Every finding on record at Holy Cross Health Center

Based on observation, record review and interviews, the facility failed to ensure appropriate sanitization of dishware for 1 of 1 kitchen observed. Findings include:Observation on 2/23/26 at 9:00 a.m. in the dishwashing room revealed the dish machine had a final rinse temperature of 176 F (degrees Fahrenheit). During the next run, the final rinse temperature was 172 F. Interview on 2/23/26 at 9:05 a.m. with Staff A (Dietary Aide) confirmed the above findings. Staff A stated that the dish machine is a high temperature unit.Review on 2/23/26 of the February 2026 dish machine temperature logs revealed the following dates that the final rinse temperature was below 180 F with no documented corrective action: 2/1/26 (172 F),2/4/26 (170 F), 2/11/26 (175 F), 2/12/26 (175 F, 178 F), 2/13/26 (175 F), 2/14/26 (170 F), 2/15/26 (174 F), 2/15/26 (165 F), 2/16/26 (174 F), 2/18/26 (179 F), 2/23/26 (176 F) and 2/23/26 (172 F). Review on 2/23/26 of the facility's policy titled Dishwasher Temperature, revised on 6/1/2022, revealed, The final rinse temperature shall be 180 F or above but not to exceed 194 F. Corrective actions shall be taken for any final rinse temperature below the required final rinse temperature.5. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. Review on 2/23/26 of the FDA Food Code 2022, retrieved from: https://www.fda.gov/media/164194/download, revealed: .4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions .501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: .(2) For all other machines, 82 C (180 F) .Review on 2/23/26 of the ECOLAB XL-HT dish machine specification revealed, .Operating temperatures sanitizing rinse (minimum) 180 F.Interview on 2/23/26 at 2:00 p.m. with Staff C (Director of Nursing) confirmed the above policy and manufacturer's instructions.

Based on interview and record review, it was determined that the facility failed to ensure that the required committee members attended Quality Assurance Performance Improvement (QAPI) meetings at least quarterly for 3 of the 4 quarterly meetings reviewed for 2024. Findings include: Review on 1/3/25 of the first quarter QAPI meeting attendance sheet, dated 1/26/24, revealed that the Medical Director or designee (required member) was not in attendance. Review on 1/3/25 of the second quarter QAPI meeting attendance sheet, dated 4/26/24, revealed that the Infection Preventionist (required member) was not in attendance. Review on 1/3/25 of the fourth quarter QAPI meeting attendance sheet, dated 10/25/24, revealed that the Infection Preventionist (required member) was not in attendance. Interview on 1/3/25 at approximately 2:00 p.m. with Staff A (Administrator) confirmed the above findings. Interview on 1/3/25 at approximately 11:00 a.m. with Staff B (Infection Preventionist) revealed that he/she did not attend the above mentioned QAPI meetings because they were working as a nurse on the unit during scheduled quarterly QAPI meetings.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 6 of 92 days reviewed for Quarter 4 - 2022 (July 1 - September 30, 2022). Findings include: Review on 1/25/23 of the facility's Payroll Based Journal Staffing Data Report for Quarter 4 - 2022 revealed that there were no RN hours for the following days; 7/4/22, 7/9/22, 7/10/22 and 8/20/22. Review on 1/26/23 of the facility's daily staffing for 7/1/22 through 9/30/22 revealed the following; - On 7/4/22, 7/9/22, 7/10/22, 8/20/22, 9/4/22 and 9/5/22 revealed that a RN was not scheduled or documented as worked. - These 6 days fell either on a weekend or a holiday. Interview on 1/26/23 at 1:12 p.m. with Staff A (Director of Nursing), who is an RN, confirmed that there was not an RN working the above days. Staff A confirmed that he/she and Staff C (RN, Infection Perfectionist) work Monday through Friday with holidays off. Staff A confirmed that he/she had worked Monday through Friday from 12/25/22 through 1/26/23. Review on 1/26/23 of the facility's daily staffing for 12/25/22 through 1/27/23 revealed that there was an RN working 8 hours daily (the past 33 days).

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were secure and unavailable to unauthorized staff and residents on 1 out of 1 nursing units (Resident identifier is #17). Findings include: Observation on 1/25/23 at approximately 10:00 a.m. of Resident #17's room revealed the following medications unattended (no staff or residents in the room) on the bedside table: 1. Alphagan 0.1 percent (%) ophthalmic drops 2. Dorzolamide hydrochloric acid (HCL) ophthalmic 2% drops 3. Latanoprost 0.005% ophthalmic drops 4. Biofreeze (gel) Observation on 1/25/23 at approximately 11:00 a.m. of Resident #17's room revealed the above medications unattended on the bedside table. Observation on 1/26/23 at approximately 9:00 a.m. of Resident #17's room revealed the above medications unattended on the bedside table. Interview on 1/26/23 at approximately at approximately 12:50 p.m. with Staff A (Director of Nursing) revealed that Resident #17 keeps his/her self-administrated medications on the bedside table. Interview on 1/26/23 at approximately 1:55 p.m. with Staff B (Licensed Nursing Assistant) revealed that there are a few residents that wander on the unit. Review on 1/26/23 of the facility policy titled, Self-Administration of Medications, Revision Date February 2021 revealed: . 2.f The resident is able to safely and securely store the medication. . 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. .

Based on interview, and policy review, it was determined that the facility failed to maintain infection control practices according to accepted national standards for 1 of 1 staff member reviewed for returning to work after COVID-19 infection. Findings Include: Review on 1/26/23 of the Centers for Disease Control (CDC) Interim Guidance for Managing Healthcare Personnel with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) . Infection or Exposure to SARS-CoV-2, updated on 9/23/22 and retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Freturn-to-work.html, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection . HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: - At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and - At least 24 hours have passed since last fever without the use of fever-reducing medications, and - Symptoms (e.g., cough, shortness of breath) have improved. *Either a NAAT [Nucleic Acid Amplification Test] (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later . Review on 1/26/23 of the facility's form titled COVID-19 Positive Staff Members in the Last Four Weeks as of 1/26/23 revealed Staff D [title omitted] had onset of symptoms on 1/12/23 and tested positive for COVID-19 on 1/14/23. Further review revealed that Staff D tested negative for COVID-19 on 1/18/23 and returned to work on 1/19/23. Further review revealed that in the past 4 weeks only 1 other staff member testing positive and had not yet returned to work. Review on 1/26/23 of the facility's form titled COVID-19 Testing January 9-January 15, 2023 revealed that Staff D tested negative for COVID-19 on 1/12/23 and tested positive for COVID-19 on 1/14/23. Review on 1/26/23 of the facility's daily staff assignments for 1/19/23 and 1/20/23 revealed that Staff D worked both days. Review on 1/26/23 of the facility's policy titled COVID-19 Testing and Transmission-Based Precautions/Quarantine Policies and Procedures, updated 9/27/22, revealed, .Quarantine .for staff members . Symptomatic - Positive Test. Symptomatic staff members will be asked to quarantine for 5 days from onset of symptoms or positive COVID-19 test. Day zero is the day in which one test positive or the day of onset of symptoms. The subsequent day is day one . Interview on 1/26/23 at 11:03 a.m. with Staff C (Registered Nurse/Infection Preventionist) revealed that Staff D had a symptom of fatigue on 1/12/23 and tested negative for COVID-19. On 1/14/23 Staff D had an additional symptom of congestion and tested positive for COVID-19. Staff C stated that the facility used CDC guidance for the return to work after COVID-19 and stated it was 5 days if tested and no symptoms. It was requested that Staff C produce the CDC guidance stating this. Review on 1/26/23 of the CDC COVID-19 Ending Isolation and Precaution for People with COVID-19, updated 8/31/22 and provided by Staff C (which was the guidance the facility was using) revealed, . This page is intended for use by healthcare professionals who are caring for people in the community setting . These recommendations do not apply to healthcare personnel in the healthcare setting . For healthcare settings, please see Managing Healthcare Personnel with SARS-CoV-2 infection . Interview on 1/26/23 at 1:50 p.m. with Staff C confirmed that the facility was using the incorrect guidance and confirmed this guidance was not intended for health care personnel. Staff C confirmed that the facility's policy needed to be updated based off the correct guidance of at least 7 days. Staff C confirmed that Staff D should not have returned to work on 1/19/23.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse was on duty for 8 consecutive hours a day 7 days a week for 9 out of 10 weekend days reviewed (1/1/22 to 2/3/22). Findings include: Review on 2/3/22 of the facility's daily staffing from 1/1/22 to 2/3/22 revealed that a Registered Nurse was not scheduled or documented as worked on Saturday or Sunday for the following days; 1/2/22, 1/8/22, 1/9/22, 1/15/22, 1/16/22, 1/22/22, 1/23/22, 1/29/22 and 1/30/22 (total of 9 days). Interview on 2/3/22 at 8:45 a.m. with Staff B (Director of Nursing) and Staff C (Administrator) revealed that the facility typically did not have a Registered Nurse working on the weekends. Staff C stated the facility was actively recruiting to hire Registered Nurses. Staff B stated that he/she and Staff D (Staff Development) are both Registered Nurses and are on-call every weekend. Review on 2/3/22 of Staff B's and Staff D's January 2022 schedule revealed that Staff D worked 2.5 hours on Sunday 1/23/22 with no other weekends worked. Interview on 2/3/22 at 9:23 a.m. with Staff D confirmed Staff D did not work any weekend day in January 2022 other than the above hours on 1/23/22. Staff D stated he/she was performing COVID-19 testing on 1/23/22 to employees. Staff D confirmed he/she was on-call every weekend. Interview on 2/3/22 at 9:45 a.m. with Staff B confirmed he/she had not worked any weekends in January 2022. Review on 2/3/22 of the facility's Resident Census and Conditions of Residents (Form 672) revealed that the current census was 23 of 40 certified beds.

Based on interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with the comprehensive person-centered care plan, and the residents' goals for 1 resident out of 3 residents reviewed for pain management in a final sample size of 12 residents. (Resident identifier #1.) Findings include: Interview on 2/2/22 at approximately 10:27 a.m. with Resident #1 revealed that they had pain in their toes that makes it difficult to walk and that they receive Tylenol but it does not help. Resident #1 stated that nursing is aware that the Tylenol does not help. Review on 2/3/22 at approximately 9:12 a.m. of Resident #1's medical record revealed the most recent physician's note dated 12/29/21, stated pain in toes, Tylenol not effective with recommendation to start [NAME] Gel 1 % (percent) twice a day to right toes. Further review of Resident #1's medical record revealed a physician's telephone orders dated 12/30/21 to Change [NAME] Gel order to the generic form, Diligence Sodium 1% Gel. Review on 2/3/22 at approximately 9:15 a.m. of Resident #1's medical record revealed on the January 2022 MAR (Medication Administration Record)/TAR (Treatment Administration Record) an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .D/C [discontinue] Insurance doesn't cover [NAME] . Further review of February 2022 MAR / TAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 2/3/22 at approximately 9:15 a.m. of Resident #1's medical record revealed no physician orders to discontinue Diligence Gel. Further review of Resident #1's medical record revealed no documentation that the provider was notified that the medication was not being utilized. Interview on 2/3/22 at approximately 9:20 a.m. with Staff A (Registered Nurse) confirmed that there was no order to discontinue Diligence Gel and no documentation to the provider regarding the medication no being utilized. Review on 2/3/22 at approximately 9:30 a.m. of Resident #1's January 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 1/3/22 for general discomfort results documented as + (positive effect); 1/6/22 for right foot and toe pain results documented as +; 1/7/22 for right foot pain results documented as +; 1/8/22 for right foot pain results documented as fair; 1/9/22 for right foot pain results documented as + sleep; 1/26/22 for right foot pain results documented as pending. Review on 2/3/22 at approximately 10:00 a.m. of Resident #1's pain care plan revealed a goal of .will not have interruption in normal activities due to pain .will verbalize adequate relief of pain . both revised on 1/7/22 and an intervention dated 12/29/21 .[NAME] Gel 1% apply twice daily to right toes . Interview on 2/3/22 at approximately 1:30 p.m. with Staff B (Director of Nursing) confirmed that Resident #1 did not receive the Diligence Sodium Gel as it was not transcribed on to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that perishable food and liquids in two of two resident refrigerators on the nursing units observed were not expired or past perish dates. Findings include: Observation on [DATE] at approximately 10:10 a.m. revealed a staff member removing liquids to give to a resident from the first floor resident refrigerator. Observation on [DATE] at 10:10 a.m. of the first floor resident refrigerator revealed the following: -One chocolate supplement shake with a hand written date of ,[DATE]; -Two [MEDICATION NAME] milks with manufacturer stamped date of [DATE]; -One fat free milk with manufacturer stamped date of ,[DATE]; -One fat free milk with manufacturer stamped date of ,[DATE]; -One ensure plus with manufacturer stamped date of 1 [DATE]; -One medium size container of applesauce that was ,[DATE] full that had a hand written date of ,[DATE] and a hand written use by date of ,[DATE]; -One loaf of wheat bread with a manufacturer fresh through date of ,[DATE] and a hand written date of ,[DATE]; -One half loaf of raisin bread with a manufacturer fresh thru date of ,[DATE]. It did not have a hand written date on it. Interview on [DATE] at 10:15 a.m. with Staff B (Director of Nursing) confirmed there were outdated items in the refrigerator. Staff B stated he/she thought that the kitchen staff were responsible for checking for expired items. Interview on [DATE] at 10:15 a.m. with Staff A (Administrator) revealed that due to COVID-19 the aides were responsible for checking the refrigerators. Observation on [DATE] at 10:20 a.m. of the second floor resident refrigerator revealed the following: -One loaf of raisin bread that had a manufacturer fresh through date of ,[DATE] and a hand written date of ,[DATE]; -One loaf of wheat bread that had a manufacturer fresh through date of ,[DATE]. It did not have a hand written date on it. Interview on [DATE] at approximately 10:30 a.m. with Staff C (Food Service Director) confirmed that the above items in both refrigerators, including the containers of milk, shakes, applesauce and breads were out of date and should be discarded. Staff C stated it was the facility's policy to date foods when they are removed from the freezer (such as the breads) and confirmed that this was not done for the above items. Staff C stated that when bread was pulled from the freezer, they were good for 10 days. Interview on [DATE] at 9:30 a.m. with Staff D (Licensed Practical Nurse) confirmed that the food and liquids in the first floor refrigerator were being currently used for the residents on the 100 hall. Staff D stated that the staff would make toast and offer juice or milk for the residents. Review on [DATE] of the facility's Policy and Procedure titled Refrigerators and Freezers revised [DATE] read, in part, This facility will . observe food expiration guidelines 7. All food shall be appropriately dated to ensure proper rotation by expiration dates Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufactures when expiration date are in question or to decipher codes.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that all drugs and biological's used in the facility were labeled in accordance with manufacturer's instrutions for 1 of 2 medication carts reviewed. Findings include: Observation on 01/20/21 at 12:45 p.m. of the medications stored in the medication cart located on the 2nd floor with Staff E (Charge Nurse) revealed the following medications located in the unit's medication cart did not have the date written on the bottle of when they were opened to determine how long the medication could be used to medicate facility residents: Resident #17 [MEDICATION NAME] Insulin 100 units/milliliter had no open or open expiration date on the container to then be able to determine the expiration date per manufacturer's instructions. Review of [MEDICATION NAME] manufacture's instructions. Noted in the section 'After vials have been opened'; paragraph 2 'Throw away all opened LEVIMIR vials after 42 days, even if they still have insulin left in them' Interview on 1/20/21 at 1:15 p.m. with Staff E revealed when Staff E (Licensed Practical Nurse) confirmed that the [MEDICATION NAME] was opened and was in use.

Based on review of facility reported incident, medical records, policy and procedures, witness statements and interviews, it was determined that the facility failed to report 4 of 4 allegations immediately to the facility administrator and failed to report to the State agency in a timely manner. (Resident identifiers are #1, #2, #3 and #4.) Findings include: Resident #1 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C (License Nursing Assistant). Review on 2/27/20 at approximately 9: 00 a.m. of Staff A's (License Practical Nurse) witness statement dated 2/5/20 revealed that Staff C was in Resident #1's room when Staff A heard Resident #1 yelling, checking with Staff C, Staff C indicated to Staff A that Resident #1 was trying to hit Staff C. Resident #1 who has dementia was unable to explain what was happening. Staff A spoke to Staff C about this incident, but did not report this to either Staff D (Director of Nurses) or Staff [NAME] (Administrator) at that time. Interview on 2/27/20 at approximately 8:30 a.m. with Resident #1 revealed that Resident #1 was not afraid of staff and could not recall any staff mistreating Resident #1. Review on 2/27/20 of Resident #1's medical record revealed the latest BIMS (Brief Interview For Mental Status) dated 12/13/19 was a 4, which means severe cognitive impact. Resident #2 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C. Review on 2/27/20 of Resident #2's medical record revealed the latest BIMS dated 12/24/19 was a 2, which means severe cognitive impact. Resident #3 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C. Review on 2/27/20 of Resident #3's medical record revealed the latest BIMS dated 1/16/20 was a 1, which means severe cognitive impact. Resident #4 Review on 2/27/20 of a facility reported incident dated 1/31/20 of allegation of verbal abuse towards Resident #1 revealed that the allegation of abuse took place on 1/30/20 during the 3-11 and 11-7 shifts by Staff C. Review on 2/27/20 at approximately 9 :00 a.m. of Staff B's, (License Practical Nurse) witness statement dated 1/30/20 revealed Staff B over heard Staff C to pee in your diaper I will change you. if you ever call out for help again I will put you on your recliner. I am not bothered by your screaming, I've got kids at home. Staff C did transfer Resident #4 to the recliner in the middle of the night due to Resident #4 yelling out help help. when Staff B did notice that Resident #4 was in the recliner Staff B returned Resident #4 to bed. Review on 2/27/20 of Resident #4's medical record revealed the latest BIMS dated 12/12/19 was a 8, which means moderately cognitive impact. Interview on 2/27/20 at approximately 11:00 a.m. with Staff B by phone confirmed that Staff C was yelling Residents #1, #2, #3 and #4 at different times beginning at the end of (MONTH) and continuing into (MONTH) but did not report it to Staff D or E. Staff B was afraid to report the incidents to Staff D and E. Staff C could not give any specific dates other then the general month. Staff B, finally reported the occurrences on the morning of 1/30/20 to Staff D and E. Review of the facility's policy and procedure titled Abuse and Neglect- Clinical Protocol, revision date (MONTH) (YEAR) revealed: Reporting: . 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. Protection of patients during investigations; and reporting of incidents, investigations, and center response of their investigations. Review of the facility's Policy and Procedure titled Reporting Abuse Protocol, revision date 1/2018 revealed: When investigating a report of abuse whether Resident-to -Resident or Staff to Resident, the following needs to be completed. 1. Intervene and ensure the residents well-being. 2. Report the incident to the Charge Nurse. Charge Nurse will: IMMEDIATELY 3. Remove the person involved to a private area and get their written statement. 4 Contact BOTH (Staff D Director of Nurses), (phone numbers omitted) AND (Staff [NAME] Administrator) , (phone numbers omitted). If you must leave a message, specify the time you called and that you need a call back ASAP (As soon as possible) regarding a complaint. Interview on 2/27/20 at approximately 11:30 a.m. with Staff [NAME] confirmed that the allegations were not reported to Staff [NAME] or to Staff D within 24 hours of the occurrences. Staff [NAME] revealed that Staff C was reported to the Board of Nursing on 2/6/20 and Staff C was terminated.

Based on observation, record review and interview, it was determined that the facility failed to meet professional standards of quality for the medication pass for 1 resident in a survey sample of 12 residents. (Resident identifier is #11.) Findings include: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 3/28/17 at 8:10 a.m. of medication pass task with Staff A (Licensed Practical Nurse) revealed Resident #11's physician order [REDACTED].= 75 mg) every day - hold for systolic BP (blood pressure) less than 90 or HR (Heart Rate) less than 60. Staff A did not check BP or HR during observation. Review on 3/28/17 of Resident #11's MAR (Medication Administration Record) revealed that the medication [MEDICATION NAME] had blood pressure parameters that had not been done prior to the medication administration. The BP and HR had a box indicated in the MAR for documenting the readings. These boxes were empty. In February 2017 there were 12 BP omissions in the MAR and in March 2017 there were 22 BP omissions in the MAR. Interview on 3/28/17 at approximately 8:15 a.m. with Staff A confirmed that Resident #11's BP and HR were not performed prior to medication administration on 3/28/17 during observation of medication administration. Interview on 3/28/17 at approximately 8:50 a.m. with Staff B (Assistant Director of Nurses) confirmed that there was no record of BP's or HR's in Resident #11's medical record.

Based on record review and interview it was determined that the facility failed to have completed CAA (Care Area Assessment) Trigger Summary for 8 residents in a survey sample of 10. (Resident identifiers are, #2, #3, #4, #5,#6, #7, #8, and #9). Findings include: Record review revealed that the CAA trigger summaries failed to have documentation for the reason the resident did or did not need care in several clinical areas. Interview with Staff C (MDS Coordinator) confirmed that the areas that failed to have clinical documentation are sections A, G, H, I, J, M, N, O, P, V, X, and Z. Staff C also indicated that the first Admission, Annual or Significant change MDS which all include CAAs were not completed correctly since 6/25/13 until present. Staff C also indicated that Staff C was unaware that each area needed documentation for the above section but did confirm that all care plans were complete.

Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, revealed the following page 707 that "...The six of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation Right Medication. A medication order is required for every medication you administer to a client... Right Documentation. ....After administering the medication, indicate which medications were given on the client's MAR per agency policy to verify that the medication was given as ordered Based on observation and interview the facility failed to administer medications according to professional standards of quality on 1 Resident in a standard survey sample of 10. (Resident identifier is #3.) Findings include: Observation on 2/12/14 at 6:45 p.m. revealed medication was given to Resident #3 during medication pass observation. When reconciling the medications with the Physician Orders, it was found that the order [MEDICATION NAME] mg 1 tab 2 times a day had been discontinued on 11/13/13. Medication listed above was not on current MAR for Resident #3 so therefore can not be documented on MAR as being administered. Interview with Staff A (LPN), on 2/12/14 stated "It must be there the resident has been on it forever". Interview with Staff B (Director of Nursing) confirmed order had been discontinued on 11/13/13 and was not on the current MAR and should not have been administered.

Based on observation and interview the facility failed to ensure that a resident receives only those medications, in dose & for the duration clinically indicated to treat the resident's assessed condition for 1 resident in a standard survey sample of 10. (Resident identifier is #3.) Findings include: Observation on 2/12/14 at 6:45 p.m. revealed medication was given to Resident #3 during medication pass observation. When reconciling the medications with the Physician Orders, it was found that the order [MEDICATION NAME] mg 1 tab 2 times a day had been discontinued on 11/13/13. Medication listed above was not on current MAR for Resident #3 so therefore can not be documented on MAR as being administered. Interview with Staff A (LPN), on 2/12/14 stated "It must be there the resident has been on it forever." Interview with Staff B (Director of Nursing) confirmed order had been discontinued on 11/13/13 and was not on the current MAR and should not have been administered.

Based on record review and interview it was determined that the facility failed to stabilize, and not transfer 2 of 2 residents by hoyer who sustained a fall with pain/ soreness in a survey sample of 10. (Resident identifier are: #4 and #7) Findings include: Review of the facility falls assessment policy states 1. All residents will be assessed by licensed nurse before moving. 2. Stabilize the resident at the side of the incident-use blankets, pillows, etc Review of the facility's "Post Fall Decision Tree" states: Lower ROM (hip, leg, foot) @ baseline. No external rotation or pain...If no call 911 Review of the facility's "Sample of Nurse's Note and Caregiver Statement Documentation"...When asked if she has any pain, soreness, discomfort she replied 'yes/no' If yes, where is pain, how much pain if she can use 0-10 scale or facial expressions if she cannot. IF IN PAIN/DISCOMFORT DO NOT MOVE, CALL 911 SEND TO ER. AND CHECK VITALS. Resident #4 During record review it was documented in the nurses notes dated 11/11/13 at 8:35 a.m. "Resident sitting up on bathroom floor c/o (complaining of) rt (right) hip pain, able to move upper extremities, (no) range of motion to right leg, leg positioned to side, not able to move right leg. Pointed to rt (right) hip area 'that hurts' ...resident hoyered into bed". Another nurses note was written on 11/11/13 at 1:40 p.m. "Transported by ambulance via stretcher." Just prior to this nurses note was a entry that states "...X ray ordered, + (positive) for rt (right) femoral neck fracture (with) moderate displacement". Interview with Staff B (Director of Nurses) on 2/13/14 confirmed the above findings and stated that Resident #4 should not have been hoyered after a fall with positive signs of pain and inability to move their lower right extremity resident should have been made comfortable on the floor and 911 should have been called. Resident #7 On 10/20/13 at 2300 nurses notes indicated, "While passing meds I was stationed in the hallway by Sr's (Sisters) room. A loud noise was heard followed up by a call for 'help'. LNA & (and) nurse both entered the room. Resident was sitting on the floor on R(right) hip area facing the door and supporting self (with) R (right) hand. Walker not positioned near resident, ROM (Range of Motion). WNL (Within Normal Limits) however resident stated that R (right) hip, groin & (and) pelvic area on R (right) side was sore...myself along with 2 LNA's hoyered resident to lying position on bed..." On 10/21/13 at 0200 nurses notes states "Res (Resident) c/o (complaining of) 10/10 to R (right) hip/pelvic area @(at) approximately 0130. (physician) notified....send resident to (hospital)...". The Ombudsman report that was provided by the facility dated 10/20/13 indicates "...At 0600 this morning, our staff was notified that sister has a fractured hip and that she was admitted ..." Resident #7 also was showing soreness, and as stated under the "Sample of Nurse's Note and Caregiver Statement Documentation"... " When asked if she has any pain, soreness, discomfort she replied 'yes/no' If yes, where is pain, how much pain if she can use 0-10 scale or facial expressions if she cannot. IF IN PAIN/DISCOMFORT DO NOT MOVE, CALL 911 SEND TO ER. AND CHECK VITALS".

Based on record review, observation and interview, the facility failed to ensure that a resident is fully informed in advance about treatment involving the use of [MEDICAL CONDITION] drugs for 1 of 10 residents in a standard survey sample and 1 out of sample resident. (Resident identifiers are #7 and #11.) Findings include: Review of the facility's policy named Nursing Protocol [MEDICAL CONDITION] Medications Policy reveals that : All orders for antipsychotic, antidepressants, anti-anxiety, sedative medications need to have a "target" behavior or behaviors indicated on the MD(Medical Doctor) order...At the start of a new [MEDICAL CONDITION] medication: 1. A signed consent is required by the resident (if DPOA(Durable Power of Attorney) has not be activated) 2. or the DPOA (if the DPOA has been activated) must give verbal consent before the medication can be started, This must be noted on the form in this manner "DPOA notified and will sign during next visit". You must sign this statement. 3. The resident or DPOA are informed of the effects and side effects (risks and benefits) of the medication and this needs to be documented in the nurse's notes..." Resident #7. Review on 4/3/13 of Resident #7's medical record revealed that Resident #7 was admitted to the facility on [DATE] with an order for [REDACTED]. Review of Resident #7's record revealed no documented evidence of a written consent form or documentation in the medical record about the use, risks and benefits of the antipsychotic medication had been explained to the resident prior to administration of the medications. Interview on 4/3/13 at 3:15 p.m. with Staff B ADON (Assistant Director of Nursing) revealed that the facility does use consent forms for the use of antipsychotic medications but that there was no consent documentation for Resident #7's use of [MEDICATION NAME] since the orders were obtained in the community and the orders were continued when admitted to the facility. Review of Resident #7's medical record revealed no documented evidence that Resident#7 had been explained the use, risks and benefits of the antipsychotic medication [MEDICATION NAME] had been explained to the Resident #7. Resident #11. During medication pass on 4/2/13 at 1:00 p.m. it was observed that Resident #11 received [MEDICATION NAME] 0.5 ml topically at 1 p.m. and was told that it was "lotion" by Staff A, RN (Register Nurse). Review on 4/2/13 of Resident #11's medical record revealed that Resident #11 had a DPOA activated on 2/5/11. Review of the physician's orders [REDACTED]. Review of the nurse's note written by Staff C, LPN, (Licensed Practical Nurse) on 6/22/12 revealed that the DPOA (pronoun omitted) is away for the weekend left message for her/him to call r/t (related to) n/o (new order). Review of Resident #11's record revealed no documented evidence of a written consent form or documentation in the medical record that the use, risks and benefits of the antipsychotic medication have been explained to the resident and/or responsible party prior to administration of the medications. Interview on 4/2/13 at 1:00 p.m. with Staff D, DON ( Director of Nursing) revealed that the facility does use consent forms for the use of antipsychotic medications but that there was no consent documentation for Resident #11's use of [MEDICATION NAME] or that a follow up called had been place to DPOA.

Based on record review and observation it was determined that the facility failed to follow the professional standard of practice for the administration of medication and transcribing for 1 resident in a standard survey sample of 10 residents. (Resident identifier is #4.) Findings include: Review of "Fundamentals of Nursing," Patricia A. Potter and Anne Griffin Perry, Mosby, 2009, 7th Edition, St. Louis, Missouri revealed the following professional standards on page 713 states, "Sometimes the nurse or a designated unit secretary writes the prescriber's complete order on the appropriate medication form, (e.g., the MAR) or enters the order into the client's electronic medical record." On page 709, under "Right Documentation" it states "After administering the medication, indicate which medications were given on the client's MAR (medication administration record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client." Review of E-book "Clinical Nursing Skills and Techniques," Patricia A. Potter and Anne Griffin Perry, Wendy R Ostendorf, Elsevier Mosby, 2014, 8th Edition, St. Louis, Missouri revealed the following professional standards on page 473, "The Joint Commission (TJC) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety (TJC,2012a). Medication errors include inaccurate prescribing; administrating the wrong medication, route, and time interval; and administering extra doses or failing to administer a medication." On page 488, Under the section "Pre-Administration Activities... 7. Use good hand-hygiene techniques. Avoid touching tablets and capsules. Use sterile techniques for [MEDICATION NAME] medications. Wear clean gloves when administrating [MEDICATION NAME] medications and certain topical medications..." Resident #4 On 4/2/13 at approximately 12:45 p.m. during the Observation of the Medication Pass, Staff A RN, (Register Nurse)was observed pouring 2 caplets of [MEDICATION NAME] 500 mg (milligrams). Staff A, poured the medication in Resident #4's hand after elevating the head of the bed up. Staff A removed a caplet from Resident #4's hand after Resident #4 already had taken one of the caplets. When this surveyor interview Staff A at the time of the medication Pass why Staff A removed the caplet with Staff A's bare hand Staff A indicated that Staff A hands were clean and that Staff A was afraid Resident #4 would drop the other caplet in the bed. Staff A indicated that Staff A should have used the medication cup instead. Review of Resident #4's medical record revealed the physician's orders [REDACTED]. Review of the March and April's MAR (Medication Administration Record) revealed that the [MEDICATION NAME] is given at 0600 (6:00 a.m.),1300 (1:00 p.m.) and 2100 (9:00 p.m.), which does not fit the parameters of every 8 hours.

Based on observation and interview the facility failed to remove expired medication from the medication room and to ensure glucose control solutions are labeled correctly and to ensure that the 1 of 2 of the medication carts were locked on the 2nd floor. Findings include: On [DATE] at approximately 12:40 p.m. during the Observation of the Medication Room with Staff A , this surveyor was observed a bottle of Acetaminophen 500 mg.(milligrams) 1000 caplets with had an expiration date of ,[DATE]. During an interview at the same time Staff A, RN (Registered Nurse) confirmed that the bottle of Acetaminophen had an expired date of ,[DATE] and that it should go into the pharmacy box to be discarded so no one would use it. Observation of the one of the medication cart (south corridor)on the 2nd floor on [DATE] at 12:45 p.m. one of the medication carts was observed to be unlocked (the lock was in the partial open position.) Staff A was not near the cart but in the Medication Room an prior to that at the other medication cart around the corner. Staff A upon returning to the cart immediately locked the cart and confirmed by interview that the cart was left unlocked and should not be left unlocked at any time. At approximately 2:45 p.m. while looking in the one of the medication cart(east/west corridor) for the glucose control solution for the glucose monitors revealed that the date when the solutions had been opened had been rubbed off therefore, the staff was unable to know when the solution had been opened and had no idea when the 90 days would be to throw away. All this surveyor could see was what appeared to be a reddish dot. Interview with Staff A at this time confirmed the above findings of the glucose control solutions.

Based on interview and record review, the facility failed to report to the administrator immediately a new identified bruise, failed to report 2 separate incidents of a bruise within 24 hours to the State survey and certification agency, failed to complete a thorough investigation of 2 separate incidents of a bruise and failed to report the results of the investigation of 2 separate incidents of a bruise within 5 days to the State survey and certification agency for 1 Resident in a survey sample of 10 residents. (Resident identifier is #6.) Findings include: On 3/27/12 during review of the medical record for Resident #6, a nurse note dated 1/25/12 (3-11) revealed the following: "LNA reported bruises R (Right) side of cheek and R hand near thumb and forefinger about 1/2 dollar size. Nurse/writer assessed no swelling/redness. Incident report done." On 3/27/12 review of a facility document titled "Incident/Accident Report" for Resident #6 dated 1/25/12 documents the bruises were of "unknown etiology" During an interview on 3/27/12 with Staff B, (Director of Nursing) it was revealed that the facility did not have documentation of investigation and conclusion of the incident. It was further revealed during the interview that the bruise was not reported to the State survey and certification agency within 24 hours and the facility did not report the final investigation and conclusion to the State survey and certification agency within 5 days. On 3/27/12 during review of the medical record for Resident #6, a nurse note dated 2/9/12 (3-11) signed by Staff C (Agency LPN) revealed the following: "Called to bedside by LNA. Patient (symbol for with) 2 x 2 cm bruise noted to L (Left) outer elbow. Skin intact. No other new areas noted." During an interview on 3/27/12 with Staff B, it was revealed that Staff B that Staff C failed to report the incident to the Administrator immediately of the bruise, there was no incident report completed and the facility did not complete an investigation and conclusion of the incident. It was further revealed during the interview that the bruise was not reported to the State survey and certification agency within 24 hours and the facility did not report the final investigation and conclusion to the State survey and certification agency within 5 days.

Based on interview and record review, the facility failed to follow written policies and procedures for abuse/neglect training: The facility failed to report to the administrator immediately a new identified bruise, failed to report 2 separate incidents of a bruise within 24 hours to the State survey and certification agency, failed to complete a thorough investigation of 2 separate incidents of a bruise and failed to report the results of the investigation of 2 separate incidents of a bruise within 5 days to the State survey and certification agency for 1 Resident in a survey sample of 10 residents. (Resident identifier is #6.) Findings include: Policy: Review of the facility's Abuse/Neglect Policy revealed the following: 2. Training b. ...Holy Cross Health Center provides orientation and in-service training on resident abuse, mistreatment and neglect... c. ix "Alleged abuse or neglect will be reported to the state DHHS, Ombudsman and appropriate state certification agencies within 24 hours by the DON, Director of Social Services or Administrator. 4. Identification a. "Bruises and injuries of unknown origin are fully investigated to determine cause. 5. Investigation b. "Notes will be taken during interviews of all staff, residents and family members involved with the alleged incident. The investigation will "look back" 24-48 hours depending on the incident... c. The Director of Nursing, Director of Social Services or Administrator will perform all investigations of abuse... 7. Reporting/Response... a. All alleged violations are reported immediately to the office of the Long Term Care Ombudsman, state DHHS and appropriate state certification agencies. b. A summary of the investigation, corrective action and determination, if possible, will be faxed to the office of the Ombudsman no later than 5 working days from the date of the complaint. ...Findings include: On 3/27/12 during review of the medical record for Resident #6, a nurse note dated 1/25/12 (3-11) revealed the following: "LNA reported bruises R (Right) side of cheek and R hand near thumb and forefinger about 1/2 dollar size. Nurse/writer assessed no swelling/redness. Incident report done." On 3/27/12 review of a facility document titled "Incident/Accident Report" for Resident #6 dated 1/25/12 documents the bruises were of "unknown etiology" During an interview on 3/27/12 with Staff B, (Director of Nursing) it was revealed that the facility did not have documentation of an investigation and conclusion of the incident. It was further revealed during the interview that the bruise was not reported to the State survey and certification agency within 24 hours and the facility did not report the final investigation and conclusion to the State survey and certification agency within 5 days. On 3/27/12 during review of the medical record for Resident #6, a nurse note dated 2/9/12 (3-11) signed by Staff C (Agency LPN) revealed the following: "Called to bedside by LNA. Patient (symbol for with) 2 x 2 cm bruise noted to L (Left) outer elbow. Skin intact. No other new areas noted." During an interview on 3/27/12 with Staff B, it was revealed by Staff B that Staff C failed to report the incident of the new bruise to the Administrator immediately and Staff C failed to complete an incident report. Staff B stated that Staff B was not aware of the incident and the facility did not complete an investigation and conclusion of the incident. It was further revealed during the interview with Staff B that the bruise was not reported to the State survey and certification agency within 24 hours and the facility did not report the final investigation and conclusion to the State survey and certification agency within 5 days. Review of an undated document titled Orientation For Licensed Nurses revealed that one of the topics on the checklist is as follows: Accident Reporting - All skin tears, Bruises, open areas / Fall Packet & MD/DPOA notification On 3/27/12 during interview with Staff B, it was revealed the facility failed to follow their policy and complete the orientation checklist with Staff C which included the role of the nurse for reporting of bruises.