Every finding on record at Honorage Nursing Center

Based on interviews and record review, the facility failed to provide adequate supervision for Resident (R)50, to prevent potential accidents. Findings include: The facility does not have a policy on Supervision for residents. Review of R50's Face Sheet revealed R50 was admitted to the facility on [DATE], with diagnoses including but not limited to: insomnia, altered mental status, post concessional syndrome, contusion of unspecified part of head, and unspecified dementia. Review of R50's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/24, revealed R50 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating R50 has severe cognitive impairment. Review of R50's Care Plan with an onset date of 02/08/24, revealed R50 has a potential for wandering with no rational purpose and he enjoys walking down the halls and stopping at resident rooms to speak/converse with other residents. An approach to reach this goal is to observe him for the following behaviors and notify the doctor if persistent or not easily altered (Restlessness, wandering, elopement efforts, fearfulness, agitation, profanity, or other behaviors which may be a threat to myself or others.) Review of R50's Progress Note dated 08/08/23 at 1:58 PM, revealed, Resident will also use profanity. Resident also keeps a pair of tongs in his back pocket as uses as a reacher. Resident will also intrude on the privacy of other residents as he opens closed doors to speak to all without knocking prior to. Res is able to verbalize most of his basic needs in clear speech but has difficulty maintaining a lengthy, coherent conversation. Review of R50's Progress Note dated 11/07/23 at 3:12 PM, revealed, Resident will enter other resident's rooms without invitation to speak even if the door is closed. Behavior is not easily altered even with much encouragement offered to not do so. Review of R50's Progress Note dated 12/25/23 at 9:00 PM, revealed, Resident approached Rm 49 where a female resides and opened closed door without knocking and female was receiving peri care and female yelled out, Get out of my room, I'm naked. He opened the door a 2nd time and the female said for him to get out. He then yelled at female, **** you, you mother******* *****. He was redirected by staff. RN [Registered Nurse] Supervisor attempted to redirect him on importance of not entering closed doors and just opening the doors. He stated to RN, Yes, I remember you told me not to but I did it anyway. He cursed at staff, ADN walked away. Review of R50's Progress Note dated 01/07/24 at 11:46 AM revealed, Resident do walk down halls opening other resident's room doors and is redirected by staff. Review of R50's Progress Note dated 05/04/24 at 11:23 PM revealed, 2 [NAME] county deputies came and spoke to resident about incident that dayshift nurse reported. Res spoke with deputies but did not remember the incident. Res encouraged to stay on [NAME] End of facility and not go in other residents room. Residents acknowledged but has dementia and roaming around facility is one of his behaviors ever since res arrived at facility. Review of R50's Progress Note dated 05/21/24 at 10:24 AM, revealed, Res will enter the rooms of other residents without invitation to greet them. Resident requires close supervision and much redirection. Res can be easily agitated when redirected and uses strong profanity. Strict limits are set on inappropriate behaviors as they occur. During an interview on 05/30/24 at 2:40 PM, Certified Nursing Assistant (CNA)1 revealed, He goes in other residents' rooms late at night, when they are getting dressed and he doesn't knock he just opens the door. CNA1 states she talked about this with the nurses, but they state that this is his home and they can try what they can. This has continued almost every night since September of last year. Some of the residents enjoy it but there are a lot that don't like the attention. CNA1 further states, [R50] doesn't think he knows what he is doing or means any harm. He goes to the end of the hall and looks out the door. He goes into the male rooms and does the same thing, opens their doors as well. During an interview on 05/30/24 at 3:02 PM, the Social Services Director (SSD) revealed, they don't have a separate dementia unit and they have a resident that invades others privacy, but he has significant cognitive damage and they try to redirect and reeducate the resident to remain clear of certain areas. He is not at a 100% but with constant reminders he is doing a little better. The SSD states, Staff are asked to support and encourage the complainant, not to be aggressive and assist in that process and ask that they understand that they are on two different levels. If they see the resident in that area, try to keep him away from those residents that had concerns, so there is no interaction. We tried to put stop signs across the residents' doors in the past but that was not effective, he would pull them down and it didn't help, they have also in-serviced the staff on the importance of redirecting because he is verbally aggressive. They have not tried any other interventions as reporting to the physician or seeking any assistance from psychological services. The SSD further states, This has been bought to her attention a couple of months or so ago. During an interview on 05/30/24 at 3:31 PM, the Executive Director (ED) states, [R50] does not enter their rooms or harass them, the female residents are just frustrated with him, he will open the door and use profanity at times, when the residents yell to get out, he will yell back at them. The ED revealed she is not aware of him going in anyone's room where anything inappropriate happened. The ED states she has talked with residents one to one about what they decided to do with R50, the residents were hesitant but they were willing to try. The ED states her expectation is for the staff to keep redirecting R50, shut the fire doors of the residents areas that have concerns and try to calmly and nicely redirect him. It is the intent to make sure the residents feel safe wherever they are or remove the factor that is making them feel uncomfortable. The ED concluded, R50 is not mentally, physically, or sexually abusive so in her mind, he has not done any harm.

Based on record review, interviews, and review of facility policy, the facility failed to honor Resident (R)8's choices for bathing and showering, for 1 of 2 residents reviewed for Activities of Daily Living (ADL). Findings include: Review of the undated facility policy titled, Activities of Daily Living revealed, staff assists or performs activities of daily living (bathing, dressing, grooming, eating, toileting, etc ) as indicated. Review of R8's Face Sheet revealed R8 was admitted to the facility on [DATE], due to system conversion, original admitted was 06/15/23, with diagnoses including but not limited to: heart failure, morbid obesity, muscle weakness, major depressive disorder, Parkinson's Disease and acquired absence of left leg above the knee. Review of R8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R8 is cognitively intact. Further review of the MDS revealed functional abilities and goals, R8 is dependent; needing assistance taking a shower and bath, and also dependent needing assistance with tub and shower transfer. Review of R8's Care Plan with a revision date of 05/23/24 revealed, a need for extensive assistance to total care by staff members to help with bed mobility, transfers, bathing, and personal hygiene with an approach to offer a shower, shampoo, and nail care at least twice weekly and as needed; also a shower should be performed 2-3 times weekly. Use mechanical lift if indicated. Review of R8's Completed Care Task dated 05/01/24 - 05/30/24 revealed resident had only bed baths during the date range above with exception of dates 05/07/24, 05/09/24, 05/14/24, 05/15/24, and 05/23/24, where no bathing or showering was performed. Review of an undated Manufacturer Manual for a Supply Manual shower bed revealed, there is a 450 pound (lb) weight capacity. Review of an undated Manufacturer Manual for a Direct Supply shower chair revealed, there is a 500 lb weight capacity. During an interview on 05/29/24 at 2:36 PM, R8 revealed she doesn't receive showers. R8 further stated it may be because she is so large, I'm trying to lose weight. During an observation on 05/30/24 at 3:00 PM, with the Executive Director (ED) and the Director of Nursing (DON) revealed, the shower room is a small, tiled room, with shower area, tub and a sink. Inside was one shower bed and two shower chairs. During an observation on 05/30/24 at 3:27 PM, with ED revealed, a shower chair purchased for R8. The shower chair was located in the business office hallway. The chair was white in color, made of PVC pipe, oversized, with pink mesh backing. During an interview on 05/30/24 at 1:04 PM, Certified Nursing Assistant (CNA)2 revealed she was only trained to give R8 bed baths, never trained to give R8 a shower. CNA2 stated R8 never requested a shower. During an interview on 05/30/24 at 2:50 PM, the ED and DON revealed resident gets a bed bath daily. The Unit Manager follows bathing/showering for unit. The ED stated she talked to R8's daughter, R8's daughter told her shower room was too small for her mom. The ED stated, It's very hard for her with two staff members. The DON stated she investigated more, they ordered a shower chair for her in the past. ED and DON both stated, resident stated chair pinched her. During an interview on 05/30/24 at 4:25 PM, R8's daughter revealed, My mother may get a bath later in the day due to low staffing or staff going home. My mother gets a shower once a week, as far as I knows, have not inquired lately. I would never ever say I don't want my mother to take a shower. I have called the facility with concerns in the past about bathing and showering, my mother gets regular bed baths as well. My mother does need help from multiple staff members to perform baths and showers. During an interview on 05/30/24 at 4:35 PM, R8 revealed she never saw a shower chair. Staff introduced her to a shower bed, the bed was too tight for her. R8 stated she washed herself and they helped her to wash. R8 does not remember sitting in a chair and was not pinched by equipment.

Based on record reviews, interviews and review of the facility policy titled, Bedhold Notification/Policy, the facility failed to ensure Resident (R)32, R30, R33 and R51 and/or their responsible party received the Bedhold Notification Policy with the bed hold amount in a timely manner for 4 of 4 residents reviewed for hospitalization s. Findings include: The facility admitted R32 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/15/22 at 1:30 PM of the medical record for R32 revealed confirmation of a hospital stay starting 1/8/22 and returning to the facility on [DATE]. Review of the Bed Hold Notification mailed to the responsible party was dated 1/13/22, 3 days after R32 returned from the hospital. An interview on 3/15/22 at 1:30 PM with the Business Office Manager confirmed that R32 was transferred to the hospital on 1/8/22 and returned on 1/10/22 and also that he mailed the Bedhold Notification to the responsible party for R32 on 1/13/22. The BOM confirmed the notification did not include bedhold amounts, as required. Review on 3/15/22 at 1:45 PM of the facility policy titled, Bedhold Notification Policy, states, This Nursing Center will hold a bed for a resident transferred from the facility as follows: Medicaid Resident: Medicaid residents are eligible for bedhold up to ten (10) days while in the hospital . If the hospitalization exceeds the allotted ten (10) days bedhold period that Medicaid allows, will be discharged from the facility as of day eleven (11). This determination means that if the resident is not back in the facility by midnight (12:00 AM) on day eleven (11), the resident will have exceeded their bedhold and will be discharged . You can call and request that additional days be added to the bedhold. However these additional days will be billed privately, and the resident's family will be responsible for the payment of the additional days. This request must be made to our Business Office no less than 3 days of the resident exceeding their allotted ten (10) days. If a resident exceeds their allotted 10 days and additional days are not requested, again the resident will be discharged from the facility. There is no amount informing residents or resident's representatives how much each day will cost them if they happen to exceed the 10 days, therefore would not be able to make a decision or arrangements for the cost. On 3/15/22 at approximately 3:45 PM, a review of the medical record for R30 revealed that on 2/3/22 at 10:00 PM, the Resident Representative (RR) had been notified and Bed hold completed. Further review revealed on 2/3/22, R30 had been sent to the local hospital on 2/3/22 at 10:16 PM, due to increased lethargy and decreased blood pressure. R30 had been admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22 at approximately 10:25 AM, a review of the facility provided bedhold notice for R30 revealed Date to Hospital: 2/3/22 and Date Mailed to RR: 2/7/21 (2022). There was no listing in the bedhold document for the charge amount, if additional days were requested. R33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 3/14/22 at 11:35 AM with R33 revealed that in January of 2022, they were sent to the hospital, due to COVID-19 complications. Record review on 3/15/22 at 10:45 AM of Progress Notes dated 1/15/22 revealed R33 tested positive for COVID-19 and having shortness of breath. The RR and Medical Doctor were notified of new orders. Record review on 3/15/22 at 2:25 PM of a Bed Hold Transfer Agreement dated 1/15/22 revealed R33 was sent to the hospital on 1/15/22 and the transfer agreement was mailed to the RR on 1/27/22. R51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 3/15/22 at 10:38 AM of a Progress Note dated 1/31/22 revealed Called to room per Certified Nursing Assistant (C.N.A), resident noted to have increased confusion and not responding appropriately to staff. Medical Doctor made aware, 911 called and called Resident Representative, voice message stated unable to receive calls at this time, contacted second contact and made aware of new order to send to emergency room . Record review on 3/15/22 at 2:30 PM of a Bed Hold Transfer Agreement dated 1/31/22 revealed R51 was sent to the hospital on 1/31/22 and the transfer agreement was mailed to the appropriate Resident Representative on 2/3/22.

Based on record reviews, interviews and review of the facility policy titled, Medication Administration Schedule Policy and Procedure, the facility failed to ensure complete and accurate medical records for Resident (R)32 related to documenting medication given for chest pain x 2 doses on the Medication Administration Record. Findings Include: The facility admitted R32 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/17/22 at 10:45 AM of the Nurses Notes dated, 1/8/22 at 4:44 AM stated, Went to check on resident, resident sitting on side of bed, continues to complain of not feeling, well and also complained of chest pain. Nitro administered at 4:50 AM with no results. The Nurses Note on 1/8/22 at 5:15 AM stated, Second Nitro administered with no effects. MD notified. New order to send to the emergency room for evaluation and treatment. The [MEDICATION(S)] 0.4 mg was not administered as ordered every five minutes x 3 doses for chest pain. The Nurses Note on 1/8/22 at 7:30 AM states, Emergency Medication Service (EMS) notified of need to transport. EMS in route. Review on 3/17/22 at 10:46 AM of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation could be found on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 3/17/22 at 11:20 AM with the Director of Nursing verified R32's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/17/22 at 11:30 AM of the facility policy titled, Medication Administration Schedule Policy and Procedure, the policy reads, Registered or licensed practical nurses administer medications upon MD (Medical Doctor) orders in accordance with the Medical and Nurse Practice Act of the state. Under the PRN (as needed) it reads, Nurse must evaluate the resident to determine if dose is needed. The last paragraph states on the policy, All administered medications shall be noted in the resident's eMAR by recording the name of the drug given, dosage, route of administration, and initials of the nurse administering the dose. Any dose refused or not given shall be documented on the eMAR.

Based on observations, record reviews, interviews, manufacturer package insert, pharmacy labeling and facility policy, the facility failed to assure that in-use insulin was properly dated as to opening and expiration dates and that expired insulin had been removed from active storage on 1 of 4 medication carts. Findings include: On [DATE] at approximately 10:26 AM, inspection of the East Wing Medication Cart A revealed one opened [MEDICATION(S)] R Insulin vial, 100 U (unit)/ml (milliliter), belonging to Resident (R)43, not dated as to date of opening or expiration and one [MEDICATION(S)] R Insulin [MEDICATION(S)] 100 U/ml, belonging to R29, dated by the facility as opened [DATE] with no expiration date. A pharmacy label had been attached to each container to indicate opening and expiration date along with specified number of days until expiration once opened. On [DATE] at approximately 10:33 AM, Licensed Practical Nurse 1 confirmed these findings and stated that nurses should check for dating each time medications are administered. The manufacturer (NovoNordisk) package insert dated [DATE] states under Table 2: Storage Conditions and Expiration Dates for [MEDICATION(S)] R that in-use (opened) multidose vials are to be discarded after 42 days when stored below 77 degrees F (Fahrenheit) and in-use Flexpens are to be discarded after 28 days when stored below 86 degrees F. Review of the Facility Policy Titled: 5.3 Storage and Expiration Dating of Medications, Biologicals revision date [DATE], PROCEDURE 5. states Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary container (vial, bottle, inhaler) when the medication has a shortened date once opened or opened. 5.3 states If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 18. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.

Based on record reviews, interviews and review of the facility's policy titled, Medication Administration Schedule Policy and Procedure, the facility failed to ensure Resident (R) 32 was free of significant medication errors. R32 did not receive the medication, [MEDICATION(S)] 0.4 milligrams (mg) as ordered for chest pain for 1 of 4 residents reviewed for hospitalization . Findings Include: The facility admitted R32 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/17/22 at 10:42 AM of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review on 3/17/22 at 10:45 AM of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review on 3/17/22 at 10:45 AM of the Nurses Notes dated 1/8/22 indicated, at 4:03 AM, Called to room per resident, resident complained of severe headache and feeling anxious inside. Vital signs, blood pressure 115/65, heart rate 78, respirations 18 and temperature is 98.2 degrees Fahrenheit and O2 saturation is 98 % on room air. Tylenol administered at this time, awaiting results. The Nurses Note on 1/8/22 at 4:44 AM stated, Went to check on resident, resident sitting on side of bed, continues to complain of not feeling well and also complained of chest pain. Nitro administered at 4:50 AM with no results. The Nurses Note on 1/8/22 at 5:15 AM stated, Second Nitro administered with no effects. MD notified. New order to send to the emergency room for evaluation and treatment. The [MEDICATION(S)] 0.4 mg was not administered as ordered every five minutes x 3 doses for chest pain. The Nurses Note on 1/8/22 at 7:30 AM states, Emergency Medication Service (EMS) notified of need to transport. EMS in route. R32 returned to the facility on [DATE] at 11:11 AM with orders to follow up with a Cardiologist in 2-3 weeks. Review on 3/17/22 at 11:15 AM of the Care Plan for R32 included, Problems with heart function, blood pressure or circulation because of history of high blood pressure, [CONDITION(S)], high cholesterol, low red blood cells, vascular disease, chest pain, [CONDITION(S)], and stent placement. An interview on 3/17/22 at 11:20 AM with the Director of Nursing, verified R32 had not received the 3 doses of [MEDICATION(S)], as ordered, for Chest Pain. Review on 3/17/22 at 11:30 AM of the facility policy titled, Medication Administration Schedule Policy and Procedure, the policy reads, Registered or licensed practical nurses administer medications upon MD (Medical Doctor) orders in accordance with the Medical and Nurse Practice Act of the state. Under the PRN (as needed) it reads, Nurse must evaluate the resident to determine if dose is needed. The last paragraph states on the policy, All administered medications shall be noted in the resident's eMAR by recording the name of the drug given, dosage, route of administration, and initials of the nurse administering the dose. Any dose refused or not given shall be documented on the eMAR.

Based on observations, interviews and review of the facility's FOOD BROUGHT INTO RESIDENTS' ROOM FROM OUTSIDE SOURCES, the facility failed to ensure the food was distributed and served appropriately for 1 of 1 nutrition rooms observed and 1 of 1 main kitchen observed. The resident's nutrition unit refrigerator was noted with expired Ensure and the main kitchen was noted with water in large serving spoon, a stained food strainer and soiled/stained utensils noted to be mixed with cleaned eating utensils. Sixty-two (62) residents had the potential of being affected. The findings included: An observation on [DATE] at approximately 2:43 PM of the unit refrigerator revealed three (3) expired 8 ounce bottles of Ensure nutritional drinks. Further review of the Ensure nutritional drinks revealed they had expired since [DATE]. An observation and interview on [DATE] at approximately 2:50 PM with Licensed Practical Nurse (LPN) #1 confirmed the findings and stated the nurses are responsible for making sure items in the resident's nutrition room has not expired. An interview on [DATE] at approximately 3:13 PM with the Certified Dietary Manager and LPN #1 revealed if the items in unit refrigerator come from the kitchen, dietary would be responsible for checking the expirations dates. If the items come from a family member the nursing staff will be responsible for checking the expirations dates. LPN #1 acknowledged there were no residents names on the expired Ensure and that it did not belong to staff. A review of the facility FOOD BROUGHT INTO RESIDENTS' ROOM FROM OUTSIDE SOURCES policy revealed Special circumstances, such as persistent weight loss or unique food preferences may require that food be brought into the facility from the outside. Due to potential for food borne illness or interference with nutrition treatment, family members and/or visitors who bring food in from the outside will be educated on safe food handling practices and the importance of diet order compliance. Food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety. Under #4 for procedure: Nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal. An interview on [DATE] at approxiately 11:30am with Certified Dietary manager (CDM), stated that all silverware is pre-soaked before being washed to remove food substance. An observation on [DATE] at approximately 11:45am, while in the main kitchen with a surveyor, observed one big spoon had water on it while it was nesting with clean silverware, one strainer with unknown dark substance was with clean silverware, and 3 out of 49 spoons had unknown substance on them while being stored with clean silverware. An interview with the CDM on [DATE] at approxiately 11:46am, the CDM confirmed all listed above items stating s/he would have the kitchen staff re-wash the items.

Based on observation, interview and policy review, the facility failed to ensure appropriate standard and transmission based precautions were implemented to prevent the spread of coronavirus (COVID)-19. Qualified Environmental Protection Agency (EPA)-registered disinfectants were not being used to clean residents' rooms. The Assistant Housekeeping Director did not realize the product used was not registered with the EPA for being an effective chemical against COVID-19. The disinfectant being used required specific timelines for the product to dwell on surfaces in order to breakdown all membranes that surrounded bacteria [MEDICAL CONDITION]. Interview with staff responsible for using the EPA-registered disinfectants revealed two (2) out of four (4) environmental staff were not aware of the proper dwell times. The failure to utilize disinfectant products as required to prevent the spread of COVID-19 had the potential to affect all the residents in the facility. Findings include: Review of the Novel Coronavirus policy updated on 4/7/2020, included information for cleaning and disinfecting. Listed under Environmental Infection Control the plan indicated, Housekeeping staff shall adhere to transmission-based precautions as applicable. Housekeeping staff will clean using disinfectants known to be effective against emerging [MEDICAL CONDITION] pathogens or novel coronavirus. The Facility Assessment undated documented, Supplies necessary for appropriate cleaning and disinfection procedures ( e.g., EPA-registered, for use in healthcare facilities, including products labelled as effective against [DIAGNOSES REDACTED]icille and norovirus) are available and used according to manufacturer instructions for use. The policy Environmental Services Guidelines, revised July 2011 documented, All horizontal surfaces such as tabletops, windows, ledges, bedside stands, counters, sinks, tubs, shower floors, toilet seats, floors, etc. will be cleaned daily with an acceptable hospital grade disinfectant/germicide. This procedure will vary with the item being cleaned. Follow manufacturer's recommendations and the recommendation of the infection preventionist. All chemicals used in the facility must have an approved EPA registration number; be labeled with the product name, product action, and correct use. An interview was conducted with the Assistant Director of Environmental Services on 9/29/2020 at 10:30 a.m. He/she stated, We use CDC-10, we leave it on for about five (5) minutes. We clean countertops, handrails and anything being touched a lot with this. Upon reading the container of CDC-10 it was documented the product was to remain on the surface for 10 minutes. The Assistant Director of Environmental Services stated they had used the product for years. On 9/30/2020 at 9:15 a.m., Housekeeper #1 who normally worked on the east hall, stated in an interview, We clean heavily soiled areas such as toilets and sinks with CDC-10. I leave it on the surfaces for about three (3) to five (5) minutes. CDC-10 was observed on the housekeeping cart. On 9/30/2020 at 9:30 a.m., Housekeeper #2 who was working on the east hall, stated in an interview, I clean with CDC-10 and leave it on surfaces for about three (3) to five (5) minutes. CDC-10 was observed on the housekeeping cart. On 9/30/2020 at 10:30 a.m., the Customer Service Representative from Spartan Chemicals stated, CDC-10 hasn't made it to the list of approved chemicals from the CDC (Center for Disease Control) yet. It doesn't have a COVID kill claim per CDC. In an interview on 9/30/2020 at 10:45 a.m. the Housekeeping Supervisor stated, I didn't realize there was a problem with the dwell time. I am coming back to work tomorrow. I will fix the situation. I will in-service the staff. Review of information obtained from the Environmental Protection Agency (EPA) government website revealed CDC-10 was not listed as being effective against COVID-19. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2. On 9/30/2020, at 2:00 p.m., the Administrator stated in an interview, We are going to remove the CDC-10 from the carts and only use chemicals from the CDC list. According to the Administrator, at one time the facility had a total of 16 residents and 12 staff positive with COVID-19. On 9/30/2020, at 2:15 p.m., the Assistant Housekeeping Director stated, I'm going to remove the CDC-10 from the housekeeping carts before I leave work today. I didn't realize it wasn't approved. The facility's failure to ensure staff utilized EPA-registered disinfectants properly when cleaning surface areas of the facility increased the risk of the spread of infections to all residents, including the spread of COVID-19.

Based on observation and interview the facility failed to maintain 2 of 2 ice machines in safe, clean and good condition and failed to ensure removal of food items on or prior to use by dates in 1 of 1 facility kitchens. The findings included: An observation on [DATE] at approximately 10:37 AM revealed the corner of the lid for ice machine #1 was observed to be cracked and broken exposing the insulation and preventing a secure seal when closed. The filters of both ice machines were pulled out and observed to have visible build up of dust and debris. The inside lid of ice machine #2 was observed to have a black residue that when wiped with a paper towel came off onto the towel. The Certified Dietary Manager (CDM) and Dietary Consultant observed and confirmed along with this surveyor. Further observation of the facility's dry food storage and emergency food supply revealed a plastic bin of saltines with multiple packages open and contents in bottom of bin, two 12-count packages of hamburger buns with use by date of [DATE], four #10 cans of chili con carne with best by date of ,[DATE], and nine large cans of chicken noodle soup with best by date of ,[DATE]. The CDM stated that food out of the packages should be thrown out. In an interview on [DATE] at approximately 3:40 PM, the CDM provided copies of facility policies entitled Policy for Ice Machines and Ice Storage Containers which stated, It it the policy of this facility that ice machines and ice storage containers will be maintained in a clean and sanitary manner. Also that all ice machines will be cleaned on a preset schedule and a maintenance inspection of ice machines should be completed on a regular basis and any necessary repairs made to ensure that water contamination within the machinery does not occur. The policy stated that monthly inspection is recommended but the CDM stated the schedule will be adjusted to bi-monthly and as needed cleaning based upon the observation. The CDM stated it is expected that all expired food items should be removed from the food supply.

Based on observation, interview and review of the facility policy titled, Housekeeping and Maintenance Department Duties and Responsibilities, staff failed to ensure that the facility was free of chemical hazards in one of one laundry. Chemicals and equipment were readily accessible. The findings included: Observation on 4/10/19 at 3:33 PM revealed that the laundry was found unsecured with chemicals and equipment readily accessible to residents who were mobile and cognitively impaired. There were 3 commercial washers and 4 commercial dryers in the laundry. Inside of the laundry room, there were four 5-gallon containers of laundry chemicals: -rust stain remover 5 gallons marked as corrosive about 1/3 full -fabric softener plus sanitizer 5 gallons 1/5 full -liquid laundry destainer 5 gallons 2/3 full -laundry detergent 5 gallons 1/2 full During an interview on 04/10/19 at 03:40 PM, the Housekeeping Laundry Supervisor confirmed that the door to the laundry room was not locked. Tubing from three of the four containers could be pulled out of the buckets enabling easier access to the chemicals. On 2 of the 4 containers, screw tops were open. No residents were observed in the immediate area at this time. On 4/11/19 at 3:05 PM, surveyors observed that the locks/door knob had been replaced by a key pad entry. During an interview on 4/11/19 at 3:31 PM, the Housekeeping and Laundry Manager displayed the tools that where used to screw the tops off the containers. S/he stated that these tools would be the only way to open the 5-gallon containers. At that time, s/he was unaware that the containers were open as noted above. On 04/11/19 at 03:37 PM, surveyors observed the same containers of chemicals in the same condition. At this time, surveyors observed a resident knocking on the door and attempting to get into the laundry room. After the Administrator removed the resident from the area, s/he entered the laundry and confirmed the condition of the chemical storage. The Administrator verified the open containers and that 3 of the 4 tubings could be pulled out of the buckets. The laundry was located where all residents had to pass to get to the dining room. The facility policy titled Housekeeping Maintenance Department and Responsibilities states,Careful attention must be paid to the proper handling of chemicals: Chemicals must be either in your possession or locked in the appropriate cabinet at all times. Laundry detergents are kept in the laundry room, and the tools to access the laundry detergents are kept in the locked storage cabinet in the laundry room. This is to protect residents who are confused from potential exposure to hazardous chemicals. The policy provided did not address locking the laundry room.

Based on record review, observation, and interview, the facility failed to turn and reposition and/or apply devices for 2 of 2 reviewed for positioning. Resident #8 and #23 were observed in the same position and/or without devices on multiple observations. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review of Resident #8's care plan on 4/10/19 at 10:19 AM revealed carrot or hand roll to left hand daily as tolerated. Review of the Certified Nursing Assistant (CNA) care plan revealed to position for comfort with supportive devices as needed and to encourage/assist resident to turn and reposition every two hours as tolerated. Notify nurse if declined. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 had short and long term memory problems with severely impaired cognitive skills for daily decisionmaking. Further review revealed for bed mobility Resident #8 needed extensive assist with one person assist. Observations of the resident during the survey process revealed the following: 4/8/19 at 2:40 PM-lying in the same position as earlier in the day; 4/8/19 at 3:20 PM- lying in the same position; 4/8/19 at 4:38 PM-lying in the same position; 4/9/19 at 9:01 AM-pillow between legs not seen; 4/9/19 at 11:24 AM-no hand roll or splint in left hand; 4/9/19 at 11:45 AM-CNA confirmed no pillow between resident legs; 4/10/19 at 2:10 PM-lying in bed, no neck pillow observed; 4/11/19 at 11:30 AM-up in geri-chair, no positioning devices observed. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Record review on 4/10/19 at 3:54 PM of Resident #23's care plan did not address turning and repositioning every two hours. Further review of the care plan revealed an intervention for pain was to use devices to support my body while in and out of bed such as towel rolls and extra pillows as needed. Review of the CNA care plan revealed the resident was to be positioned for comfort with supportive devices as needed and encourage/assist the resident to turn and reposition every two hours as tolerated. Staff were to notify the nurse if resident declined turning and positioning. Review of the Quarterly MDS dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status score of 3. Review of bed mobility revealed Resident #23 was extensive assist requiring one person assist. Further review of the medical record revealed the resident was admitted with a pressure sore to the sacrum and at present on 4/1/19 was a healing Stage IV measuring .2 x .1 x .1 with 100% [MEDICATION NAME] tissue. Review of the Braden assessment dated [DATE] revealed a score of 13 (12 or less represents high risk). Observation of the resident revealed the following: 4/10/19 at 10:09 AM-lying on left side in bed; 4/10/19 at 11:21 AM-remains on left side; 4/10/19 at 2:10 PM-lying on left side; 4/10/19 at 4:30 PM-lying on left side; 4/11/19 at 10:30 AM-up in geri-chair in room on back; 4/11/19 at 11:30 AM-remains in geri-chair on back; 4/11/19 at 1:58 PM-remains up in geri-chair. During an interview with CNA #1 on 4/11/19 at 1:59 PM, s/he stated residents were supposed to be repositioned every two hours. During the interview, CNA #1 did not dispute Resident #23 had been up in the geri-chair for an extended time. S/he stated it was difficult to reposition the resident while in the geri-chair and to do this s/he would have to return the resident back to bed. During the survey process, no policy was provided related to turning/positioning resident or for positional devices.

Based on record review, observation, and interview, the facility failed to follow the resident's care plan related to turning and positioning and/or application of devices for 2 of 2 reviewed for positioning. Resident #8 and #23 were observed in the same position and/or without devices on multiple observations. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review of Resident #8's care plan on 4/10/19 at 10:19 AM revealed carrot or hand roll to left hand daily as tolerated. Review of the Certified Nursing Assistant (CNA) care plan revealed to position for comfort with supportive devices as needed and to encourage/assist resident to turn and reposition every two hours as tolerated. Notify nurse if declined. Observations of the resident during the survey process revealed the following: 4/8/19 at 2:40 PM-lying in the same position as earlier in the day; 4/8/19 at 3:20 PM- lying in the same position; 4/8/19 at 4:38 PM-lying in the same position; 4/9/19 at 9:01 AM-pillow between legs not seen; 4/9/19 at 11:24 AM-no hand roll or splint in left hand; 4/9/19 at 11:45 AM-CNA confirmed no pillow between resident legs; 4/10/19 at 2:10 PM-lying in bed, no neck pillow observed; 4/11/19 at 11:30 AM-up in geri-chair, no positioning devices observed. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Record review on 4/10/19 at 3:54 PM of Resident #23's care plan did not address turning and repositioning every two hours. Further review of the care plan revealed an intervention for pain was to use devices to support body while in and out of bed such as towel rolls and extra pillows as needed. Review of the CNA care plan revealed the resident was to be positioned for comfort with supportive devices as needed and encourage/assist the resident to turn and reposition every two hours as tolerated. Staff were to notify the nurse if resident declined turning and positioning. Observation of the resident revealed the following: 4/10/19 at 10:09 AM-lying on left side in bed; 4/10/19 at 11:21 AM-remains on left side; 4/10/19 at 2:10 PM-lying on left side; 4/10/19 at 4:30 PM-lying on left side; 4/11/19 at 10:30 AM-up in geri-chair in room on back; 4/11/19 at 11:30 AM-remains in geri-chair on back; 4/11/19 at 1:58 PM-remains up in geri-chair. During an interview with CNA #1 on 4/11/19 at 1:59 PM, s/he stated residents were supposed to be repositioned every two hours. During the interview, CNA #1 did not dispute Resident #23 had been up in the geri-chair for an extended time. S/he stated it was difficult to reposition the resident while in the geri-chair and to do this s/he would have to return the resident back to bed. During the survey process, no policy was provided related to turning/positioning resident or for positional devices.

Based on record review and interview, the facility failed to appropriately notify 2 of 3 sampled beneficiaries reviewed for Medicare non-coverage. The facility failed to confirm telephone notification/contact by written notice of Medicare non-coverage mailed on that same date for Residents #32 and #50. The findings included: Review of Resident #50's CMS (Centers for Medicare and Medicaid Services)- NOMNC (Notice of Medicare Non-Coverage) and the CMS-approved letter of non-coverage revealed that the resident's last covered Part A day was 1-22-18. Further review revealed the family was notified per telephone on 1-19-18 and the notices were signed on 1-25-18. There was no evidence that the forms were mailed for signature and telephone contact confirmed by written notice mailed on 1-19-18. Review of Resident #32's CMS- NOMNC and the CMS-approved letter of Medicare non-coverage revealed that the resident's last covered Part A day was 1-2-18. Further review revealed the family was notified per telephone on 12-28-17 and the notices were signed on 1-2-18. There was no evidence that the forms were mailed for signature and telephone contact confirmed by written notice mailed on that same date. During an interview at 3:35 PM on 3-6-18, the business office representative verified the above and stated s/he was not aware they had to follow a phone call with an immediate mailing.

Based on record review, interview, and review of the facility's policy, Pressure Ulcer/Wound/Skin Management the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #44, 1 of 5 residents reviewed for pressure ulcers. Resident #44 refused in 2014 to wear heel protectors and the facility failed to follow-up when the resident stated he/she would think about using positioning devices to elevate his/her feet. The findings included: The facility admitted Resident #44 with [DIAGNOSES REDACTED]., On 03/07/18 at 02:44 PM, review of the wound assessments revealed a Stage II pressure ulcer with onset date of 12/13/17. On 12/20/17 the wound measured 2.60 x 2.50 x 0.10 cm (centimeters) the assessment indicated the wound had 80% granulation tissue and 20% slough. The wound was documented as a Stage III and noted as deteriorated. At 4:15 PM on 03/07/18, review of the care plan revealed a problem dated 05/18/17 for potential for alteration in skin integrity and further stated Note: L (left) heel stage II healed 10/30/14 and also noted the resident had a [DIAGNOSES REDACTED]. Interventions included: weekly body audits, preventative and routine treatments as ordered, pressure relieving mattress to the bed, encourage the resident to be out of bed daily, administer medications as ordered, and treatments for fungal infections that had resolved. There were no interventions to prevent pressure to the heels listed on the care plan. Further review of the care plan revealed heel protectors (Heel Medix) were ordered on [DATE] and a specialty air mattress was ordered on [DATE]. During an interview on 03/07/18 at 05:05 PM, Registered Nurse (RN) #1 confirmed there were no interventions to prevent development of a pressure ulcer to the feet. The RN provided a copy of a 2014 care plan that indicated Resident #44 had requested the heel protectors be removed. In addition, the RN provided nursing note dated 11/27/17 that stated the resident was asked about elevating the heels instead of the boots to which the resident responded I'll think about it. RN #1 confirmed the issue was not addressed with the resident again. The RN also confirmed that the 12/20/17 assessment indicated the wound had deteriorated and that the specialty mattress was not ordered until 12/27/17. Review of the facility's policy entitled Pressure Ulcer/Wound/Skin Management, revealed All residents will receive routine skin care. Routine skin care includes but is not limited to the following: a. Pressure reducing mattress b. Use of positioning and pressure reducing devices such as cushions, pillows, positioning devices, etc. (et cetera) . During an interview 03/09/18 at 08:35 AM, The Director of Nursing (DON) stated the nurses needed to follow-up after the resident stated he/she would think about elevating his/her feet. The DON also stated they should have followed-up at least with every quarterly assessment. In addition, the DON confirmed that it should be care planned if the resident refused. The Director further confirmed the specialty mattress should have been ordered on [DATE] when the pressure was first observed as deteriorated.

Based on observation and interview, one of 4 dryer filters were in poor repair. Dryer #4 filter had a 5-6 inch tear on the right side of the frame which presented a potential fire hazard related to lint buildup. The findings included: During observation of linen handling in the laundry on 3-6-18 at 11:23 AM, dryer #4 filter was observed with a 5-6 inch tear along the right side of the frame, allowing accumulation of lint behind the filter. When asked about the size of the opening, the Laundry Aide stated, About 5 inches.

Based on record review and interviews, the facility failed to protect one of three residents sampled for abuse/neglect. Resident # 97 was transferred inappropriately with a hoyer lift that resulted in injury. The findings included: The facility admitted resident #97 with [DIAGNOSES REDACTED]. Review of the Nurses Notes (NN) revealed on 6/2/16 at 8:02 PM, called to room per CNA (Certified Nursing Assistant). upon (sic) entering room, res was in the hoyer lift with the right front hoyer pad not attached to the hoyer. per (sic) cna, res was being transferred from w/c to bed via hoyer lift when the front bar which holds the hoyer pad tilted sideways and the right front hoyer pad hook slid off of the metal bar of the hoyer lift. the (sic) res (resident) was assisted to the floor by this Nurse and CNA. res was then assisted to bed by staff x 3. injury noted to res Left lower leg skin tear with deep laceration 1 inch long by 1 inch deep. Res complained of right arm pain. No apparent bruising or redness noted to this area at this time. VS (vital signs) noted BP (blood pressure) 112/75, P-115, R-20, T-98.8. O2 (oxygen) sats 94% with O2 via NC (nasal cannula). 8:15 PM Orders to send to ER (emergency room ). 10:50 PM- Resident admitted to hospital for fracture of Right Shoulder and Elbow. Review of the facility investigation revealed an Incident Report dated 6/2/16. The incident report stated the CNA stated the right front hoyer pad had slid off of the metal bar of the hoyer lift, the resident was assisted to the floor by the nurse and CNA. The Nurse, Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor on 1/11/17 at 2:51 PM. The LPN stated when s/he entered the resident's room the resident was in the hoyer lift leaning to one side. The nurse stated the resident did not fall, s/he was eased down to the floor by the nurse and the CNA. The LPN stated that one of the straps was not attached. One part was not hooked, it was not ripped. I talked to the CNA. I asked if s/he had any assistance. S/he said s/he could not find anybody. I told her/him s/he shouldn't have lifted the resident by her/himself. The policy is always 2 people assist with lift. The nurse demonstrated the hoyer lift and how the pad attached to the lift. The lift bars contained a type of clip that would prevent a strap from slipping off the hook if the strap was hooked appropriately. Review of the facility Policy and Procedure on the Hoyer Lift revealed. It is policy of _____ that the Hoyer Lift is operated with two facility employees present at all times while resident is being transferred. Lift Pads are to be placed under the resident while in bed. Prior to transfers make sure chains/straps are properly secured to hoyer lift bar. Do not attempt to operate the Hoyer Lift alone or with the assistance of family members, friends, or volunteers.

Based on record review, and interviews, the facility failed to provide adequate supervision to prevent incidents/accidents for 1 of 3 residents with injuries related to fall and or transfer. Resident #97 was transferred inappropriately which resulted in fracture. The findings included: Cross refer to F224 regarding inappropriate transfer with resulting fracture. The facility admitted resident #97 with [DIAGNOSES REDACTED]. Review of the Nurses Notes (NN) revealed on 6/2/16 at 8:02 PM, called to room per CNA (Certified Nursing Assistant). upon (sic) entering room, res was in the hoyer lift with the right front hoyer pad not attached to the hoyer. per (sic) cna, res was being transferred from w/c to bed via hoyer lift when the front bar which holds the hoyer pad tilted sideways and the right front hoyer pad hook slid off of the metal bar of the hoyer lift. the (sic) res (resident) was assisted to the floor by this Nurse and CNA. res was then assisted to bed by staff x 3. injury noted to res Left lower leg skin tear with deep laceration 1 inch long by 1 inch deep. Res complained of right arm pain. No apparent bruising or redness noted to this area at this time. VS (vital signs) noted BP (blood pressure) 112/75, P-115, R-20, T-98.8. O2 (oxygen) sats 94% with O2 via NC (nasal cannula). 8:15 PM Orders to send to ER (emergency room ). 10:50 PM- Resident admitted to hospital for fracture of Right Shoulder and Elbow. The CNA transferred the resident without assistance.

Based on record review, facility files review and interviews, the facility failed to follow their policy on abuse/neglect for 3 of 3 resident's reviewed for reportable incidents. Resident #97 received a fracture during an inappropriate transfer. The incident was not reported timely. Resident #96 had an unwitnessed fall with injury that was not investigated or reported. Resident #43's allegation of abuse was not reported timely. The findings included: Review of the facility Policy and Procedure on Abuse/Neglect revealed the section of Abuse Investigation stated, Investigations will be performed by the Director of Nurses (DON), Supervisor and/or designee to evaluate: 1. Identify the type of reportable incident 2. If abuse is alleged, identify the type of abuse 3. Details of Incident- Describe the injury, circumstances, prior condition, treatment required, history of similar injuries, [DIAGNOSES REDACTED]. 4. Witness Statements (double witnessed or notarized) 5. Incident report and documented actions taken to prevent recurrence Abuse Protocol:: 1. Witnessed Suspected Abuse: Protect the Resident 2. Immediately report the abuse or suspected abuse to Supervisor 3. The Supervisor will report the allegation of abuse to the DON and or ED (Executive Director). 4. The DON or Designee will report abuse to the attending MD/Medical Director/RP 5. The DON or designee will immediately notify the following: Ombudsman- DEC (Department of Health and Environmental Control) Certification- Local Police Department 6. DON or Nursing Supervisor will complete the TLC (Long Term Care) Ombudsman Initial 24 hour report and the DEC Initial 24 hour our report and fax report to the appropriate authority A final written report including investigation data, findings and conclusion, etc .will be completed by the DON or Nursing Supervisor and sent to the Ombudsman, DHEC Certification within 5 working days, as well as kept on file per facility protocol. The facility admitted resident #97 with [DIAGNOSES REDACTED]. Review of the facility investigation revealed an Incident Report dated 6/2/16. The incident report stated the CNA stated the right front hoyer pad had slid off of the metal bar of the hoyer lift, the resident was assisted to the floor by the nurse and CNA. Review of the facility investigation revealed the facility did not report the incident to state agencies until 7/20/2016, after review of incidents during Quality Assurance. The facility admitted resident #96 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Quarterly Minimum Data Set ((MDS) dated [DATE]. The resident was coded to have a cognitive deficit with a Brief Interview for Mental Status (BIMS) of 6 out of 15. The resident's functional status was coded as extensive assistance was required with bed mobility, transfers (one person assist), ambulation in room, locomotion off unit, dressing, toilet use, and personal hygiene. The resident was coded to have had one (1) fall, no injury. Review of Nurses Notes from 12/4/15 through 2/6/2016 revealed the resident was alert and verbal. 2/5/16 1:26 PM: Resident on floor with right arm noted behind back large amount of blood noted on floor under res face, pressure drsg (dressing) applied. Res remains alert and verbal . Dr. notified new order to send to hospital ER (emergency room ) for eval (evaluation). There was no investigation to determine if fall had resulted from neglect or as to how the fall had occurred. There was no reporting to Certification. Resident #43 was admitted to the facility with [DIAGNOSES REDACTED]. On 1/11/17 the facility's reportable incidents were reviewed by the surveyor. Review of facility reportable incidents revealed, On 1/18/16 the facility reported an allegation of abuse from resident #43, that occurred on 1/16/16. Review of the file revealed the resident had reported the incident to a Registered Nurse (RN) on 1/16/16. The RN conducted an investigation. The allegation was the Licensed Practical Nurse (LPN) told the resident to hold up her damn arm. There was a CNA that witnessed the interaction and stated the nurse did not curse at or to the resident. The resident later said that the nurse just didn ' t understand that she was holding up her arm the best she could. The nurse did not report the allegation to DHEC or to Administration until 1/18/16. The Director of Nurses, (DON) was interviewed by the surveyor. The DON was aware of the incident and confirmed the allegation of abuse had not been reported timely to Administration or DHEC.

Based on record review, observation and interview, the facility failed to follow the care plan for 1 of 3 reviewed for pressure ulcers. Resident #72's pressure mattress was observed not functioning. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of Resident #72's care plan on 1/12/17 listed a problem with skin with an approach for a low air loss mattress to bed at all times as ordered-verify pump is on and functioning every shift-notify maintenance of malfunctions. Observation of Resident #72 on 1/10/17 at 3:28 PM revealed he/she was up in the wheelchair and the air mattress was not inflated. Observation on 1/11/17 at 9:31 AM revealed Resident #72 was in bed and the air mattress was not functioning. At that time, the Director of Nursing was notified who confirmed the mattress was not functioning.

Based on observation, record review and interview, the facility failed to ensure prevention of pressure sores was implemented and pressure sore treatment was applied per physician's orders. Resident #72 was observed with the air mattress not functioning properly and a pressure ulcer treatment not transcribed correctly. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Record review on 1/12/17 revealed Resident #72 had a Stage II pressure area to the left buttock and a Stage III to the right buttock. Review of the physician orders for pressure ulcer care listed a treatment to cover with [MEDICATION NAME] alginate gauze, skin prep to peri wound and secure with paper tape-change every three days. Review of the resident's care plan listed an approach for skin for Resident #72 to have an air mattress at all times. Observation of Resident #72 on 1/10/17 at 3:28 PM revealed he/she was up in the wheelchair and the air mattress was not inflated. Observation on 1/11/17 at 9:31 AM revealed Resident #72 was in bed and the air mattress was not functioning. Observation of the pressure ulcer wound treatment on 1/13/16 at 10:15 AM revealed Registered Nurse(RN)#1 after donning gloves cleansed the right buttock, removed gloves, washed hands, donned gloves and cleansed the left buttock. He/she dressed the wounds with [MEDICATION NAME]. After washing his/her hands and donning gloves, he/she placed a dressing to the right buttock. After sanitizing his/her hands and donning gloves, RN #1 reached into his/her pocket and obtained scissors and cleansed them with an alcohol swab. He/she cut another piece of [MEDICATION NAME] to place on the left buttock due to the [MEDICATION NAME] not staying in place on the first attempt. A dressing was placed on the area. After the treatment, RN #1 placed the trash in a bag, realized his/her scissors had been placed in the bag and reached into the bag and retrieved his/her scissors and placed them on the resident's over the bed table. RN#1 obtained an alcohol swab and wiped the scissors and placed them in his/her pocket. After sanitizing his/her hands, RN#1 placed the trash in the soiled utility room. During an interview with the Director of Nursing on 1/11/17 at 9:31 AM, he/she confirmed the air mattress was not functioning at that time. On 1/13/17 at 11:08 AM, during an interview with RN #1, after bringing to his/her attention related to placing the scissors on the over the bed table, he/she stated would obtain items to clean the over the bed table. On 1/13/17 at 12:32 PM, during an interview with RN #2, he/she stated the treatment was not done as ordered related to placing skin prep to the peri wound and the order had not been transcribed correctly. Review of the facility policy titled Dressing Change(Clean Technique) revealed the following under the Procedure section #19. Clean the wound according to order . The policy did not address if the resident had more than one wound and treating one wound at a time.

Based on record review and interview, the facility failed to provide services to meet professional standards for 1 of 3 resident's reviewed for change in condition/hospital transfer. Resident #1 had a change in condition and was not appropriately assessed by the licensed nursing staff. The findings included: Cross refer to F309 related to quality of care provided to Resident #1 with a change in condition. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident had a change in condition on 10/13/14. The change was identified at 10:49 AM. The resident was taken to the hospital emergency room (ER) at 12:18 PM by a transport ambulance and not 911. The nurse did not assess the resident's condition/changes. Vital signs were obtained once by a Certified Nursing Assistant (CNA). The nurse was not aware that the resident's blood pressure was low. The physician gave orders to send the resident to the hospital ER. The family did not want the resident to go to the ER. The nurse did not follow the physician's orders [REDACTED]. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Departmental Notes dated 10/10/14 at 2:31 PM indicated the resident was readmitted to the facility from the hospital. 10/11/14 at 1:00 PM the resident was out on leave with her/his daughter returning at 8:31 PM, the facility was notified by the daughter that the resident had fallen at home. "S/he lost balance and she bumped her face against the wall. Redness and tenderness was noted to the right side of the face." The facility obtained x-rays with no fractures noted. 10/13/14 at 10:49 AM the nurse was called to the room by a Certified Nursing Assistant. "Resident mumble calling out a unfamiliar names. Resident stated, 'She was at home.' Resident knew daughters name. Resident denies pain and discomfort. Resident continue moaning." The physician was notified and orders obtained to send resident to the hospital emergency room (ER). The resident's family was notified but did not want the resident to be sent to the hospital. 10/13/14 at 11:50 AM a family member was in the facility. The family member stated, "S/he is not responding to me." The family member was informed by the staff that there was a change in the resident's condition that the daughter was aware and refused to allow the facility to send the resident to the hospital. 12:01 PM the transport service was called to transport the resident to the hospital ER. At 12:06 Vital signs were obtained, Temperature (T)-97.4, Pulse (P)-68, Respirations (R)-20, Blood Pressure (B/P) 96/38. The physician was notified and the resident was sent to the hospital with mental status change. On 10/28/14 at approximately 9:45 AM, Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor. When asked about the resident's condition, the LPN stated the resident was not the same. "S/he knows me but was calling a different name. S/he has been like that before but comes out of it. " The LPN stated the CNA's obtained the vital signs and did not report the low blood pressure to the nurse. When asked by the surveyor about assessing the resident, the LPN stated s/he felt the residents [MEDICAL TREATMENT] graft and made sure it was alright.

Based on record review and interviews, the facility failed to provide the necessary services to Resident #1 related to a change in condition (1 of 3 residents reviewed for change in condition). Resident #1 was not assessed for a change in condition and the physician's orders [REDACTED]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Departmental Notes dated 10/10/14 at 2:31 PM indicating the resident was readmitted to the facility. 10/11/14 at 1:00 PM the resident was out on leave with the daughter when s/he returned at 8:31 PM the facility was notified by the daughter that the resident had fallen at home. "S/he lost balance and s/he bumped her/his face against the wall. Redness and tenderness was noted to the right side of the face." The facility obtained x-rays with no fractures noted. 10/13/14 at 10:49 AM the nurse was called to the room by a Certified Nursing Assistant. "Resident mumble calling out a unfamiliar names. Resident stated, 'S/he was at home.' Resident knew daughters name. Resident denies pain and discomfort. Resident continue moaning." The physician was notified and orders were obtained to send the resident to the hospital emergency room (ER). The resident's family was notified and did not want the resident to be sent to the hospital. 10/13/14 at 11:50 AM a family member was in the facility. The family member stated "S/he is not responding to me." The family member was informed that there was a change, that the daughter was aware and refused to send the resident to the hospital. 12:01 PM the transport service was called to transport the resident to the hospital emergency room . 12:06 Vital signs were obtained, temperature-97.4, pulse-68, respirations-20, blood pressure-96/38. The physician was notified and the resident was sent to the hospital with mental status change. The surveyor interviewed Licensed Practical Nurse (LPN) on 10/28/14 at approximately 9:45 AM when asked about the resident's condition, the LPN stated the resident was not the same. "S/he knows me but was calling a different name. S/he has been like that before but comes out of it." The LPN stated the (Certified Nurse Aide) CNA's obtained the vital signs and did not report the low blood pressure to the nurse. When asked by the surveyor about assessing the resident, the LPN stated s/he felt the residents [MEDICAL TREATMENT] graft and made sure it was all right. In an interview with the surveyor on 10/28/2014 at 12:55 PM the physician stated it was the facility protocol to send the resident out to the emergency room if there was a concern by the nursing staff. Review of the hospital History and Physical dated 10/13/14 revealed, "S/he was brought in not by EMS (911) but by a medical transport ambulance. When s/he arrived at the hospital, s/he was in cardiopulmonary arrest. The patient is presently intubated and not making any efforts to cooperate with exam or answer questions." The hospital discharge summary dated 10/16/14 revealed the resident's cause of death as severe hypoxic [MEDICAL CONDITION] after cardiopulmonary arrest.

On the days of the survey, based on observations, record reviews and interviews, the facility failed to ensure that standards of clinical practice related to drug storage and administration established by the pharmaceutical company FDA (Food and Drug Administration) approved package inserts, Lexi-Comp Drug Information for Nursing and the facilities' policy and procedures on drug storage were followed on 1 of 2 nursing units. The finding included: During inspection of the West Medication Room on 1/25/11 at approximately 9:50 AM, 20 vials of Insulin Injection, 2 vials of [MEDICATION NAME] Injection, 1 syringe of [MEDICATION NAME] Injection, 2 vials of [MEDICATION NAME] B Adult P/F (preservative- free) Injection, 1 vial of [MEDICATION NAME] Injection, 9 -[MEDICATION NAME] Suppositories, 2 -Bisac-Evac Suppositories, 8- [MEDICATION NAME] Suppositories, 32 -[MEDICATION NAME] Suppositories and 41- Tucks [MEDICATION NAME] Suppositories were stored in the medication room refrigerator at a temperature of 20 degrees F (Fahrenheit). Two of the Insulin vials were frozen. During an interview on 1/25/11 at approximately 10:50 AM, LPN (Licensed Practical Nurse) # 1 stated that if she observed a refrigerator temperature of less than 36 degrees F, that she would turn up the refrigerator temperature and take the insulin to be administered out of the refrigerator to warm to room temperature prior to administering. During an interview on 1/25/11 at approximately 3:10 PM LPN # 1 and LPN # 2 stated that if the thermometer was observed to be less than 36 degrees F they would let the DON (Director of Nursing ) know and that the DON or Pharmacy would tell them what to do in terms of administering the drug, They stated that the DON usually tells them to let it warm to room temperature and then administer. They stated that the medication refrigerator temperature checks are usually made and recorded on first shift, but are sometimes done on third shift and that this responsibility is not assigned to any one person. According to pharmaceutical manufacturer standards (package inserts and manufacturer's labelling), Lexi-Comp Drug Information for Nursing and the facilities' policy and procedures the Insulin, [MEDICATION NAME] B, [MEDICATION NAME] and [MEDICATION NAME] Suppositories should be stored between 36-47 degrees F in order to ensure integrity of the drug. Bisac-Evac and [MEDICATION NAME] Suppositories should be stored at 59-86 degrees F and Tucks [MEDICATION NAME] Suppositories should be stored 68-77 degrees F. Based on observation, record reviews and interviews, facility nurses failed to seek guidance from the Pharmacy and or Physician as to the safety of administering medications improperly stored. Nursing staff when interviewed, stated that they had been instructed by the Director of Nursing to continue to administer medication known to have been improperly stored. There was no documentation that this directive was questioned. This action resulted in the potential for harm for residents who were ordered by their physicians to receive the medications which were improperly stored and subsequently administered. Medications which are improperly stored may lose efficacy or potency, therefore compromising the desired effect. It was determined that the Immediate Jeopardy existed starting 11/2/2010 when the facility was first notified in writing by the Pharmacy of improper temperature controls. The Immediate Jeopardy at F281 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of "E".

On the days of the survey based on observations, record reviews and interviews the pharmacy failed to ensure that medications were stored in 1 of 2 medication room refrigerators at temperatures specified by FDA (Food and Drug Administration) approved package inserts, manufacturer package labelling and the Facility's Policy and Procedures of drug storage. The findings included: Inspection of the West Medication Room medication refrigerator on 1/25/11 at approximately 9:50 AM revealed a temperature reading of 20 degrees F (Fahrenheit). The refrigerator contained, on the top shelf, in a plastic basket ,2 opened vials of Novolin R Insulin 100 U (units)/ml (milliliter) which were frozen, 5 opened vials of Lantus Insulin 100 U/ml. Contained in a plastic bin on the second shelf were 2 vials of Procrit Injection 20,000 U/ml, 1 syringe of Aranesp Injection 40 mcg (micrograms)/ml, 2 vials of Engerix B Adult P/F (preservative- free) Injection 20 mg (1 was opened) and 1 opened vial of Tubersol Injection. Stored on the bottom of the refrigerator, in a plastic bin, were 9 Acephen 650 mg Suppositories, 2-Bisac-Evac 10 mg Suppositories, 8 Bisacodyl 10 mg Suppositories, 32 Phenadoz 25 mg Suppositories and 41 Tucks Hemorrhoidal Suppositories. The refrigerator door contained 1 vial of Lantus Insulin 100 U/ml and 10 vials of Novolin R Insulin 100 U/ml. A review of the FDA approved manufacturer's package inserts and manufacturer package labelling conducted on 1/25/11 at approximately 10:15 AM showed that the Insulin, Procrit, Aranesp, Engerix-B, Tubersol and Phenadoz Suppositories should be stored at 36-46 degrees F. The Acephen, Bisac-Evac and Bisacodyl Suppositories should be stored 59-86 degrees F and the Tuck Hemorrhoidal Suppositories should be stored 68-77 degrees F. On 1/25/11 at approximately 4:45 PM the Consultant Pharmacist, during a telephone interview, stated that medications should be stored according to specified standards by the manufacturer and that in December, 2010 she had concerns about the type of thermometer being used in the West Medication room refrigerator and that she told the nurse on duty. She was unable to identify the name of the nurse, stated that this was the first time she was aware of the problem and did not acknowledge review of the daily recordings of medication refrigerator temperatures. On 1/25/11 at approximately 5:00 PM a review of the "MED ROOM INSPECTION NURSING STATION INSPECTION REPORT" dated 1/21/11 revealed that CPhT # 1 had written "Temp was very low - like 12 degrees - suggest adjusting". Further review of "MED ROOM INSPECTION NURSING STATION INSPECTION REPORT" dated 11/2/10 revealed that CPhT # 2 had written "Ref too cold 25 degree F". There was no inspection done in December and neither the DON or Pharmacy could provide proof of inspection during October, 2010. On 1/26/11 at approximately 12:03 PM a telephone interview with the Medical /Director revealed that he was unaware of a problem with medication refrigerator temperatures and commented that "It sounds like the person didn't recognize there was a problem. Good news is that they were checking". He agreed that the observed temperature of 20 degrees F (Fahrenheit) and previously recorded temperatures were too low, but was unaware of any problems with patient sugars being too low or too high. He stated that the staff should have reported this as a problem months ago and that the Pharmacy Consultant should have been notified. He did not remember this concern being discussed at the Quality Assurance Committee. On 1/26/11 at approximately 2:30 PM a review of the October-December, 2010 and January 1-25, 2011 "REFRIGERATOR/FREEZER TEMPERATURE CHECK" logs for the West Wing medication refrigerator revealed a total of 116 daily temperatures recorded (a recording for January 17, 2011 was missing). Of these there were 8 recordings (6.9 % (percent)) of temperatures 36-46 degrees F, 56 (48.3%) at 30-35 degrees F, 45 (38.8%) at 20-29 degrees F (of which 7 or 6% were at 20 degrees F), 7 (6.0%) at 10 - 19 degrees F. On 1/26/11 at approximately 3:05 PM, during a telephone interview, CPhT # 1 stated that she discussed refrigerator temperature concerns with the DON on 1/21/11. There was discussion about where the temperature dial should be set (1-7) and where the thermometer should be placed and this resulted in the dial being set to "1" and the thermometer being placed on the second shelf. She was asked to clarify the temperature recorded (12 degrees or 20 degrees?) on the 1/21/11 inspection report, but could not recall the temperature. She agreed to pull the record at her home and advise on 1/27/11. As of 1/27/11 at approximately 11:30 AM contact with CPhT # 1 was unsuccessful. On 1/26/11 at approximately 4:00 PM a review of the Quality Assurance Committee attendance records October-December, 2010 failed to show attendance by the Consultant Pharmacist. The minutes did not reflect any discussion of medication refrigerator temperature concerns. Based on record review and interviews, the facility's Consulting Pharmacist failed to assure that the Pharmaceutical service oversight for which it was contracted to provide, continued to identify, evaluate and prevent the improper storage of medications. There was no immediate action documented which indicated the Pharmacy assessed the improperly stored medications at the time of discovery, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure the concern was immediately corrected. It was determined that the Immediate Jeopardy existed starting 11/2/2010. The Immediate Jeopardy at F425 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of "E".

On the days of the survey based on observations, record reviews and interviews the facility failed to ensure that medication were stored in 1 of 2 medication room refrigerators at temperatures specified by FDA (Food and Drug Administration) approved package inserts, manufacturer package labelling and the Facilities Policy and Procedures of drug storage. The findings included: Inspection of the West Medication Room medication refrigerator on 1/25/11 at approximately 9:50AM revealed a temperature reading of 20 degrees F (Fahrenheit). The refrigerator contained, on the top shelf, in a plastic basket ,2 opened vials of Novolin R Insulin 100 U (units)/ml (milliliter) which were frozen, 5 opened vials of Lantus Insulin 100 U/ml. Contained in a plastic bin on the second shelf were 2 vials of Procrit Injection 20,000U/ml, 1 syringe of Aranesp Injection 40 mcg (micrograms)/ml, 2 vials of Engerix B Adult P/F (preservative- free) Injection 20 mg (1 was opened) and 1 opened vial of Tubersol Injection. Stored on the bottom of the refrigerator, in a plastic bin, were 9 Acephen 650 mg Suppositories, 2-Bisac-Evac 10 mg Suppositories, 8 Bisacodyl 10 mg Suppositories, 32 Phenadoz 25 mg Suppositories and 41 Tucks Hemorrhoidal Suppositories. The refrigerator door contained 1 vial of Lantus Insulin 100 U/ml and 10 vials of Novolin R Insulin 100 U/ml. This finding was verified by LPN (Licensed Practical Nurse) # 1 on 1/25/11 at approximately 9:55 AM. LPN # 1 stated that the temperature dial was set on "1", but she was unsure as to whether that was the lowest of highest temperature setting. On 1/25/11 at approximately 10:00 AM the DON (Director of Nursing stated that she and CPhT (Certified Pharmacy Technician) # 1 discussed the low refrigerator temperature on 1/21/11 during a pharmacy inspection and that the temperature dial was set to "1". The DON stated that she was first aware that there could be a temperature problem about one month ago and that a problem found during inspection was supposed to be discussed with her, but that she was not always there. A review of the FDA approved manufacturer package inserts and manufacturer package labelling conducted on 1/25/11 at approximately 10:15AM show that the Insulinm, Procrit, Aranesp, Engerix-B, Tubersol and Phaenadoz Suppositories should be stored 36-46 degrees F. The Acephen, Bisac-Evac and Bisacodyl Suppositories should be stored 59-86 degrees F and the Tuck Hemorrhoidal Suppositories should be stored 68-77 degrees F. On 1/25/11 at approximately 4:45 PM the Consultant Pharmacist, during a telephone interview, stated that medications should be stored according to specified standards by the manufacturer and that in December, 2010 she had concerns about the type of thermometer being used in the West Medication room refrigerator and that she told the nurse on duty. She was unable to identify the name of the nurse and stated that this was the first time she was aware of the problem. On 1/25/11 at approximately 5:00 PM a review of the "MED ROOM INSPECTION NURSING STATION INSPECTION REPORT" dated 1/21/11 revealed that CPhT # 1 had written "Temp was very low - like 12 degrees - suggest adjusting". Further review of "MED ROOM INSPECTION NURSING STATION INSPECTION REPORT" dated 1/2/10 revealed that CPhT # 2 had written "Ref too cold 25 degree F". There was no inspection done in December and neither the DON or Pharmacy could provide proof of inspection during October, 2010. On 1/26/11 at approximately 2:30 PM a review of the October-December, 2010 and January 1-25, 2011 "REFRIGERATOR/FREEZER TEMPERATURE CHECK" logs for the West Wing medication refrigerator revealed a total of 116 daily temperatures recorded (a recording for January 17, 2011 was missing). Of these there were 8 recordings (6.9 % (percent)) of temperatures 36-46 degrees F, 56 (48.3%) at 30-35 degrees F, 45 (38.8%) at 20-29 degrees F (of which 7 or 6% were at 20 degrees F), 7 (6.0%) at 10 - 19 degrees F. On 1/26/11 at approximately 2:55 PM a review of the Maintenance Logs for the past year did not show any work requests or repairs for the West Wing Medication Refrigerator. On 1/26/11 at approximately 3:05 PM during a telephone interview CPhT # 1 stated that she discussed refrigerator temperature concerns with the DON on 1/21/11. There was discussion about where the temperature dial should be set (1-7) and where the thermometer should be placed and this resulted in the dial being set to "1" and the thermometer being placed on the second shelf. She was asked to clarify the temperature recorded (12 degrees or 20 degrees) on the 1/21/11 inspection report, but could not recall the temperature. She was to pull the record at her home and advise on 1/27/11. As of 1/27/11 at approximately 11:00 AM contact with CPhT # 1 was unsuccessful. Based on record reviews and interviews, the failure of Administration to correct a known concern related to medication storage and to have directed staff to continue to administer the medications placed residents at risk for serious harm. The standard for medication storage per the code of Federal Regulations states: "All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions in accordance with requirements, if any, in the labeling of such drugs, or with requirements in the current edition of an official compendium, such as the United States Pharmacopeia/National Formulary (USP/NF). It was determined that the Immediate Jeopardy existed starting 11/2/2010 when the facility received written notification that the medication room refrigerator was improperly storing medications. The Immediate Jeopardy at F431 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of "E".

On the days of the survey, based on observation, record reviews and interviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Facility Admininstration failed to take immediate action when notified of improper medication refrigerator temperatures. Nursing Administration failed to educate and instruct facility staff on the appropriate use of medications which were known to have been improperly stored. The findings included: On 11/2/2010 a 'Med Room Inspection Nursing Station Inspection Report' (completed by the Consulting Pharmacy Technician) and submitted to the facility identified the West Nursing Station refrigerator as being "too cold" at 25 degrees Farenheit. A subsequent 'Med Room Inspection Nursing Station Inspection Report' dated 1/21/11 also documented "Temp was very low - like 12 degrees - suggest adjusting". The facility failed to initiate a plan of action which assured correction of the identified concern. Additionally, nursing staff when interviewed, stated that they had been instructed by the Director of Nursing to continue to administer medication known to have been improperly stored. The failure of Administration to correct a known concern related to medication storage and to have directed staff to continue to administer the medications placed residents at risk for serious harm. The standard for medication storage per the code of Federal Regulations states: "All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions in accordance with requirements, if any, in the labeling of such drugs, or with requirements in the current edition of an official compendium, such as the United States Pharmacopeia/National Formulary (USP/NF). It was determined that the Immediate Jeopardy existed starting 11/2/2010 when the facility received written notification that the medication room refrigerator was improperly storing medications. The Immediate Jeopardy at F490 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of "E".

On the days of the survey, based on observations, interviews, record reviews, and review of facility policies, the facility failed to maintain a Quality Assessment and Assurance Committee which fully identified quality deficiencies related to medication storage at improper temperature ranges. The facility failed to address the concern and implement corrective action to ensure medications were stored within the appropriate temperature range to prevent compromising the integrity of the medications. The findings included: During an interview on 1/27/11 at approximately 10:30 AM, the Director of Nursing (DON) was asked how the facility identified issues which would require quality assessment and assurance action. At that time, the DON was asked if the Quality Assessment and Assurance Committee had identified medication refrigerator temperatures as a concern. The DON indicated during the interview that this concern had not been identified and taken to the committee for review. On 1/26/11 at approximately 12:03 PM a telephone interview with the Medical /Director revealed that he was unaware of a problem with medication refrigerator temperatures and commented that "It sounds like the person didn't recognize there was a problem. Good news is that they were checking". He agreed that the observed temperature of 20 degrees F (Fahrenheit) and previously recorded temperatures were too low, but was unaware of any problems with patient sugars being too low or too high. He stated that the staff should have reported this as a problem months ago and that the Pharmacy Consultant should have been notified. He did not remember this concern being discussed at the Quality Assurance Committee. It was determined that Immediate Jeopardy existed starting 11/2/2010 when the facility received written notification that the medication room refrigerator was improperly storing medications. Notification of the concern was provided to the facility but the concern was not addressed and the temperature readings logged in by staff continued to be consistently below acceptable parameters. The Immediate Jeopardy at F520 was removed upon verification of implementation of the Allegation of Compliance by the survey team on 1/27/11 prior to exit. At that time the citation remained but was lowered to a scope and severity of "E".