Every finding on record at Hampton Court Nursing and Rehabilitation Center

Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one (Resident #109) out of three residents whose assessments that were reviewed, as evidenced by Resident 109 was discharged home but the discharge assessment indicated the resident was discharged to an acute hospital. The findings included Review of the medical records for Resident #109 revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included but not limited to: Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding. Record review of Resident #109 's MDS dated [DATE] indicate in Section C for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 indicating the residents is cognitively intact. Review of Resident # 109's Minimum Data Set (MDS) dated [DATE] the Discharge Status coded the resident was discharged to Short-Term General Hospital (acute hospital) on 01/14/2025. Record review of Resident #109's Care Plans revealed the Resident can be safely discharged upon completion of the rehabilitation program as planned to home. Interview on 04/03/25 at 12:55 PM, Staff B, MDS Coordinator, revealed she was initially informed that Resident # 109 had been discharged to her home. Upon reviewing the records, the miscode was identified. Review of the facility policy and procedure revised October 15, 2024, regarding resident assessments stated residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: Omnibus Budget Reconciliation Act (OBRA) required assessments -conducted for all residents in the facility. Quarterly Assessment -conducted not less frequently than three months following the most recent OBRA assessment of any type.

Based on observation, record review and interview, the facility failed to assist in obtaining oral surgery dental services for one (Resident #26) out of one Medicare pay resident reviewed for dental services. There were 105 residents residing in the facility at the time of the survey. The findings included: Record review of the Dental Services Policy and Procedure revised 03/2025 documented: Policy-It is the policy of this facility to assist residents in obtaining routine and emergency dental care; Policy Explanation and Compliance Guidelines-1) The dental needs of each resident are identified through the physical assessment and MDS (Minimum Data Service) assessment processes and are addressed in each resident's plan of care and 4) The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location. Observation and interview with Resident number 26 on 3/31/25 at 9:45 AM revealed the resident sitting up in bed, watching television with missing top and bottom teeth. The resident revealed she couldn't remember the last time she saw a dentist and wanted to see a dentist. Review of the Demographic Face Sheet for Resident number 26 documented the resident was initially admitted on [DATE] with a diagnosis of diabetes mellitus, hypertensive heart disease, chronic kidney disease, hypertension and chronic obstructive pulmonary disease. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident number 26 documented the resident's Mental Status (BIMS) Summary Score was 13, indicating no cognitive impairment and able to make her needs known and she required substantial/maximal to dependent assistance for ADLs (activities daily living) and setup assistance for eating. Review of the Physician's Order Sheets (POS) dated March 2025 and April 2025 for Resident number 26 documented the resident was on a Consistent Carbohydrate, No Added Salt, Regular diet and dental care consultation as needed. Review of the care plans for Resident number 26 revealed no dental care plan was available. Review of the dental consults for Resident number 26 documented the following: Dated 5/28/24-Periodontal Exam; No extractions have been completed recently #20 tooth fx (fracture) at gum line. Refer to [ ] nurse for referral to community oral surgeon to extract #20 tooth; dated 6/04/24-Periodontal Exam; Refer patient to oral surgeon for offending teeth lower left & lower right and dated 7/17/24-Periodontal Exam. Review of the Nurses' Progress Notes for Resident number 26 documented the following: Dated 06/05/2024 at 02:48 pm-Receive final dental report dated June 4th from [ ] dentist impression: Resident to follow up with removal of left lower right tooth via oral surgeon. Spoke with nurse practitioner. Practitioner verbalized she will follow up with listed surgeons. Dated 06/10/2024 at 06:59 pm-Residential dental coverage providers. Was able to reserve an appointment with [ ] dental provider office date July 11 at 11 AM. Resident is agreeable with plan of care. Dated 07/05/2024 at 05:21 pm-Call placed to [ ] non-emergency medical transportation and informed [ ] representative that resident has new appointment scheduled 7/11/2024 at 11AM with oral surgeon. [ ] representative stated she is unable to schedule transportation with wheelchair for the resident at this time, but she will call 7/8/2024 in the morning to set up transportation services for resident. Dated 07/08/2024 at 04:59 pm-Call placed to [ ] non-emergency medical transportation and spoke with [ ] representative. [ ] representative informed nurse that their company is unable to provide transportation for resident appointment on 7/11/2024 due to [ ] insurance provider not reimbursing their company for services. Nurse to reschedule transportation with another provider. -Dated 07/11/2024 at 02:28 pm-Received call from medical doctor's office spoke from office manager. I was informed that the resident approval for initial consultation with oral surgeon has not been provided by dental insurance at this time. Office manager and myself agree to continue to reach out to provider and reschedule consultation appointment. All identifying resident information has been reviewed with office manager. [ ] Resident number 26 made aware of the same and is agreeable with plan. She denies any complaint of tooth pain. Resident did verbalize she would like the crack tooth fixed. All transmissions were faxed to oral surgeons office. Will keep resident informed. Dated on 07/11/2024 at 07:01 pm-Reached out to [ ] health care insurance. Spoke with advocate [ ]. List of oral surgeons available under resident dental plan under [ ] health care insurance made available to writer. Will follow-up next business day. On 4/03/25 at 10:01 AM, interview and record review with Staff A, Registered Nurse. She confirmed that the progress notes concerning the oral surgery dental written on 6/05/24, 6/10/24 and 7/11/24 were written by her. She stated, I vaguely remember this situation. I will have to discuss with the case manager about the situation. Subsequent interview on 4/03/25 at 11:21 AM she confirmed that no further arrangements were made for Resident number 26 to have oral surgery as recommended by the dentist. On 4/03/25 at 10:17 AM with the Director of Social Services. She stated, I started working here on 3/17/25. The Social Worker will make appointments for dental for in-house. If the resident is going out, someone else makes the arrangements. Subsequent interview on 4/03/25 at 11:02 AM. She stated, We reviewed the notes and I asked what happened with the oral surgery dental appointment. I asked the nurse was there an appointment made for the extraction and the answer was no. I am going to arrange an appointment for extraction. On 4/03/25 at 12:17 PM with Staff B, MDS (Minimum Data Service) Coordinator. She stated, There is no dental care plan for the resident.

Based on observation, record review and interview, the facility failed to ensure pharmaceutical procedures were being followed for one (300-North) out of two medication carts observed out of the four medication carts in the facility. As evidenced by incorrect narcotic count for one controlled medication on the narcotic sheet (Resident #2) and two loose capsule/pill were found on one cart (300-North). The findings included: Observation on 10/24/23 at 01:16 PM, Medication cart 300 - North was observed with Staff A, RN (Registered Nurse). A yellow capsule with the number 215 and a small orange pill with the number 1G - 206 was found underneath medication blister packs in the medication drawers. During review of the narcotic sheet for Resident #2's Tramadol 50 milligram to be given by oral route two times a day revealed that there were 19 tablets remaining, the blister pack for Resident #2's Tramadol 50 milligram was observed with 18 tablets. On 10/24/23 at 1:20 PM, in an interview with Staff A, when asked, What is the facility's policy for signing out narcotics and recording them? Staff A, stated, When I open a blister pack, I sign it out on the narcotic sheet and check it out in the MAR (Medication Administration Record). I gave Resident #2's Tramadol 50 milligrams at 9:03 AM. I forgot to sign it out in the book. Staff A, showed the Surveyor that Tramadol 50 milligrams was given on 10/24/23 at 9:03 AM to Resident #2 on the electronic health record and proceeded to make the correction on the narcotic sheet for Tramadol 50 milligrams, making the count 18. On 10/25/23 at 1:58 PM, in an interview with the Director of Nursing (D.O.N) when asked, What is the facility's policy for signing out narcotic medications? The D.O.N. stated, Once the medication is removed from the bingo card, the nurse is to sign off the medication. Once the resident swallows the medication and it's verified that the resident received the medication. It's charted in the electronic medication administration record. A record review of Resident #2's Physician orders revealed, Tramadol 50 milligrams one tablet to be given orally two times a day for pain. A record review of Resident #2's Medical Diagnosis revealed, a diagnosis of Pain, unspecified. A record review of the Minimum Data Set, dated dated dated [DATE] revealed, in Section C: Cognitive Patterns, a brief interview of the mental status score was a five indicating severe cognitive impairment. In section J: Pain management, the Resident receives a scheduled pain medication regimen and receives non-medication intervention for pain. Pain frequency was rare over the last five days. The pain intensity was moderate. In section N: Medications, opioid medication was given seven days out of seven days. Review of facility's policy titled Controlled Substance Administration and Accountability. Revised 3/23/2023. The Policy purpose statement states, It is the policy of this facility to promote safe, high-quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. Under Policy Explanation and Compliance Guidelines, 2: Storage and Security, A: Nursing units utilize a substantial-constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use. 3. Obtaining/Removing/Destroying medication, A. the entire amount of controlled substances obtained or dispensed is accounted for. 4: Inventory Verification, B: The dispensing nurse documents all narcotic administration on the patient's MAR (Medication Administration Record) immediately after administering the narcotic to the patient and must document on the narcotic countdown sheets when the narcotic is removed from the blister card. Prior to the end of shift and or during shift to shift narcotic count any missing documentation on the count down sheets must be corrected by the administering nurse.

Based on interviews and record review, the facility failed to develop and implement a care plan related to discharge for one resident (Resident number 113) out of one resident reviewed for discharge. Resident number 113 discharge plans were to be discharged back to the community. The findings included: Record review of the facility's Comprehensive Care Plan Policy and Procedure (revised 10/18/2022) documented the following: Policy-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1) The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care; 2) The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment and 3) The comprehensive care plan will describe, at a minimum, the following: d) The resident's goals for admission, desired outcomes and preferences for future discharge. Closed record review of the Demographic Face Sheet for Resident number 113 documented the resident was admitted to the facility on [DATE] with diagnoses to include rhabdomyolysis, heart failure, peripheral vascular disease, atrial fibrillation, hypertensive heart disease, dementia and major depressive disorder. The resident was discharged back to the community on 8/24/2023. Review of the Minimum Data Set (MDS) 5-Day Assessment for Resident number 113 dated 8/14/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 04 out of 15 indicating severe cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and the family expected the resident to be discharged to the community. Review of the care plans for Resident number 113 revealed there was no care plan written for discharge. Review of the Social Services Progress Notes for Resident number 113 documented the following: Dated 8/09/23: Resident's daughter stated that the goal is for him to return home but it also depends on how he does in rehab and Dated 8/21/23: Resident's daughter was advised that her father was issued NOMNC (Notice of Medicare Non-Coverage) from [ ] insurance company with a discharge date for 8/24/23. The last skilled day will be 8/23/23. NOMNC form has been reviewed, copy provided. [ ] local state agency number to appeal provided and appeal process with the time frame to appeal was provided. Discharge planning services discussed on home health services, and medical equipment. Review of the Physician's Order Sheets (POS) for Resident number 113 for August 2023 documented the resident was discharged home by the insurance provider on 8/24/2023. On 10/26/23 at 8:15 AM, interview and record review with the Director of Social Services. She stated, He had [ ] insurance company and they are a [NAME] for the days. We received a notice from them that his last day for coverage was 8/23/23. The daughter received the NOMNC (Notice of Medicare Non-Coverage) form and she decided not to appeal the decision. There was no discharge care plan done for him. It should have been done at the time of admission. On 10/26/23 at 9:31 AM, interview with the Director of Nursing (DON). She stated, He went home with his daughter. He was here only for short term rehab. The plan was always for him to go back home. Review of the Care Area Return to Community Referral Care Plan dated 8/29/23 documented it was handwritten, the resident was at the facility for short term and the resident was care planned for discharge to return home. The document was received on 10/26/23 at 12:14 PM from Staff C, from Medical Records. The discharge care plan was written after the resident was discharged from the facility on 8/24/23. On 10/26/23 at 12:14 PM, interview with Staff C, from Medical Records. She stated, I found it in his hard copy record. The written care plan for discharge was on 8/29/23. They said they gave it to me but I don't remember it.

Based on observation, interview and record review, the facility failed to ensure the South Station Pantry refrigerator used exclusively for the resident's food contained food items that were labeled with the resident's name and room number. This has the potential to affect forty-eight residents out of sixty residents who eat orally residing on the South Station unit. The findings included: Record review of the Use and Storage of Food Brought in by Family or Visitors Policy and Procedure (revised 4/2023) documented, the following: Policy: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Policy Explanation and Compliance Guidelines: 1) Family members or other visitors may bring the resident food of their choosing; 2) All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a) The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. Observation of the South Station Nourishment Pantry Refrigerator on 10/24/23 at 9:13 AM revealed, a container with food in a plastic bag that was dated, but was not labeled with the resident's name nor the resident's room number. Photographic evidence submitted. On 10/24/23 at 9:16 AM, observation and interview of the South Station Nourishment Pantry refrigerator with Staff B, South Station Unit Secretary. She stated, My food is temporarily in there. I will be taking it out of there to the employee refrigerator. I know that is not supposed to be in there.

Based on observation, interview, and record review the facility failed to maintain dignity while dining for two residents (Resident #24 and Resident #250) of 31 residents dependent on staff for dining. Findings included: 1. An observation on 11/7/22 at 12:45 PM revealed Staff I, a Certified Nursing Assistant (CNA), standing over Resident #24 feeding her lunch. No chair was observed in the room. Staff I stated she usually would sit. She confirmed the policy was to sit when feeding a resident. An observation on 11/8/22 at 12:52 PM revealed Staff J, CNA standing at the bedside of Resident #24. A chair was to the side of the bed and observed to be at a height below the height of the bed. Staff J was observed standing over the resident with a prepackaged drink in her hand. Also observed was the staff member's cell phone lying on the bedside table of the resident next to her plate of food. The bed was observed to be at waist height of the CNA while she was standing. Staff stated Resident #24 did not like the lunch, and then looked down at her phone and swiped the phone screen during the observation and interview. An attempted interview at this time with Resident #24 was unsuccessful. She would not respond. A medical record review revealed the resident's cell phone and charger were in the safe. A review of the resident's face sheet showed Resident #24 had an original admitted [DATE] and a readmitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's Minimum Data Set assessment, dated 9/1/22, revealed in Section C for Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Section G for Functional Status indicated for Activities of Daily Living (ADLs) Assistance for Eating a score of 4for self- performance and a score of 2 for support, indicating total dependence on staff with a one-person physical assist. Resident #24's active care plans included the following: -Focus of ADL Total, effective 8/25/22, showed: I (Resident #24) require extensive to total assistance with all aspects of mobility and self-care, related significant change. I have been refusing medications, treatments, and care and I also choose not to participate in my care at times. I may become feisty towards staff and my caregiver. I am no longer ambulating and have had weight loss as I sometimes choose not to eat or eat 25% (percent). I have had weight loss. My diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . I am now enrolled in palliative care through hospice services related to my end stage diagnosis. I continue to require total assistance because I am able to assist with ADLs, but I choose not to. The interventions included assist me with meals and fluid intake. Record % consumed. Notify RD (Registered Dietitian), SLP (Speech Language Pathologist), and my doctor of new onset signs of chewing/swallowing difficulty promptly. - Focus of Nutritional Status: Risk for Decline in Nutritional Parameters, effective 8/18/22, showed at times I (Resident #24) report I receive the same foods every day, however this is due to my poor eyesight. Interventions included, provide assistance as needed with meals and minimize distractions during meals. On 11/9/22 at 12:36 PM, Resident #24 was observed in her room drinking tea from a straw in a coffee cup and with her lunch tray set up for her and untouched. There was no staff member in the room assisting her. She stated, It is hard for me because I can't see the food. Review of the facility's policy titled, Meal Service, revised 5/25/21, revealed the policy as, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights for each resident. The Policy Explanation and Compliance Guidelines revealed, 1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes .4. Focus on the resident while talking to him/her and addressing him/her individually, 5. All staff will be seated, if possible, while feeding a resident. On 11/9/22 at approximately 2:00 PM, the Nursing Home Administrator (NHA) was interviewed. The NHA confirmed the expectation was for staff to sit when providing assistance with feeding for a resident. 2.On 11/07/22 at 12:33 PM, an observation was made of Resident #250 in her room during lunch meal. Staff G, a Certified Nursing Assistant (CNA) from an agency was observed standing while assisting the resident with lunch meal. Staff G stated the resident was eating well, typical of her consumption which was about 50%. Staff G did not know if she should be sitting during the process of providing assistance when feeding a resident. Review of the face sheet for Resident # 250 showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an active Care Plan for Resident #250, dated, 11/03/22, under nutritional status showed the resident is at risk for decline in nutritional parameters due to advanced age, on a mechanically altered and therapeutic diet, on diuretics and [CONDITION(S)]. An intervention in the care plan showed to provide assistance with meals as needed. Review of a document titled, Care Plan Activity Report, dated 11/4/22, showed an ADL focus indicating Resident #250 requires limited assistance with eating. An interview was conducted on 11/08/22 at 12:50 PM with Resident #250 and the Director of Rehabilitation. Resident #250 stated she did not speak English. The Director of Rehabilitation interpreted for her. The Resident stated she can feed herself but will ask for help if needed. The Director of Rehabilitation stated the resident does not require meal assistance all the time, she needs cues and prompts and if the resident needed assistance, staff should provide assistance. The Director of Rehabilitation stated if staff are assisting the resident, they should sit at eye level. On 11/09/22 at 10:32 AM, an interview was conducted with Staff H, an agency CNA. Staff H stated, I was trained when assisting a resident with a meal, sit them upright in bed, at an angle, place a clothing protector on the resident if they wish, and then sit down next to them and take my time feeding them. Staff H stated she asks the residents what they wanted and assists them accordingly. On 11/09/22 at 9:45 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated some CNAs are new and they have forgotten the expectations related to meal supervision and assistance. The NHA stated they have started in-services on basic nursing care expectations. The NHA stated they did not have specific training material related to standing during meal assist. She stated it is an assumed best practice to sit at eye level when assisting the resident with meal.

Based on observations, interviews and record review the facility failed to ensure reasonable accommodations were provided to maintain independence for assistance related to the use of the call light for one resident (Resident #53) out of two residents reviewed for pain. Findings included: On 11/07/22 at 10:35 a.m. Resident #53 was heard moaning in pain from the hallway. A staff member entered the room to assist the resident and closed the door. On 11/07/22 at 11:39 a.m. Resident #53 was observed in bed and moved her left hand to show the area of pain she had in her right shoulder and neck area. Resident #53's call light was then observed to be dangling from the headboard behind the right side of the head of her bed and out of reach. On 11/07/22 at 11:40 a.m. Staff K, a Licensed Practical Nurse (LPN) confirmed Resident #53 was able to use the call light. She assisted Resident #53 and placed the call light within reach of the resident, and confirmed they have repositioned Resident #53 and provided her with Tylenol. On 11/08/22 at 12:59 PM, Resident #53 was observed in bed covered and her lunch was on the bedside table positioned across her bed and untouched. She stated she was no longer in pain and she was given Tylenol and was feeling good. Resident #53 did not know where her call light was when asked. The call light was then observed wrapped around the headboard and dangling so the bulb was touching the ground and out of reach. (Photographic Evidence Obtained). At this time, Staff J, a Certified Nursing Assistant (CNA) entered the room to assist and stated the call light should be clipped on and proceeded to clip the call light to Resident #53's blanket. Resident #53 stated, I was looking for that. A review of the Resident Face Sheet showed Resident #53 was admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 53's Minimum Data Set (MDS) assessment, dated 8/25/22, revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired. Section G - Functional Status indicated for Activities of Daily Living (ADLs) Assistance the resident needed extensive assistance with bed mobility, dressing, and personal hygiene. A review of Resident 53's active care plans included the following: -Focus of Pain, effective as of 3/1/22, showed I (Resident #53) am at risk for Alteration in comfort: Pain related to impaired mobility, weakness, diabetes with [CONDITION(S)] and [CONDITION(S)]. Interventions included to place call bell within easy reach when in room. -Focus of ADLs, effective as of 3/1/22, showed I require assistance with my self care and mobility as follows: supervision, set-up with cues at mealtime and extensive assist to total assist for bed mobility, transfer, dressing, toileting, grooming, and bathing I have generalized weakness . Interventions included to place items close to me. In an interview on 11/08/22 at 4:22 p.m. Staff E, LPN stated, Yes, she (Resident #53) uses the call light. She confirmed the expectation was the call light should be clipped onto the sheet. She confirmed they (staff) check to make sure the call lights are in place when doing rounds, and positioning or assisting a resident. On 11/09/22 around 2:00 PM, the Nursing Home Administrator (NHA) confirmed the expectation was for staff to ensure the call light was placed for the resident, so that it could be easily reached. Review of the policy titled, Call Lights: Accessibility and Timely Response, revised 10/18/22, showed the policy as: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. The Policy Explanation and Compliance guidelines showed: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .5. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview and record review, the facility failed to ensure one resident ( Resident #18) out of seven residents reviewed for receiving oxygen via nasal cannula was free from the use of an unnecessary medication. Findings included: An observation of Resident #18 was conducted on 11/7/22 at 12:28 PM, Resident #18 was observed to have a nasal cannula pulled down around her neck with the oxygen concentrator running. The resident was eating at the time. An additional observation on 11/8/22 at 4:10 PM showed Resident #18 was lying in bed with a nasal cannula in place with oxygen running at 3 liters per minute. A review of admission records indicated Resident #18 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's care plan records revealed the resident has a care plan in place for respiratory disorders. The care plan does not mention the use of oxygen therapy. A review of Resident #18 vital signs records showed oxygen saturation and respirations have been monitored each shift with no abnormal values. A review of Resident #18's medical records did not show an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #18's progress notes revealed nursing notes on 10/13, 10/22, and 10/29/22 that indicated the resident was on oxygen via nasal cannula. On 11/9/22 at 9:30 a.m. Resident #18 was lying in bed with the oxygen concentrator running at 3 liters per minute with her nasal cannula in place (Photographic evidence obtained) The Nursing Home Administrator provided a list of all facility residents that receive oxygen via nasal cannula; Resident #18 was not included on that list. An interview was conducted with Staff D, a Respiratory Therapist (RT) on 11/9/22 at 9:20 a.m. he stated Resident #18 is not one of the residents he tracks. He stated for residents receiving oxygen via nasal cannula, the nurse will get an order from the provider. He stated occasionally Respiratory Therapy is asked to evaluate the resident if needed. He confirmed the resident should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Director of Clinical Services on 11/9/22 at 10:08 a.m. She stated that for a resident receiving oxygen via a nasal cannula the nurse will talk to the provider for an order unless it is an emergency. An interview was conducted with Staff E, Licensed Practical Nurse (LPN) on 11/9/22 at 10:37 a.m. Staff E stated she was assigned to Resident #18. She confirmed the resident is on oxygen via nasal cannula. Staff E was observed reviewing Resident #18's orders. She stated she looked at the current order and history and there is no oxygen order. An interview was conducted with Staff F, Assistant Director of Nursing (ADON,) on 11/9/22 at 10:43 a.m. She was observed reviewing Resident #18's medical record. She reviewed the history and current orders and stated no, don't see any order. She said she looked at the PRN and regular orders. The ADON confirmed the resident needs an order to be on oxygen. Staff F was also observed reviewing the nursing progress notes. She confirmed there were multiple notes indicating the resident was using oxygen. She stated there isn't any reason to keep looking back, she has been on it a while. She said she doesn't know when or why the resident would have been put on oxygen. Staff F said she was going to get RT to assess the resident and see if she needs the oxygen. On 11/9/22 at 1:00 p.m. Staff D, RT stated Resident #18 has an oxygen saturation of 100% on oxygen. He removed the oxygen and waited 15 minutes and reassessed and continued to monitor. He stated without the oxygen she was maintaining an oxygen saturation of 97% and the oxygen was not needed. A facility policy titled Oxygen Administration, dated 5/26/22 was reviewed. The policy stated the following: Oxygen is administered to residents who need it, consistent with profession standards of practice, the comprehensive person-centered care plans and the residents' goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermitted and/or when to discontinue. A facility policy titled Unnecessary Drugs-Without Adequate Indication for Use, dated 10/20/22 was reviewed. The policy stated the following: 3. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was below 5.00%. A total of twenty-five medications were observed, and six medications errors were observed for two residents (Resident #66 and Resident #305) out of five residents observed for medication administration. The medication errors constituted a medication error rate of 24 percent. Findings included: A medication administration observation was conducted with Staff A, Registered Nurse (RN) on 11/8/22 at 9:12 a.m. Staff A prepared medication for Resident #66. Staff A removed two [MEDICATION(S)] 4% Pain Relief patches from the medication cart. She stated the resident gets one on each of her knees. Staff A proceeded to place a [MEDICATION(S)] path on the front of Resident #65's left and right knee just below the knee cap. The order reconciliation revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order located for a [MEDICATION(S)] Patch for the left knee. A review of admission records indicated Resident #66 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with Staff A, RN on 11/8/22 at 2:33 p.m. Staff A reviewed Resident #66 and confirmed the order for a [MEDICATION(S)] Pain Relief Patch 4% was only for the right knee. Staff A stated the resident requested it for her left knee as well because it was hurting. Staff A reported she said, that is where the most pain was. Staff A confirmed she did not call the provider. Staff A stated she will talk to the charge nurse and get her to call the doctor for an order. Staff A stated there were no other orders for medication for the the left knee. An interview was conducted with Staff C, RN, Charge Nurse on 11/8/22 at 2:43 p.m. Staff C stated Resident #66 has had issues with her right knee and that is why she get the [MEDICATION(S)] patch. The resident still has pain in her right knee and the patch is only for the right knee. Staff C confirmed Resident #66 should not be getting a [MEDICATION(S)] Pain Relief Patch 4% on her left knee without an order. Staff C stated that she thought the resident only had one on her right knee and she was not aware of her getting a patch on the left knee. Staff C stated she would speak with the nurse and call the doctor for an order. A review of progress notes revealed a note dated 11/8/22 at 3:35 p.m. indicating the provider was called regarding Resident #66's left knee pain and an order was obtained. A medication administration observation was conducted with Staff B, Licensed Practical Nurse (LPN) on 11/8/22 at 10:47 a.m. Staff B prepared the following medications to administer to Resident #305: [MEDICATION(S)] 500 mg (milligram), [MEDICATION(S)] 5 mg, Losartan 100 mg/[MEDICATION(S)] 25mg, [MEDICATION(S)] 75 mg, [MEDICATION(S)] 10 mg, and Acetaminophen 325 mg two tablets. The medications were administered to the resident at 10:50 a.m. An order reconciliation revealed that [MEDICATION(S)] 500 mg, [MEDICATION(S)] 5 mg, Losartan 100 mg/[MEDICATION(S)] 25mg, [MEDICATION(S)] 75 mg, and [MEDICATION(S)] 10 mg were all scheduled to be administered at 9:00 a.m. The medications were administered one hour and forty-seven minutes after their scheduled time. A review of admission records indicated Resident #305 was last admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Staff B, LPN on 11/8/22 at 12:31 p.m. Staff B stated Resident #305's medications were in the medication cart; she was late giving them because she had a lot of medications to give. Staff B stated she has to give all the residents their medications and also give pain medications or things people ask for in between giving the scheduled medications. Staff B stated she knows medications should be given one hour before or after the time they are ordered; with all the back and forth they are sometimes late. Staff B confirmed the provider was not notified. An interview was conducted on 11/8/22 at 2:47 p.m. with the facility's Director of Clinical Services. She stated their policy is medications are given one hour before or after the time scheduled unless the resident refuses or requests something different. Sometimes staff stretch it a little depending on the medication if there is a good reason, but if they are late the nurse should call the provider. Review of the facility's policy revealed a facility policy titled Medication Administration-General Guidelines, dated January 2019 was reviewed. The policy stated the following: A. 4- Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . If the label and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . B. 2- Medications are administered in accordance with written orders of the attending physician. B. 10- Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. A facility policy titled Medication Orders, dated 5/25/22, was reviewed. The policy stated the following: 1. Medications should be administered only upon the signed order of a person lawfully authorized to prescribe.

Based on observation, interview and record review, the facility failed 1) to ensure proper temperature inside the one of two walk-in refrigerators, and 2) failed to ensure proper holding temperature during tray line. As evidenced by, the dairy walk-in refrigerator temperature and sampled milk containers inside the walk-in refrigerator and in the food tray cold section were over 41 degree Fahrenheit (°F). This deficient practice has the potential to affect ninety residents eating by mouth, out of one hundred eight residents residing in the facility at the time of the survey. The findings include: Review of the facility's Policy and Procedure for Cold Food Temperatures at Meal Service, no date, revealed: Proper food temperatures will be maintained during meal service. Prior to service, canned fruits, desserts, salads, puddings, cottage cheese, juices, milks and other cold food items in the meal service are placed in the refrigerator at least 3-4 hours before serving. Food should be chilled to less or equal 41 °F. It further showed At the time of the service cold food items will be taken from the refrigerator one tray at time to be used at the meal service. Milk will be iced for use at meal service. Cold temperature will be taken and recorded prior to service to assure foods are below 41 °F. On 10/06/20 at 08:41 AM, during the initial tour in the kitchen, observation revealed that the thermometer inside the dairy walk-in refrigerator was reading 47°F . The Director of Food Service (DFS) stated that this was because they were receiving delivery at that time. In addition, she stated that the outside thermometer for the walk-in refrigerator was not working properly. On 10/07/20 at 04:30 PM, during observation of the tray line, the cold section revealed internal temperature of 47 °F and 45°F for two sampled 8 ounces (oz.) containers of milk. The temperature check for the dairy walk-in refrigerator/cooler outside thermometer indicated a temperature reading of 47°F. The Cook (Staff A) stated that the outside thermometer was not working properly. The two internal thermometers located in the middle of the dairy walk-in refrigerator/cooler indicated a temperature of 44 °F. Two selected samples of milk containers inside the cooler showed an internal temperature of 47°F and 48 °F. On 10/07/20 at 04:45 PM, the Cook, Staff A, stated that the thermometer outside of the cooler was not functioning properly, the temperature goes down sometimes and does not read properly. The Director of Food Service stated that the company came two weeks ago to check it. On 10/08/20 at 09:53 AM, during an interview with the Director of Food Service (DFS) and Regional Dietitian (RD), the DFS stated that the cooler (dairy walk-in refrigerator) was working fine. They discarded the containers of milk inside the cooler from the previous day and they kept the cooler empty until they realized what happened. The DFS stated on the previous day (10/07/20), during dinner, the containers of milk were grabbed from the cooler at the time when the food tray line was ready to start and they iced them down in a plastic tray. The DFS explained that the facility have food delivered on Tuesdays and Fridays and the containers of milk were delivered on Tuesday ,10/06/2020. The DFS reported that the decision was made to use the thermometer inside the cooler to check the temperature since the outside thermometer was not working properly. Based on the temperature of the thermometer inside, because around two weeks ago, she noticed that the cooler was not working properly and they tried to get it repaired. The company that was called to check the cooler came and changed the fan inside the cooler.

Based on interview, and record review the facility failed to document Interdisciplinary Team (IDT) involvement in the care planning process for 3 of 4 residents reviewed for care plans (Residents #35, #47 and #99). The facility also failed to update Resident #35's care plan after a documented significant change. There were 108 residents residing in the facility at the time of the survey. The findings included: Record review on 10/08/20 revealed resident #35 was admitted on [DATE] with a most recent readmission of 05/09/20. Resident #35's [DIAGNOSES REDACTED]. Resident #35's Minimum Data Set (MDS) of 05/16/20 assessed Resident #35 as having a significant change in status on readmission of 05/09/20. Review of the Interdisciplinary Care Plan Meeting attendance record on 05/27/20 revealed that no Registered Nurse with responsibility for the resident, Certified Nurse's Aide with responsibility for the resident, and no Respiratory Therapist participated in the care plan meeting. During an interview on 10/08/20 at 12:35 PM Staff F, a Registered Nurse and Respiratory Therapist, stated that the Respiratory Therapists do not often attend care planning sessions. Staff F was asked if he had participated in Resident #35's care plan meeting for her assessed significant change, Staff F stated that he had not. On 10/09/20 the review of the facilitys policy and procedure titled Comprehensive Care Plans, revised October 1, 2019 indicated: The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but not limited to: A Registered Nurse with responsibility for the resident, a Nurse Aide with responsibility for the resident, and appropriate staff of professionals in disciplines as determined by the resident's needs. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. Review of sampled residents revealed; Resident #35's Interdisciplinary Care Plan Meeting Attendance Record dated 05/27/20 did not reflect any direct care staff (Nurses and Certified Nursing Assistants who provide daily care) or a Respiratory Therapist participating in the IDT Care Plan Meeting. Resident #47's was admitted to the facility on [DATE]. Resident #47's Annual MDS with a target date of 07/29/20. Interdisciplinary Care Plan Meeting Attendance Record dated 08/05/20 did not reflect any direct care staff participating in the IDT Care Plan Meeting. Resident #99's was admitted to the facility on [DATE]. Resident #99's Quarterly MDS with a target date of 09/16/20. Interdisciplinary Care Plan Meeting Attendance Record dated 09/23/20 does not reflect any direct care nurse participating in the IDT Care Plan Meeting. During an interview on 10/09/20 at 2:00 PM Staff C, Minimum Data Set (MDS) Coordinator and Registered Nurse and Staff B, MDS Coordinator and Licensed Practical Nurse, were asked about IDT involvement in the care planning process. Staff B stated the entire IDT was involved in each resident's comprehensive care plan, and that they have care plan meetings and they documented IDT participation on the Care Plan Meeting Attendance Record. Regarding the discrepancies identified with Residents #35, #47 and #99, Staff C stated that they do struggle to get direct care staff to participate in the Care Plan Meetings. Staff C stated that Respiratory Therapist do not often participate in ventilator dependent residents Care Plan Meetings. When asked to provide an example of a Respiratory Therapist participating in any residents Care Plan Meeting, Staff C stated that she could not. During an interview on 10/09/20 at 4:10 PM these findings were reviewed with the Administrator who is a Registered Nurse. The Administrator agreed with the findings.

Based on observation, interview, and record review, the facility failed to ensure a resident's Fall Risk Care Plan was followed related to implementing an intervention for the use of bilateral floor mats after a fall incident for 1 of 3 residents (Resident #94) sampled for falls. The findings included: Review of Resident #94's Progress Notes revealed Resident #94 fell while in the dining room on 01/23/2019 resulting in a [MEDICAL CONDITION]. Resident #94's 01/23/2019 Progress Note described that she stood up without warning and slid to the floor. Review of Resident #94's Comprehensive Care Plans revealed a care plan for Falls dated 01/28/2019. The problem stated: I am at risk for falls and injuries since I had a fall which resulted in a left [MEDICAL CONDITION]. I have impaired mobility and I need help to stand and walk. I have decreased strength, pain in my left hip and impaired balance. The care plan was reviewed on 02/01/2019 for significant decline in over all status related to my [MEDICAL CONDITION] and surgery. Interventions included: I was provided with 2 floor mats to use when I am in bed. (effective 1/28/19) An observation of Resident #94 on 03/27/2019 at 9:31 am revealed Resident #94 in bed with her eyes closed. She was not observed trying to get out of bed. No staff was in the room. No floor mats were observed on the floor next to her bed. An observation of Resident #94 on 03/28/2019 at 1:47 pm revealed Resident #94 in bed with her eyes closed. She was not observed trying to get out of bed. No staff was in the room. No floor mats were observed on the floor next to her bed. An interview conducted on 03/29/2019 at 10:50 am with Registered Nurse (RN) Supervisor C revealed, Resident #94 had a fall on 01/23/2019 while in the dining room which resulted in a [MEDICAL CONDITION]. Resident #94 was readmitted to the facility from the hospital on [DATE]. RN Supervisor C listed bilateral floor mats while in bed as a post fall intervention for Resident #94. She stated, Resident #94 should have bilateral floor mats while in bed during the day or at night. An observation of Resident #94 on 03/29/2019 at 1:47 PM revealed, Resident #94 in bed with her eyes closed. She was not observed trying to get out of bed. No staff was in the room. Bilateral floor mats were observed on the floor next to her bed. An observation of Resident #94 on 03/29/2019 at 2:31 PM revealed, Resident #94 in bed with her eyes closed. She was not observed trying to get out of bed. No staff were in the room. Bilateral floor mats were observed on the floor next to her bed. An interview was conducted with Certified Nursing Assistant I (CNA I) on 03/29/2019 at 02:32 pm. She stated Resident #94 uses floor mats. An interview was conducted with RN J on 03/29/2019 at 2:32 PM. She stated Resident #94 uses floor mats. An interview was conducted with the Administrator/Risk Manager on 03/29/2019 at 3:08 PM, she reported placing bilateral floor mats was one of the interventions care planned for Resident #94 after her fall in the dining room. She stated, the floor mats should be used when Resident #94 is in bed. Review of facility's policy titled, Fall Prevention Policy (revised 08/25/2017) showed: 2. Interventions are implemented according to the patient/resident needs that have been identified. and 5. If a fall should occur the Interdisciplinary Team meets to review the post fall recommendations and updates the intervention(s) in the care plan.

Based on interviews, and record review of the facility's grievance log and policy, the facility failed to support Resident's Right relating to the assurance of prompt efforts conducted in resolving grievances for two residents (R#1 and R#87) out 25 sampled residents, for whom grievances went unresolved. Concerns related to care, treatment, and behavior of staff went un-addressed and unresolved. This facility practice has the potential to affect all 113 adults residing at this facility at the time of this survey. The Findings Included: Review of the facility's grievances policy and procedure, revised on January 2017, revealed: To support each resident's right to voice grievances . and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately appraised of its progress toward resolution. Each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment, which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding the facility staff. The facility will make prompt efforts to resolve grievances the resident may have. Prompt efforts .to resolve included facility acknowledgment of complaint/grievances and the active working towards resolution of the complaint/grievance. Record review of the Grievance Log revealed, no grievances were reported by or on behalf of any resident during the survey year. During an interview with the Social Worker, on 1/23/2018 at approximately 10:00 AM she revealed, the facility immediately addressed all residents' concerns. The goal was to keep concerns from rising to the level of a grievance. (The concern book was an internal document kept by the facility's owner, in her office.) 1. Interview and observation on 1/23/2018 at 9:20 AM revealed, resident #1 was laying in bed, wearing her night gown, with purple stains noted on the chest area. The resident appeared alert and oriented and stated, she had a lot to say. She agreed to the interview, later. Interview and on 1/23/2018 at 10:48 AM with Resident # 1 revealed, Resident #1 remained in bed, in the same position, still wearing her nightgown, with stains noted. The resident expressed concerns related to care and treatment in the facility. Resident #1 stated, she normally had to wait hours to receive Activity of Daily Living (ADL) Care, for example, the resident stated, she had been waiting to urinate since before you got here this morning (approximately 9:20 AM). Resident #1 told her Certified Nursing Assistant (CNA) (staff X), but her CNA said she was busy caring for the roommate at the time, the CNA then left the room without assisting Resident #1 to the toilet. The resident reported, they do clean you, you just don't know when, could be at 11 in the morning or three in the afternoon, I just wait The resident reported, on Saturday, she waited 4 hours for assistance to use the toilet. During the interview, Resident #1 also expressed concerns with staff treatment, the resident stated, she felt ignored; nobody talked to her or even said good morning, I've been here for a while and I don't know a soul, they don't talk to me. Another concern was that the roommate had visitors that were sick. According to the resident, the roommate's visitors were coughing a lot! To the point that she (R#1) yelled at them to go to the hospital! Resident #1 explained, she was worried about catching anything because she had problems with her lungs. In addition, the resident explained, she was very vocal and that she told her concerns to the woman in charge that sits at the nurses' station, she told the woman in charge about each of the above-mentioned concerns but, the resident explained; they didn't believe me! Interview on 1/25/2018 at 8:46 AM with Staff A, a Registered Nurse (RN), revealed she was a charge nurse sometimes in charge of the North nurses station, familiar with Resident #1. The Charge nurse reported, resident #1 never reported any of the above-mentioned concerns. She explained, the process for addressing resident concerns, The resident never reported to me, if that was the case, I would find out who the visitors were .I would let staff know, and we have visitors' messages to use precautions . I would not document it necessarily, but I would informally take care of it. If she reported having to wait (four hours), I would ask for more information to find out the time, to focus my investigation, I would talk to staff responsible, and do education to all, I would document the education and then I would fill out a concern form for that resident. Interview on 1/25/2018 at 9:15 AM with Resident #1 revealed, R#1 was sitting on her bed, well dressed and nicely groomed, accompanied by her nephew awaiting discharge papers. The resident reported she would be absolutely happy! to again voice, her concerns to facility staff, and that she was so happy she was going home. During an interview on 1/25/2018 at 9:20 AM with Resident #1, the Resident's family member and Staff A. Resident #1 reported she just met staff A, after all of this happened. The resident told staff A about the above-mentioned concerns; I sit here all day, the other day there were sick people in my room! The other day I had to wait four hours to use to the toilet. The family member stated that the resident told him about that, and that he was upset to hear that she had to wait that long. He said to her just get up and go to the bathroom! Resident #1 explained, but I was told I could not get up on my own because it was risky, and I had to wait for somebody to stand behind me when I walk, isn't that right? (Staff A agreed). The resident continued, Nobody says anything to you here, they treat you like you are nothing. Interview on 01/25/2018 at 10:52 AM with staff C, RN and Charge Nurse, revealed she was a charge nurse sometimes in charge of the North nurses station, and familiar with Resident #1. The Charge nurse reported that resident #1 never reported any of the above-mentioned concerns. When informed about the resident's concerns, the charge nurses immediate response was that does not happen here. The charge nurse explained the process, If a resident tells me, I talk to the CNA, because I have to interview everybody not just the patient, because the patient might be confused. If the resident says that she needs to go to the bathroom and has been 4 hours I would possibly, interview the CNA and address the issue . if she says it happened yesterday, I'd apologize and then talk to the cna and nurses and keep that from happening again. I would not document if it was the first time, I would talk to the CNA and the nurse and reassure the Resident. If it happens, again we would have to write. If concerns with care, the first thing I do is talk to the resident, or the CNA . I have not heard of any concerns. 2. Interview on 1/23/18 at 10:07 AM with resident #87, revealed she had concerns related to A lack of clothing protectors and room temperatures in the dining room as well as seating arrangements. Resident #87 stated, the dining room was very cold most of the times. The resident reported that she expressed her concerns to the woman that was in charge of the dining room (later identified as staff H, a Restorative CNA). The resident stated, other residents' complained also, but staff H said there was nothing they could do. During the interview, the resident reported that she preferred to not sit alone in the dining room and wanted to sit with her friend; she liked to talk and sitting alone was a problem for her. She asked staff H if she could arrange for her to sit with her friend. According to the resident, the woman in charge of the dining room was very strict with seating and said no, to her requests. The resident also wanted to use clothing protectors. She voiced her concerns about getting her clothes stained, but Staff H told her that the facility no longer offered clothing protectors. During an interview on 1/26/2018 at 10:14 AM, with Staff H, she explained that the facility no longer offered clothing protectors because it was a dignity concern. The CNA was aware that R#87 liked to engage in conversations with other residents and that she wanted to sit with her friend. Staff H explained, it would be inconvenient to sit the resident's friend at another table. The CNA agreed there was space on other tables and re-arranging might be possible, she told R#87 she could sit anywhere else. The CNA was also aware that the resident had concerns with the room temperature; the CNA explained, she attempted to make corrections by re-arranging seating assignments. The CNA made no mention of following the grievance procedure for any of the above-mentioned concerns.

Based on observation, interview and record review, the facility failed to implement the developed care plans related to providing oxygen at the prescribed level ordered by the physician to one (Resident #10) of two residents reviewed for Respiratory Care out of the sixteen residents receiving Respiratory Therapy. The lack of implementing care plans has the potential to directly affects the care, treatment and services delivered to all 113 residents residing in the facility at the time of this survey. The findings include: Record review of the facility's policy subject title: Comprehensive Care Plans dated 11/28/17 intent: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, services and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable, and based on resident needs. A resident's care should have the appropriate intervention and provide a means of interdisciplinary communication to ensure continuity in care. Procedures: 1. Health Care Professionals contribute to the interdisciplinary care plan. 2. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights set forth and that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified. 1) Record review of the face sheet revealed the resident was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Observation on 01/23/18 at 8:43 AM Resident # 10 was observed sitting up in bed with oxygen concentrator in use and via nasal cannula. Nebulizer machine at bedside on the nightstand table. The bedside table had the meal tray, Resident #10 was eating breakfast. The oxygen concentrator flow meter was set at 3L/min (3 liters per minute). Interview on 01/23/18 at 8:43 AM Resident #10 reported, he gets the oxygen continuously, which was something started in the hospital. He never had oxygen before going to the hospital. Observation 01/23/18 at 09:10 AM, Resident #10 was receiving continuous oxygen with the flow meter set at 3L/Min. Observation on 01/23/18 at 12:09 PM the oxygen concentrator was running at this time. There were now two oxygen concentrators in the room. One was on the left side of the bed, not in use at this time. The other oxygen concentrator on the right side of the bed was in use. The flow meter was set at 3L/min with the nasal cannula in place. Interview on 01/23/18 at 12:12 PM with Resident #10 revealed, one of them was not working. He had to make staff aware it was broken. They brought in another one to replace it. Record review of the electronic Physician order [REDACTED]. Record review of the Monitoring order noted the status as standing, dated 11/29/17 at 12:00 PM. The order: Oxygen Device: Nasal Cannula; Rate: 2L/Min continuously for Shortness of Breath. The monitoring schedule: Every Day at 11:00pm-7:00am; 3:00pm-11:00pm; 7:00am-3:00pm. Entered by STAFF-S. Record review of the Care Plan for Respiratory Disorder: Dyspnea with an effective date of 12/04/17 noted, I exhibit dyspnea related to [MEDICAL CONDITION]. Goals: I will have no episodes of dyspnea as evidenced by no complaints of shortness of breath, use of accessory muscles or cyanosis. Interventions: Oxygen Therapy as per physician order. Auscultate lung sounds as ordered and prn (as ordered). Administer medication per physician order. Monitor respiratory status-oxygen saturation, cyanosis, shortness of breath, use of accessory muscles, rate, etc. Provide treatment per physician order. Elevate head of bet to > (greater than) 45 degrees. Access oxygen and level of anxiety. Observation on 01/23/18 at 4:28 PM revealed the oxygen concentrator flow meter setting at 3L/min. Observation on 01/24/18 a 9:03 AM revealed the flow meter on the oxygen concentrator setting at 3L/min with the nasal cannula in place. Observation on 01/24/18 at 11:50 AM revealed the flow meter on the oxygen concentrator set at 3L/min. Observation on 01/24/18 at 12:50 PM the facility staff had delivered the meal tray which was on the bedside table. The oxygen concentrator's flow meter setting at 3L/min. Observation on 01/24/18 at 5:25 PM revealed the oxygen concentrator set at 3L/Min. The facility staff had delivered the evening meal tray which was on the bedside table. Observation on 01/24/18 at 5:28 PM with the attending Licensed Practical Nurse (STAFF-B) revealed she bent down slightly to read the flow meter of the oxygen concentrator. She stated the setting was at 3 Liters. She did not know what the prescribed order was at this time but stated she would have to check it. During the observation with STAFF-B at this time, Resident #10 replied he does not touch that machine when asked. Interview on 01/24/18 at 5:29 PM STAFF-B reported the physician's orders [REDACTED]. She said she was going to change the setting at this time. STAFF-B washed her hands in the bathroom and proceeded to the resident's bedside to adjust the oxygen concentrator setting. Record review of the Oxygen (O2 SAT) Saturation noted form 12/28/17 to 1/25/18 was conducted. It revealed the results ranged from 96% to 98%. The oxygen saturation done by the LPN (Licensed Practical Nurse) STAFF-A on 01/24/18 at 3:46 PM was recorded prior to the observation conducted on 01/24/18 at 5:25 PM. The oxygen concentrator settings of 3L/Min observed before and after the recorded time of the O2 SAT. STAFF-B would have been aware of the incorrect flow meter's setting. Interview on 01/25/18 at 08:45 AM with the facility's Administrator revealed she was made aware of the findings related to the oxygen setting for Resident #10. She stated Resident #10 was care planned because he would adjust the settings on the concentrator. During an interview on 01/25/18 at 09:45 STAFF-A presented two forms about Resident #10. One of the forms noted the resident was educated on the behavior of the oxygen. She said he was educated on removing the nasal cannula and the order prescribed by the doctor for the setting of two liters. They have documented he was educated since December 2017. STAFF-A did not have documentation to show the staff and other caregivers were educated on the newly identified behaviors of Resident #10. She was informed of the multiple observations during the past two days about the flow meter setting on the oxygen concentrator. She agreed it should be set and administered according to the physician's orders [REDACTED].>Record review of the form titled Resident/Family Education revealed the resident received education on 11/21/17 and 11/22/17. The form had noted on 12/11/17 the topic, information, instruction: noted was oxygen use/safety as resident removes O2 (oxygen) at times-order at 2L/min. (liters per minute). Record review of the form titled Care Plan Activity Report with the effective date of 01/24/18 noted the focus as Behavioral Symptoms: Adjusts his own Oxygen. I prefer to adjust my oxygen myself despite there being a doctors' order for 2L per minute. Entered by the facility's Social Worker. The Care Plan goals: I will allow staff to adjust my oxygen daily through the next review date. The Care Plan Interventions: I need education on the importance of following doctor's orders and possible complications. Offer me encouragement to cooperate. Interview with Resident #10 on 01/26/18 at 10:01 AM conducted with the facility's Administrator revealed she confirmed the facility staff removed the broken concentrator from his room yesterday. The resident repeated to us that he does not touch the machine (oxygen concentrator), ever. Interview on 1/26/18 at 2:20 PM with Resident #10, confirmed the facility educated him on the importance of keeping the tube changed, water in the bottle to prevent his nose from drying out, and the setting of the machine should be at 2 Liters. This occurred when during admissions to the facility not recently. At that time, staff told him not to touch the machine. He repeated again, he does not touch the machine. He denied any additional education provided by staff related to the oxygen machine.

Based on observation, interview and record review, the facility failed to provide Oxygen at the level prescribed by the physician which was consistent with the care plan for one (Resident #10) of two residents reviewed for Respiratory Care out of sixteen residents receiving Respiratory Therapy. The treatment and services established and recognized practice standards had the potential to affect the quality of care provided to all 113 residents that resided in the facility. The findings are: Record review of the facility's policy titled, Oxygen Concentrator dated 08/25/2017 noted: To administer oxygen for the treatment of [REDACTED]. Policy Explanation and Compliance Guidance: Oxygen should be administered only under orders of the attending physician. Care to the Resident: Obtain physician's orders [REDACTED]. Turn the unit on to the desired flow rate and assess for proper functioning. Place the nasal cannula on the resident adjusting to achieve resident comfort. Change tubing weekly, change humidifier bottle every seventy-two hours or as recommended by maker. Change nebulizer tubing every seventy-two hours. The main body cabinet should be dusted when needed. Record review of the face sheet revealed, the resident was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Observation on 01/23/18 at 8:43 AM Resident # 10 observed sitting up in bed with oxygen concentrator in use and via nasal cannula. Nebulizer machine at bedside on the nightstand table. The bedside table had the meal tray, Resident #10 was eating breakfast. The oxygen concentrator flow meter was set at 3L/min (3 liters per minute). Interview on 01/23/18 at 8:43 AM Resident #10 reported, he gets the oxygen continuously, which was something started in the hospital. He never had oxygen before going to the hospital. Observation 01/23/18 at 09:10 AM Resident #10 was receiving continuous oxygen with the flow meter set at 3L/Min. Observation on 01/23/18 at 12:09 PM the oxygen concentrator was running at this time. There were two oxygen concentrators in the room. One was on the left side of the bed, not in use at this time. The other oxygen concentrator on the right side of the bed was in use. The flow meter was set at 3L/min with nasal cannula in place. Interview on 01/23/18 at 12:12 PM Resident #10 reported one of them was not working. He had to make staff aware it was broken. They brought in another one to replace it. Record review of the electronic Physician order [REDACTED]. Record review of the Monitoring order noted the status as standing, dated 11/29/17 at 12:00 PM. The order: Oxygen Device: Nasal Cannula; Rate: 2L/Min continuously for Shortness of Breath. The monitoring schedule: Every Day at 11:00pm-7:00am; 3:00pm-11:00pm; 7:00am-3:00pm. Entered by STAFF-S. Observation on 01/23/18 at 4:28 PM revealed the oxygen concentrator flow meter setting at 3L/min. Observation on 01/24/18 a 9:03 AM revealed the flow meter on the oxygen concentrator setting at 3L/min with the nasal cannula in place. Observation on 01/24/18 at 11:50 AM revealed the flow meter on the oxygen concentrator set at 3L/min. Observation on 01/24/18 at 12:50 PM the facility staff had delivered the meal tray which was on the bedside table. The oxygen concentrator's flow meter setting at 3L/min. Observation on 01/24/18 at 5:25 PM revealed the oxygen concentrator set at 3L/Min. The facility staff had delivered the evening meal tray which was on the bedside table. Observation on 01/24/18 at 5:28 PM with the attending Licensed Practical Nurse (STAFF-B) revealed she bent down slightly to read the flow meter of the oxygen concentrator. She stated, the setting was at 3 Liters. She did not know what the prescribed order was at this time but stated she would have to check it. During the observation with STAFF-B at this time, Resident #10 replied he does not touch that machine when asked. Interview on 01/24/18 at 5:29 PM STAFF-B reported, the physician's orders [REDACTED]. She said she was going to change the setting at this time. STAFF-B washed her hands in the bathroom and proceeded to the resident's bedside to adjust the oxygen concentrator setting. Record review of the Oxygen (O2 SAT) Saturation noted form 12/28/17 to 1/25/18 was conducted. It revealed the results ranged from 96% to 98%. The oxygen saturation done by the LPN (Licensed Practical Nurse) STAFF-A on 01/24/18 at 3:46 PM was recorded prior to the observation conducted on 01/24/18 at 5:25 PM. The oxygen concentrator settings of 3L/Min observed before and after the recorded time of the O2 SAT. STAFF-B would have been aware of the incorrect flow meter's setting. Interview on 01/25/18 at 08:45 AM with the facility's Administrator revealed she was made aware of the findings related to the oxygen setting for Resident #10. She stated Resident #10 was care planned because he would adjust the settings on the concentrator. During an interview on 01/25/18 at 09:45 STAFF-A presented two forms about Resident #10. One of the forms noted the resident was educated on the behavior of the oxygen. She said he was educated on removing the nasal cannula and the order prescribed by the doctor for the setting of two liters. They have documented he was educated since December 2017. STAFF-A did not have documentation to show the staff and other caregivers were educated on the newly identified behaviors of Resident #10. She was informed of the multiple observations during the past two days about the flow meter setting on the oxygen concentrator. She agreed it should be set and administered according to the physician's orders [REDACTED].>Record review of the form titled, Resident/Family Education revealed the resident received education on 11/21/17 and 11/22/17. The form had noted on 12/11/17 the topic, information, instruction: noted was oxygen use/safety as resident removes O2 (oxygen) at times-order at 2L/min. (liters per minute). Record review of the form titled Care Plan Activity Report with the effective date of 01/24/18 noted the focus as Behavioral Symptoms: Adjusts his own Oxygen. I prefer to adjust my oxygen myself despite there being a doctors' order for 2L per minute. Entered by the facility's Social Worker. The Care Plan goals: I will allow staff to adjust my oxygen daily through the next review date. The Care Plan Interventions: I need education on the importance of following doctor's orders and possible complications. Offer me encouragement to cooperate. Interview with Resident #10 on 01/26/18 at 10:01 AM conducted with the facility's Administrator present revealed, the resident confirmed the facility staff removed the broken concentrator from his room yesterday. He repeated to us that he does not touch the machine (oxygen concentrator), ever. Record review of the Care Plan for Respiratory Disorder: Dyspnea with an effective date of 12/04/17 noted, I exhibit dyspnea related to [MEDICAL CONDITION]. Goals: I will have no episodes of dyspnea as evidenced by no complaints of shortness of breath, use of accessory muscles or cyanosis. Interventions: Oxygen Therapy as per physician order. Auscultate lung sounds as ordered and prn (as ordered). Administer medication per physician order. Monitor respiratory status-oxygen saturation, cyanosis, shortness of breath, use of accessory muscles, rate, etc. Provide treatment per physician order. Elevate head of bet to > (greater than) 45 degrees. Access oxygen and level of anxiety. Interview on 1/26/18 at 2:20 PM with Resident #10, confirmed the facility educated him on the importance of keeping the tube changed, water in the bottle to prevent his nose from drying out, and the setting of the machine should be at 2 Liters. This occurred when during admissions to the facility not recently. At that time, staff told him not to touch the machine. He repeated again, he does not touch the machine. He denied any additional education provided by staff related to the oxygen machine.

Based on observation, interview, and record review, the facility failed to ensure that: 1) resident rooms were in good condition in five (room 207, room 210, room 211, room 305, room 306) resident rooms, and 2) resident care equipment was not stored properly in two (room 205 and room 211) resident rooms, out of 37 rooms observed for environmental concerns out of 62 rooms in the facility. Findings included: Record review of the facility's policy and procedure dated 04/07/2014, titled, Resident Rooms, revealed, The facility will provide each resident with: functional furniture appropriate to the resident's needs. The facility's policy and procedures did not include any specific information for the maintenance and upkeep of residents' rooms that involved resident furniture or interior repairs; nor, was there anything about storage of resident care equipment. Observations conducted in Room 207: Observation on 01/23/2017 at 3:39 pm of Room 207 revealed that the dresser on the right side of bed B was in disrepair; there were numerous engravings in the wood of the dresser. The wall behind the bed was chipped in the center of the wall. The wardrobe closet on the left side of bed B was not in good condition and the wood was chipped. Observation on 01/24/2017 at 11:25 am of Room 207 revealed that the furniture and wall by bed B were still not in good condition. The residents' bathroom door was in disrepair; the base and the length of the bathroom door was not in good condition. Observations conducted in Room 305: Observation on 01/24/2017 at 10:00 am of Room 305 revealed that the residents' bathroom door was not in good condition; the inside and outside of the door was observed to have chipped wood and the base of the door was in disrepair. Observations conducted in Room 210: Observation on 01/24/2017 at 1:02 pm of Room 210 revealed that the wardrobe closet on the left side of bed B was in disrepair; the wood was chipped. Observations conducted in Room 211: Observation on 01/24/2017 at 12:51 pm of Room 211 revealed that the base of the bathroom door was not in good condition, with engravings in the wood. The wall behind bed A on the right side had chipped paint in the not in good condition; chipped paint. Interview with the Maintenance Director and Administrator on 01/25/2017 at 4:00 pm revealed that the Maintenance Director had been working in the facility since October 2016. His responsibilities included making sure that the facility was safe, preparing everything in 100% order. He would go into the residents' rooms to check for any holes in the walls, any leakage in the bathrooms, making sure that the beds were working, air conditioning (AC) was working, and lights were working. The Maintenance Director said that nursing staff would complete maintenance work orders if they were any problems in resident's rooms, and he would check them regularly. Any parts or supplies were ordered as needed; the facility had accounts with hardware stores and could make repairs that same day. Also, they facility had a company that could deliver supplies within 24 hours. Tour of the rooms in question with the Maintenance Director and Administrator: Observation and interview on 01/25/2017 at 4:06 pm of Room 305 revealed that the Maintenance Director and Administrator confirmed that the resident's bathroom door needed to be repaired. Observation and interview on 01/25/2017 at 4:08 pm of Room 306 revealed that the Maintenance Director and Administrator confirmed that the dresser stand was in disrepair. Observation and interview on 01/25/2017 at 4:10 pm of Room 207 revealed that both the Maintenance Director and Administrator confirmed the wardrobe closet, the bathroom door, and wall needed to be fixed. Observation on 01/25/ at 4:12pm of Room 210 revealed that the Maintenance Director and Administrator confirmed that the wardrobe closet next to bed B needed to be repaired. Observation and interview on 01/25/2017 at 4:16 pm of Room 211 revealed that the Maintenance Director and Administrator confirmed that the resident's bathroom door and wall behind bed A needed to be repaired. Record review of the Maintenance Request Logs for the months of November 2016 to January 2017 for both the North and South Unit revealed no maintenance requests documented for the concerns observed in the rooms mentioned. 2). Observations conducted in Room 205: Observation on 01/23/2017 at 3:29 pm of Room 205 in the residents' bathroom there were wheelchair parts on the left side of the resident's toilet, and a brown electrical extension cord on the toilet tank. Observation on 01/24/2017 at 11:36 am of Room 205 revealed that the wheelchair parts and electrical extension cord were still in the residents' bathroom in the same locations. Observation on 01/25/2017 at 3:44 pm of Room 205 revealed that the wheelchair parts were still in the bathroom on the left side of the resident's toilet; however, the brown electrical extension cord was gone. Observations conducted in Room 211: Observation on 01/24/2017 at 12:51 pm of Room 211 revealed that there was a rolling walker stored on the right side of the toilet in the residents' bathroom. Observation on 1/25/2017 at 3:48 pm of Room 211 revealed that there was still a rolling walker stored on the right side of the toilet in the residents' bathroom. Tour of the rooms in question with the Maintenance Director and Administrator: Observation and interview on 01/25/2017 at 4:18 pm of Room 211 revealed that the Administrator confirmed that the rolling walker should not be in the residents' bathroom. Observation and interview on 01/25/2017 at 4:21 pm of Room 205 revealed that the Administrator confirmed that there should be no resident care equipment stored in the residents' bathroom. Observation on 1/23/17 at 12:16 pm revealed the dresser stand used for the television in Room #306 was in disrepair and not in good condition. The dresser stand had peeled paint and one drawer had no handle on it.

Based on observation and interview, the facility failed to maintain a clean environment in resident rooms for 12 out of 16 rooms sampled out of 62 rooms in the facility related to: 1) multiple air conditioning units observed with a thick accumulation of dust and/or debris on outside vents and internal gratings and/or resident rooms observed with structural damage in 10 out of 14 rooms sampled (Room 111, Room 314, Room 403, Room 404, Room 414, Room 413, Room 315, Room 411, Room 409, and Room 305), and 2) suction machines were observed with dust for 2 out of 2 room (room 302D and room 306W). This has the potential to affect 21 out of 111 residents that receive respiratory treatment residing in the facility at the time of this survey. The findings included: 1. An observation of Room 111 on 11/03/2015 at 12:14 pm showed the knob to the bedroom door was loose with the metal cover detached from the surface of the door. An observation of Room 111 on 11/04/2015 at 3:21 pm showed the door knob was loose with the metal covering detached from the surface of the door. An observation of Room 314 on 11/03/2015 at 11:18 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with a heavy accumulation of dust and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 314 on 11/04/2015 at 8:35 am revealed the air conditioning unit continued to have a heavy accumulation of dust and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 403 on 11/03/2015 at 11:06 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with a heavy accumulation of dust, black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. The baseboards located on both sides of the bathroom door were missing, exposing wall material and holes. An observation of Room 403 on 11/04/2015 at 8:35 am revealed the air conditioning unit continued to have a heavy accumulation of dust, black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. The baseboards remained missing. An observation of Room 404 on 11/03/2015 at 11:50 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with a heavy accumulation of dust, black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 404 on 11/04/2015 at 9:22 am revealed the air conditioning unit continued to have a thick accumulation of dust and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 404 on 11/04/2015 at 5:29 pm showed the air conditioning unit continued to have a heavy accumulation of dust, black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 414 on 11/03/2015 at 10:13 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with an accumulation of dust and black spots on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 414 on 11/04/2015 at 9:22 am revealed the air conditioning unit continued to have an accumulation of dust and black spots on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 413 on 11/03/2015 at 10:17 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with a heavy accumulation of dust, many black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 413 on 11/04/2015 at 9:22 am revealed the air conditioning unit continued to have a heavy accumulation of dust, many black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 413 on 11/04/2015 at 11:03 am revealed the air conditioning unit continued to have a heavy accumulation of dust, many black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 413 on 11/04/2015 at 4:52 pm showed the air conditioning unit continued to have a heavy accumulation of dust, many black spots, and debris on the outer plastic vents and within the area of the unit's inner grating. An observation of Room 315 on 11/04/2015 at 8:28 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with a thick accumulation of dust on the right side of the unit's inner grating. An observation of Room 411 on 11/04/2015 at 11:03 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with an accumulation of dust on the outer plastic vents and within the area of the unit's inner grating. The baseboards and trim around the bathroom door were noted to be missing. An observation of Room 411 on 11/04/2015 at 05:08 pm revealed the air conditioning unit continued to have an accumulation of dust on the outer plastic vents and within the area of the unit's inner grating. The baseboards and trim continued to be missing. An observation of Room 409 on 11/04/2015 at 11:10 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with a heavy accumulation of dust and debris on the outer plastic vents and within the area of the unit's inner grating. Also within the area of the unit's inner grating, behind the outer plastic vents, was an empty sugar packet, a small blue plastic object, and a brown object approximately 1 inch long. The baseboards on both sides of the bathroom door were noted to be missing. An observation of Room 409 on 11/04/2015 at 3:31 pm revealed the air conditioning unit continued to have a heavy accumulation of dust and debris on the outer plastic vents and within the area of the unit's inner grating. The empty sugar packet, the small blue plastic object, and the brown object were still present. The baseboards continued to be missing. An observation of Room 409 on 11/05/2015 at 8:45 am revealed the air conditioning unit continued to have a thick accumulation of dust and debris on the outer plastic vents and within the area of the unit's inner grating. The empty sugar packet, the small blue plastic object, and the brown object were still present. The baseboards continued to be missing. An observation of Room 305 on 11/04/2015 at 11:49 am revealed the room had a large, individual air conditioning unit affixed to the wall. The air conditioning unit was noted with a heavy accumulation of dust and debris on the outer plastic vents and within the area of the unit's inner grating. Observations during the survey revealed housekeeping was in progress daily throughout the day and early evening shifts in the 300 and 400 hallways and in the 100 and 200 hallways. An observation of the identified rooms was conducted with the facility's Director of Nursing (DON) on 11/05/2015 at 10:12 am. The outer plastic vents had been cleaned in Room 413 but the area within the inner grating continued with a heavy accumulation of dust, debris, and black spots. The outer plastic vents in Room 409 had been cleaned but the packet of sugar, blue object, and brown object remained in the area of the inner grating along with a heavy accumulations of dust and debris. The outer plastic vents had been cleaned in Room 404 but a heavy accumulation of dust remained in the area of the inner grating. The outer plastic vents had been cleaned in Room 403 but a heavy accumulation of dust remained in the area of the inner grating. The baseboards in Room 403 were still missing. Room 305 continued to have a heavy accumulation of dust and debris on the outer vents and inner grating. The outer plastic vents had been cleaned in Room 315 but a heavy accumulation of dust remained in the area of the inner grating. Room 314 continued to have a heavy accumulation of dust on the outer vents and inner grating. Room 414 continued to have an accumulation of dust and black spots on the outer vents and inner grating. The door handle in Room 111 continued to be loose with the metal covering no longer affixed to the door. The DON confirmed the observations and stated that the Maintenance Department is responsible for the inner areas of the air conditioning units and Housekeeping is responsible for the outer vents. She stated the Administrator oversees housekeeping and maintenance activities. The DON stated that the units should be clean. An interview was conducted with the Administrator on 11/05/2015 at 11:21 am. The Administrator stated the facility's Director of Housekeeping was out of town this week. The Administrator confirmed that housekeeping is responsible for wiping the outside of the units and maintenance cleans the inside. She stated that housekeeping staff clean the outside of the air conditioning units when they do a monthly deep cleaning for each room and maintenance staff clean the inside of the units once a month. A brief tour was conducted with the Administrator during the interview. The inner grating in the air conditioning unit in Room 413 was noted to have been cleaned. The empty sugar packet, small blue object, and brown object had been removed from the air conditioning unit in Room 409. The air conditioning unit in Room 305 had not been cleaned yet. The Administrator stated that the facility will need to change the schedule to increase the frequency for cleaning the air conditioning units. Regarding the areas of the rooms in disrepair, the Administrator stated the facility is renovating rooms and it is difficult to get to all the rooms quickly. Review of the Maintenance Department's schedule for cleaning of the air conditioning units revealed the last time the units in the 100 and 200 hallways were cleaned was on 10/30/2015 and the last cleaning for the 300 and 400 hallways was on 10/7/2015. 2. Record review of the facility policy titled Room Cleaning-Daily is dated for 02/01/2015. The policy had noted the resident rooms will be cleaned at least daily by the Housekeeping Department and terminally at least once a month and prn (as needed) as indicated. The Procedure: Environmental staff will sweep and mop patient rooms at least daily and as needed throughout the day. Bedside stands, wardrobe, bed frames and other room furniture will be dusted and wiped down with disinfectant indicated for the room at least daily and whenever necessary. Medical equipment such as IV poles, O2 Concentrators, nebulizers, feeding pumps and other types of equipment shall be cleaned according to manufacturer recommendations daily. When equipment that is not being used on a daily basis and once cleaned will have a plastic cover over the equipment to protect from various elements and be removed from the resident room and stored in the designated located. Observation on 11/02/2015 at 11:39AM of the resident's room (302D) revealed there was a suction machine and nebulizer machine located on the night stand which was not covered. The suction machine had a white sticker on the top of it with the date of 02/07/15. The sticker was labeled as Hampton Court Electrical Inspect with a place to write the date and initials. The top surface area of the motorized section of the suction machine had a visible coating of dust. The canister section of the suction machine had a light blue colored lid that was layered with dust. The bottom portion of the canister was stored in a red biohazardous bag. The top surface area of the night stand had was also coated with a layer of dust. Observation on 11/02/2015 at 11:49AM resident room, 306W, revealed there was a suction machine located on the night stand at the bedside which was not covered. The motorized section of the unit was beige in color with a black metal base and a canister that had a light blue colored lid. The black metal base of the unit and the back of the beige colored motorized section was heavily coated with dust. The suction machine did not have an inspection sticker attached. Observation on 11/02/2015 3:28PM in room 302D revealed the suction machine was not covered. The nebulizer and suction machine remained coated with the layer of dust. Observation on 11/02/15 at 3:29PM in room 306W revealed the suction machine remained uncovered and coated with the layer of dust. Observation on 11/02/15 at 6:15PM in room 302D revealed the suction machine remained uncovered. The area still had the coating of dust on the top of the suction machine, night stand and nebulizer machine. Observation on 11/03/15 at 8:10AM of room 302D revealed the suction machine remain uncovered, the nebulizer and top surface area of the night stand still had the coating of dust. Observation on 11/03/15 at 8:11AM of room 306W revealed the suction machine remained uncovered and still had the dust on the outer surface of the black metal base and back of the motorized section. Observation on 11/03/15 at 11:15AM of room 302D revealed the suction machine remain uncovered, the nebulizer and top surface area of the night stand still has the coating of dust on it. Observation on 11/03/15 at 11:16AM of room 306W revealed the suction machine remained uncovered and still had the dust on the outer surfaces of the black metal base. Observation on 11/03/14 at 4:45pm revealed the suction machine remained uncovered and the dust was present. Interview on 11/03/15 at 4:46pm with the Certified Nurse Assistant (CNA) revealed that he provides the daily care to the residents in rooms 302D and 306W. He denied the resident had been congested and was not aware if either of them had to be suctioned recently. Interview on 11/03/15 at 4:49pm with the attending Registered Nurse (RN), confirmed she takes care of the residents in room 302D and 306W. Observation of room 306W at this time the RN saw the suction machine was coated with dust and she revealed the yanker was attached to the end of the tubing. The RN stated the yanker should be covered and agreed the machine should not be covered with dust. Observation on 11/03/15 at 4:51pm conducted with the RN, revealed the suction machine in room 302D was uncovered and coated with dust. The RN revealed there was a yanker attached to the machine and the yanker should be covered. Interview on 11/03/15 at 6:20pm with the Respiratory Therapist stated the facility covers the suction machine after they clean it. He said if a resident goes to the hospital the facility would clean the suction machine, cover and store it away. He agreed the suction machine should not have dust and the yanker should always be covered. Interview on 11/04/15 at 8:10am with the Housekeeping Staff-C reveal that she cleans the rooms on the 300 wing. She says the cleaning includes wiping off the nebulizer machines and other equipment on the night stand as well as the night stand. Interview on 11/04/15 at 9:26AM with the Licensed Practical Nurse-Staff-D confirmed she cared for the residents in room 302 and 306. She stated she had not had to suction the resident in room 302D during her shift but was aware of orders for suctioning and that a suction machine was available. She stated she provided care, treatment and services for the resident in room 306W. She stated the resident had not required suctioning on her shift but was being monitored for congestion. Observation on 11/04/15 at 9:35AM revealed only the yanker on the suction machines in room 302D and 306W were covered. The night stand, nebulizer machine and suction machine in room 302D had been cleaned as well as the suction machine in room 306W. Both suction machines remained uncovered. Interview on 11/04/15 at 12:12PM with the Maintenance Director revealed he had a log of the suction machines and would submit a copy. Observation on 11/04/15 at 1:55PM revealed the suction machines in room 302D and 306W were covered with plastic bags, dated and labeled. Record review of the log titled Suction Machine Equipment Electrical Check had noted the Date Inspected, the Serial Number (#) and Room Number (#). The form showed the suction machines in room 302W and 306W were inspected on 02/07/15. Interview on 11/04/15 at 6:30pm with the facility administrator revealed the labels used for the electrical equipment does not stick well. The facility had planned to use additional tape to ensure the inspection stickers remain in place. She stated Housekeeping staff were responsible for cleaning the residents' care equipment that was in the residents' rooms (which included suction machines).

Based on observation, interview, and record review the facility failed to ensure that staff maintained an accurate account of narcotic medications for 1 (100 hallway medication cart) out of 4 medication carts reviewed. The findings include: Observation of medication cart for the 100 hallway on 11/05/2015 at 10:57 am, observed a medication blister card with 18 tablets of hydromorphone 2 milligrams (mg) for resident #253. Review of the facility's Controlled Drug Receipt/Record/Disposition Form showed that the amount left was 19. The amount of hydromorphone present does not reflect the amount on the Controlled Drug Receipt/ Record/ Disposition Form. Review of the Facility's Shift Drug Count Record for the month of November 2015 two signatures on 11/05/2015 between the 11:00 pm- 7:00 am shift and 7:00 am to 3:00pm shift. The document showed Your signature below certifies that you have counted the controlled drugs and are accepting them as correct. Any deficiency after your signature is your responsibility. Interview and Observation on 11/05/2015 at 10:57 am with Licensed Practical Nurse (LPN) F revealed that every morning narcotic count is completed and then signed off. LPN F confirmed the discrepancy and at this time did not state reason for discrepancy. Interview on 11/05/2015 at 11:59 am with the Director of Nursing (DON) revealed that the oncoming nurse and the nurse leaving count together the narcotics and they have to sign off that it was counted. The DON revealed that this count occurs in the beginning and end of the shift. The DON revealed that when discrepancies are noted, she needs to be notified. The DON stated that this is the first a discrepancy has occurred for her and she will have to read her policy and procedures on how to handle the situation. The DON revealed that she needs to check the narcotic box and will have to call pharmacy as well. Interview on 11/05/2015 at 12:50 pm with LPN revealed that the medication fell on the floor and she forgot to document that it was wasted. Present in the interview was LPN K, LPN F stated that she witnessed the medication disposal. The nurse revealed that she reported to the DON what happened after the discrepancy was found with the hydromorphone. LPN F revealed that she did not tell anyone when the medication fell on the floor and the process is to notify the DON when wasting a medication. Interview on 11/05/2015 at 5:59 pm with the DON revealed that when wasting medication, the nurse needs to look for another nurse to witness the disposal of the medication and document, with two nurses' signatures. Review of the facility's education/In service sheet showed that both LPN F and LPN K were in serviced on controlled substances by the DON. Review of the Policy and Procedures for Medication Storage in the Facility revision date December 2009 showed .at each shift change, or when keys are transferred, a physical inventory of all controlled substances, including the emergency supply, is conducted by two licensed nurses and is documented. Any discrepancy in controlled substance counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator .

Based on observation, interview, and record review the facility failed to accurately monitor residents for pain to assess the effectiveness of ordered pain medication for 2 (resident #258 and #251) out of 15 residents interviewed for pain out of 57 residents on pain management program. The findings include: 1.) Interview and observation on 11/02/2015 at 11:42 am resident # 258 revealed she fell on her knees at home. Resident #258 stated that one night she had pain to both her knees, and the nurse was made aware and pain medication was given. Resident #258 stated that the pain medication does not last for too long. Resident #258 revealed at this time she is not having any pain. Observed resident #258, resident is calm, not in any distress, and does not demonstrate any facial grimacing, moaning, restlessness or crying. Observation on 11/04/2015 at 4:16 pm observed resident in bed with eyes closed. Resident #258 did not appear to be in any distress at this time. Interview and observation on 11/04/2015 at 4:55 pm resident #258 stated that she is feeling better. Resident #258 revealed that her pain level is at a 4-5 on a scale 0-10, with 10 being the highest level. The pain is located to her knees. The pain is not constant and resident #258 stated that it comes and goes. Resident #258 revealed that she is getting [MEDICATION NAME] for pain, the medication helped a little. Resident #258 stated that the medication [MEDICATION NAME] made her nauseous and gave her headaches every time she took it. Resident #258 did report the problem and has not asked for pain medication since. Resident #258 also revealed that the medication interferes with the [MEDICATION NAME]. Resident #258 revealed that medication for nausea was not offered, but was given an anti-[MEDICAL CONDITION] to help with the swelling. Resident #258 revealed that when she first came to the facility she had severe pain to the knees and [MEDICATION NAME] was given, but it was discontinued. The resident revealed that currently the pain is tolerable and that she will be going home tomorrow. Resident #258 stated that she will speak with her physician to get an order for [REDACTED]. Observed resident #258, resident is calm, not in any distress, and does not demonstrate any facial grimacing, moaning, restlessness or crying. Interview on 11/05/2015 at 3:22 pm with Registered Nurse (RN) G revealed that usually the residents would ask for pain medication, the medication can be as needed (PRN) or around the clock. When a resident reveals that they are having pain, RN G stated that he would check the Medication Administration Record (MAR) and check the order, after the medication is given the pain level would be checked again for effectiveness. RN G revealed that if a resident continues to have pain, the physician would be notified. RN G revealed that with resident #258 would ask for pain medication, and then does not remember that she complained of pain. RN G revealed that resident #258 has not complained of nausea during his shift. RN G revealed that when resident #258 was admitted , she had an order for [REDACTED]. The physician changed the medication to as needed. Resident #258 did not want [MEDICATION NAME] or [MEDICATION NAME]. RN G revealed that he and Certified Nursing Assistants (CNAs) check residents for pain every hour. Interview on 11/05/2015 at 3:31 pm with Licensed Practical Nurse (LPN) H revealed that resident #258 did not want [MEDICATION NAME] routine. The physician discontinued the [MEDICATION NAME] and ordered [MEDICATION NAME] as needed. The physician left medications [MEDICATION NAME] and Tylenol #3 active so that resident #258 can choose either one of the medications for pain, then after [MEDICATION NAME] was discontinued. Interview on 11/05/2015 at 3:32 pm with RN I revealed that for resident #258 the order was changed due to the resident stating that she did not want to take medication around the clock, the resident wanted medication when she wanted it. RN I revealed that the resident has not complained of any nausea. Review of the Hampton Court Nursing and Rehab Resident's Admission History and Physical dated 11/02/2015 showed resident #258's Primary [DIAGNOSES REDACTED]. Past History showed resident #258 is status [REDACTED]. Comments: .4.) Discontinue [MEDICATION NAME], 5.) Tylenol/ [MEDICATION NAME] as needed for pain . The History and Physical did not show reason for discontinuing [MEDICATION NAME] and changes in Pain medication. Review of the physician Telephone orders showed on: 10/29/2015 resident #258 was ordered [MEDICATION NAME] 5/325 mg one tablet by mouth every 6 hours for 7 days. On 10/31/2015 order showed to change [MEDICATION NAME] to every 6 hours as needed for severe 7-10 pain as per patient request. On 11/01/2015 [MEDICATION NAME] 5/325mg one tablet by mouth every 6 hours as needed for severe pain 7-10 and Tylenol #3 one tablet by mouth every 4 hours as needed for moderate pain 4-6. On 11/02/2015 discontinue [MEDICATION NAME] 50 mg every 8 hours as needed pain. On 11/03/2015 discontinue [MEDICATION NAME]. Review of physician progress notes [REDACTED]. Interested in outpatient. Improved pain. Review of the Medication Administration Record (MAR) for October 2015 showed resident #258 received pain medication [MEDICATION NAME] 4 times, [MEDICATION NAME] 6 times and Tylenol #3 once for that month. The MAR showed initials to monitor signs and symptoms of pain every shift. Review of pain flow sheet not dated, without a record of resident #258's pain level and intervention, and side effects for October 29, 2015, October 30, 2015, and October 31, 2015. Review of the MAR for the month of November 2015 showed to monitor signs and symptoms of pain every shift. The documentation is initialed but does not show resident #258's pain level. Review of the pain flow sheet for November 2015 did not show documentation of resident #258's pain level, interventions done, and side effects for November 1 and November 2, 2015. Resident #258 received [MEDICATION NAME] 3 times between November 1, 2015 and November 2, 2015. The Pain flow sheet did reflect the MAR to monitor signs and symptoms of pain every shift. Review of the MAR for the month of October 2015 showed resident was given [MEDICATION NAME] and [MEDICATION NAME] on 10/31/ 2015. The documentation showed that resident #258 refused to take the medication but did not state reason. Review of the MAR on 10/30/2015 showed resident was given Tylenol #3 for knee pain, response showed effective, but did not show residents pain level before and after administration as in the pain the pain flow sheet to determine effectiveness of the medication. Review of the Nursing Notes from 10/29/2015 to 11/05/2015 did not reflect resident #258's or physician's reason for the changes in pain medication. The Nursing Notes did not show reason for resident refusing pain medication [MEDICATION NAME] and [MEDICATION NAME] on 10/31/2015. 2) Interview and observation on 11/03/2015 at 12:01pm with resident #251 revealed that the pain medication is not strong enough and cannot sleep due to the pain. Resident #251 revealed that she is waiting for the doctor and that she did notify the nurse regarding her pain. Resident #251 stated that she is taking 15mg of [MEDICATION NAME] the morning and night. Resident #251 stated that they started giving her [MEDICATION NAME] for breakthrough pain and it is not enough. Resident #251 reported that the pain is to her left hip and sometimes her back. Resident #251 revealed that the medication takes too long to start working and the pain goes down to a 7 after the medication is given but does not last long. Observed resident sitting on a wheelchair calm and without signs of distress. Resident #251 is not grimacing, moaning, crying or showed restlessness during the interview. Interview and Observation on 11/04/2015 at 4:06 pm resident #251 stated that she is feeling better. Resident #251 revealed that her pain level is at a 7 from a scale 0-10 to the left hip (with 10 being the highest level). Resident #251 revealed that she will not get pain medication until 9:00 tonight. Resident #251 stated that the pain was sharp and aching. Resident revealed that she gets the [MEDICATION NAME] for breakthrough pain but does not get it at times and it depends who is working. Resident #251 revealed that she told the Physician Assistant about the pain, but did not say anything after. Resident #251 revealed that the pain comes when standing up and trying to turn. Interview on 11/04/2015 at 4:54 with Certified Nursing Assistant (CNA) J revealed that she does not have resident #251 every day, but notified the nurse yesterday that resident #251 was not feeling well. The resident did not state reason. CNA J revealed that she placed the resident in the bathroom, then placed her in bed, and reported to the nurse. CNA J revealed that when a resident complains of pain she is to report it immediately to the nurse. Interview on 11/05/2015 at 3:39 pm with RN G revealed that resident has [MEDICATION NAME] around the clock, every 12 hours. Resident #251 has Tylenol and [MEDICATION NAME] as needed. Resident #251, between the 12 hours, resident is getting [MEDICATION NAME] is given if she has pain the medication is given as needed. RN G revealed that the effectiveness of the pain medication is documented in the chart. The Pain flow sheet is documented only when the medication ordered as needed is given. RN G revealed that documentation in the chart is completed once a shift, which includes residents pain status. Documentation in the chart can be completed more than once a shift if a resident is not stable. RN G revealed that resident pain is assessed every hour. RN G revealed [MEDICATION NAME] is ordered for resident #251 for breakthrough pain. Review of the Hampton Court Nursing and Rehab Resident's Admission History and Physical dated 10/28/2015 showed that residents Present illness and/or complaint: was chronic back pain. Past History: .chronic back pain status [REDACTED]. 3.) Chronic Back Pain. Review of the Physician order [REDACTED].#251 taking [MEDICATION NAME] 200mg by mouth twice daily for arthritis, [MEDICATION NAME] 300mg by mouth for [MEDICAL CONDITION], [MEDICATION NAME] mg by mouth every 12 hours for pain, [MEDICATION NAME] 50g by mouth every 6 hours as needed for break through pain, and Tylenol 325 mg give 2 tablets (650mg) by mouth every 6 hours as needed for pain or temperature. Review of the MAR for the month of October and November 2015 showed Monitor signs and symptoms of pain every shift. The documentation showed an initial and did not show residents pain level. Review of Pain flow sheet for the month of October and November 2015 did not show documentation of pain assessment between 10/23/2015 to 10/27/2015. Review of the Controlled Drug Receipt/Record/ Disposition form, and MAR showed that on 10/30/2015 [MEDICATION NAME] was removed at 2:00 am and at 8:00 am. The Pain flow sheet showed on 10/30/2015 documentation of pain assessment once for the entire day. Resident #251's pain was at a 7 from a scale 0-10 (with 10 being the highest), interventions were positioning, relaxation, and [MEDICATION NAME] was given. Pain was reassessed and residents pain at a 0. The pain assessment on 10/30/2015 did not show what time pain was assessed. Review of Pain flow sheet did not reflect the MAR or POS for the month of October 2015 to monitor signs and symptoms of pain every shift. Review of the Controlled Drug Receipt/Record/Disposition form showed on 10/31/2015 [MEDICATION NAME] was removed at 2:00pm. The Pain flow sheet showed on 10/31/2015 no documentation of resident#251's pain assessment for the entire day. Review of Pain flow sheet did not reflect the MAR or POS for the month of October 2015 to monitor signs and symptoms of pain every shift. Review between the Controlled Drug Receipt/ Record/ Disposition form and Pain flow sheet showed on 11/1/2015 [MEDICATION NAME] was removed at 2:00 am and at 2:00 pm. The Pain flow sheet showed on 11/01/2015 one pain assessment for the entire day. The pain flow sheet showed that on 11/01/2015 at 2:00 pm resident #251 had pain to the left hip at a 7 from a scale 0-10. Interventions were relaxation, positioning and [MEDICATION NAME] was given. The pain was reassessed and level was at a 0. Review of Pain flow sheet did not reflect the MAR or POS for the month of November 2015 to monitor signs and symptoms of pain every shift. Review of the MAR for the month of November 2015, showed [MEDICATION NAME] was given once at 2:00 am. The Controlled Drug Receipt/Record and Disposition form did not reflect the MAR, that the medication was given twice. Review between the Controlled Drug Receipt/Record/Disposition form and Pain flow sheet showed on 11/02/2015 [MEDICATION NAME] was removed once at 1:00 am. The Pain flow sheet showed on 11/02/2015 one pain assessment for the entire day. The pain flow sheet showed that on 11/02/2015 at 1:00 am resident #251 had pain to the left hip at a 7 from a scale 0-10. Interventions were relaxation, positioning and [MEDICATION NAME] was given. The pain was reassessed and level was at a 0. Review of Pain flow sheet did not reflect the MAR or POS for the month of November 2015 to monitor signs and symptoms of pain every shift. Review between the Controlled Drug Receipt/Record/Disposition form and Pain flow sheet showed on 11/03/2015 [MEDICATION NAME] was removed twice at 7:00 am and 7:00 pm. The pain flow sheet showed on 11/03/2015 one pain assessment for the entire day. The pain flow sheet showed on 11/03/2015 with no time resident #251 had pain to the left hip at a 7 from a scale 0-10. Intervention were relaxation, positioning and [MEDICATION NAME] was given. The pan was reassessed and level was at a 0. Review of the Pain flow sheet did not reflect the MAR or POS for the month of November 2015 to monitor signs and symptoms of pain every shift. Review of the MAR for the month of November 2015, showed [MEDICATION NAME] was given once at 2:00 am. The Controlled Drug Receipt/Record and Disposition form did not reflect the MAR, showing that the medication was given twice. Review between the Controlled Drug Receipt/ Record/ Disposition form and Pain flow sheet showed on 11/04/2015 [MEDICATION NAME] was removed twice at 7:00am and 7:00 pm. The pain flow sheet showed on 11/03/2015 one pain assessment for the entire day. The pain flow sheet showed on 11/04/2015 with no time resident #251 had pain to the left hip at a 7 from a scale 0-10. Interventions were relaxation, positioning and [MEDICATION NAME] was given. The pain was reassessed and level was at a 0. Review of the pin flow sheet did not reflect the MAR or POS for the month of November 2015 to monitor signs and symptoms of pain every shift. Review of the MAR for the month of November 2015 showed that [MEDICATION NAME] was initialed only once. The Controlled Drug Receipt/Record and Disposition form did not reflect the MAR and that the medication was given twice. Interview on 11/05/2015 at 7:37 pm with the Director of Nursing (DON) revealed that the nurse assess resident every 1-2 hours for pain. If resident is having pain prn medication will be given and pain level is documented in the flow sheet. The DON revealed that in the MAR, nurses are to sign every shift for pain. The initial indicates that during that shift, the interventions were done if the resident had pain. If there are no interventions on the pain flow sheet and a signature in the MAR to monitor signs and symptoms of pain, it indicates that the resident's pain was being monitored. Review of the facility's Policy and Procedure for Pain observation dated January 2015 showed All residents shall be observed each shift for the presence of pain. Residents taking PRN (as needed) medication shall be asked to classify their pain level on a scale of zero to ten , with zero being the least and 10 being the most severe pain they can imagine, if symptoms of pain are observed or reported by the resident (or family) Observation of pain shall include location, pain rating before and after treatment, alternative treatment, behavior and effectiveness of treatment . Attempts to control pain will be employed until the resident reaches acceptable comfort level. Residents shall be instructed to report reoccurrence of pain and previously effective methods of pain control.

Based on observation, interview and record review the facility failed to ensure that the essential equipment is in safe operating condition. This has the potential to affect 82 out of 108 (75.9%) residents that eat orally. The findings include: Observation on 09-02-14 at 9:05am during the initial kitchen tour with the FSD (Foodservice Director). Inspection of the first Double Door Reach-In unit had peeling on the inner surface area of the divider section. The white colored coating flaked off the surface area when touched The FSD was present and observed the substance. Observation of the 09-02-14 at 9:05am revealed that the second Double Door Reach-in Refrigerator unit had a grate on the ceiling of the unit that had peeling and slight discoloration. The substance flaked off when touched. The FSD stated that the maintenance director would be contacted. The FSD instructed the staff not to place any items in the unit at this time. On 09-03-14 at 8:20am inspection of the kitchen conducted showed that Double Door Reach-in units had signs posted on the front that read "Do Not Use" with the date of 09-02-14. The unit was sealed closed with plastic ties on the door handles to ensure the staff would not use them. The FSD stated that the facility Administrators planned to have the unit inspected for repair. On 09-03-14 at 8:15am during an interview with the Maintenance Director, he stated that he had not seen the interior of the Double Door Reach-in units. An inspection of the interior surfaces of the second unit was conducted by the Maintenance Director. The metal grid on the upper section of the unit was attached to the ceiling by four screws. The grate had some discoloration and peeling on the surface areas. On 09-03-14 at 10:24am during an interview with the AC Company Technician, he explained that the repair of the Double Door Reach-in unit interior was not advisable because they are over [AGE] years old. He stated that the aluminum coating on the interior surface areas of the units had worn away so badly that they were peeling. He stated that the units were old and the facility had planned to replace them instead of repair. On 09-05-14 at 8:40am the Administrator submitted a letter from the Air Conditioning company dated 09-04-14. It is noted the reason for the visit was the Reach-in Refrigerators at Hampton Court. It was noted that the factory coating failed due to the age of the refrigerators. The options were given to replace the interior walls or purchase new units. The facility chose to purchase new refrigerators.