Every finding on record at Glenridge on Palmer Ranch Inc.

Based on record review, facility policy review, resident and staff interviews, the facility failed to ensure that 1 (Resident #46) of 3 residents reviewed for psychotropic medications had documentation in the medical record to support the continued use of a PRN (as needed) psychotropic medication beyond 14 days.The findings included:Review of the facility provided policy and procedure for Psychotropic Medication Use with an effective date of 12/1/07 and a revision date of 3/1/25 revealed that the policy establishes guidelines for the safe and appropriate use of psychotropic medications in residents in a long term care facility, ensuring safe and effective treatment of mental health conditions, while minimizing risks and adverse effects, in accordance with current practice guidelines and regulatory requirements.The policy specified, PRN orders for psychotropic medications should be limited to no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician/prescriber every 14 days and reviewed by a pharmacist at least monthly . If the physician/prescriber believes that it is appropriate for a PRN psychotropic order . to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for use .Review of the medical record for Resident #46 revealed an admission date of 3/21/26. Diagnoses included but were not limited to sequelae of cerebral infarction (stroke), epileptic seizures, chronic kidney disease, stage 3, and major depressive disorder.Review of the admission Minimum Data Set (MDS) assessment with an assessment reference date of 3/27/26 revealed Resident #46 scored 13 of 15 on the Brief Interview for Mental Status, indicating intact cognitive skills for daily decision making.The physician's order dated 3/26/26 noted to administer lorazepam (psychotropic medication), 1 milligram orally every 4 hours as needed for a diagnosis of anxiety disorder. The stop date for the order was 9/26/26.Review of the Medication Administration Record (MAR) from 3/26/26 through 6/11/26 revealed that Resident #46 received one dose of lorazepam on 3/26/26 at 8:22 p.m., and one dose of lorazepam on 6/10/26 at 3:56 a.m. On 3/26/26 the licensed nurse documented anxious/restless for the PRN administration of the lorazepam. On 6/10/26, the nurse documented C/O (complain of) sob (shortness of breath) . becoming anxious for the PRN administration of lorazepam. Both times, the nurse documented the lorazepam was effective. No other dose of lorazepam was documented on the MAR from 3/26/26 through 6/11/26. The clinical record lacked documentation that non-pharmacological interventions were ruled out to treat Resident #46.On 3/26/26 at 1:59 p.m., the physician documented in a progress note, Worsening chronic illness. Patient is comfort measures/end of life care at this facility due to progressive severed debility. We have him on Ativan (lorazepam) PRN in order to control his anxiety attacks. He is using it quite regularly for this purpose. He endorses dyspnea (difficulty breathing) which causes severe anxiety and this helps calm him down and keep him comfortable. Assessment & Plan: End of life care- Continue comfort measures including Ativan for anxiety and panic attacks. Can preemptively be given for anxiety related to dyspnea .On 3/30/26, the physician documented in a progress note, He is effectively on hospice at his facility. We have him on Ativan PRN in order to control his anxiety attacks. He is using it quite regularly for this purpose. He endorses dyspnea which causes severe anxiety and this helps calm him down and keep him comfortable .The Consultant Pharmacist's monthly medication regimen review for Resident #46 for 4/2026 and 5/2026 failed to address the use of the PRN lorazepam beyond 14 days.On 6/10/26 at 12:42 p.m., in an interview, Registered Nurse (RN) Staff D said that PRN psychotropic drugs were limited to 14 days. The order must be renewed or changed to routine after 14 days. On 6/10/26 at 12:45 p.m., in an interview, RN Staff C said that Resident #46 was on comfort care, not on hospice. RN Staff C said that she was not sure if an order for PRN lorazepam needed a 14-day stop.On 6/10/26 at 12:48 p.m., in an interview, the Director of Nursing (DON) said that a physician's order for PRN lorazepam is limited to 14 days, unless the provider believes it is appropriate to extend the order beyond 14 days, but Resident #46 was comfort measures. The DON said that the facility's comfort care guidance specifies a stop date of 6 months from the start date for PRN lorazepam.Review of the facility provided policy and procedure (undated) titled, Comfort Care revealed, Comfort Care Guidance . Medication interventions may include . Lorazepam intensol oral 2mg/ml give 0.25 ml-0.5 mg every 4 hours PRN. Stop date of 6 months from start date .On 6/11/26 at 9:04 a.m., in a telephone interview, the consultant pharmacist verified that he reviewed Resident #46's medication regimen in April 2026 and May 2026 but did not make recommendations to the prescribing physician related to the continued use of the PRN lorazepam beyond 14 days since the order had a stop date of 9/26/26. He said that when he started working at the facility, he was told that the facility's comfort care policy included the use of PRN lorazepam for six months. He said that he was not going to make the recommendation to the physician just to have it declined.On 6/11/26 at 12:55 p.m., in an interview, Resident #46 said he only got the lorazepam about once. He said that the nurse gave him the lorazepam for wheezing. He really wanted his inhaler, but it was out of stock. Resident #46 said that he was not anxious and had never taken lorazepam before. He was not sure what it would do to him. The nurse said that it would relax him and he agreed. He said that he fell asleep after taking the medication. Resident #46 said that he does not have anxiety, and he is not taking lorazepam on a regular basis.On 6/11/26 at 1:52 p.m., in a telephone interview, Resident #46's physician said that he ordered the lorazepam after the resident was admitted to the facility to keep him comfortable. He said that the pharmacist did not tell him the lorazepam order required a 14-day stop date. He would have discontinued the medication if he had known that Resident #46 only had two doses of the lorazepam since it was ordered in March. The physician said that he did not know why he documented in his notes on 3/26/26 and 3/30/26 that the resident takes the Ativan regularly.

Based on observations, record review, facility policy review, resident and staff interviews, the facility failed to ensure the safe storage of medications at the bedside for 1 (Resident #10) of 5 residents sampled for medication storage.The findings included:Review of the facility provided policy and procedure for Storage and Expiration Dating of Medications and Biologicals with an effective date of 12/01/07 and revision date of 6/30/25 revealed, Bedside Medication Storage : Facility should not administer/provide bedside medications without a Physician/Prescriber order and approval by the interdisciplinary Care Team and facility administration. Facility should store bedside medications or biologicals in a locked compartment within the resident's room.On 6/8/26 at 1:08 p.m., observation of Resident #10's room revealed two bottles of over the counter eye drops used to quickly relieve eye redness stored on the resident's bedside table. In an interview, Resident #10 said she uses the eye drops when she wakes up in the morning to relieve redness and dryness. Photographic evidence obtained.On 6/8/26 at 1:13 p.m., review of the clinical record for Resident #10 failed to reveal a physician's order for the over the counter eye drops observed stored on the resident's bedside table.On 6/8/26 at approximately 1:15 p.m., in an interview, Licensed Practical Nurse (LPN) Staff A said that Resident #10 had no order for eye drops and she did not know if the resident was able to self-administer the eye drops.On 6/9/26 at 9:33 a.m., Resident #10's room was observed with LPN Staff B. The over the counter bottles of eye drops remained at the resident's bedside. Resident #10 was holding one bottle and one bottle was observed on the resident's bedside table. In an interview, LPN Staff B verified that the over the counter bottles of eye drops were not stored properly. She said that on 6/8/26, she heard about the unsecured bottles of the over the counter eye drops stored on the resident's bedside table.

Based on record review, staff and resident interview, the facility failed to produce written documentation, the resident and the representative, if applicable, were provided with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 5 (Resident #2, #6, #51, #54 and #157) of 6 residents reviewed for baseline care plans. This had the potential to cause confusion as to the care expected to be provided by the facility. The findings included: 1. On 7/15/19 at 1:22 p.m., Resident #2 said she was not sure if she ever received a written summary of the baseline care plan. She said whatever she received was in the green folder in her bottom drawer. After receiving permission from the resident to view the folder, there was no evidence of a written summary of the baseline care plan and no list of medications and dietary instructions. On 7/17/19, record review revealed there was no evidence a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instructions was provided to the resident or resident representative as required. 2. On 7/15/19 at 10:33 a.m., Resident #6 said she did not recall ever receiving a written summary of the baseline care plan. On 7/17/19, record review revealed there was no evidence a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instructions was provided to the resident or resident representative as required. 3. On 7/15/19 at 11:33 a.m., Resident #54 said she did not recall ever receiving a written summary of the baseline care plan. On 7/18/19, record review revealed there was no evidence a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instructions was provided to the resident or resident representative as required. 4. On 7/17/19 at 9:52 a.m., Resident #51 said he did not recall ever receiving a written summary of the baseline care plan. On 7/16/19, record reviewed revealed there was no evidence of a written summary of the baseline care plan which included initial goals, and a summary of current medications and dietary instruction was provided to the resident or resident representative as required. 5. In an interview on 7/15/19 at 11:42 a.m., the spouse of Resident #157 said he was not sure of the facility's plan for toileting the resident. The spouse said the resident was not incontinent but required a lift to transfer to the toilet. The spouse said the resident had been in the facility nine days and was not getting to the toilet often enough. The spouse also said there was an issue with the medications and the resident was not getting the medications she was on prior to going to the hospital for surgery. The spouse said it took a week to get the medications straightened out and the resident had increased behavior issues. In an interview on 7/17/19 at 1:31 p.m., the Minimum Data Set (MDS) Coordinator said when the facility initially started the process of reviewing the baseline care plan summary with the resident/family, the form was hand written with service and treatment goals and listed the resident's medications. The MDS Coordinator said the form included a statement, signed by resident/responsible person, and that a copy was received. The MDS Coordinator said management pointed out that the electronic medical record had the capacity to print a summary of baseline care plans. The facility changed to using the care plan summary printout from the electronic system. The MDS Coordinator said the new printed form did not contain the statement that the resident received a copy. The MDS Coordinator said now there was no documentation that the resident received a copy of the summary. A review of the computer-generated baseline care plan summary for Resident #157 found a generic list of goals and an list of physician orders [REDACTED]. The baseline care plan summary for Resident #157 did not specify the services and treatments to be administered by the facility and personnel acting on behalf of the facility nor did the baseline care plan summary include any updated information based on the details of the comprehensive care plan. In an interview on 7/18/19 at 12:05 p.m., the Assistant Director of Nursing, the Nursing Supervisor, and the MDS Coordinator acknowledged there was no documentation the resident/family received a copy of the baseline care plan summary. The nursing managers said the facility was using the baseline care plan summary as generated by the electronic medical record system. The nursing managers acknowledged that the summary, as generated, was not easily understood by residents and family. The MDS Coordinator said she read the document to the residents and family and verbally interpreted and expanded descriptions of services but did not revise the document. The MDS Coordinator said she did not include updated information of services and treatments in the summary. The MDS coordinator acknowledged that for Resident #157 there had been changes in medication and diet orders from the time of the resident's admission to the facility to the time the baseline care plan summary was generated. The baseline care plan summary was not formatted to be easily understood by residents and family and was not specific in the services and treatments to be administered.

Based on observation, record review, policy review, staff, resident and resident representative interview, the facility failed to ensure 11 (Residents #50, #3, #34, #44, #19, #27, #9, #23, #1, #28, and #47) of 11 residents reviewed for accidents were assessed for danger of entrapment prior to use of side/bed rails or attempted alternative interventions prior to the use of bed rails. In addition, the facility failed to ensure they had informed the residents and/or their representative of the risks versus benefits of bed rails, obtain an informed consent prior to use of the bed rails, and conducted periodic maintenance of the bed rails to ensure they remained safe for residents use. This had the potential to cause serious injury to the residents. The findings included: The facility's policy for Proper Use of Side Rails (bed rails), Policy #1408, last date revised 11/28/16 stated: The facility will attempt to ensure that residents will be afforded appropriate alternatives prior to installation of a bed rail, included but not limited to the following elements: 1. Assess the resident for risk of entrapment from bed rails prior to installation. 2. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. 3. Ensure, that the bed's dimensions are appropriate for the resident's size and weight. 4. Follow the manufacturer's recommendations and specifications for installing and maintaining bed rails. 1. On 6/18/18 at 10:25 a.m., bilateral ¼ bed rails were observed in the up position on the bed of Resident #50. At the time of observation, Resident #50 said she used the bed rails to help get in and out of bed. On 6/19/18, record review of Resident #50 revealed no documented evidence the resident was assessed for alternative interventions prior to use, no documentation Resident #50 was informed of the risks and benefits of bed rails, no documentation of informed consent and no documented evidence periodic maintenance of the bed rails was performed. 2. On 6/18/18 at 12:11 p.m., bilateral ¼ bed rails were observed in the up position on the bed of Resident #3. Resident #3 had been determined to be incapacitated. On 6/19/18, record review of Resident #3 revealed no documented evidence the resident was assessed for alternative interventions prior to use, no documentation the resident representative for Resident #3 was informed of the risks and benefits of bed rails, no documentation of informed consent and no documented evidence periodic maintenance of the bed rails was performed. 3. On 6/18/18 at 12:12 p.m., Resident #34 observed in bed with bilateral ¼ bed rails in the up position. Resident #34 had been determined to be incapacitated. At the time of observation, Resident #34's spouse said no one had discussed the risk versus benefits or obtained consent for the use of bed rails. On 6/19/18, record review of Resident #34 revealed no documented evidence the resident had been assessed for alternative interventions prior to use, no documentation the resident representative for Resident #34 was informed of the risks and benefits of bed rails, no documentation of informed consent and no documented evidence periodic maintenance of the bed rails was performed. 4. On 6/18/18 at 2:14 p.m., bilateral ¼ bed rails were observed in the up position on the bed of Resident #44. At the time of observation, Resident #44 said she used the bed rails to help get in and out of bed. On 6/19/18, record review of Resident #44 revealed no documented evidence the resident was assessed for alternative interventions prior to use, no documentation Resident #44 was informed of the risks and benefits of bed rails, no documentation of informed consent and no documented evidence periodic maintenance of the bed rails was performed. 5. On 6/18/18 at 9:45 a.m., Resident #19 was observed sleeping with ¼ bed rails in the up position. Resident #19 had been determined to be incapacitated. On 6/19/18, record review of Resident #19 revealed no documented evidence the resident was assessed for alternative interventions prior to use; no documentation the resident representative for Resident #19 was informed of the risks and benefits of bed rails, no documentation of informed consent and no documented evidence periodic maintenance of the bed rails was performed. 6. On 6/18/18 at 2:17 p.m., Resident #27 was observed sleeping with ¼ bed rails in the up position. Resident #27 had been determined to be incapacitated. On 6/19/18, record review of Resident #27 revealed no documented evidence the resident was assessed for alternative interventions prior to use; no documentation the resident representative for Resident #27 was informed of the risks and benefits of bed rails, no documentation of informed consent and no documented evidence periodic maintenance of the bed rails was performed. 7. On 6/19/18 at 8:44 a.m., during interview, Resident #9 said she liked the bed rails up at night for security and to help her reposition in bed when needed. A review of Resident #9's chart revealed no documented evidence the resident was assessed for alternative interventions prior to the use of the bed rails, no documentation that Resident #9 was informed of the risks of entrapment with the use of bed rails and the facility was unable to provide documentation periodic maintenance of the bed rails was performed. 8. On 6/18/18 at 10:46 a.m., and on 6/20/18 at 9:21 a.m., Resident #23 was observed in bed with bed rails on both sides of the bed in the up position. A review of Resident #23's chart revealed no documented evidence the resident was assessed for alternative interventions prior to the use of the bed rails, no documentation that Resident #23 was informed of the risks of entrapment with the use of bed rails and the facility was unable to provide documentation periodic maintenance of the bed rails was performed. 9. On 6/19/18 at 10:03 a.m., Resident #1's bed was observed to have bed rails. Resident #1 said she used the rails to help her move and transfer out of bed. Resident #1's chart revealed no signed consent, no documented evidence the resident was assessed for alternative interventions prior to the use of the bed rails, no documentation Resident #1 was informed of the risks and benefits of bed rails and the facility was unable to provide documentation periodic maintenance of the bed rails was performed. 10. On 6/19/18 at 10:05 a.m., Resident #28 was observed lying in bed with bed rails up. Resident #28's chart revealed no signed consent, no documented evidence resident was assessed for alternative interventions prior to the use of the bed rails, no documentation Resident #28 was informed of the risks and benefits of bed rails and the facility was unable to provide documentation periodic maintenance of the bed rails was performed. 11. On 6/19/18 at 10:04 a.m., bedrails were noted to be raised on Resident's #47's bed. Resident #47's chart revealed a consent for siderails signed by Resident #47 and nurse on 11/28/17. Resident #47's chart revealed no assessment for alternative interventions, no evidence of assessment for entrapment and the facility was unable to provide documentation that periodic maintenance of the bed rails was performed. On 6/20/18 at 10:21 a.m., the Maintenance Director said when they received a work order for the bed rails they would look at them. The Maintenance Director said no regular scheduled maintenance was done to them. On 6/21/18 at 7:55 a.m., in an interview, the facility Assistant Director of Nursing confirmed the facility failed to ensure residents were assessed for entrapment prior to installation of bed rails. In addition, she confirmed there was no documented evidence residents were assessed for alternative interventions; risks and benefits were discussed with the resident or resident representative prior to use or an informed consent was obtained prior to use of bed rails.

Based on record review and staff interview, the facility failed to ensure documented rationale was provided when pharmacy recommendations were denied for 1 (Resident #1) of 5 residents sampled for medication review. This has the potential for the resident to receive unnecessary medication. The findings included: On 8/16/17, record review of the medications for Resident #1 revealed the following: 1. Pharmacy recommendations dated 9/7/16, 12/6/16, 3/5/17, and 6/15/17 noted Resident #1 was receiving [MEDICATION NAME] (a medication used to treat anxiety) 0.25 mg daily at bedtime. The [MEDICATION NAME] was originally started in June, 2016. The recommendation was to consider a gradual dose reduction (GDR) to ensure the resident was receiving the lowest possible/effective optimal dose. The physician disagreed with each recommendation but failed to provide any documented rationale for the disagreement. 2. Pharmacy recommendations dated 11/7/16 and 5/2/17 noted Resident #1 was receiving [MEDICATION NAME] (a medication used to treat depression and anxiety) 10 mg daily. The [MEDICATION NAME] was originally started in May, 2016. The recommendation was to consider a gradual dose reduction (GDR) to ensure the resident was using the lowest possible/effective optimal dose. The physician disagreed with each recommendation but failed to provide any documented rationale for the disagreement. 3. Pharmacy recommendation dated 8/9/16 noted Resident #1 was receiving [MEDICATION NAME] (an atypical, antipychotic medication used to improve behavior, thinking, and mood) 0.25 mg three times a day. The [MEDICATION NAME] was originally started in May, 2016 for a [DIAGNOSES REDACTED]. The recommendation was to evaluate current therapy to assure resident is receiving the lowest possible dose and document why the benefits of therapy outweigh the risk. The physician disagreed with the recommendation but failed to provide any documented rationale for the disagreement. 4. Pharmacy recommendation dated 1/17/17 noted [MEDICATION NAME] can cause drowsiness and depression. [MEDICATION NAME] is a long acting benzodiazepine and should be avoided in the older population. Due to their long half-life leading to sedative side effects such as confusion, cognitive impairment, increased fall risk and unsteadiness, [MEDICATION NAME] should not be used. Evaluate the continued use of [MEDICATION NAME] 0.25 mg at bedtime. In addition, the recommendation noted, [MEDICATION NAME] can cause [MEDICAL CONDITION]/fatigue. Recommend reducing the [MEDICATION NAME] to 5 mg daily. The recommendation also included [MEDICATION NAME] 0.25 mg in the morning and 0.5 mg at lunch and evening can cause fatigue, sedation, constipation, dry mouth, and nausea/vomiting and recommended reducing the [MEDICATION NAME]. The physician disagreed with the recommendations but failed to provide any documented rationale for the disagreement On 8/16/17 at 9:01 a.m., the facility's pharmacy consultant confirmed the physician disagreed with each pharmacy recommendation for Resident #1 but failed to provide any documented rationale for the disagreement. She said it is very hard to get the doctors to provide any documented rationale. She added, I have identified this every month but nothing changes. On 8/16/17 at 9:32 a.m., the facility's Director of Nursing confirmed the physician disagreed with each pharmacy recommendation for Resident #1 but failed to provide any documented rationale for the disagreement. She said the facility has addressed the issue about not providing documented rationale with the physician multiple times, but he does not comply. She added, He just does his own thing.

Based on observation, record review and interviews, the facility failed ensure standard precautions were followed when doing a procedure with exposure to bodily fluids, for 1 (Resident #71) of 1 resident observed for blood sugar monitoring. The failure to follow standard precautions had the potential for cross contamination and expose other residents to possible infection with blood borne pathogens. The findings included: The facility's policy for Infection Control/Standard Precautions said standard precautions applied to blood, body fluids, secretions, and excretions regardless of whether or not they contained visible blood, non-intact skin and mucous membranes. Wash hands after touching blood, bodily fluids, and contaminated items, whether or not gloves were worn. Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. On 7/27/16 at 11:24 a.m., Registered Nurse (RN) Staff A was prepared to do a [MEDICATION NAME] (to check blood sugar level) procedure on Resident #71. Staff A said she had already washed her hands before gathering her equipment. Staff A entered Resident #71's room and without applying gloves preceded to do a finger stick to obtain a blood sample from the resident's finger. Staff A after obtaining the blood sample left the room and was not observed washing her hands. Staff A brought out the [MEDICATION NAME] machine and set it on the medication cart. Staff A briefly wiped the machine with a sani-wipe (disinfectant wipe) and set it on a paper towel to dry. Staff A did not wash her hands after handling the potentially contaminated device. Staff A then preceded to draw up Humalog insulin to administer to Resident #71. After preparing the syringe, she entered Resident #71's room and administered the insulin. She then wiped the injection site on the resident's abdomen and left the room without washing her hands. Staff A disposed of her supplies at the cart, and preceded to make entries on the computer. On 7/27/16 at 11:37 a.m., RN Staff A confirmed she did not wear gloves when obtaining a fingerstick blood sample or when giving an injection. Staff A said she did not think she had to and was unsure of what the facility policy may be. Staff A said she washed her hands prior to going into the residents room to obtain the finger stick and used sanitizer afterwards but confirmed she did not wash her hands. Staff A confirmed she did not wash or sanitize her hands after administering the resident an injection. Staff A said she did not usually wash her hands before exiting a resident's room after contact with the resident but will sanitize her hands using a sani-wipe when she got back to her medication cart. On 7/27/16 at 3:50 p.m., the facility's Infection Control Nurse confirmed staff were to wear gloves and practice good handwashing when there was a potential for contact with bodily fluids. She acknowledged Staff A did not follow the facility's policy for standard precautions.

Based on observation and interviews, the facility failed to maintain the laundry room in a clean and sanitary manner to prevent potential contamination of resident linens. The findings include: On 7/16/15 at 10:46 a.m., a tour of the facility's laundry area was conducted along with the Assistant Director of Nursing/Infection Control Designee. In the clean linen area the following observations were made: there were openings into the ceiling several inches wide around 3 of the 3 pipes, with a 12 inch by 3 inch open area located near stacks of clean linen; a large laundry ironing machine spanned the length of the wall was observed to have multiple areas of rust, was heavily soiled with dust, and several stacks of clean linen was observed leaning against the machine and the belts. In an interview with a laundry worker (Staff A) at the time of the observation, she said the ironing machine is cleaned by a service company every 3 months. Staff B was present and said the top of the ironing machine is to be cleaned weekly but did not believe the belts of the machine had been changed or cleaned in the last year. Staff B confirmed the openings into the ceiling around the pipes and said she would let maintenance know. **Photographic evidence on file**

Based on observation, record review, and interviews, the facility failed to post the total number of actual hours worked for the Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) that were on duty each day. The findings include: On 7/14/15 at 9:30 a.m., during a tour of the facility, the posting for the number of nursing staff on duty was observed at the front desk in the lobby. The posting did not have the number of RN staff or LPN staff identified or the actual hours worked. On 7/15/15 at 2:05 p.m., in an interview with the facility's staffing coordinator, he said he does the daily posting of staffing numbers and has only been putting the number of staff on duty not the actual hours worked. On 7/15/15 at 2:21 p.m., in an interview with the Director of Nursing, she confirmed the current posting format did not include the actual hours worked by RN, LPN and CNA staff.

Based on observations, record reviews and interviews, the facility failed to maintain a medication administration error rate of less than 5% as evidenced by 2 medication administration errors in 29 observed opportunities (6.8%). The findings include: 1. On 6/17/14 at 8:44 a.m., surveyors observed Staff A, a Licensed Practical Nurse (LPN), administer Vitamin B 12 1000 mcg 1 tablet to Resident #61. The medication card indicated the tablet was to be given sublingually (under the tongue). The resident was handed the tablet in a medication cup and given a glass of thickened water to drink with the pill. Staff A did not instruct the resident to place the pill under her tongue or not to swallow it. The resident's clinical record was reviewed and it was revealed that it contained a physicians order, dated 3/3/14, for the medication Vitamin B-12 1000 mcg to be given daily sublingually. On 6/17/14 at 8:57 a.m., the surveyors confirmed this finding with Staff A who stated the resident usually swallows the pill. 2. On 6/18/14 at 8:49 a.m., surveyors observed Staff B, a Licensed Practical Nurse (LPN), administer the medication [MEDICATION NAME] XR 60 mg to Resident #50. The medication card had a pharmacy sticker on it instructing staff the medication was to be given on an empty stomach. On interview with Resident #50 at the time of the administration, she stated to the surveyors that she had eaten breakfast and had just returned to her room. The surveyors asked Staff B what drug reference book the facility used and she showed the surveyors a 2014 Nursing Drug Handbook by Lippincott, Williams & Wilkins. On page 1405, under administration, the reference directed the medication [MEDICATION NAME] was to be given at least an hour before a meal or on an empty stomach. On 6/18/14 at 9:30 a.m., the surveyors confirmed with Staff B that the pharmacy recommendation and facility's drug reference book indicated the medication was to be given on an empty stomach. Staff B stated the medication was not scheduled for a specific time but would change it to be given at least 1 hour before breakfast.

Based on observations and interviews, the facility failed to ensure medications were not expired and failed to ensure medications were stored under proper temperature. The findings include: 1. During observation on [DATE] in the Medication Prep room the surveyor did a spot check of the emergency drug kit (EDK). The EDK contained Zolpidem 5 milligrams with expiration date [DATE]. At 9:40 a.m., Staff C confirmed the medication was expired. 2. During observation on [DATE] in the Med Prep room, the surveyor noticed the room was warm. Initial check showed the room temperature was 80 degrees. Reviewing the acetaminophen on the shelf, the manufacturer's label instructed, store at ,[DATE] degrees Fahrenheit. At 1:25 p.m., the surveyor calibrated his thermometer. At 1:30 p.m., the surveyor placed the calibrated thermometer on a shelf on in the Med Prep room. A recheck of the thermometer at 1:55 p.m., showed 80 degrees. At 1:56 p.m., Staff C confirmed the 80 degree reading. The staff nurse said, "It's always been warm in this room."

Based on observation, clinical record review, and staff interview the facility failed to complete accurately a Minimum Data Set (MDS) and a Significant Change assessment which reflects the resident ' s dietary, nutritional status for 3 (Resident #27, #55 and #70) of the 3 residents sampled for nutritional status. The facility ' s lack of current accurate assessments contributed to delays in initiating dietary intervention which would prevent weight lost for residents at risk for nutritional issues. The findings include: 1. A review of Resident #27 ' s medical record documenting [DIAGNOSES REDACTED]. Record review and staff interview identified Resident #27 met the criteria for significant weight loss per the Minimum Data Set - Significant Status Change, underweight; and not receiving a nutritional supplement per staff interview. The medical record review documented Resident #27 had a fall and was sent to the hospital on [DATE]. Resident #27 returned to the facility on [DATE], with the [DIAGNOSES REDACTED]. The resident's last weight before hospitalization was noted as 102.6 pounds (lbs.) taken on 4/10/2013. The Nursing Admission Assessment, dated 4/16/2013, does not provide an admission weight. The next weight is noted on 4/22/2013, at 101.8 lbs., which is 6 days post hospitalization . The next weight is noted on 5/6/2013 at 97 lbs. and the most recent weight is documented on 5/14/2013 at 94.4 lbs. The medical record review of the Nutritional Services Care Plan, revision date of 4/17/2013, documented "Now on pureed diet." A review of diet order and communication dated 4/16/2013 noted "Diet Regular Pureed." The 4/19/2013 order noted "Pureed may have up to 6 oz. mechanical soft foods up on request for pleasure. " The 4/23/2013 order noted, "Diet change Mechanical Soft." The 4/29/2013 order noted "Dining room changes to patient eat in restorative dining room. " A review of the Minimum Data Set (MDS) Significant Change Assessment, dated 4/23/2013, section K0200 documented weight as 101 lbs. and section K0510 as D -" Therapeutic diet (e.g., low salt, diabetic, low cholesterol)." The medical record review did not provide documentation of orders for a Therapeutic Diet. A resident observation was conducted on 5/14/2013 at 1:00 p.m. Resident #27 was observed in the dining room with a cup of chili in front of her. She ate approximately 25%. On 5/15/2013, at 7:30 a.m., Resident #27 was observed in her room eating breakfast, consuming approximately 50% of the meal. During interview on 5/14/2013, at 3:00 p.m., the Dietary Manager stated she did not know who performed the assessment on the MDS, which documented Resident #27 was on a therapeutic diet. She continued to state she was not in the position during the assessment period. She stated Resident #27 is on a regular mechanical soft diet. During interview on 5/15/2013, at 8:00 a.m., the MDS Coordinator stated, "There is an error, I am unsure where the order for the therapeutic diet came from, I do not complete each of the sections on the MDS, I depend on dietary to complete section K of the MDS. While we did not have a Dietary Manager at that time I am not sure who completed that section. I will have to check. There was a definite decline in the resident's condition when she returned for the hospital. She has been with us for some time and has had a history of [REDACTED]. I will have to check to see where that came from." During interview on 5/15/2013, at 8:45 a.m., the Registered Dietician stated "Several of the residents fall through the cracks with weight issues. I am going to state something should have been done last week, week and a half; I was out of town for a week. The facility did not have a Dietary Manager for almost a month and the resident was not brought to my attention on a communication sheet. I am scheduled to make weekly visits to the facility." It was confirmed a nutritional supplement were not provided. The Registered Dietician stated we started Resident #27 on Med Pass 2.0 - 3 oz. - three times a day yesterday, 5/14/2013. During interview on 5/15/2013, at 10:00 a.m. the Medication Nurse on the Green Wing stated "I made an error, I made the wrong selection on the dietary section the resident is not on a Therapeutic diet, and she is on a Regular Mechanical Soft diet this was done on 4/23/2013." The Dietary Manager, the Registered Dietician, the MDS Coordinator, and the Medication Nurse confirmed the therapeutic diet noted on the MDS was an error. The MDS does not provide an accurate assessment of Resident #27 ' s current dietary status. The Registered Dietitian ' s note, dated 5/14/2013, included Med Pass 2.0 - 3 oz. - three times a day; will monitor weekly weights may also try fortifying some appropriate favorite foods if this intervention does not promote a weight gain. 2. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review and staff interview identified Resident #55 met the criteria for a significant weight loss which is noted as follows: ? Minimum Data Set (MDS) on 2/08/2013 recorded a weight of 179 pounds (lbs.) ? MDS on 2/13/2013 recorded weight is 171 lb. ? Most recent weight recorded on 05/07/2013 indicated the resident weight is at 153.6 lbs. This calculates out to a 15% weight loss, which is considered significant. Resident #55's weight upon admission was documented at 217 pounds (lbs.). After an interview on 5/14/2013 at 2:00 p.m., about the weights, the Certified Dietary Manager (CDM) identified the weight was incorrect. The CDM explained the Restorative staff member that recorded the weight forgot to subtract the weight of the wheel chair. Review of the most recent MDS, dated [DATE], including Section K, the nutrition was not coded for nutritional issues and did not identify the significant weight loss. Review of the resident's clinical record revealed the failure to update the nutritional assessment, which would have been completed by the Registered Dietitian (RD). The Certified Dietary Manager (CDM) was asked on 5/14/2013 at 2:00 p.m., about the nutritional assessment for Resident #55. The CDM said she had just been hired into the position of CDM, but would research to see if there was a nutrition assessment noted on the resident ' s clinical record. The CDM stated that she was in the process of completing her section of the nutritional assessment on Resident #55, and would consult with the RD to complete the assessment. The CDM stated that the facility had been without a CDM for the past month, and the resident might have been over looked in regards to his significant weight loss for this reason. The CDM stated the Registered Dietitian had been on vacation, and before leaving for vacation was not made aware of the resident needed an assessment to establish nutritional interventions in regards to Resident #55's nutritional needs for his weight loss. On 05/15/2013 at 9:00 a.m., the RD was interviewed about Resident #55 ' s significant weight loss. The RD stated she was not made aware of the resident significant weight loss, but was in the process of initiated a nutritional assessment for Resident #55. 3. Resident #70 was readmitted to the facility on [DATE] from the hospital due to a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), including Section K, Nutrition was not coded for nutritional issues. Review of the clinical record did not document a nutrition assessment for Resident #70. The Certified Dietary Manager (CDM) was asked on 5/14/2013 at 2:00 p.m. about the nutritional assessment for Resident #70. The CDM said she had just been hired into the position of CDM, but would research to see if there was a nutrition assessment noted on the resident's medical record. The CDM stated that she was in the process of completing her section of the nutrition assessment on Resident #70.

Based on staff interview and record review, the facility failed to honor the Resident Rights regarding the right to be fully informed of health status for 2 (Resident #30 and #55) of 3 residents sampled. The findings include: 1. A review of the facility record for Resident # 30 was conducted on 05/14/2013. The nursing notes were reviewed. On 03/4/2013 the nurse documents the "...Medical Doctor (MD) and family made aware of an injury to the right shin." On 03/10/2013 the nurse documented Resident #30 has two open areas on the right buttock. The areas are documented as a 1.0 X 0.5 centimeters (cm) and the other area is 0.5 cm. A review of the facility documentation did not include the notification of the responsible party of the change in skin condition. The facility was unable to present documentation the change in skin condition was communicated to the responsible party. The next nursing entry is dated 03/14/2013. On 03/14/2013 the nurse documents the current status of Hospice was discussed with the responsible party. Review of the documentation provided by the facility does not include documentation of informing Resident #30 ' s responsible party regarding the change skin condition and the treatment for [REDACTED]. 2. A review of the facility ' s hospital transfer report documented Resident #55 was assessed and sent to hospital for [MEDICAL CONDITION] on 05/7/2013. A review of the facility ' s hospital transfer report was conducted on 05/14/2013. The transfer report had an entry for "Contact Person" with a check mark entry next to "Relative." The entry for "Notified of transfer?" and "Aware of clinical situation?" are blank without entry. The Director of Nursing (DON) was interviewed on 05/14/2013 at 4:00 p.m. The DON confirmed the information regarding the contact person was incomplete. The DON stated "I will check with the nurse, it is not documented on the sheet." An interview with the DON was conducted at 10:38 a.m., on 05/15/2013. The DON presented a copy of the transfer document. The DON nodded in an affirmative head motion in agreement the section for "Contact Person" section was not complete. The facility failed to notify responsible party for 2 of the 3 resident's sampled.

Based on interview and record review, the facility failed to ensure that 1 (Resident #55) of 3 residents sampled for poor nutritional status, had a revised comprehensive care plan. Resident #55 did not having a care plan to identify a significant weight loss, including Nutritional Interventions. The findings include: Resident #55 was admitted to the facility on [DATE] with a diagnosis, including [MEDICAL CONDITION] and Diabetes Mellitus. Resident #55 was documented to have a significant weight loss: ? Minimum Data Set (MDS) on 2/08/2013 recorded a weight of 179 pounds (lb.) ? MDS on 2/13/2013 recorded weight of 171 lb. ? Most recent weight recorded on 05/07/2013 documented Resident #5 ' s weight at 153.6 lbs. This calculates out to a 15% weight loss, which is considered significant. A review of Resident #55 ' s Comprehensive Care Plan, dated 2/14/2013, revealed a failure to identify concerns, goals, or interventions for a significant weight loss. A review of Resident #55 ' s clinical record failed to demonstrate that the Registered Dietitian (RD) had identified the significant weight loss in the Nutritional Assessment that would include interventions to prevent further weight loss. A review of Resident #55 ' s Comprehensive Care Plan, dated 2/14/2013, revealed a failure to be updated to reflect the significant weight loss, or nutritional interventions put in place to prevent further weight loss. During an interview on 5/14/2013 at 2:00 p.m., the Certified Dietary Manager (CDM) was questioned on whether there was a nutritional assessment or an updated care plan for Resident #55. The CDM stated she had just been hired into the position of CDM and she would research to see if there was a nutrition assessment or an updated care plan documented on the resident's clinical record. The CDM stated that the facility had been without a CDM for the past month, and Resident #55 might have been over looked in regards to his significant weight loss for this reason. The CDM said the Registered Dietitian had been on vacation, and before leaving for vacation was not made aware of the resident needing further interment for the weight loss. During an interview on 05/15/2013 at 9:00 a.m., the RD stated she was not made aware of Resident #55 ' s significant weight loss, and was in the process of initiating a nutritional assessment for the resident. The RD asked why the care plan was not updated. RD confirmed the care plan should have been updated to include nutritional interventions for the weight loss, again said she was not made aware of the weight loss by the facility staff.

Based on observation, clinical record review, and staff interview, the facility ' s nursing and the dietary departments failed to coordinate/communicate. Their lack of coordination for 1 (Resident #27) of 3 residents sampled for nutritional status contributed to a delay in initiating dietary interventions to prevent weight lost for residents at risk. The facility failed to provide care and services to maintain the resident's highest practicable physical condition. The findings include: A review of Resident #27 ' s medical record documenting a [DIAGNOSES REDACTED]. Resident #27 had a significant weight loss per the Minimum Data Set (Significant Status Change) and underweight and no supplements. The medical record review documented Resident #27 had a fall and was sent to the hospital on [DATE]. The resident returned to the facility on [DATE], with the [DIAGNOSES REDACTED]. The resident's last weight before hospitalization was noted as 102.6 pounds (lb.) taken on 4/10/2013. The 4/16/2013 Nursing Admission Assessment, does not provide an admission weight. The next weight is noted on 4/22/2013, at 101.8 lb., which is 6 days post hospitalization . The next weight is noted on 5/6/2013 at 97 lb. and the most recent weight is documented on 5/14/2013, at 94.4 lb. A review of Resident #27 ' s medical record diet order and communication dated 4/16/2013 noting, "Diet Regular Pureed." Resident #27 ' s medical record Nutritional Services Care Plan, with a revision date of 4/17/2013, noted "Now on pureed diet." The 4/19/2013 order notes " Pureed may have up to 6 oz. mechanical soft foods up on request for pleasure. " The 4/23/2013 order notes, "Diet change Mechanical Soft. " The 4/29/2013 order notes "Dining room changes to patient eat in restorative dining room." A review of the Minimum Data Set (MDS) Significant Change Assessment, dated 4/23/2013, section K0200 notes weight as 101 lbs. and section K0510 D "Therapeutic diet (e.g., low salt, diabetic, low cholesterol)." The medical record review did not provide documentation of order(s) for Therapeutic Diet. During an observation on 5/14/2013, at 1:00 p.m. Resident#27 in the dining room with a cup of chili in front of her. She ate approximately 25%. On 5/15/2013, at 7:30 a.m., Resident #27 was observed in her room eating breakfast, juice glass of juice, oatmeal, consuming approximately 50% of the meal. During an interview on 5/14/2013, at 3:00 p.m., the Dietary Manager stated she did not know who performed the assessment on the MDS, documenting the resident was on a Therapeutic diet. The Dietary Manager stated she was not in the position during the assessment period. She stated the resident is on a Regular mechanical soft diet. During interview, on 5/15/2013, at 8:00 a.m., the MDS Coordinator stated "There is an error, I am unsure where the order for the Therapeutic diet came from, I do not complete each of the sections on the MDS, I depend on dietary to complete section K of the MDS. While we did not have a Dietary Manager at that time, I am not sure who completed that section I will have to check. There was a definite decline in the resident's condition when she returned from the hospital. She has been with us for some time and has had a history of [REDACTED]. I will have to check to see where that came from." During interview on 5/15/2013, at 8:45 a.m., the Registered Dietician stated, "Several of the residents fall through the cracks with weight issues. I am going to state something should have been done last week a week and half; I was out of town for a week. The facility did not have a Dietary Manager for almost a month and the resident was not brought to my attention on a communication sheet. I am scheduled to make weekly visits to the facility." It was confirmed supplements were not provided. She continued to stated we started Resident #27 on Med Pass 2.0 3 ounces (oz) three times a day yesterday, 5/14/2013. During interview on 5/15/2013, at 10:00 a.m., the Medication Nurse on the Green Wing stated "I made an error I made the wrong selection on the dietary section the resident is not on a Therapeutic diet, she is on a Regular Mechanical Soft diet this was done on 4/23/2013." The Registered Dietary on 5/14/13 noted Med Pass 2.0 3 oz three times a day; will monitor weekly weights, may also try fortifying some appropriate favorite foods if this intervention does not promote a weight gain.

Based on observation, interview, and record review the facility failed to ensure that appropriate nutritional parameters were in place for 1 (Resident #55) of 3 sampled residents identified for weight loss. The resident had not been identified for an 11.1% weight loss in a 4 month period, which resulted in the resident not receiving nutritional intervention to prevent the further decline of weight. The findings include: Resident # 55 was admitted to the facility on [DATE], with a diagnosis, including [MEDICAL CONDITION] and Diabetes Mellitus. Resident # 55 record is noted as follows: ? Minimum Data Set (MDS) on 2/08/2013 recorded a weight of 179 pounds (lbs.). ? MDS on 2/13/2013 recorded weight is 171 lb. ? Most recent weight recorded on 05/07/2013 indicated the resident weight is at 153.6 lbs. This calculates out to a 15% weight loss, which is considered significant. Resident #55's weight upon admission was documented at 217 pounds (lbs.). During an interview on 5/14/2013 at 2:00 p.m., in regards to the weight, the Certified Dietary Manager (CDM) identified the weight was incorrect. The CDM explained the Restorative staff member that recorded the weight forgot to subtract the weight of the wheel chair. Clinical record reviews of the weights generated by the Restorative Staff documented Resident #55's weight as: ? 2/12/2013 - 170.6 lb. ? 3/13/2013 - 168.4 lb. ? 4/21/2013 - 167.8 lb. ? 4/30/2013 - 159.6 lb. ? 5/07/2013 - 153.6 lb. This is a weight loss of 11% in a 4 month period Resident #55 was observed during dinning on 05/15/2013 at 12:00 p.m. The resident was seated at the table. The resident was observed to have a chopped Turkey Sandwich, and a glass of Soy Milk. Resident #55 was cutting his sandwich, then proceeded to take a spoon, and dunk his sandwich in the soy Milk, and proceeded eating the food that he had dunked in the milk. During this observation Resident #55 had eaten about 35% of the sandwich, and drank approximately half a glass of Milk. There was no assistance by staff given to the resident during the observation of meal services. Review of the most recent MDS dated [DATE] under section C documented Resident #55 has a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact. Review of the most recent MDS dated [DATE]; including section K for nutrition that was not coded for nutritional issues and did not identify the significant weight loss. Review of the resident's clinical record revealed a failure to include an updated nutritional assessment, which would have included a decline in weight; Protein and calories needs of the resident. This Comprehensive Nutritional assessment is designated to be completed by the Registered Dietitian (RD). Review of the clinical record including the Comprehensive Care plan for the resident completed on 2/14/2013 revealed a failure to include an update of the resident's significant decline in weight, or interventions in place to avoid a further decline in nutritional status. Review of the clinical record documented that blood levels were draw on 5/07/2013 indicated the resident had [MEDICAL CONDITION], but the report did not identify an [MEDICATION NAME] level, or a Total Protein level, that would identify nutritional status was in decline. Review of the clinical record did not identify any other blood work that had been completed for Resident #55 in the past 4 months. During an interview 5/14/2013 at2:00 p.m., the Certified Dietary Manager (CDM) was asked about a nutritional assessment for Resident #55. The CDM said she had just been hired into the position of CDM, but would research to see if there was a nutrition assessment noted on the resident's clinical record. The CDM stated that she was in the process of completing her section of the nutritional assessment on the resident and would consult with the RD to complete the assessment. The CDM was made aware of the observation made during meal time, and commented, that apparently the resident needs assistance with meals. CDM was asked about Resident #55 receiving a nutritional supplement (nutritional supplements, are used for patients with a need for extra calories and protein). CDM confirmed at this time the resident was not receiving a nutritional supplement. The CDM stated the facility had been without a CDM for the past month, and the resident might have been over looked in regards to his significant weight loss for this reason. The CDM stated the Registered Dietitian had been on vacation, and before leaving for vacation was not made aware Resident #55 needed an assessment to establish nutritional interventions in regards to the resident's nutritional needs for his weight loss. During an interview on 05/15/2013 at 9:00 a.m., the RD was asked about Resident #55's significant weight loss. The RD stated she was not made aware of the resident significant weight loss, but was in the process of initiating a nutritional assessment for the resident. RD was asked if Resident #55 was receiving a nutritional supplement, and said that in the past he was not receiving, a supplement, but she had plans to add this to the resident's daily diet. RD was asked about updating the care plan to include a significant weight loss, and intervention to prevent further weight loss. The RD confirmed the care plan had not been updated to include the weight loss issue or the interventions.

Based on observation, staff interview, and record review, the facility failed to ensure accurately labeled medication. The failure to coordinate medication orders with the pharmacy to ensure accurate medication labeling can result in medication errors for 1 (Resident #61) of the 9 resident observed during med-pass. The findings include: During a medication observation on 5/14/2013 at 4:30 p.m., the nurse removed one Enteric Coating Aspirin 325 milligram (mg) from the medication box and dispensed it into the medication cup. A review of the medication box label noted "Aspirin 325 mg Enteric Coating, take one tab by mouth as needed stat for chest pain if patient is not on anticoagulant." The medication nurse was asked, did Resident #61 have chest pain? The answer was " no, but I know she is to be given the Aspirin routinely, the label is wrong. " During a review of the medication orders,, there was an order dated 3/24/2013, "Request resident currently taking Aspirin 325 mg every evening, lately having intermittent swallowing issues and the family request if Aspirin might be changed to Enteric Coating to ease swallowing." The order is signed by the physician. The facility failed to ensure the medication labeling coordinated with the order changes.

Based on observation and interview, the facility failed to ensure staff served food in a sanitary manner; in regards to two Food Service Workers (FSW-A and FSW-B) who were not handling food in a sanitary manner to prevent cross contamination, which has the potential of causing food borne illness. The findings include: On 4/18/12, at 11:15 p.m., observation during the noon meal tray assembly revealed FSW-A had a bandage located on her left lower lip. When questioned about what was wrong with FSW-A's face, the Certified Dietary Manager (CDM) replied that employee "had her faced pierced last night, so I made her put a bandage over the area." Observation revealed FSW-A touching the bandage on her face while placing the residents' completed trays on the food cart. FSW-A was never observed to wash her hands before or after these actions. The CDM was made aware of the observation and removed FSW-A from her duties on the tray line. On 4/18/12, at 11:15 p.m., observation of the tray line revealed FSW-B assembling the residents' food trays with a bandage wrapped around her left index finger. FSW-B did not wear gloves, and the bandage on her finger continually touched surfaces of residents' tray, dishes, flatware, and containers of food. When questioned, the CDM stated she was not aware FSW-B had a bandage on her finger. The CDM immediately released FSW-B of her duties, and instructed FSW-B to don a pair of gloves. FSW-B returned to the tray line to assemble the residents' trays and during this time, observation revealed her continually touching and adjusting her eye glasses. FSW-B never washed her hands or replaced her gloves with a clean pair after touching her eye glasses.

Based on record review and interview with staff, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. One (Resident #39) of 10 sampled residents had a duplicate order for Tylenol, no intensity of pain for Tylenol PM and no parameters of time for [MEDICATION NAME]. The findings include: During a review of Resident #39's physician's orders [REDACTED]. - an order for [REDACTED]. - an order for [REDACTED]. - an order for [REDACTED]. Review of the "Routine/PRN Pain Flow Sheet" contained documentation from 4/8/12 through 4/16/12, the current intensity/pain behavior was a four (4). Location of pain was back/legs. Tylenol 650 mg was administered 5 times. Tylenol PM 500/25 was administered 3 times. During an interview, on 4/18/12, at 12:35 p.m., the Director of Nurses confirmed the orders did not document parameters of time for the [MEDICATION NAME], the Tylenol was a duplicate order, and there was no parameter for intensity of pain for the Tylenol PM.

Based on observation and interview, the facility failed to ensure all medications were stored and labeled properly and were not expired for 2 (Blue Hall and Memory Unit) of 4 medication storage rooms and 1 (Blue Hall Cart) of 4 medication storage carts in the facility. The findings include: 1. On 4/17/12 at 1:00 p.m. observation in the medication storage room on the Blue Hall revealed 6 Fleets Enemas in the cabinet - each for an individual resident. Two of the enemas had expiration dates of 12/11, one with an expiration date of 2/12 and one with an expiration date of 4/12. Observed in the medication storage room were 7 individually labeled bottles of Milk of Magnesia. Four of the bottles were noted to be expired with expiration dates of 3/12 and 4/12. 2. Observation of the medication storage cart on the Blue Hall revealed a box titled Proventil Inhaler. There was no pharmacy label on the box identifying the name of the resident, the instructions for use, cautionary instructions, the physician's name, or the date the medication was distributed. Handwritten on the box was a last name of a resident. There were torn spaces on the box which appeared as if the pharmacy label had been removed. In an interview, on 4/17/12, at 1:00 p.m., during observation of the medication storage room on the Blue Hall, the Director of Nursing (DON) confirmed the existence of the expired medications. She stated the facility changed the way these medications were being delivered from the pharmacy and now were not being delivered for everybody with an as-needed order. The DON stated the facility would keep one or two medications in the main storage room and the nurses would use them when needed and the pharmacy would charge the resident when it was used. She confirmed the box containing a Proventil Inhaler had no pharmacy label containing required information, having a handwritten last name of a resident. The DON stated it appeared as if the label had been removed from the box. 3. On 4/17/12, observation of the medication storage cart on the Memory Unit revealed an opened bottle of Mylanta labeled for a specific resident with an expiration date of 2/12. The nurse responsible for distributing medications on the day shift, on 4/17/12, at 2:25 p.m., confirmed the bottle of Mylanta was expired and disposed of the medication. She stated the nursing supervisor was responsible for checking for expired medications, and was not able to recall when the last time the medications were checked for expiration dates. 4. On 4/17/12, during medication pass observation on the Blue Hall, Resident #42 received Singulair 10 milligrams (mg). The physician's orders [REDACTED]. The label on the box of medication gave instructions to administer at bedtime. The label did not match the current physician's orders [REDACTED]. The nurse administering medications on the Blue Hall, to Resident #42, on 4/17/12, at 8:40 a.m., confirmed the directions on the label did not match the current physician's orders [REDACTED]. On 4/17/12 during medication pass observation on the Blue Hall, Resident #42 received Lasix 20 mg. The label on the box of medication in the medication cart had a warning label indicating the medication may cause drowsiness. Drowsiness is not a side effect of Lasix. The nurse administering the medication, on 4/17/12, at 8:40 a.m., to Resident #42 confirmed the warning label was incorrect as drowsiness is not a side effect of Lasix.

Based on observation, interviews and record review, the facility failed to identify events, such as suspicious bruising of residents, fracture and injuries of unknown origin, occurrences, patterns, and trends that may constitute abuse and determine the direction of the investigation. The facility failed to recognize its Falling star program was ineffective and failed to develop and implement a plan of action for repeated occurrences of falls. The findings include: 1. Observation on 5/12/11 at 9:40 a.m. revealed Resident #1 in her room, seated in a wheelchair being fed breakfast by her personal caregiver. The caregiver was questioned about the reddish-purple area to the top of the resident's left hand. She stated she was aware of the area, that staff at the facility were also aware and she said it was from the resident "rubbing" the top of her hand repeatedly. The caregiver pointed to a washcloth that was folded as an animal and stated, "This is what we try and give her to help her stay away from rubbing her hand." She stated the resident will sometimes pick at her forehead, too. The caregiver's not sure why she does what she does, but tried to keep her from doing those specific behaviors. Observation on 5/12/11 at 11:30 a.m. revealed Resident #1 seated in her wheelchair with a bedside table in front of her. A washcloth in the shape of an animal and a carton of plastic Easter eggs were directly in front of her, resting on the table. The resident was holding neither. Observation on 5/12/11 at 2:45 p.m. revealed the resident in bed. She was not holding a washcloth. There was nothing placed at her bedside to deter her from "rubbing" her hands. Clinical record review revealed the resident was admitted to the healthcare portion of the facility on 11/06/09 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/17/2011, revealed the resident as alert and oriented. No mood indicators were present. The resident is extensive to totally dependent on 1-2 staff for ADLs (Activities of Daily Living). The resident is functionally impaired to one upper extremity and to both lower extremities. No falls, or history of falls, are indicated. No skin issues are identified on this assessment. Review of the monthly summaries for the dates of 1/29/11, 2/27/11, 3/30/11 and 4/2011 revealed the resident as having short- and long-term memory problems, difficulty finding words/finishing thoughts, makes negative statements and "recurring statements that something terrible is about to happen." Abrasions and bruises to the resident's skin are also documented. Review of the nurses' notes revealed the following: 8/02/10 - 12:00 p.m. "Resident noted to have a bruise to left inner ankle noted by CNA ...approximately 9 cm x 7 cm. Resident does not know how it happened. CNA states she didn't bump area with her ..." 9/19/10 - 10:00 a.m. "Call to room by private nurse noted resident had bruise on right upper arm approximately 5 cm x 5 cm and bruise on right forearm. Resident does not know how it happened. Private nurse states she doesn't know ...she did not bump her arm or anything. She was walking with her and touched her arm and resident complained of pain, she checked her arm and found bruises ..." 9/27/10 - 2:30 p.m. "Bruise remains present to left upper arm, denies pain or limitation of movement ..." 9/28/10 - 8:00 a.m. "CNA called writer to room noted resident to have skin tear to left middle finger approximately 1.5cm. Resident does not know how it happened. CNA does not know how it happened ..." 10/10/10 - 9:15 a.m. "CNA found resident pinching left hand above thumb. Resident has red area from pinching, CNA also reported bruised area on back of right hand and does not know how it happened. Spoke with private duty nurse and she states resident had bruise in that area, but this looked a little darker ..." 10/10/10 - 10:00 p.m. "CNA observed blood on TED stocking when getting resident ready for bed, presented with 2.5 x 4 cm crescent shaped skin tear of superficial thickness ..." 10/11/10 - Facsimile Transmission: "Resident complaint of right arm, complained of fall in room to caregiver, no record or incident of fall, no swelling right arm, but does complain of pain with range of motion, may we have order to x-ray right arm, fading bruising on right arm from incident 9/19, x-ray right humerus-forearm-elbow all negative..." 10/12/10 - 9:00 p.m. "X-ray results back from Mobilex. Results Acute Right humerus fracture, fracture involving right humeral neck without displacement. Shoulder joint is grossly intact ..." 11/07/10 - 10:10 p.m. "CNA called nurse to room this a.m. Showed nurse bruise on resident's left top of forearm approximately 5 cm x 2 cm. Resident does not know how it happened, spoke with private duty nurse and it was not there yesterday, but she must have hit it on bedrails or w/c (wheelchair) private duty said ...also has small blue/purple area between left index finger and thumb approximately 1 cm ..." 11/15/10 - 12:00 p.m. "Resident went leave of absence to see orthopedic ...resident noted during visit to have bruise on outer aspect on right elbow of unknown origin ..." 11/19/10 - 12:00 p.m. "Resident noted by private caregiver to have bruise on right middle finger. Resident does not know cause, private caregiver does not know cause and CNA stated she did not see bruise during a.m. care ..." 12/01/10 - 9:30 a.m. "CNA called this nurse to look at resident's left foot/ankle while resident in shower. Ankle/foot observed to be slightly swollen around ankle and foot ...1 p.m. Resident pulled foot away from tactile stimulation ..." 12/02/10 - 1:00 p.m. "...Left ankle still has bruise (brownish) on top, slow resolve ..." 12/25/10 - 11:00 a.m. "CNA walking past room noted resident sliding out of w/c, CNA assisted resident to the floor in front of w/c, this writer and CNA did assessment ...noted bruise on left hand approximately 4 cm x 3 cm. Resident did not know when or how bruise happened ..." 1/27/11 - 2:30 a.m. "Right ankle [MEDICAL CONDITION] ...elevated on pillow. Will monitor." 2/01/11 - 2:00 a.m. "CNA discovered ecchymotic area measuring 3 x 4.5 cm on right outer calf during incontinence care. Resident unaware of how bruise occurred. Will monitor area ..." 3/06/11 - 2:00 p.m. "Sitter noted small bruise to left wrist (inner) aspect and older looking bruise to right mid forearm, unknown cause, approximately 2 cm x 2 cm left wrist. 2 x 3 cm right forearm ..." 3/09/11 - 6:30 a.m. "CNA noted 5 x 1 ? cm ecchymotic area on left elbow area. Skin intact, resident denies pain at site. Resident unable to state how bruise occurred ..." 3/19/11 - 7:00 a.m. "CNA noted sm (approx. 1 cm) ST (skin tear) inner aspect 3rd finger right hand ...unknown origin ..." 3/20/11-3:30 p.m. "Resident noted to have 1 cm open area on right side of face ..." 3/21/11 - 7:00 a.m. "CNA reported bruise to left forearm 5 cm long x 1.5 cm wide ..." 4/02/11 - 10:30 p.m. "While doing weekly skin sweep at 1 a.m., blood blister was noted below right knee - area intact and fluid filled ..." 4/14/11 - 6:00 a.m. "CNA noted 2 x 2 cm bruise to right outer ankle, no swelling ..." 4/16/11 - 10:30 p.m. "Right outer ankle bruise now 5 x 5 cm square with center being reddish color and rest of area blue color - some swelling noted to both ankle with slight more to right ..." 5/08/11 - 12:24 p.m. "CNAs called nurse, they were laying resident down for nap, found bruise on left hand, nurse examined, found approx. 5 cm x 4 cm purple-like area on back of left hand ...Resident did not know how it happened, might have hit hand on w/c or bed side rail ..." Interview with the resident's primary CNA on 5/12/11 at 9:55 a.m. revealed the nurses let her know in report when the resident has bruises. Most of the time, the CNAs find them and they report it to the nurses. Most of the time, Resident #1 is observed taking her skin and pulling it on her hands. They try and keep sweaters on her and give her a bear to hold to distract her from rubbing or picking. There was no rationale for the resident's previous fractured right humerus, bruises to the arms, legs and ankles. The CNA offered no other interventions, other than the bear or long sleeve sweaters, in relation to the resident's self-injurious behaviors of picking or rubbing. Interview with the primary LPN on 5/12/11 at 10:07 a.m. revealed the resident does have a tendency to pull or rub at her skin, but the LPN can't be sure every discolored area is from that behavior. The LPN stated the aides are encouraged to report any discolored areas and are to handle the resident as gently as possible, as she has fragile skin. She stated the resident does not have any behaviors and has not had a history of [REDACTED]. They monitor the areas that have been identified to avoid skin breakdown, measure the areas and report the discolored areas to the physician and family. During a second interview, conducted on 5/12/11 at 1:09 p.m., the resident's primary nurse (an LPN) stated as best she could remember, the caregiver/companion came and told her when she touched the resident's arm, the resident complained of pain. She went into the room and there was a bruise there and when she tried to do ROM (Range of Motion), the resident complained of pain. The nurse called the doctor and got an order for [REDACTED]. An initial plan of care addressing the resident's skin integrity (developed on 11/06/09 and updated through 4/14/11) identifies skin tears and bruises. The plan of care, however, does not list the resident's self-injurious behavior of rubbing or picking at her skin, which may cause the discolorations to her hands. The plan of care was not revised to reflect the interventions of offering the resident a bear or wash cloth to avoid self injury. The plan of care was without effective interventions in relation to the ongoing bruising sustained by the resident. Record review with the Health Services Supervisor, on 5/12/11 at 10:36 a.m. revealed incident reports were completed for the dates of 5/08/11, 4/02/11, 3/21/11, 3/19/11, 3/09/11, 3/06/11, 2/01/11, 12/25/2010, 11/07/10, 10/12/10 for the humerus fracture, 9/27/10, and 9/19/10. She confirmed the investigations into these incidents were all classified as injuries of unknown origin. When asked about the other injuries and whether they were investigated, she stated she did not have incident reports completed for them. She stated the caregiver and daughter-in-law, who is the Health Care Surrogate, told the facility the resident has a tendency to rub or pick at her hands or face, but could not explain how the other injuries occurred. She stated the facility had no idea as to how the resident fractured her right humerus, why her ankles became swollen and bruised or how most of the skin tears developed. On 5/12/11 at 1:32 p.m. during an interview, the PT (Physical Therapist) stated Resident #1 began receiving treatment on 10/07/10 because she was having increased pain to the right shoulder and, according to Occupational Therapy (OT) notes, she was grimacing. Review of the OT evaluation, dated 10/07/10, under Environmental Factors/Social Support, " Pt. has been a resident at the SNF at the Glenridge. Pt has had increased c/o (complaints of) right UE (upper extremity) pain. An x-ray was taken and was negative for a fracture. Pt. grimaces with any movement and is very limited with regard to her motion." Review of 10/14/11 Therapy weekly notes revealed, "caregiver reports slight decrease with pain during self cares and movement. Spoke with nursing regarding need for further x-ray." OT progress note of 10/21/10 reveals "pt has dx (diagnosis) of fx (fracture) in right shoulder. Has order for gentle ROM (range of motion) elbow to hand pendulum for right shoulder." Interview with the resident's private duty (PD) caregiver on 5/14/10 at 9:47 a.m. revealed the resident complained of intermittent bouts of pain to her right arm between the suspected fracture of unknown origin on 9/19/10 until it was confirmed she did have an actual fracture on 10/12/10. There was no explanation of the fracture. The PD states that on the morning after the fracture, she touched her arm and the resident recoiled from pain. The PD looked at the arm and there was no bruising. The PD states bruises showed up the next day. She stated that back in September and October (2010), the former Director of Nurses (DON) came to her regarding the resident getting multiple bruises in different areas in such a short time, but that was all. No one has ever approached her with an investigation after November. The PD stated she is the one who usually reports the bruises to staff and they notify the doctor. She stated she herself is a RN and is aware of some of the bruises, but not all. She couldn't determine what goes on in the facility when she is not there, and she is only at the facility between 8:00 a.m. and 11:00 a.m. daily. When she suggested padding the side rails, the DON at that time stated the resident doesn't thrash about in bed and didn't think the rails needed to be padded. Interview with Health Services Supervisor on 5/12/11 at 12:28 p.m. confirmed the private duty caregiver is with the resident in the morning only. Review of the facility's Abuse Investigation Protocol revealed the following policy statement: "For all reports of resident abuse, neglect, or injuries of an unknown source, the facility management promptly and thoroughly investigates resident-to-resident abuse and resident to staff abuse." The protocol further revealed the following: "1. Should an incident or suspected incident of resident abuse, neglect, or injury of an unknown source become known, the facility management will investigate resident-to-resident abuse and/or resident-to-staff abuse reported via Incident report form and will follow the incident report policy and procedure. The reporting individual's supervisor must complete the incident report. The Administrator and Risk Manager will be notified immediately. The reporting person will be instructed to contact 1-800-96 ABUSE. The Risk Manager will investigate the suspected incident ...18. Should an alleged/suspected violation or substantiated incident of mistreatment neglect, injuries of an unknown source, or abuse ....be reported, the facility Administrator, or designee, will promptly notify the following persons or agencies (orally and written) of such incident: a. The state licensing/certification agency responsible for surveying/licensing the facility (AHCA), b. The local/State ombudsman, c. The resident's representative of record, d. Adult protective services, e. Law enforcement officials, f. The resident's attending physician." During an interview on 5/12/11 at 2:52 p.m., the Social Service Director, who is the Abuse Liaison, stated she was not aware of the above identified areas sustained by the resident, but knew the resident had a broken humerus and the cause was uncertain. When asked what her role in the facility was as Abuse Liaison, she stated she participates in investigating allegations of abuse. She did not investigate injuries of unknown origin, only those of abuse. She stated she did not have a specific job description or procedure to follow as it related to her role as the Abuse Liaison. She stated that incident report investigations were turned over to the Risk Manager and it was up to the Risk Manager to determine whether further investigation was warranted. She stated she was never made aware of the resident's multiple injuries of unknown origin. Interview with the Risk Manager (RM), who is also the Administrator and Registered Nurse, on 5/12/11 at 12:50 p.m., revealed she didn't know about the resident's right humerus fracture until November. She stated an investigation was conducted on 9/19/10 related to the bruises on the resident's upper and lower right arm and an x-ray was taken which revealed no fracture. A second x-ray was taken on 10/12/10 which revealed an acute [MEDICAL CONDITION] humerus. She didn't think a second incident occurred which caused a fracture. She confirmed it was an injury of unknown origin. She stated after the fracture, staff met with the family and caregiver and suggested a 2-person transfer for the resident and for the resident to be transported by the wheelchair van. Transfer education was provided to staff. These interventions occurred between 11/2010 and 12/2010. When asked whether she was aware of the other "ongoing " injuries of unknown origin of the resident, she stated she "didn't know they amounted to that many," and she relied on her previous Director of Nurses. The RM confirmed there were no other investigations other than the ones that the Health Services Supervisor presented. About the injuries of unknown origin she was aware of, she "felt were pretty typical of the resident," and did not feel further investigation was warranted. She confirmed none of the injuries of unknown origin were ever reported as per the facility's abuse protocol. The RM stated the facility was small; everyone knew one another and felt no one in the facility was capable of abusing anyone. When asked how she could know this without a thorough investigation, she stated, "I know." The RM was unaware the resident displayed recurring statements that "something terrible is about to happen (as noted by the nurses on the monthly summaries)." 2. A review of incident report logs for Resident #7 revealed documentation of incident reports for 7/4/10, 7/10/10 (a fall with laceration), 8/8/10 (skin tear right arm), 9/28/10 (skin tear), 11/1/10 (red area bruise), 11/11/10 (bruise), 12/12/10 (bruise on right arm), 12/15/10 (fall), 12/15/10 (fall), 1/9/11 (abrasion), and 4/23/11 (skin tear on the left elbow). Resident #7's incident reports indicate on 7/10/10 there was a skin tear developed from catching the resident's skin on the shirt while applying the resident's clothing. On 8/8/10, the resident developed a skin tear from hitting the resident's arm while in the wheelchair. On 9/28/10, a 2.0 by 1.0 cm (centimeter) area was open and draining a small amount serosanguinous drainage. The area was bruised, reddish, and purple in color. An injury of unknown origin investigation worksheet was initiated on 9/28/10, documenting the 7-3 aide indicated "(CNA) told us patient bumped his leg on his side rail." A second staff interview revealed the same information. The third aide stated she was unsure how the incident happened stating, "maybe leaning on side rail." There was no interview with the aide identified in the first interview. On 11/1/10, there was a incident report indicating the aide reported, at time of care, that Resident #7 had "a red area on the right forearm 10 by 5 cm in size," and "left arm has a 7 by 4 cm on the left arm below the elbow." There was no investigation regarding the development of this area. A review of the nurse's note, dated 11/1/10, revealed the resident was "unable to vocalize regarding arms." On 11/11/10, documentation in the incident report revealed "a bruise on the right arm approximately 2.5 to 3 inches about the wrist and approximately 3 cm by 1.5 cm. The resident could not report what happened." The documentation in the injury of unknown origin investigation worksheet, dated 11/11/10, revealed interviews with 4 different staff members who essentially stated they were unaware of the cause of the bruise. There was an incident report, dated 12/12/10, noting there was "a bruise on the left arm, 16 cm by 9 cm, located from below the left elbow to mid forearm." The injury of unknown origin investigation worksheet, dated 12/12/10, documented an interview with an 11-7 staff member who reported finding the area. The LPN for the 11-7 shift indicated she had not seen the resident for 1 week. During another interview, it was revealed the third staff member did not take care of Resident #7. There was a 4th interview with a staff member from the 11-7 shift, who took care of the resident on 12/11/10 and did not see the bruise at that time. A progress note, dated 12/12/10, documented the finding of the bruise. No other investigation was performed. An incident report, dated 12/22/10, identified the resident had a skin tear to the left lateral elbow, which was noted by the evening shift. An injury of unknown origin investigation worksheet was initiated. There was an interview with 1 staff member only, who indicated he had found the skin tear, but stated that although he was unaware of the cause, stated, "it looks old." No other investigation was performed. There was an incident report, dated 1/9/11, indicating Resident #7 had a "red mark to the forehead on the left side, a 2.5 cm scratch to the right knee, a 1 cm red area on the right knee, and an abrasion on the right medial knee." The documentation further indicated these injuries were found at 3:30 a.m. The injury of unknown origin investigation worksheet revealed interviews with 2 staff members; one "had not seen the resident in 7 days," and the other reported the finding, but the resident "was new to her." No determination as to cause; injury of unknown origin. The monthly summary, dated 4/13/11, indicated Resident #7 "has altered level of consciousness." The mood and behavior monthly summary, dated 3/10/11, indicated "withdrawal from activities of interest and memory loss." The February monthly summary indicated the resident's function "varied over the course of the day, with periods of altered perception." During an interview on 5/13/11 at 11:13 a.m., the DON stated she was not the DON at the time of the resident's incidents. She stated the practice is that the nurse who fills out the incident report does the investigation. That nurse would talk to the staff from the shift to attempt to learn the status of the injury. During an interview on 5/13/11 at 11:40 a.m., the primary LPN caring for Resident #7 indicated the process for the floor staff is to initiate the incident report. They also initiate the injury of unknown origin investigation worksheet. She further stated she would talk to all of the staff present on the shift, and to the shift immediately prior if they were still present in the facility, but would not call other shifts as that investigation is done at the next level of review. In an interview on 5/13/11 at 11:33 a.m. the administrator was questioned as to the role of the abuse coordinator. The administrator state the abuse coordinator gets involved if there is a specific allegation of abuse. The administrator stated the abuse coordinator is not brought in to investigate bruises or injuries of unknown origin. In an interview on 5/13/11 at 11:00 a.m. the administrator/risk manager, stated that all of the incidents: skin tears, bruises, and falls are aggregated onto a spread sheet, with a description of each incident according to location (resident hall) and shift on a monthly basis. The aggregated information is reported monthly to the QA committee. The administrator stated that the QA Committee has not come to some conclusion regarding prevention of these incidents. The administrator stated no pattern appeared to develop; all incidents are independent with no commonality. 3. During an interview on 5/12/11 at 4:10 p.m., the administrator and risk manager, when asked about the "Falling Star Program," with regards to Resident #25, confirmed the policy needed to be corrected. The administrator stated the staff could not observe high-risk fall residents when the door to their rooms were closed. When presented with three incidents of injuries of unknown origin and only one or two shifts documented for investigation, the administrator confirmed there was not enough investigation done for injuries of unknown origin. When presented with two investigations of Resident #25, who had 5 falls, the administrator could not say why the investigations were not completed.