Every finding on record at Hillview Health Center

Based on observation and interview, the facility failed to maintain resident room doorways and hallways in good repair and a homelike environment for 4 resident rooms (#205, #207, #209, #210) of 24 rooms observed for homelike environment on 2 of 5 hallways observed. The findings include: During an environment tour of 5 Halls and 24 rooms on 11/14/2023, starting at 10:00 AM and ending at 10:30 AM, the following concerns were observed: room [ROOM NUMBER] was observed to have scratched/gouged (hole)/scuffed door jamb with missing paint. room [ROOM NUMBER] was observed to have scratched/gouged/scuffed doorjamb with missing paint. In the hallway between rooms [ROOM NUMBERS] showed the bottom portion of the wallpaper had gouged/ripped areas. room [ROOM NUMBER] was observed to have scratched/gouged/scuffed door jamb with missing paint. room [ROOM NUMBER] was observed to have scratched/gouged/scuffed door jamb with missing paint. In the hallway to the left of room [ROOM NUMBER] (exiting room [ROOM NUMBER]) showed 3 holes on the upper portion of the wall. On the 200 hallway near the clean linen room, 12 floor tiles were cracked and deteriorated. On the 300 hallway near the beauty salon, the wallpaper was peeling from the wall along both sides of the seams from trim to handrail. During an observation tour and interview on 11/14/2023 at 10:23 AM, the Maintenance Director confirmed the 200 and 300 hallway areas were in disrepair and those conditions were not a home like environment. During an observation tour and interview on 11/14/2023 at 10:35 AM, the Administrator confirmed the 200 and 300 hallway areas were in disrepair.

Based on policy review, record review, observations, and interviews the facility failed to develop a baseline care plan to include an indwelling urinary catheter (a tube inserted into the bladder to drain urine) for 1 resident (Resident #214) of 18 new admissions reviewed for baseline care plans. The findings include: Review of the facility policy titled, Care Plans-Baseline, undated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .The Interdisciplinary Team will review the healthcare practitioner's orders .and implement a baseline care plan to meet the resident's immediate needs including .Physician orders . Resident #214 was admitted to the facility on [DATE] with diagnoses including Neoplasm of Right Lung, Benign Prostatic Hyperplasia, and End Stage Renal Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was a new admit and the MDS had not been completed. Review of the Physician's Orders dated 11/7/2023, showed .16 FR [French] with 10cc [unit of measurement] indwelling catheter care each shift, change foley cath [catheter] daily as needed, irrigate every 8 hours with sterile water as needed. Review of #214's baseline care plan dated 11/7/2023, showed a section titled Foley Cath which was unchecked and not addressed on the care plan. During an observation on 11/12/2023 at 11:10 AM showed Resident #214 laying in bed with indwelling urinary catheter covered with dingnity bag hanging on bed rails below the bladder level. During an interview on 11/13/2023 at 3:55 AM, the Director of Nursing (DON) confirmed the facility failed to include the indwelling urinary catheter on the baseline care plan.

Based on facility policy review, observation, and interview the facility failed to ensure expired supplies were not available for resident use in 1 of 2 medications storage rooms observed. The findings include: Review of the facility policy titled Storage of Medications, revised ,d+[DATE], showed .The facility stores all .biologicals in a safe, secure, and orderly manner .outdated .biologicals are .to be .destroyed . During an observation and interview on [DATE] at 9:32 AM, in the Station 2 Medication Storage room with Registered Nurse (RN) #1 showed: (2) gray top vacuette tubes (tubes used to collect blood for laboratory values) with an expired date of [DATE]; (2) IV start kits with an expired dated of [DATE]; (1) IV start kit with an expired date of [DATE]; and (7) Invervenous (IV) start kits (a kit used to prepare the arm for IV-a small tube inserted into the vein to administer medications or fluids) insertion with an expired date of [DATE]. RN #1 confirmed the supplies were expired and available for resident use. The medication storage rooms are to be checked once a month by the central supply person, nursing, and pharmacy for expired supplies. During an interview on [DATE] at 9:59 AM, the Director of Nursing confirmed the vacuette tubes and the IV start kits were expired and were available for resident use. It was her expectation that expired supplies to be disposed of when found, and the medication storage rooms are to be checked monthly for expired supplies by the supply stock person, nursing, and pharmacy.

Based on facility policy review and interview the facility failed to ensure all allegations of abuse were reported to appropriate state entities for 1 resident of 4 residents reviewed for abuse. The findings include: Review of the facility Abuse Prevention Policy & Procedure revised 10/1/2017 revealed .All allegations involving abuse, neglect, exploitation or mistreatment .are reported immediately to the state survey agency, adult protective services and all other agencies or required, per state and federal guidelines . Interview and review of a social media video with the Director of Nursing (DON) on 1/11/2021 at 11:40 A.M., in the conference room, revealed the DON was contacted by a unknown person stating an employee of the nursing facility had posted a video to social media of an unknown resident. Continued interview and review of a video revealed the nurse working on the COVID unit in personal protective gear shaking her head. Further review review revealed no residents or facility indicators present in the video. Interview with the DON and Social Services Director (SSD) on 1/12/2021 at 12:05 P.M., in the social services office, revealed the facility failed to report the allegation of abuse to state entities.

Based on observation and interview, the facility failed to properly label and date foods available for resident consumption in 2 of 2 nourishment refrigerators, potentially affecting 65 of 65 residents in the facility. The findings include: Observation and interview with the Dietary Manager (DM) on 3/6/19 at 10:11 AM, in the upstairs nourishment room, revealed: 1 open and unlabeled pint frozen dessert 1 open and unlabeled 15 ounce French onion dip Interview with the DM on 3/6/19 at 10:16 AM, in the upstairs nourishment room, confirmed unlabeled items were available for resident use. Observation and interview with the DM on 3/6/19 at 10:20 AM, in the country kitchen nourishment room (downstairs), revealed: 13 unlabeled 16.9 ounce sodas 7 unlabeled 16.9 ounce flavored waters 1 open, undated, and unlabeled frozen dessert 1 open and unlabeled quart of frozen dessert 2 unlabeled 4 ounce frozen cookies 3 undated and unlabeled freezer pops 4 unlabeled 7 ounce breakfast bowls 1 unlabeled 17 ounce box of breakfast biscuits Interview with the DM on 3/6/19 at 10:32 AM, in the country kitchen nourishment room (downstairs), confirmed undated and unlabeled items were available for resident use. Interview with the Director of Nursing (DON) on 3/6/19 at 2:11 PM, in the DON's office, confirmed the facility failed to properly store foods available for resident consumption.

Based on review of the Resident Assessment Instrument (RAI) Manual Version 3.0, review of the Minimum Data Set (MDS), review of Physician Orders, review of Medication Administration Record [REDACTED]#61) for anticoagulant (medication used to prevent [MEDICAL CONDITION] and blood clots) use of 8 residents reviewed for unnecessary medications of 17 sampled residents. The findings include: Review of the RAI Manual Version 3.0 section N: Medications revealed .Coding instructions .N0410A, Antipsychotic: Record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period .N0410E, Anticoagulant (e.g., (example) [MEDICATION NAME], or low-molecular weight [MEDICATION NAME]) .Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period .code medications according to a drug's pharmacological classification . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual MDS assessment with an Assessment Reference Date (ARD) date of 12/4/18 revealed .Section N - Medications .N0410A: Medication received: Days: antipsychotic 0 . Medical record review of Resident #11's Physician Recapitulation Orders for the month of (MONTH) (YEAR) revealed .OLANZEPINE (antipsychotic medication to treat [MEDICAL CONDITION] Disorder) 15 MG (milligram) TABLET BY MOUTH AT BEDTIME . Medical record review revealed Physician Recapitulation Orders for (MONTH) (YEAR) revealed .OLANZEPINE 15 MG TABLET BY MOUTH AT BEDTIME . Medical record review of Resident #11's (MONTH) (YEAR) MAR indicated [REDACTED] 11/2818 - 11/30/18. Medical record review of Resident #11's (MONTH) (YEAR) MAR indicated [REDACTED] 12/1/18 - 12/4/18. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS assessment with an ARD date of 12/6/18 revealed .Section N - Medications .N0410E: Medication received: Days: anticoagulant 0 . Medical record review of the (MONTH) (YEAR) Physician Recapitulation Orders for (MONTH) (YEAR) revealed .XARELTO (medication to treat blood clots) 15 MG TABLET BY MOUTH AT BEDTIME FOR [MEDICAL CONDITION] . Medical record review of the (MONTH) (YEAR) Physician Recapitulation Orders revealed .XARELTO 15 MG TABLET BY MOUTH AT BEDTIME FOR [MEDICAL CONDITION] . Review of Resident #22's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #22's (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS assessment with an ARD date of 1/18/19 revealed .Section N - Medications .N0410E: Medication received: Days: anticoagulant 0 . Medical record review of the (MONTH) 2019 Physician Recapitulation Orders revealed .XARELTO 20 MG TABLET. GIVE 1 TAB (tablet) EVERY NIGHT with a start date of 10/17/18. Medical record review of Resident #36's (MONTH) 2019 MAR indicated [REDACTED]. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission MDS assessment with an ARD date of 2/13/19 revealed .Section N - Medications .N0410E: Medication received: Days: anticoagulant 0 . Medical record review of Resident #61's Physician Recapitulation Orders for the month of (MONTH) 2019 revealed .ELIQUIS 2.5MG TAKE 1 TABLET BY MOUTH TWICE DAILY . Medical record review of the (MONTH) 2019 MAR indicated [REDACTED]. Interview with MDS Coordinator #2 on 3/5/19 at 12:58 PM, in the MDS office, confirmed the facility failed to document the resident had received an antipsychotic medication during the 7 day look back period for the 12/4/18 assessment. Interview with MDS Coordinators (#1, #2) on 3/5/19 at 12:58 PM, in the MDS office, confirmed .we are not coding Eliquis or Xarelto as anticoagulants . Interview with MDS Coordinator #2 on 3/6/19 at 2:02 PM, in the MDS office, confirmed the MDS for Resident #36 dated 1/18/19 on the 7 day look back period revealed no anticoagulant use. Interview with MDS Coordinator #2 on 3/6/19 at 2:28 PM, in the MDS office, confirmed Eliquis and Xarelto are anticoagulant medications and the assessments for Resident #22 and #61 had not been coded for anticoagulant use.

Based on review of facility policy, medical record review, and interview the facility failed to develop a comprehensive care plan to address anticoagulant (medication used to prevent [MEDICAL CONDITION] and blood clots) for 2 residents (#36 and #61) of 6 residents reviewed for unnecessary medications of 17 residents sampled. The findings include: Review of facility policy Care Planning-Interdisciplinary Team revised 2013 revealed .Our facilities Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #36's Care Plan, dated 10/17/18 revealed the care plan did not address the resident's use of anticoagulant medication. Medical record review of the Physician's Recapitulation Orders for the month of (MONTH) 2019 revealed .10/17/18 .XARELTO (a blood thinner used to prevent blood clotting) .20mg (milligram) TABLET. GIVE 1 TAB (tablet) EVERY NIGHT. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #61's Care Plan, dated 2/7/19 revealed the care plan did not address the resident's use of anticoagulant medication. Medical record review of the Physician's Recapitulation Orders for the month of (MONTH) 2019 revealed .2/7/19 .ELIQUIS 2.5MG TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY . Interview with Minimum Data Set (MDS) Coordinator #2 on 3/5/19 at 1:23 PM, in the MDS office, confirmed a care plan to address the use of an anticoagulant medication had not been developed for Resident #61. Interview with the Director of Nursing (DON) on 3/5/19 at 1:23 PM, in the MDS office, revealed the anticoagulant had not been addressed on Resident #61's care plan. Interview with MDS Coordinator #2 on 3/6/19 at 2:38 PM, in the MDS office, confirmed a care plan had not been developed to address the use of anticoagulant medication for Resident #36. Interview with the DON on 3/6/19 at 3:25 PM, in the DON's office, confirmed the care plan for Resident #36 did not reflect the use of anticoagulant medication. Continued interview confirmed the facility failed to follow the Care Planning/Interdisciplinary Team policy.

Based on review of facility policy, medical record review, and interview the facility failed to ensure Physician Orders Life Sustaining Treatment (POLST) forms were completed for 2 residents (#18 and #324) of 17 residents reviewed. The findings include: Review of the facility policy Do Not Resuscitate Order, revised 4/2017, revealed, .A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form dated 3/24/17 revealed the Physician had not signed and dated Resident #18's POLST form. Medical record review revealed Resident #324 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the POLST form dated 2/19/19 revealed the Physician had not signed and dated Resident #324's POLST form. Interview with the Director of Nursing (DON) on 3/5/19 at 2:28 PM, in the conference room, confirmed the POLST form was incomplete for Resident #324. Continued interview confirmed a POLST form must be signed by the Physician to be valid. Interview with the DON on 3/6/19 at 3:25 PM, in the DON's office, confirmed the POLST form was incomplete for Resident #18. Continued interview confirmed the facility failed to follow the do not resuscitate order policy.

Based on facility policy review, medical record review, observation, and interview the facility failed to correctly administer medication for 2 residents (#173, #174) of 30 opportunities resulting in a greater than 5% medication error. The findings included: Review of the facility policy Medication Administration revealed .5. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route . Medical record review revealed Resident #173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current physician order sheet revealed .Folic Acid (type of vitamin) .1 mg (milligrams) give 1 tablet .one time a day . Medical record review revealed Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current physician order sheet revealed .[MEDICATION NAME] (anti acid medication) .150 mg .give 1 tablet .two times a day . Observation of Charge Nurse #1 on 4/3/18 at 8:09 AM, on the skilled hall unit, revealed the charge nurse administered 800 mcg (micrograms) of folic acid to Resident #173. Observation of Charge Nurse #2 on 4/4/18 at 8:48 AM, on the skilled unit, revealed the charge nurse administered 75 mg of [MEDICATION NAME] to Resident #174. Interview with Charge Nurse #2 on 4/4/18 at 9:30 AM, on the skilled unit, confirmed the charge nurse administered 75 mg of [MEDICATION NAME] instead of the 150 mg dose. Interview with Charge Nurse #1 on 4/4/18 at 10:00 AM, on the skilled unit, confirmed the charge nurse administered 800 mcg of Folic Acid instead of the ordered 1 mg. Interview with the Director of Nursing (DON) and review of the facility Medication Administration policy on 4/4/18 at 11:03 AM, in the conference room, confirmed the charge nurses failed to administer medications as ordered.

Based on facility policy review, observation, and interview the facility failed to disinfect the hands between residents in 1 of 7 dining areas. The findings included: Review of the facility policy, Hand Hygiene Technique, dated 9/14/15, revealed, .The purpose of this procedure is to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections .If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: a. Before or after direct contact with residents .i. After contact with inanimate objects .in the immediate vicinity of the resident . Observation of the meal service on 2/29/16 from 12:00 PM to 12:15 PM, in the main dining room revealed Certified Nurse Aide (CNA) #1 (with bare hands) assisted a resident at Table 1 with cutting meat on the dinner plate then moved to Table 4 to assist a resident with meal set-up (positioning the plate and eating utensils for the resident's convenience). Continued observation revealed CNA #1 touched the bowl of a resident at Table 3, and then patted a resident on the shoulder at Table 4 before moving to set-up the meal for a resident at Table 6. Further observation revealed CNA #1 touched a resident seated at Table 6, then set-up the meal for a resident at Table 7. Continued observation revealed CNA #1 touched another resident at Table 6 and repositioned the resident's plate. Continued observation revealed CNA #1 placed her hands in her pockets. Further observation revealed CNA #1 set-up utensils and repositioned the plate of a resident seated at Table 3, patted the resident on the shoulder, and then moved to Table 5 where she touched a resident seated at that table. Interview with CNA #1 on 2/29/16 at 12:15 PM, in the hallway outside the main dining room confirmed she had not disinfected her hands after touching the residents and assisting the residents with the meal setup. Interview with the Director of Nurses (DON) on 3/1/16 at 10:30 AM, in the DON's office confirmed the facility failed to follow their policy for infection control prevention by disinfecting the hands in between contact with the residents.

Based on observation and interview the facility failed to maintain a clean and sanitary area around the dumpsters to ensure garbage and refuse were disposed of properly. The findings included: Observation with the Dietary Manager on 3/2/16 at 9:52 AM, of the outside dumpsters revealed the area surrounding 2 dumpsters was littered with soft drink bottles, rubber gloves, paper items and multiple cigarettes butts. Interview with the Dietary Manager on 3/2/16 at 10:01 AM, in the kitchen, confirmed the facility failed to dispose of garbage properly.

Based on medical record review, observation, and interview, the facility failed to follow up on a dietary recommendation for one resident (#10) of three residents reviewed for weight loss of thirty-one residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nutritional Risk Review and assessment dated [DATE], revealed "...IWR (ideal weight range) 108-132...weight status gain or loss stable within past 3 months...Intake meets 50-75% of estimated needs..." Medical record review of a dietary note dated December 17, 2013, revealed "December wt (weight) 144# (pounds) Significant wt loss 12#/7.69% x 1 mo (month)...eating 65% average per 7 day review of below nutrition poc (plan of care) including fortified foods tid (three times a day) providing: 2535 cal (calories), 98 gm (grams) pro(protein)/day. Meeting est (estimated) needs with current intake/poc...since wt loss (continues) will recommend house supplement 2 oz (ounces) qid (four times a day) to provide 480 cal, 20 gm pro/day to prevent further wt loss..." Medical record review of a dietary note dated January 7, 2014, revealed "...January wt 144# Weight stable since last mo (month)...continues to meet est needs...encouraged...stable wt since last review...continue current nutrition poc..." Medical record review of the December 2013, and January 2014, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on January 23, 2014, at 8:00 a.m., revealed the resident sitting up in bed eating breakfast of scrambled eggs, whole milk, apples, toast, juice, oatmeal, bacon, and coffee. Interview on January 23, 2014, at 8:00 a.m., with LPN (Licensed Practical Nurse) #1 (nurse responsible for the resident), in the hall, confirmed the resident was not receiving a nutritional supplement. Interview on January 23, 2014, at 8:10 a.m., with the DON (Director of Nursing), in the conference room, confirmed the resident did not receive the house supplement per dietary recommendation. Interview on January 23, 2014, at 8:50 a.m., by telephone, with the Registered Dietician, confirmed was aware the resident had not received the house supplement, and had recommended the house supplement in December because of the resident's continued weight loss. Continued interview confirmed the resident's weight was stable in January and the resident was still meeting estimated needs otherwise would have recommended the supplement again in January.

Based on medical record review, observation, and interview, the facility failed to develop a care plan for weight loss for one resident (#10) of thirty-one residents reviewed. The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a dietary note dated December 17, 2013, revealed "December wt (weight) 144# (pounds) Significant wt loss 12#/7.69% x 1 mo (month)...eating 65% average per 7 day review of below nutrition poc (plan of care) including fortified foods tid (three times a day) providing: 2535 cal (calories), 98 gm (grams) pro(protein)/day. Meeting est (estimated) needs with current intake/poc...since wt loss (continues) will recommend house supplement 2 oz (ounces) qid (four times a day) to provide 480 cal, 20 gm pro/day to prevent further wt loss..." Medical record review of the care plan reviewed on January 13, 2014, revealed no care plan to address the resident's weight loss. Observation on January 23, 2014, at 8:00 a.m., revealed the resident sitting up in bed eating breakfast of scrambled eggs, whole milk, apples, toast, juice, oatmeal, bacon, and coffee. Interview on January 23, 2014, at 8:10 a.m., with the DON (Director of Nursing), in the conference room, confirmed a care plan had not been developed for weight loss.

Based on review of the Trial Balance form for the resident trust accounts, the facility failed to ensure the Patient Fund Bond (surety bond) was sufficient to cover the amount of money in the resident trust account for nine of nine residents with resident trust accounts. The findings included: Review of the Trial Balance form dated January 23, 2014, revealed there were nine residents with trust fund accounts with a total of thirteen thousand, three hundred, thirty-nine dollars,and eight cents ($13,339.08). Review of the Patient Fund Bond revealed the bond amount was ten thousand dollars ($10,000.00). Interview on January 23, 2014, at 9:25 a.m., with the Business Office Manager and the Administrator, in the Administrator's office, confirmed the Patient Fund Bond was not sufficient to cover the amount of money in the resident trust account.

Based on observation, review of Material Safety Data Sheet, and interview, the facility failed to ensure that the resident environment remained free of accident hazards. The findings included: Observation on November 26, 2012, at 10:40 a.m., in the Beauty Shop, revealed the door unlocked, a curling iron on the sink plugged in, hot to touch, and a 64 ounce bottle of barbicide (disinfectant solution) labeled keep out of reach of children. Observation and interview on November 26, 2012, at 10:43 a.m., in the Beauty Shop, with Licensed Practical Nurse (LPN) #1 confirmed the curling iron was hot and the barbicide was not in a locked cabinet. Continued observation revealed LPN #1 exited the Beauty Shop, walked down the hall, and failed to lock the Beauty Shop door. Review of Material Safety Data Sheet (MSDS) for Barbicide revealed "...Health Hazards: Irritating to skin and eyes...Storage: Keep out of reach of children..." Observation and Interview on November 26, 2012, at 10:48 a.m., in the Beauty Shop, with the Director of Nursing (DON) confirmed the curling iron was hot, the barbicide was not in a locked cabinet and the Beauty Shop door should be locked.

Based on medical record review, review of facility documentation, interview, and observation, the facility failed to follow physician's order's for one resident (#9) of thirty-two residents reviewed and failed to complete behavior monitoring for use of an anti-psychotic for one resident (#5) of ten residents reviewed for unnecessary medications. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's order dated November 19, 2012, revealed "...Cath UA (urinalysis) C&S (culture and sensitivity)..." Medical record review of a laboratory result dated November 19, 2012, revealed "...await C&S..." Review of facility documentation on November 28, 2012, revealed no C&S had been performed by the laboratory. Interview with the Director of Nursing (DON) on November 28, 2012, at 1:55 p.m., in the DON office, confirmed the facility failed to follow a physician's order for a C&S for resident #9. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident had long and short term memory problems; severely impaired cognition; no mood or behavior symptoms; active [DIAGNOSES REDACTED]. Medical record review of the Physician's Orders and Medication Administration Records (MAR) revealed the resident had received [MEDICATION NAME] (anti-psychotic) 2.5 milligrams every evening for agitation since April 5, 2011. Medical record review revealed Behavior Forms were present with the MARs for May through November 2012, and were printed with behavior symptoms, interventions, side effects, number of episodes, and outcomes to be monitored. Further review of the Behavior Forms revealed all the forms were blank and had not been completed by staff. Observations on November 27, 2012, at 4:20 p.m., November 28, 2012, at 7:45 a.m., 10:15 a.m., and 1:30 p.m., and on November 29, 2012, at 8:35 a.m., revealed the resident was in bed, sleeping with covers over head or restless, fidgeting and speaking nonsensical language. Interview with the Director of Nursing on November 29, 2012, at 9:40 a.m., in the conference room, confirmed staff were to complete the Behavior Forms daily and the forms had not been completed.

Based on medical record review, observation, and interview, the facility failed to develop a comprehensive care plan to reflect use of an anti-psychotic for one resident (#5) of thirty-two residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident had long and short term memory problems; severely impaired cognition; no mood or behavior symptoms; active [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of the Behavior Forms for May through November 2012, revealed the forms were printed with anti-psychotic side effects, but the forms were blank and had not been completed by staff to indicate the behavior symptoms to monitor, interventions, or side effects monitored. Medical record review of the Care Plan dated October 8, 2012, revealed, "...administer [MEDICATION NAME] per M.D. (physician) orders..." Further review of the care plan revealed no specific interventions, monitoring, or side effects for [MEDICATION NAME] was care planned. Observations on November 27, 2012, at 4:20 p.m., November 28, 2012, at 7:45 a.m., 10:15 a.m., and 1:30 p.m., and on November 29, 2012, at 8:35 a.m., revealed the resident was in bed, sleeping with covers over head or restless, fidgeting and speaking nonsensical language. Interview with the Director of Nursing on November 29, 2012, at 9:40 a.m., in the conference room, confirmed anti-psychotics were to be care planned to include side effects and the care plan was not comprehensive to reflect side effects and interventions related to administration of anti-psychotics.

Based on medical record review, facility documentation review, and interview, the facility failed to respond timely to a grievance for one resident (#9) of thirty-two residents reviewed. The findings included: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact for daily decision making. Interview with the resident on November 26, 2012, at 4:00 p.m., in the resident's room, revealed the resident had received a purse and wallet for the resident's birthday. Continued interview at this time confirmed the purse and wallet were missing. The Director of Social Service was made aware and failed to respond to the grievance. Interview with the resident's daughter on November 28, 2012, at 3:00 p.m., in the resident's room, revealed the Social Worker was made aware during a care plan meeting the purse and wallet were missing. Interview with the Director of Social Service on November 28, 2012, at 3:50 p.m., at the Station Two Nurse's Station, confirmed the facility failed to formally document the resident's concern, after a care plan meeting, and failed to respond to the grievance in a timely manner.

Based on medical record review and interview the facility failed to ensure unnecessary medications were not administered for one resident (#48) of ten sampled residents of thirty-two residents reviewed. The findings included: Resident #48 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's telephone order dated October 23, 2012, revealed "...UA (urinalysis)...C&S (culture and sensitivity)...cath..." Medical record review of a physician's telephone order dated October 25, 2012, revealed "[MEDICATION NAME] (antibiotic) 100 mg (milligram) po (per mouth) BID (twice daily) x (times) 10 d (days)..." Medical record review of the final culture report dated October 25, 2012, revealed the organism [MEDICATION NAME] Aerogenes had been identified and was not sensitive to [MEDICATION NAME]. Medical record review of a physician's telephone order dated October 31, 2012, revealed "...Cipro (antibiotic) 250 mg po q 12 hours x 3 days...C&S received resistant to [MEDICATION NAME]" Interview with the Director of Nursing (DON) on November 28, 2012, at 10:08 a.m., in the station two nurse's station, confirmed the organism was not sensitive to [MEDICATION NAME], the facility failed to notify the physician, and the resident received thirteen doses of [MEDICATION NAME] an unnecessary medication.

Based on medical record review, observation, and interview, the facility failed to provide supervision to prevent accidents and ensure safety devices were in place for one resident (#10) of fifteen sampled residents reviewed. The findings include: Resident #10 was admitted to the facility September 22, 2008, with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set ) dated March 7, 2010, revealed the resident had short and long term memory loss, moderately impaired cognitive skills for daily decision making and was independent with ambulation. Medical record review of the MDS dated [DATE], revealed the resident had short and long term memory loss, severely impaired cognitive skills for daily decision making, was totally dependent for transfer and locomotion on unit, required a wheelchair for mobility, and had a history of [REDACTED]. Medical record review of Falls Risk Assessments dated September 22, 2008, through June 19, 2010, revealed the resident to be at high risk for falls. Medical record review of the nurse's notes and facility documents dated March 27, 2010, through July 20, 2010, revealed the resident had a history of [REDACTED]. Medical record review of the care plan updated May 22, 2010, following a fall on that date, revealed a planned new approach "...mats placed on left side of bed ..." Medical record review of a facility document dated May 25, 2010, revealed "...resident lying in floor beside of bed..." "Immediate intervention implemented: placed non-skid socks on resident." Further review revealed no documentation the safety mat was in place at the time of the fall. Interview with the Director of Nursing, (DON) July 29, 2010, at 9:15 a.m., in the conference room, confirmed there was no documentation of the mat being in place at the resident's bedside at the time of the fall. Medical record review of the care plan dated June 10, 2010, revealed approaches listed: "...Mats on floor at bedside and bed alarm used for safety...assistance of one or two for transfers and uses a wheelchair for locomotion with assistance of one...Certified Nursing Assistants to assist ...to bed directly after meals...non-skid socks applied." Medical record review of documents provided by the facility dated June 13, 2010, revealed, "resident noted to be laying on floor at doorway to room 30...u-shaped laceration in crown area of head with small abrasion on right side of head...Possible cause of event listed as "...resident up in stocking feet, in hallway walking ..." Immediate intervention implemented..."resident instructed not to ambulate without assistance, to use his wheelchair, and to wear shoes." Further review revealed the facility implemented additional interventions: "...6-13-10 bed alarm; 6-14-10 moved to Rm (room) ... for closer observation ..." Interview with the DON, July 29, 2010, at 9:15 a.m., in the conference room, revealed the resident had got out of bed and ambulated to the doorway and confirmed there was no documentation the resident was wearing non-skid socks, no documentation the bed alarm or mat was in place at the time of the fall. Medical record of the facility document dated June 18, 2010, at 2:20 a.m., revealed "...resident sitting on floor beside of bed next to window ...1 cm skin tear on left hand ...0.25 cm bruise on right arm, abrasion on lower right side of back..." Interview with the DON, July 29, 2010, at 9:15 a.m., in the conference room, confirmed there was no documentation of the care planned non-skid socks on the resident, the mat on the floor at bedside, or of the bed alarm in place and functioning at the time of the fall. Observation on July 29, 2010, at 10:00 a.m., in the resident's room, revealed the resident to resting on the bed. The pad was on the floor at the left side of the bed, the pressure pad alarm was still in place, but the non-skid sock was not on the right foot.