Every finding on record at Keystone Nursing Care Center INC

Based on observations, interviews, and record review, the facility failed to properly transfer 1 of 4 residents reviewed for mechanical lift transfers (Resident #1). Staff transferred Resident #1 into the shower without the use of a mechanical lift and a second staff person assisting directly with the transfer as directed in her Care Plan. This resulted in a fall with a fractured femur. The facility reported a census of 39 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that Resident #1's diagnoses included osteoarthritis, right knee pain, weakness, and unspecified hearing loss. A Brief Interview for Mental Status (BIMS) revealed a score of 10 out of 15, which indicated the resident had moderate cognitive impairment. The resident was dependent on staff for transfers. An untitled undated CNA Assignment Sheet directed staff that Resident #1 was a transfer assist of 2 staff using a mechanical lift (Hoyer). A Progress Note dated 12/30/24 at 1:32 p.m., documented that, the nurse was called to the whirlpool room and found Resident #1 laying on her right side on the floor. A Certified Nurse Aide (CNA) was sitting next to Resident #1. Water was noted on the floor. This resident was assessed for pain and injuries. A large skin tear was noted on Resident #1's left shin. The area was cleaned and Steri-strips were applied. A dressing was applied over this. Resident #1 complained of pain to her upper leg and knee area. It was very difficult for this resident to move her leg. An order was obtained to send Resident #1 to the emergency room (ER) for evaluation. Ambulance was called and daughter-in-law was notified. Resident #1's vital signs (VS) were: temperature 97.9 Fahrenheit, pulse 102 beats per minute, respirations 20 breaths per minute, and blood pressure was 148/84. Resident #1's oxygen saturation was 94% on room air. A Progress Note dated 12/30/24 at 2:30 p.m., documented that a call was placed to Resident #1's daughter-in-law regarding the fall this a.m. in the whirlpool room. Staff B (LPN), reported to the daughter-in-law that the resident was being pivot transferred with 1 staff member and not the mechanical lift when the fall occurred. Staff B told the daughter-in-law that the facility would have to report this fall to the state and that the employee who improperly transferred the resident at the time of the fall was suspended immediately until the investigation was complete. A Progress Note dated 12/30/24 at 5:24 p.m., documented that the nurse received a call from the ER. The family was not wanting any interventions at this time. The provider splinted Resident #1's leg and a urinary catheter was placed. Resident received pain medication at 5:15 p.m., and would need to get comfort care medication orders for her the following day. The resident was being brought back to the facility at this time. A Progress Note dated 12/30/24 at 8:19 p.m., documented that Resident #1's right leg was still wrapped. Staff at the hospital had stated the resident was trying to take it off. A Progress Note 12/31/24 at 12:56 a.m., documented that Resident #1 was resting quietly in bed. Resident does moan and yell out in pain when being repositioned. PRN (as needed) pain medication was given. A Progress Note dated 12/31/24 at 5:43 a.m., documented that Resident #1 was yelling that she needed to have a bowel movement. This nurse and a medication aide got Resident #1 on to a bed pan. Resident #1 was yelling and screaming loudly in pain. PRN pain medication was given. This resident was on the bed pan for about 10 minutes and she never went. Gave drinks of water. A Progress Note dated 12/31/24 at 9:06 a.m., documented that this resident was yelling to get up. Reassurance was offered but not effective. Resident #1 was very restless and taking her gown off. Call was placed to the daughter-in-law to report resident's confusion and as to why she cannot get up currently was due to extreme pain. Pain pill was given. A Progress Note dated 12/31/24 at 12:42 p.m., documented that a fax was sent to the provider asking for comfort medications. A Progress Note dated 12/31/24 at 4:37 p.m., documented that the daughter-in-law wanted a referral to Hospice. All necessary paperwork for admission was faxed to Hospice. A Progress Note dated 1/1/25 at 9:29 p.m., documented that at 8:30 p.m., Resident #1 was without a heartbeat and was not breathing. It documented that the funeral home arrived at 10:00 p.m., and her body was released. ED (Emergency Department) Provider Notes with a date of service of 12/30/24 at 11:16 a.m., documentation included the following for Resident #1: A [AGE] year-old female presented to the ED via EMS (Emergency Medical Services) ground (ambulance) for evaluation of a fall. This patient had a fall onto her right knee earlier on this day. Patient had a history of right knee pain however it appeared more swollen and was acutely tender to the patient at this time. Patient was able to wiggle her toes however did have a large amount of pain in her right lower extremity. Patient was extremely hard of hearing and was minimally conversant secondary to the hearing difficulties. It documented that this resident was in acute distress. It documented her right upper leg had swelling, edema and deformity. It documented her right knee had swelling and deformity with decreased range of motion. The ER provider documented they were unable to perform examination of right lower extremity secondary to large amount of pain for the patient. X-rays were done with diagnoses of hip dislocation, femur fractures, and patellar (kneecap) dislocation. Family elected to go with the hospice route instead of surgery. Patient was discharged back to the facility via ambulance and was given hydrocodone (narcotic medication) for uncontrolled pain every 4 hours. Manipulation was performed with mild improvement of the bone fragments being better aligned in her leg. A long leg splint was placed on her leg. An undated Internal Investigation, documented that at approximately 9:00 a.m. on 12/30/24, the Director of Nursing (DON) was called to the whirlpool room by Staff B. When the DON entered the room, Resident #1 was found on the ground with Staff A, CNA. Resident had on just her shirt. She was not wearing pants, socks, shoes and didn't have a gait belt on. There also was not a mechanical sling in her wheelchair. Resident had a large skin tear to her left shin that Staff B was concerned about. The area was cleansed and area was approximated easily. Steri-strips were applied and area was covered. Resident was noted to be in pain. Resident is extremely hard of hearing and was having difficulty explaining where it was hurting. She was grabbing at her right thigh/right upper leg. Resident was further assessed and no rotation or shortening was noted but right knee was noted with swelling and increased pain with touch/palpation. Staff B received an order to have resident evaluated in emergency room for evaluation and treatment. Staff A was called to the Administrator's office at 9:40 a.m. after the incident. When Staff A was questioned if she was aware that Resident #1 was a Hoyer transfer, she stated yes. When asked what happened she stated that she told Staff D, CNA, that she would just transfer Resident #1 real quick from the wheelchair to the whirlpool chair and she asked Staff D to pull down the residents' pants when she lifter her. Staff A stated she didn't know why she chose to transfer this way, but did state she (Resident #1) is just a tiny little thing and I thought I could just do it really quick. Staff A stated that when she was assisting this resident up she put her arms under the resident's arms and Staff A had just bought herself a new pair of Crocs shoes over the weekend, Staff A's foot slipped and she and the resident fell down to the ground together. Once it was determined that Resident #1 had sustained a fracture, Staff A was notified her position with the facility was ending due to improper transfer and not following the Care Plan per regulations. Staff A stated she wasn't going to lie about it, it was her fault and she felt terrible. Staff D was asked about the incident and Staff D stated that this was her 2nd day on the floor after her training. Staff D asked Staff A for assist to get Resident #1 into the whirlpool. Staff D and Staff A took Resident #1 into the whirlpool room and Staff A stated she would transfer Resident #1 herself. Staff A wanted Staff D to pull down Resident #1's pants when Staff A stood Resident #1 up. Staff D questioned Staff A regarding transfer status and Staff A told Staff D that they were currently working on getting her to a different transfer status, so it was ok. On 1/12/25 at 2:40 p.m., the DON stated that it was a terrible situation. The DON stated that Staff A knew that the resident required a mechanical lift with 2 staff for all transfers. She stated she just thought she could pick her up and put her in the chair. The DON stated they suspended Staff A right away and then waited to hear if there was an injury. When that was confirmed they let her go. The DON stated that Staff D told Staff A that Resident #1 was to be a mechanical lift, however Staff A insisted on transferring Resident #1 without a mechanical lift and Staff A told Staff D that the facility was working on getting this resident to transfer without the mechanical lift. When asked how the CNAs know the transfer status for each resident, the DON stated that there is a CNA sheet that each CNA carries. It is updated frequently. The DON stated the facility was not trialing getting Resident #1 to a different transfer status. On 1/13/25 at 2:50 p.m., the DON stated that Staff A should have chosen the right transfer method for Resident #1. She stated that unfortunately it was around 9:00 a.m. in the morning and that was break time. The DON stated that the initial documentation of this incident in the Progress Notes was put in at the wrong time. It was documented in the afternoon but should have shown the incident occurred in the morning. On 1/13/25 at 1:56 p.m., Staff B stated she was at the nurses' station when Staff D told her Resident #1 had fallen. Staff B stated Resident #1 was on the floor in the whirlpool room and Staff A was sitting on the floor next to Resident #1. Staff B first noticed there was blood on the floor and Resident #1 had a skin tear on her left shin. Resident #1's right knee looked kind of swollen, Resident #1 was saying that her right knee was hurting, she was having some pain in the right knee. Staff B stated staff were getting ready to put Resident #1 into a whirlpool (chair), Resident #1's top half was dressed. Staff A was transferring Resident #1 from the wheelchair to the whirlpool chair. Staff B stated that the whirlpool chair is on a track and it kind of rolls into the whirlpool. The brakes were locked on the whirlpool chair. Staff B stated that it was probably right at 9 a.m. or a little after. Staff B acknowledged her documentation was dated 12/30/24 at 1:32 p.m., and that was wrong as it happened earlier that morning. Staff B stated that Resident #1 was grimacing and holding that leg. Staff B was putting a dressing on Resident #1's skin tear and Resident #1 was grimacing and saying ooo. Staff B stated Staff A and Staff D should have done a 2 person transfer with a mechanical lift. Staff B stated they have bath slings that are used specifically for the whirlpool. Staff B stated she was upset and asked why, and the CNA told her she thought they were going to change Resident #1 to an easy stand transfer. Staff B stated when she walked into the shower room, she asked where is your Hoyer (mechanical lift) and Staff A said she's not sure why she did it that way, she was rushed, she really didn't have a good reason why. She felt terrible, obviously. Staff B stated that Staff D was just learning and fresh off of orientation. Staff B stated that Staff D actually questioned Staff A why they weren't using a Hoyer. Staff B did not know what Staff A told Staff D in response. Staff B stated that after they got Resident #1 safely back to her bed, Staff B asked Staff D where Staff A went and Staff D didn't know. Staff B found out later that Staff A had gone on break. Staff B stated that Resident #1 came back from theER on comfort medications. Staff B stated that she found out Resident #1 had a broken right femur right above her knee. It was just a terrible situation. On 1/15/25 at 11:37 a.m., the Licensed Nursing Home Administrator (LNHA), stated that on the day of the incident, the DON came into the LNHA's office and said that Staff A had just transferred Resident #1 in the whirlpool room, Staff A fell down as her foot had slipped and Resident #1 landed on top of her. The DON said Resident #1's leg might be broken. The LNHA stated she immediately asked how could that have happened with the mechanical lift? The DON told the LNHA that Staff A had not used the mechanical lift. The LNHA then told the DON that they needed to call her into the office right away and suspend her for not following the Care Plan. Staff A then went into the LNHA's office and stated her foot slipped, she fell and Resident #1 landed on top of her. Staff A said she knew it was really bad that she didn't use the mechanical lift and said it was completely her fault. The LNHA stated that at this point, the DON had already told the LNHA that Staff D had questioned Staff A about using the mechanical lift. The LNHA then asked Staff A, and Staff A confirmed that Staff D did ask her about the mechanical lift. Staff A said she told Staff D they were trying to change the transfer method for Resident #1. Staff A said she didn't know why she said that nor why she decided to transfer Resident #1 that way. The LNHA then talked with Staff D. Staff D stated she had asked Staff A for help to get Resident #1 into the whirlpool tub. Staff D said Staff A told her she was going to stand Resident #1 up and wanted Staff D to pull Resident #1's pants down after Staff A stood Resident #1 up from the wheelchair and before sitting Resident #1 back down into the whirlpool chair. Staff D said she showed Staff A the CNA sheet that directed Resident #1 was to be transferred by 2 staff using a mechanical lift. Staff D said that Staff A said the facility was trialing a different transfer method with Resident #1. Staff D reported that Staff A picked Resident #1 up and fell backwards with her. On 1/15/25 at 1:47 p.m., Staff C, CNA, stated that she worked the day of Resident #1's fall incident. She stated they transfer Resident #1 the way the CNA Care Plan reads. She stated Resident #1 was to be transferred with a mechanical lift, so they used the mechanical lift to transfer Resident #1. On 1/14/25 at 4:06 p.m., Staff A stated that on 12/30/24 before 9:00 a.m., they were kind of late getting people out to breakfast that day. It was just kind of a crazy day. The nurses were asking where the other residents were who were not out at breakfast. Residents are supposed to be out by 9:00 a.m. Staff A thought there were at least 2 or 3 residents left to get up. Staff A stated they didn't have a late start getting residents up, they just had to answer call lights and things like that in between. Sometimes the call lights are going off more than other days. On this day the call lights were going off more. Staff A stated they had enough staff working. Staff A stated it was Resident #1's shower day. Staff A said that Resident #1 seemed normal to her. Staff A had asked Staff D to pull down the residents britches. Staff A stated with that transfer it was her that had a hold of Resident #1. Staff A said that Resident #1 did not have a gait belt on. When Staff A went to transfer Resident #1, Staff A's foot slipped and Staff A started to fall down. Staff A tried to pull Resident #1 on top of her, so Resident #1 would land on her to break the fall. Resident #1 did land on Staff A but Resident #1's leg hit something. Staff A thought her leg hit the whirlpool chair or the wheelchair, she was not sure which one it was. Staff A stated she had gotten new Crocs shoes and hadn't worn them before at work. There was a puddle on the floor and Staff A slipped in it. Staff A said they were supposed to transfer Resident #1 with 2 staff and a mechanical lift. Staff A stated that she had not transferred Resident #1 before that day without using a mechanical lift. Staff A said she honestly didn't know why they didn't use a mechanical lift, they were just running behind that day. Staff A stated that Staff D didn't really say anything much, Staff D just kind of had a look on her face like she was worried because she was a brand-new CNA. Staff A said she noticed the look on Staff D's face in the whirlpool room before the fall, when Staff A asked Staff D to pull down Resident #1's britches. Staff A said she told Staff D to go get the nurse after the fall. Staff A said they did not talk about the fall, Staff D just left to get the nurse. Staff A stated she held Resident #1 on the floor. Resident #1 was on top of her and she was trying to hold Resident #1 as still as possible until the nurse got there. Staff A stated that Resident #1 apologized to her and she told Resident #1 to not apologize as it was her fault. Staff A stated that Resident #1 then kind of put her head on Staff A's shoulder and said it's okay. Staff A said that Resident #1 appeared to be in pain. Resident #1 kept saying her leg hurt her and was pointing toward her right leg. Staff A said that Staff B came into the whirlpool room and then the DON came in as well. They adjusted Resident #1's leg up because her legs were kind of sideways so they adjusted her legs straight out in front of her. Resident #1 responded when they positioned her legs. Resident #1 was moaning and was in pain. The 3 of us then got Resident #1 up off the floor with a gait belt, one on each side of her and the 3rd one holding her legs to minimize movement and sat Resident #1 back in her wheelchair. Staff A stated she was on one side of Resident #1, Staff B had Resident #1's other side and the DON held her legs. They then wheeled her down to her room and lifted Resident #1 with the mechanical lift into her bed. The nurse and someone else helped get Resident #1 in bed. Staff A stated she knew that she was supposed to follow the Care Plan and she knew that Resident #1 was a mechanical lift transfer with 2 staff. Staff A stated that she just thought Resident #1 doesn't weigh very much, she didn't know what she was thinking, it was stupid on her part. On 2/7/25 at 3:30 p.m., Staff D stated she asked Staff A to assist her with transferring Resident #1 with the mechanical lift into the whirlpool as on the CNA sheet it directed to use a mechanical lift with Resident #1 for all transfers. Staff D stated that it was a two person job to run the Hoyer mechanical lift. Staff D stated she was walking down the hall and she saw Staff A in a different residents room. Staff D asked Staff A that when she was done, would she come and help her and Staff A said yes. Staff D went on to the whirlpool room and then after about 2 minutes Staff A came in to the whirlpool room. Staff D had left the mechanical lift outside of the whirlpool room and was waiting for Staff A to come in and bring the mechanical lift in with her. Staff A came in to the whirlpool room without a mechanical lift. Staff A didn't say anything to Staff D at first. Staff D stated she thought they were going to put the shower sling under Resident #1 first, but then Staff A said that therapy was working with Resident #1 to do a pivot transfer instead of a mechanical lift. Staff D stated this made her feel uneasy. Staff D said that typically they transfer residents needing a mechanical lift out of bed with the whirlpool sling on their bath days. Staff A started transferring Resident #1 out of the wheelchair. Resident #1 was not wearing a gait belt. Staff D stated normally you would use a gait belt with a pivot transfer. Staff A asked Staff D to pull down Resident #1's pants. Staff A put her arms under Resident #1 and held on to her pants to pull Resident #1 up. Staff D didn't know if Staff A tripped over something but Staff A fell back. Staff D said that right as they fell Staff A said 'of course this would happen'. Staff D ran to get the nurse. Staff D stated Resident #1 still had her pants on, as soon as Resident #1 stood up Staff A fell back and had Resident #1 fall on top of her. Resident #1 kind of let out a yell when they fell and then she started crying because she hit her leg. An undated Safe Resident Handling/Transfers policy, directed the following: Policy: To ensure that residents are handled and transferred safely to prevent or minimize risk for injury. Procedure: 1. Nursing Staff (Nurses, CNA's, Nurse Aids in Training) will lift and transfer residents according to a resident's individual plan of care. Individual plan of care is determined by therapy and/or nursing department. 2. Mobility needs will be addressed on admission and reviewed quarterly and after a significant change in condition or based on direct care staff observations or recommendations.

Based on clinical record review, resident and staff interviews and facility policy review, the facility failed to notify the Physician for elevated blood sugars for 1 of 2 residents reviewed for insulin usage (Resident #205). The facility reported a census of 48. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #205 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognitively intact. The MDS identified medical diagnosis of diabetes mellitus. The MDS revealed the resident received insulin injections 7 out 7 days. The Care Plan entry dated 12/17/21 revealed a focus problem of diabetes mellitus. Interventions dated 12/17/21 documented daily administration of Novolog injections (insulin medication) and finger tip blood sugars monitored per Medical Doctor (MD) orders. The interventions dated 12/17/21 explained hyperglycemia signs and symptoms of increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (abnormal breathing pattern characterized by rapid, deep breathing), fruity breath, stupor (state of near-consciousness), or coma needed monitored, documented, and reported as needed. Interventions dated 6/16/23 revealed administration of glargine insulin at bedtime and blood sugars checks before meals and at bedtime. During an interview on 6/19/23 at 1:59 PM, Resident #205 stated since admission her blood sugars were up to 500 mg/dl (milligrams per deciliter) and they gave her extra insulin. The Electronic Medical Record (EMR) revealed medical diagnosis of Type II diabetes mellitus with other diabetic kidney complication and long term (current) use of insulin. The Physician Orders revealed the following: a. Novolog (insulin aspart) pen fill subcutaneous solution cartridge 100 unit/ml (milliliter) ordered on 6/5/23- Inject 9 unit subcutaneously one time, and inject 5 unit subcutaneously one time a day, and inject 2 unit subcutaneously one time a day. b. Check blood sugar before meals and at bedtime ordered on 6/5/23. c. Insulin glargine (Lantus) solution pen-injector 100 unit/ml ordered on 6/13/23- Inject 20 unit subcutaneously at bedtime Review of Resident #205's blood sugars revealed the following information: a. On 6/6/2023 at 8:14 PM, blood sugar documented as 486.0 mg/dL and the record lacked documentation of the doctor being notified. b. On 6/7/2023 at 8:05 PM, blood sugar documented as 409.0 mg/dL and the record lacked documentation of the doctor being notified. c. On 6/14/2023 at 8:05 PM, blood sugar documented as 414.0 mg/dL and the record lacked documentation of the doctor being notified. d. On 6/15/2023 at 9:12 PM, blood sugar documented as 402.0 mg/dL and the record lacked documentation of the doctor being notified. e. On 6/18/2023 at 8:03 PM, blood sugar documented as 416.0 mg/dL and the record lacked documentation of the doctor being notified. f. On 6/20/2023 at 8:12 PM, blood sugar documented as 418.0 mg/dL and the record lacked documentation of the doctor being notified. During an interview on 6/21/23 at 8:00 AM, Staff A, Licensed Practical Nurse (LPN) queried on the policy for blood sugars and she stated if blood sugars were under 60 mg/dl and over 400 mg/dl the Nurse notified the Doctor. During an interview on 6/21/23 at 2:09 PM, Staff B, LPN queried on the policy for blood sugars and she stated anything under 60 mg/dl or over 400 mg/dl the Nurse called the Physician. Staff B asked about the expected interventions for a blood sugar over 400 mg/dl and she stated they reviewed the blood sugars with the Doctor for any new orders. During an interview on 6/21/23 at 3:13 PM, Staff C, LPN queried if they facility had a Blood Sugar Policy and she stated she didn't know but she personally notified the physician if a blood sugar below 70 mg/dl or above 400 mg/dl. Staff C asked if she knew about Resident #205's elevated blood sugars and she stated yes, they received orders to monitor them for a week and then notify the Doctor. Staff C queried if they needed to notify the Physician for blood sugars over 400 mg/dl for Resident #205 and she stated no. During an interview on 6/21/23 at 3:43 PM, the Director of Nursing (DON) queried if the facility had a policy for blood sugars and she responded yes if a blood sugar were under 50 or above 400 they notified the doctor. The DON asked about Resident #205 blood sugars and if she expected notification to the doctor when the blood sugar was over 400 mg/dl and she stated yes. The DON asked if she expected the nurse to notify the Physician for any blood sugar over 400 and she responded yes, unless the Physician ordered a different parameter for the resident. The DON asked if Resident #205 parameters were different and she responded no. The Facility Policy named Guidelines for elevated for fingertip blood sugar dated 2/1/18 revealed the resident's provider will be notified immediately for a fasting blood sugar greater than 400 mg/dl.

Based on clinical record review and staff interview, the facility failed to document non-pharmacological interventions attempted prior to the administration of as needed (PRN) anxiolytics (medications used to treat anxiety) for 1 of 2 residents reviewed for prn anxiolytic use(Resident #26). The facility reported a census of 48 residents. Findings Include: The Minimum Data Set (MDS) Assessment tool, dated 4/20/23, listed diagnoses for Resident #26 which included Parkinson's disease, mild cognitive impairment, and adult failure to thrive. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 7 out of 15, indicating severely impaired cognition. Care Plan entries, dated 8/8/22, stated the resident utilized as needed medications such as lorazepam (an anxiolytic) and directed staff to administer the medication as ordered. The entries directed staff to encourage the resident to vent feelings and frustrations, reduce background noise as able, and monitor frustration level. The June 2023 Medication Administration Record (MAR) listed an order for lorazepam tablet 0.5 milligrams (mg), 1 tablet by mouth every 4 hours as needed. The MAR documented the resident received the medication at the following times: a. On 6/3/23 at 1:07 a.m. b. On 6/4/23 at 4:24 a.m. and 10:01 p.m. c. On 6/7/23 at 4:58 p.m. d. On 6/10/23 at 2:45 a.m. e. On 7/18/23 at 1:04 a.m. f. On 6/19/23 at 2:48 a.m. The facility records lacked documentation staff attempted non-pharmacological interventions prior to the above administrations. On 6/21/23 at 12:46 p.m., Staff A Licensed Practical Nurse (LPN) stated she documented 3 interventions prior to the administration of PRN anxiolytics such as snacks and toileting. On 6/22/23 at 8:17 a.m., the Director of Nursing (DON) stated staff should document interventions attempted prior to the administration of prn anxiolytics. During an interview on 6/22/23 at 10:22 a.m., the DON stated the facility did not have a policy related to the administration of PRN anxiolytics.

Based on observation, staff interview and policy review, the facility failed to ensure expired food items were served to residents and failed to label and date food items when opened to reduce the risk of contamination and food-borne illness. The facility reported a census of 40 residents. Findings Include: On [DATE] at 9:20 AM during the initial tour of the facility kitchen with the Dietary Supervisor and facility Dietician, revealed the following: a. A clear plastic bin containing small candy M&M's in an open bag not labeled or dated when opened or a best by date. b. A clear plastic bin containing small white chocolate chips in an open bag not labeled or dated when opened or a best by date. c. A partial pasta bag not dated when opened. d. 11 boxes of cherry chip cake mix with a best by date of [DATE]. e. 3 boxes of orange supreme cake mix with a best by date of [DATE]. f. 3 bags of Lays potato chips with a best by date of [DATE]. In an interview on [DATE] at 8:28 AM, the Dietary Supervisor reported it is an expectation any food item be labeled and dated when opened. The Dietary Supervisor further revealed staff are to check expiration dates to ensure no outdated food is used. He stated he planned to re-educate the Dietary Staff on the policy of Food Receiving and Storage. The facility provided policy titled Food Receiving and Storage dated [DATE], revealed foods are to be labeled and dated and the use by date of the manufacturer labeled food dates are acceptable.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to provide complete peri care for 1 of 4 residents observed. (Resident #10) The facility census was 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. The Care Plan dated 2/1/19, directed extensive assist of 2 staff and a Hoyer (mechanical lift) for toilet use and management of incontinent products and peri-care after each incontinent episode. During observation on 4/11/19 at 12:51 p.m., Staff G, Certified Nurse Aide CNA unhooked the resident's brief and reported the resident was incontinent. Staff G with a soapy wash cloth, wiped down the right side and back up the right side and down the middle with out changing the surface of the wash cloth. Staff G rolled the resident to the right revealing bowel movement that Staff G wiped away with the brief and changed gloves with out hand hygiene. Staff G used disposable wipes to wipe away the bowel movement up the rectal area then back down the rectal area toward the vagina. Staff G continued to wipe in a circular motion around the left buttock with out changing the surface of the wipe. Staff G rolled the resident to the left side and wiped the right buttock in circular and back and forth motion with out changing surface of the wipe each time. Staff G placed new brief with out removing gloves or completing hand hygiene. During interview on 4/12/19 at 1:17 p.m., Staff C, CNA stated when a resident was incontinent the expectation was to wash the resident with a wash cloth, in a front to back motion only, change surface of the cloth after each swipe, and after cleaning remove gloves wash hands before touching anything else. During interview on 4/12/19 at 1:24 p.m., the Director Of Nursing (DON) reported staff use wash cloths for incontinent care and are to wash in a front to back motion and change the surface of the cloth with each swipe. Staff are expected to remove gloves and wash hands after providing incontinence care before handling other items. Facility provided a procedure titled Skills Check list # 28 undated, directing at 6 if gloves are soiled remove and complete hand hygiene.

Based on facility record review, facility policy review and staff interview, the facility failed to provide financial records to residents or resident representatives on quarterly basis. The facility census was 43 residents. Findings include: During interview on 4/12/19 at 10:58 a.m., the Bookkeeper stated resident fund statements are provided upon request or when a resident is discharged from the facility, but not quarterly. The Bookkeeper reported the Administrator put that direction in place years ago. During interview on 4/12/19 at 11:06 a.m., the Administrator reported the facility provided resident fund statements only when requested, not on a quarterly basis. The facility provided a policy titled Resident Funds undated, directing at point # 5. The financial record is available through quarterly statement and on the request to the resident or his/her legal representative.

Based on observation and staff interview, the facility failed to maintain sanitizable cutting board in order to prevent cross contamination. The facility census was 43 residents. Findings include: 1. During observation on 1/10/18 at 9:45 a.m., with the Dietary Supervisor, six cutting boards approximately 18 inches by 12 inches was noted to have deep grooves, discolored and fuzz on all boards making them unsanitizable. During interview on 1/10/18 at 10:00 a.m., the Dietary Supervisor acknowledged the grooves and fuzz and overall condition of all cuttings boards and stated new ones would be obtained.

Based on clinical record review, facility policy review and staff interview, the facility failed to report an allegation of verbal abuse in a timely manner for one of 16 residents reviewed. (Resident #5) The facility census was 43 residents Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. During interview on 1/17/17 at 2:00 p.m., the former Director of Nursing reported she did not hear of the incident until three days after it happened and reported they completed an investigation, interviewed staff and the resident involved. The former DON reported the facility reported to the department of inspection and appeal as soon as they knew of the event. During an interview on 1/18/18 9:30 a.m. the Administrator reported Resident #5 was assisted to the dining room when Staff D, Certified Nurse Aide, CNA made a comment about the resident pissing her off. The comment was heard by Staff A, CNA and Staff B, CNA. The Administrator reported staff failed to inform supervisory staff until a few days later, even though both staff had been educated about how to report abuse. An employee statement dated 5/16/17, documented Staff A, CNA failed to report a recent incident where a new staff member stated a resident was pissing her off in front of the resident because she did not believe the resident heard it and she was overwhelmed with the work that evening. An employee statement dated 5/16/17, documented Staff B, CNA failed to report a recent incident where a new staff member stated a resident was pissing her off in front of the resident. The employee statement documented the staff member did not know she needed to report verbal abuse. The facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 12/21/16, directed staff to report all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative.

Based on observation, interview, and document review, the facility failed to maintain sanitary conditions in the kitchen. The facility reported a current census of 83 residents. Finding include: Observations during the initial dietary tour on 11/23/15 at 9:45 a.m. accompanied by the Dietician revealed the following. 1. Inside the Kolpak walk-in refrigerator: a. Eight strawberry pies uncovered, unlabeled and undated. b. A plastic storage container that contained approximately 1 1/2 quarts of a thick liquid food item labeled, Nacho Cheese and dated 11/09/15. c. A smaller plastic storage container that contained approximately 3/4 quart of a thick liquid food item labeled Cream of Mushroom Soup and dated 11/19/15. 2. An accumulation of dust hanging from a black pipe located directly above the stovetop in the kitchen. Observation on 11/25/15 at 8:50 a.m. showed the same accumulation of dust, as seen two days before, still hanging from the black pipe located directly above the stovetop in the kitchen. 3. A bucket filled with a chemical solution used for the sanitizing the tabletops and food preparation surfaces, tested at 175 parts per million (ppm), below the minimum 200 ppm concentration recommended for effective sanitization. Observation on 11/25/15 at 8:50 a.m. revealed the bucket filled with a chemical solution used for the sanitization of tabletops and food preparation surfaces tested at 200 ppm, the minimum concentration recommended for effective sanitization. A Food Receiving and Storage policy with a revision date of December 2008 specified that all foods stored in the refrigerator or freezer will be covered, labeled and dated with a use by date. During an interview on 11/25/15 at 8:50 a.m., the Dietary Supervisor reported he expected, and staff should have, covered, labeled, and dated the strawberry pies according to the policy. During an interview on 11/23/15 at 9:45 a.m., Staff A, Cook, reported the identified food items had a shelf life of 3 days, and staff should have discarded them 3 days after opening. During an interview on 11/25/15 at 8:50 a.m., the Dietary Supervisor reported he takes responsibility for cleaning the pipe above the stove. He stated that although that particular chore does not appear on the cleaning schedule, he assumes responsibility for doing it. According to the Martin Brother's instruction sheet for testing quaternary sanitizer, the user should mix the solution at a minimum of 200 ppm, not to exceed 300 ppm. During an interview on 11/25/15 at 8:50 a.m., the Dietary Supervisor reported, Martin Brother's Distributing Company replaced the faulty tip of the dispenser hose, which had caused the device to dispense an inaccurate ratio of the chemical and water solution. The Dietary Supervisor stated that Martin Brothers had recently been having problems with the dispenser hose tip malfunctioning.

Based on observation and staff interview, the facility failed to ensure hazardous chemicals were maintained in a locked room in order to prevent accidental ingestion. The facility identified 17 independently mobile residents. The facility census was 42 residents. Findings include: 1. Observation on 10/21/14 at 2:00 p.m., revealed a door to the clean utility room at the beginning of the Administration Hall as opened when pulled on. Further inspection revealed the clean utility room stored the following six chemicals on the shelf at wheelchair height: a. Pure Bright gallon bottle, 1/4 full b. Citrus Stride that contained 750 milliliters, full bottle. c. Conqueror 103, full gallon. d. Nenown gallon bottle, 3/4 full per DON. e. DMQ gallon bottle, 1/4 full per DON. f. Windex gallon bottle, 1/2 full per DON. All six chemical containers had a label directing to keep out of reach of children. During interview on 10/21/14 at 2:30 p.m., Staff J, Maintenance Supervisor reported no knowledge of the door not working as it should. The door was expected to be locked.

Based on observation, clinical record review and staff interview, the facility failed to provide complete peri care for two of five residents observed during personal cares. (Resident #1 & #4) The facility census was 42 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident was dependant on staff for transfers dressing and toilet use. During observation on 10/21/14 at 8:20 a.m., Staff A certified nurse aide, CNA cleansed the resident's rectal area with a cloth in a back and forth motion six times to remove the stool. Staff A utilized a clean cloth to cleanse the residents buttocks in a circular motion five times with out changing the surface of the wipe. 2. The MDS assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident required extensive assistance for transfer and toileting. During observation on 10/20/14 at 12:50 p.m., Staff C, CNA cleansed the residents rectal area in a back and forth motion three times. Staff C continued to cleanse in a circular motion over the residents buttocks. During interview on 10/23/14 at 9:25 a.m., the Assistant Director of Nursing, ADON reported on an annual basis CNA's complete a skills fair.

Based on record review, and interviews with staff and laboratory medical record staff, the facility failed to provide a timely laboratory test, as ordered by the physician for 3 of 9 residents reviewed (Resident #4, #10, and #16) The facility reported a census of 37 residents. Findings include: 1.Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 3/25/13 which identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident scored 7 out of 15 for the brief interview for mental status. A score of 7 reflected the resident as severely cognitively impaired. The MDS reflected the resident required extensive assistance of two staff members for transfers, walking, and toilet use and had a history of [REDACTED]. An Incident Report dated 8/30/12 at 4:30 p.m. revealed the resident fell in the activity room bathroom. The report reflected the resident did not use the call light and stood from the toilet independently and then fell to the floor. The Activity Director had been educated not to leave the resident alone in the bathroom, and the resident had been educated to use the call light for assistance. The Incident Report did not document an injury as a result of the fall. An Incident Report dated 11/11/12 with documented time of 9:40 p.m. indicated the resident had been found sitting in front of a recliner in the resident's room, and the resident reported to the staff that the resident hit his/her head on the recliner, but denied pain. The Incident Report documented no injury to be found post fall assessment. The Incident Report included interventions of resident education to ask for assistance, and placed non-skid strips in front of the resident ' s recliner. An Incident Report dated 3/22/13 at 3:30 p.m. revealed the resident had been found lying on his/her back in the doorway of the resident's bathroom with pants below the waist and the walker in front of the resident. The wheelchair rested in the doorway of the resident ' s room. The Incident Report did not indicate an injury. An intervention was initiated to toilet the resident between 2:00 p.m. and 3:00 p.m. The Resident Care Plan identified a problem of self- care deficit (resident requires assistance with daily cares related to weakness) with start date of 11/26/12. The Resident Care Plan directed staff to provide medications and treatments as ordered. A hospital Emergency Report dated 4/29/2013 indicated the resident had lower extremity swelling. The report identified a duplex venous test was performed to the resident ' s left leg. The finding revealed the resident had a [MEDICAL CONDITION] (blood clot). The resident was started on [MEDICATION NAME] (anticoagulant-reduces risk for blood clots) medication. A Physician's Telephone order dated 5/03/13 directed staff to discontinue [MEDICATION NAME] , continue [MEDICATION NAME] and notify the laboratory to check a [MEDICATION NAME] time (PT-measures how quickly blood clots) and international normalized ratio (INR-the results of a PT test converted into standard units on 5/7/2013).(In combination, physicians use the PT and INR blood tests to monitor the effectiveness of [MEDICATION NAME] therapy by determining how quickly the person ' s blood will make clots.) On 5/21/2013 at 1:00 p.m., the MDS Coordinator documented, in the Progress Notes, the resident had scattered bruises to both, upper and lower extremities, abdomen, back and left side of the face and chin. Resident #4 was currently taking 5 mg (milligrams) of [MEDICATION NAME] and the last INR result was 1.72 on 5/3/2013. Documentation reflected the facility staff placed a telephone call to the Physician Assistant ' s office regarding these findings and left a message with the nurse. The facility received a new order to draw a PT/INR today and facility staff notified the laboratory of the request to draw the PT/INR. A Laboratory Report with collection date of 5/21/13 documented the PT result as 141.1 (expected range 9.4-11.0 seconds), and the INR as 14.58 (expected rage .80- 1.20) An Physician Telephone Order dated 5/21/2013 at 4:15 p.m. directed staff to administer 5 mg of vitamin K, in the muscle, immediately (Vitamin K reverses the effect of blood thinning). Do not give today ' s [MEDICATION NAME], monitor the resident for falls, confine the resident to their room for supper tonight and breakfast in the morning and draw another PT/INR in the early morning on 5/22/2013. A laboratory report for blood collected on 5/22/2013 at 9:14 a.m. from Resident #4 documented the PT result was high at 104.5 and the INR result was critically high at 10.74. A Physician Telephone Order dated 5/22/13 at 11:30 a.m. directed the staff to give the resident a Vitamin K injection immediately, and to draw a PT and INR on 5/23/13 and allow the resident to come out of their room. A laboratory report for blood collected on 5/23/2013 at 9:46 a.m., from Resident #4 documented the PT result was high at 30.7 and INR result was high at 3.08. A Physician Telephone Order dated 5/23/13 at 3:00 p.m. directed staff not to give the resident [MEDICATION NAME] and to draw a PT and INR on 5/24/2013. A laboratory report for blood collected on 5/24/2013 at 8:08 a.m. from Resident #4 documented the PT result was high at 18.8 and the INR was high at 1.86 with a note stating " INR therapeutic ranges for oral anticoagulant therapy 2.0-3.0 [MEDICATION NAME]/treatment of [REDACTED]. " A Physicians Telephone Order dated 5/24/13 directed staff to give the resident [MEDICATION NAME] 2.5 milligrams by mouth daily for seven days then repeat a PT and INR on 5/31/2013. A May 2013 calendar provided by the Administrator from the employee ' s disciplinary file lacked documentation on 5/07/13 that the resident had been scheduled for a PT and INR. An Employee Disciplinary Report dated 5/23/13 revealed the Director of Nursing called the laboratory and no order for the PT INR for 5/07/13 could be found. The Consultant Pharmacist Review sheet for May 2013, dated 5/9/2013 indicated the resident to be on [MEDICATION NAME] and [MEDICATION NAME] (both medications are blood thinners) with a date of 4/29/2013. The Pharmacy review lacked documentation of lab results for the PT INR due on 5/7/2013. A documented labeled Keystone Nursing Care Center Recommended Laboratory Tests with reviewed date of 9/12/12 indicated [MEDICATION NAME] ([MEDICATION NAME]) would have a PT INR completed monthly or as ordered. During an interview on 7/23/13 at 2:10 p.m. a medical records staff member of Marengo Memorial Hospital reported the residents ' clinical record lacked documentation of a service date or an order for [REDACTED]. During an interview on 8/12/13 at 8:38 a.m. the facility pharmacy consultant reported doing a medication review for Resident #4 on 5/09/13, and acknowledged that a PT INR had been ordered for 5/07/13. The pharmacy consultant reported she/he would review [MEDICATION NAME] therapy every month but does not write down all the results. The pharmacy consultant reported if he/she would have asked for the 5/07/13 PT INR results maybe it would not have been missed. The pharmacy consultant was unsure why the 5/07/13 PT INR did not get done. During an interview on 7/25/13 at 9:00 a.m. Staff C, Registered Nurse reported that on 5/21/13 she noticed the resident had small tiny bruises on the face, then upon record review realized the PT and INR was missed, then immediately notified the physician. During an interview on 8/12/13 at 9:20 a.m. the Director of Nursing (DON) and the Assisted Director of Nursing (ADON) reported the process of getting a physician's order [REDACTED]. 1. Order written or verbally documented 2. Document order in the nurses notes 3. Document new order in the shift book (to use in shift to shift report) 4. Call pharmacy if necessary with medication changes 5. Notify family of new order 6. If a lab is ordered put the resident name and lab ordered on the calendar 7. Fax order to the lab 8. Pass order onto next shift in report The DON and ADON reported the next shift should review the orders written by the previous shift, and a pink copy of the orders goes to the MDS Coordinator for review for possible care plan updates. Then the pink copy is given to the ADON until the original order comes back from the physician signed. A yellow copy of the order remains in the resident's chart. On 8/12/13 at 10:13 a.m. Staff Y, License Practical Nurse (LPN), was interviewed and reported a communication book (shift book) is used at report between shifts to go over new orders. Staff Y reported the MDS/Care plan Coordinator puts the routine labs on the lab calendar. Staff Y reported when an order is written for a lab the laboratory is faxed, and the resident ' s name and lab ordered is put on the calendar. Staff Y reported the MDS/Care plan coordinator, the DON and the ADON double check the orders. Safety precautions put in place for Resident #4 for elevated PT INR had been staff educated in report to be careful for potential skin injury, and to keep the resident in the room. Staff Y reported that the resident stayed in his/her room for about three days for safety. Staff Y reported the resident had a history of [REDACTED]. During an interview on 8/12/13 at 8:53 a.m. Staff Z, Licensed Practical Nurse (LPN) reported if a PT INR lab is drawn in the morning, the results are back the same day, and Thursdays are the usual lab draw days. Staff Z reported other nurses do check orders that are written like the DON or the ADON. Staff Z reported the steps to follow up on a physician's order [REDACTED]. Staff Z reported the calendar for labs is to be check at the beginning of the shift. Staff Z reported the step that she missed when documenting the order for Resident #4 had been not putting the PT INR on the calendar or faxing the order to the laboratory. During an interview on 8/12/13 at 2:30 p.m. the ADON reported that PT and INR's are done monthly for residents that are on (receiving) [MEDICATION NAME]. The ADON reported interventions put in place for Resident #4 due to the elevated PT INR were education to the resident to ask for assistance for cares, started a press pad alarm in the chair, the resident stayed in his/her room. The ADON reported the resident made no attempts to get up on his/her own. During an interview on 8/12/13 at 8:50 a.m. the Administrator reported two nurses go over all the orders that are written. The labs got missed by them as well. During an interview on 8/12/13 at 12:12 p.m. the resident ' s Physician reported the fall precautions were put in place to have the resident remain in his/her room with monitoring, daily PT INR labs, discontinue the [MEDICATION NAME], and administer Vitamin K. The resident ' s Physician reported if the resident fell and had internal bleeding the result could have been death. The resident ' s Physician reported if the resident was admitted to a hospital there would not be much difference in the plan of care, and the facility to his knowledge did not have a history of a missed lab to that caliber of a concern. 2. Resident #10 had an MDS with reference date of 2/14/13, which documented the resident had the [DIAGNOSES REDACTED]. The MDS revealed the resident had been on anticoagulant therapy ([MEDICATION NAME]). The Care Plan with admitted [DATE], identified a problem with a risk for bleeding related to [MEDICATION NAME] use. The Care Plan directed staff to monitor labs as ordered and report to the physician. The approach dated 12/06/12 documented the resident received education on the risks for bleeding due to elevated PT/INR, along with a sign posted in the resident ' s room. Discharge Orders dated 2/07/13 directed staff to obtain a PT INR on 2/19/13. The February lab calendar lacked documentation that the resident needed a PT INR on 2/19/13. The Nurses Note ' s lacked documentation of a PT INR lab draw for 2/19/13. Upon review of the clinical record, no PT INR results for 2/19/13 could be found and the next PT INR draw had been dated 3/28/13. The February 2013 Medication Record documented the resident received [MEDICATION NAME] therapy. During an interview on 8/12/13 at 2:30 p.m. the ADON reported she could not find the PT INR for 2/19/13. 3. The MDS with reference date 1/22/13 indicated Resident #16 had [DIAGNOSES REDACTED]. The MDS documented the resident had been on anticoagulant medications (blood thinner medications). The residents Care Plan lacked anticoagulant therapy as a concern. The resident ' s Medication Record dated January 2013 documented the resident received [MEDICATION NAME]. A Laboratory test result dated 1/24/13, documented a physician order [REDACTED]. The January 2013 lab calendar lacked documentation of a lab PT INR draw for Resident #16 on 1/31/13. The Nurses Note dated 1/24/13 at 4:00 p.m. lacked documentation the lab had been faxed related to a lab draw for 1/31/13. Upon clinical record review no PT INR lab results could be found for the date 1/31/13, the next PT INR drawn was dated 3/07/13. During an interview on 8/12/13 at 3:15 p.m. the ADON reported the 1/13/13 PT INR results could not be located. Note: At the time of the survey investigation, the deficiency was coded at a "J", immediate and serious jeopardy. By August 14, 2013, the faciltiy had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to a "D" level. All professional nursing staff were assigned courses to prevent medical errors. All staff were re-educated about high risk medication in al all nurse in service held on 8/14/2013 by a local pharmacist. A new double check form sheet was implemented as a secondary system of checks. The facility also ordered a new [MEDICATION NAME] Machine on 8/13/2013 so [MEDICATION NAME] could be performed in house and monitored in hourse. As of August 22, 2013, exit conference, the facility continued to need to: . Continue to inservice staff in order to prevent medication administration errors, . Continue to monitor the implementation of physician orders, . Continue to monitor the use of the secondary sytem of checks so all laboratory tests are performed.

Based on observation, record review and staff interview, the facility failed to follow physician's orders for 1 of 10 residents reviewed (Resident #6). The facility reported a census of 37 residents. Findings include: Resident #6's Care Plan dated 6/13/13 documented [DIAGNOSES REDACTED]. The Care Plan also documented the resident had a deficit in Activities of Daily Living self-care performance related to dementia and limited mobility, and was totally dependent on 1- 2 staff for dressing. The Care Plan lacked documentation-directing staff to place the T.E.D. hose on the resident, in accordance with physician order dated 4/12/13. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED]. The MDS also documented the resident required total assistance of 2 staff for dressing, transfers, and toilet use. Physician's Order Sheet dated 7/1/13 to 7/31/13 documented an order dated 4/12/12 that directed staff to put T.E.D. hose (Tight stockings that decrease swelling in the legs and help prevent blood clots by increasing circulation.) on the resident in the morning and take them off at bedtime. Resident #6's Treatment Record dated 7/01/13 to 07/31/13 lacked documentation directing staff to place T.E.D. hose on the resident. Observation on 7/22/13 at 2:15 p.m. showed Resident #6 sitting in a wheelchair in the hallway without wearing T.E.D. hose. Observation on 7/23/13 at 8:10 a.m. showed the resident sitting at the dining room table without wearing T.E.D. hose. Observation on 7/24/13 at 8:40 a.m. showed the resident sitting at the dining room table without wearing T.E.D. hose. Observation on 7/25/13 at 8:28 a.m. showed the resident sitting by the nurses' station in a wheelchair without wearing T.E.D. hose. During an interview on 7/25/13 at 12:30 p.m., the Assistant Director of Nursing reported she called the pharmacy and the pharmacy representative told her that someone from the nursing home had called the pharmacy and said to take the T.E.D. hose off the treatment record, but not the physician's orders. The Assistant Director Nursing reported she does the monthly physician's order checks and she must have missed it, and reported the resident did not want to wear the T.E.D. hose.

Based on observation and document review, the facility failed to ensure all residents received their medications in accordance with the facility's drug handbook resulting in a medication error rate greater than 5 percent. The facility had 3 errors out of 25 medication administrations observed resulting in a 12% medication error rate (Resident #'s 3, 12, and 13) The facility census was 37 residents. Findings include: Medication pass observation completed 7/22/13 and 7/23/13 consisted of observations in 2 areas of the facility with 3 staff members, 4 different routes of medication administration, and from different shifts. 1. Observation on 7/22/13 at 4:20 p.m. revealed Staff A, licensed practical nurse, LPN instructing Resident #3 on how to use the [MEDICATION NAME] 500/50 Diskus inhaled medication (a synthetic corticosteroid used to open airways in the lungs). Staff A instructed the resident to inhale 2-puffs of the medication. Staff A failed to provide water and instruct the resident to rinse their mouth after inhaling the medication in accordance with the facility's 2013 Nursing Drug Handbook. 2. Observation on 7/22/13 at 4:22 p.m. revealed Staff A, LPN, instructing Resident #12 on how to use the [MEDICATION NAME] 250/50 Diskus. Staff A instructed the resident to inhale 1-puff of the medication. Staff A failed to provide water and instruct the resident to rinse their mouth after inhaling the medication in accordance with the facility's 2013 Nursing Drug Handbook. Review of the Nursing 2013 Drug Handbook pages 618 and 619 revealed [MEDICATION NAME] is a synthetic corticosteroid with potent anti-[MEDICAL CONDITION] activity. The patient teaching section instructed patients to rinse their mouth after inhalation to prevent oral candidiasis (a fungal infection). 3. Observation on 7/23/13 at 7:10 a.m. revealed Staff B, certified medication assistant, CMA instilling 1 drop of [MEDICATION NAME] 0.5 % (an eye medication used for [MEDICAL CONDITION]) into the Resident #13's left eye. Staff B failed to apply light finger pressure on the lacrimal sac (tear duct) for 1 minute after instilling the drug, to minimize systemic absorption, in accordance with the facility's 2013 Nursing Drug Handbook. Review of the 2013 Nursing Drug Handbook page 1328 for [MEDICATION NAME] administration instructed the user to apply light finger pressure on the lacrimal sac for 1 minute after instilling drug to minimize systemic absorption.

Based on document review and interview, the facility's pharmacy consultant failed to monitor diagnostic test results related to medication reviews for 1 of 9 residents reviewed (Resident #4). The facility reported a census of 43 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) Resident Assessment reference date, 3/25/13 documented [DIAGNOSES REDACTED]. The MDS also documented the resident had a history of [REDACTED]. A Physician's Telephone order dated 5/3/13 directed staff to discontinue Lovenox, continue Coumadin and notify the laboratory to check a prothrombin time (PT-measures how quickly blood clots) and international normalized ratio (INR-the results of a PT test converted into standard units) on 5/7/13. In combination, physicians use the PT and INR blood tests to monitor the effectiveness of Coumadin therapy by determining how quickly the person's blood will make clots. The Consultant Pharmacist's May Review sheet dated and initialed on 5/9/13, documented on 4/29/13, the resident was on Lovenox and Warfarin (both medications are blood thinners). The pharmacy review lacked documentation of laboratory results for the PT/INR that was due on 5/7/13. During an interview on 8/12/13 at 8:38 a.m., the facility Pharmacy Consultant reported conducting a medication review for Resident #4 on 5/9/13, and acknowledged the physician had ordered a PT/INR for 5/7/13. The Pharmacy Consultant confirmed, she reviews Coumadin therapy every month but does not write down all the results and said, maybe, if she had asked for the 5/7/13 PT/INR results they would not have missed them; she was unsure why staff missed the 5/7/13 PT INR. Resident #4's clinical record lacked laboratory results for the PT/INR test ordered on date 5/7/13. A laboratory report for blood collected on 5/21/13 at 2:00 p.m., from Resident #4, documented the PT result was high at 141.1 (expected range 9.4-11.0 seconds), and the INR result was critically high at 14.58 (expected rage .80- 1.20). A Physician Telephone Order dated 5/21/13 at 4:15 p.m., directed staff to administer 5 mg of vitamin K, in the muscle, immediately (Vitamin K reverses the effects of blood thinning). Do not give today's Coumadin, monitor the resident for falls, confine the resident to their room for supper tonight and breakfast in the morning and draw another PT/INR in the early morning on 5/22/13.

Based on clinical record review, staff interview, and pharmacist interview, the facility delayed acquisition of medication for 1 of 2 residents who utilized VA medications which resulted in no administration of [MEDICAL CONDITION] medication for 4 days. ( Resident #3). The facility census was 33 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. Review of the clinical record revealed a facsimile (fax) dated 5/21/12 to the physician/PA (physician assistant) that stated: Resident (#3) has not received [MEDICATION NAME] (a [MEDICAL CONDITION] medication) for 4 days as this was a VA (Veteran's Administration) med. On 6/27/12 at 10:45 a.m., when asked how to obtain medications if a VA medication doesn't arrive for a resident, Staff B, licensed practical nurse (LPN), stated she orders it from the facility pharmacy and they bring the medication out. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurse's medication notes failed to document the reason for the lack of administration of the medication to Resident #3. On 6/27/12 at 11:00 a.m. an interview with Staff A verified he/she faxed the pharmacy for the medication on 5/16/12 as the pharmacy communication sheet documented no date for the requested [MEDICATION NAME] 100 mcg. Staff A indicated the medication as not received. Staff A indicated Staff D, LPN, as responsible for checking the fax report to the pharmacy with the medications received and this not done on the evening shift of 5/16/11. Review of the 5/2012 MAR indicated [REDACTED]. Review of the nurse's medication notes failed to document the reason for the lack of administration of the medication to Resident #3. Interview with Staff C on 6/27/12 at 11:15 a.m. revealed she thought she contacted the pharmacy on 5/18/12 to make notification for the need of the medication. On 6/27/12 at 11:30 a.m., Staff C reported some trouble with the facility fax machine around that time but thought the [MEDICAL CONDITION] medication would come in on that Friday (5/18/12) as she felt she had contacted the pharmacy. Staff A, LPN indicated on 6/27/12 at 11:30 a.m. that she had called the pharmacy to see what happened and the pharmacy indicated no arrival of the facsimile taking place to notify them of the need for the resident's medication. Staff A stated she learned of the continued need for the medication on Monday (5/21/12) so she drove to the pharmacy and picked up the medication so Resident #3 could take his/her [MEDICAL CONDITION] medication. Review of the 5/2012 MAR indicated [REDACTED]. The nurse's medication notes reflected the medication not given as unavailable on both dates. Review of the physician's orders [REDACTED]. Completion of a blood draw for Resident #3 took place on 6/4/12 and the result reported to the facility on [DATE] of an abnormal high result of 5.10 for the TSH. (normal range 0.36 - 3.74). Review of a telephone order from the resident's physician/P.A. revealed an order to increase the medication of [MEDICATION NAME] 100 mcg. to [MEDICATION NAME] 125 mcg. and to repeat TSH and free T4 in 2 months. Interview on 6/28/12 at 10:05 a.m. with the pharmacist revealed 24 hour on call services and many times the pharmacy had provided Resident #3 with medication until the VA medication could get to the facility. The pharmacist reported she did not remember any correspondence from the facility related to the resident's need for the [MEDICAL CONDITION] medication in May and had no documentation to that effect. The pharmacist indicated he/she as having no facsimile from the facility and that he/she as on call Friday and Saturday (5/18 &5/19) with no record of being notified of the facilities' request for medication for Resident #3.