Every finding on record at Lakelands Nursing And Rehabilitation Center

Based on review of the RAI Manual, record review, and interviews, the facility failed to ensure the quarterly comprehensive assessment for 2 of 2 residents (R)4 and R28 was transmitted timely. Findings include: Review of the RAI Version 2.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments revealed MDS assessments are edited to verify that clinical responses are within valid ranges, dates are reasonable, and assessments are consistent with the previous assessments completed for the same resident. The facility is notified of the results of this evaluation on the Initial Feedback Report or the Final Validation Report. Timeliness Criteria: Assessment Transmission: Comprehensive assessments must be transmitted electronically within 31 days of the Care Plan Completion Date (VB4). All other MDS or MPAF assessments must be submitted within 31 days of the MDS Completion Date (R2b). A Performance Improvement Plan (PIP), which began with the arrival of the current Minimum Data Set (MDS) Coordinator on 03/28/24 was presented. The goal of the PIP was to ensure that all MDS assessments and care plans are up to date and completed in a timely manner. The PIP was in place until August of 2024. Review of the MDS assessments revealed R28 had a MDS due with a target date of 02/19/25. R28's MDS was not submitted until 04/16/25, which was more than 14 days after the target date and more than 31 days after the MDS completion date. R4 had a MDS due with a target date of 03/03/25. R4's MDS was not submitted until 04/16/25, which was more than 14 days after the target date and more than 31 days after the MDS completion date. During an interview on 04/16/25 at 05:30 PM, Licensed Practical Nurse (LPN)1 revealed she is a contract MDS nurse. LPN1 stated, I had a mess to clean up. The MDS nurse before me left unexpectedly. There were many late assessments. We did a performance improvement plan for late assessments. We should be pretty much caught up. LPN1 verified that R28's Quarterly assessment dated [DATE] remained In Progress. LPN1 also verified that R4's Quarterly MDS dated [DATE] remained In Progress. She stated that she did not know why the assessments continued to be in progress, but she would check on it. LPN1 revealed that the two assessments in question did not pull over when she submitted the batch, so these assessments were not submitted. During an interview on 04/17/25 at 02:56 PM, the Administrator revealed that LPN1 sends the MDS to a Registered Nurse (RN) in the consultant company. The RN signs the MDS and hits the complete button. A software issue did not allow the system to register that the RN hit the complete button, so the MDS' for R28 and R4 were not submitted.

Based on review of the facility policy, observations, record review and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent (%). Additionally, the facility failed to ensure an ordered medication for Resident (R)4 was administered timely. The medication administration error rate was 8 %. Findings include: Review of the facility policy titled, Medication Administration - General Guidelines, revised 02/25/2025 states: Procedures : B. Administration 10) An adequate amount of water (approx 4 ounces (oz.) or other acceptable liquid is offered with oral medications. More liquids may be necessary when administering certain medications (e.g., bisphosphonates). Check with the manufacturer's recommendations or pharmacist if unsure. 12) Medications are administered within 60 minutes before or after the medication administration record (MAR) scheduled times were possible. During a medication administration observation on 04/16/25 at 08:45 AM for R239 revealed Registered Nurse (RN)1 failed to measure out the appropriate amount of water for administering the Miralax. RN1 used a 4 oz. cup, however, it was not filled completely with water to equate to the required amount of liquid. Review of R239's Medication Administration Record (MAR) revealed an order that read, Clearlax Powder 510 gm [grams]. Mix 1 capful (17 gm) in 4-8 oz. liquid of choice and take by mouth daily. Review of R4's MAR revealed an order that read, Lantus Solostar U100 Insulin- 15 units subq once a day. The administration time was noted as 07:00 AM. Observation with RN1 of R4 revealed the Insulin was administered late at 09:10 AM. R4 had a 06:00AM blood sugar of 167. During an interview on 04/16/25 at approximately 11:32 AM, RN1 revealed that she forgot to measure the water for the Miralax. She stated she is use to the cups, so she did not think about it. RN1 revealed that she is not as use to the cart. She said, Time gets away from you, if you are not used to it. During an interview on 04/16/25 at 11:45 AM, the Director of Nursing (DON) revealed, I expect the nurses to give medications on time, measure out the necessary amount of liquid as the Physician ordered for the Miralax and practice good infection control when administering medication. We will review, have reminders and refreshers. We will conduct in-services on infection control when administering medication, proper timeframes for administering medications as well as measuring the necessary amount of liquid as the physician ordered for the Miralax. The DON was notified that the medication error rate is 8.0%.

Based on interviews, record review and review of the Abuse Prevention and Complaint Investigation Policy, the facility failed to provide an environment free form verbal abuse for Resident #1, 1 of 3 reviewed for abuse. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set Assessment indicated a Brief Interview of Mental Status score of 15, indicating s/he is cognitively intact. The facility submitted an allegation of verbal abuse for Resident #1 by Certified Nursing Assistant (CNA) #1 to the State Agency on 5/30/2021 via facsimilie. Review of the initial report indicated the incident occurred and the facility became aware on 5/29/2021 at 6:59 pm per a signature on the 2/24 initial report by the Director of Nursing (DON). During an interview with CNA #2 on 8/10/21 at 1:15 p.m., s/he stated that s/he was working 2nd shift the night of the allegation on 5/29/21. CNA #2 states that s/he went into Resident #1's room because the call light was on and witnessed CNA #1 arguing and cursing at Resident #1. CNA #2 states that Resident #1 told him/her to get CNA #1 out of the room. CNA #2 states that s/he tried to get CNA #1 to drop it and leave the room, but s/he would not leave. CNA #2 left the room to tell the Licensed Practical Nurse (LPN) what was going on, and s/he called CNA #1 out of the room. CNA #2 states that s/he told CNA #1 that s/he was wrong for what s/he did, and CNA #1 responded that s/he will not be disrespected. During an attempted interview with CNA #1 on 8/10/21 at 1:41pm via telephone, s/he asked this surveyor not to call him/her again and if s/he had any questions that his/her lawyer needed to be contacted. During an interview with the DON on 8/10/21 at 1:55 pm, s/he states that s/he received a called from the LPN indicating Resident #1 had an altercation with a CNA #1. S/he states that since Resident # 1 has these episodes frequently, s/he told the LPN to reassign CNA #1 to another room and let CNA #2 care for Resident #1 and get statements from the employees. The next morning, when s/he received the statements and saw that the use of profanity from CNA#1 was used during the altercation, s/he immediately suspended CNA #1. The DON also states during the interview with CNA#1, s/he admitted that s/he did use profanity during the altercation. A written statement from CNA #1 was never given to the facility after several attempts via phone messages. CNA#1 did send in his/her resignation via e-mail dated 5/31/21. During an interview with the LPN on 8/10/21 at 2:05 p.m., who was the nurse the night of the allegations, s/he states that s/he was administering medications when CNA #2 came to tell him/her that Resident #1 and CNA #1 was arguing with each other. LPN states that CNA #1 stated that Resident #1 accused him/her of being on the telephone while s/he was only supposed to be counting his/her respirations. CNA #1 stated to LPN that the resident was using profanity but CNA #1 did not admit to using profanity at that time. LPN states in this interview that s/he does not remember if CNA #1 admitted to using profanity or not, however, LPN wrote in his/her statement on 5/30/21 that CNA #1 admitted to using profanity. CNA #1 was reassigned and continued to work that evening.

Based on policy review and record review, the facility failed to report allegations of verbal abuse to the State Agency within 2 hours. Findings Include: The facility submitted an allegation of verbal abuse for Resident #1 by Certified Nursing Assistant #1 to the State Agency on 5/30/2021 via facsimilie. Review of the initial report indicated the incident occurred and the facility became aware on 5/29/2021 at 6:59 pm per a signature on the 2/24 initial report by the Director of Nursing (DON). Review of the facility's policy titled, Abuse Prevention and Complaint Investigation Policy indicates: 1) The facility reports alleged violations involving mistreatment, neglect, abuse, exploitation, including injuries of unknown source and misappropriation of resident property or any criminal act against a resident to officials in accordance with State law and State/Federal Regulation, State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities. These include: A. No later than 2 hours after forming the suspicion, if the events that cause the allegation involve abuse or result in serious bodily injury to the Administrator of the facility and other officials including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. An interview with DON and Administrator confirmed the findings, indicating they had not become aware that profanity was used between CNA #1 and Resident #1 until 5/30/2021, although staff on shift at the time of the incident were aware.

Based on observations and interviews, the facility failed to ensure that residents were treated with respect and dignity during the dining experience. Three to four residents were served or being assisted with eating by staff at one table while 18 plus residents were seated at tables in the dining room on the 100 Unit with clothing protectors in place for over 45 minutes and not served or eating.1 of 2 Unit dining rooms observed. The findings included: During a random lunch observation on 1/14/19 at approximately 11:50 AM of the dining room on the 100 Unit revealed residents seated in the dining room on the 100 Unit and residents being transported to the 100 Unit dining room. Staff was observed offering and placing clothing protectors on all residents in the dining room. At approximately 12:15 PM, one table with four (4) residents were served with two of the four residents requiring staff assistance with eating. There were two long tables with multiple residents and two smaller tables with three to four residents with clothing protectors on waiting to be served. Some residents were looking at the table were the residents were eating independently or being assisted by staff. At approximately 12:26 PM two food carts were delivered pass the residents seated in the dining room down the hallways while the resident remained in the dining room on the 100 Unit not served or eating. One resident was observed self-ambulating from the dining table in his/her wheelchair. The resident asked staff when the food was coming. Staff informed the resident not to leave the table because lunch was coming. During an interview on 1/14/19 at approximately 12:46 PM with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 revealed the residents at the table being served is restorative dining residents. Both confirmed the observations of 4 residents seated at a dining table and eating or being feed while other residents were waiting to be served. RN #2 and LPN#1 stated the facility has been delivering food to the dining room this way for a long time. At approximately 12:53 PM on 1/14/19, a food cart was delivered to the 100 Unit dining room to serve the other residents seated at the four other tables in the dining room. During the agency group interview on 1/15/19 at approximately 10:59 AM, one of five group members expressed concerns about having to wait close to an hour on the 100 Unit dining for lunch while one group of residents were served and eating. The group member that expressed concerns eat meals in the dining room on the 100 Unit. The group member stated he/she has expressed concerns, but he/she does not want to cause any trouble. The group member further stated food delivery for lunch has been going on like that for a long time. A lunch observation on 1/15/19 at approximately 12 PM revealed staff offering multiple residents clothing protectors on the 100 Unit dining room. There were residents seated at 2 long tables and three smaller tables. At approximately 12:11 PM one cart was delivered to the dining room. At 12:14 PM, staff was observed serving three residents at a small table that required assistance with eating while multiple residents were seated at two (2) long table and two (2) other smaller tables. At 12:25 PM, two food carts had passed the residents seated in the dining room not served or eating while wearing clothing protectors waiting to eat. The two food carts were delivered to the hallways on the 100 Unit. At approximately 12:47 PM on 1/15/19 an observation and interview with the facility consultant confirmed the observation of one table with residents being served and eating while multiple residents in the dining room had not been served or eating. The facility consultant stated he/she did not know why the dining experience was set up that way, but he/she would check and find out. At approximately 12:48 PM on 1/15/19, a staff member ambulated a resident who was in a wheelchair to the dining room to be served. The resident was place at a long table where other residents were waiting to be served. The resident was heard stating you got me out here while they are eating. Staff informed the resident that lunch was on the way, but the resident expressed disagreement verbally and with hand moments. The resident continued to express disagreement about the one table with residents being feed and he/she had to wait. LPN #1 and the facility's Pharmacy Consultant was present and heard the resident's disappointment in having to be in the dining room waiting while others are eating. LPN #1 attempted to console the resident and informed him/her that the food was on the way as he/she still expressed concerns. At approximately 12:55 PM another resident seated at the long table near the glass door in back of the dining room stated he/she was ready to eat. During an interview on 1/15/19 at approximately 1 PM with LPN #2 revealed there was no policy as to why one table with residents are served while the others are waiting. LPN #2 further stated the facility has been serving the residents this way for a long time. During the interview, food carts were observed being delivered to the dining room to serve the other residents waiting to be served.

Based on record reviews and interviews, the facility failed to ensure that residents responsible parties were notified of changes that affected the resident's care while in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134's responsible party was not notified of a skin tear that required a bandage/dressing. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LFA. Further review of Resident #134's record revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred, and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and did not document the incident. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did not know who applied the first bandage/dressing to Resident #134 LFA but he/she placed the second dressing to the resident's LFA at approximately 4:26 AM and he/she went off duty. It was reported to him/her later that the resident pulled off the second bandage/dressing that required a hospital visit and 17 sutures. RN #2 acknowledged there was no documentation of when the second injury occurred that required the hospital visit and he/she thought it was best to call the responsible party at a decent hour so the responsible party was notified by 7 AM.

Based on record reviews and interviews, the facility failed to ensure that a resident's medical record accurately document the care and services that was received while placed in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134 with treatment being given without documentation as to what occurred that required treatment. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LFA prior to 5/07/18. During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and wrote no documentation. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did not know who applied the first bandage/dressing to Resident #134 LFA but he/she placed the second dressing to the resident's LFA at approximately 4:26 AM and he/she went off duty. It was reported to him/her later that the resident pulled off the second bandage/dressing that required a hospital visit and 17 sutures. RN #2 acknowledged there was no documentation of when the second injury occurred that required the hospital visit and he/she thought it was best to call the responsible party at a decent hour so the responsible party was notified by 7 AM. Further record review revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . The interview on RN #2 on 1/16/19 revealed he/she applied the second dressing at 4:26 AM and there was no documentation as to when the second bandage was removed by the resident.

Based on record review and interview, the facility failed to ensure accuracy of assessments. Resident #23's Minimum Data Set (MDS) was coded inaccurately for insulin administration, diuretics, and Urinary Tract Infection (1 of 1 sampled resident reviewed for hospitalization ). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. During record review of the MDS on 12/5/17 at 2 pm revealed the MDS with assessment review date (ARD) of 9/25/17 had Insulin coded as 0 under medications, and did not have the [DIAGNOSES REDACTED]. Further review of the MDS ARD of 10/24/17 revealed Urinary Tract Infection was not coded under active diagnoses, and had diuretics inaccurately coded as 7 under medications. Review of the Medication Administration Record [REDACTED]. Review of the September MAR indicated [REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for a UTI. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse #1 verified inaccurate coding on the 9/25/17 MDS regarding Insulin, and did not code the presence of a UTI. S/he also verified the inaccurate coding on the 10/24/17 MDS regarding diuretics under medications.

Based on record review and interview, the facility failed to revise the comprehensive care plan. Resident #23 was hospitalized and treated for [REDACTED].# 13 did not include a problem and interventions regarding Blepharitis of the left eye (1 of 1 sampled resident for infections, and 1 of 2 sampled residents reviewed for UTI). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for treatment of [REDACTED]. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse (RN) #1 verified the comprehensive care plan was not updated to reflect the UTI or antibiotic therapy on 9/7/17 or 10/26/17 after readmission to the facility from the hospital. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. During an observation on 12/4/17 at 1:45 pm, Resident #13 was noted to have a large amount of dried beige drainage to the left eye and eyelash with swelling and redness of the lower lid. Review of the care plan on 12/5/17 at 4 pm revealed no evidence in the care plan to address the chronic Blepharitis condition of left eye drainage, redness and swelling or the ordered interventions including antibiotic eye ointment and cleansing of the eye with baby soap twice a day. During an interview on 12/6/17 at 10:25 am, MDS RN #1 verified there was no comprehensive care plan to address the Blepharitis [DIAGNOSES REDACTED].

Based on record review and interviews, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/Centers for Medicare/Medicaid (CMS) form to 3 of 3 sampled residents reviewed for Medicare Part A Services. Residents #38, #44 and #80 received the Notice of Medicare Non-Coverage (NOMNC), but did not receive the required SNFABN/CMS form. The findings included: Review of the medicare non coverage notices on 12/04/17 at approximately 3 PM revealed Residents #38, #44 and #80 had services ended with additional days left for services. There was no CMS forms provided by the facility. During an interview on 12/04/17 at approximately 3:10 PM with the Administrator, the Administrator confirmed the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (CMS ) form for Residents #38, #44 and #80. The Administrator stated the CMS would only be given if it was requested by the resident/responsible party. An interview with the facility consultant on 12/05/17 at approximately 3:48 PM revealed the facility does not provide the SNFABN/CMS form until the resident/responsible party request they want to appeal the Medicare non coverage decision.

Based on observation and interviews, facility failed to maintain the dignity of residents during meal service on 2 of 2 units. Resident room trays were not distributed in a sequential manner on Unit 1. The privacy curtain was not pulled for a resident who was fed by Gastrostomy tube, when other residents were served in the room. Residents were not offered glasses for canned drinks and supplements served in cartons on Units 1 and 2. Resident #85 was served with plastic utensils without documented current need. The findings included: During observation of the noon meal on 03-13-17 at 12:38 PM, Certified Nursing Assistant (CNA) #1 was the only staff member distributing room trays on Unit 1. S/he served the resident nearest the door in room [ROOM NUMBER], but did not provide a tray for the second occupant in the room or pull the privacy curtain before moving on to the next room (room [ROOM NUMBER]). It was approximately 20 minutes before the second resident in room [ROOM NUMBER] was served. room [ROOM NUMBER] was occupied by 3 residents. CNA #1 served 2 of the 3 residents sequentially. The third resident was nourished by use of a gastrostomy (G-) tube. The CNA did not pull the privacy curtain between residents. Therefore, the resident with the [DEVICE] was fully able to see other residents eating their meals. During meal observation on 03-14-17 at 12:35PM, all residents in the dining rooms on Units 1 and 2 who were served Ready Shakes and/or canned sodas were not offered or provided with glasses for these beverages. During an interview on 03-14-17 at 12:50PM, Registered Nurse (RN) #2 indicated that some residents preferred to have their beverages directly from the container. S/he stated that the kitchen usually sent extra cups on the set up cart. No extra cups/glasses were noted during observed meal times. On 03-14-17, Resident #85 was observed eating with plastic utensils in the Wing 2 dining room at 8:40 AM and at 12:40 PM. Review of the resident's diet card revealed that s/he was to have plastic ware sent with each meal. Review of the incomplete 3/7/17 dietary assessment noted plastic utensils only. Quarterly nutrition notes dated 7-12-16, 10-4-16, and 12-20-16 did not mention the use of plastic utensils. After observing the second meal, an interview with the Assistant Director of Nurses at 12:45 PM revealed that Resident #85 had become aggressive a couple of years ago and attempted to stab a nurse with a fork and it was care planned that s/he would use plastic ware from then on. No disruptive behaviors were observed during the survey. On 03-16-17 at 1:07PM, record review revealed no Physician's Order for plastic utensils. Review of Nurses Notes revealed no recent documented behaviors. Review of the 2-6-17 Minimum Data Set assessment revealed no documented behaviors. The care plan did not include a reference to associated/ongoing behavioral concerns for which the use of plastic ware was indicated. Use of plastic ware was not included in planned interventions.

Based on record review and interview, the facility failed to provide evidence of non-pharmacological intervention prior to administration of an antipsychotic for 1 of 5 sampled residents reviewed for unnecessary medications. Staff administered [MEDICATION NAME] multiple times to Resident #36 without documented evidence of behaviors and/or evidence of non-pharmacological interventions prior to administration. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 3-15-17 at 12:08PM revealed physician's orders [REDACTED]. Review of behavior monitoring for January through March, 2017 on 3/16/17 revealed no documented behaviors. Review of the Medication Administration Records revealed that [MEDICATION NAME] was administered twice in 1-17 (on 1-1-17 and 1-20-17), six times in 2-17 (on 2-8-17, 2-9-17, 2-19-17, 2-23-17 x 2, and 2-24-17), and five times in 3-17 (on 3-3-17, 3-4-17, 3-5-17, 3-9-17, and 3-10-17) for yelling out, hollering out, agitation, and anxiety. Review of Nurse's Notes revealed there was no evidence of evaluation of the underlying cause of the behavior and no attempts at non-pharmacological interventions prior to administering the medication. There were no behaviors documented when agitation or anxiety was noted as the reason for administration of the medication. Review of the care plan revealed When res(ident) noted to be yelling out, paranoid, agitated after misinterpretation of others actions or conversation, staff to approach calmly, attempt to get res to talk, give time to express self, take res to a more comfortable area, offer snacks and liquids, and if this does not work offer to take back to room. Reassure res r/t (related to) whatever is causing her (him) agitation. Make nurse aware of behaviors and meds as ordered. Call her (his) daughter or other family member when requested. During an interview on 3-16-17 at 9:44AM, Licensed Practical Nurse (LPN) #1 stated that prior to administering a PRN medication, especially antipsychotics, staff should typically try to always check for pain first and check the patient care record for behaviors. Per LPN #1, staff should do less aggressive measures before administering drug and be sure to check the environment for irritants, check their activities of daily living, and check for pain. A preliminary drug policy was provided by the Director of Nurses on 3-16-17 which did not define parameters for interventions prior to administration of PRN psychoactive medication.

Based on interview and medical record review, the facility failed to ensure that irregularities identified by licensed pharmacist during drug regimen review were addressed in a timely manner by the attending physician for one of five residents reviewed for unnecessary medications. The findings included: Resident #23 was admitted to the facility in May 2016 with [DIAGNOSES REDACTED]. Review of the medical record on 3/15/17 at 4:30 PM revealed that the Consulting Pharmacist initiated three Note to Attending Physician/ Prescriber communication forms on 11/22/2016 regarding recommendations related to irregularities identified during monthly medication regimen review for resident #23. Review of one of the three recommendations submitted by the Licensed Pharmacist on 11/22/2016 revealed request submitted for consideration of Gradual Dose Reduction (GDR) for hypnotic medication from scheduled to as needed (PRN) dosing, this request was not addressed by the Family Nurse Practitioner (FNP) until 2/2/2017, when it was approved. Review of a second communication form submitted by the Licensed Pharmacist on 11/22/2016 addressed irregularity regarding fasting blood glucose levels and request for consideration to change dose of Lantus insulin from 10 units every 12 hours to 20 units every morning to address this issue, which was not addressed by the FNP until 2/2/17, where the request was denied with the following reason provided resident has had multiple hyperglycemic episodes- Lantus increased-HgbA1c 7.8 on 11/21/16. Review of the third communication form submitted by the Licensed Pharmacist on 11/22/2016 revealed that resident #23 was identified with weight loss, difficulty swallowing, and abnormal Thyroid Stimulating Hormone (TSH) laboratory test results with request for consideration to change medication dose for Levothyroxine followed by labs in 8 weeks, where the request was not addressed until 2/2/17 when it was approved and medication was changed and laboratory test was ordered to be done in 8 weeks. During an interview with the Director of Nursing (DON) on 3/16/17 at 10:58 am, s/he stated that after review of the medical record and discussion with the nursing staff, s/he was not able to determine a reason for the delay between when the Licensed Pharmacist submitted recommendations on 11/22/2016 and when the FNP acknowledged and initiated orders related to those recommendations 73 days later on 2/2/2017.

Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medication were removed from medication storage in 3 of 8 medication carts and 2 of 2 units reviewed. Expired medications were on the medication carts after the expiration date. The findings included: On 3/13/17 at 12:24 PM, an observation with RN#1 of the Hall 1/Unit 1 medication cart revealed a Novolog FlexPen (Lot #FP ) with approximately 225 units of fluid insulin remaining. The Novolog FlexPen had an open date of 2/10 and expiration date 3/10. Following the observation, RN #1 verified the Novolog FlexPen was expired and stated, The insulin pen should have been removed from the cart. On 3/14/17 at 1:20 PM, an observation with RN #2 of the Hall 2/Unit 1 treatment cart revealed 1-2-3-Paste with a pharmacy stamped expiration date of 1/24/17. Following the observation, RN #2 verified the 1-2-3 Paste was expired and indicated the paste should have been removed from the cart. On 3/14/17 at 1:45 PM, an observation with RN #1 of the Hall 1/Unit 2 treatment cart revealed Premarin vaginal cream .625 mg/g with a manufactures stamped expiration date of 9/16. Following the observation, RN #1 verified the Premarin vaginal cream was expired and indicated the cream should have been removed from the cart. On 3/14/17 at 10:45 AM, a review of the facility policy entitled, Medication Storage in the Facility, revealed under Expiration Dating (Beyond-use dating), procedure (G.) All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. On 3/14 at 2:55 PM, review of the manufacture recommendations for Novolog Flex Pen states under section How should I store Novolog FlexPen, Bullet (2) states, Store the FlexPen you are currently using out of the refrigerator below 86 degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The Novolog FlexPen should be thrown away after 28 days, even if it still has insulin left in it.

Based on observation and review, the facility's laundry contractor failed to follow agreed upon policy and procedure for transfer of soiled linen from the facility on 1 of 2 units reviewed for Infection Control. The findings included; Observation of the facility's contracted Laundry Service delivering and retrieving laundry on 03/16/17 at 10:14 am revealed that the handler used an unlined and unmarked container which was used to bring clean linen to the facility to retrieve soiled linen. The handler also placed unbagged soiled linen in the container. In an interview on 03/16/17 at 10:14 am while loading the container into the vehicle for transport, the handler stated that the carts are cleaned once or twice a week. Subsequent review of the contractor's policy revealed that Soiled linen containers should be lined with an impervious liner. Do not allow soiled linens to simply be dropped into a container. At designated times, laundry workers using a large bin For Soiled Linen Use Only will go to each Soiled Linen Room to pick up the soiled linens. During observations from 3-13-16 through 3-16-17, resident care equipment was stored in an improper/unsanitary manner: (1) An uncovered, unlabeled bedpan was initially noted on the floor behind the toilet in room [ROOM NUMBER] (semi-private) bathroom on 03/13/2017 at 3:04 PM. (2) On 03/14/2017 at 9:35 AM, an uncovered, unlabeled bedpan was found on the grab bar in the bathroom for room [ROOM NUMBER] (semi-private). An environmental tour was conducted with the Housekeeping/Environmental Manager, Plant Maintenance Manager, Area Manager and Assistant Maintenance Manager on 3/16/17 at 2:35 PM. The bedpans had not been moved or properly stored for the duration of the survey. All staff present verified the storage of the items. The Housekeeping Manager stated that this concern was the responsibility of the nursing department. During an interview on 3/16/27 at 2:54 PM, Registered Nurse (RN) #3 verified that the items were present in both residents' bathrooms. When asked about the protocol for storage, RN #3 stated that bedpans should be bagged and labeled.

Based on record review and interview, the facility failed to notify the physician/nurse practitioner and/or other qualified professional of significant weight loss for Resident #12, 1 of 3 residents reviewed for nutrition. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. During the Stage I Census Record review at 5:14 PM on 6/13/16, Resident #12 was noted to have a significant weight loss. On 6/16/16 at approximately 3:15 PM, record review revealed the resident's weight on 6/15/16 was 96.0, on 6/1/16 96.7 pounds, on 5/04/16 106.1 pounds, on 3/08/16 109.0 pounds and on 11/4/15 110.2 pounds. Review of the Nurse's Notes revealed no documentation that the physician, family or Registered/ Licensed Dietitian was notified of the resident's significant weight loss. There was no documentation of any recent changes in dietary intake or [MEDICAL CONDITION], diarrhea or vomiting. Record review revealed the RD completed an assessment dated [DATE] and noted the resident consumed 50-75% of meals and recommended ReadyCare. The RD had not re-assessed the resident related to the significant weight loss. During an interview at 2:59 PM on 06/16/2016, the Certified Dietary Manager (CDM) reviewed the weight sheets and stated that Resident #12 was not on the list for weight loss and that a weight for June had not been recorded. When informed that the resident's weight on June 1st was 96.7 pounds, the CDM stated and that's a major loss. The CDM stated for a resident under 100 pounds, a re-weight is done if there is a difference of 3 pounds and the unit manager notified. The CDM stated that s/he would then be notified and in turn notify the RD. In addition, the CDM stated the RD had been at the facility on 6/15/16 and had not been informed. During an interview at 3:27 PM on 06/16/2016, the Director of Nursing (DON) provided documentation of the June weights but stated that the Dietary manager informed her that she had not received the weights. The Dietary Manager usually receives the monthly weight sheets, inputs the information into the computer which calculates the percentage of weight loss. The computer generates a report of significant weight losses. The DON confirmed that the RD did not have access to that report when she was at the facility yesterday. The RD usually comes weekly. The DON also confirmed the MD was not notified of the weight loss until today.

Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment upon identification of decline in continence, development of a pressure ulcer, and decline in bed mobility for Resident #20, 1 of 2 residents reviewed with a Significant Change in Status. The findings included: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. At 3:31 PM on 06/15/2016, comparison of the 2/3/16 Admission MDS (Minimum Data Set) to the 4/18/16 Quarterly MDS revealed the resident had an improvement in her/his BIMS (Brief Interview for Mental Status) score, mood and behaviors. The resident was also noted to have a decline from limited assistance to extensive assistance with bed mobility, a decline in continence from occasional to frequent incontinence, and the development of a Stage III pressure ulcer. Review of the Care Plan Progress Notes revealed a note dated 4/21/16 that stated the resident was noted to have decline in the following areas; incontinence, pressure ulcer stage 3 to sacrum, pain symptoms, and one area of ADLs (Activities of Daily Living) (bed mobility). Will begin Significant change review. There was no documentation or results of a review for a significant change in the record. On 6/16/16 review of the Bladder Incontinence Evaluation done 4/11/16 revealed the resident had incontinent episodes daily and was updated on 4/20/16 that indicated the resident remained frequently incontinent of bladder. During an interview at 5:31 PM on 06/15/2016, the RN MDS Coordinator stated the IDT (Interdisciplinary Team) had determined the resident did not have a significant change in status. During the interview, the Social Services Director reviewed the chart and confirmed there was no documentation of an IDT review or determination that the resident had returned to baseline. The MDS Coordinator stated the pressure ulcer was healed on 4/26/16. At 12:09 PM on 06/16/2016 the MDS Coordinator confirmed the documentation on the bladder assessment that the resident remained frequently incontinent on 4/20/16 and that a Significant Change in Status Assessment should have been completed.

Based on observation, interview and review of the facility's policies, 1 of 5 nurses observed during the Medication Pass failed to meet professional standards of practice during medication administration for Resident #56. LPN #1 dropped a pill during med pass, retrieved it from the floor and administered it to the resident. The findings included: During medication pass observation on 06/16/2016 at 9:40 AM , LPN (Licensed Practical Nurse) #1 dropped a pill from the medicine cup onto the floor. The LPN picked up the pill, placed it back in the medicine cup and administered it. During an interview on 06/16/2016 at 9:43 AM, the LPN confirmed s/he dropped the pill on the floor, picked it up and proceeded to administer the medication. The LPN then asked what would be the right thing to do in that case. Review of the facility policy entitled Medication Storage in the Facility revealed Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication destruction . Review of the policy entitled Oral Medication Administration Procedure 6. a. page 20 revealed Avoid touching medications if at are possible.

Based on observation, interviews, and a review of the policy provided by the facility entitled "Administration of Insulin", a facility nurse failed to properly administer Insulin to Resident #77, 1 of 1 resident observed during medpass for the administration of Insulin. The nurse failed to keep the [MEDICATION NAME] needle embedded in the skin for the appropriate time frame to ensure the full amount of Insulin had been administered. The findings included: The facility admitted Resident #77 with [DIAGNOSES REDACTED]. Observation on 5/13/15 at approximately 4:10 PM revealed Licensed Practical Nurse (LPN) #1 administering 4 units of [MEDICATION NAME] Insulin via flex pen to Resident #77 for a fingerstick blood sugar of 250. The nurse injected the Insulin into the resident's left upper arm and held the flex pen in place for less than 2 seconds before removing it. After removing the flex pen, the nurse immediately pulled the resident's sleeve down and the surveyor was unable to determine if there was any leakage of Insulin. During an interview after the medpass observations of the nurse, the surveyor asked LPN #1 if s/he was aware that there was a specified amount of time that the flex pen needle was to stay under the skin while administering the Insulin. The surveyor informed the nurse that s/he had been observed to leave the needle in for less than 2 seconds. LPN #1 thought s/he had kept the needle under the skin for 2-5 seconds; and was unsure of the required time frame. On 5/13/15 at 4:17 PM, the Unit Manager was asked about how long the flex pen needle would need to stay under the skin. The Unit Manager was unsure, and stated s/he would check the policy to make sure of the timeframe. Registered Nurse (RN) #1 spoke with the consultant pharmacist by phone and reported that the consultant pharmacist had stated that to ensure the full dose of Insulin had been given with the [MEDICATION NAME], that s/he recommended the nurse hold the pen needle in place for 10 seconds to ensure all the Insulin had been administered. A review of the policy provided by the facility entitled "Administration of Insulin" revealed information to "...Leave needle embedded within skin for 5 seconds with 10 seconds for insulin [MEDICATION NAME] for pen insulin administration.." A review of Novo-[MEDICATION NAME] manufacturer information dated April 2015 regarding the use of the [MEDICATION NAME] at the website [MEDICATION NAME].com, revealed that the needle should be left under the skin for at least 6 seconds while administering insulin with the [MEDICATION NAME].

On one day of the survey, based on observations, interviews, and review of the facility policy titled "Employee Guidelines-Infection Control Practices" and "Food Handling Guidelines," the facility failed to serve and distribute food under sanitary conditions. Observations during the lunch meal distribution on the 100 Unit and 200 Unit Halls and 100 Unit Day area revealed facility staff touched food items with their bare hands. The findings included: Observation on 2/4/14 at approximately 12:45 PM revealed staff serving trays and setting-up residents' lunch in the 100 Unit day area. The menu included cornbread delivered in a paper wrapping. Observation revealed RN #1 and CNA's #1, 2, and 3 reached into the package, retrieved the cornbread with their bare hands, and placed the cornbread onto the plate when serving residents. In addition, RN #1 was observed to take the cornbread into his/her bare hands, break the bread into two pieces, and place the pieces into containers beside the plate while serving one of these residents. During an interview with CNA #3 on 02-07-14 at approximately 11:30 AM, he/she confirmed the surveyor's findings. During an interview with CNA #1 on 02-07-14 at approximately 11:45 AM, he/she stated, "okay." During an interview with RN #1 on 02-07-14 at approximately 2:45 PM, he/she stated, "I don't remember doing this, but it should not be done." CNA #2 was unavailable for interview. Review of the facility policy titled "Employee Guidelines-Infection Control Practices" revealed in section "All Food and Nutrition Services Employees" the following: "Handle plates by the bottom or the edge; keep hands off the eating surface. Keep thumb and fingers away from food on the plate." Review of the facility policy titled "Food Handling Guidelines" revealed in section "Prevention of Food Infection" the following: "Minimize hand contact with food by the use of utensils or disposable gloves."