Every finding on record at Heritage Health Care & Rehab Inc

Based on observations, interviews, medical record review and review of a facility policy titled HAND HYGIENE the facility failed to ensure Employee Identifier (EI) #4, Certified Nursing Assistant (CNA), washed and sanitized her hands in between glove use and prior to opening and retrieving a gown out of the Personal Protective Equipment (PPE) isolation cart. This had the potential to affect 45 out of 45 residents on unit one who received care from EI #4. Findings include: A review of the facility policy titled, HAND HYGIENE with a revised date of 11/2020 documented the following: PURPOSE: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 1. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Resident Identifier (RI) #9 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #9 had a current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #11 was admitted to the facility on [DATE]. RI #11 had a current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/26/2022 at 8:25 AM, EI #4 CNA was observed entering RI #11's room after donning gown in the hallway, she donned gloves in the room and picked up the resident's breakfast tray and set it on a red bin and disposed of the disposable food container, milk carton, orange juice container and plastic silverware. She doffed gloves. She then without sanitizing or washing hands donned gloves and adjusted the resident's bed to preference, adjusted the sheets and covers. She doffed gloves and then lowered the bed without gloves or washing or sanitizing her hands. She donned gloves without sanitizing her hands and she took the plastic food tray and placed it on the floor by the wall next to the door. She doffed gown and gloves and went in the hallway. She then without washing or sanitizing her hands opened up the PPE isolation cart and pulled out a gown and walked toward RI #9's room where she was stopped by the surveyor. On 7/26/22 at 8:34 AM an interview was conducted with EI #4. EI #4 was asked when she sanitized her hands after she took off her PPE. EI #4 said she did not sanitize her hands. When asked why she did not sanitize her hands before getting the gown out of the isolation cart, EI #4 said, she did not know. EI #4 was asked when should she have washed or sanitized her hands. EI #4 replied before going into the room and in between glove change. When asked what the risk was of not washing or sanitizing her hands after going and providing care for a COVID positive resident and going to the isolation cart and removing PPE, EI #4 said, spread of infection. On 7/27/2022 at 4:30 PM an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked when should staff wash their hands. EI #3 said, before and after care with a resident, when they are visibly soiled, and between glove changes. When asked when a staff member should not wash or sanitize their hands after leaving a COVID positive resident's room. EI #3 said, never they should always wash their hands. When asked what the risk was of not washing or sanitizing hands after leaving a COVID positive residents' room, EI #3 said, they could take whatever contaminants and spread it around. On 7/28/2022 at 9:50 AM EI #2, Director of Nursing (DON), was asked when should staff wash their hands after wearing gloves. EI #2 replied, when they remove gloves and before applying gloves. EI #2 was asked, what is the risk of staff not washing their hands after caring for a COVID positive resident. EI #2 replied, cross contamination. EI #2 was asked, when should staff go into a PPE isolation cart to retrieve PPE without washing their hands after leaving a COVID positive resident's room. EI #2 said, they should not, they must wash their hands. This deficiency was cited as a result of the investigation of complaint/report number AL 948.

Based on interviews, record review, and facility procedure review titled, Restorative Nursing Program, the facility failed to update Resident Identifier (RI) #48's care plan with recommendations from the speech therapy department. This deficient practice affected RI #48, one of 25 sampled residents whose care plans were reviewed. Findings Include: A review of a facility procedure titled, Restorative Nursing Program, written in November of 2016 and revised in November of 2017, revealed in part, Those residents on a restorative program will have a care plan developed to reflect the goal(s) of the restorative program. RI #48 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #48's Care Plan, with a problem onset date of 09/27/18, indicated the resident was at risk for impaired nutrition and hydration related to issues including a history of [CONDITION(S)] ([CONDITION(S)]) and had a self-care deficit related to [CONDITION(S)] with left-sided [CONDITION(S)] (paralysis of half of the body). Interventions included Requires supervision with meals and Provide assistance with ADL's [activities of daily living]. The care plans regarding impaired nutrition and hydration and self-care deficit lacked updating since 09/27/18. The care plans also lacked interventions recommended in a functional maintenance plan (FMP) developed by the speech therapy department. A Speech Therapy Functional Maintenance Plan (FMP), with a run date of 01/11/21, indicated the patient presented with swallowing deficits, including pocketing, with recommendations to provide minimal verbal and visual cueing as needed to take one sip from a cup rim after one to two bites to improve oral clearance. Recommendations also included providing instruction and demonstration to use swish and swallow as needed at the end of meals to completely clear the oral cavity. An ST [Speech Therapy] - Therapist Progress & Discharge Summary, dated 01/15/21, indicated therapy staff designed and implemented an FMP with caregiver education provided. The summary identified that recommendations and education included providing verbal and visual cueing frequently to promote self-feeding during meals and providing verbal instruction to use one-to-one cyclic ingestion and/or swish-and-swallow technique to facilitate oropharyngeal clearance at meals to improve airway safety. During an interview on 01/27/22 at 10:55 a.m., EI #2, Director of Nursing (DON), stated that, when there were therapy recommendations, the nurses received communication from therapy and an order was entered. The DON stated supervisory nursing staff were responsible to ensure recommendations and/or orders were added to resident care plans. During an interview on 01/27/22 at 11:09 a.m., EI #11, Registered Nurse (RN) Supervisor, stated care plans should be updated within 24 hours after a new intervention was recommended. EI #11 noted that any information or intervention that needed to be communicated to staff should be included with the update. EI #11 stated that nursing staff were responsible for updating care plans. During an interview on 01/27/22 at 11:15 a.m., EI #1, Licensed Nursing Home Administrator (LNHA), stated that care plans should be reviewed quarterly. The LNHA stated resident care plans should be updated as needed with changes, and that nursing staff were responsible for updating the care plan.

Based on observations, interviews, record review, and review of a facility policy titled, Activities of Daily Living (ADLs) the facility failed to provide Resident Identifier (RI) #48 and RI #62 with necessary and appropriate care and services with eating. This deficient practice affected RI #48 and RI #62, two of three residents reviewed for assistance with ADLs. Findings Include: A review of the Activities of Daily Living (ADLs) policy, written in January of 2018 and last reviewed in January of 2020, which was provided by EI #2, revealed, . C. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1.) RI #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #62's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 12/03/21, revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated RI #62 had severe cognitive impairment. Further review of the MDS revealed RI #62 required total assistance with meals and received 51% or more daily calories from a feeding tube. A review of RI #62's Care Plan, dated 12/31/20, revealed the resident had an ADL self-care deficit related to issues including weakness and cognitive impairment and was dependent on staff for eating. The plan also identified that RI #62 was at risk for an alteration in respiratory status related to dysphasia. Interventions included providing assistance with ADLs. RI #62's Care Plan, dated 12/31/20, revealed the resident was at risk for impaired nutrition/hydration related to requiring assistance with eating, dysphagia, and use of a therapeutic diet. Interventions directed staff, in part, to observe RI #62 for nausea, vomiting, and shortness of breath and to provide speech therapy services as ordered. Review of a Fiberoptic Endoscopic Evaluation of Swallowing (FEES) document, dated 06/11/21, revealed that recommendations for RI #62 included providing small portions of pureed food with honey thick liquids per spoon presentation at a slow rate with cyclic ingestion. A review of RI #62's Speech Therapy Functional Maintenance Plan (FMP), dated 06/16/21, indicated RI #62 benefited from the use of strict safe swallow precautions and feeding strategies of feeding in ½ teaspoon quantities for both liquids and purees. RI #62 was not to be allowed to drink from a cup or straw. Per the plan, staff were to alternate bites and sips utilizing a slow rate and ensure RI #62's mouth was clear of all food and fluids following intake. A meal observation was conducted on 01/25/22 at 12:37 p.m. RI #62 was observed receiving assistance from EI #6, a Certified Nursing Assistant (CNA). The resident received thickened liquids per the speech therapy recommendation. RI #62 was observed to cough and gag after each bite of food. The serving size of the pureed food was observed to be a heaping serving filling the entire standard spoon. EI #6 was observed to hold a cup of tea to the lips of RI #62, though staff were to offer thickened liquids to the resident via spoon. The resident was observed to take a drink and start coughing. EI #6 was observed to give RI #62 two to three servings of pureed food and then hold the cup of fluid to the mouth of RI #62 to take a drink. EI #6 was observed to wipe the excess food coming out of the mouth of RI #62 with the edge of the spoon and place it in RI #62's mouth while RI #62 was actively coughing. EI #6 was observed to hold the cup of fluid to the mouth of RI #62 while RI #62 was actively coughing and encouraged RI #62 to take a drink, causing RI #62 to gag and continue to cough. An interview was conducted with EI #6 on 01/25/22 at 1:10 p.m. EI #6 stated that feeding responsibilities were rotated among all assigned CNAs. EI #6 stated there was no specific training for feeding RI #62, but noted instructions were posted on the wall above the bed, which EI #6 thought directed staff to use a spoon when feeding RI #62. An observation on 01/25/22 at 1:10 p.m. of the posted signage was made with EI #6. The posted signage contained the message, Please only feed [RI #62] ½ teaspoon quantities for both drinks and food. No cups or straws please. A nursing Departmental Note, dated 01/25/22 at 1:56 p.m., revealed staff reported RI #62 was coughing with lunch. EI #6 reported that she gave the resident a rest period after coughing episodes then resumed. The nursing note contradicted the observation made by the surveyor. An interview was conducted with EI #5, a CNA, on 01/26/22 at 10:07 a.m. EI #5 stated that, when assigned to a resident that needed assistance, staff were supposed to look at the posted instructions at the head of the bed. EI #5 stated that RI #62 got small bites of food, which was just a small amount at the end of the spoon. Per EI #5, if RI #62 coughed, they waited a few minutes and tried again, but if the coughing continued then the nurse was informed immediately. EI #5 stated that signs of gagging, facial expressions, and excessive coughing were signs to stop the feeding and notify the nurse. EI #5 stated that fluids were served from the cup they arrived in, and after peeling the lid off, the cup was held to the mouth of RI #62 from which to take small sips. An interview was conducted with EI #11, a Registered Nurse (RN) Supervisor, on 01/26/22 at 10:40 a.m. EI #11 stated that RI #62 received pleasure feedings because the family wanted RI #62 to eat, and RI #62 wanted to eat as well. EI #11 stated that EI #3, a Speech Language Pathologist (SLP), had informed them that coughing during the meal was beneficial to help keep the passage clear. However, if the cough was continuous or wet, the feeding should be stopped, and nursing needed to be informed. EI #11 stated that if the resident was coughing, nothing else should be put in the mouth, and the resident needed to rest and then be asked to continue. EI #11 stated that the main goal was to make sure RI #62 was safe during the meal. EI #11 stated that EI #6 had reported the continuous coughing of RI #62 the previous day after EI #6 had completed feeding RI #62. An observation of the lunch meal on 01/26/22 at 12:21 p.m. revealed EI #11 was feeding RI #62. EI #11 was using a standard spoon and feeding a small amount of puree at the tip of the spoon, allowing RI #62 to swallow between each bite of food. The same method was used to deliver the fluids during the meal and fluids and pureed food were alternated during the meal. There was no coughing noted during the meal. RI #62 was noted to clear their throat without coughing during the meal. An interview was conducted on 01/26/22 at 2:30 p.m. with EI #3. EI #3 stated they received a referral from nursing for RI #62 related to difficulty with the meals. EI #3 stated that the FEES report recommended small bites of solids and fluids served from a spoon for both pureed food and fluids. EI #3 stated that the posted signage was correct, and that no cups or straws should be used during the meal because there was no control of the portion consumed. EI #3 stated that coughing was beneficial and could help clear the throat. However, EI #3 noted that RI #62 should be monitored for signs and symptoms of aspiration. An interview was conducted with EI #14, a Registered Dietitian (RD), on 01/26/22 at 2:50 p.m. EI #14 stated RI #62 had swallowing problems and required total assistance with meals and depended on the staff to provide this care. An interview with EI #1, the Administrator, was conducted on 01/27/22 at 9:20 a.m. EI #1 stated it was their expectation that staff followed the diet orders for every resident and reported any problems to the nursing staff, who would then follow up with either an RD or SLP. An interview was conducted with EI #2 on 01/27/22 at 10:30 a.m. EI #2 stated that staff were to follow physician and SLP therapy orders, and staff were expected to report any problems or concerns to nursing staff, who would then follow up with an SLP, RD, or physician. 2.) The facility admitted RI #48 on 09/27/18 and RI #48 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #48's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #48's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 11/13/20, indicated a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS also indicated RI #48 ate independently with set-up help. A review of RI #48's Care Plan, with a problem onset date of 09/27/18, indicated the resident was at risk for impaired nutrition and hydration related to issues including a history of [CONDITION(S)] ([CONDITION(S)]) and had a self-care deficit related to [CONDITION(S)] with left-sided [CONDITION(S)] (paralysis of half of the body). Interventions included Requires supervision with meals and Provide assistance with ADL's. A nursing Departmental Note, documented as written on 12/20/21 at 10:41 p.m. by Employee Identifier (EI) #15, Licensed Practical Nurse (LPN), indicated RI #48 was noted to be holding food in their mouth upon giving the resident their 4:00 p.m. medications. Per the note, RI #48 swallowed the remaining food when drinking fluids. A Speech Therapy Functional Maintenance Plan (FMP), with a run date of 01/11/21, indicated the patient presented with swallowing deficits, including pocketing, with recommendations to provide minimal verbal and visual cueing as needed to take one sip from a cup rim after one to two bites to improve oral clearance. Recommendations also included providing instruction and demonstration to use swish and swallow as needed at the end of meals to completely clear the oral cavity. A ST [Speech Therapy] - Therapist Progress & Discharge Summary, dated 01/15/21, indicated therapy staff designed and implemented a functional maintenance program with caregiver education provided. The summary identified recommendations including providing verbal and visual cueing frequently to promote self-feeding during meals and providing verbal instruction to use one-to-one cyclic ingestion and/or swish-and-swallow technique to facilitate oropharyngeal clearance at meals to improve airway safety. A review of RI #48's Completed Care Tasks, which showed ADL task documentation, revealed the resident ate independently with no setup or physical help from staff on 01/20/22 and ate independently after setup help on 01/21/22, 01/22/22, 01/23/22, 01/24/22 at 8:39 p.m., 01/25/22, and 01/26/22. Extensive one-person physical assistance was documented as required for RI #48 while eating on 01/24/22 at 11:48 a.m. A nursing Departmental Note, documented as written on 01/26/22 at 3:40 p.m. by EI #11, a Registered Nurse (RN) Supervisor, revealed that RI #48 was pocketing food at lunch and staff on the following shift were made aware to observe the resident during meals. A nursing Departmental Note, documented as written on 01/26/22 at 3:31 p.m. by EI #10 , LPN, revealed RI #48 had a large amount of food in their mouth and EI #10 had RI #48 take several sips of water before the resident was able to clear their mouth completely. On 01/25/22 at 12:28 p.m., observation revealed RI #48 had a lunch tray on an overbed table. While speaking with the resident, the surveyor identified that RI #48 had food in their mouth that they had not swallowed. On 01/25/22 at 1:13 p.m., RI #48 was observed in their room. The lunch tray had been removed. While speaking with the resident, the surveyor identified that RI #48 had food in their mouth that they had not swallowed. On 01/26/22 at 2:42 p.m., RI #48 was observed in their room. The lunch tray had been removed. While speaking with the resident, the surveyor identified that RI #48 had food in their mouth that they had not swallowed. During an interview on 01/26/22 at 2:49 p.m., EI #4, a Certified Nursing Assistant (CNA), said that RI #48 required set up and encouragement during meals. EI #4 said some people assisted RI #48 to finish eating and that RI #48 did fine swallowing their food, but would sometimes pocket food. EI #4 said that when RI #48 pocketed food, the resident needed to be encouraged to chew it up and wash it down. During a concurrent observation and interview on 01/26/22 at 2:54 p.m., EI #10 stated RI #48 required setup, supervision, and cueing when eating. EI #10 observed RI #48 with pocketed food in their mouth. EI #10 assisted RI #48 with clearing their mouth with cueing. During an interview on 01/26/22 at 3:04 p.m., EI #11 stated RI #48 would be assigned a CNA for assistance during meals, noting CNAs were currently supposed to provide supervision during meals. During an interview on 01/27/22 at 10:11 a.m., EI #10 stated that if residents required assistance following discharge from therapy, an FMP would be developed for restorative therapy. Per EI #10, if there were recommendations to be carried out on the floor, an order would be placed, which would be communicated to CNAs from therapy staff. During an interview on 01/27/22 at 10:55 a.m., EI #2, the Director of Nursing (DON), stated that when there were therapy recommendations, the nurses received communication and an order was entered. The DON stated the nursing staff were responsible to ensure orders were carried out. During an interview on 01/27/22 at 11:04 a.m., EI #3, Speech Language Pathologist (SLP), stated that if residents were appropriate for an FMP, one was put in place. EI #3 stated the nursing staff monitored staff to ensure the FMP was carried out. EI #3 clarified she had not worked with RI #48 and was not personally involved in the development of RI #48's FMP based on her hire date. EI #3 stated that, once staff were trained to implement an FMP, SLP staff did not conduct routine monitoring of facility staff's implementation of the FMP. During an interview on 01/27/22 at 11:15 a.m., EI #1, the Licensed Nursing Home Administrator (LNHA), stated that upon discharge from therapy, when an FMP was written, the CNAs were trained on carrying it out.

Based on observations and interviews the facility failed to ensure: 1. dietary staff did not take food temperatures by sticking the thermometer through plastic wrap or foil and 2. staff dated resident's food before placing it in the unit refrigerators. This had the potential to affect 140 of 156 residents receiving meals from dietary and two of four unit refrigerators. 1. The following observations were made on [DATE] of the lunch tray line service: At 11:15 a.m., of the tray line service. EI (Employee Identifier) #2 was observed taking the temperature of the black forest cake by placing the thermometer through the plastic wrap covering and into the cake. At 12:08 p.m., more cake was brought out and the temperature was taken of the cake by EI #3. EI #3 was observed taking the temperature by sticking the thermometer through the plastic wrap and into the cake. At 12:12 p.m., a second pan of chicken and dumplings was brought out to the tray line. EI #3 took the temperature of the chicken by sticking the thermometer through the foil wrapping. An interview was conducted on [DATE] at 10:20 a.m, with EI #2, Dietary Aide. EI #2 was asked how temperatures of the food should be taken. EI #2 replied, you take the thermometer and stick it into the biggest part of your food and hold it until it stops, then take it out and wipe it with an alcohol pad. EI #2 was asked, how did she take the temperature of the cake on [DATE]. EI #2 replied, she took the thermometer and stuck it towards the middle of the cake. EI #2 was asked, should she stick a thermometer through plastic wrap to take a temperature. EI #2 replied, no. EI #2 was asked, did she stick the thermometer through the plastic wrap when taking the temperature of the cake on [DATE]. EI #2 replied, she did not think she unwrapped it. EI #2 was asked, did you stick the thermometer through the plastic wrap. EI #2 replied, yes she did. EI #2 was asked, what was the potential concern, of taking the temperature of food, by sticking the thermometer through the plastic wrap. EI #2 replied, the outside of the wrap was probably not clean. On [DATE] at 10:26 a.m., an interview was conducted with EI #3, Dietary Aide. EI #3 was asked how temperatures of the food should be taken. EI #3 replied, with a calibrated thermometer. EI #3 was asked, should you stick a thermometer through plastic wrap to take a temperature. EI #3 replied, no. EI #3 was asked, should you stick a thermometer through foil to take a temperature. EI #3 replied, no. EI #3 was asked, did she stick the thermometer through the plastic wrap when taking the temperature of the cake on [DATE]. EI #3 replied, yes. EI #3 was asked, did she stick the thermometer through foil to take the temperature of chicken and dumplings on [DATE]. EI #3 replied, yes. EI #3 was asked, what was the potential concern of taking the temperature of food by sticking the thermometer through the plastic wrap. EI #3 replied, it could probably get stuck in there and caught in the food. EI #3 was asked, what was the potential concern of taking the temperature of food by sticking the thermometer through the foil. EI #3 replied, foil could get trapped in the food. On [DATE] at 10:30 a.m., an interview was conducted with EI #1, Dietary Manager. EI #1 was asked, should the temperature of food be taken by sticking a thermometer through plastic wrap or foil. EI #1 replied I guess we were not supposed to. EI #1 was asked, what was the potential concern of the temperature being taken by sticking the thermometer through plastic wrap or foil. EI #1 replied, cross contamination. 2. The USDA Food Code (YEAR) specifies regarding the labeling of food items: ,[DATE].17 Ready -to- Eat, Time/Temperature Control for Safety Food, Date Marking . Commercially processed food * open and hold cold . (D) A date marking system that meets the criteria . (3) Marking the date or day . with a procedure to discard the Food on or before the last date or day by which the Food must be consumed on the premises, . or discarded . On [DATE] at 08:36 a.m., during a tour of the Unit Three refrigerators with EI #4, RN Supervisor, an observation was made of a container from (name of deli) with a creamy, soupy substance in it with a resident's name and room number written on it, but no date. On [DATE] at 08:44 a.m., during tour of the Unit Four refrigerator with EI #5, RN, observed was a plastic bag with a food container of BBQ labeled with the name and room number of a resident, but no date. Also observed was two bags from (fast food eatery's) and a pizza box containing two slices of pizza, none of these items observed in the refrigerator had a name or date. On [DATE] at 10:10 a,m., an interview was conducted with EI #4. EI #4 was asked who was responsible for checking the unit refrigerators for expired foods. EI #4 replied, the Eleven to Seven shift. EI #4 was asked, how were foods supposed to be labeled. EI #4 replied, they should be labeled with the name and the date. EI #4 was asked, how many days could a food item remain in the refrigerator. EI #4 replied, three days if opened. EI #4 was asked, were any food items found in the refrigerator on [DATE] on Unit Three without a date. EI #4 replied, yes. EI #4 was asked, what was the potential concern of an item not being dated. EI #4 replied, that somebody unknowingly would feed it to a resident and it would have passed the expiration date. On [DATE] at 10:14 a.m., an interview was conducted with EI #5. EI #5 was asked, who was responsible for checking the unit refrigerators for expired foods. EI #5 replied, usually night shift but they all check them. EI #5 was asked, how were foods supposed to be labeled. EI #5 replied, with a name and a date on them. EI #5 was asked, how many days could a food item remain in the refrigerator. EI #5 replied, usually, they do not like to leave it in there more than four to five days. EI #5 was asked, were any food items found in the refrigerator on [DATE] on Unit Four without a date. EI #5 replied, yes a couple of things. EI #5 was asked, what was the potential concern of an item not being dated. EI #5 replied, maybe a resident getting a hold of something outdated or spoiled. On [DATE] at 10:30 a.m., an interview was conducted with EI #1, Dietary Manager. EI #1 was asked, who was responsible for checking the unit refrigerators for expired foods. EI #1 replied, the nurses. EI #1 was asked, how were foods supposed to be labeled. EI #1 replied, the date and the expiration date. EI #1 was asked, how many days could a food item remain in the refrigerator. EI #1 replied, it depended on what it was. EI #1 was asked, what was the potential concern of an item not being dated. EI #1 replied, spoilage or contamination.

Based on observations, interviews, record reviews, review of the Potter and Perry, Fundamentals of Nursing, Ninth Edition, and review of facility policies titled, OXYGEN ADMINISTRATION, METERED DOSE INHALER ADMINISTRATION PR[NAME]EDURE and USING GLOVES, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not reapply Resident Identifier(RI) #88's nasal cannula after it was found on the floor under RI #88's bed, 2. a.) RI #89's oxygen tubing was dated, b.) a Licensed Practical Nurse (LPN) cleaned RI #89's inhaler after administration and before storing it in the medication cart, and 3. an LPN changed her gloves and washed her hands after touching potentially contaminated objects when obtaining RI #116's finger stick blood sugar, administering RI #116's nebulizer treatment and during administration of RI #116's medications via gastrostomy tube. These deficient practices affected RI #88, RI #89 and RI #116, three of 31 sampled residents. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Unit V, Foundations for Nursing Practice, Chapter 29, Infection Prevention and Control, page 459, revealed the following: .Table 29-6, Centers for Disease Control . Standard Precautions . for Use with All Patients . Perform hand hygiene before, after, and between direct contact with patients. Perform hand hygiene after contact with . body fluids, mucous membranes, . excretions, . after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. A review of a facility policy titled, OXYGEN ADMINISTRATION, Revised: 12-17, documented: . VI. Follow up phase: . 3. Change humidifier bottle and O2 (oxygen) tubing weekly . A review of a facility policy titled, METERED DOSE INHALER ADMINISTRATION PR[NAME]EDURE, Revised: 04-01, revealed: Purpose: .VIII. Dry the mouthpiece and always replace cap . IX. Rinse the inhaler with warm water . A review of a facility policy titled, USING GLOVES, Reviewed: 11-16, documented: . IV. When to Use Gloves . C. Wash hands immediately after removing gloves to prevent cross-contamination with organisms, which could have passed through a defect in the gloves to the hands. D. Gloves must be changed as indicated between care procedures and treatments provided to the same resident . 1.) RI #88 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #88's medical record and document titled, Physician order [REDACTED]. .OXYGEN AT 2 LITERS PER MINUTE AS NEEDED FOR O2 SAT (Saturation) LESS THAN 90% . On 05/14/19 at 10:49 a.m., the surveyor observed RI #88's oxygen tubing on the floor under the bed with the 02 (oxygen) concentrator running. Resident asked surveyor to pick up tubing. Surveyor told resident she would get a staff member. Surveyor went out in hallway and asked a Certified Nursing Assistant (CNA) if she could help the resident. CNA into room and resident asked her to get oxygen tubing. The CNA was observed picking the nasal cannula with attached tubing up from the floor under the resident's bed and putting it in place for the resident at that time. On 05/16/19 at 8:51 a.m., an interview was conducted with Employee Identifier (EI) #13, CNA. EI #13 was asked, where was RI #88's oxygen tubing when she assisted him/her on 05/14/19. EI #13 said on the floor under the bed. EI #13 was asked what did she do when she found it on the floor. EI #13 stated she picked it up and put it back on, the resident. EI #13 was asked what was the concern with anything from the floor being given back to or placed on a resident. EI #13 answered, the floor has germs. 2.) RI #89 was readmitted [DATE], with [DIAGNOSES REDACTED]. a.) A review of RI #89's medical record and document titled, Physician order [REDACTED]. .OXYGEN AT 2.5 LITERS PER MINUTE VIA NASAL CANNULA ROUTINELY . Further review of RI #89's medical record revealed RI #89's Respiratory Care Plan with the following intervention: .Change oxygen tubing weekly . The following observations were documented by the surveyor: 05/14/19 10:16 AM Resident had O2 infusing at 2 L/M via nasal cannula from concentrator. There is no date noted on the tubing. 05/15/19 09:37 AM Oxygen tubing still not dated at this time. 05/16/19 08:59 AM Oxygen tubing still not dated at this time. EI #14, Director of Nursing was asked to accompany surveyor to room to look at tubing and confirmed that no date was on the tubing. EI #14 confirmed there was no date on the tubing. The policy provided by EI #14 revealed the tubing was to be changed weekly. b.) EI #6, LPN, was observed administering RI #89's Atrovent Inhaler on 05/15/19 at 3:05 p.m. and replacing the cap on the inhaler's mouthpiece without wiping or cleaning the inhaler and storing it in the medication cart drawer. On 05/16/19 at 11:13 a.m., a telephone interview was conducted with EI #6, LPN. EI #6 was asked, what should she do before recapping and storing an inhaler in the medication cart. EI #6 said, clean off the mouthpiece. EI #6 was asked if she cleaned off RI #89's mouthpiece after she administered RI #89's inhaler. EI #6 replied no. EI #6 was asked should she have, she replied yes. EI #6 was asked what was the concern with not cleaning the mouthpiece before recapping the inhaler. EI #6 answered, germs and contamination. 3. RI #116 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 05/15/19 at 3:31 p.m., EI #11, LPN, was observed administering RI #116 medications. The surveyor made the following observations of EI #11: 1. opened door of room and out to cart to get cups for water, back into room, gloves on without washing hands after touching door knob; 2. gloves on, nebulizer mask taken out of bag, bed height adjusted via control on rail while wearing gloves, both vials of medication poured into reservoir and mask attached, mask placed on resident with band around head, nebulizer machine turned on; 3. while wearing same gloves, piston syringe taken out of plastic bag, 30 cc water drawn up, pump placed on hold, syringe placed in tube and water administered; 4. more water obtained from faucet to make 30 cc's (cubic centimeter) of water in meds, wearing same gloves used to turn faucet on and off, gloved finger over tip of syringe and plunger shaken to mix medications, and 5. while still wearing the same gloves, rinsed syringe in sink and dried with paper towels and placed syringe in plastic bag, On 05/15/19 at 6:03 p.m., an interview was conducted with EI #11, LPN. EI #11 was informed of the surveyor's observations during RI #116's medication pass provided by EI #11. EI #11 was asked when should she wash her hands and change gloves. EI #11 said before she started any task, when she removed gloves, between procedures and when she contaminated them. EI #11 was asked what was the concern with not changing gloves and washing her hands as stated in the observations. EI #11 answered, contamination and risk for infection. On 05/16/19 at 11:52 a.m., an interview was conducted with EI #12, Registered Nurse/Infection Control. EI #12 was asked, when should a nurse wash her hands and change her gloves when administering medications. EI #12 said, prior to and anytime they touch anything potentially contaminated in the room and before they leave the room. EI #12 was asked, should a nurse wear the same gloves after touching a door knob, faucet, and bed control when administering medications via tube and/or set up a nebulizer treatment for [REDACTED].#12 replied, no, she should wash her hands and change her gloves because she was touching something potentially contaminated. EI #12 was asked, when should oxygen tubing be changed. EI #12 stated, weekly, if they go out, if it touches the floor and anytime it was contaminated. EI #12 was asked, should medications be mixed in the syringe with the tip of the syringe covered by gloves worn while touching potentially contaminated objects. EI #12 said, no. EI #12 was asked, what was the concern with touching potentially contaminated objects and administering medications without changing gloves and washing hands. EI #12 answered, they are potentially carrying whatever potential contamination to the resident getting the medication and with a gastrostomy tube it was direct contamination because when they touch the tip of the syringe it goes straight into the tube.

Based on interviews, observations and a facility's document titled FEEDING THE IMPAIRED RESIDENT, the facility failed to ensure Resident Identifier (RI) #406 did not wait thirty minutes to receive assistance with the dinner meal on 05/14/2019. This deficient practice affected one out of five sample residents who required assistance with feedings Findings include: A facility document titled, FEEDING THE IMPAIRED RESIDENT, revealed: . Residents are assisted, as needed, to consume each meal so adequate nutrition is provided. III. SPECIAL POINTS D. Charge nurses are to supervise the feeding of residents to ascertain that all residents are fed in a timely fashion in order to meet individual needs of each resident . RI (Resident Identifier) #406 was admitted to the facility on [DATE]. RI # 406 [DIAGNOSES REDACTED]. A review of RI #406's care plans included needing assistance with eating, date 4/30/19. On 05/14/19 at 06:00 pm, Surveyor observed, RI #406 sitting in the wheel chair in resident's room, with a dinner meal tray on the bedside table on a tray with a dome cover removed and lying on the bed. RI #406 reported, He/she was waiting on someone to help them eat. At 06:15 pm, Surveyor made a second observation of RI #406 sitting in the wheel chair in room with meal tray sitting on the bedside table. On 05/14/19 at 06:18 pm, Surveyor interviewed Employee Identifier (EI) #6, Licensed Practical Nurse (LPN) Supervisor. Surveyor asked EI# 6, how long did residents have to wait to eat their meals once they are delivered, if they need assistance. EI #6 replied, no more than five or ten minutes. Surveyor asked EI #6, had she known of residents waiting longer than five or ten minutes for assistance with their meals. EI# 6 replied, no ma'am. Surveyor asked EI# 6, did RI #406 require assistance with meals. EI# 6 replied, yes ma'am. Surveyor asked EI #6, did she know how long RI #406 had been waiting for assistance. EI# 6 replied, not that day. Surveyor asked EI# 6, what was the harm with a resident waiting for meal assistance. EI# 6 replied, the food would get cold, RI #406 was probably hungry and RI #406 would probably get a little upset. Surveyor asked, whose responsibility was it to ensure RI #406 received assistance with meals in a timely manner. EI #6 replied, it's all the staffs responsibility. The Certified Nursing Assistant that delivered the tray should ensure everything was ready for a resident to eat. On 05/14/19 at 06:26 pm, Surveyor made a third observation with EI #6 of RI #406 sitting in the wheel chair with dinner meal on the bedside table. RI #406 was waiting on assistance with the dinner meal. No food had been eaten or disturbed. Surveyor observed, the call light in resident's room. At 06:30 pm, EI#7, RN, entered RI #406's room and asked if the resident was ready to eat. On 05/15/19 at 03:27 pm, Surveyor interview with EI #7. Surveyor asked EI #7, what did she observe regarding RI #406 dinner on 5/14/19. EI #7 replied, staff reported RI #406 needed to be fed for supper. Surveyor asked EI #7, what was the facility's policy regarding delivering meal trays and residents that required assistance with meals. EI #7 replied, she thought the policy was to deliver the tray when you are ready to feed the resident and not before. Surveyor asked EI #7, did she observe RI # 406's dinner tray sitting on the bedside table uncovered and untouched. EI #7 replied, she did. Surveyor asked EI #7, did she see RI #406's call light on when she entered the room to assist with her dinner meal on 5/14/19. EI #7 replied, she did, she knew that was probably why the call light was on at that time. Surveyor asked EI #7, who delivered the dinner tray to the resident's room on 5/14/19. EI #7 replied, EI #8. Surveyor asked, who was responsible for ensuring residents were fed in a timely manner. EI #7 replied, the LPN Supervisor. Surveyor asked EI #7, did she consider thirty minutes, or more, a timely manner to receive assistance with a meal after it was delivered and uncovered. EI #7 replied, she thought that was too long. It was going to be ice cold. Surveyor asked EI #7, what was the potential harm when a resident waited thirty minutes for assistance with a meal that was delivered and uncovered. EI #7 replied, the food would be cold for sure and then they would not eat it. Eventually, weight loss if it continued. Surveyor asked, could RI #406 feed his/herself. EI #7 replied, no ma'am, not even a cracker. Surveyor asked, were both Resident # 406 's hands contracted. EI# 7 replied, yes they were. Surveyor asked, who fed RI #406 dinner meal on 5/14/19. EI #7 replied, she did. Surveyor interviewed with EI #8 on 05/15/19 at 04:33 pm. Surveyor asked EI #8, did she deliver a dinner tray to RI #406 on 5/14/19. EI #8 replied, yes she did. Surveyor asked EI #8, did she remove the dome cover over the plate and place it on the bed in the room. EI #8 replied, yes she did. Surveyor asked EI #8, what time was that. EI# 8 replied, she had no idea. Surveyor asked EI #8, what time were the dinner trays normally delivered to residents on the hall. EI #8 replied, on her unit where she worked it was about five thirty. Surveyor asked EI #8, did she deliver meal trays on her unit. EI #8 replied, no ma'am she was pulled to this unit yesterday. Surveyor asked EI #8, what was the facility's policy regarding residents that required assistance with meals. EI #8 replied, you wait till all the trays are out and then feed the feeders. Surveyor asked EI #8, did she deliver the meal tray to resident's that required assistance without assisting with the meal. EI #8 replied, no. Surveyor asked EI #8, how did the facility inform staff of resident's needs. EI #8 replied, through the patients charts and the nurse will notify you if they have special needs. Surveyor asked, did she look at RI #406's chart before delivering the resident's dinner meal tray on 5/14/19. EI #8 replied, no she did not. Surveyor asked, did the nurse notify her of the resident's. EI# 8 replied, no because the resident was not on her assignment. Surveyor asked EI # 8, whose responsibility was it to find out which resident's required assistance with meals. EI #8 replied, it was the CNA's responsibility. Surveyor asked EI # 8, hers. EI #8 replied, yes. Surveyor asked EI #8, did she know how long RI #406 waited with the meal delivered and uncovered, for assistance. EI# 8 replied, no. Surveyor asked, would she consider the resident waiting thirty minutes to be assisted with a dinner meal delivered and uncovered, in a timely manner or acceptable. EI #8 replied, no. Surveyor asked EI #8, what was the potential harm with a resident waiting thirty minutes to be assisted with their meal after being delivered and uncovered to their room. EI #8 replied, it was cold and who wants cold food. EI #8 stated, she did not. EI #8 further stated, RI #406 could have been hungry.

Based on observations, interview, medical record review and a facility's policy titled, COLOR CODES/LABELING, the facility failed to ensure the spine of the medical chart and the end of the bed for RI (Resident Indentifer) #405 had the correct code status label. This deficient practice affected one out of 30 sampled residents. Findings include: A review of a facility's document titled, COLOR CODES/LABELING, with a revised date of 03-10 revealed: .I. Chart back will be labeled on the spine of the chart to indicate whether resident a full code or DNR. A. Black (label) No Code B. Red (label) Full Code . III. Procedure: . B. The color on the chart label should match the code status . D. Full code residents are to have their name and MD (Medical Doctor) name on the foot of the bed in red. RI # 405 was readmitted the facility on 5/15/19. On 05/15/19 at 08:15 am, a review of RI # 405 medical records revealed, a form titled Alabama Board of Health Administration Code . Appendix II Alabama Portable Physician Do Not Attempt Resuscitation (DNR). The form was signed and dated 5/1/19 by the RI #405 and signed by the Physician on 5/2/19. Surveyor asked EI #9 (Employee Identifier) Registered Nurse, how did the staff know what the code status was of RI #405. EI #9 replied, the label that was on the end of the bed and the spine that was on the end of the chart. Surveyor asked EI #9, what was the difference in the labels and spines for full code and DNR (Do Not Resuscitate) status. EI #9 replied, the color of them. Surveyor asked EI #9, what color label was on the spine of RI #405 chart. EI #9 replied, white with red writing. Surveyor asked EI #9, what code status did white with red writing represent. EI #9 replied, a full code. Surveyor asked EI #9, was RI #405 a full code. EI #9 replied, no, RI #405 was a DNR. Surveyor asked EI #9, was RI #405's chart labeled wrong. EI #9 replied, yes. Surveyor asked EI #9, what was the potential harm of the wrong code status label on RI# 405's chart and bed. EI #9 replied, coding someone that should not be coded. On 05/15/19 at 08:32 AM, Surveyor and EI #9 observed RI #405's room, including a red and white label on the end of RI #405's bed. Surveyor asked EI #9, what color writing was observed on the label on the end of the RI # 405's bed. EI #9 replied, white with red writing. Surveyor asked EI #9, what code status did that represent to the staff. EI #9 replied, full code.

Based on interview, medical record review and a review of the facility's policy titled, CHARTING AND D[NAME]UMENTATION GUIDELINES, the facility failed to ensure licensed staff documented an assessment of Resident Identifier (RI) #313's [MEDICAL CONDITION] and skin status on 05/20/18. This affected one of one sampled resident with a [MEDICAL CONDITION]. Findings Include: A review of the facility's policy titled, CHARTING AND D[NAME]UMENTATION GUIDELINES with a revised date of 04-16, revealed the following: . III. PR[NAME]ESS: a. Rules for Charting and Documentation 1. Chart all pertinent changes in the resident's condition, . as well as routine observations . 4. Chart sufficient information to identify the resident's assessments, . and services provided. 5. Document . pertinent observations . RI #313 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RI #313's Admission Minimum Data Set ((MDS) dated [DATE] revealed RI #313 had a Brief Interview for Mental Status score of 15, indicating cognition intact. A review of the facility's Departmental Notes for RI #313's revealed the following: . 5/10/2018 10:27 PM Role: Nursing . Late entry 6:00 PM Resident arrived to facility by private auto with daughter . A review of RI #313's (MONTH) (YEAR)'s Physician order [REDACTED]. 5/21/18 . Start Date 5/21/18 . Orders . [MEDICATION NAME] 0.025% (PERCENT) OINTMENT CHANGE [MEDICAL CONDITION] BAG AND WAFER EVERY DAY FOR 3 DAYS. APPLY [MEDICATION NAME] OINTMENT TO IRRITATED AREA ONLY, CLEAN SKIN GENTLY . On 05/22/18 at 9:21 AM, during initial tour, RI #313 and the resident's daughter reported to the surveyor that on Sunday, (MONTH) the 20th, the resident's [MEDICAL CONDITION] was leaking and the nurse did not clean her up. RI #313 and the resident's daughter said the stool stayed on her skin all day and no one did anything. RI #313 said the skin got irritated and the doctor had to give some medications for the irritated area. The surveyor asked who did they report this to. The resident and the daughter said to Employee Identifier (EI) #1, LPN/Licensed Practical Nurse. On 05/23/18 at 8:17 AM, during an interview with EI #2, LPN, the surveyor asked when an assessment is made what is done with that assessment information. EI #2 stated, We document if there is nothing abnormal, do a nurse's note. The surveyor asked what if there was something abnormal, or she identified an abnormal finding. EI #2 stated, We still document and we contact (name of physician) if it's skin, he is our dermatologist here, anything other than skin we contact their primary physician. The surveyor asked prior to yesterday, when did she see RI #313 and why. EI #2 stated, I had her Sunday, she was my assigned resident. The surveyor and the LPN reviewed the computerized notes and the surveyor asked where was her assessment for Sunday, (MONTH) 20, (YEAR). After reviewing the computerized notes, EI #2 stated, There is not one. The surveyor asked why not. EI #2 stated, I just didn't document. The surveyor asked should she have documented. EI #2 stated, I should have done a note, yes ma'am. The surveyor informed EI #2 that RI #313 had some issues regarding the resident's [MEDICAL CONDITION] on Sunday, and asked when was she made aware. EI #2 stated, The resident did not voice any complaints to me on Sunday. Where is the documentation for Sunday, (MONTH) 20th, to reflect the resident had no concerns regarding the [MEDICAL CONDITION]. EI #2 stated, I did not do (document) a nurses' note. The surveyor asked regarding the facility's policy for documentation, was the policy followed for this resident's [MEDICAL CONDITION]. EI #2 stated, No, ma'am.

Based on interview, medical record review and a review of Potter and Perry's FUNDAMENTALS OF NURSING EIGHT EDITION, and the facility's policy titled, ADMISSIONS, the facility failed to ensure Resident Identifier (RI) #313's [MEDICATION NAME] medication was available upon admission to the facility. This affected one of 14 residents admitted to the facility with admission orders [REDACTED] Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING EIGHT EDITION, page 584 -585, Box 31-6 PR[NAME]ESS FOR MEDICATION RECONCILIATION, revealed the following: . 22. Clarify: Make sure that the list of medications . frequencies is accurate; clarify the list with as many people as necessary ( ., patient, caregiver, health care providers. pharmacist) to ensure accuracy . Attitudes To administer medications safely . Standards . Nurses verify medication information . or when patients transfer from one nursing unit or health care setting to another . A review of the facility's policy titled, ADMISSIONS with a reviewed date of 08-15, revealed the following: . II. C. Facility must demonstration ability to meet individuals' needs and that adequate, appropriate accommodations are available . III. Prior to admission, . the following documents (signed and dated by the attending physician) available to the facility for review: . B. physician's orders [REDACTED]. Prior to admission, orders are received from the discharging facility . the orders are faxed to (Name of Pharmacy) . and will be delivered to the facility that evening. If an admission occurs after 5 PM, staff notifies (Name of Pharmacy) by phone and any medication that is needed is ordered from back up and delivered. A review of the facility's document dated 05/23/18, signed by the Infection Control/Quality Assurance, Registered Nurse/RN, Employee Identifier (EI) #5, revealed the following: It was discussed with our medical director Doctor ., about (RI #313s) daughters concern regarding a medication that she had stated (RI #313) needed but was not scheduled to be administered at the time she had questioned the nurse about it. Doctor . was informed of the medication name and the scheduled times for the medication while in our facility. Doctor . put in place a standing order for a resident or sponsor who requests a medication that is not scheduled for administration to give a one-time dose of that medication for . resident's only. All staff will be educated for any resident being admitted early to fax pharmacy and get the medication that is due from backup or pull from staff and if admitted late, still fax pharmacy and get from backup . RI #313 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RI #313's Admission Minimum Data Set ((MDS) dated [DATE] revealed RI #313 had a Brief Interview for Mental Status score of 15, indicating cognition intact. A review of the facility's Departmental Notes for RI #313's revealed the following: . 5/10/2018 10:27 PM Role: Nursing . Late entry 6:00 PM Resident arrived to facility by private auto with daughter . A review of RI #313's Post hospitalization Patient Info,Referrals,Assessments revealed the following: Referrals (name of facility Service Date: 05/10/18 . Patient to CONTINUE taking the following meds: . Pyridostigmine [MEDICATION NAME] ([MEDICATION NAME]) 60 MG (milligram) . by mouth, three (3) times per day . On 05/22/18 at 9:21 AM, during initial tour, RI #313's daughter complained the resident has a [DIAGNOSES REDACTED]. The daughter and the resident said that they reported to EI #1, Licensed Practical Nurse/LPN and that EI #1 never did come back in the resident's room. The daughter stated around one or 2 am that morning, after the resident was admitted , she went ahead and remembered the resident had the [MEDICATION NAME] medication for the [DIAGNOSES REDACTED] and she gave RI #313 one of the resident's pills herself. The daughter and the resident also said that the [MEDICATION NAME] was very important because, the levels has to be maintained and the medication needed to be given on scheduled. On 05/23/18 at 8:57 AM, during an interview with EI #4, RN/Registered Nurse Supervisor, the surveyor asked what was her responsibility. EI #4 stated, I mainly help with admission, I look at hospital referrals. The surveyor asked what did that entail. EI #4 said she looked at hospital records, history and physicals, consultations, therapy notes, medication record, to see if the facility could meet the resident's needs and if the referral is accepted and/or if the resident is admitted to the facility. The surveyor asked what about the new admission orders [REDACTED]. The surveyor asked when medications are reviewed, who ensures that the medications or anything pertinent to that patient is available. EI #4 stated, Typically the station RN carry it from there. The surveyor asked when is that done. EI #4 stated, Prior to the resident's arrival. The surveyor asked was that policy and procedure for this facility to ensure that medications and anything pertinent to that resident's admission orders [REDACTED]. EI #4 stated, Oxygen is available here, the medications are faxed before 5 o'clock pm, so they are delivered that evening, but if it was something that the resident needed prior to arrival, we have a backup, where the pharmacist is called and they get the medication and it is called in to our local pharmacy, like (name of local pharmacy). EI #4 said a nurse will run and pick the medication up, if it was something that they do not carry there in their stat box. EI #4 also said if the medication is not there, the pharmacy will get it from the back up pharmacy. The surveyor asked if a medication was not available in house, when was the back up pharmacist called and/or the information faxed to ensure the medication was available on time prior to the resident's arrival. EI #4 stated, If a patient comes in at 6 pm, and they needed a medication, if they needed it then, and we don't have it in the backup, we call the pharmacist and let the pharmacist know, we can't wait until the tote comes on the night shift, and tell them we need the medication. On 05/23/18 at 3:01 PM, during an interview with EI #1, LPN/admitting nurse, the surveyor asked what did RI #313 and the resident's daughter tell her about the resident's medications when she was admitted on [DATE]. The surveyor provided a copy of the resident's computerized medications. EI #1 stated, They were asking me about the resident's medications and what time the medications would be in. EI #1 said she explained the medications came from another county, and the weather and construction slows the medications up. EI #1 stated, The daughter said they had the resident's medications with them. The surveyor asked what medications did the family have. EI #1 stated, I did not look at them but I told the daughter if she wanted I could look at the physician's admit orders and see what the resident had ordered to see if the daughter had the medications that the physician had ordered. EI #1 said she told the daughter she would give the resident the medications, just one dose of each medication that was due for that evening, only if pharmacy had not brought the medication in. EI #1 said the pharmacy did not get in until between 9pm-10 pm. The surveyor asked which resident's personal medication did she administer. EI #1 stated, I didn't administer any of the resident's own medication. The surveyor asked what happened with the resident's [MEDICATION NAME] medication. EI #1 said, I did not even see on the MAR. The surveyor asked when did she review the physician's admission orders [REDACTED]. The surveyor provided RI #313's admission physician's orders [REDACTED]. After review, EI #1 stated, Yes, these are the orders, it was included and should be given three times a day. The surveyor asked what time should the resident have received. EI #1 stated, Our three times a day is 8, 12, and 4. The surveyor asked when did the family or the resident ask for the [MEDICATION NAME]. EI #1 stated, They did not. The surveyor asked should the dosage levels be maintained. EI #1 stated, Yes. The surveyor asked EI #1 who did she asked when was the resident last given a dose of the [MEDICATION NAME]. EI #1 stated,I didn't ask. The surveyor informed EI #1 the resident and the daughter said that EI #1 was told that the resident needed her [MEDICATION NAME]. EI #1 stated, I don't remember them telling me that. The surveyor informed EI #1 that an alert and oriented resident and a family member said that EI #1 was made aware that the resident needed the [MEDICATION NAME] medication and that she never came back with any information regarding the [MEDICATION NAME]. EI #1 stated, I did tell them that all of the resident's medication would be in between 9 and 10. The surveyor asked did the medications come in. EI #1 stated, Yes, between 9 and 10. The surveyor asked after the medications came in what did she administer and what did she tell the family. EI #1 stated, I gave (RI #313) the 2.5 [MEDICATION NAME]. On 05/23/18 at 4:17 PM, during an interview with EI #1, LPN, the surveyor asked where did she get the [MEDICATION NAME] from that she administered to RI #313. EI #1 said she borrowed it. The surveyor asked from whom and where. EI #1 stated, Off team 2, I forgot the resident's name. The surveyor asked who had given her the other resident's medication. The LPN stated, (EI #3). On 05/23/18 at 4:41 PM, during an interview with EI #3, LPN, the surveyor asked when did she give a nurse a resident's medication to give to another resident. EI #3 stated, I did for (RI #313). The surveyor asked who was the nurse that asked for the medication. EI #3 stated, (EI #1). The surveyor asked what was the policy and procedure for giving one resident's medication to another resident. EI #3 stated, It's not part of the policy. The surveyor asked why did she give another resident medication to RI #313. EI #3 stated, Because (EI #1) said that the family and the resident were upset about getting the medicines.

Based on interview, medical record review and a review of Potter and Perry's FUNDAMENTALS OF NURSING EIGHT EDITION, the facility's policies titled, ADMISSIONS, and Procedure: MEDICATION ADMINISTRATION GUIDELINES, the facility failed to ensure Resident Identifier (RI) #313 received the [MEDICATION NAME] medication upon admission to the facility. The facility further failed to ensure RI #313 did not received an unsampled resident's medication. This affected one of 14 residents admitted to the facility with admission orders [REDACTED] Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING EIGHT EDITION, page 584 -585, Box 31-6 PR[NAME]ESS FOR MEDICATION RECONCILIATION, revealed the following: . 2. Clarify: Make sure that the list of medications . frequencies is accurate; clarify the list with as many people as necessary ( ., patient, caregiver, health care providers, pharmacist) to ensure accuracy . Attitudes To administer medications safely . Standards . follow the six rights of medication administration consistently every time you administer medications. 1. The right medication . 3. The right patient . Nurses verify medication information . or when patients transfer from one nursing unit or health care setting to another . A review of the facility's procedure titled, MEDICATION ADMINISTRATION GUIDELINES with a revised date of 02-16, revealed the following: . X. Nurses must remember the 5 Rights of medication administration. Right resident . Right medication . A review of the facility's policy titled, ADMISSIONS with a reviewed date of 08-15, revealed the following: . II. C. Facility must demonstrate ability to meet individuals' needs and that adequate, appropriate accommodations are available . III. Prior to admission, . the following documents (signed and dated by the attending physician) available to the facility for review: . B. physician's orders [REDACTED]. Prior to admission, orders are received from the discharging facility . the orders are faxed to (Name of Pharmacy) . and will be delivered to the facility that evening. If an admission occurs after 5 PM, staff notifies (Name of Pharmacy) by phone and any medication that is needed is ordered from back up and delivered. A review of the facility's document dated 05/23/18, signed by Infection Control/Quality Assurance, Registered Nurse/RN, Employee Identifier (EI) # 5, revealed the following: It was discussed with our medical director, Doctor ., about (RI #313s) daughters concern regarding a medication that she had stated (RI #313) needed but was not scheduled to be administered at the time she had questioned the nurse about it. Doctor . was informed of the medication name and the scheduled times for the medication while in our facility. Doctor . put in place a standing order for a resident or sponsor who requests a medication that is not scheduled for administration to give a one-time dose of that medication for . resident's only. All staff will be educated for any resident being admitted early to fax pharmacy and get the medication that is due from backup or pull from stat and if admitted late, still fax pharmacy and get from backup . RI #313 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RI #313's Admission Minimum Data Set ((MDS) dated [DATE] revealed RI #313 had a Brief Interview for Mental Status score of 15, indicating cognition intact. A review of the facility's Departmental Notes for RI #313's revealed the following: . 5/10/2018 10:27 PM Role: Nursing . Late entry 6:00 PM Resident arrived to facility by private auto with daughter . A review of RI #313's Post hospitalization Patient Info,Referrals,Assessments revealed the following: Referrals (name of facility Service Date: 05/10/18 . Patient to CONTINUE taking the following meds: . Pyridostigmine [MEDICATION NAME] ([MEDICATION NAME]) 60 MG (milligram) . by mouth, three (3) times per day . On 05/22/18 at 9:21 AM, during initial tour, RI #313's daughter complained the resident has a [DIAGNOSES REDACTED]. The daughter and the resident said that they reported to EI #1, Licensed Practical Nurse/LPN and that EI #1 never did come back in the resident's room. The daughter stated around one or 2 am that morning, after the resident was admitted , she went ahead and remembered the resident had the [MEDICATION NAME] medication for the [DIAGNOSES REDACTED] and she gave RI #313 one of the resident's pills herself. The daughter and the resident also said that the [MEDICATION NAME] was very important because, the levels has to be maintained and the medication needed to be given on schedule. On 05/23/18 at 8:57 AM, during an interview with EI #4, RN/Registered Nurse Supervisor, the surveyor asked what was her responsibility. EI #4 stated, I mainly help with admission, I look at hospital referrals. The surveyor asked what did that entail. EI #4 said she looked at hospital records, history and physicals, consultations, therapy notes, medication record, to see if the facility could meet the resident's needs and if the referral is accepted and/or if the resident is admitted to the facility. The surveyor asked what about the new admission orders [REDACTED]. The surveyor asked when were the medications reviewed, who ensures that the medications or anything pertinent to that resident was available. EI #4 stated, Typically the station RN carry it from there. The surveyor asked when was that done. EI #4 stated, Prior to the resident's arrival. The surveyor asked was that policy and procedure for this facility to ensure that medications and anything pertinent to that resident's admission orders [REDACTED]. EI #4 stated, Oxygen is available here, the medications are faxed before 5 o'clock pm, so they are delivered that evening, but if it was something that the resident needed prior to arrival, we have a backup, where the pharmacist is called and they get the medication and it is called in to our local pharmacy, like (name of local pharmacy). EI #4 said a nurse will run and pick the medication up, if it is something that they do not carry there in their stat box. EI #4 also said if the medication was not there, the pharmacy will get it from the back up pharmacy. The surveyor asked if a medication was not available in house, when was the back up pharmacist called and/or the information faxed to ensure the medication was available on time prior to the resident's arrival. EI #4 stated, If a patient comes in at 6 pm, and they needed a medication, if they needed it then, and we don't have it in the backup, we call the pharmacist and let the pharmacist know we can't wait until the tote comes on the night shift, and tell them we need the medication. On 05/23/18 at 3:01 PM, during an interview with EI #1, LPN/admitting nurse, the surveyor asked what did RI #313 and the resident's daughter tell her about the resident's medications when RI #313 was admitted on [DATE]. The surveyor provided a copy of the resident's computerized medications. EI #1 stated, They were asking me about the resident's medications and what time the medications would be in. EI #1 said she explained the medications came from another county, and the weather and construction slows the medications up. EI #1 stated, The daughter said they had the resident's medications with them. The surveyor asked what medications did the family have. EI #1 stated, I did not look at them but I told the daughter if she wanted I could look at the physician's admit orders, and see what the resident had ordered to see if the daughter had the medications that the physician had ordered. EI #1 said she told the daughter she would give the resident the medications, just one dose of each medication that was due for that evening, only if pharmacy had not brought the medication in. EI #1 said the pharmacy did not get in until between 9pm-10 pm. The surveyor asked which resident's personal medication did she administer. EI #1 stated, I didn't administer any of the resident's own medication. The surveyor asked what happened with the resident's [MEDICATION NAME] medication. EI #1 said, I did not even see on the MAR. The surveyor asked when did she review the physician's admission orders [REDACTED]. The surveyor provided RI #313's admission physician's orders [REDACTED]. After review, EI #1 stated, Yes, these are the orders, it was included and should be given three times a day. The surveyor asked what time should the resident have received the [MEDICATION NAME]. EI #1 stated, Our three times a day is 8, 12, and 4. The surveyor asked when did the family or the resident ask for the [MEDICATION NAME]. EI #1 stated, They did not. The surveyor asked should the dosage levels be maintained. EI #1 stated, Yes. The surveyor asked EI #1 who did she ask when was the resident last given a dose of the [MEDICATION NAME]. EI #1 stated,I didn't ask. The surveyor informed EI #1 the resident and the daughter said that EI #1 was told that the resident needed her [MEDICATION NAME]. EI #1 stated, I don't remember them telling me that. The surveyor informed EI #1 that an alert and oriented resident and a family member said that EI #1 was made aware that the resident needed the [MEDICATION NAME] medication and that she never came back with any information regarding the [MEDICATION NAME]. EI #1 stated, I did tell them that all of the resident's medication would be in between 9 and 10. The surveyor asked did the medications come in. EI #1 stated, Yes, between 9 and 10. The surveyor asked after the medications came in what did she administer and what did she tell the family. EI #1 stated, I gave (RI #313) the 2.5 [MEDICATION NAME]. On 05/23/18 at 4:17 PM, during an interview with EI #1, LPN, the surveyor asked where did she get the [MEDICATION NAME] from that she administered to RI #313. EI #1 said she borrowed it. The surveyor asked from whom and where. EI #1 stated, Off team 2, I forgot the resident's name. The surveyor asked was that policy and procedure. EI #1 stated,No. The surveyor asked why did she give RI #313 another resident's medication. EI #1 stated, Because (RI #313) was wanting (the) medicines. The surveyor asked was policy and procedure followed for administering correct resident's medication, five rights for medication administration. The LPN stated, No. The surveyor asked who had given her the other resident's medication. The LPN stated, (EI #3). On 05/23/18 at 4:41 PM, during an interview with EI #3, LPN, the surveyor asked when did she give a nurse a resident's medication to give to another resident. EI #3 stated, I did for (RI #313). The surveyor asked who was the nurse that asked for the medication. EI #3 stated, (EI #1). The surveyor asked what was the policy and procedure for giving one resident's medication to another resident. EI #3 stated, It's not part of the policy. The surveyor asked why did she give another resident medication to RI #313. EI #3 stated, Because (EI #1) said that the family and the resident were upset about getting the medicines. The surveyor asked what was the nursing standard regarding that issue. EI #3 stated, Don't use anyone else medications. The surveyor asked meaning what. EI #3 stated, I only used what is prescribed for that particular resident.

Based on observations, interviews, record reviews, and review of policies Medication Administration, Isolation Precautions and Using Gloves, the facility failed to ensure: 1. Licensed staff did not pour liquid potassium chloride back in the medication bottle when she was preparing medication for Resident Identifier (RI) #15, and licensed staff did not use a feeding syringe to administer medications by Gastrostomy that she had dropped on the resident's clothing two times. This was observed on 4/5/17 and affected one of one residents observed receiving medications by tube; 2. an activity staff failed to follow contact isolation precautions when she entered RI #16's room for one on one activities; and 3. staff failed to wash their hands after removing soiled gloves and before putting on clean gloves. This was observed on 4/6/17 during the provision of catheter care for RI #9. This affected one of 2 residents sampled with catheters. Findings Include: 1. A review of Potter and Perry's Fundamentals of Nursing Chapter 31 Medication Administration page 614 revealed, . j. Prepare liquids: . (3) Place medication cup at eye level .Fill to desired level . (4) Discard any excess liquid . A review of RI #15's Physicians Orders for April 2017 revealed Potassium Chloride 20 MEQ (milliequivalents) give 15 ml (milliliters) per tube daily . RI #15 was readmitted to the facility 3/20/17 with a [DIAGNOSES REDACTED]. On 4/5/17 at 8:20 a.m., Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN), was observed preparing medications for RI #15. Medications included liquid Potassium Chloride 15 ml. EI #2 poured too much into the medication cup then poured the overage back into the medication bottle. EI #2 then went into RI #15's room to give the medication by gastrostomy tube using a feeding syringe. On two occasions, while administering the medications by tube, EI #2 dropped the barrel of the syringe on the resident's clothing then picked it up and continued to give the medications to RI #15. On 4/5/17 at 12:30 p.m., an interview was conducted with EI #2, LPN. EI #2 was asked what was the policy on pouring liquid medication back into the bottle if too much was poured out. EI #2 replied it should be wasted. EI #2 was asked if she poured the excess back into the bottle; she replied yes. EI #2 was asked what was the potential for harm in pouring the excess back into the bottle. EI #2 replied there could be germs and then the bottle of medication could be contaminated. EI #2 was asked what was the policy for using a syringe that had dropped on the resident's clothing while giving medications by tube. EI #2 replied should not use a syringe that touched the resident's clothing, it should have been disposed of. EI #2 was asked what was the harm in using a syringe that had been dropped onto resident items and clothing, then administering medications. EI #2 replied, germs from the resident's clothing could get into the resident. On 4/6/17 at 8:10 a.m., an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked when should a nurse pour liquid medication back in the medication bottle. EI #3 replied never. EI #3 was asked what was the potential for harm in a nurse pouring excess medication back in the medication bottle. EI #3 replied it could be put in the wrong bottle and mix medications; also, it could contaminate the medication in the bottle. EI #3 was asked if a nurse should use a feeding syringe that was dropped on the resident then picked it up and continued giving the medication to the resident. EI #3 replied no. EI #3 was asked what would the potential for harm be in a nurse using a syringe that had been dropped on the resident's clothing then used to give medications. EI #3 replied it could contaminate the medications. 2. A review of facility policy titled, ISOLATION PRECAUTIONS, with a revised date of 10-16, revealed, I. Transmission-Based Precautions will be initiated when there is indication that a resident has an infectious or communicable disease. V. Contact Precautions . B. Gloves must be applied immediately upon entering the room . RI # 16 was readmitted to the facility 4/30/10 with [DIAGNOSES REDACTED]. On 4/5/17 at 10:00 a.m., an observation was made of EI #4, Activity Aide, entering RI #16's room to provide one-on-one activities. EI #4 was observed providing activities to include giving RI #16 some fluids from a cup while touching the straw with her bare hands. EI #4 did not put on gloves while in RI #16's room. On 4/5/17 at 10:35 a.m., an interview was conducted with EI #4. She was asked if RI #16 was on contact isolation. EI #4 replied yes, however, she did not know for what. EI #4 was asked if she put on protective equipment and she replied no. EI #4 was asked why she did not put on the protective equipment. EI #4 replied she just did not think about it. EI #4 was asked what was the harm in not following the isolation precautions. EI #4 replied she could carry the germs to herself then to other residents. EI #4 was asked when should she practice isolation procedures. EI #4 replied any time she went into a room that the resident was on isolation. On 4/6/17 at 8:10 a.m., an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked who should wear gloves when entering the room of a resident that was on isolation precautions. EI #3 replied everyone; anyone going in the room. EI #3 was asked if an activity aide should be performing one on one activity, to include giving the resident a drink from a cup, to a resident on contact isolation without wearing gloves. EI #3 replied no. EI #3 was asked what was the harm in staff not wearing gloves while assisting a resident on isolation precautions. EI #3 replied there was the risk for passing the infection to themselves as well as others as they leave that room. 3. A review of facility policy titled, .Using Gloves . revealed the following: .E. Wash hands after removing gloves . RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/24/2017, assessed RI #9 as being severely impaired for decision making and total dependence of one person assist for personal hygiene support. On 04/06/2017 at 8:50 a.m., an observation was made of EI #7, a Certified Nursing Assistant (CNA), performing catheter care on RI #9. EI #7 completed the final cleaning of the catheter tubing removed her gloves and regloved to apply RI #9's brief without washing her hands. On 04/06/2017 at 9:08 a.m., an interview was conducted with EI #7. EI #7 was asked what was she trained to do after removing soiled gloves. EI #7 stated, Wash my hands. EI #7 was asked if she had washed her hands after removing her gloves. EI #7 replied, No I didn't. EI #7 was asked what was the risk in not washing hands after removing gloves. EI #7 replied, Contamination. On 04/06/2017 at 11:05 a.m., an interview was conducted with EI # 3, Infection Control Nurse. EI #3 was asked what was staff trained to do after removing soiled gloves. EI #3 stated Wash their hands. EI #3 was asked what was the risk in not washing hands after removing gloves. EI #3 said bacteria could get on their hands and be carried to other residents or staff.

Based on observations, interviews, and a record review of a facility policy on Medication Storage in the Facility, the facility failed to ensure: 1. A red locked tackle box containing controlled medications in the refrigerator on Station 4 was permanently affixed in the refrigerator. This affected one of two stations observed for drug storage on 04/05/17 and 04/06/17. 2. Three intravenous antibiotic medication containers of Ceftriaxone (Rocephin) in refrigerator on Station 4 had not expired. This affected one of two stations observed for drug storage on 04/05/17 and 04/06/17. Findings Include: A review of a facility policy titled MEDICATION STORAGE IN THE FACILITY, with an effective date of July 1, 2009 revealed the following: . STORAGE OF MEDICATIONS .Procedures . M. Outdated .containers .are immediately removed from stock, disposed of according to procedures for medication disposal . On 04/05/2017 at 4:50 p.m., an observation accompanied by Employee Identifier (EI) #5, Licensed Practical Nurse (LPN) Supervisor, was made of the refrigerator in the medication room on Station 4. A red tackle box with a lock on it was noted in the refrigerator. EI #5 removed the box from the refrigerator and set it on the medication room counter so the contents could be observed. EI #5 removed from the box three vials of Lorazepam (Ativan), a controlled medication. The red locked tackle box was not permanently affixed to the refrigerator. An observation of a brown plastic bag was noted in the refrigerator. EI #5 removed the brown plastic bag which contained three intravenous antibiotic medication containers of Ceftriaxone (Rocephin), each with an expiration date of 01/27/17. On 04/05/2017 at 5:30 p.m., an interview was conducted with EI #6, Registered Nurse (RN) Supervisor. An observation accompanied by EI #6 was made of the refrigerator in the medication room. EI #6 was asked to retrieve the brown plastic bag which contained three intravenous antibiotic medication containers of Ceftriaxone (Rocephin) which had expired. EI #6 was asked why the expired medications were still in the refrigerator. EI #6 replied she did not notice them earlier when she was checking the refrigerator. EI #6 was asked what was the facility's policy on expired medications. EI #6 said they write them up then give them to the Director of Nursing, EI #1. The DON, another nurse and the pharmaceutical consultant then destroy them. EI #6 was asked what would be the risk in having expired medications in the refrigerator. EI #6 replied there was a potential problem if they were used they would be potentially harmful to the resident. On 04/06/2017 at 12:21 p.m., an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked what was the facility's procedure on expired medications. EI #1 replied the 11 pm-7 am nursing staff LPNs do a match back weekly to check all medications on the units to ensure they were within date, when one was found to be expired it would be pulled. EI #1 was asked should a lock box in the refrigerator containing controlled medication be removable. EI #1 replied it should be affixed to the refrigerator. EI #1 was asked what the risk would be in having expired medications in the refrigerator. EI #1 replied there could be adverse affects for resident or it could not be a full benefit to the resident. EI #1 was asked what would be the risk of not storing controlled medications in a locked box affixed to the refrigerator. EI #1 said it could be easily taken from the premises.

Based on observations, record review and interview: 1. The facility failed to assure proper cleaning/sanitizing of food preparation equipment, dishes and utensils by effectively sanitizing to destroy potential food borne organisms. The dishmachine's rinse cycle failed to maintain 180 degrees Fahrenheit (F) per facility policy; 2. The facility failed to assure liquid filled glasses were handled in a manner to prevent potential cross-contamination to the lip contact surface; and, 3. The facility failed to thaw frozen chicken according to professional practice standards. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 173 residents receiving meal trays from dining services. Findings include: 1. The 2013 Food Code by the United States Public Health (USP) and the Food and Drug Administration (FDA) included the following: 4-204.113 Warewashing Machine, Data Plate Operating Specifications. A WAREWASHING machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operation specifications including the: .(A) Temperatures required for washing, rinsing, and SANITIZING; . On 3/15/2016 at 3:08 PM, a record review of the facility Dish Machine Temperature monitoring/documenting log for March 2016, revealed that no data had been recorded for the March 15th, noon meal. The Dietary Manager, Employee Identifier (EI) #10, was asked to identify a problem with the monitoring log. EI #10 responded that there were no documented temperatures for the lunch meal. EI #10 was asked if there should have been and he responded, yes. EI #10 was asked why there was no documentation and what was the potential harm. EI #10 responded that he was unsure about the lack of documentation and did not answer as to the potential harm. On 3/16/16 at 9:30 AM, machine dishwashing was observed. The machine rinse failed to reach 180 degrees F in one of eight opportunities. This deficient practice was called to the attention of the operator, EI #13. At this time, EI #13 ran 4 trays through two times. Only one of the eight times did the rinse reach 180 degrees F. On 03/16/16 at 9:35 AM, the Dietary Manager, EI #10 phoned a company for maintenance of the dishmachine. EI #10 was asked to explain what was wrong when 4 trays went through the dish machine and the rinse temperature failed to reach 180 degrees F. EI #10 did not offer a response. On 03/16/16 at 11:20 AM, a representative from the dishmachine company was on site. He indicated there was a problem with the booster heater. On 3/17/2016 at 8:17 AM, the Administrator, EI #16 was asked if breakfast had been served on paper plates. EI #16 was asked if the dishmachine was still being worked on and the response was They are still back there. On 3/17/16 at 8:40 AM, a company manager for the dishmachine was on site. He was asked, what was wrong with the machine. He answered, Long and short, the booster heater is not working, so we have converted the machine to chemical sanitizing while we continue to search for (the) booster problems. It is currently sanitizing. 2. The facility policy, titled, Employee Guidelines - Infection Control Practices, revealed the following: .PROCEDURES: . Handle glasses and cups by the bottom, without touching the rims. The rim is the part that makes contact with the customer's mouth . On 3/16/2016 at 11:56 AM, a Dietary Aide was observed to pick up a glass of tea with fingers touching the lip contact surface. The Dietary Aide's fingers were not gloved. At 11:58 AM, EI #13 responded that the employee was new and had been advised not to do anything in the dining room. 3. The 2013 Food Code by the United States Public Health (USP) and the Food and Drug Administration (FDA) included the following: 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (Centigrade) (41oF) or less; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below (2) With sufficient water velocity to agitate and float off loose particles in an overflow . On 3/16/2016 at 9:25 AM, frozen chicken was observed in a sink in a metal container with holes (colander). Water was running, but not emptying out of the sink. Water was pooled 3/4 up the container, stagnant and not draining from the sink. On 03/16/16 at 10:00 AM the process was discussed with the contract services supervisor, and the facility Registered Dietitian, EI #12. EI #12 advised an employee that it was better to thaw in a solid container. On 3/17/2016 at 9:15 AM, and interview with the Dietary Manager EI #10 about the normal procedure and he stated refrigerator or running water. EI #10 was asked how it was actually done and EI #10 stated the water was running but did not drain out. EI #10 was asked to describe the potential harm and responded potential biological contamination.

Based on observation, interview and record review, the facility failed to ensure residents in the group meeting held on 03/16/16 were aware of the survey results, where they were located in the facility, and had easy access to those results. This affected 12 out of 13 residents in the group meeting. The facility further failed to ensure there were notices in the facility indicating the location of the survey results. This was observed on two of three days of the survey and had the potential to affect all residents in the facility. Findings include: A review of a form titled RESIDENT'S RIGHTS located in the Admissions Agreement revealed the following: .16. To review the results of all governmental surveys of the facility and plans to correct the deficiencies . On 03/15/16 at 2:15 PM during the initial tour of the facility the surveyor was unable to locate the survey results on all halls and lobbies. Also there was no notice found indicating where the survey results were located. On 3/16/16 at 10:10 AM, a resident council meeting was held. A total of 13 residents attended the meeting. The residents were asked if they were aware of their right to see a copy of the latest survey results and where it was located. Twelve of 13 residents at the meeting stated they were were not aware of their right to see a copy of the latest survey results nor did they know where the results were located in the facility. On 03/16/16 at 11:05 AM, the surveyor was unable to locate survey results in the facility, and there were no signs throughout the facility indicating where they were located. On 03/16/16 at 11:15 AM, the surveyor toured the facility and located the survey results. They were posted on a bulletin board in the back hall across from the dining room. On 03/17/16 at 8:40 AM, the surveyor conducted an interview with EI (Employee Identifier) #8, the Social Worker. EI #8 was asked how residents were made aware of their right to see a copy of the latest survey results. EI #8 stated the report was posted on the bulletin board by the dining room. EI #8 was asked if there were any notices posted informing residents where the survey results were located. EI #8 said, No. EI #8 was asked why it was important for residents to know what the survey results were and where they were located. EI #8 said it is the residents' right.

Based on observation, interview, and record review, the facility failed to ensure a care plan intervention for a bed alarm was followed for RI (Resident Identifier) #11, a resident with a history of falls. This affected one of 24 residents for whom care plans were reviewed. Findings included: A review of the facility policy titled, RESIDENT CARE PLANNING, with a most recent revised date of 12/2015 revealed the following: .IV. Care Plan Review Process: .E. Staff to implement care plan approaches as indicated on individual plan of care . RI #11 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [MEDICAL CONDITION] following a Cerebral Infarction. RI #11's most recent quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 1/26/2016 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated intact cognition. RI #11's MDS also revealed unsteady balance and extensive assistance with bed mobility and transfer. RI #11's care plan with a problem onset date of 8/22/2014 revealed the following: .At risk for falls related to hx (history) of falls, unsteady gait and requires 2 person assistance for transfers, hx [MEDICAL CONDITION] with left side impairment . Approaches .11/23/15 Bed alarm applied to bed to alert staff if attempts to get out of bed without assist . RI #11's Nurses Notes dated 12/06/2016 at 11:18 PM and Incident Report, signed by EI #11, LPN (Licensed Practical Nurse), dated 12/6/2016 at 10:55 PM, revealed RI #11 was found on the floor beside the bed. The Nurses Note and Incident Report did not include any documentation of the presence or use of a bed alarm for RI #11. On 3/17/2016 at 2:00 PM, EI #9, RN (Registered Nurse) Supervisor was asked if RI #11 had a bed alarm. EI #9 said, yes. On 3/17/2016 at 2:30 PM, EI #11 was asked if she remembered RI #11's fall in December 2015. EI #11 said, yes. When asked if RI #11 was supposed to have an alarm, EI #11 did not know. When asked if there was an alarm on the bed sounding, EI #11 said it was not. When asked why that was not documented on the investigation, EI #11 said she did not think RI #11 had an alarm. When asked who was responsible to ensure alarms were on and functioning properly, EI #11 said CNAs (Certified Nursing Assistants) and LPNs taking care of residents should make sure. When asked why it would be important for alarms to be in place and functioning properly, EI #11 said to prevent injury or falls.

Based on observation, interview, and record review, the facility failed to ensure RI (Resident Identifier) #10 received a regular diet as ordered. This occurred on 3/16/2016 at the breakfast and lunch meal. This affected one of fourteen residents for whom meals were observed. Findings include: RI #10 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #10's Diet Requisition Form dated 1/28/2016 revealed Regular Nutrient Content and Texture were checked for RI #10. RI #10's physician orders [REDACTED].REGULAR DIET . RI #10's REHABILITATION SCREENING FORM dated 1/29/2016 by the SLP (Speech Language Pathologist) revealed the following: .Patient readmitted for LTC (Long Term Care) .is alert and talkative. Able to express wants/needs .is tolerating a regular diet at this time . RI #10's Nutrition assessment dated [DATE] revealed the following: .Diet texture . Regular .Comments: .Diet: Regular . At risk for altered nutrition . RI #10's most recent quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 2/5/2016 revealed a BIMS (Brief Interview for Mental Status) score of 14 which indicated intact cognition. The MDS also revealed RI #10 was independent for eating with set up help only. On 3/15/2016 at 3:35 PM during the initial tour of the facility RI #10 said the facility was providing ground meat at meals and RI #10 did not like it, did not want it, and had told someone but could not remember who it was. RI #10 could not remember which staff member it was that had told RI #10 to try the ground meat because of getting choked. On 3/16/2016 at 8:10 AM, breakfast was served to RI #10 in bed. The tray card revealed .Regular . Ground Sausage Patty . RI #10 did not eat any of the ground sausage. RI #10 did eat some of the grits and biscuit and drank some of the fluids and Ensure offered. On 3/16/2016 at 12:45 PM, lunch was served to RI #10 and set up by the staff. RI #10 was served chopped fish. RI #10's tray card revealed .Regular . Ground Baked Fish . On 3/16/2016 at 12:50 PM, RI #10 did not want the chopped fish and told the CNA. The CNA told RI #10 they have to chop it up. The CNA offered to get RI #10 a piece of chicken, but added, they would have to chop it up. RI #10 did not want any meat chopped. On 3/16/2016 at 4:55 PM, EI (Employee Identifier) #9, RN (Registered Nurse) was asked about RI #10's chopped meat diet. EI #9 said, let her look. EI #9 reviewed RI #10's diet order and said, it was a regular diet and she did not know why they were chopping RI #10's meat. EI #9 said RI #10 had not talked to her about the chopped meat and RI #10 had the regular diet order since readmission. On 3/16/2016 at 5:30 PM, EI #10, Food Service Director, was asked what diet RI #10 should receive. EI #10 said it was a regular diet. EI #10 was asked why RI #10 had been receiving chopped meats. EI #10 said he did not know. EI #10 was asked who was responsible for ensuring the diet was verified when RI #10 was readmitted on [DATE]. EI #10 said it was whoever got the diet requisition form in dietary and they should have signed for receipt of the form. EI #10 was asked why did they not sign for the form. EI #10 said they did not put it into the system the way they should have. EI #10 was asked why it was important for residents to get meals as ordered. EI #10 said, so that residents could enjoy their meals.

Based on record review and interviews, the facility failed to ensure [MEDICATION NAME] levels were not collected on Resident Identifier (RI) #4 on 04/21/2015, 08/12/2015, and 02/11/2016 without a physician's orders [REDACTED].#4, one of two for whom lab results were reviewed. Findings Include: Review of the facility's policy titled, LAB PROCEDURES (ORDERS, DRAW, PICK-UP), revised 05/2005 revealed the following: . STANDARD Diagnostic testing should be scheduled by a physician's orders [REDACTED]. RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. RI #4's printed March 2016 physician's orders [REDACTED]. A review of RI #4's LAB DRAW DOCUMENTATION SHEET indicated [MEDICATION NAME] levels were collected on 04/06/2015, 04/21/2015, 08/12/2015, and 02/11/2016. The lab results reports indicated all of these labs had fallen within normal reference ranges. On 03/16/2016 at 1:25 PM, Employee Identifier (EI) #1, the Director of Nursing, provided copies of RI #4's previous lab orders. The orders provided by EI #1 indicated RI #4's [MEDICATION NAME] level was ordered on [DATE] for every 6 months and changed to every year on 04/06/2015, as indicated on RI #4's printed physician's orders [REDACTED].#4, EI #1 asked to go review RI #4's Medical Records. On 03/16/2016 at 3:25 PM, EI #1, the Director of Nursing, was asked if she had a chance to look for lab orders for the 04/21/2015, 08/12/2015, and 02/11/2016 [MEDICATION NAME] levels. EI #1 said she had but was unable to locate orders for those dates. EI #1 said she knew what happened and explained when RI #4 was readmitted a previous order for [MEDICATION NAME] levels every six months was entered. She said the order for the lab every six months was entered into the computer on 04/03/2015. On 04/06/2015, the doctor made rounds and said to discontinue the order for every six months and change it to every year. EI #1 said the new order for the yearly [MEDICATION NAME] level was not communicated to the appropriate person. EI #1 said RI #4's [MEDICATION NAME] levels collected on 04/21/2015, 08/12/2015 and 02/11/2016 were probably not all medically necessary. EI #1 said collecting labs without orders could lead to unnecessary sticks for the resident.

Based on observation, record review, and interviews, the facility failed to ensure staff placed Resident Identifier (RI) #4's call light within reach to enable the resident to notify staff of the need for assistance. This was observed on two of three days of survey and affected RI #4, one of 24 residents sampled. Findings include: Review of the facility's policy titled, ANSWERING THE CALL LIGHT, reviewed 07/2015, revealed the following: .PURPOSE: Call lights serve as notice to the staff the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident . II. PROCESS . F. Place the call light within reach of the resident before leaving the room . RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #4's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2016 documented RI #4 had moderately impaired cognition and required extensive to total assistance with all Activities of Daily Living. This assessment also indicated RI #4 had range of motion impairment on one side for both upper and lower extremities and was always incontinent of bowel and bladder. RI #4's current care plan with a problem onset date of 10/01/14 listed an intervention to always ensure the call bell was within reach. During the initial tour of the facility on 03/15/2016 beginning at 2:27 PM, RI #4 was observed in the room in a geri chair with feet elevated. RI #4's left hand was contracted. RI #4 expressed having been in the chair since 9:00 AM that morning and would really like to get in the bed. When RI #4 was asked if there was a call light, RI #4 pointed to the other side of the bed. The call light was noted hanging from the opposite side of the bed out if the resident's reach. When RI #4 was asked if the call light was used when in reach, RI #4 said Yes, you just said the magic word; if I can get to it. At 2:55 PM, Employee Identifier (EI) #5, a Licensed Practical Nurse, entered the room to inform RI #4 she would be the nurse for the evening; however, after EI #5 left RI #4's room, the call light remained out of reach. On 03/16/2016 the following continuous observations were made: At 11:44 AM, RI #4 was again observed in the room in a geri chair with feet elevated. The call light was not within reach. When asked where the call light was, RI #4 pointed to the other side of the bed and said, Over there and can't get to it. RI #4 was asked what was done if something was needed and the call bell was out of reach. RI #4 said, Pray or try to get it or get up. RI #4 said the call light was not doing any good if out of reach. RI #4 also pointed and said, It's wrapped around the side rail over there. RI #4 said when up in the chair, the call light is out of reach. At 11:55 AM, a Certified Nursing Assistant (CNA) entered RI #4's room but immediately left without placing the call light within RI #4's reach. At 12:10 PM, EI #4, a CNA, entered RI #4's room and talked with RI #4. While in the room the CNA unwrapped the call light from the side rail and placed it within RI #4's reach. Upon exiting the room, EI #4 was asked why she moved RI #4's call light. She stated because it was not within RI #4's reach. EI #4 was unsure who put RI #4 in the room but said the call light needed to be within reach in case the resident needed something. When asked if RI #4 utilized the call light, EI #4 said yes, usually when something was needed. When asked what could happen if RI #4 was unable to reach the call light, EI #4 said a fall or pain if RI #4 was unable to let them know. EI #3, another CNA, was interviewed on 03/16/2016 at 12:18 PM. EI #3 said he placed RI #4 in the room about 9:15 AM. EI #3 said he had not placed the call light with RI #4's reach. When asked why it was important to make sure residents can get to their call lights, EI #3 said in case there was an emergency or something was needed. EI #2, the Registered Nurse Supervisor, was interviewed on 03/16/2016 at 12:20 PM. EI #2 said the call light should be placed as close, within reach of residents as possible. She explained if a resident is in a geri chair, staff should place the call light on the resident's lap, on the bedside table, or clip it to a blanket. EI #2 said the call light should be within residents' reach so they can call if assistance is needed.

Based on observation, record review, and interviews, the facility failed to ensure Employee Identifier (EI) #s 3 and 6, Certified Nursing Assistants (CNAs), transferring Resident Identifier (RI) #17 from a wheelchair in the hall to the resident's bed using a mechanical lift did so in accordance with manufacturer specifications to ensure RI #17's safety. This affected RI #17, one of one residents observed for transfers. The facility further failed to ensure bed alarms were on and functioning properly for RI #'s 1 and 11, resident's with histories of falls. This affected two of nine resident's reviewed for falls. Findings Include: 1) Review of the facility's policy titled, PORTABLE PATIENT LIFT, written 10/2015, revealed the following: . VII. LIFTING/MOVING THE RESIDENT . B. Pump the lift handle or press the UP button to raise the resident .G. Press the DOWN button . or open the control valve . lowering the resident so that his feet rest on the base of the lift, straddling the mast . Review of the Owner's Operator and Maintenance Manual for the facility's mechanical lift revealed the following: . WARNING . The Invacare Patient Lift is NOT a transport device. Moving a person suspended in a sling over ANY distance is NOT RECOMMENDED . Lifting/Moving the Patient . 1. Pump the lift handle or press UP button to raise the patient . 2. When the patient is lifted . he/she will be raised to a sitting position . 6. Press the DOWN button .so that his feet rest on the base of the lift, straddling the mast . NOTE: The lower center of gravity provides stability making the patient feel more secure and the lift easier to move . RI #17 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #17's Initial Minimum Data Set (MDS) with an Assessment Reference Date of 02/19/2016 documented RI #17 required extensive assistance of two people for transfers and had limited range of motion on both sides for both upper and lower extremities. On 03/16/2016 at 11:57 AM, EI (Employee Identifier) #s 3 and 6, CNAs (Certified Nursing Assistants) were observed transferring RI #17 from a wheelchair in the hall to the resident's bed using a mechanical lift. Staff raised RI #17 up onto the lift. RI #17's head was higher than EI #6's during transport to the B bed (located on the far side of the resident's room). EI #s 3 and 6 did not lower RI #17 prior to transport. RI #17's legs were dangling in the air. EI #6 was interviewed on 03/16/2016 at 12:04 PM. She said she received training on using the lift when she started working at the facility. When asked to explain the process for transferring a resident from a wheelchair to the bed, EI #6 said you position the sling under the resident and make sure it is hooked up properly. She further stated once the resident is raised up out of the chair, you keep them at the same height to move them to the bed. EI #6 said because the room was smaller than some of the others it was easier to use the lift to take the residents from the hallway to their room. During an interview on 03/16/2016 at 3:25 PM EI #1, the Director of Nursing, said staff should not transport residents in the hallway. She said they should get as close to the bed/chair as possible to do a transfer with a mechanical lift. EI #1 also stated if staff were going to transfer a resident in the hall using a mechanical lift, the resident should be as low on the lift as possible. When asked why it was important to lower the resident, EI #1 said fear and something could happen such as a fall due to the accident factor. EI #7, a Licensed Practical Nurse, was interviewed on 03/16/2016 at 3:55 PM. EI #7 said she teaches staff how to utilize the lift. When asked to explain the process of transferring a resident from a chair to the bed using a mechanical lift, EI #7 said they do not transfer residents in the hall. She further stated, It's a transfer technique, not transport. She said she instructs staff to lower the resident before actually moving the lift because the lift can become unbalanced and lead to a fall, creating the potential for injury. 2) The facility policy titled, INCIDENTS AND ACCIDENTS, with a revised date of 6/07, revealed the following: .PURPOSE: The resident environment remains as free of accident hazards as is possible . III. PROCESS: .B. Documentation .3.c. A nurse will review and/or revise each resident's plan of care to activate new preventive approaches. RI (Resident Identifier) #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of RI #1's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/05/16 revealed RI #1 had both short and long term memory loss and moderately impaired cognitive skills for daily decision making. RI #1 also required extensive ADL (Activities of Daily Living) assistance and was not ambulatory in the room or in the corridor during this assessment. The MDS further revealed RI #1 had suffered falls during this assessment. Review of RI #1's care plans revealed a care plan dated 10/16/15 for At risk for falls related to hx (history) of falls . with an approach of .Bed/chair alarm used to alert staff if (RI #1) attempts to get up without assistance . Review of a facility form titled, Fall Risk Assessment with dates of 04/01/15, 06/19/15, 09/03/15, 11/18/15 and 02/05/16 revealed RI #1 had unsteady gait and falls within the past six months. Further review revealed Safety Devices in place were bed alarm and chair alarm. Review of the facility's incident/accident reports revealed that over the past year, RI #1 had six falls. Further review revealed on 05/13/15 it was noted RI #1's bed alarm was on and working, on 07/19/15 a CNA (Certified Nursing Assistant) responded to the bed alarm, on 10/16/15 staff reported the bed alarm was on but did not sound because of the position RI #1 was in at the time, and on 10/24/15 staff responded to the bed alarm. Review of Departmental Notes documented on 02/24/15 at 9:25 P.M. RI #1's bed alarm was on and working, on 05/13/15 at 9:59 P.M. the bed alarm was on, on 07/19/15 at 10:26 P.M. CNA responded to the bed alarm and at the time of this note, the bed alarm was on, on 10/16/15 at 7:22 A.M. the bed alarm was on but not sounding, and on 10/24/15 at 10:44 P.M. the nurse noted she heard the bed alarm going off and responded. On 03/17/16 at 4:02 P.M., EI (Employee Identifier) #14, LPN (Licensed Practical Nurse) was asked if RI #1 was supposed to have a bed/chair alarm to which she stated yes. She further stated that on 07/19/15 (after review of the incident report) the bed alarm was on and a CNA responded. When asked who was responsible for ensuring alarms were functioning properly, EI #14 stated that everyone who came in contact with the resident was responsible. When EI #14 was asked how were alarms monitored to ensure they were functioning properly, EI #14 stated that each time she came in contact with a resident (with an alarm) she would check to make sure the green light was on and the switch was turned on. When asked if these findings were documented anywhere, EI #14 said she would document in the nurses notes. When asked how the facility ensured alarms were functioning properly, EI #14 said she did not know. EI #14 was asked why it was important for alarms to be monitored to ensure they were functioning properly and what the potential harm was to a resident if the alarms were not functioning properly and monitored on a regular basis, EI #14 said because a resident who may be a fall risk could get up and hurt themselves and could possibly fall without anyone knowing. On 03/17/16 at 4:15 P.M., EI #9, RN (Registered Nurse) Supervisor, was asked if RI #1 was supposed to have a bed/chair alarm to which she stated RI #1 was to have both. When asked to review the fall incident reports, EI #9 stated that on two of the three dates (10/16/15 and 10/24/15) the alarm was functioning but on 12/29/15 there was no mention of an alarm sounding. EI #9 was asked who was responsible for ensuring alarms were functioning properly to which she stated all RNs, LPNs and CNAs were responsible. She further stated they ensure alarms are functioning properly by looking at them every day but when asked where this information was documented, EI #9 said it was not documented. EI #9 was asked why it was important for the alarms to be monitored to ensure they were functioning properly and what would be the potential harm if they were not. EI #9 said it was for the safety of the resident; they could fall and hurt themselves. On 03/17/16 at 4:30 P.M. EI #15, RN Supervisor (11-7 shift) was asked if RI #1 was supposed to have bed/chair alarm to which she stated she was pretty sure RI #1 had both. When asked who was responsible for ensuring the alarms were functioning properly, EI #15 said all staff was and when she checked the alarms she looked to see if the alarm sounded by pressing the on/off. When asked where these findings were documented, EI #15 said they only document when the batteries were changed out, not the functioning of the alarms. When asked why it was important for the alarms to be monitored and ensured for proper function and what could be the potential harm if they were not, EI #15 said because they had to know when the resident(s) might be in danger and to be sure the alarm was going to work, if not, the resident could get up and have an injury without the staff being alerted to their attempt. 3) RI #11 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED] following a Cerebral Infarction. RI #11's care plan with a problem onset date of 8/22/2014 revealed the following: .At risk for falls related to hx (history) of falls, unsteady gait and requires 2 person assistance for transfers, hx of CVA (Cerebrovascular Accident) with left side impairment . Approaches .11/23/15 Bed alarm applied to bed to alert staff if attempts to get out of bed without assist . RI #11's CARE PLAN CLOSET DOOR SIGN dated 1/26/2015 revealed the item .Devices Personal alarm: .Bed . was not checked for RI #11. RI #11's Nurses Notes dated 12/06/16 at 11:18 PM and Incident Report dated 12/06/16 at 10:55 PM, signed by EI #11, LPN (Licensed Practical Nurse), revealed RI #11 was found on the floor beside the bed. The Nurses Note and Incident Report did not include any documentation of the presence or use of a bed alarm for RI #11. RI #11's most recent quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 1/26/2016 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated intact cognition. RI #11's MDS also revealed unsteady balance and extensive assistance with bed mobility and transfer. On 3/17/2016 at 2:00 PM, EI #9, RN (Registered Nurse) Supervisor was asked if RI #11 had a bed alarm. EI #9 said, yes. On 3/17/2016 at 2:30 PM, EI #11 was asked if she remembered RI #11's fall in December 2015 when RI #11 tried to reach a drink on the bed side table. EI #11 said, yes. When asked if RI #11 was supposed to have an alarm, EI #11 did not know. When asked if there was an alarm on the bed sounding at the time of the fall, EI #11 said, there was not. When asked why that was not documented on the investigation, EI #11 said, she did not think RI #11 had an alarm. When asked who was responsible to ensure alarms were on and functioning properly, EI #11 said CNAs (Certified Nursing Assistants) and LPNs taking care of residents should make sure. When asked how she knew which residents had alarms and which ones did not, EI #11 said, the residents who get up a lot had bed alarms. When asked how bed alarms were monitored to make sure they were on and functioning properly, EI #11 said, when she went into residents rooms to give medication she would make sure the light is on and flashing. When asked where she documented that the alarms were checked, EI #11 said, there was not a place that she was aware of that documented alarm checks. When asked why it would be important for alarms to be in place and functioning properly, EI #11 said, to prevent injury or falls. On 3/17/2016 at 4:00 PM, EI #9 was asked who was responsible to ensure that alarms were on and functioning properly. EI #9 said, all of the nurses and CNAs check alarms everyday. When asked how staff knew which residents had alarms, EI #9 said, it was on the care plans and placed on the closet door signs by the RNs on each station. When asked how the facility ensures alarms were on and functioning properly, EI #9 said, they look at them everyday. EI #9 admitted there was not a monitor sheet for documenting the alarm function. EI #9 was asked what the potential for harm was if a resident had an alarm that was not functioning properly and alarms were not monitored on a routine basis. EI #9 said, if a resident came out of the bed or chair the staff would have no way of knowing and the resident could fall and hurt themselves.

Based on observations and interview, the facility failed to assure waste was properly contained in dumpster's (doors closed), for two of three units and were maintained in a manner to prevent insect and rodent attraction, harborage and the feedings of pests. This deficient practice had the potential to affect all 174 residents who reside in the facility. Findings include: The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit . On 3/16/2016 at 6:00 PM, the facility's outside refuse receptacles were observed. There were three containers (dumpsters). Dumpster one and two failed to prevent the feeding of pest by assuring the (two) side doors were securely closed. On 3/17/2016 at 10:20 AM, the facility Registered Dietitian, Employee Identifier (EI) #12, was asked what would be the potential harm (when the dumpster doors were not securely closed). EI #12 replied that the potential harm would be rodents.

Based on record reviews and interviews, the facility failed to ensure Resident Identifier (RI) #15's medication ([MEDICATION NAME]/[MEDICATION NAME]) was held as directed by the physician. From November 1 through November 18, 2010, RI #15 received duplicate doses of [MEDICATION NAME], 600 milligrams (mg) at bedtime daily. On 11/18/10, after receiving a call from the resulting laboratory of the resident's critical [MEDICATION NAME] level, 30.5 ug/ml (micrograms per milliliter), (reference range 10.0 - 20.0 ug/ml), a Registered Nurse Unit Supervisor documented a verbal order, "...Hold [MEDICATION NAME] x 3 days Restart [MEDICATION NAME] @ (at) 200 mg PO (by mouth) q (every) HS (bedtime)..." The facility's licensed staff continued to administer [MEDICATION NAME] Dosium Extended, 300 mg capsule, 1 capsule by mouth at bedtime to RI #15 through the PM dose on 11/22/10. On 11/23/10, RI #15 was admitted to the hospital with [REDACTED]. The consultation report from the local hospital, dated 11/23/10, for RI #15, documented the physician's impression as: "...1. [MEDICAL CONDITION] with episodic [MEDICAL CONDITION] 2. [MEDICATION NAME] toxicity..." This affected 1 of 25 sampled residents with medications reviewed. Findings Include: The facility's policy and procedure, entitled Physician Orders, dated 11/05, documented: "...PURPOSE: The physician retains control of the resident's medical plan of care... Standard: 1. Verbal Orders... E. Follow through with orders by contacting the pharmacy, lab, revising medication and treatment sheets, as appropriate..." The facility's policy and procedure, entitled Medication Orders, revised 09/03, documented: "...B. Documentation of Medication Orders 1... The order should be recorded on the physician order [REDACTED]. When a new order changes the dosage or a previously prescribed medication, discontinue previous entry by writing DC'd (discontinued) and the day (may highlight and draw line). 4. Enter the new order on the MAR..." RI #15 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #15's September 2010 physician's orders [REDACTED]. On 10/19/10, Employee Identifier (EI) #13, a Registered Nurse, Unit Supervisor, wrote a verbal physician's orders [REDACTED]." The October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order for the [MEDICATION NAME] ([MEDICATION NAME]) 100 mg - give 3 caps (300 mg) at bedtime was not indicated on the October 2010 MAR; although it was ordered on [DATE]. Neither did the October MAR indicated was discontinued. The November 2010 MAR for RI #15, indicated by the nurses' initials, the resident was administered [MEDICATION NAME] Dosium Extended 300 mg cap at bedtime and also 3 caps (100 mg each) of [MEDICATION NAME] ([MEDICATION NAME]) at bedtime from November 1 through November 18, 2010. A nurse's note, dated 11/18/10 at 11:15 AM, signed by EI #13, documented: "Critical lab called - [MEDICATION NAME] 30.5 - MD (Medical Doctor) notified awaiting response. 12:10 PM New orders received - Hold [MEDICATION NAME] x (times) 3 days..." On 11/18/10, EI #13 documented a verbal order, "...Hold [MEDICATION NAME] x 3 days Restart [MEDICATION NAME] @ (at) 200 mg PO (by mouth) q (every) HS (bedtime)..." RI #15's lab report, dated 11/19/10, documented the resident's [MEDICATION NAME] ([MEDICATION NAME]) level as 30.5 ug/ml (micrograms per milliliter). The reference range was 10.0 - 20.0 ug/ml. RI #15's [MEDICATION NAME] level was critically high and had exceeded the high end of the reference range. A review of the November 2010 MAR for RI #15, revealed, as indicated by the nurses' initials, the administration of the [MEDICATION NAME] Dosium Extended 300 mg cap at bedtime continued until 11/23/10, when RI #15 was admitted to the hospital; although on 11/18/10, a verbal order was given to hold the [MEDICATION NAME] times 3 days. EI #13 was interviewed on 1/05/11 at 5:30 PM. EI #13 stated RI #15 was readmitted to the facility on [DATE] with an order for [REDACTED]. EI #13 further stated the resident should have been receiving 300 mg of [MEDICATION NAME] a day. EI #13 stated the 3 - 100 mg caps were not administered until beginning November 1; although [MEDICATION NAME] in this form should have been initiated in October. The RN stated she did not transcribe the orders to the MAR, as she should have. When asked what period of time did the resident receive more [MEDICATION NAME] than what was prescribed for her, the RN replied from November 1st through the 23rd, 2010. Based on review of the November 2010 MAR, the resident received 600 mg of [MEDICATION NAME] daily, from 11/01/10 through 11/18/10. EI #13 provided a hand written statement, dated 1/06/11, which documented: "...I didn't (did not) follow through with the entire order process, therefore, I did not hold [MEDICATION NAME] for 3 days." A hand-written statement by EI #1 (Director of Nursing) was provided to the surveyor on 1/06/11. The hand-written statement documented: "An order was written on 11/18/10 by (EI #13) and (the nurse practitioner), to hold [MEDICATION NAME] x 3 days and start [MEDICATION NAME] 200 mg p.o. (by mouth). The RN (Registered Nurse, also EI #13) didn't follow through completely with the order process so therefore [MEDICATION NAME] wasn't (was not) held x 3 days as ordered."

Based on observation, interviews and record reviews, the facility failed to ensure RI (Resident Identifier) #1 was medicated for pain, prior to providing wound care to seven pressure sores: a stage I to the right outer ankle, a stage II to her left gluteal, a stage II to the left outer heel, a stage II to the left anterior lower leg, a stage III to her left heel, a stage IV to her right heel, and one unstageable pressure sore to the left lateral lower leg. The facility also failed to administer pain medication when RI #1 exhibited verbal (cursing and calling out for help) and facial expressions (grimacing) and physical expressions (clenching of fists) of pain during the wound care on 1/05/11. RI #1 had a physician order dated 12/27/10, for a [MEDICATION NAME] 75 MCG (micrograms), apply one patch every 72 hours. According to the Medication Administration Record (MAR), the [MEDICATION NAME] was applied on 1/03/11 at 8:00 AM. Based on RI #1's verbal and facial expressions of pain during wound care, the [MEDICATION NAME] was not controlling her pain. RI #1, who was admitted to Hospice on 12/08/10, had Hospice standing orders dated 12/08/10, for sublingual Roxonol 20 mg/ml (milligrams per milliliters) every 15 minutes until pain is controlled and also sublingual [MEDICATION NAME] 20 mg/ml every 3-4 hours for breakthrough pain. The facility had physician orders dated 12/17/10 for RI #1 to include: [MEDICATION NAME] 5/325 300 mg by mouth every 6 hours as needed and Tylenol 500 mg one tablet by mouth every 4 hours as needed for pain or fever. This affected 1 of 6 residents observed during wound care. Findings include: RI # 1 was admitted to Hospice on 12/08/10 and to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1, who was admitted to Hospice on 12/08/10, had Hospice standing orders dated 12/08/10, for sublingual Roxonol 20 mg/ml (milligrams per milliliters) every 15 minutes until pain is controlled and also sublingual [MEDICATION NAME] 20 mg/ml every 3-4 hours, as needed for breakthrough pain. The Admission MDS (Minimum Data Set), with an assessment reference date of 12/23/2010, was reviewed. The MDS revealed the following assessment for RI #1: 1. Being able to make herself understood and able to understand others. 2. Having frequent pain in the last 5 days with a rating of 6 on a 1-10 scale 3. Complaints of difficulty or pain when swallowing. 4. pressure ulcers, stage I, II, III and IV. A review of the physician orders for wound care and pain medication, revealed the following: "12/17/10. Clean blood blister to left anterior lower leg with NACL (Saline), apply antibiotic ointment, cover with [MEDICATION NAME], wrap with Kerlix, tape daily until healed. Apply [MEDICATION NAME] to right outer ankle, cover with a dry dressing daily, until healed. Clean left heel with NACL, Apply [MEDICATION NAME] ointment, cover with an ABD (Abdominal) pad, wrap with Kerlix, tape daily and PRN (as needed)... Clean left outer ankle with NACL, apply [MEDICATION NAME] ointment, apply NACL moist dressing to wound bed, cover with dry dressing wrap with Kerlix, tape daily and PRN dislodgement/drainage until healed. Clean areas to right heel and left lateral lower leg with NACL, apply [MEDICATION NAME], cover with a dry dressing daily and PRN dislodgement until healed. Clean left gluteal with NACL, apply Safe gel and Allevyn daily and PRN until healed." Physician orders for pain medications were as follows: "12/17/10 [MEDICATION NAME] 5/325 300 mg tab give 1 tab by mouth Q(every) 6 hrs PRN,pain. 12/17/10 Tylenol 500 mg tab give 1 tab by mouth Q 4 hrs PRN pain/fever. 12/27/10 [MEDICATION NAME] Patch 75 mcg/hr patch Apply 1 patch Q 72 hrs." RI #1's Care Plans, dated 12/17/10, for each of the seven pressure sores included the approach: "...*Assess for pain related to pressure ulcer or its treatment..." The care plans, dated 12/17/10, for the stage I to the right outer ankle, stage III to the left heel, stage IV to the right heel, stage II to the left anterior lower leg and the unstageable pressure ulcer to the left lateral lower leg and the stage III to the right outer ankle include the approach: "...Give pain medication as ordered..." Wound care was observed for RI #1 on 01/05/2011 at 8:45 AM. When the left foot was raised to remove the bootie, RI #1 cried out, "Oh, Oh." RI # 1 was observed to have her eyes tightly closed with facial grimacing noted. When the LPN (Licensed Practical Nurse) EI ( Employee Identifier) #4 removed the dressing from the left leg and ankle, RI #1 again cried out, "Oh." During the cleaning of the left outer leg, RI # 1 cried out "Oh hurt", when the left leg was lowered to the bed. RI #1 kept her eyes tightly closed. During the cleaning of the pressure ulcer on the left ankle, RI #1 cried out, "Oh, Oh God Oh." RI #1 was observed to be moving her hands and arms in the air. Then wound care was provided to the left heel. After the wound care was completed to the left lower extremity, the leg was lowered to the bed. RI #1 cried out, "Oh, Oh, hurt, Oh." EI # 4 then provided wound care to the right upper leg. When the right leg was raised, RI # 1 cried out, "Oh, Oh hurt." EI # 1 was observed to wave her hands in the air and to close her eyes tightly. During cleaning of the wound to the right ankle, RI #1 cried out. "Oh, My God, Oh." When RI #1 was positioned to the left side for wound care to the left gluteal, RI # 1 grabbed EI #4's hair and cried out, "Oh hurt, Oh, Oh,." RI #1 was observed to have facial grimaces and to have her eyes tightly closed. When the resident's grip was released from EI # 4's hair, she was noted to clench and unclench her hands. During the cleaning procedure for the coccyx area, RI #1 was crying out, "Oh, Oh, damn Oh." After wound care was finished, RI #1 was positioned on her right side, RI #1 called out "Oh" when being repositioned. A review of the facility's "Pain management", dated 12/17/10, revealed: "Assess for signs and symptoms (s/s) of pain. If s/s of pain are seen or reported ask resident to describe their pain on a scale of 1-10: with zero being no pain and 10 being the most severe. If unable to describe the pain to you, look for visible signs of pain... and severity and assess the relief of this pain." A review of the facility's policy and procedure for pain management, dated 10-07, revealed: "1...pain screen and assessment may be performed at any time deemed necessary by the staff. 2... The LPN or RN will review the MAR and determine if the pain management is appropriate for the resident's specific pain care needs. ...4 The plan of care will include asking the physician to manage pain according to three basic concepts of pain management through the use of basic pharmacological measures..." A review of the Hospice physician orders reveal "Standing Orders" for control of moderate to severe pain control. Medications listed include the sublingual route. The care plan, dated 12/08/10, initiated by hospice includes the following; "Problems : Pain/symptom Control Medication Management" The hospice admission orders [REDACTED] "Comfort Measures: pain management..." The "Comprehensive Nursing Assessment" provided by hospice documented the "family and /or patient expectations of Hospice, reveals: Comfort, medication management..." The MAR documents: "1/5/2011, RI #1 spit out/ refused her AM medications." The MAR also noted no attempt to administer any PO (per oral) PRN medication on 1/5/2011, the day wound care was observed by the surveyor. Documentation was noted on the MAR that RI #1 had refused/spit out her 8 AM and 4 PM medications for the month of January as well as December, the 20th - 26 th. RI # 1 had a physician order for [REDACTED]. A further review of the MAR for the month of January reveals no attempt by the nurse to administer the Tylenol or the [MEDICATION NAME]. There was no documentation of any other PRN medication being administered. Not until 1/5/11 at 2:45 PM (after the surveyor's observation of wound care) was a physician's order obtained for a pain medication to be administered by a route other than by mouth. A review of the hospice nurses note, dated 12-28-10, revealed: Facility/Patient/Family education notes: instructed to call (name of hospice) if increase in pain medication not effective. The facility nurses note, dated 12/17/10, revealed, RI #1's sponsor wishes for resident to receive medications as ordered and be kept comfortable. On 01/06/2011 at 9:50 AM, the medication LPN, EI #6, was interviewed. EI #6 was asked if RI #1 spit out her medications a lot. She responded that the resident spits the medications out a lot and that she had only managed to get them down one or two times. EI #6 stated that she had provided wound care for RI #1 this weekend, and stated, RI#1 had verbalized pain saying, "You are hurting me and Oh my God." When EI # 6 was asked how she had responded, she stated she had tried to comfort her, telling her she would be through as soon as she could and would try to be gentle. EI # 6 was asked if she felt RI #1 was in pain. EI #6 stated that the way her wounds looked she would say yes, that she knew she was in pain. EI #6 was asked if she had added pain medication to the cup of medication she had attempted to administer before the wound care. EI #6 stated that it had been her regular morning medication, there was no pain medication in the cup. The hospice nurse, RN, EI #7, was interviewed on 01/06/2011 at 11:00 AM. The Hospice nurse was asked if the facility had notified them of the pain RI #1 was experiencing during wound care. EI # 7 stated the facility nurse had not notified them, and that they could administer Roxonol to the [MEDICATION NAME] cavity for breakthrough pain, it is concentrated and would take affect with in 5-10 minutes and not cause residual drowsiness. When asked if seeing the documentation of the wounds did she feel there was pain with wound care, EI #7 stated that she did. EI # 7 was asked, as a nurse what did she feel should be done if a resident was experiencing pain during wound treatment and spitting out her medications. EI #7 stated that an alternate route should be found immediately. The RN supervisor, EI # 5, was interviewed on 01/06/11 at 1:20 PM. When asked if she had assessed RI #1 to see if the [MEDICATION NAME] Patch was effective she stated she had not. EI # 5 was asked what should have been done for RI #1, since she had multiple wounds and was spitting out her po medications, she replied hospice should have been contacted. EI #5 was asked if the LPN had talked with her about how she (RI#1) reacts during wound care. EI #5 stated she was told RI #1 yells out, that it is painful. EI # 5 was asked what the wound care nurse did when the resident complained of pain. EI #5 stated that the wound nurse told her. When asked what she had done, EI #5 stated she had done nothing since RI #1 was spitting out her medications. EI #5 was asked what she would expect a nurse to do when a resident complained of pain during wound care. EI#5 stated she would expect them to rewrap the dressing and tell me to contact the physician. When asked if this had been done, she stated she was not aware that it had been done. The RN (EI # 8), who assisted with the wound care, was interviewed on 1/6/2011 at 2:15 PM. EI # 8 was asked how RI #1 usually reacted during wound treatment. EI #8 stated she acted like she had during the wound observation on 1/5/11, crying out. When asked if she felt RI #1 was hurting, she said that she felt like she was hurting. When asked what a nurse should do if during wound care they realized the resident was hurting, she stated the nurse should give them something for pain. When asked if that had been done for RI #1, she stated the physician had been notified later that afternoon (1/5/11, the day of the surveyor's observation). When asked why RI # 1 was on hospice, she stated she was end of life and her daughter wanted to keep her comfortable. EI # 8 was asked with RI #1 experiencing pain during wound care, spitting her medications out and no new order until yesterday afternoon for another pain med, did she feel the resident was being kept comfortable. EI # 8 stated she did not think she was. EI # 8 was asked what was the facility's policy and procedure for assessing for pain. EI #8 responded that it was to find out the level of pain anytime a resident is complaining of pain and to administer pain medication. The wound care LPN, EI # 4, was interviewed on 1/6/2011 at 2:45 PM. EI # 4 was asked if RI #1 usually responded during wound care as she had yesterday. EI #4 stated that she cries out a lot during the care. When asked if she felt RI #1 was in pain during the wound care, she responded yes because she had cursed, was grimacing and the movements of her arms and body showed she was in pain. EI#4 was asked what she should do if a resident was experiencing pain during treatment. EI #4 stated she should be given pain medication. EI #4 was asked if she had given any pain medications. She stated she had not. When asked if she had checked the MAR to see if RI #1 had been given pain medication before she started the treatment, she stated she had not. EI # 4 was asked if she had discussed with anyone after the treatment, the fact that RI #1 had been in pain, she stated she had not. On 1/6/2011 at 3:05 PM, the Pharmacist, EI #2, was interviewed. EI #2 was asked what recommendations she had made related to the fact that RI #1 was spitting her medications out. EI #2 stated that she had reviewed (RI #1's) medications yesterday. She had recommended if RI #1 continued to spit her medications out for staff to contact hospice for an alternate route for pain medications. The Director of Nursing, EI # 1, was interviewed on 1/6/2011 at 3:45 PM. EI #1 was asked what she would expect the nurse to do if a resident complained of pain during a treatment. EI #1 stated she would expect the nurse to stop the treatment and assess the resident, she might have to stop the treatment altogether if she was in too much pain.

Based on record reviews and interview, the facility failed to ensure Resident Identifier (RI) #15 was not administered duplicate doses of [MEDICATION NAME] ([MEDICATION NAME]) from November 1, 2010 through November 18, 2010. In September 2010, the physician ordered "...(start date 9/22/10) [MEDICATION NAME] DOSIUM EXTENDED 300 MG (milligrams) CAP (capsule) give 1 cap by mouth at bedtime..." for RI #15. On 10/19/10, a Registered Nurse (RN) clarified the physician's orders [REDACTED]. The RN failed to discontinue the [MEDICATION NAME] Dosium Extended 300 mg capsule, prior to beginning the administration of the three - 100 mg capsules (300 mg) at bedtime, which did not begin until November 1, 2010. Based on RI #15's medication administration records (MAR), the resident received a total of 600 mg of [MEDICATION NAME] at bedtime, daily from 11/01/10 through 11/18/10. On 11/18/10, the Registered Nurse Unit Supervisor was informed by the laboratory of RI #15's critical [MEDICATION NAME] level, 30.5 ug/ml (micrograms per milliliter), reference range (10.0 - 20.0 ug/ml). Although the RN received a verbal order to: "...Hold [MEDICATION NAME] x 3 days Restart [MEDICATION NAME] @ (at) 200 mg PO (by mouth) q (every) HS (bedtime)...," the facility's licensed staff continued to administer the [MEDICATION NAME] Dosium Extended 300 mg capsule through bedtime on 11/22/10. On 11/23/10, RI #15 was admitted to the hospital with [REDACTED]. The consultation report from the local hospital, dated 11/23/10, for RI #15, documented the physician's impression as: "...1. [MEDICAL CONDITION] with episodic [MEDICAL CONDITION] 2. [MEDICATION NAME] toxicity..." This affected 1 of 25 sampled residents with medication regimes reviewed. Findings Include: The facility's policy and procedure, entitled Medication Orders, revised 09-03, documented: "...Transcribe newly prescribed medications on the MAR indicated [REDACTED]. When a new order changes the dosage or a previously prescribed medication, discontinue previous entry by writing DC'd (discontinued) and the date (may highlight and draw line). 4. Enter the new order on the MAR..." RI #15 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #15's September 2010 physician's orders [REDACTED]. The Pharmacist documented on 10/7/10: "...(2) Clar (clarify) Dil ([MEDICATION NAME]) - 3 X (times) 100..." On 10/19/10, Employee Identifier (EI) #13, a Registered Nurse, Unit Supervisor, wrote a verbal physician's orders [REDACTED]." The October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order for the [MEDICATION NAME] ([MEDICATION NAME]) 100 mg - give 3 caps (300 mg) at bedtime was not indicated on the October 2010 MAR; although it was ordered on [DATE]. The November 2010 MAR for RI #15, indicated by the nurses' initials, the resident was administered [MEDICATION NAME] Dosium Extended 300 mg cap at bedtime and also 3 caps (100 mg each) of [MEDICATION NAME] ([MEDICATION NAME]) at bedtime from November 1 through November 18, 2010. RI #15's [MEDICATION NAME] level, dated 11/19/10, was 30.5 ug/ml (micrograms per milliliter). The reference range was 10.0 - 20.0 ug/ml. RI #15's [MEDICATION NAME] level was critically high and had exceeded the high end of the reference range. The nurses' notes for RI #15 documented: "...11/17/10 7:00 AM ...Resident confused in talk... 11-17-10 9:00 AM Resident very confused this AM... Resident not oriented to time, place or year... 10:00 AM... Resident remains very confused - not oriented to time, place, or situation... 11:25 PM Resident very confused this evening..." The nurses' notes for RI #15 documented: "...11/18/10 4:00 AM ... Very confused... 8:30 PM Resident confused... 11-19-10 7:00 PM Resident confused... 11-20-10 12:00 PM Resident confused c/o (complains) 'being kidnapped'... 11-21-10 12:00 Resident confused. Taking her clothes off..." The November 2010 MAR for RI #15, indicated by the nurses' initials, the administration of the [MEDICATION NAME] 300 mg extended cap continued through 11/22/10, when RI #15 was transferred to the hospital and admitted on [DATE]. RI #15's History and Physical, dated 11/23/10, documented the reason the resident was admitted was "... treatment of [REDACTED]. She became psychotic, delusional, aggressive, angry, assaultive toward a co-patient... Her behavior was socially intolerable and at the nursing home, particularly violent behavior. According to the information, this violent behavior had not been present in the past. The patient had been getting severely paranoid, claiming the staff was trying to poison her and to kill her..." The consultation report from the local hospital, dated 11/23/10, for RI #15, documented the physician's impression as: "...1. [MEDICAL CONDITION] with episodic [MEDICAL CONDITION] 2. [MEDICATION NAME] toxicity..." EI #13 was interviewed on 1/05/11 at 5:30 PM. EI #13 stated RI #15 was readmitted to the facility on [DATE] with an order for [REDACTED]. EI #13 further stated the resident should have been receiving 300 mg of [MEDICATION NAME] a day. EI #13 stated the 3 - 100 mg caps were not administered until beginning November 1; although [MEDICATION NAME] in this form should have been initiated in October. The RN stated she did not transcribe the orders to the MAR, as she should have. When asked what period of time did the resident receive more [MEDICATION NAME] than what was prescribed for her, the RN replied from November 1st through the 23 rd, 2010. Based on review of the November 2010 MAR, the resident received 600 mg of [MEDICATION NAME] daily, from 11/01/10 through 11/18/10. From 11/19/10 through 11/22/10, RI #15 continued to receive 300 mg of [MEDICATION NAME] daily at bedtime. The RN further explained the resident had a [MEDICATION NAME] critical value on 11/19/10, which could have caused instability in gait and confusion.