant with R225 and no family present. There was a blue falls mat placed on the floor next to her bed. The commode was placed on top of the blue falls mat toward the foot of the bed. During interview on 10/3/12, at 9:35 a.m. DON confirmed R225 had a blue falls mat placed next to her bed with a commode placed on top of it. DON verified she had identified that as a contributing factor to her pervious fall. DON confirmed the commode should not be place on the mat and was not sure if the mat needed for R225. DON asked NA-A if R225 needed the falls mat placed next to the bed as it may not be safe. During interview on 10/3/12, at 11:37 a.m. NA-A stated R225 was at fall risk because she "jumps out of bed without putting her light on." NA-A stated prior her shift the nursing assistants do a verbal report to one another to communicate residents needs. NA-A confirmed that morning she put the blue falls mat next to R225's bed because the charge nurse told her too for resident safety if she tried to get out of bed on her own. NA-A stated she just followed the charge nurses orders and put the blue falls mat on the floor with the commode on the falls mat. NA-A reported R225's family was frequently in the room during the day and did not require one to one staff monitoring. The facility's fall reduction policy revised 2/11, indicated transitional care unit residents identified at risk for falling based on Johns Hopkins Fall Risk Assessment Tool, would have appropriate interventions according to the residents risk category. The policy indicated that an interdisciplinary plan of care would identify specific fall precautions and safety interventions as well as documentation to reflect the appropriate interventions were implemented. It indicated, in the event of a call staff should objectively document in the medical record a description of the event, patient reaction to the event, the name of the physician notified and time notified, the name of the family member notified and time notified, actions taken as a result of the event and patient response to any actions taken. This was not done following R225's fall.

Based on observation, interview and record review the facility failed to maintain kitchen equipment in a sanitary manner to minimize the risk of food borne illness that had the potential to affect 24 of the 25 resident who resided on the transitional care unit (TCU). Findings include: The initial tour of the kitchen was conducted at 8:30 a.m. on 1/10/12, with the Executive Chef (EC) and the Nutritional Services Operations Manager (NSOM). There were four kitchen appliances in a row in the room services kitchen area next to each other. These included the oven, grill, griddle and merry chef oven. There was brown, black burned substance build up and dry food particles on the bottom and sides of the oven. Per the EC, this oven was used to keep food warm. The grill had thick black gray colored burned build up, the outer edge was covered with aluminum foil, which also had dried, grimy, greasy spills on it. The griddle was next to the grill, and was approximately six inches taller than the grill. The outer right side of the griddle had thick brown grease like burned substance from greasy spills from prior food preparation. The Merry Chef oven had thick black burned substance on the door, bottom and sides. The wall behind the grill and griddle was visibly dirty with shiny, grease spills. The EC verified the above, and stated staff does weekly deep cleaning. Per the EC, staff were expected to clean kitchen equipment after use if got dirty during food preparation. When requested the cleaning schedule for kitchen appliances, the EC explained staff did not use a particular check off list and all staff were trained regarding expectations during orientation. During an interview at 10:45 a.m. on 1/12/12, after the full kitchen tour, the EC stated there was more than a week worth of dirt found on the above listed appliances. The "Definition/cleaning expectations" undated, schedule provided by the EC as cleaning policy on 1/13/12, was reviewed. The policy indicated daily cleaning was expected for Merry Chef oven, "set cool down sequence at closing, clean and sanitize using correct chemicals, including filters." Daily cleaning was expected also for the Flat top (griddle) to "remove all grease and food from the flat top and empty and clean grease trap". The weekly/bi-weekly cleaning schedule (undated) included: "oven - clean and sanitize inside and outside of stove", "char broiler (grill) - remove grates, flame diffusers and drip tray, clean all surfaces of the char broiler", and "wall behind equipment - degrease and clean wall behind stove, flat top, and char broiler."

Based on observation, interview and document review, the facility did not ensure control solutions used for glucometer calibration were not expired in 3 of 4 glucometer kits. This had the potential to affect all five diabetic residents in the facility who currently received blood glucose monitoring. Findings include: On [DATE], expired control solutions used for daily glucometer calibration were observed in three of the four glucometer kits used in the facility. At 8:05 a.m. on [DATE], two blood glucose kits (unlabeled) were observed in the linen/supply room (#406) in the west hall. Each kit was stocked with single use lancets, alcohol pads, SureStepPro glucometer test strips (two bottles), a SureStep Flexx glucometer, and a high and low control solution (sure step pro control) for glucometer calibration. There were cotton balls and extra single use lancets in a small drawer in the front of the kits. Both high controls in the kits had an expiration date of ,[DATE], and a low control in one of the kits had an expiration date of ,[DATE]. All of the controls had been opened; however, there were no open dates on any of the bottles. At 9:05 a.m. on [DATE], two blood glucose kits were observed in the linen/supply room (#425) in the east hall. A kit labeled "4 Rehab (rehabilitation) C" (the other kit was not labeled) had a low control with an expiration date of ,[DATE], and a high control with an expiration date of ,[DATE]. The low control had no open date documented, and the high control had an open date documented on the bottle of ,[DATE]. The manufacturer's instructions for the "SureStepPro" glucose control solution dated ,[DATE], indicated the control solution could be used for three months after opening the vial. The instructions directed to write the open date on the control solution vial when it was first opened, and discard the remaining control solution three months after the vial was first opened. The instructions further indicated, "Do not use control solution that has passed the expiration date." At 9:53 a.m. on [DATE], the registered nurse (RN-B) confirmed the in use controls were expired and immediately discarded them. RN-B stated staff (nurses and aides) had all been trained on calibrating the glucometers, and part of the training was to check that the controls were not expired. RN-B verified staff should be checking the expiration dates, and stated the glucometers were calibrated on the night shift every 24 hours. At 11:45 a.m. on [DATE], the director of nursing (DON) stated the aides should be documenting the open date on the controls, checking the date before calibrating the glucometers, and discarding the solution after three months. The DON added, the control solution could be less effective when expired. At 12:06 p.m. on [DATE], the consultant pharmacist (CP-E) stated if a control was expired it could decrease the effectiveness of the solution for testing. The SureStep Flexx Glucose Meter Quality Control policy dated as effective [DATE], indicated quality control would be completed once per day of use, after cleaning, when a test result conflicts with clinical symptoms, and when troubleshooting the system. The policy directed staff to record the open date on the bottle of the high and low control solutions, discard any unused portion three months after opening, and "Do not use after the expiration date printed on the vial label."

Based on interview and document review, the facility failed to adequately identify, assess, and monitor clinical indications for continued use of blood pressure, antipsychotic, and sleep medications for 2 of 10 residents (R204, R225) in the sample whose medications were reviewed. Findings include: R204 received [MEDICATION NAME] and [MEDICATION NAME] (both medications used to decrease blood pressure) since 12/15/11; however, the physician ordered parameters for use were not followed. R204's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. A review of the Medication Administration Reports (MARs) for December 2011, and January 2012, indicated as follows: December 2011 - [MEDICATION NAME] 75 mg was given on 12/17/11, with a BP of 123/59; on 12/21/11, with a pulse of 58; on 12/24/11, with a BP of 103/62; on 12/29/11, with a BP of 96/60 and a pulse of 59; and on 12/30/11, with a BP of 108/69. According to the parameters directed by the physician the medication should have been held. In addition, [MEDICATION NAME] 5 mg was given on 12/29/11, with a BP of 96/60. The medication should have been held. January 2012 - The [MEDICATION NAME] dosage was decreased on 1/2/12/11, from 75 mg to 50 mg with the same parameters to hold the medication; however, the 50 mg dosage was given on 1/2, with a BP of 101/66, and should have been held. At 11:45 a.m. on 1/12/12, the director of nursing (DON) confirmed R204's blood pressure medications should have been held according to the physician's orders [REDACTED]. R225 received [MEDICATION NAME] 50 mg (antipsychotic medication) TID (three times a day) and Trazadone 50 mg (medication used for depression, and at times for [MEDICAL CONDITION]) at bedtime (HS), without adequate indication and monitoring. R225 was admitted to the Transitional Care Unit (TCU) with [DIAGNOSES REDACTED]. The medication and treatment electronic records were reviewed started on 1/4/12, did not mention to monitor sleep cycle or target behaviors. The nurses progress notes were reviewed since admission, there were no notes related to R225's sleeping pattern or mood/ behaviors. The nurse practitioner's progress notes dated 1/6/12, and 1/4/12 ,did not address [MEDICATION NAME] and Trazadone use. The Medication Management report written by the pharmacist on 1/7/12, indicated "Most medications are clearly indicated and dose correctly with exception of [MEDICATION NAME], no indication found in H&P (history and physical)." The report did not address lack of indication and lack of appropriate monitoring for Trazadone use. There was no evidence that lack of indication for [MEDICATION NAME] use was reported to the physician. The DON was interviewed at 5:55 p.m. on 1/11/12. The DON reviewed the electronic medical record for R225 and stated there was no evidence that staff did any kind of sleeping pattern or behavior monitoring. The DON also verified there was no appropriate indication for [MEDICATION NAME] and Trazadone use. At 6:45 p.m. on 1/11/12, the DON stated the floor nurses reported to her the previous computerized system they used prior March 2011, had built in monitoring for the nurses, however the current Epic system did not replicate that. An interview was conducted with the Consultant Pharmacist (CP-E) at 9:20 a.m. on 1/13/12. CP-E stated when pharmacists find irregularities, the pharmacist will contact the physician for clarifications. After reviewing R225's medical record CP-E verified there was no accurate indication for [MEDICATION NAME] and Trazadone use, and per CP-E's knowledge the Trazadone 50 mg was usually used for [MEDICAL CONDITION]. CP-E reviewed the medication regiment review dated 1/7/12, and verified there was no irregularity identified related to Trazadone use, and did not know if the physician was notified regarding lack of indication for [MEDICATION NAME] use as it was identified on 1/7/12. The policy for [MEDICAL CONDITION] medication use was requested. The DON stated they did not have one. There was no evidence to evaluate the effectiveness of the [MEDICAL CONDITION] medication use.

Based on interview and document review, the consultant pharmacist did not identify the lack of adequate indication and monitoring related to Seroquel and Trazadone use for 1 of 10 (R225) residents reviewed for medication administration. Findings include: R225 was taking Seroquel (psychotropic medication) 50 mg (milligram) TID (three times a day) and Trazadone 50 mg (medication used for depression, and at times insomnia) at bedtime, without adequate indication or monitoring. R225 was admitted to the Transitional Care Unit (TCU) with [DIAGNOSES REDACTED]. The medication and treatment electronic records were reviewed started on 1/4/12, did not mention to monitor sleep cycle or target behaviors. The nurses progress notes were reviewed since admission, there was no note related to R225's sleeping pattern or mood/ behaviors. The nurse practitioner's progress notes dated 1/6/12, and 1/4/12, did not address Seroquel and Trazadone use. The Medication Management report written by the pharmacist on 1/7/12, indicated, "Most medications are clearly indicated and dosed correctly with exception of Seroquel, no indication found in H&P (history and physical)." The report did not address lack of indication and lack of appropriate monitoring for Trazadone use. There was no evidence that lack of indication for Seroquel use was reported to the physician. The Director of Nursing (DON) was interviewed at 5:55 p.m. on 1/11/12. The DON reviewed the electronic medical record for R225 and stated there was no evidence that staff did any kind of sleeping pattern or behavior monitoring. The DON also verified there was no appropriate indication for Seroquel and Trazadone use. At 6:45 p.m. on 1/11/12, the DON stated floor nurses reported to her that the previous computerized system they used prior to March 2011, had built in monitoring for the nurses, however the current Epic system did not replicate that. An interview was conducted with the Consultant Pharmacist (CP-E) at 9:20 a.m. on 1/13/12. CP-E stated when pharmacists find irregularities, the pharmacist will contact the physician for clarifications. After reviewing R225's medical record CP-E verified there was no accurate indication for Seroquel use, and per CP-E's knowledge the Trazadone 50 mg was usually used for insomnia. CP-E reviewed the medication regiment review dated 1/7/12, and verified there was no irregularity identified related to Trazadone use, and did not know if irregularity regarding Seroquel was called to the physician or not. When the policy for psychotropic medication use was requested, the DON stated they did not have one. There was no evidence to evaluate the effectiveness of the psychotropic medication use.

Based on observation and interview, the facility failed to post the current census and staffing hours for public information in a readable format, and did not retain records of census and staffing for the 18 month period required. This failure would affect all of the 24 residents, families and visitors to the facility. Findings include: Two bulletin boards were observed in the main public hallway of the facility that contained numerous messages to the public. Neither of these boards contained the required census and staffing hours sheet. A white board was permanently affixed to the wall, behind the nursing station that listed residents rooms, care givers, and the current census. It did not list the total or actual hours worked by category of staff. At 8:00 a.m. on 1/10/12, the survey team entered the facility,during a brief tour of the unit provided by the administrator, the staff posting was not observed. At 11:30 a.m. on 1/11/12, there was not a current census/staffing hours posting observed. At 1:00 p.m. on 1/12/12, the environmental tour was conducted and no staff/census posting was noted. At 4:15 p.m. on 1/12/12, an interview was conducted with the charge registered nurse (RN-B), and the Administrator. There was a staff assignment board (erasable white board) that contained census information and assignments, but did not contain total hours and actual hours worked by category. The posted white board did not meet the requirements of the regulation and the information was not kept for the required 18 months. At 10:00 a.m. on 1/13/12, the administrator was interviewed. The Administrator stated, "when we put up the white board we thought it met the regulations but we were mistaken".

Based on observation and interview, the facility failed to store and distribute foods under sanitary conditions, which had the potential to affect some of the 15 of the 21 residents. Findings include: During the kitchen tour on 3/21/11, at 3:00 p.m. the following was observed: - there were four soiled fans with brown debris that were blowing on clean dishes in the dishwashing/drying area. The ceiling above one of the fans was also soiled with brown debris. The nutritional director said the fans were cleaned monthly or as needed. - The return air vent in the dishwashing area was soiled with a thick, black residue which was verified by the nutritional director. - There were seven of seven bedside trays stacked with moisture, two of seven bedside trays were cracked/chipped along the edges. - There was an accumulation of brown debris on the hood vent above the hot food preparation area. The nutritional director director said the hood vent was cleaned twice a week, once on the weekend, and verified it did not appear to have been cleaned one-two days ago. - There were four of four Teflon fry pans with scratches and flaking, which were disposed. - The floor in the hot food preparation area was soiled with black residue where a steamer vat was previously located. The nutritional director said the steamer had been removed last Thursday (four days ago).