Every finding on record at Gracewood NSG Facility(Unit 9)

Based on record review, observation, interviews, and review of the facility policy titled, Physical and Nutritional Supports, 03-522, the facility failed to maintain acceptable parameters of nutritional status, to include body weight, for one of one resident (R) R#4 reviewed for nutritional status; resulting in significant weight loss of 5.82% in 30 days. Findings include: Review of facility's policy titled Physical and Nutritional Supports, 03-522 reviewed 12/2/21, page 6 of 15 Section E - Significant Weight Loss/Gain or Severe Weight Loss/Gain ii indicates Medical staff are notified immediately of weight loss or gain that falls outside of the established parameters for the specific individual, and/or if there is an unintentional significant or severe loss or gain from the previous month. It is the responsibility of the staff member that identifies the weight loss or gain to notify the unit charge nurse who notifies the medical staff and dietician. Review of the record indicates R#4 was admitted to the facility on [DATE]. R#4 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#4's April 2022 Physician Orders (PO) revealed the following: Enteral Feeding Fluids - 1200 CALORIES per day: 1 can Two Cal HN + 140 ml of BOTTLED WATER with a rate 85 ml/hour from 12 midnight to 8 a.m. daily via G-tube. 300 ml of BOTTLED WATER every 6 hours at 12 a.m., 6 a.m., 12 p.m., 6 p.m. Flush lumen with 30 ml of warm BOTTLED WATER after administration of medications, Calcium/Vitamin D 500 mg-200 International Units (IU), Multivitamin liquid 15 ml, Potassium Chloride 10% solution 20meq/15 ml (10 meq), Sodium Chloride 1 Gm Tablet. According to the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 3/2/22, R#4 had a Brief Interview for Mental Status (BIMS) of 99, which indicated the resident has a severe cognitive impairment. Review of R#4's care plan revealed a care plan initiated 12/3/21 with a revision date of 4/27/22, listed at risk for inadequate nutrition: as evidenced by (AEB) any weight gain/loss. R#4's expected outcome: Will maintain weight within ideal range. The interventions for R#4 include: Nurse/DCS will maintain an accurate weight record. Ideal Weight Range: 115-125 pounds, refer to physician any weight loss of five pounds or a weight gain of five pounds or more, R#4 will receive prescribed diet and/or supplement as ordered by the physician in consultation with the Dietitian as indicated, Diet by tube: 1 can Two Cal HN + 140 ml bottled water at 85 ml/hr. from midnight to 8 a.m. daily. Give 300 ml bottled water every 6 hours at 12 a.m., 6 a.m., 12 p.m., 6 p.m., Nurse/Dietician will monitor fluid intake, caloric needs and other dietary needs as indicated, R#4 teaching in terms she can understand regarding dietary modifications and plan of care, routine review by licensed nurse at least quarterly. Review of R#4's EMR revealed a significant weight loss of -5.82% / 6.7 lbs. within the 30-day timeframe of 3/1/22 through 4/4/22. Review of the resident's record revealed a Quarterly Health and Incident Review and Nursing Care Recertification dated 4/21/22. April 2022 weight was discussed in this meeting with the interdisciplinary team that included the Physician, Registered Nurse, and Dietician. Observation on 5/1/22 at 8:43 a.m., R#4 was lying in bed. The head of bed was elevated. The kangaroo feeding pump was on with water infusing to the peg tube as ordered. Interview on 5/1/22 at 9:06 a.m. with Certified Nursing Assistant (CNA) AA, she verified the current for R#4 weight of 108.5 on 4/4/22 was the current weight for R#4. She also stated that the CNA's are responsible for obtaining the monthly weights at the beginning of each month and the weights are then given to the nurses and that the nurses instruct the CNA's when reweighs are needed. CNA AA stated that all weights are communicated to the nurse because a weight loss or gain of 5 pounds is a trigger for them to do something for the residents. Interview on 5/1/22 at 9:18 a.m. with Licensed Practical Nurse (LPN) BB, revealed that nurses are responsible for tracking the residents' weights. She also stated that the nurses should notify the physician and RN Supervisor as soon as they are aware a resident has a loss or gain of 5 pounds or more. After looking through the paper record and electronic record, she verified that the physician was not informed of R#4 weight loss until 4/21/22. Interview on 5/1/22 at 10:41 a.m. with Registered Nurse (RN), Nurse Manager (NM) CC, revealed that the nurses are responsible for recording weights and notifying the physician and dietician if there is a weight gain or loss of 5 pounds or more. She also stated that the physician should be notified at the time the significant weight loss or gain is identified. Interview on 5/1/22 at 11:33 a.m. with the Director of Nursing (DON), revealed that it is the nurse's responsibility to notify the physician and the RN Nurse Manager of weight loss and weigh gain of 5 pounds or more. She stated that the physician should be notified as soon as the nurse is aware of the significant weight changes. She reviewed meeting notes and R#4's weight was not addressed with the physician until 4/21/22. She reviewed the paper and electronic record and verified that the physician was not notified. DON stated, No he was not notified prior to 4/21/22, I have looked, it is what it is.

Based on observation, record review, staff interview and a review of the facility policy and procedure Medication Administration in DBHDD Hospitals, the facility failed to ensure the medication error rate was less than five percent (5%). There were two errors with 26 opportunities by two of three nurses observed which resulted in a medication error rate of 7.14%. Findings include: 1. On 9/25/19 at 7:45 a.m., Registered Nurse (RN) AA was observed giving R#16 his morning medications. The medications included Levetiracetam 100 milligrams (mg) / 2.5 milliliters (ml). After preparing all of the medications for R#16, RN AA verified she poured 2.5 ml in a liquid medication cup. A review of the Physician's Orders dated 9/12/19 revealed to administer Levetiracetam 100 mg/ml solution, 500 mg twice daily starting on 9/23/19. During an interview on 9/25/19 at 9:15 a.m., RN AA verified that she did not check the Medication Administration Record (MAR) and only went by the label instructions on the medication bottle which was for 2.5 ml twice daily. She confirmed that the label on the medication bottle did not match the current Physician Order An interview with the Nurse Manager on 9/25/19 at 9:56 p.m. revealed the medication nurses are responsible for checking the MAR prior to administering any prepared medications. 2. Observation on 9/25/19 at 11;58 a.m. of Licensed Practical Nurse (LPN) BB giving R#6 his medications. The medications included a multivitamin liquid suspension. After giving R#6 all of the medications via a [DEVICE], she confirmed she did not shake well the liquid multivitamin as per the manufacturer's instructions. An interview with the Nurse Manager on 9/25/19 at 12:45 p.m. confirmed that LPN BB did not follow the manufacturer's instructions or the facility's policy for the liquid multivitamin by not shaking it well prior to administration. A record review of the Medication Administration in DBHDD Hospitals reviewed and revised on 3/4/2019 revealed the following information: D. Medication Preparation 5. Liquid or suspension medications are shaken well (if not contraindicated) prior to measuring for administration. E. Medication Administration 2. The nurse reviews eMar or MAR and 24-Hour Support Plan (if apllicable), to identify medications to be administered along with consistency, texture, adaptive equipment, positioning, and other guidelines required for medication administration. 15. Medications are administered ensuring that the eight rights are maintained: a. Right Medication: Compare drug container label to the eMAR/MAR three (3) times (as described above). Note expiration date. Know action, dosage, and method of administration. Know side effects of the drug and any allergies [REDACTED]. An interview on 9/25/19 at 12:50 p.m. the Pharmacist revealed they were aware of the incorrect medication label for the Levetiracetam 100 mg/2.5 ml, administer 2.5 ml. The label should read 100mg/2.5 ml administer 5 ml. The pharmacist also stated that the liquid multivitamin is a suspension and requires to be shaken well prior to administering. An interview with the Administrator on 9/26/19 at 12:11 p.m. revealed his expectations of the nursing staff are to administer medications as ordered.

Based on observations, staff interview, and the facility policy titled Policy -Food Purchasing, Receiving, Production, and Preparation 03-6647 Storage, the facility failed to ensure one of one walk in freezer was maintained in a clean sanitize condition and that food items were properly labeled and stored in a sanitary manner in one of two walk in coolers , one of one walk in freezer, and one of three food storage floor bins . This had the potential to effect 10 residents receiving oral fed diets. Findings include: Record review of the facility policy titled Policy-Food Purchasing, Receiving, Production and Preparation, 03-6647 Storage revealed the following: (1). protect food from contamination and spoiling during storage and preparation. Discard food in open containers within three (3) days of opening. (4). b. store all food in original containers or in NSF internationl approved containers. and once removed from the original containers store unused portion of opened food in tightly closed approval food grade bulk containers. (b). as appropriate cover with cool wrap or aluminum foil and label with the contents and dated (c). label all perishable food with the date it was put in the container and a use-by date determined according to Georgia DPH (Department of Public Health) Food Service Rules and Regulation Observation of one walk in freezer 's floor on 9/23/19 at 11:53 a.m. revealed the following concerns: 1. small bits of food particles and one unwrapped chicken breast patty on the freezer floor 2. dark brown substances, and pieces of white and brown cardboard scattered on the freezer floor 3. unlabeled opened sausage links wrapped in Saran wrap with no open date and expiration date 4. unlabeled open hash brown in a plastic bag with no open date with no open date and expiration date 5. open bag of carrots (unlabeled) stored in a plastic bag not properly sealed and stored in a large cardboard box with flaps not properly sealed Observation of one walk in cooler on 9/23/19 at 11:56 a.m. revealed the following concerns: 1. a pan of cooked bacon in a 1/3 loaf pan dated 9/17/19 (open date) to 9/21/19 (discard date) 2. a pan of cooked green beans in a 1/3 loaf pan dated 9/19/19 (open date) to 9/28/19 (discard date) 3. a pan of cooked puree green beans in a 1/3 loaf pan dated 9/19/19 (open date) to 9/28/19 (discard date) 4. a pan of cooked beef in a 1/3 loaf pan dated 9/17/19 (open date) to 9/21/19 (discard date) Observation of flour bin on 9/23/19 at 11:58 a.m. revealed the following: 1. Scoop merge down into the flour bin with only the handle being exposed. Further observation of the scoop revealed the handle completely covered with sticky and flakily white substance (flour). Interview on 9/23/19 at 12:02 p.m. with the Register Dietician/Food Service Director (RD) revealed that her expectations are for food items to be labeled and dated, stored in a sanitary manner to prevent food borne illness. All leftover food items should be properly labeled for a 72 hour or three-day time usage. RD-DM further stated that she has new dietary staff who require more in-services on labeling and 72 hours policy on discarding of cooked food items. She was unaware that the freezer floor was not maintained in a clean sanitary manner. She described the white substances on the scoop in the flour bin as flour. She stated that the scoop should be washed after each use and stored in a separate container. RD further stated that staff are trained on the Dietary Policies during orientation, quarterly, and as needed.

Based on record review and staff interview, the facility failed to ensure that the annual 12-hour minimum education for Certified Nursing Assistants (CNA) included Dementia Care training for three of three CNA education transcripts reviewed. Findings include: Review of the employee files for CNA AA, CNA BB and CNA CC revealed all three CNAs had completed an annual minimum education/training of 12 hours, however, the training did not include the required annual Dementia Care training. Interview on 8/18/18 at 9:00 a.m. with the Training Program Administrator (TPA) and the Registered Nurse Educator (RNE) revealed that Dementia Care training is typically conducted in (MONTH) of each year. The TPA and the RNE stated they did not have record of the rosters for Dementia Care training in (MONTH) (YEAR). They stated another person was in the position. They stated that they looked but could not find the roster sign-in sheets. The RNE stated the facility did not have a policy related to required education for CNAs.

Based on observations, review of the policy titled Enteral Nutrition Pump- Cleaning and Disinfection and staff interviews, the facility failed to maintain tube feeding poles in a clean and sanitary condition for nine of 17 resident (R) (#25, #3, #7, #76, #10, #9, #14, #15, and #178) that received enteral tube feeding, and failed to maintain clean and dust free hallway walls in one of two units (Unit 1). Findings include: 1. Observations of the tube feeding pole for R#25 on 8/17/18 at 12:00 p.m., on 8/18/18 at 8:40 a.m. and 11:30 a.m., and on 8/19/18 at 8:50 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 2. Observations of the tube feeding pole for R#3 on 8/17/18 at 12:45 p.m., on 8/18/18 at 8:30 a.m., 11:35 a.m. and 2:40 p.m., and on 8/19/18 at 8:40 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 3. Observations of the tube feeding pole for R#7 on 8/17/18 at 1:00 p.m., on 8/18/18 at 8:25 a.m., 11:40 a.m. and 2:36 p.m., and on 8/19/18 at 8:45 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 4. Observation of the tube feeding pole for R#76 on 8/17/18 at 1:15 p.m., on 8/18/18 at 9:05 a.m., 11:45 a.m. and 2:43 p.m., and on 8/19/18 at 8:30 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 5. Observations of the tube feeding pole for R#10 on 8/17/18 at 1:10 p.m., on 8/18/18 at 9:10 a.m., 11:50 a.m. and 2:40 a.m., and on 8/19/18 at 8:35 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 6. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for Resident (R)#9 in bed A had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#9 in bed A had a large amount of dried, beige-colored substance in the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#9 in bed A had a moderate amount of dried, beige-colored substance on the base of the pole. There was a housekeeping log sheet titled, Camelia Unit Pole Accountability, on the back of the door of room [ROOM NUMBER] which documented the tube feeding pole for bed A was cleaned on 8/18/18 and 8/19/18, however, a moderate amount of dried, beige-colored substance remained on the base of the pole. 7. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for R#14 in bed B had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#14 in bed B had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#14 in bed B had a moderate amount of dried, beige-colored substance on the base of the pole. There was no housekeeping log sheet available for R#14 in bed B. 8. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for R#15 in bed C had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/19 beginning at 10:50 a.m. revealed the tube feeding pole for R#15 in bed C had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#15 in bed C had a moderate amount of dried, beige-colored substance on the base of the pole. There was no housekeeping log sheet available for R#15 in bed C. 9. Observations of the tube feeding pole for R#178 on 8/17/2018 at 11:00 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. Observations of the tube feeding pole for R#178 on 8/18/2018 at 9:44 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. Observations of the tube feeding pole for R#178 on 8/19/2018 at 9:30 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. There was no housekeeping log sheet available for R#178. Observation on 8/17/18 at 1:33 p.m. there was brown dripping stains on walls and dust on lower portion of walls in hallway throughout living unit one. Observation on 8/18/18 at 8:47 a.m. there was brown splatter stains on right side of the wall near the window. Observation on 8/18/18 at 8:49 a.m. There were brown stains on wall near rooms [ROOM NUMBERS] that looks like spillage. There was also black staining noted towards the lower areas of the wall. There continues to be dust on walls throughout the hallway of unit one. Interview on 8/19/18 at 11:34 a.m. with the on-call Housekeeping Team Leader who reported that housekeeping staff should pull trash, make beds, clean restroom, clean activity rooms, and closets. It was further reported resident rooms should be wiped down to include the walls. Housekeeping tour began at 8/19/18 11:38 a.m. with on-call Housekeeping Team Leader and the following was confirmed: 1. Observation in room [ROOM NUMBER] revealed splatter on wall. 2. Observation of hallway across from room [ROOM NUMBER] and room [ROOM NUMBER] revealed dust buildup on lower wall and dripping stains on walls. 3. Loose baseboards near room [ROOM NUMBER] and near water fountain unit 1. 4. There was dust buildup under sink in hallway and dust buildup on walls throughout Unit 1. During an interview with the on-call Housekeeping Team Leader on 8/19/18 at 11:50 a.m. it was reported that inspections are supposed to be done weekly by the supervisor to assure that areas are being cleaned. She further reported that when she does her inspections if areas of concerns are identified the worker is notified to correct the issue. She further reported that as areas are identified the expectation is that the areas will be cleaned. Interview on 8/19/18 at 12:15 p.m. with Nurse Manager who reported that it is the expectation that staff will correct an issue if they see it, when addressing the splatter stains on the wall in room [ROOM NUMBER]. Explaining that they can wipe something and clean it instantly, but if they are not able to clean they are to notify housekeeping so that they can address the issue. She further reported that the stains in the hallway look as if someone sprayed something and did not wipe the wall thereafter. Observation on 8/19/18 with the Nurse Manager beginning at 10:00 a.m. and ending at 10:20 a.m. confirmed the tube feeding poles and bases were dirty and had dried tube feeding drippings on the base for R#25, R#3, R#7, R#76, R#10, R#9, R#14, R#15 and R#178. She confirmed that the tube feeding nozzles for R#76 and R#10 was not in use but was not capped off. The Nurse Manager stated she had spoken with the staff about ensuring the tube feeding nozzles were capped off when not in use and to keep the caps in the plastic bag at bedside when tube feeding was in use. She confirmed that not capping off the tube feeding nozzles could cause dripping unto the base of the pole and the floor. She stated that it is just a matter of laziness. She stated she just spoke with staff about this last Wednesday. The Nurse Manager stated the responsibility to ensure the poles are clean is between both the nurses and the housekeeping staff. She stated that housekeeping had tried to clean the poles bases before and that the tube feeding had dried to the point they had trouble removing it. The Nurse Manager confirmed that if the caps were properly used and the tube feeding was wiped off when it drips or on a regular basis, it would not be dried to the point of difficult removal and cleaning. The Nurse Manager stated they had discussed getting new tube feeding poles but had not yet ordered any. Interview on 8/19/18 at 12:25 p.m. with the Nurse Manager revealed they do not have a policy for cleaning the tube feeding poles and that the current policy only addresses cleaning the kangaroo pump itself. She further stated they do not have a policy and procedure related to capping the tube feeding nozzles when disconnected from the residents and not in use. Review of the policy titled Eternal Nutrition Pump- Cleaning and Disinfection approved 4/14/10 documented A pump in continuous client use will be surface cleaned of all spills on the living area as needed or at least weekly. The policy did not address cleaning of the pump pole.

Based on observation and staff interviews, the facility failed to maintain a clean floor in the satellite kitchen in Building 15 of the hospital complex and to clear state who is responsible for cleaning the ktichen floor. The facility census was 29. Findings include: Observation of the satellite kitchen in Building 15 on 8/18/18 at 11:30 a.m. revealed three dead cockroaches in the corner of the room next to a broken dishwasher and two dead cockroaches underneath the dishwashing sink next to the broken dishwasher. During an observation of the satellite kitchen in Building 15 with the Assistant Food Service Manager (FSM) on 8/18/18 at 12:19 p.m., he confirmed the presence of the dead cockroaches. He stated the facility received routine visits from a local pest control service to address problems with bugs throughout the facility complex as evidenced by the cockroaches being dead. He stated the satellite kitchen was used to receive bulk cooked food from the main kitchen. The food is placed on the steam table, checked for appropriate serving temperatures, plated and transported to the skilled nursing facility (SNF) for the residents. He further stated the kitchen staff was responsible for cleaning the areas of the satellite kitchen where food is handled but the housekeeping staff was responsibility for cleaning the satellite kitchen floor when the kitchen staff was done for the day. On 08/18/18 at 2:28 p.m., the Assistant FSM supplied the pest control service records dating back one year from (MONTH) (YEAR) to date which detailed monthly service calls, services provided and areas of concentration including the satellite kitchen. The satellite kitchen received monthly treatments for roaches. The last pest control service visit was 8/14/18. During an observation of the satellite kitchen in Building 15 with the Housekeeping Team Leader on 8/19/18 at 1:21 p.m. she confirmed the presence of the dead bugs still in the same places for the second day of observation. She stated, to her knowledge, the housekeeping staff was not responsible for cleaning the satellite kitchen floor. She stated she could reach her manager by phone, if necessary. During a telephone interview with the Housekeeping Manager (HM) on 8/19/18 at 1:32 p.m., she stated before the facility used that location as a satellite kitchen, the housekeeping staff was responsible for cleaning that area because there is a dining room next to it which serves other non-SNF residents of the hospital complex. She stated once the dietary staff began using it as a satellite kitchen, it became the responsibility of the dietary staff to clean the kitchen daily, including the floor. She further stated she would have her staff clean the satellite kitchen floor that day but would speak to her Director as soon as possible to address the controversy of cleaning responsibilities in the satellite kitchen. During an interview with the Administrator on 8/19/18 at 1:50 p.m. he stated he was unaware the satellite kitchen floor was not being cleaned on a regular basis. He stated the kitchen areas of the complex were part of the hospital and not the SNF and the kitchen and dietary staff work for the hospital. He stated the SNF received its food directly from the satellite kitchen but is prepared in the main kitchen. He stated he was not sure which department was responsible for cleaning the satellite kitchen. He stated he would attempt to locate any policies which address the responsibilities of the housekeeping and dietary departments, but he doubted there were any policies specific to that situation. He finally stated he would assist each department in determining their areas of responsibility going forward.

Based on observation and staff interview, the facility failed to date opened food items prior to storage in one (1) of two (2) dry storage rooms, in three (3) of four (4) walk- in refrigerators, and in one (1) of two (2) walk- in freezers; failed to appropriately store scoops in the containers of sugar, rice and flour in one (1) of two (2) dry storage rooms; failed to ensure that the fan was free of dust in one (1) of four (4) walk-in refrigerators. The census was forty-two (42) residents. Finding include: Observations on 3/21/16 at 10:45 a.m. revealed the following: Observation of one (1) of the two (2) dry storage rooms revealed one (1) open five (5) pound bag of Quick Grits, one (1) open two (2) pound bag of Bran Flakes cereal and one (1) open two (2) pound bag of oatmeal. These items were noted to be opened but were not labeled with the date the items were opened. Further observation revealed a scoop, with the handle touching the food items, in each of the following containers: sugar, rice and the flour container. Observation in the walk-in refrigerator #1 revealed one (1) opened plastic bag of hamburger patties that was not labeled with the open date. Observation also revealed a build-up of dust on the fan in the walk-in refrigerator #1. Observations of the walk-in refrigerator #2 revealed one (1) opened bag of French fries and one (1) opened bag of flour that were observed to be open but did not have the dates of when they were opened. Observation also revealed one (1) plastic bag of an unidentified substance on the floor under the food that was not dated or labeled. Observation of the walk-in refrigerator #3 revealed one (1) opened package of sliced cheese that was opened but did not have the date when it was opened. Observation of the walk-in freezer #4 revealed one (1) opened package of chocolate chip cookie dough that did not have the date when it was opened. Interview on 3/21/16 at 2:00 p.m. with the Registered Dietician /Dietary Manager, revealed that all the food items in the dry storage area, in the refrigerators and in the freezers should be labeled with the name of the item and all opened items should be dated with the dates the items were opened. Further interview revealed that the scoops should not have been submerged in the containers of sugar, rice and flour. Interview on 3/24/2016 at 3:50 p.m. with the Dietary Food Service Manager revealed that she expected the staff to label all food items and to label the opened items with the date the item was opened. Further interview revealed that the Food Service Manager constantly informed dietary staff that all opened food items in the dry storage areas, in the refrigerators and in the freezers were supposed to be labeled and dated. Review of the facility's policy of food storage revealed that opened food items should be closed, contents listed, and the date the item was open, documented on the item, prior to the item being stored in the refrigerators, freezers, or the dry storage area.

Based on record review, facility staff and Nurse Practitioner interviews, the facility failed to follow the Care Plan/Client Profile for turning and re-positioning for (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Review of Care plan/Client Profile for resident #1 documents turn and reposition turn every two (2) hours. Interview on 3/24/2016 at 2:45 p.m. with the Nurse Practitioner (NP) revealed that the resident had current Physician orders [REDACTED]. On 3/24/16 at 3:00 p.m. the NP confirmed that the resident was not fully turned and repositioned as per the Physician/NP orders. Interview with the Director of Therapy on 3/24/16 at 1:46 p.m. revealed that the resident was supposed to be fully turned on his/her left side or right side and those positions were maintained with the use of supportive devices. Continued interview revealed that multiple wedges and positioning devices were available and that the certified nursing staff had been trained how to use the wedges and the positioning devices. Interview with the Director of Nursing on 3/24/16 at 1:48 p.m. revealed that she expected the staff to turn and reposition residents as they were trained. Continued interview revealed that the facility did not have a specific policy for turning and repositioning residents but the nursing staff were taught proper procedure during training and were expected to follow the physician's orders [REDACTED]. Cross refer to F314

Based on observation, record review, facility staff and Nurse Practitioner interview, the facility failed to properly turn and re-position one (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Observation on 3/22/2016 at 6:50 a.m. and at 8:10 a.m., revealed the resident was lying on his/her back in the bed placing pressure on the pressure sores on the resident' s right hip and the right ischium. Observation on 3/22/16 at 10:20 a.m., revealed the resident was lying on his/her back in the bed. Staff had placed a wedge under the resident's left middle back and the resident was observed lying on his/her right side with direct pressure being placed on the resident' s pressure sores on the resident's right hip and right ischium. Observation on 3/22/2016 at 11:55 a.m., revealed the resident was lying on his/her back in the bed. Although the staff had placed a wedge under his/her right hip, the resident's pressure sore on his/her right ischium was observed to remain in contact with the mattress. Observation on 3/22/2016 at 1:32 p.m., revealed the resident was lying on his/her back in the bed with unrelieved pressure on the pressure sore on the right ischium. Interview on 3/24/2016 at 2:45 p.m. with the Nurse Practitioner (NP) revealed that the resident had current Physician orders [REDACTED]. On 3/24/16 at 3:00 p.m. the NP confirmed that the resident was not fully turned and repositioned as per the Physician/NP orders. Interview with the Director of Therapy on 3/24/16 at 1:46 p.m. revealed that the resident was supposed to be fully turned on his/her left side or right side and those positions were maintained with the use of supportive devices. Continued interview revealed that multiple wedges and positioning devices were available and that the certified nursing staff had been trained how to use the wedges and the positioning devices. Interview with the Director of Nursing on 3/24/16 at 1:48 p.m. revealed that she expected the staff to turn and reposition residents as they were trained. Continued interview revealed that the facility did not have a specific policy for turning and repositioning residents but the nursing staff were taught proper procedure during training and were expected to follow the physician's orders [REDACTED].

Based on observation, record review, facility staff and physician interview, the facility failed to accurately and completely document the appearance of non-pressure wounds for one (1) resident (#5). The sample size was twenty-two (22) residents. Findings include: Review of resident #5's Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident was at risk of pressure ulcer development and had a Stage 2 pressure ulcer. Review of the care plan dated 06/11/15 revealed that the resident was at risk for impaired skin integrity as related to history of decubitus and high risk assessment score for decubitus. Further review of this care plan revealed that it was updated on 01/26/16 to note that the resident's buttocks had some small red areas, and to continue with current treatment and monitor. Review of a hospital wound care assessment dated [DATE] revealed that resident #5's buttocks had several unmeasurable areas of maceration and redness; evidence of peeling and open skin to some areas; bloody and dark brown drainage; and full thickness ulceration to the sacrum and bilateral buttocks extending to the posterior thighs. Review of resident #5's Nurse's Notes on re-admission to the facility dated 01/29/16 noted the resident's sacrum had full-thickness ulceration, but there was no measurements or other description of the appearance of the wound. Review of a Hospital Return Nursing assessment dated [DATE] noted that the section labeled Body Chart was left blank with no abnormalities listed. Review of a Health Note dated 01/29/16 noted that resident #5 had returned from the hospital, a body inspection was completed with an RN and the attending physician DD, and multiple open areas were noted to the buttocks, crease as well as an open area to the groin. Further review of this form revealed that the wounds were not classified as to the type of wound, measured, nor any documentation of the appearance of the wounds. Review of Registered Nurse (RN) Wound Care Nurse CC's first assessment of the wound after return to the facility dated 01/31/16 noted that wound care was done, but there was no documentation of the appearance or measurements of the wounds. Review of RN Wound Care Nurse CC's wound notes dated 02/10/16 noted wounds to the buttock area which were pink in color with no signs of infection, but no documentation of size, depth, or any drainage. Review of the wound care nurse's notes dated 02/15/16 noted an area to the right medial buttock which was open, and five distinct areas of redness with thick and rough skin, and noted she was unable to measure due to the resident's breathing issues. Wound care notes dated 02/22/16 noted inability to measure the wounds due to the resident ' s inability to maintain position, and that the wounds appeared to be decreasing. Review of wound care notes dated 03/21/16 noted the buttocks had an offensive odor, were macerated with approximately five areas with redness and one area at tip of coccyx that was bleeding, but no documentation of exact locations, type and measurements of the wounds. During interview with the RN Wound Care Nurse CC on 03/22/16 at 1:33 p.m., she stated the facility did not use a special form to document wounds, whether they were pressure-related or not. She further stated that the attending physician had classified resident #5's wounds to the buttocks as moisture-related breakdown rather than pressure. Observation of the resident's buttocks on 03/23/16 at 10:10 a.m. with Licensed Practical Nurse (LPN) EE revealed that there were four areas of skin on the buttocks that were covered with Xeroform gauze. Further observation revealed that three of the areas of skin under the gauze were dark pink with no ulceration noted. Further observation revealed that there was one large (unmeasured) triangular-shaped area on the left buttock with a shallow ulceration and drainage, and an odor was noted. Continued observation revealed that it took three staff to turn the resident and LPN EE to pull back the Xeroform gauze, but resident #5 was noted to have no respiratory distress during the observation. During interview with LPN EE at this time, she stated that the treatment nurse would be the one to document the appearance of the wounds. During interview with the Director of Nurses (DON) on 03/23/16 at 1:05 p.m. she verified that the Body Chart section on the Annual Nursing Assessment/Hospital Return dated 01/29/16 was not completed, and stated the receiving nurse should have done this. During interview with the resident's attending physician DD on 02/23/16 at 1:40 p.m., she stated that she felt the areas to resident #5's buttocks were from maceration, and not from pressure. During interview with the DON on 03/23/16 at 5:41 p.m., she stated that she had talked to wound care nurse CC earlier that day, and had been told that there was no other documentation of the measurements and/or description of the wounds to the resident's buttocks. Upon further interview, the DON stated that she was not aware of any policy and procedure related to non-pressure wounds measurement and tracking. Review of the facility's Prevention of Pressure Ulcer Development policy and procedure docuemented that direct care staff would observe skin integrity, and if the nurse determined that any impaired skin was not a pressure ulcer, the nature of the impaired skin integrity would be determined, documented and reported.

Based on observations, and staff interviews, the facility failed to maintain an effective pest control program in the kitchen. The facility census was twenty-two (22). Findings include: Observation in the kitchen on 7/16/13 between 1:45 p.m. and 2:00 p.m., revealed the following concerns: a red roach crawling on top of the table next to the steamer machine, a small black bug crawling on the wall next to the pantry door, a red roach crawling on the floor behind the steam table and a red roach crawling on a stack of Styrofoam plates on top of the steam table. Observation of the kitchen on 07/17/2013 at 9:00 a.m., revealed two (2) brown roaches crawling on the post near the steam stable and one (1) dead roach on the bottom of the post. Continued observation revealed four (4) small black bugs crawling on the post, a brown roach and a small black bug crawling on the lower shelf on the middle of the steam table. Interview with the Dietary Supervisor on 7/16/13 at 2:05 p.m. revealed that from time to time there are issues with roaches in the kitchen . Continued interview revealed that there are four (4) wooden pallets in the kitchen, and had seen roaches crawling on these pallets. She indicated that she has been trying to replace these pallets. Interview on 7/17/13 at 9:00 a.m. with the Dietary Supervisor revealed that approximately two (2) weeks ago she had noticed a worsening problem with the bugs and had notified the pest control provider, Orkin, who came the evening of 7/1/13, providing treatment. Interview with the Administrator on 7/17/2013 at 2:35 p.m., revealed that she was not aware of any current problems with pest in the kitchen; however, the facility has had problems in the past and contracted with Orkin, who would come quarterly and as needed.

Based on observations and staff interview, it was determined that the facility failed to ensure that two (2) portable fans with dust/debris did not blow over uncovered food. Census= two (22) residents. Finding include: 1. Observation on 7/15/13 at 12:30 p.m. revealed a large portable fan, with an accumulation dust/debris sitting on the floor behind the steam table. This fan was blowing directly towards the steam table where meal trays were being prepared. 2. Observation on 7/16/13 at 1:35 p.m. revealed one (1) of the two (2) portable fans with an accumulation of dust/debris blowing towards the food prep area where food items were being prepared. Observation on 7/16/13 at 1:40 p.m. revealed , the second fan, with an accumulation of dust and debris, on top of a rolling cart, next to the conveyor belt, where clean dishes were coming out of the dishwasher. This fan was blowing directly on three (3) large metal pans. 2. Observation on 7/17/13 at 9:00 a.m. revealed a fan with an accumulation of dust/debris clinging to it, in the steam table area. This fan was blowing across a multiple level cart of food, some uncovered. Interview with the Dietary Supervisor on 7/17/13 at 9:00 a.m., revealed that the fan should not be blowing across the steam table.

Based on record review and staff interview, the facility failed to hold Quality Assessment and Assurance (QAA) meetings at least quarterly and failed to ensure that a physician attended those meetings. The facility census was twenty-two (22). Findings include: Review of the QAA minutes, provided by the facility during the standard survey, revealed that the meetings were held on 3/29/12, 7/30/12, 11/30/12, 4/10/13 and 6/28/13. Continued review revealed that the physician was present for two (2) of the five (5) meetings, on 4/10/13 and 6/28/13; however, there was no evidence there was any quarterly QAA meeting held between November 2012 and April 2013. Interview with the Unit Manager on 7/17/13 at 1:00 p.m., revealed that the physician was not present at every meeting and confirmed there was no evidence of a meeting being held between November 2012 and April 2013. Telephone interview with the Administrator on 7/24/13 at 2:30 p.m. during the QA process revealed that there was no evidence of any QAA meeting sign in sheets for the physician.

Based on observation, record review and staff interview, the facility failed to ensure that their medication error rate was less than 5%. Five (5) errors out of fifty (50) opportunities for four (4) of ten (10) residents were noted by two (2) of five (5) nurses on two (2) of two (2) units. The facility's medication error rate was 10%. Findings include: 1. During an observation on 01/10/12 at 8:15 a.m., Licensed Practical Nurse (LPN) "HH" crushed all of resident #7's pills, including a [MEDICATION NAME] Delayed Release Orally Disintegrating Tablet, then mixed them with applesauce and gave them to the resident by mouth. However, according to the physician's orders [REDACTED]. A review of the Geriatric Dosage Handbook, 12th Edition, revealed that orally-disintegrating [MEDICATION NAME] ([MEDICATION NAME]) tablets should not be swallowed whole or chewed, but could either be placed on the tongue and allowed to dissolve, or dispersed in 10 milliliters (mL) of water in an oral syringe and administered. 2. On 01/10/12 at 11:42 a.m., LPN "HH" was observed giving medications to resident #25. HH gave the resident two puffs from an Atrovent inhaler in quick succession and then immediately gave the resident Iwo quick puffs of an [MEDICATION NAME] inhaler. However, review of the manufacturers' package inserts for the inhalers revealed that they had not been administered correctly. The nurse was supposed to firmly press the Atrovent canister against the mouthpiece one (1) time and then wait at least 15 seconds before repeating. If a resident's doctor prescribed more than one spray of [MEDICATION NAME] ([MEDICATION NAME]) then, the facility should have waited one (1) minute and shaken the inhaler again (before administering another spray). On 01/10/12 at 2:35 p.m., LPN "HH" confirmed that he/she had crushed the [MEDICATION NAME] tablet for resident #7. She provided the pharmacy packaging for the [MEDICATION NAME], which was labeled to include instructions to dissolve the drug before giving it. He/ She confirmed having given the [MEDICATION NAME] and Atrovent inhaler puffs without waiting in between each one. He/She said he/she was not aware of a facility policy of how long to wait. On 01/10/12 at 3:06 p.m., the Unit Manager provided the facility's Nursing Procedure on the administration of inhalers, which confirmed that the staff should have waited 2 minutes before a second inhalation. 3. LPN "AA" administered medications to resident #20 at 8:35 a.m. After that observation, the physician's medication orders were reviewed. There was an order for [REDACTED]. 4. LPN "AA" administered medications to resident #16 at 9:15 a.m. There was an order for [REDACTED].

Based on observation, record review, and staff interview, the facility failed to ensure that facility staff washed their hands and/or changed their gloves after handling a contaminated object for one resident (#30). The sample size was twelve (12) residents. Findings include: On 01/11/12 at 7:45 a.m., an observation of resident #30's skin was done with Registered Nurse (RN) "CC." When the incontinent brief was pulled back, the resident had a small amount of non-formed stool in the brief, as well as a plastic thermometer probe cover. The nurse removed the probe cover from the brief with his/her gloved fingers and threw it in the trash. Without changing his/her gloves or washing his/her hands, he/she then removed and replaced the resident's heel protectors, pulled down the resident's shirt, pulled up the bed covers and patted the resident on the back before removing her gloves and washing her hands. On 01/11/12 at 8:55 a.m., the Unit Manager stated that if the gloves were contaminated then she expected the staff to change gloves and/or wash their hands before they provided any other care. Review of the facility's Infection Control Policy on Standard and Transmission Based Precautions outlined that hand hygiene was the single most effective method to prevent the spread of disease. Employees and clients should wash their hands frequently and thoroughly and use good hand washing technique after removal of gloves and anytime there was exposure to blood or body fluids. Clean, non-sterile gloves should be worn when touching or at risk of touching excretions, and changed between procedures on the same client. However, during an interview on 01/11/12 at 11:00 a.m., RN "CC" confirmed that he/she did not immediately change gloves after handling the thermometer probe cover that had been in resident #30's incontinent brief.

Based on observations, staff interviews and review of the facility policy, the facility failed to ensure that six (6) wheelchairs on two (2) of two (2) halls and one (1) IV pole were free of an soiled matter. Findings include: Random observations of wheelchairs during the environmental rounds on 1/10/11 at 2:00 p.m. revealed that there was a build up an ivory colored, dried substance on sides and under the bottoms of the crossbars on six (6) different wheelchairs. Living Area 1 1. The purple wheelchair in room 116 had an dried, ivory substance on the left side and under its cross bars. 2. The blue wheelchairs in room 109 had an dried, ivory colored substance on the left side and under its crossbars. Living Area 2- The blue wheelchairs in rooms 267, 266, 259 and 256 had an ivory, colored substance on both sides and under their crossbars. During an interview on 1/10/12 at 2:50 p.m., Certified Nursing Assistant (CNA) "FF" said Occupational Therapy department (OT) had a staff member who was responsible for pressure washing all of the wheelchairs. "FF" said that the dried, Ivory colored substance on the wheelchairs was formula. In an interview on 1/11/12 at 10:49 am, the OT/Physical Therapy Tech "EE" said that all of the wheelchairs were scheduled to be cleaned every six weeks. "EE" said the wheelchairs had last been cleaned on 11/16/11. "EE" explained that he/she was behind on the cleaning schedule because of the holidays. "EE" said that there was not a facility policy for cleaning. She/He said that he/she was responsible for pressure washing all of the wheelchairs for the whole campus. "EE" added that the CNAs on each unit were responsible for cleaning the wheelchairs, if it was needed before the scheduled time for pressure cleaning. Review of the Pressure Washing schedule indicated that the last steam cleaning for the wheelchairs were done between 11/15/11-11/21/11. Living Area 2 The bottom bottom of the IV/ tube feeding pole In room 258 was soiled with a dried, ivory substance.

Based on observations and interviews with staff, the facility failed to post the nurse staffing data on all three days of the survey. Findings include: During observations in Liviing Areas 1 and 2 on 1/9/12, 1/10/12, and 1/11/12, it was noted that the facility had failed to post the required notice about nurs staffing data. The facilty had not posted a notice whcih included the following information: the facility name; the day's date; the total number and actual number of hours worked by licensed and unlucensed nursing staff providieng direct resident care on each shift and; resicent census. During an interview on 1/11/11 at 11:05 am, the Director of Nursing said that the facility had not posted the (nurse) staffing data the survey. The Director of Nursing said that she had not been poating the required informaton but only the nurses'schedule. In an interview on 1/11/12 at 11:10 a.m., the Infection Control Nurse said that she was unaware of the regulation for posted staffing.

Based on record review and staff interview the facility failed to have evidence that injuries of unknown source were thoroughly investigated. This was supported by the failure to interview all staff who may have been in contact with/or witnessed an incident related to the fractured tibia and fibula of one (1) resident #23 of twenty one (21) sampled residents. The failure to conduct a thorough and complete investigation of an injury of unknown origin resulted in harm to resident #23. Findings include: Record review revealed that resident #23 was [AGE] years old, non-verbal and has [DIAGNOSES REDACTED]. The annual MDS, conducted 11/10/09, assessed the resident as having severely impaired cognitive skills, unable to make needs known and totally dependent on staff for all care and activities of daily living. The resident was also assessed as requiring 2 persons or more for positioning, transfers and lifting. Further record review revealed a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee and lower leg area, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Review of the facility's Investigative Report dated 3/05/10 revealed that on 3/03/10 the resident was sent to the emergency room (ER) for evaluation of the swelling and discoloration of the right lower extremity. The ER confirmed that the resident sustained [REDACTED]. In addition, the Registered Nurse Manager provided an attachment of five (5) statements from Certified Nursing Assistants and one (1) from an Occupational Therapy Technician who worked either first or second shift. However, there was no evidence of interviews or inquiries from staff who worked third shift (11:00 p.m.-7:00 a.m.) the morning the injury was discovered. An interview on 9/22/10 at 3:15 p.m. with the Registered Nurse Manager confirmed that three (3) Certified Nursing Assistants and two (2) Licensed Practical Nurses would have worked the third shift (the morning the injury was noted). However, no interviews or statements were available from this staff to further determine how the injury may have occurred. The results of the Investigative Report concluded that the resident's injury may have occurred during lift/transfer from bed to chair, stretcher, or shallow tub or during personal care/dressing. The corrective action based on this investigation was to have the resident evaluated by Occupational Therapy (conducted 4/05/10) followed by inservice of all CNA staff regarding positioning, manual lifting /transfers and a determination that no mechanical lifts were to be used for this resident.

Based on record review and staff interview the facility failed to provide services that met professional standards of quality. This was evidenced by the failure to clarify with the physician the urgency of providing x-ray services to rule out a possible fractured extremity resulting in harm for one (1) resident #23 of twenty one (21) sampled residents. Findings include: Record review revealed that resident #23 had a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Based on facility assessments (MDS, dated [DATE]) the resident was unable to communicate or make her needs known and was totally dependent on staff for all activities of daily living. Review of a physician's orders [REDACTED]. Review of a Health Note dated 3/02/10 at 10:00 a.m. revealed the nurse indicated that the x-ray would be done on 3/03/10, 24 hours after the injury was identified. In an interview on 9/22/10 at 11:00 a.m. with Licensed Practical Nurse (LPN) "AA" she acknowledged the physician's orders [REDACTED]. She added that since the physician did not request "stat" (immediate) x-rays she accepted that date without question. The nurse did not clarify with the physician the urgency of obtaining the x-rays sooner than 3/03/10. The Registered Nurse (RN) Manager was also present at the time of the interview with this LPN and later indicated that because of the resident's condition she would have expected the LPN to report the 24 hour delay of x-ray services to the RN Manager for further guidance. This was not done. The RN Manager acknowledged that other arrangements could have been made to have the x-ray services provided in a timelier manner. Standards of Practice for Licensed Practical Nurses-- In accordance with 2.3.2 Standards Related to Licensed Practical Nurses: The licensed practical nurse [MEDICATION NAME] under the direction of a registered nurse ... ... ...licensed physician or other authorized licensed health care provider: A. Conducts a focus nursing assessment, which is an appraisal of the client's status and situation at hand that contributes to ongoing data collection. E. Seeks clarification of orders when needed.

Based on record review and staff interview the facility failed to ensure that, residents were closely monitored for acute pain, following a new injury. This was evidenced by the failure to assess for potential pain for one (1) resident #23 following a leg injury and resulted in harm to the resident. The sample size was twenty one (21) residents. Findings include: Record review revealed that resident #23 was [AGE] years old, non-verbal and has [DIAGNOSES REDACTED]. Further record review revealed a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee and lower leg area, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Review of a Health Note dated 3/03/10 at 2:00 a.m. indicated the resident's right lower extremity was painful to touch when assessed. In another note dated 3/03/10 at 3:00 a.m. nursing staff indicate the resident's right leg is tender to touch. In the Health Note dated 3/03/10 at 5:30 a.m. nursing staff indicate the resident was transported to the hospital emergency room via ambulance and determined to have sustained a fractured tibia and fibula. Record review revealed the resident had a physician orders [REDACTED]. Review of the resident's March 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The first dose of [MEDICATION NAME] was administered nine (9) hours after the injury was identified. There was no documentation that the resident was being monitored and assessed more closely for potential pain during that nine (9) hour period. This was confirmed in an interview with the Registered Nurse Manager on 9/22/10 at 3:30 p.m.