Every finding on record at Hardin Home

Based on the TN Department of Health Guidelines for Sex Offenders, Registered Sex Offender Registry review, policy review, personnel file review, and interview, the facility failed to protect 24 of 24 residents from 1 of 3 (Licensed Practical Nurse (LPN) A), whose criminal background check revealed a criminal conviction and placement on the Tennessee Bureau of Investigation (TBI) Registered Sex Offender Registry. The findings include: 1. Review of the Tennessee Department of Health Guidelines for Sex Offenders revealed, .individuals with certain sex offender convictions are permanently prohibited from working in long-term care facilities due to background check requirements. The Tennessee Department of Health (TDH) prohibits employment for anyone with a disqualifying event which includes specific sex-related offenses . 2.Review of the TBI Sex Offender Registry revealed LPN A was placed on the registry on 3/28/2023 for aggravated statutory rape, exploitation of a minor by electronic means, and solicitation of a minor. 3. Review of the facility's undated policy titled, POLICY - ABUSE, NEGLECT AND EXPLOITATION, revealed, .Policy .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone including but not limited to.facility staff The facility must .Not employ or otherwise engage individuals who: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property by a court of law.Facility administration should report to the . nursing board, any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. 4. Review of the personnel record for LPN A revealed a hire date of 8/31/2023. The criminal background check dated 8/30/2023 revealed a felony conviction of aggravated statutory rape, solicitation of a minor, aggravated rape, and soliciting sexual exploitation of a minor. During an interview on 9/18/2025 at 3:30 PM, the Administrator was asked if he was aware LPN A was on the Tennessee Sex Offender Registry. The Administrator stated, .yes, I was . The Administrator was asked if (LPN A) was currently employed at the facility as a direct care nurse. The Administrator stated, .yes . The Administrator was asked was he aware that sex offenders should not be employed at a care facility. The Administrator stated .yes.

Based on review of the facility ' s Licensure Staffing Requirements, daily staffing schedules, staff time punches, and interview, the facility failed to ensure a Registered Nurse (RN) was on duty at least 8 consecutive hours a day, 7 days a week, for 111 of 160 days reviewed. The findings include: 1. Review of the facility ' s daily working schedule for 1/2025, revealed no RN was on duty for 8 consecutive hours on 1/1/2025-1/3/2025, 1/6/2025-1/11/2025, 1/13/2025-1/17/2025, and 1/19/2025-1/30/2025. Review of the facility ' s time punches dated 1/2025, revealed RN E worked 7 hours and 45 minutes on 1/4/2025, 1/12/2025 and 1/18/2025, resulting in no RN coverage for 8 consecutive hours on those days. 2. Review of the facility ' s daily working schedule for 2/2025, revealed no RN was on duty for 8 consecutive hours on 2/3/2025-2/5/2025, 2/7/2025, 2/10/2025-2/14/2025, 2/17/2025-2/19/2025, 2/21/2025-2/23/2025, and 2/25/2025-2/28/2025. Review of the facility ' s time punches dated 2/2025, revealed RN F worked 7 hours and 45 minutes on 2/8/2025 and 2/9/2025, and RN E worked 7 hours and 45 minutes on 2/15/2025 and 2/16/2025, resulting in no RN coverage for 8 consecutive hours on those days. 3. Review of the facility ' s daily working schedule dated 3/2025, revealed no RN was on duty for 8 consecutive hours on 3/3/2025, 3/5/2025, 3/7/2025, 3/10/2025-3/14/2025, 3/17/2025, 3/19/2025-3/21/2025, 3/24/2025-3/28/2025, and 3/31/2025. Review of the facility ' s time punches dated 3/2025, revealed RN E worked 7 hours and 45 minutes on 3/1/2025, 3/2/2025, 3/16/2025, and 3/29/2025. RN F worked 7 hours and 45 minutes on 3/8/2025, resulting in no RN coverage for 8 consecutive hours on those days. 4. Review of the facility ' s daily working schedule dated 4/2025, revealed no RN was on duty for 8 consecutive hours on 4/2/2025-4/4/2025, 4/7/2025-4/11/2025, 4/14/2025, 4/15/2025, 4/17/2025, 4/18/2025, 4/21/2025-4/25/2025, and 4/28/2025-4/30/2025. 5. Review of the facility ' s daily working schedule dated 5/2025, revealed no RN was on duty for 8 consecutive hours on 5/1/2025, 5/2/2025, 5/5/2025-5/9/2025, 5/12/2025-5/16/2025, 5/19/2025-5/23/2023, and 5/26/2025-5/30/2025. 6. Review of the facility ' s daily working schedule dated 6/2025, revealed no RN was on duty for 8 consecutive hours on 6/1/2025-6/6/2025, and 6/9/2025. During an interview on 6/10/2025 at 2:13 PM, the Assistant Director of Nursing (ADON) confirmed she makes the schedules for Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. The ADON confirmed that the Director of Nursing (DON) is scheduled for 4 hours each day Monday through Friday. During an interview on 6/10/2025 at 3:00PM, the Administrator confirmed the DON, and the facility owner are RNs, and they can cover if needed. The Administrator confirmed that the facility does not have a staffing waiver.

Based on facility policy and interview, the facility failed to follow its policy and provide education and vaccination for COVID-19 to 3 of 5 (Licensed Practical Nurse (LPN) C, Laundry Supervisor, and Certified Nursing Assistant (CNA) D staff members interviewed. The findings include: 1. Review of the undated facility policy titled, COVID-19 Vaccination, revealed .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine .It is the policy of this facility, in collaboration with the medical director, to have an immunization program against COVID-19 disease in accordance with national standards of practice .The facility will educate and offer the COVID-19 vaccine to .staff and maintain documentation of such . 2. During interview on 6/10/2025 at 3:43 PM, LPN C confirmed that she had not been offered education or vaccination for COVID-19. During interview on 6/10/2025 at 3:53 PM, the Laundry Supervisor confirmed that she had not been offered education or vaccination for COVID-19. During interview on 6/10/2025 at 3:57 PM, CNA D confirmed that she had not been offered education or vaccination for COVID-19. During interview on 6/10/2025 at 4:36 PM, the Director of Nursing (DON) confirmed that they do not offer education and vaccination for COVID-19 to employees.

Based on facility policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors when 2 of 7 (Licensed Practical Nurse (LPN) A and LPN B) nurses failed to follow physician orders for 1 of 5 (Resident #5) residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Administration of Drugs, dated 1/21/2022, revealed .Medications shall be administered as prescribed by the attending physician .Medications must be administered in accordance with the written orders of the attending physician . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Paroxysmal Atrial Fibrillation, Major Depressive Disorder, Hypertension, and Cerebrovascular Disease. Review of the Physician Order dated 11/20/2023, revealed .Metoprolol Tartrate Oral Tablet .Give 12.5 mg [milligram] by mouth two times a day .HOLD IF HEART RATE IS LESS THAN 60 bpm [beats per minute] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS). Review of the Care Plan dated 5/21/2025, revealed . [named Resident #5] has hypertension (HTN) .Give anti hypertensive medications as ordered. Monitor for side effects .Metoprolol Tartrate Oral Tablet (Metoprolol Tartrate) Give 12.5 mg [milligrams] by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF HEART RATE IS LESS THAN 60 bpm [beats per minute] . Review of the Medication Administration Record (MAR) dated 5/2025, revealed Metoprolol Tartrate was given as follows: On 5/11/2025 at 7:00 AM with heart rate of 59 by LPN A. On 5/19/2025 at 7:00 AM with heart rate of 58 by LPN A. On 5/27/2025 at 7:00 AM with heart rate of 52 by LPN A. On 5/28/2025 at 7:00 AM with heart rate of 56 by LPN A. On 5/31/2025 at 7:00 AM with heart rate of 58 by LPN B. 3. During an interview on 6/10/2025 at 2:08 PM, the Director of Nursing (DON) confirmed staff should follow physician orders. During an interview on 6/10/2025 at 3:22 PM, LPN A confirmed that she gave Metoprolol Tartrate at 7:00 AM when Resident #5 had a heart rate of less than 60 bpm on 5/11/2025, 5/19/2025, 5/27/2025, and 5/28/2025.

Based on the Infection Control Policy and Procedure Manual, and interview the facility failed to provide a qualified Infection Control Preventionist who was responsible to monitor and maintain the facility ' s Infection Prevention and Control Program. This could have affected the 26 residents residing in the facility. The findings include: Review of the facility ' s Infection Control Policy and Procedure Manual INFECTION CONTROL PROGRAM revealed, .The goals of the Infection Control Program are to .Decrease the risk of infection to patients and personnel .Monitor for occurrence of infection and implement appropriate control measures .Identify and correct problems relating to infection control practices .Insure compliance with state and federal regulations relating to infection control .The administrator is ultimately responsible for the Infection Control Program .Responsibility is delegated to the Infection Control Practitioner (ICP) to carry out the daily functions of the Infection Control Program .Patient Infections Cases are monitored by the ICP .The ICP completes the .listing of infections and monthly report form and reports .Monthly to the Administrator .Quarterly to the Infection Control Committee . Review of the Infection Prevention Control Officer Training Certificate dated [DATE] revealed the facility ' s Infection Preventionist Certificate had expired three years from the date the certificate was issued. During an interview on [DATE] at 4:45 PM, the Administrator confirmed the Infection Preventionist certification had expired and stated, .we didn't know till you showed us . During an interview on [DATE] at 5:10 PM, the Director of Nursing (DON) confirmed that her Infection Preventionist Training had expired and stated, I had no idea it had expired .

Based on facility policy review, medical record review, and interview, it was determined the facility failed to report an injury of unknown origin and an allegation of sexual abuse to State Agencies within 2 hours for 2 of 3 (Resident #1 and #2) sampled residents reviewed for alleged abuse. The findings include: 1. Review of the facility's undated policy titled Policy - Abuse, Neglect and Exploitation revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .GUIDELINES: 1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or Social Worker. Report allegations or suspected abuse, neglect or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures .The Facility Must .In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law . 2. Review of the Emergency Department Progress Note dated [DATE], revealed .nurse from [NAME] Home Nursing Home, called with report on patient [Resident #1]. Reports that patient was found in bed approximately 20 minutes ago with deformity of left shoulder. Reports that a CNA [Certified Nursing Assistant] went to her room to get her up for a bath and found her in bed with obvious deformity of left shoulder. Denies that any staff knows what happened . Review of the facility's Incident/Accident Report dated [DATE], revealed .Resident [Resident #1] was being showered and CNA made nurse aware of (L) [left] shoulder looking different that (R) [right] .apparent dislocation to (L) shoulder . Review of the medical record revealed Resident #1 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease, Vascular Dementia, Dislocation of Left Shoulder Joint, Osteoarthritis, Cerebrovascular Disease, and Vitamin D Deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored 3 on the Staff Assessment for Mental Status which indicated severely impaired cognition. Resident #1 was dependent upon staff for all Activities of Daily Living (ADLs). Observations on [DATE] at 10:40 AM in the lobby revealed Resident #1 was reclined in a geri-chair. The resident's eyes were closed, and she did not respond when name called. A sling used for a mechanical lift was underneath the resident. 3. Review of the medical record revealed Resident #2 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Metabolic Encephalopathy, Vascular Dementia, Cerebrovascular Disease, Hemiplegia and Hemiparesis of Left Non-Dominant Side, Adjustment Disorder, and Impulse Disorder. The resident expired on [DATE]. Review of the Speech Language Pathologist typed statement dated [DATE], revealed .I was getting ready to leave the room and [Named Resident #2] says, you have to get me out of here I'm being sexually assaulted .I then reported this to [Named ADON] . Review of the Significant Change MDS assessment dated [DATE], revealed Resident #2 scored 9 on the Brief Interview of Mental Status which indicated moderately impaired cognition. Resident #2 was dependent upon staff for all ADLs. Review of the Advanced Practice Registered Nurse's summary dated [DATE], revealed .When I asked him [Resident #2] about his anxiety, depression, or concerns, he stated that he had been assaulted .I spoke with [Named ADON] . Review of the Social Worker's typed statement dated [DATE], revealed .I was informed by [Named ADON] that resident [Resident #2] had reported being sexually assaulted .I approached resident who was resting in bed .I asked him if anything else had taken place and his response was 'he tried putting his fingers inside me' .I immediately reported this to [Named ADON] and the Administrator . 4. During an interview with the Administrator on [DATE] at 3:04 PM, when asked what was the timeframe for reporting an injury of unknown origin or an allegation of abuse, the Administrator stated, I thought it was 5 days, or is it 24 hours? I missed that one. I didn't know to report injury of unknown origin .

Based on policy review, observation, and interview, the facility failed to ensure 3 of 7 staff (Certified Nurse Assistant (CNA) #1 and #2, and Registered Nurse (RN) #1) served food under sanitary conditions when staff touched food with their bare hands and failed to perform hand hygiene for 4 of 25 sampled residents (Resident #14, #18, #19, and #26) observed during dining. The findings include: Review of the facility's undated policy titled, Hand Washing Reminders, revealed .Remember to wash Hands When .After coming in contact with resident's belongings/surfaces in room . Review of the facility's undated policy titled, Meal Time Reminders, revealed .Do not touch food with bare hands. Use forks, knives, spoons, and if need wear gloves . Observation in the Dining Room on 11/7/2021 at 11:35 AM, revealed RN #1 handled Resident #19's crackers with her bare hands. Observation in the resident's room on 11/7/2021 at 11:45 AM, revealed CNA #1 moved the bedside table near Resident #14 who was sitting on the side of the bed. CNA #1 sat down in the chair at the bedside. Without performing hand hygiene, CNA #1 removed Resident #14's sandwich from a plastic bag with her bare hands and placed the sandwich in Resident #14's hands. Resident #14 lost grip of the sandwich and CNA #1 touched the sandwich with her bare hands. CNA #1 then touched the bedside table and chair to reposition them. CNA #1 touched the feeding end of the spoon with her bare hands, without performing hand hygiene, and began feeding Resident #14. Observation in the resident's room on 11/8/2021 at 4:45 PM, revealed CNA #2 handled Resident 18's sandwich with her bare hands. Observation in the resident's room on 11/8/2021 at 4:48 PM, revealed CNA #2 handled Resident 26's sandwich with her bare hands. During an interview on 11/9/2021 at 10:53 AM, the Director of Nursing (DON) confirmed that staff should not handle food bare-handed, and staff should perform hand hygiene after touching residents or objects.

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when undated, opened, unlabeled, and unsecured medications were observed in 2 of 23 resident bathrooms (Resident #24 and Resident #238's bathroom) which could have potentially affected 2 identified wanderers (Resident #14 and Resident #20) in the facility. The findings include: Review of the facility's policy titled, POLICY- MEDICATION STORAGE ROOM, dated 9/21/2021, revealed .treatment supplies will be kept in .original packages .All containers will be labeled with expiration date and date opened . Observations in Resident #24's and Resident #238's bathroom on 11/7/2021 at 9:02 AM, 10:50 AM, 12:55 PM, and 2:30 PM, revealed 2 opened plastic medication cups with an unidentified white substance sitting on the bathroom shelf that was undated, opened, unlabeled, and unsecured. The facility identified 2 wanderers (Resident #14 and Resident #20) who could have potentially been affected by unsecured medications left unattended in resident bathrooms. During an interview on 11/7/2021 at 2:35 PM, Licensed Practical Nurse (LPN) #1 was asked what was in the 2 medication cups in Resident #24's and Resident #238's bathroom. LPN #1 stated, .I think this is Baza cream [a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .not sure what kind of medication it is .no it shouldn't be left here . During an interview on 11/9/2021 at 11:26 AM, the Director of Nursing (DON) confirmed that the undated, opened, unlabeled, and unsecured medications should not have been left unattended in a resident bathroom.

Based on medical record review and interview, the facility failed to accurately assess residents for activities of daily living for 2 of 13 sampled residents (Resident #3 and #7) reviewed for Minimum Data Set (MDS) assessments. The findings include: Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 required supervision for bed mobility and was independent for eating. Review of the quarterly MDS dated [DATE], revealed Resident #3 required limited assistance for bed mobility and required supervision for eating. During an interview on 11/9/2021 at 10:10 AM, MDS Coordinator #1 confirmed the MDS dated [DATE] for Resident #3 was inaccurate for bed mobility and eating, and should have been assessed as supervision for bed mobility and independent for eating. Medical record review, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #7 required extensive assistance for eating. Review of the annual MDS dated [DATE], revealed Resident #7 was totally dependent on staff for eating. During an interview on 11/9/2021 at 10:10 AM, MDS Coordinator #1 confirmed the MDS dated [DATE] for Resident #7 was inaccurate and should have been assessed as totally dependent on staff for eating.

Based on policy review, medical record review, bank statements, and interview, the facility failed to refund 2 of 6 (Resident #86 and 87) resident's account balances within 30 days of death. The findings include: 1. The facility's Financial Agreement revised ,[DATE] documented, .If a Resident that has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these funds to the individual or probate jurisdiction administering the Resident's estate or other entity as required by State law or regulation . 2. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #86's Discharge Summarydated [DATE] documented, .pt (patient) expired @ (at) (Named Facility) on [DATE] . Review of Resident #86's bank statement revealed an ending balance of $330.36 on [DATE]. There was no documentation the resident's funds had been conveyed to the individual administering the residents' estate. 3. Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #87's Discharge Summary dated [DATE] documented, .pt. expired @ (Named Facility) . Review of Resident #87's bank statement revealed an ending balance of $845.21 on [DATE]. There was no documentation the resident's funds had been conveyed to the individual administering the residents' estate. 4. Interview with the Administrator on [DATE] at 4:00 PM, in the Dining Room, the Administrator was asked to provide evidence that the residents' families had received the balance of the residents' accounts after the residents had expired. The Administrator stated, .the bank does that .there is a procedure the family has to go through to receive the resident's money .we are not able to do that .we have set up the resident's trusts account up incorrectly . The facility was not able to provide documentation families had received the balance of their loved ones trust accounts after the residents had expired.

Based on policy review, personnel file review and interview, the facility failed to ensure employees were free of communicable diseases for 3 of 8 (the Dietary Manager, the Activity Director, and the Social Worker) employees. The findings included: The facility's POLICY FOR COMMUNICABLE AND CONTAGIOUS DISEASES policy documented, .The facility will perform a TB ([DIAGNOSES REDACTED]) screening on all employees on an annual basis . Review of the personnel files for the Dietary Manager, Activity Director and Social Worker did not contain a physician statement the employees were free of communicable disease or a TB skin test. Interview with the Director of Nursing (DON) on 11/7/17 at 12:21 PM, in the DON's office the DON was asked if the employee health screens were signed by a physician. The DON stated, No. The DON was asked if the employees had received a TB skin test. The DON stated, No.

Based on medical record review and interview, the facility failed to ensure an assessment was complete and accurate related to wandering for 1 of 18 (Resident #32) sampled residents reviewed of the 24 residents included in the Stage 2 review. The findings included: Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #32 had behaviors of wandering 4-6 days of the 7 days of the look back period. Review of the care plan dated 4/29/16 did not include interventions for the behaviors of wandering. Review of the medical record did not reveal wandering behaviors. Interview with Licensed Practical Nurse (LPN) #1 on 8/30/16 at 1:50 PM, in the Director of Nursing Office, LPN #1 was asked if Resident #32 had a care plan for wandering. LPN #1 stated .it (wandering section of the MDS) was an error

Based on medical record review, observation, and interview, the facility failed to revise the care plan for falls for 1 of 18 (Resident #38) sampled residents reviewed of the 24 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed yes to fall since admission, and 1 fall with minor injury since admission. Review of the nurses' notes revealed Resident #38 fell on [DATE], 8/19/16, and 8/22/16. Review of the FALL INVESTIGATION dated 7/1/16 revealed an intervention of a bed alarm and a bedside commode (BC) at night (but this intervention was crossed out). The care plan dated 7/6/16 and revised 8/22/16 documented, .At risk for falls secondary to poor judgement and impaired awareness .Approaches .Bedside Commode @ (at) HS (hour of sleep). 7-1-16 . Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 on 8/30/16 at 10:31 AM, in the DON office, the DON stated, We thought the BSC may confuse him at that time (7/1/16) and decided not to do it .Yeah, it should have been taken off of the care plan. LPN #1 stated, I probably missed it, should have crossed it off, was on the first page, so I missed it .

Based on medical record review, observation, and interview, it was determined the facility failed to accurately assess a resident for vision/glasses for 1 of 12 (Resident #6) sampled residents reviewed of the 24 residents included in the stage 2 review. The findings included: Medical record review for Resident # 6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment with an assessment reference date of 1/10/13 documented, "...Section B B1000. Vision 1 ...Impaired - sees large print, but not regular print in newspapers/books... B1200. Corrective Lenses 0 (indicating no corrective lenses used)... Section C Cognitive Patterns... Brief Interview for Mental Status (BIMS) C0500. Summary Score 14 (indicating cognitively intact)..." Observations in Resident #6's room on 3/5/13 at 1:40 PM, revealed Resident #6's glasses were noted on his bedside table. Observations in Resident #6's room on 3/6/13 at 10:00 AM, revealed Resident #6's glasses on his bedside table. During an interview in Resident #6's room on 3/6/13 at 3:00 PM, Resident #6 showed the surveyor his glasses. Resident #6 was asked if he wears the glasses. Resident #6 stated, "When I have to, like when I want to read fine print..." During an interview at the nurses' station on 3/6/13 at 3:05 PM, the MDS Coordinator was asked about Resident #6's glasses. The MDS Coordinator stated, "Did not know he (Resident #6) had glasses..." The glasses were then shown to the MDS Coordinator on his table in his room.

Based on medical record review, observation, and interview, it was determined the facility failed to have a care plan for vision for 2 of 12 (Residents #6 and 21) sampled residents reviewed of the 24 residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment with an assessment reference date of 1/10/13 documented, "...Section B B1000. Vision 1 ...Impaired - sees large print, but not regular print in newspapers/books... B1200. Corrective Lenses 0 (indicating no corrective lenses used)... Section C Cognitive Patterns... Brief Interview for Mental Status (BIMS) C0500. Summary Score 14 (indicating cognitively intact)..." Review of the care plan dated 12/17/12 and updated 1/17/13 did not document a care plan for impaired vision. Observations in Resident #6's room on 3/5/13 at 1:40 PM, revealed Resident #6's glasses were noted on his bedside table. Observations in Resident #6's room on 3/6/13 at 10:00 AM, revealed Resident #6's glasses on his bedside table. During an interview in Resident #6's room on 3/6/13 at 3:00 PM, Resident #6 showed the surveyor his glasses. Resident #6 was asked if he wears the glasses. Resident #6 stated, "When I have to, like when I want to read fine print..." During an interview at the nurses' station on 3/6/13 at 3:05 PM, the MDS Coordinator was asked about Resident #6's glasses. The MDS Coordinator stated, "Did not know he (Resident #6) had glasses..." The glasses were then shown to the MDS Coordinator on his table in his room. 2. Medical record review for Resident #21 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS assessment with an assessment reference date of 2/6/13 documented, "...Section B B1000. Vision 1... Impaired - sees large print, but not regular print in newspapers/books... B1200. Corrective Lenses 0 (indicating no corrective lenses used)..." Review of the care plan dated 2/6/13 did not include care for impaired vision. Observations in Resident #21's room on 3/7/13 at 8:45 AM, revealed Resident #21 asleep in the bed with a newspaper laying open on his bed. During an interview at the nurses' station on 3/7/13 at 8:50 AM, Nurse #1 confirmed Resident #21 had glasses. Nurse #1 stated, "The last time he went to hospital they (glasses) were lost and wife did not wish to buy another pair at this time..." During an interview at the nurses' station on 3/7/13 at 8:50 AM, Certified Nursing Assistant #1 stated, "...(Resident #21) looks at newspaper every day, not sure if he is reading..." During an interview at the nurses' station on 3/7/13 at 9:35 AM, the MDS Coordinator confirmed there was no care plan present for impaired vision. The MDS Coordinator stated, "...(Resident #21) had exam for glasses and eye doctor is coming here to fit resident..."

Based on review of "MED-PASS COMMON INSULINS" provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, it was determined the facility failed to ensure 1 of 2 (Nurse #2) nurses administered medications without a significant medication error. Nurse #2 failed to administer Resident #7's insulin within the proper time frame related to food. The findings include: Review of "MED-PASS COMMON INSULINS: Pharmacokinetics, Compatibility, and Properties" provided by the American Society of Consultant Pharmacists for typical dosing administration of insulin related to meals documented, "[MEDICATION NAME] ...ONSET (in hours, unless noted) ...15 min (minutes)... TYPICAL DOSING / COMMENTS... 5- (to)10 minutes before meals..." Medical record review for Resident #7 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #7's room on 3/6/13 at 7:00 AM, Nurse #2 administered [MEDICATION NAME] 70/30 insulin SQ in Resident #7's right upper arm. The breakfast tray for Resident #7 was not delivered to her room until 7:34 AM; 34 minutes after receiving the insulin. The administration of the [MEDICATION NAME] more than 5 to 10 minutes prior to Resident #7 receiving her meal tray resulted in a significant medication error. During an interview in the employee education room on 3/7/13 at 9:21 AM, the Director of Nursing stated, "It (insulin) should be... given before they eat, should eat either 15 minutes or 30 minutes before. I would have to check manufacturer's recommendation (when to administer)... insulin... "

Based on policy review, observation and interview, it was determined the facility failed to ensure practices to prevent the potential spread of infection were followed for handwashing by 3 of 7 staff members (Certified Nursing Assistants (CNA) #1, 2 and 3) during dining observations and 1 of 6 (Nurse #4) nurses observed providing care. These findings included: 1. Review of the facility's "Hand Washing" policy documented the following instances when to wash hands, "...before and after caring for each resident, before having contact with the resident's face and mouth, after handling used dressings, before and after eating..." a. Observations in the dining room, during the lunch meal, on 5/16/11 at 12:00 PM, CNA #1 assisted to pull a resident up in a Broda chair, used hand gel on hands, then returned to a different resident and began to feed the resident. CNA #1 failed to follow the facility's handwashing policy. b. Observations in room [ROOM NUMBER], during the supper meal, on 5/16/11 at 4:55 PM, CNA #3 took the meal tray into the room, rolled the head of the bed up, patted the resident on the shoulder, put the side rail down, then opened the carton of milk, poured the milk into a glass and opened the straw. CNA #3 took the tops off the tea and bowl of food, opened the silverware and started feeding the resident. CNA #3 did not wash her hands during this observation. c. Observations in room [ROOM NUMBER], during the supper meal, on 5/16/11 at 5:16 PM, CNA #2 took the meal tray into the room, sat the tray down on the overbed table then walked back down the hall. At 5:20 PM, CNA #2 returned with towels. CNA #2 then put the side rail down on the bed, rolled the head of the bed up, uncovered food, handled silverware and condiments with her bare hands. CNA #2 then walked across the hallway into room [ROOM NUMBER] and came back into room [ROOM NUMBER] with a folding chair, unfolded the chair at the resident's bedside and started feeding the resident without washing her hands. During an interview in the dining room on 5/17/11 at 9:05 AM, the Director of Nursing (DON) was asked what was expected of the staff concerning handwashing and meal tray pass. The DON stated, "...wash hands prior to delivery of tray and after, give the resident the correct tray, wash the resident's hands prior to eating, staff wash hands before they go to the next resident, and if they touch nose, face, hair, wash hands. Wash hands after resident contact..." During an interview outside the DON's office on 5/17/11 at 9:50 AM, the DON stated, "...staff is supposed to use soap and water daily with hand gel in between residents. I do expect if they touch the resident to wash hands with soap and water..." 2. Review of the facility's "WOUND CARE PROCEDURE FOR MAJOR WOUNDS" policy documented, "...H. Put on gloves... I. Remove the soiled dressing and place in a bag at bedside... J. Remove gloves and discard in the bag... L. WASH YOUR HANDS... M. Put on clean gloves..." Observations in room [ROOM NUMBER] on 5/17/11 at 10:35 AM, Nurse #4 put gloves on, removed the old dressing and cleaned the wound with wound cleanser and gauze without washing her hands or changing gloves.

Based on observation and interview, it was determined the facility failed to store and label medications with expiration dates in 1 of 3 (medication cart #2) medication storage areas. The findings included: Observations at the nurses' station on 5/17/11 at 9:45 AM, revealed medication cart #2 contained the following medications with no expiration dates: a. Two bubble packs of Tramadol Hydrocloride (HCL) 50 milligram (mg). b. A bubble pack of Oxycodone HCL 5 mg. c. A bottle of Levothyroxine 50 microgram (mcg). d. A bottle of Anaspaz 125 mcg. e. A bottle of Mirapex 0.125 mg. During an interview at the nurses station on 5/17/11 at 10:00 AM, Nurse #4 confirmed there were no expiration dates on the medications as listed above. During an interview at the nurses station on 5/17/11 at 10:14 AM, the Director of Nursing stated, "...would expect there is a visible expiration date..." During an interview at the nurses station on 5/17/11 at 10:18 AM, the pharmacist stated "There's supposed to be a yellow sticker with the lot and expiration date on it (bottle) when it leaves the store. On any bubble pack ...the lot and expiration date should be on the back of the package..."

Based on observation and interview, it was determined the facility failed to deliver meal trays in a timely manner during 1 of 2 (supper) dining observations. The findings included: Observations on hall 3 on 4/16/11 revealed the meal cart arrived at 4:49 PM and the staff began to deliver the meal trays to the residents. The last tray was delivered to room #38 by Certified Nursing Assistant (CNA #4) at 5:39 PM. A total of 50 minutes had lapsed since the meal cart had arrived on the hall. During an interview in the Director of Nursing's (DON) office on 5/17/11 at 11:30 AM, the DON stated, "...I don't know why the trays were late if there was available staff..."

Based on medical record review, observation and interview, it was determined the facility failed to obtain a physician's order or assess a resident's ability to self-administer medications for 1 of 1 (Resident #5) sampled residents self administering medication. The findings included: Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's order dated 4/29/11 documented, "[MEDICATION NAME] 0.083% (percent) INH (metered dose inhaler) SOL (Solution) TX (Treatment) QID (four times a day)..." There was no documentation of a physician's order allowing Resident #5 to self-administer medications. The facility was unable to provide documentation that an assessment was completed to asses Resident #5's ability to self administer medications. Observations in Resident #5's room on 5/16/11 at 6:35 PM, Nurse #3 filled Resident #5's reservoir of the nebulizer machine with [MEDICATION NAME] 0.083% solution. Nurse #3 then turned the machine on, gave the mouthpiece and tubing to Resident #5 and left the room. Nurse #3 was not observed to go back and check on Resident #5. During an interview in the Director of Nursing's (DON) office on 5/17/11 at 11:AM, the DON stated, "...We put the medication in and go back periodically to check..."