Every finding on record at Joseph L Morse Health Center Inc the

Based on observation, interview, and record review, the facility failed to ensure supervision for 1 of 4 sampled residents (Resident #67) related to wandering, which also affected Resident #117 and Resident #15. The findings included: Resident #67 was admitted on [DATE] with diagnosis that included Alzheimer's and anxiety disorder Review of the Minimum Data Set (MDS) assessment, dated 02/24/22, documented Resident #67 as being severely cognitively impaired. Resident #67's Care Plan for Wandering Risk, effective date 10/15/21, documented interventions of offering snacks in between meals, provide reassurance and comfort when anxious, assist with calling son, check wander guard for proper placement and function, and update Code Purple folder (wanderers identification book) with resident's picture and important information. On 04/11/22 at 10:44 AM during an interview, Resident #117 wrote that Resident #67 comes in his room uninvited, sometimes uses his restroom and they (the staff) must physically remove her. He communicated that it upsets him, and that he has complained to the nurses. Review of the MDS assessment dated [DATE] documented Resident #117 as being cognitively intact with diagnosis that include inability to speak due to surgical removal of his voice box, altered breathing due to breathing through a hole in his neck and requiring limited to extensive assistance for all activities except eating. On 04/11/22 at 11:29 AM during an interview, Resident #15 stated a confused woman in a wheelchair who speaks Spanish, a foreign language, comes in her room and fiddles with her bedding. She also said that sometimes it unnerves her because she is sleeping and feels someone messing with her bed. Review of the MDS assessment dated [DATE] documented Resident #15 as being cognitively intact with diagnosis that included [CONDITION(S)] and requiring extensive assistance for all activities except eating. On 04/13/22 at 8:20 AM, Resident #117 communicated that Resident #67 came in his room again yesterday and had to be escorted out. He also communicated that he complained again to the staff about it. On 04/13/22 at 2:00 PM, Staff A CNA (Certified Nursing Assistant) stated he is aware of Resident #67 wandering in other people's rooms and about her going into Resident #117's room. He stated he goes and gets her out. Staff A said they try to redirect her but sometimes he is busy giving care to someone else and does not know she has gone into another resident's room. On 04/13/22 at 2:15 PM, Staff B, Registered Nurse (RN) stated that she is aware of Resident #67's wandering and going uninvited into other residents' rooms. She said they put a wander guard on her chair to keep her from leaving the floor. She also stated they try to have her sit by the nurse's station so they can watch her. On 04/13/22 at 4:22 PM, Resident #117 communicated in the presence of another surveyor that Resident #67 came in his room again and had to be removed yesterday. He said that it bothers him, he does not like it, it has been going on for months and he has complained about it to the staff. On 04/13/22 at 4:25 PM, Resident #15 stated in the presence of another surveyor that Resident #67 comes in her room uninvited and messes with her bedding. She stated that it bothers her, actually it bothers everyone. Review of the Progress Note, titled, Nursing on 12/23/21 at 5:57 AM, stated, resident woke up around 5:15 AM and started making a lot of noise roaming around calling in Spanish [her native language] she pulled the alarm of the emergency door, security was called to reset the alarm. Redirected several times, she got aggressive. Review of the Progress Note, titled, Nursing on 01/16/22 at 1:45 AM, stated, received resident awake out of bed roaming around in her wheelchair, going door to door waking up other residents; she went to a resident's room broke a picture frame then threw stuff on the floor. Review of the Interdisciplinary Behavior Observation Form dated 01/18/22, documented Resident #67 with behaviors of yelling, screaming, being verbally abusive and entering other residents' rooms. Review of the Interdisciplinary Behavior Observation Form dated 03/02/22, documented Resident #67 with behaviors of being verbally abusive, threatening, screaming at others, cursing, and being physically abusive. Interventions used for the behaviors listed separating Resident #67 from the other resident, redirect, and return her to her room. Review of the Interdisciplinary Behavior Observation Form dated 03/10/22, documented Resident #67 in other resident's room with behaviors of being verbally abusive, threatening, screaming at others, cursing, and being physically abusive, kicking, attempts to hit, and very combative. Review of the Progress Note, titled, Nursing on 03/10/22 at 4:11 PM, stated Resident was very aggressive today. Went to other resident's room used the toilet and attempts to kicks the Resident (#117) . when Writer trying to take (Resident#67) out, she started, yelling, shouting, and kicking. (Resident #67) went to another resident's room trying to kick another resident. ANRP (nurse practitioner) notified, received new order [MEDICATION(S)] 0.5 milligram intramuscular (sedation shot). [MEDICATION(S)] given in the left arm. Review of the Progress Note, titled, Medical on 03/16/22 at 2:41 PM, documented under Behaviors: yelling, screaming, biting, delusions, verbally and physically abusive, going into other rooms and hoarding. Review of the Progress Note, titled, Geri-Psychiatry Follow-up Evaluation on 03/17/22 at 2:35 PM, documented under Assessment: Worsening anxious moods, sundowning (state of confusion spanning into the night), wandering and agitation. Review of the Progress Note, titled, Activities on 03/27/22 at 5:11 PM, stated Resident #67 can self-propel her wheelchair around the unit and is noted to wander into other resident's rooms. Review of the Progress Note, titled, Medical on 03/31/22 stated Resident # 67 has been exhibiting the following behavior of yelling, biting, resisting care, delusions, verbally and physically abusive, going into other rooms, hoarding and states the behaviors occur randomly throughout day and night hours. Resident #67 was observed during the survey to self-propel her wheelchair in the hallways and dining room on her unit.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety that included failure to hold cold foods at regulatory temperatures of 41 degrees F or below. The findings included: Subsequent observations were conducted in Satellite Kitchens on 03/09/21 and 03/10/21. Food temperatures were taken by the use of the facility's calibrated thermometer and, it was noted that cold foods were not being maintained at the regulatory requirement of 41 degrees F or below, by the following: Mack 1 on 03/09/21 at 8:15 AM: Half Pan Cottage Cheese (20 servings) = 44 degrees F Edwards -3 on 03/10/21 at 12:45 PM: Chicken Salad = 46 degrees F Cottage Cheese = 60 degrees F Salami/Turkey Slices = 65 degrees F Mack 2 on 03/10/21 at 1 PM : Egg salad = 44 degrees F Turkey/Bologna Slices = 46 degrees F During the observations and interviews on the aforementioned dates and times, the Director of Nursing and Dietary Supervisor acknowledged the findings.

Based on observation, interview, and record review, the facility failed to initiate a care plan for a resident with an altered airway, for 1 of 1 sampled residents reviewed for Respiratory Care (Resident #149). The findings included: Resident #149 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A laryngectomy is a surgical procedure to remove part or all of the larynx usually to [MEDICAL CONDITION]. A total laryngectomy implies the complete surgical removal of the larynx and therefore a disconnection of the upper airway (nose and mouth) from the lungs. A patient with a laryngectomy will have a permanent opening of the trachea to the front of the neck (stoma) to allow breathing. A person with a stoma would have oxygen administered through the stoma, not through the nose or mouth. A review of Resident #149's care plans failed to identify a care plan for altered airway care, which would address the resident's goals, risks, and interventions to prevent airway complications and emergencies such as mucus plugging (blockage of tracheal airway hole with secretions). During an interview with the Physician, Staff D, and Senior Vice President of Health Center Operations on 03/10/21 at 10:00 AM a care plan for altered airway was requested. None was provided prior to survey exit. An interview was conducted with Staff E, the Minimum Data Set (MDS) Coordinator, on 03/10/21 at 9:00 AM, which revealed that there is no specific care plan for altered airway.

Based on observation, interview, and record review, the facility failed to ensure routine care, emergency care, and staff training for a resident with an altered airway for 1 of 1 sampled residents for Respiratory Care (Resident #149). The findings included: Resident #149 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A laryngectomy is a surgical procedure to remove part or all of the larynx usually to [MEDICAL CONDITION]. A total laryngectomy implies the complete surgical removal of the larynx and therefore a disconnection of the upper airway (nose and mouth) from the lungs. A patient with a laryngectomy will have a permanent opening (stoma) of the trachea to the front of the neck to allow breathing. A person with a stoma would have oxygen administered through the stoma, not through the nose or mouth. A [MEDICAL CONDITION] is a surgically created hole through the front of the neck and into the trachea (windpipe) without the surgical removal of the larynx. It can be temporary or permanent. A person with a [MEDICAL CONDITION] would have oxygen administered through the stoma, not through the nose or mouth. The Minimum Data Set (MDS) admission assessment with an assessment reference date (ARD) of 07/22/2016 revealed the resident to have a brief interview for mental status (BIMS) of 14 which indicates the resident is cognitively intact. A review of the Advanced Registered Nurse Practitioner (ARNP) progress note for Resident #149 dated 07/16/16 revealed that he came to the facility with a past medical history of [REDACTED]. A review of the [MEDICAL CONDITION] consult dated 08/12/16 revealed Resident #149 had shortness of breath after receiving his treatment this morning and states he has been short of breath past 3 days. Mostly feel like something is stuck. Resident suctioned for large amount thick mucus from stoma. A review of recent nursing progress notes dated 12/13/20 and 02/21/21 revealed the resident needed to be suctioned for secretions with decreased oxygen levels or for feeling something stuck in his throat. The progress note dated 02/21/21 revealed the resident had 2 liters of oxygen via nasal cannula for an oxygen saturation of 86%. Values under 90% are considered low. A review of the physician's orders [REDACTED].#149 revealed an order to [MEDICAL CONDITION] as needed. A review of the physician's orders [REDACTED]. An interview was conducted with the resident on 03/09/2021 at 4:00 PM, which revealed that the resident had been suctioned by the nurses as needed. No suction equipment noted in the room. He also revealed that they bring the suction equipment into the room on a cart when he needs suctioning. An interview was conducted on 03/09/21 at 4:15 PM with Staff B, the Registered Nurse assigned to the resident, regarding what she would do if Resident #149 needed respiratory care. Staff B stated that she was new, and the Nurse Manager would obtain the policy for her and assist. The Nurse Manager, Staff C was present and agreed. When asked about suctioning and equipment, Staff C further revealed that the suctioning equipment was on the crash (emergency) cart. There is no suction equipment in the resident's room. The cart was observed located down the hall with the suction equipment (lid, container, machine) unassembled in a knotted clear plastic bag. An interview was conducted with the Physician for the facility, Staff D, along with the Senior Vice President of Health Center Operations and two additional surveyors on 03/10/21 at 10:00 AM. The Physician was asked about the altered airway for Resident #149. The Physician stated that the resident had a laryngectomy. When asked if Resident #149 had an airway emergency would they ventilate (breath for) him through the hole in his neck? Staff D stated yes and continued to articulate and demonstrate how the resident would be ventilated. The connector for the ambu bag (a manual resuscitator) would be inserted into the stoma. A tight seal would be created by wrapping his fingers around the connector tight to the skin, which is necessary to ventilate him. This surveyor asked to see documentation of staff training for emergency care of altered airway for Resident #149. None was provided prior to survey exit. An additional interview was conducted with the DON on 3/10/2021 at 1:35 PM regarding who is trained and approved in all aspects of stoma care and suctioning. The DON replied that there is no training for stoma care and suctioning because they follow the Nurse Practice Act. A review of Resident #149's care plans failed to identify altered airway care, needs, and address specific risks for airway complications and emergencies such as mucus plugging (blockage of tracheal airway hole with secretions).

Based on observation, interview, and facility provided product data, the facility failed to properly clean the glucometer for 1 (Resident #92) of 3 sampled residents who were observed for accuchecks (the process of obtaining a blood sample to determine the blood sugar level). The findings included: An observation to obtain an accucheck for Resident #92, who resided on the Resnick 3 unit, was made on 06/18/19 at approximately 4:45 PM. Staff A, a Registered Nurse (RN), gathered supplies for the accucheck, including a glucometer (the machine/devise used to get the blood sugar reading). The RN opened the bottom drawer of his medication cart, and pulled a Purell Hand Sanitizing Wipe from the container and proceeded to clean the glucometer. Staff A used the glucometer to obtain the blood sample for Resident #92, returned to the medication cart, and again cleaned the glucometer with a Purell Hand Sanitizing Wipe. Review of the container at the time of the observation documented, Kills 99.99% of illness causing germs, but lacked any directions for use. On 06/19/19, after surveyor observations of accuchecks, the surveyor requested the manufacturer's instructions for both the Evencare ProView glucometer, the glucometer used by Staff A, and the manufacturer's instructions for the disinfectant being used by the facility for the glucometers. The Risk Manager provided the booklet for the Evencare ProView Meter, along with the manufacturer's instructions for MicroKill Bleach Germicidal Bleach Wipes. The Risk Manager confirmed the facility practice was to use the MicroKill wipes to clean and disinfect the glucometers. On 06/19/19 at 5:45 PM, Staff A, verified that he used the Purell wipes to clean the glucometer. At this time, he was on the Resnick 4 unit at the treatment cart. Staff A looked in the treatment cart and did not find any of the Purell wipes. Staff A went to the nurse's station and identified two containers of the Purell Hand Sanitizing Wipes on the counter, and stated, Yes, I used these. Staff A agreed he pulled the incorrect wipe to clean the glucometer. Observations with the Chief Nursing Officer, of the medication carts on Resnick 3 and 4 on 06/19/19 beginning at 5:55 PM, lacked any Purell wipes. Each of the carts had individual packets of the MicroKill Bleach wipes with the glucometer for each cart, for use to clean and disinfect. The Chief Nursing Officer stated the Purell wipes were used to wipe off counters or medication carts. Interviews with three nurses and additional observations by another surveyor confirmed the facility practice for the use of the MicroKill wipes for the glucometers. During an interview on 06/20/19 at 9:42 AM, the Senior Vice President and Chief Nursing Officer provided the Technical Data for the Purell Hand Sanitizing Wipes. Review of this data lacked information that it was effective on all blood borne pathogens. The Chief Nursing Officer also provided education and training for 40 employees, one of which was Staff A, related to blood glucose monitoring competency. Review of the Manufacturer's Instructions for the Evencare ProView Meter documented the use of a CaviWipe towelette or EPA registered disinfecting wipe. Review of the list of EPA's Registered Antimicrobial Products, dated 01/04/18 documented the MicroKill Bleach wipes as an approved product, but lacked the Purell Hand Sanitizing Wipes.

Based on observation, record review and interview, the facility failed to ensure an accurate account of all controlled medications to ensure an accurate reconciliation for 4 of 13 residents reviewed (Residents #621, #389, #47 and #357). The facility also failed to ensure proper locked storage of medications for 1 of 19 medication carts (R4 unit, B cart). The findings included: 1) During the medication storage observation on the Mack 1 unit, for the middle medication cart on 02/14/17 at 1:34 PM with Staff E, a Licensed Practical Nurse (LPN), the contolled medications were reviewed. Review of the Controlled Medication Utilization Record for Resident #621 documented Tramadol 50 mg (milligrams) was removed from the narcotic box 11 times between 02/11/17 and 02/14/17. Review of the Medication Administration Record [REDACTED]. Staff E confirmed the lack of documented administration at the time of the observation. An observation of the medication cart on unit R3, medication cart 2 was made on 02/14/17 at 2:11 PM with Staff F, a Registered Nurse (RN). Review of the Controlled Medication Utilization Record for Resident #389 documented Percocet 5/325 mg tablets were removed from the narcotic box of the medication cart 39 times between the dates of 01/01/17 through 02/14/17. Review of the January 2017 and February 2017 MARs for Resident #389 documented the Percocet was administered only 31 times during those two months. During a side-by-side record review on 02/14/17 at 2:30 PM the Vice President of Clinical Service confirmed the issues. An observation of the medication cart on unit R4 cart 1 was made on 02/14/17 at 2:45 with Staff D, an LPN. Two residents were reviewed for the controlled medications. Review of the Controlled Medication Utilization Record for Resident #47 revealed Tramadol 50 mg (one-half tablets) were removed from the narcotic box of the medication cart twice in February 2017. Review of the February 2017 MAR for Resident #47 lacked the administration of the Tramadol that was removed on 02/13/17 at 12:27 PM. Review of the Controlled Medication Utilization Record for Resident #357 documented Ativan 0.5 mg was removed 10 times between 02/21/17 and 02/11/17. Review of the February 2017 MAR for Resident #357 lacked the documented administration of the Ativan on 2/6/17 at 9:00 AM. During this review, Staff D agreed with the findings for both residents, and further stated that she removed the dose on 2/6/17 at 9:00 AM. Staff D further stated that the process is to sign the controlled medication out on the narcotic sheet and then to sign it out on the MAR indicated [REDACTED] 2) During a routine observation R4 unit on 02/14/17 at 1:15 PM it was noted that 2 resident medication carts were located along the wall next to the nurses station. Further observation noted that no nursing staff were in the visible area of the nurses station and medication carts. Further observation noted that 1 (Cart B) of the 2 medications carts was not securely locked and the cart drawers could be pulled open. The Unit Manager was requested by the surveyor to observe the issues and confirmed that 1 of the medication carts (Cart B) was not locked. The Charge Nurse summoned the medication nurse (Staff C) that was responsible for the cart who also confirmed that the cart was not properly locked. Further interview with staff A, revealed that she has had difficulty locking Cart B recently but had not reported the issue to nursing administration. The nurse also stated that she does not test the drawers after locking to ensure that the cart is properly secured.

Based on observation and interview conducted on 01/04/16 , it was determined that the facility failed to store, prepare, distribute, and serve food under sanitary conditions that include; failure to maintain refrigeration and freezer units; failure to maintain the air conditioning ventilation system; failure of male staff to properly cover facial hair, and failure of staff to properly sanitize hands between serving resident meals for 3 out of 3 sampled residents (Resident #73, #244 and #429). This has the potential to affect 289 of the facility's 296 residents, who eat orally. The findings include: 1) During the kitchen food service sanitation tour conducted in the main kitchen on 01/04/16 at 9 AM and accompanied with the facility's Executive Chef and Vice President of Clinical Services, the following concerns were noted: (a) Observation of the internal fan covers, located within the walk-in refrigerator and walk-in freezer were noted to have a heavy build-up of a white dust like substance. It was discussed with the Executive Chef at the time of the observation that matter was being blown out of the refrigeration/freezer unit and potential landing of refrigerated/ frozen foods being stored within the units. Documentation was submitted by the facility on 01/05/16, that an outside refrigeration vendor repaired the issues on 01/04/16. (b) Observation of the internal temperature of the walk-in refrigerator revealed a recorded temperature of 65 degrees F (Fahrenheit). The issue was discussed with the Executive Chef at the time of the observation. The Executive Chef could not explain why the temperature was well above the minimum required refrigeration of 41 degrees F. (c) During observation of the exterior surface of the walk-in refrigerator, it was noted that there was a heavy build-up of dripping condensation. Observation of the interior of the walk-in freezer revealed a heavy build-up of ice on the interior door , interior ceiling, and interior freezer unit. It was also noted that many cases of food being stored within the unit were covered in a thick layer of ice. It was discussed with the Executive Chef at the time of observation that the freezer unit was potentially contaminating foods and was in need of immediate repair. Documentation was submitted by the facility that an outside refrigeration vendor repaired the issue on 01/04/16. (d) Ceiling vent #1, located directly outside the walk-in refrigerator and freezer, and ceiling vent #2, located in the 3-compartment sink directly over the clean preparation pots and pans were noted to have a heavy build-up of condensation and were dripping down on any foods, staff, and equipment that passed below the vents. It was discussed at the time of the observation with the Executive Chef that the dripping condensation may contain bacteria and other pathogens could potentially contaminate foods, staff, equipment, etc. that may pass below these vents. Documentation was submitted that an outside refrigeration/air conditioning vendor repaired the issue on 01/04/16. (e) During the kitchen tour that included storage areas, preparation areas, serving areas, and the dish room area it was noted that 7 male staff (Staff H, I, J, K, L, M, and N) failed to have a covering for their facial hair growth. It was discussed with the Executive Chef at the time of the observation that facial hair could potentially fall into foods, equipment, and preparation equipment. 2) During an observation of the lunch meal in the R3 (Resnick 3) Dining Room on 01/04/16 beginning at 1:01 PM, Resident #73, #244 and #429 were observed sitting at one table. On 01/04/16 at 1:09 PM Staff A, who identified herself as a Unit Secretary and Patient Care Specialist, was observed feeding Resident #244 and #429. Staff A was using both hands to adjust the clothing protector and also wiped the mouth of Resident #429 with her clothing protector. Staff A was feeding both Resident #244 and #429 without hand washing or sanitizing between contact with each of these residents. During this continued observation on 01/04/16 at 1:22 PM it was noted that Staff A moved to the other side of the table and sat between Residents #73 and #244. Again, Staff A did not hand wash or sanitize. Staff A fed Resident #73 a few bites, then turned to Resident #244 and began feeding her without hand washing or sanitizing. At 1:28 PM Staff A left the dining room. On 01/04/16 at 1:38 PM Staff A returned to the R3 Dining Room. Staff A was headed toward the table with Residents #73, #244, and #429 when the Unit Manager called her over and told her to sanitize her hands. During an interview, immediately after this dining observation, the Unit Manager confirmed that she did instruct Staff A to sanitize her hands. The Unit Manager was made aware that the surveyor observed Staff A assisting all three residents without hand washing or sanitizing between each resident. During an interview on 01/07/16 at 11:49 AM, Staff A agreed that she failed to hand wash or sanitize between assisting the three residents on 01/04/16. Staff A stated that she was a little overwhelmed with Resident #244 on the day of the observation. Review of the facility policy titled Hand Hygiene/Handwashing revised July 2015 documents, When to wash Hands (at a minimum) . Before and after assisting member(s) with meals (soap and water). ABHR (alcohol based hand rub) may be used while assisting two resident(s)/patients(s) at meal time if hands become soiled. Example: Wiping resident(s)/patients) face during feeding.

Based on observation, record review, and interview it was determined the facility failed to accommodate the needs for 1 (Resident #73) of 23 sampled residents. This was evidenced by the failure to position Resident #73 appropriately at the dining room table, and failure to set up utensils in front of Resident #73. The findings included: Continuous observations of the R3 (Resnick 3) Dining Room were conducted on 01/04/16 during the lunch meal from 12:30 PM until 1:38 PM. During the observations it was noted that Staff began serving soup to the residents at 12:45 PM. At 12:50 PM, Resident #73 was served soup. The silverware for Resident #73 was wrapped in a napkin and out of her reach. Resident #73 was lying slightly back in her rocker chair, calm, and looking at other residents. Resident #73 was sitting at least 3 feet from the table. The resident's feet were propped up on the foot rests, centered directly toward the center support of the table. On 01/04/16 at 1:09 PM, Resident #73 was served her lunch plate. Her drinks and soup remained untouched and she remained at least 3 feet from the table. Resident #73 was mumbling and watching Staff A, a Unit Secretary/PCS (Patient Care Specialist) feeding the other two residents sitting at her table. Staff A was sitting between the other two residents across the table. At 1:14 PM Staff A stated from across the table, (Name of Resident #73), eat some of your lunch. Staff A moved to the other side of the table at 1:22 PM and began feeding Resident #73, 30 minutes after being served the soup. During the continued observation on 01/04/16 at 1:28 PM, Staff A left the R3 Dining Room. The food for Resident #73 remained out of reach, as she remained away from the table. At 1:38 PM Staff A returned to the R3 Dining Room and continued feeding Resident #73. While Staff A was gone from the dining room, the RN (Registered Nurse) assigned as the R3 medication nurse, approached Resident #73, fed her a few bites, and left. This RN did not position Resident #73 up to the table. Review of the record revealed Resident #73 was admitted to the facility on [DATE]. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] documented Resident #73 was totally dependent on staff for locomotion. Review of the current care plans documented Resident #73 has the potential for a decline in ADL (Activities of Daily Living) functioning, with a goal to maintain her current level of feeding after tray set up. This plan of care documented the need to position the resident's chair to the left of the center pedestal of the table to bring the resident close to the table. This plan of care also documented the need of the staff to open containers, and have the utensils within reach. This care plan also documented to assist the resident with meals and provide verbal cues as needed. Review of the CNA (Certified Nursing Assistant) Assignment sheet documents the resident only needs supervision and set up assistance for meals. During an interview on 01/07/16 at 10:46 AM, Staff B, a PCS (Patient Care Specialist) who normally cares for Resident #73 stated that the resident will sometimes feed herself and at other times she needs to be fed. During an interview on 01/07/16 at 10:51 AM Staff C, the PCS who is normally assigned to assist the residents at the table where Resident #73 eats, stated that sometimes the resident can feed herself, mainly finger foods or drinks, but that she usually needs to be fed. Staff C stated that she was not working on Monday 01/04/16. During an interview on 01/07/16 at 11:10 AM the Unit Manager of R3 stated that all PCSs have access to all care plans each day. The Unit Manager agreed that Resident #73 should be pushed up to the table and appropriately set up for each meal. The Unit Manager agreed that Resident #73 can feed herself at times, but needs help at other times. During an interview on 01/07/16 at 11:49 AM, Staff A confirmed she was working on the R3 unit on Monday 01/04/16 and that she received care plans for her assignment on the unit. Staff A stated that she did not pull a care plan for Resident #73 as she wasn't on her assignment, but stated that she was familiar with her. Staff A stated that Resident #73 can feed herself at times. Staff A stated that they are to push the residents up to the table when the food is delivered. Staff A stated that on Monday she was a little overwhelmed with the feeding of the other two residents at that same table. Staff A agreed that Resident #73 should have been pushed up to the table.

Based on observation, record review, and interview conducted on 01/06/16 it was determined that the approved facility menu was not followed for for 28 non-sampled residents and 1 out of 1 sampled residents (Resident #266) who requires a pureed diet. The findings included: 1) During the review of the approved menu for the lunch meal of 01/06/16 it was noted that 4 ounces of Beef, Peppers and Onions was to be served as the entree for Regular, Therapeutic and Mechanically Altered diets. Interview with the facility's Registered Dietitian on 1/6/16 at 12:15 PM, during the menu review revealed that all entree portions for lunch and dinner meals were to contain a minimum 3 ounces of edible protein. During the observation on 1/6/16 at 12:15 PM, of the lunch meal service in the E-3 (Edwards 3) kitchen/dining room it was noted that a 4 ounce ladle was being utilized as a portion of the Beef, Peppers and Onion entree, however the portion included the peppers, onion and gravy as well as the beef. At the request of the surveyor, a standard portion of of the entree which was ready to be served to a resident was weighed by the cook (Staff O), utilizing the facility's portion control scale. The weight of the entree was recorded at 1.7 ounces which was far below the the minimum required protein portion of 3 ounces. Immediately after the observation, the findings of the entree weights were discussed with the facility's Registered Dietitian who confirmed with the surveyor that the entree portion was not followed for the 01/06/15 lunch meal. 2) During the observation of the observation of the lunch meal in the E-3 kitchen/dining room on 01/06/16 at 12:15 PM, it was noted that the portions of the chopped Beef, Peppers, and Onion were being served with a mixing spoon instead of the required approved menu portion of 4 ounces scoop. Interview with the cook (Staff O) at the time of the observation revealed that he was unaware that proper portioning equipment must be utilized with the serving of the lunch entree. 3) During the observation of the lunch meal in the Edwards 3 dining room on 01/06/16 at 12:15 PM, it was noted Resident #266 was served only a portion of the pureed entree (beef) and pureed vegetable (carrots). There was no observation that the resident was served a starch portion. The resident was noted to be cognitively impaired to speak with concerning food issues. A review of the approved menu for House/Pureed diet revealed that a portion of pureed beef & peppers, pureed pasta penne, and carrots was to be served for the lunch meal. The E-3 cook (Staff O) was interviewed at the time of the observation, concerning the resident and stated he was unaware that the resident required a pureed starch and unaware that the approved menu documented a pureed penne pasta serving. The cook (Staff O), stated that he would prepare a portion of instant mashed potatoes for Resident #266. A review of the clinical record of Resident #266 on 01/07/16 noted a current physician order [REDACTED]. Interview with the Dietitian following the meal observation and interview with the E-3 cook revealed that the Puree-Dysphasia Level 1 diet was not followed for Resident #266.

Based on record review and interview the facility failed to thoroughly investigate 3 of 3 incidents related to injuries of unknown origin out of 33 incidents reported by the facility for Resident # 1, # 2 and # 3 as evidenced by failure to obtain pertinent staff and family member statements, failure to obtain pertinent time line of events; failure to provide evidence of staff education and monitoring for the recommendations identified by the root cause analysis and failure to revise care plan to include recommendations to prevent reoccurrence of the incident. The findings include: 1) Review of the facilty's Report Log disclosed an entry dated 04/22/14 related to Resident # 1 documented that swelling to the left hand was reported by an Aide. The investigation revealed the incident description as the aide reported swelling to the left hand, unknown injury. Review of Resident #1's X-ray report dated 04/23/14 documents Acute Intra articular Avulsion Fracture, Medial Base Proximal Phalanx Second Digit. The facility investigation report documents, the resident is alert and oriented and does not recall the incident, did not complain of pain; resident is diabetic and has finger sticks four times a day. The investigative report conclusion documents, "The resident has no recall of the cause of the injury, probably due to jerking and pulling during needle sticks. Plan: use right hand for needle sticks." Further review of the investigation report failed to document a timeline reflecting when the resident was last seen by a staff member prior to discovering the swelling to the left hand; statements from the nurses performing the blood sugar finger sticks and date and time of the resident interview. Interview with the Director of Clinical Education conducted on 06/17/14 at 1:24 PM revealed she is designated to perfom risk management duties. She further stated investigations are initiated by the floor staff and she assists with the investigation by pulling records, talking to the resident and nurses and then the preliminary conclusion is given to the Director of Nursing (DON) for final review. The Director explained the investigation given to the surveyor related to Resident # 1 is not the final one. She explained that the DON has a " purple " folder with the completed investigation. Upon request, the DON provided the final investigation and conclusion with corrective action which documents use right hand for finger sticks and hold hand when doing blood sugar sticks, not just the finger. Further review of Resident #1 's clinical record failed to provide evidence the care plan was updated to reflect the corrective action identified. The facility provided the resident 's Medication Administration Record [REDACTED]. There were no entries related to the technique to be used when performing the fingersticks. Interview with the Director of Clinical Education conducted on 06/17/14 at 1:48 PM revealed the Unit Manager would be the person responsible for implementing the education and corrective action. Interview with the Unit Manager of the Edwards Building, conducted on 06/17/14 at 2:01 PM revealed the staff was educated regarding how to hold the residents hand when performing finger sticks during huddles. The Manager was not able to provide evidence of staff education and/or monitoring of the nursing staff when performing the fingersticks. In addition, the Manager was not able to locate a revised care plan describing holding the resident 's hand versus the finger, as recommended by the root cause analysis of the incident. Subsequent interview with the Director of Education and the Director of Nursing on 06/17/14 at 2:30 PM confirmed there are no written statements from the nurses performing the finger sticks, a timeline to narrow the time of injury; date and time of resident interview and care plan revision, noting the recommendation for the technique to be used by staff when performing the blood sugar needlesticks. 2) Review of the facility's Report Log disclosed an entry dated 05/24/14 related to Resident # 2. The log documented an aide reported [MEDICAL CONDITION] to the resident 's right arm while attempting to assist the resident to the bathroom. The resident stated "do not touch my arm" . The X-Ray report dated 05/24/14 documents "comminuted [MEDICAL CONDITION] Humerus is noted. Fractured Distal Humerus. No dislocation, demineralization or osteoarthritic change. Pathologic fracture not completely excluded. Clinical correlation" . The facility's investigation report concluded "the resident began to complain of pain on 05/24/14; unknown injury; regular care givers caring for resident were made aware of the painful right arm; frequently transfers without assistance using hands to break the fall. " The Corrective action were noted as medicine review completed. Clinical record review indicates the resident had falls on 03/24/14; 04/05/14; 04/10/14; and 05/18/14. Behavior Observation form dated 05/19/14 documents the last episode of resisting care and being verbally abusive, prior to the incident. The interventions put in place did not alter the resident 's mood or behavior positively. Further review revealed the the investigation report failed to provide evidence of statements from staff regarding behaviors of unassisted transfers; statements from staff from the previous shifts and a timeline indicating last time the resident was seen and/or toileted. In addition, the nurse who completed the behavioral form dated 05/19/14 was not interviewed to ascertain if the episode had any relationship to the injury. Interview with the Director of Education conducted on 06/17/14 at 3:01 PM revealed the investigation does not have a timeline indicating the last time the resident was seen or toileted. There were no written statements from staff regarding behaviors of unassisted transfers or the resident using hands to break falls, as this has been identified as a past behavior. There are also no statements from staff from previous shifts to assist in determining the time of injury. 3) Interview with Resident # 3's spouse, conducted on 06/17/14 at approximately 11:40 AM revealed the resident has Dementia and can be difficult at times. The resident's right hand had a round area, protruding from his wrist, about the size of a quarter with surrounding swelling. The spouse explained the facility was not able to determine how it happened, but most likely the night aide, "who is a big guy", was attempting to care for the resident and maybe held his wrist down as the resident can be combative. The spouse stated that the resident can be difficult to handle at times but recalls the resident stating "Aide A hurt me". The spouse stated she is in the facility daily during the day and her daughter, who is a nurse visits every night after work from five to nine. They were never asked questions as to how the injury may have occurred. The Incident report documentation revealed an aide reported swelling to the right hand on 06/05/14. The investigation documents "the resident had swelling and discoloration to dorsal area of right hand; observed while the resident was asleep in bed. Resident was able to make a fist but stated it hurts". The analysis and conclusion of the event documents "swelling of right hand; regular care takers assigned to resident, observed right hand swollen injury unknown; resident has a history of agitation and will flair arms; injury on dorsal side, which may explain how injury occurred, hitting hard surface. " Further review of the investigation report failed to provide a timeline indicating last time the resident was seen by staff prior to the discovery and the resident's condition; statements from staff from previous shifts to ascertain time frame for the injury, and statements from the family members who visit the resident daily. In addition, Resident #3's clinical record does not document aggressive behaviors from 06/01/14 thru 06/05/14 with the exception of the Behavior Observation Form created for 06/03/14 which documents the resident had one episode of verbal and physical abusive behavior. The form was completed on 06/05/14, the date of the incident, by the Unit Manager. No other entries indicate aggression, combativeness or physical behaviors from the resident. Interview with the Director of Education conducted on 06/17/14 at 4:22 PM revealed the investigation does not have a timeline indicating the last time the resident was seen by staff prior to the discovery of the swelling and there were no statements from staff from previous shifts or family members to ascertain the time frame of the injury. Review of the facility policy titled "Event Reporting" with a revision date of April 2013 documents "As part of the risk management program and in compliance with FS 400.147, the facility maintains an incident reporting system. He program shall incorporate activities to facilitate reporting in a timely manner, investigate and analyze incidents and accidents affecting residents". When a resident experiences an accident/incident, the following guideline is to be initiated: a. Notify the nurse in charge who in turn notifies the nursing supervisor b. Assess the resident for any evidence of injury and extent of the injury c. Safeguard the resident d. If abuse, neglect or exploitation is suspected or alleged notify the abuse coordinator immediately. e. If equipment or product was involved, remove from care/services and save for nursing administrator. f. Notify the physician/ARNP of the events ad any abnormal findings. g. Follow the physician/ARNP ' s order h. Complete an incident report and corresponding documentation i. A root cause analysis form may be used in any situation in which the cause of injury is not known j. For residents falls complete a post fall evaluation form k. For medication variances, complete the medication variance analysis form. l. For in house acquired pressure ulcer ulcers, complete the pressure ulcer investigation form. The nursing supervisor advises of further actions, and starts a clinical event investigation if the event has resulted in fracture, transfer to a higher level of care, or where abuse, neglect or exploitation is suspected or alleged. When reviewing an injury or event that is of unknown origin, consider the following: ? if the source of the injury was not observed by another person or the source of the injury could not be explained by the resident, and ? Injury is suspicious because of the extent of the injury or the location of the injury ? If the above conditions are met, abuse or neglect must be considered ? If the above 2 conditions are not met, abuse neglect are probably not a factor but consider the resident's plan of care and medication regimen.

Based on observation, interview and document review, it was determined that the facility failed to ensure safe water temperatures for 1 out of 10 selected rooms during resident observations (Edwards 2, room 204). The findings include: During a resident observation on 7/29/13 at approximately 2:30 PM, on Edwards 2, room 204, the water in the bathroom sink was checked per survey process. The surveyor received a red mark on her hand because the water temperature was hot. The Director of Maintenance was requested to join the surveyor and obtain the temperature of the water. While waiting for the Director of Maintenance, the surveyor observed several residents wandering the unit. Edwards 2 houses long term care residents, several of them with dementia. The resident of this room is cognitively impaired, ambulatory and requires assistance with the activities of daily living. On 7/29/13 at 2:41 PM, the Director of Maintenance checked the temperature of the water in the bathroom sink with a facility owned thermometer and the water temperature registered 126 degrees Fahrenheit. This was verified by the surveyor and the Director of Maintenance. A review of Section 8 Tables, Graphs & Graphics that was provided by the Vice President of Clinical Services on 8/2/13 revealed that a water temperature of 126 degrees Fahrenheit takes 30 seconds for a first degree burn and 90 seconds for a second degree burn. An interview with the Director of Maintenance on 8/2/13 at 11:49 AM revealed that there is a Hot Water Temperature sheet that is kept in the Maintenance book. A review of the sheet provided by the Director of Maintenance documents on the second bullet that hot water temperatures must be between 105 and 115.

Based on observation, interview, record review, it was determined the facility failed to provide care and service in accordance with infection control standards as evidenced by the failure to follow isolation precautions for one of one sampled residents (Resident #546), failure to ensure hand washing occurred to prevent cross contamination, and failure to ensure proper hand washing for one of one sampled residents (Resident #581) during wound care. The findings include: 1) A review of Resident #546's clinical record reveals a physician order dated 7/07/2013 for contact precautions for a urinary tract infection. Further review of the clinical record reveals a [DIAGNOSES REDACTED]. On 7/30/13 at 9:18 AM an observation of Resident #546 in room [ROOM NUMBER] revealed a sign on the door to contact the nurse ' s station before entering the room. A cart was parked by the door with contact precaution supplies. On 7/30/13 at 9:18 AM, a Speech Therapist was observed in the room cutting up food on a food tray without gown or gloves. In an interview at 9:20 AM, the Speech Therapist stated she did not need to wear a gown and gloves because she was not touching the resident. It was noted that she did not wash her hands when she exited the room. On 7/30/13 at 9:25 AM in an interview, RN #1 stated, "The staff would not be expected to wear the gown and gloves when working with the food tray, but would need to wear the gown and gloves if they touched the resident or linen." On 7/30/13 at 10:12 AM, in room [ROOM NUMBER], the bathroom was observed to be without paper towels, to ensure that soap and water hand washing could be properly accomplished. In an interview, at 10:15 AM, direct care aide #1 stated, "They just ran out and I will replace the paper towels." On 7/31/2013 at 9:34 AM, direct care aide #2 was observed in room [ROOM NUMBER] making up the bed. She was wearing disposable gloves, but was not wearing a gown to protect her uniform from the bed spread and other objects in the room. She was observed touching various surfaces in the room including the pillows and the bed spread. She lifted the resident ' s foot and put it on a pillow. She draped a blanket over the resident, who was seated in a chair at her bedside table. She removed the gloves and put them in the trash can, but then picked up more linen and touched the wheelchair. She then went into the bathroom and washed her hands. In an interview at 9:40 AM, the aide stated, "I was not touching anything, but the next time I will put on a gown. " On 7/31/13 at 1:52 PM, the Occupational Therapist Assistant (OTA) was observed in room [ROOM NUMBER], talking to the resident and her visitor. Neither the OTA, nor the visitor had on gown or gloves. However at 1:56 PM, when the OTA noticed the surveyor observing, she went into the bathroom washed her hands and exited the room to put on the gown and gloves and reenter the room. In an interview at 1:56 PM, the COTA stated, "If I go into the room and touch anything, the gown and gloves would be necessary." On 8/01/2013 at 10:39 AM, direct care aide #3 stated, "With contact precautions we would wear the gown and gloves if we are making personal direct care contact. If you are going to make up the bed, you don't have to have a gown on. If you like you can put on the gloves. " On 08/01/2013 at 10:58 AM, RN #2 stated "The resident is still having diarrhea. The contact precaution cart is placed at the door. The sign is on the door. The aides are informed. Every time the aide enters the room, they have to wear gloves. If they are dealing with feces, then the gown is also required. To be on the safe side, make sure to wear gloves. When they exit, take everything off and wash hands with soap. " On 7/31/2013 at 3:30 PM, in an interview the DON and Executive Director stated, " If the resident is having loose stools with[DIAGNOSES REDACTED], the contact precautions would be required. The contact precautions does not require gown and gloves in all cases. Only if staff is directly handling the resident such as helping them in the bathroom, would the gown and gloves be required. " We don ' t follow CDC guidelines. We follow Association for Professional Infection Control and Epidemiology (APICP) standards for nursing homes." A review of the policy and procedure titled "Airborne, Contact and Droplet Isolation", under the paragraph titled Contact Precautions, it is states "Wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident, resident items, or environmental surfaces or if the resident is incontinent." On the next page in bold print it states "Perform hand hygiene before and after every contact with resident or the environment." 2) On 8/01/2013 at 9:15 AM, a housekeeper was observed exiting room [ROOM NUMBER] wearing gloves and continuing on to room [ROOM NUMBER] with the same gloves to pick up trash in the room [ROOM NUMBER]. She placed her gloved hand on the door frame entering the bathroom as she collected the trash. She was observed exiting the room without washing her hands. She removed her gloves and put them in the large trash bag. She then went to the biohazard room to deposit the large trash bag and immediately returned to the hallway. On 8/01/2013 at 9:45 AM, the same housekeeper was observed wearing gloves exiting the shower room, with trash and after emptying the trash, continued on to room [ROOM NUMBER] with the same gloves and no hand washing to collect trash there. After she deposited the trash in a large trash bag, she removed her gloves walked down the hall and collected packages of paper towels. She returned to her cart with the packages of paper towels, put on new gloves, and went into another room without washing her hands. In an interview on 08/01/2013 at 10:58 AM, the Registered Nurse #2 stated, "The housekeepers are watched by the staff. I know the housekeepers are supposed to remove gloves and wash their hands anytime they leave a room." In an interview at 8/01/2013 at 11:51 AM, the Director of Housekeeping stated, "The housekeeper is supposed to wash her hands and change her gloves when she exits the room. The paper towels in the isolation room should have been filled, the staff may have been on break." A review of the infection control: Hand Hygiene and Hand washing Policy in the paragraph titled When to Wash Hands: contained a bullet point -After handling any contaminated items (linens, soiled diapers, garbage, etc.). 3) A wound care observation was completed on 8/1/13 beginning at 11:46 AM with the LPN (Licensed Practical Nurse) assigned to Resident #581. The LPN gathered her supplies on a disposable tray, washed her hands and put on gloves. The LPN removed the old/contaminated dressing from the resident's left buttock and immediately cleansed the area with normal saline, without changing her gloves or performing hand hygiene. After cleaning the wound the nurse changed her gloves without washing her hands. The LPN applied a new/clean dressing. The LPN again changed her gloves and applied 'No Sting' (a protective barrier) to the resident's intact heels. The LPN did not perform any hand hygiene between the care of the contaminated wound on the resident's buttock and the care of the resident's heels. The LPN then changed her gloves again without hand hygiene and reapplied the resident's socks. The LPN then washed her hands. The LPN went to the wound care cart to obtain more 'No Sting' barrier wipes, donned another pair of gloves and applied the barrier to the resident's right lateral foot. The LPN changed her gloves again and lowered the resident's clothing to apply ointment to his right buttocks and groin because she had forgotten the ointment during the care of the wound. During an interview on 08/01/123 at 12:45 PM the LPN caring for Resident #581 was asked when during wound care she should wash her hands or perform hand hygiene. The LPN stated, "Before and after wound care and you can change gloves in between as often as you need." The LPN was unaware of the facility policy to wash hands with glove changes. Review of the facility policy "Infection Control: Hand Hygiene and Hand washing" documented, "When to Wash Hands (at a minimum) ... After removing gloves or aprons." and "...after handling any contaminated items (linens, soiled diapers, garbage, etc.)." This policy also documents, "Other Aspects of Hand Hygiene ... Change gloves during member care if moving form (from) a contaminated body site to a clean site." Review of the facility policy "Dressing Change (Aseptic)" documented, "Guidelines/Protocols" (after preparation for the dressing change) ..."#8. Wash hands, don gloves." After removing the dressing the protocol directs to "#11. Discard dressing into biohazard bag (if appropriate). Remove exam gloves and discard into biohazard bag (if appropriate). #12 Wash hands, don gloves." After wound assessment and wound care the protocol directs to "#15 Apply dressing(s) using aseptic technique. #16 Remove gloves and place in trash or in small biohazard bag if appropriate. #17 Wash hands." 4) During the observation of the lunch meal on 7/31/13 in the dining room of Edwards Two, the Minimum Data Set (MDS) Coordinator for that unit was observed to be seated between two residents feeding them. The MDS Coordinator was observed to pick up the spoon, feed the first resident, wipe the resident's mouth with a napkin, then pick up the spoon of the other resident and feed her. At no time did she clean her hands. A review of the policy and procedure titled Infection Control: Hand Hygiene and Hand washing reveals under the section When to Wash Hands (at a minimum), to wash hands before and after assisting a member with meals (soap and water). It also documents to wash hands after handling soiled equipment or utensils. An interview with the Senior Director of Nursing (SDON) on 7/31/13 at 2:20 PM reveals that a staff member may feed two residents at once as long as it remains a clean procedure. The SDON further stated that if the staff member were to wipe a resident's face with a napkin, their hands would have to be washed because they are now considered dirty. If the staff member were only touching the utensils, they wouldn't have to wash their hands.

Based on interviews and record review, the facility failed to provide notice for 3 out of 16 sampled residents before the resident's room or roommate was changed in the facility. (Resident #36, 378 and 588). The findings include: 1) Review of the Clinical Record of Resident #36 revealed that she was admitted to the facility on [DATE] into room [ROOM NUMBER] A. It is documented in the Social History/Initial Assessment Form dated on 6/24/2013 that the resident has a Brief Interview of Mental Status (BIMS) score of 15/15 indicating that she is cognitively intact. Interview with Resident #36 on 7/29/2013 at 3:46 PM regarding the notification of a room change or a change in roommate assignment revealed that she was not notified prior to the admission of her new roommate. Resident #36 stated that she is on her third roommate, and was never notified of the new roommates coming in. Review of Resident ' s Clinical Record on 8/1/2013 reveals that there is no evidence that the resident was notified of any roommate change assignment. Interview with Admissions Office Manager on 7/30/2013 at 4:00 PM revealed that the admission office is responsible for the admission of new residents from acute care settings and other facilities or other potential residents. She states that all newly admitted residents are given a gift bag that contains all pertinent information about their stay in the facility. She verified that admission personnel member goes over the necessary paperwork once the resident has settled down. However, she states that the transfer of residents already admitted in the facility is handled internally by the nursing or social services department. Interview with Vice President of Clinical Services on 07/30/2013 at 4:15 PM revealed that the social worker is the person responsible for immediately notifying the resident and family member if there is a change in room or roommate assignment. In the presence of a second surveyor, she stated that there is the assumption that if there is an unoccupied bed in a semi private room, the resident who is already occupying the room should know that there will be an admission of a new resident since the room is not a private room. She states that the facility does not request permission from the resident already occupying the room to have a new roommate. She elaborates that it is impossible to notify the resident presently occupying the room in advance or in a timely manner due to the high turnover of the admissions of residents in the short-term unit. Interview with Social Services Director (SSD) on 07/30/2013 at 4:30 PM revealed that the social worker is the person responsible for the immediate notification of the resident or the resident's legal representative if there is a change in room or roommate assignments. She stated that the receiving roommate is verbally notified the day of admission of the roommate and if it is a transfer, the resident is given the opportunity to meet the receiving roommate the day prior to the transfer or the day of the transfer. The Social Service Director provided blank copies of the Transfer Notification Form and a copy of the Admission statement that documents the following " Except in an emergency situation , the patient / resident and family member or additional party, as appropriate will be advised in advance of any room change " . Further inquiries regarding any evidence to prove that the Resident # 378 and #36 were notified of their roommate change or were verbally informed of their roommate change assignment revealed that there is no documentation to prove that the residents were given notice. The SSD stated that the Transfer Notification Form is the documentation that is initiated for the resident that is doing the transfer. However, there is no evidence to prove that notice was given to the receiving roommate for an incoming roommate. 2) Resident #378 was admitted to the facility on [DATE] into room [ROOM NUMBER]A. Review of the resident ' s Cognition / Mood State Behaviors section of the Social History/Initial Assessment Form dated 06/26/2013 documents that the resident's Brief Interview of Mental Status (BIMS) score is 13/15 indicating that he is cognitively intact. Interview with Resident #378 on 7/30/2013 at 9:22 AM revealed that he was not given notice before he received a new roommate on 07/13/2013. 3) A review of a clinical chart for Resident #588 has the following documentation on a physician order [REDACTED]." Interview with Social Worker/Discharge Planner on 08/01/2013 at 10:00 AM revealed that she is familiar with Resident # 588 transferring from room [ROOM NUMBER] B to room [ROOM NUMBER] B. She states that she is not aware of the resident's reason for the move but she is suspecting it will be a roommate issue. She states that she usually communicates with the nursing department when she returns to work after the weekend with regards to who was moved and other issues that are social work related. The surveyor requested to see Transfer Notification Form for the resident. In the presence of the surveyor, the social worker could not locate any type of evidence that the resident had opted to move by choice or whether her roommate had been notified. She stated that the Transfer Notification Form for Resident #588 was not completed because the transfer occurred during the weekend and she was not available during the weekend to fill out the transfer form. However, she acknowledges that the form should have been filled out after the transfer and there should be evidence that there was no roommate available at that time to be notified or the receiving resident should be notified.

Based on observation and staff interview, the facility failed to ensure: wet cleaning cloths were stored in sanitizing solution when not in use. This has the potential to affect all the residents who eat orally. The findings include: 1. During the initial tour of the main kitchen, conducted on July 29th, 2013, beginning at 10:45 AM and subsequent visits to the pantries accompanied by the Certified Dietary Manager (CDM), the following concerns were identified: The sanitation bucket for storage of wet dish cloths did not have adequate sanitizer solution on both the dairy and meat side of the kitchen, so that the dish cloths could foster growth of bacteria. When tested by the CDM, the sanitizer testing strips registered below 50 ppm, and did not change in color. The bucket was immediately set up with the proper concentration. 2. On July 31, 2013 at 8:30 AM, in the pantry on Edwards 3, a wet dish towel was observed lying next to the sink, and there was not a sanitation bucket in which to place the wet dish towel for proper disinfection. The CDM acknowledged wet towels are not permitted to be stored on the counter top.

Based on record review and interview the facility failed to provide pharmaceutical services for 1 of 5 sampled residents (Resident #1), as evidenced by failure to acquire and administer drugs to meet the needs of the resident. The findings include: Clinical record review conducted on 05/22/13 revealed Resident #1 arrived to the facility on [DATE] at 2:30 PM. Admitting physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Upon review of the Physician order [REDACTED]. Review of the Nurses Notes dated 04/19/13 thru 04/22/13 revealed no evidence of any entries related to why the Ritalin was not obtained from the pharmacy or administered as ordered. Review of the Clinician Progress Notes dated 04/19/13 and 04/22/13 revealed no evidence of any entries related to the Ritalin, whether to hold, clarify or discontinue the drug. Further review of the record documents Resident # 1 was discharged home on[DATE] upon resident's request. Interview with the Vice President (VP) of Clinical Services conducted on 05/22/13 at 10:45 AM revealed the process of reconciling medications upon a resident's admission to the facility. The VP of Clinical Services explained the nurse would contact the physician, go over the medications and the physician decides which medications are to be continued. The medications are then written on the Physician order [REDACTED]. Subsequent interview with the VP of Clinical Services and the Director of Nursing Rehabilitation (DONR) on 05/22/13 at approximately 2:10 PM revealed no explanation as to why the Ritalin was not administered. The DONR explained that most likely because the drug is a controlled substance that required a prescription. The pharmacy delivery receipt was requested. The DONR stated she would research the controlled drug log and the VP of Clinical Services obtained a document titled " Verbal Prescription Order, Long Term Care Facility Patient " dated 04/21/13 from the pharmacy. The document noted Ritalin 10 mg one tab every day at noon. The verbal prescription failed to address the Ritalin 20 mg prescribed at 9 AM. Controlled Drug Receipt Record dated 04/21/13 documents Ritalin 10 mg, 3 doses, were received and signed by the facility on 04/21/13. The instructions document to administer one tablet at noon. The instructions failed to address the Ritalin 20 mg prescribed at 9 AM. Interview with the VP of Clinical Services, the Senior Director of Nursing and the DONR, was conducted on 05/22/13 at 3:15 PM. The VP of Clinical Services, the Senior DON and DONR reviewed the record, including the medication administration records, the physician orders, clinician notes and nurses notes and were not able to provide an explanation as to why the medication was not obtained and/or administered timely. Facility Policy titled "Controlled Substance Drug Ordering and Receiving " documents Controlled Medications are to be dispensed in accordance with federal and state laws and regulations." Pharmacy Name "must receive a valid, written prescription signed by the practitioner prior to the dispensing of ALL controlled substances, unless an exception applies. Such exemptions are defined as: Practitioner gives the pharmacist verbal authorization in an emergency situation for a medication. The quantity authorized by the physician should be adequate enough to treat the patient's condition (not to exceed 72 hour supply)".

Based on observation, interview, and federal and state code review, it was determined the facility did not properly label medications for 1 (Resident #46) of 10 sampled residents observed during the medication administration observation. This failure was evidenced by the lack of appropriate accessory and cautionary instructions on the label of the resident's medication blister card, to inform the staff that the medication should not be crushed. Findings include: An observation of the medication administration for Resident #46 was made on 06/20/2012 beginning at 9:00 AM. The Registered Nurse (RN) assigned to Resident #46 proceeded to pour the medications and further stated, "She (the resident) needs to have her medications crushed and given in applesauce." The RN crushed all the medications for Resident #46, including the extended release Potassium Chloride tablet, and gave them mixed in applesauce. A second observation after the medication administration, confirmed the blister pack for the Potassium Chloride tablets lacked any cautionary instructions that the medication cannot be crushed. Review of the current POS (physician order [REDACTED]. requires unless C/I (contraindicated)." Further Review of the POS [REDACTED]." During an interview on 06/20/12 at 10:20 AM, the Consultant Pharmacist agreed that the K-Dur (potassium chloride) cannot be crushed. The consultant pharmacist was asked to locate and provide a copy of the facility policy regarding the labeling of medications. He stated there was no policy. A review of the Code of Federal Regulations by the Food and Drug Administration on Labeling, 21 CFR 201.5. requires adequate directions for use so one can use a drug safely, which includes the "preparation for use, i.e. shaking, dilution, or other manipulation." During an interview with the Vice President of Clinical Services on 6/21/12 at 9:30 AM with three surveyors present, she acknowledged that any medication named with ER cannot be crushed. She further acknowledged that "Do Not Crush" should be on the medication label. During an interview on 6/21/12 at 12:15 PM, the consultant pharmacist agreed that "Do Not Crush " should be listed somewhere on the medication blister card, as he further stated, "I can't argue that."

Based on observation and interviews the facility failed to maintain the garbage storage area in good condition, as evidenced by the trash compactor/dumpster leaking garbage fluids into the surrounding environment and draining into the storm drainage system, cardboard improperly contained, and trash being outside the dumpster. The findings include: Observation on 6/18/12 at 9:15 AM accompanied by the Certified Dietary Manager (CDM) and the Vice President of Support Services, the garbage storage area was observed and found to have three cardboard only dumpsters so full that the lids could not close all the way down and were pushed up so that they did not cover the card board. The trash compactor/ dumpster for food refuse had a rusty hole on the trash compactor end where the trash is deposited. A sudsy liquid was on the ground surrounding the food refuse dumpster. The sudsy liquid was draining into the storm drain in the alleyway behind the building nearby. On 6/19/12 at 9:20 AM, also accompanied by CDM and the Vice President of Support Services, a second observation of the trash compactor/ dumpster for food refuse revealed a steady stream of garbage liquid leaking from the center bottom end opposite the trash compactor end. This foul fluid was draining toward the storm drainage grate nearby. The indentations in the asphalt in which the fluids were collecting were filled with a granulated material. The CDM and Vice President of Support Services acknowledged that the dumpster was leaking at the time. On the side of the dumpster next to the fence two disposable gloves were noted to be on the ground next to the food refuse dumpster. On 6/21/12 at 9:53 AM in an interview the Vice President of Support Services stated he was unaware that the dumpster was leaking until viewed with the surveyor on 6/19/12. He further stated Waste Management was contacted on 6/19/12 and repair personnel came out on 6/21/12. According to the Vice President of Support Services, the Waste Management personnel informed him that they may not have cleaned the seal around the door properly and that prevented an appropriate seal and contributed to the leak. On 6/21/12 at 10AM in an interview, the Housekeeping Supervisor stated, "There are two guys who clean the area each morning and as needed throughout the day. We put a bubble gum scent packet to help eliminated odors. The dietary guys hose down the area with chemicals as needed and it washes into the drain in the alley. The groves in the pavement are from when they pick it up and put it down for emptying. The brown stuff is an absorbent material we put down to soak up the puddles in the pavement." On 6/21/12 at 1:04 PM in an interview with the Administrator and the Director of Quality Control, the administrator stated the hole had been patched and "kitty litter" was put down to control the flow. The Director of Quality stated that the compactor is separate from the dumpster and the way the compactor works it causes the fluids to be pushed out. She also stated she checks the dumpster daily herself.

Based on observation, interview and medical record review the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 of 6 residents sampled for unnecessary drugs as evidenced by Resident # 568 receiving a sedative/hypnotic medication without adequate monitoring of the medication's effectiveness. The findings include: Review of Resident # 568's clinical chart revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 568's admission orders [REDACTED]. Review of the resident's May 2011 Medication Administration Record (MAR) revealed Resident # 568 received [MEDICATION NAME] 15 mg on 5/1/11 at 10 PM and on 5/2/11 at 10:15 PM for a [DIAGNOSES REDACTED]. Nurses notes on 5/2/11 at 2:20 AM documented the results of taking the resident's vital signs: temperature (97.6), heart rate (72), respiration (20) and blood pressure (135/76) and "resting in bed no apparent distress noted, no complaints voiced". There was no mention in the notes if receiving the [MEDICATION NAME] at 10 PM the prior evening was effective. Nurses notes on 5/3/11 at 4:16 AM documented the results of taking the resident's vital signs: temperature (98.6), heart rate (69), respiration (20), blood pressure (112/65), "O2 saturation (97%) on O2 at 2 LPM, HOB (head of bed) up 45 degrees" and "no C/O (complaints of) discomfort at this time". There was no mention in the notes if receiving the [MEDICATION NAME] at 10:15 PM the prior evening was effective. In an interview on 05/05/11 at 1:23 PM, the Vice President of Clinical Services (VPCS) stated the monitoring of a drug was documented on the MAR. There was no other place in the clinical record for the documentation to be noted. On 05/05/11 at 2:38 PM, The VPCS presented a copy of the nurses notes and stated the nurses notes dated 05/02/11 at 0220 documented, "the resident was resting in bed in no apparent distress". The VPCS stated the nurses do not write sleeping because the fact that a resident may have their eyes closed does not mean they are sleeping. The VPCS further stated that was all the information she could provide. Review of the facility policy titled, "Medication Administration" revised 02/11 documented the following: "In addition to documenting administration of the drug on the front of the resident's MAR, whenever medications are given on an as needed (PRN) basis, the nurse administering the dose is responsible for entering all of the following information on the reverse side of the resident's MAR: The resident's complaint or symptoms for which the drug was given, the dose, time, route of administration, the results achieved from giving the dose and the nurse's signature."