Every finding on record at Laporte City Specialty Care

Based on observation, staff interview, and policy review, the facility failed to implement enhanced barrier precautions (EBP) while completing wound care for 1 of 1 resident reviewed for EBP (Resident #4). The facility reported a census of 45 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 required maximal assistance to roll left to right and was dependent on staff for transfers. The MDS included diagnoses of malnutrition, pressure ulcer and bacteremia (bacteria in the bloodstream).Review of the Care Plan for Resident #4 initiated 1/20/26 revealed the resident had a pressure related injury to the skin and directed staff to provide EBP. Review of the Physician Orders for Resident #4 revealed an order initiated 2/21/26 to apply Mepilex to the wound on the resident's sacrum. Cleanse with soap and water and pat dry with each change. During an observation 2/25/26 at 2:10 PM observed Staff A, Registered Nurse (RN), complete wound care to Resident #4's sacrum. Staff A failed to implement EBP prior to and during the completion of the wound care. The Assistant Director of Nursing (ADON) was present and observing during the initial stages of the wound treatment. On 2/25/26 at 2:22 PM, the ADON acknowledged Staff A did not implement EBP as expected during Resident #4's wound treatment. During an interview 2/26/26 at 8:15 AM, Staff A acknowledged she did not apply (don) a gown as part of EBP as expected while completing Resident #4's wound care on 2/25/26. Staff A added they had the EBP supplies readily available in the resident's bathroom. Review of facility policy titled, Enhanced Barrier Precautions, implemented 3/28/24 revealed EBP will be initiated for residents with chronic wounds such as pressure ulcers.

Based on observations, interviews, and record review, the facility failed to ensure residents receive medications as ordered by the providers for 3 of 4 residents reviewed (Resident #1, #3 and #4). The facility failed to administer medications to the right resident when Resident #1 received Resident #2's morning (a.m.) medications. The facility failed to obtain orders to hold Lasix (diuretic medication) for Resident #1 after she received Resident #2's medications, which included blood pressure (BP) lowering medications. Resident #1 was transferred to the hospital for low blood pressure and was admitted to the Intensive Care Unit. The facility failed to give Resident #3 the correct dosage of his blood pressure medication, administering both a discontinued medication along with a newly ordered medication. The facility failed to administer insulin to the right resident when Resident #4 received another resident's insulin. Resident #4 did not have an order for insulin.The facility corrected the noncompliance prior to the start of the survey on 11/6/25 by completing the following:On 11/3, the Director of Nursing (DON) notified the Director of Agency Staffing of med error by agency nurse. Administrator informed that agency nurse received a final disciplinary warning regarding med error on this date and also received education regarding 7 Rights of Medication Administration and was audited the same day for oral administration. The facility conducted additional audits administration.On 11/3, Administrator confirmed with hospice that they provided education to both hospice nurses who assessed resident on 11/2. Education given regarding necessity to discuss medications with physician when reporting a med error specifically to determine if meds are to be given or held and methods to identify residents.On 11/5, the DON and Assistant DON provided nurses with education regarding 7 Rights of Medication Administration. Education also provided to nurses regarding necessity to discuss medications with physician when reporting a med error specifically to determine if meds are to be given or held and methods to identify residents.On 11/5, DON contacted physician provider regarding their process for inquiring about medications when a med error occurs. The physician provided added a workflow process for providers to specifically ask about med error and other medications.On 11/6, the DON applied Chart Label-Name Alert stickers for medication cards to further delineate that there is more than one resident with the same name.Effective 11/6, the DON and Assistant DON began conducting audits of charge nurses for medication administration twice per week on varying shifts for four weeks. They would provide re-education as necessaryThe facility reported a census of 45.Findings include:1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included chronic kidney disease, anxiety, depression and senile degeneration of the brain (Senile degeneration of the brain refers to the progressive decline in cognitive function and brain health, often associated with aging and neurodegenerative disorders like Alzheimer's disease.). A Brief Interview for Mental Status (BIMS) documented a score of 3 out of 15, which indicated Resident #1 had severe cognitive impairment. the resident received antianxiety, antidepressant and diuretic medications. The MDS listed Resident #1 as dependent on staff for personal hygiene, putting on and taking off footwear, lower body dressing, toileting and oral hygiene. An Incident, Accident, Unusual Occurrence Note dated 11/2/25 at 7:00 a.m., documented that the author of the note (Staff A, Licensed Practical Nurse, LPN) asked Resident #1 if her name was Resident #2's name. Resident #1 nodded her head. Staff A then administered the medications to Resident #1 instead of Resident #2. Later a Certified Nurse Aide (CNA) passed by. Staff A asked the CNA who was sitting next to Resident #1. The CNA gave the name of the other resident and then said Resident #1's full name. Staff A learned they gave the medications to the wrong resident. When Staff A found out the medications were administered to the wrong person, Staff A obtained vital signs. Staff A then notified Hospice, Resident #1's daughter, and the facility's provider. Staff A received a doctor's order to monitor Resident #1's blood pressure and pulse 4 times a day until HS (hour of sleep).A Hospice Note (Hospice Staff Use Only) dated 11/2/25 at 10:00 a.m., the author of the note (Staff C, Hospice Registered Nurse (RN)), documented that she made a PRN (as needed) visit due to a report she received regarding Resident #1 receiving the wrong medications that morning. Staff C assessed vital signs, spoke with the facility nurse and Staff A. Staff C told the staff of Resident #1's vital signs and directed to continue to monitor them per the provider's recommendations. Staff C called and left a voicemail with the family notifying them of the visit. An Incident, Accident, Unusual Occurrence Note dated 11/2/25 at 10:34 a.m., the author of the note (Staff B, LPN), documented that on the morning Resident #1 was given the wrong medication. The Hospice nurse came out to the facility and did an assessment. The Hospice nurse said Resident #1's BP was 99/60, her heart rate was 53, and the resident was doing well. The Hospice nurse said she would call the family about the situation.An Incident, Accident, Unusual Occurrence Note dated 12:50 p.m., Staff B documented she called Hospice back to notify them Resident #1's BP was low at 68/38. Staff B told the Hospice staff that Resident #1 received her morning medication late around 10:30 a.m. Staff B told Hospice that she received Lasix and the lorazepam medications. Staff B asked Hospice if Staff B should give these medications that were scheduled for lunch late, and they (Hospice) said to hold them due to the low BP and to pass on to the next shift to take blood pressure before giving any medication and use nursing judgement and hold if BP was below normal. Hospice also said to encourage Resident #1 to drink more fluids and that they would send the Hospice nurse on call back out to the facility.An Order Note dated 11/2/25 at 4:19 p.m., Staff F, LPN, documented she checked Resident #1's BP at 3:30 p.m., and it was 61/36 with a pulse of 46, respirations were 16. Staff F called the on-call provider and Staff D explained about the medication error the morning. The provider ordered Resident #1 to be sent to the ER (Emergency Room) for evaluation. Phone call placed to daughter who was in agreement. The nurse called the ambulance and sent Resident #1 to the ER for evaluation at 4:00 p.m. The nurse notified hospice.A Nurses Note dated 11/2/25 at 8:52 p.m., Staff F documented she called the ER, who informed her, they admitted Resident #1 to the ICU (Intensive Care Unit), for hypotension (low blood pressure) due to medications. Staff F notified the Assistant Director of Nursing (ADON).A Medication Administration Record for the month of November 2025, directed staff to administer the following medication to Resident #2 in the AM:Amlodipine 5 mg 1 tablet by mouth (po) for hypertension (high blood pressure)Aspirin 81 mg 1 tablet po for hypertensionFerrous Sulfate 1 tablet po 325 mg for anemiaIrbesartan 300 mg 1 tablet po for hypertensionMetoprolol 25 mg ER (extended release over 24 hours) 25 mg 1 tablet po for hypertensionZoloft 50 mg 1 tablet po for depression/anxietyFlecainide Acetate 50 mg 1 tablet po twice a day (BID) for coronary artery disease (CAD)Namenda 10 mg 1 tablet po BID for dementiaOn the morning of 11/2/25, Staff A, Licensed Practical Nurse (LPN), administered all of the above medications to Resident #1 instead. Staff A signed she gave them A Medication Administration Record for the month of November 2025, directed to administer the following medications to Resident #1 in the AM:Escitalopram 20 mg 1 tablet po for major depressive disorderLasix 80 mg po 1 tablet po to control edema Senna 8.6 mg 1 tablet for constipationAcetaminophen (Tylenol) 650 mg 1 tablet po for painLorazepam 2.5 milliliters (ml) po for anxiety.On the Record, it directed to administer Lasix 40 mg po 1 tablet to control edema mid-morning. Staff B did not give the medication. She put her initials in the space for 11/2/25 for the mid-morning dose with a 0. A Provider Order dated 11/2/25 at 8:00 a.m., directed staff to monitor blood pressure and pulse due to medication error 4 times a day until HS (hour of sleep).A Provider Order dated 11/2/25 at 4:30 p.m., directed staff to send Resident #1 to the ER (Emergency Room) for evaluation.Resident #1's Blood Pressure Summary Sheet documented the following on 11/2/25:8:00 a.m.: 99/56 mm/Hg (systolic (top number represents when your heart is beating) and diastolic (lower number represents when your heart is resting between beats)).10:33 a.m.: 99/60 mm/Hg12:22 p.m.: 68/39 mm/Hg1:29 p.m.: 70/40 mm/Hg3:15 p.m.: 61/36 mm/Hg the entry was struck through on 11/9/25 at 1:42 p.m. with incorrect documentation as the reason.Resident #1's Pulse Summary sheet documented the following on 11/2/25 at:8:00 a.m.: 47 bpm (beats per minute)10:33 a.m.: 53 bpm12:22 p.m.: 60 bpm1:29 p.m. 45 bpm3:15 p.m.: 46 bpmOn 11/19/25 at 11:49 a.m., Staff A stated that on the morning of the medication error, Resident #1 was not in her room and was out by the nurses' station. Staff A asked the resident her name and Resident #1 stated her first name. Staff A asked Resident #1 if her last name was Resident #2's last name and Resident #1 stated it was her last name. Resident #1 and Resident #2 have the same first name but different last names. No staff were close by to confirm Resident #1's identity. Staff A administered Resident #2's medications to Resident #1. A staff member walked by and Staff A asked the staff member if Resident #1 was Resident #2. The staff member said no. Staff A stated she then knew she had administered the wrong medications to Resident #1. Staff A called the facility's provider and the Hospice nurse. The facility's provider told Staff A to monitor Resident #1's vital signs (VS) every 4 hours. Staff B monitored Resident #1's VS. The Hospice nurse came in after breakfast around 9:00 a.m. Staff A asked the Hospice nurse if it was okay to administer Resident #1's morning medications (Resident #1 did not receive her own morning medications as she had received Resident #2's medication). The Staff C, Hospice RN/nurse said it was okay. When Staff A asked if she should have asked the doctor instead, Staff A said yes, that is correct. Staff A was the one that took Resident #1's VS. Staff A did the 8:00 a.m. set of VS. Staff A stated that when a resident is on Hospice, usually the Hospice nurse is the one who usually communicates with the doctor. The only doctor order Staff A obtained was to monitor Resident #1's VS. Then at noon the other nurse, Staff B, LPN, working called the Hospice number back while Staff A was on break. The Lasix (diuretic) was held because it could have caused the BP to lower more. After Staff A came back from break, Staff B got an order to hold the Lasix because Resident #1 had low BP when Staff B checked it around noon. It was Staff A's first time picking up at that facility. It was in the morning when Staff A got there, and the night shift nurse showed Staff A the medication cart and the medication room. Staff A stated it was getting close to 2:00 p.m., when Staff A finished up passing medications and then Staff A gave report to the 2nd shift nurse. That day Staff B did the assessments and treatments, while Staff A was supposed to do medication only. Staff A stated that normally Staff A only passed medications to 20 or so residents and there were like 40 residents to pass the medications. Staff A had to pass medications to all of the residents at the facility on that day. Staff A said she was not comfortable with that because there were a lot of residents. It was her first time at the facility, and she didn't know any of the residents. Staff A stated she was not going to do agency nursing anymore. On 11/19/25 at 12:18 p.m., Staff B stated she was doing the floor treatments, a few insulins, assessments, the facility's hot charting, and some skilled assessments. Staff B stated the second shift did the other assessments. How it worked is the charge nurse did all the medications and then the floor nurse does the floor treatments and assessments. The morning med pass has a lot more meds to administer than the lunch time med pass did. Staff B stated the facility had other nurses who have come in and passed medications and were able to do it, it is a lot. Staff B said she knows all of the residents and Staff B is not an agency nurse, so she knows it's easier for her to pass the meds. Staff B stated she has helped before when someone came in to fill in and said they needed help and Staff B helped them. It's hard to say if it was too much. There was an RN there for a little while that morning that stayed until 8:00 a.m. Staff B stated they trained a nurse on the floor that morning. After the med error, Staff A seemed flustered. Staff B stated she asked if she could help Staff A. Staff B stated she doesn't know if she was causing Staff A more frustration or if she was just upset about having the medication error. Staff B was concerned about giving Resident #1 more Lasix as the resident's blood pressure was getting low, so Staff B called the hospice nurse about it. On 11/19/25 at 2:27 p.m., Staff C, Hospice nurse, stated the facility called a Hospice answering service. Staff C returned the call. Staff C stated that Resident #1 received the wrong medications administered by who Staff C thought was, a traveling nurse. The nurse, Staff A gave Resident #1 multiple BP medications. Staff C went into the facility. Staff C stated Resident #1 laid in bed alert and denied pain with no noted shortness of breath. Resident #1's BP was like 96 over something. Staff C let the nurse know she was there at the facility. Staff C told the nurse that Resident #1's VS were okay, and they weren't super low. Staff C stated she left a voice mail for Resident #1's daughter because nobody answered. Staff C stated Staff A asked if she should give Resident #1 her normal medications. Staff C stated she told Staff A that as long as there weren't any further BP or any diuretic medications, she felt it would be alright. Staff C stated she did not talk to anybody else after she left the building that morning. The only communication Staff C had with anybody at the facility was while she was there.On 11/20/25 at 12:16 p.m., Staff A stated that when she found out that she had given the wrong meds, she called the on-call provider, the hospice service and left a message for Resident #1's family. Staff A said Staff C came into the facility and said Resident #1 was fine. Staff A stated she had asked the Hospice nurse if Resident #1 should receive the medications that she should have gotten that morning. Staff A stated that she and Staff C then looked at the MAR and there was Lasix, Ativan, and Lexapro (antidepressant) that was not administered that morning. There was no discussion about calling the Hospice doctor. Staff C did not say anything about not giving diuretics or blood pressure medications, Staff C just said she didn't know why not to give Resident #1 the morning medications. Staff A gave the medications to Resident #1 around 10:30 a.m. Staff A said that later, after she had given Resident #1 the Lasix, Staff B, the floor nurse, did an assessment on Resident #1. Staff B stated that Resident #1's had low BP. Staff A stated Staff C ended up calling the Hospice service and the nurse Staff C talked to said to not give any more diuretics or blood pressure medications. On 11/19/25 at 2:50 p.m., Staff D, Hospice Nurse, stated she did not go into the facility. Staff D said she was just the hospice nurse that was on call. Staff C was the one who went into the facility. Staff D said that Staff A reported to Staff D that she gave the wrong medication to Resident #1 and they called Resident #1's daughter and left a message for her to call her back. Staff D stated that Resident #1 was admitted to the ICU that night. Staff D received a call from Staff B around the lunch hour. Staff B had said Resident #1's BP was 68/49. That's when Staff B told Staff D that Staff A went ahead and gave Resident #1 her other medication as well. Staff B wanted to know if she should give her Lasix and Staff D told her no. Staff D stated that after finding out later on that evening that Resident #1 was admitted to the ICU for a calcium channel overdose, Staff D call Resident #1's daughter because they couldn't provide services while in the ICU. Staff D stated she verbally called the daughter to revoke services. The daughter was upset, and she didn't understand how things like the could happen. Staff D stated she had not personally worked with Resident #1. When asked about telling Staff B to hold the Lasix, Staff D stated it was per nursing judgement to hold the medicine. She stated they can do that because Resident #1's BP was so low. On 11/20/25 at approximately 2:00 p.m., the Administrator and the Director of Nursing (DON) acknowledged the concerns with administering the wrong medications to Resident #1. They understood the concerns regarding Lasix being given after Resident #1 had received BP medications that she normally did not receive, as Lasix can lower the BP even more. They understood the need for Resident #1 being hospitalized after receiving the Lasix on top of all of the BP medications. The Administrator stated they had conversations with the nurses and the providers on how to prevent it from happening again.2. A MDS dated [DATE], documented diagnoses for Resident #3 included hypertension and orthostatic hypotension (drops in blood pressure when standing up from a sitting or lying position). A BIMS documented a score of 15 out of 15, which indicated intact cognitive functioning. A Medication Error report filled out by Staff E, LPN, dated 6/24/25, documented that Resident #3 received an additional dose of Metoprolol that a.m. The Nurse Practitioner was aware, and they had stable VS. On 7/1/25, under Notes, it documented that staff education received education about following appropriate medication rights when passing medication. Assessment was given to the provider with new orders to complete vitals and monitor. A Medication Administration Record for the month of June 2025, directed staff to administer the following medication to Resident #2:Metoprolol 100 mg (metoprolol tartrate) take 1 tablet by mouth two times a day for atrial fibrillation (Afib)(irregular heart rhythm). The start date for the medication was 6/10/25 and the discontinue date was 6/23/25 at 4:32 p.m. Staff E signed the a.m. dose on 6/23/25. All other following doses were X'd out on the MAR leaving no place to sign.Metoprolol ER (extended release) (metoprolol succinate) give one tablet by mouth one time a day for Afib. The start date was 6/24/25 at 7:00 a.m. The discontinue date was 7/5/25. Staff E signed the a.m. dose on 6/24/25. A doctor's order dated 6/24/25 at 11:00 a.m., directed staff to check BP and heart rate every hour. Resident #3's Blood Pressure Summary sheet documented the following on 6/24/25 at:9:43 a.m.: 127/79 mmHg10:47 a.m.: 123/76 mmHg1:12 p.m.: 124/79 mmHg1:34 p.m.: 134/74 mmHg2:18 p.m.: 145/88 mmHg3:31 p.m.: 146/85 mmHg3:32 p.m.: 138/87 mmHg4:10 p.m.: 149/88 mmHgResident #3's Pulse Summary sheet documented the following on 6/24/25 at:9:43 a.m.: 90 bpm10:47 a.m.: 88 bpm1:12 p.m.: 82 bpm1:34 p.m.: 78 bpm2:18 p.m.: 77 bpm3:31 p.m.: 77 bpm3:32 p.m.: 81 bpm4:10 p.m.: 91 bpmAn Incident, Accident, Unusual Occurrence Note dated 6/24/25 at 1:23 p.m., documented that Resident #3 received an additional dose of metoprolol that morning. The Nurse Practitioner notified and ordered hourly vitals. Resident #3 was aware. Vital Signs are stable. Additional metoprolol card removed and sent to the pharmacy. On 11/19/25 at 1:10 p.m., Staff E, when asked about the above medication error, stated that if she remembered correctly it was put in the computer incorrectly. Staff E stated there was maybe a duplication in the orders. She said maybe it was a different type of Metoprolol. Staff E stated she thought she found out about it the next day and so Staff E thinks there were extra VS being done. After that medication error, to prevent another error like the one, they changed procedure and made it so that other nurses on the following shift after day shift would double check that all the new orders were done correctly. That old medications were pulled from the cart and that family notifications were done.On 11/19/25 at approximately 3:00 p.m., the DON stated that she thought the medication was changed to long acting and the old card did not get pulled so Staff E gave both the new and the old Metoprolol. 3. A MDS dated [DATE], documented that Resident #4 had a diagnosis of diabetes. It documented that Resident #4 had 0 insulin orders and that the resident received 1 insulin injection during the last 7 days. His BIMS score was 9 out of 15, which indicated moderately impaired cognition. A Medication Error Incident Report dated 5/2/25 at 11:00 p.m., documented that Resident #4 received a dose of 12 units of insulin that was not ordered. Resident #4 had diabetes and had a blood sugar of 138 at time of administration. The nurse called the provider who gave orders to check blood sugar every 15 minutes for 1 hour and then every hour for 4 hours after. At that time the staff didn't note any adverse reactions. The nurse notified the family and Resident #4 of the error. A Nurses Note dated 5/2/25 at 11:13 a.m., documented Resident #4 a dose of 12 units regular insulin in error at 11:00 a.m. The nurse called the provider, who provided a new order to check his blood sugar every 15 minutes for 1 hour and every hour for 4 hours after. No adverse events were noted at the time. Resident #4's Blood Sugar Summary Sheet documented the following on 5/2/25:11:14 a.m.: 138.0 mg/dL (glucose concentration in blood)11:25 a.m.: 118.0 mg/dL11:40 a.m.: 122.0 mg/dL11:55 a.m.: 123.0 mg/dL1:02 p.m.: 145.0 mg/dL1:58 p.m.: 138.0 mg/dL3:07 p.m.: 138.0 mg/dL4:08 p.m.: 129.0 mg/dLAll of the above blood sugars were checked by Staff B.On 11/19/25 at 10:55 a.m., Staff B stated it was a busy day that day. There were 2 residents that were new to her and they were right across the hall from each other. They had similar looks, similar body build, and similar names. Staff B went in and told Resident #4 that she was there to give him his insulin. Resident #4 said 'oh, okay' and lifted up his shirt. Staff B cleaned him with the alcohol wipe and gave him the shot. Staff B stated that Resident #4 was supposed to be alert and oriented per the report she had received. After Staff B gave Resident #4 the shot, Staff B went out to chart it, and that's when she noticed the room number was different from his. Staff A stated she figured out she gave the insulin to the wrong resident. Staff A said she went back into his room and told him, she just gave him insulin, and she wasn't supposed to. Then Resident #4 yelled at her and said, 'you shouldn't have given me that I'm not a diabetic.' Staff B stated she checked his blood sugar prior to giving him the insulin and Resident #4 didn't say anything then either. Staff B said when she went out to document, she saw the room number and that is what cued her in. Staff B reported it right away to the Assistant Director of Nursing (ADON). They then notified the doctor and then she took his blood sugars several times per the provider's orders. Staff B called the wife too to let her know. Resident #4's blood sugar didn't drop low. Staff B stated she was told that he received insulin at the hospital prior to coming to the facility. Staff B said Resident #4 was alert and oriented and he knew what was going on. Resident #4 was at the facility for skilled care. The guy across the hall was here for skilled care too and they had both been admitted while Staff B was off work. On 11/20/25 at approximately 2:00 p.m., the Administrator and the DON acknowledged the medication error and understood the concern with giving insulin to a resident without an order for insulin.A Medication Administration policy revised April 2019, directed staff to administer medications in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation instructed Only persons licensed or permitted by the state to prepare, administer and document the administration of medications may do so.The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions.Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions.Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience.Factors that are considered include:Enhancing optimal therapeutic effect of the medication.Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:Checking photograph attached to medical record; andIf necessary, verifying resident identification with other facility personnel.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Vials labeled as single dose, or single use are not used on multiple residents. Such vials are used only for one resident in a single procedure.Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident.Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse verifies that the correct pen is used for that resident.Post-exposure follow up procedures are conducted if an insulin pen is used for more than one resident.Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy and approved by the Director of Nursing Services.If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated.New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility.The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned.

Based on observation and staff interview the facility failed to ensure a qualified dietary professional served as a Dietary Manager for 43 of 43 residents. The facility reported a census of 43 residents. Findings include: During an interview and observation of the kitchen on 1/2/24 at 9:36 AM with the Dietary Manager revealed she is not certified, when asked to provide a list of diets and adaptive equipment she informed she did not have access to that information and has been here only a week, however an observation of a white board in the kitchen showed a list of resident diets and adaptive equipment. During an interview on 1/2/24 at 2:43 PM the Administrator revealed they currently do not have a Certified Dietary Manager, she informed however the Dietary Manager in place is new to her role and other facilities Certified Dietary Managers are helping out but they are not employed by this facility.

Based on record review and staff interview the facility failed to complete accurate minimum data set assessments for 4 out of 14 residents reviewed (Resident #9, 17, 25 and #36). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #25 dated 11/2/22 stated the resident received an antipsychotic medication 7 day. Review of the medication administration record revealed resident did not receive antipsychotic medication. During an interview on 11/30/22 at 3:19 PM with the MDS Coordinator stated Resident # 25 is not receiving an antipsychotic and she has not been on the medication. The MDS was coded wrong. We follow the Resident Assessment Instrumnet (RAI) manual for policy when filling out the MDS. 2. The MDS dated [DATE] indicated Resident #36 had a fall with major injury. During an interview on 11/30/22 at 2:33 PM the Director of Nursing (DON) states she can not recall any injuries from a fall for Resident # 36. During an interview on 11/30/22 at 2:35 PM the MDS Coordinator stated Resident # 36 MDS is coded incorrectly. I checked and she should not have a major injury checked. The medications are probably coded wrong also I think I was looking at that as if they are taking psychotropic medications. 34821 3. The Minimum Data Set (MDS) Assessment for Resident # 9 dated 11/9/22, included diagnoses of anxiety and depression. The MDS listed the Resident's Brief Interview for Mental Status (BIMS) as 15 (intact cognition). The MDS showed Resident # 9 took a medications in the drug classification of antipsychotic for 7 days in the reference period. The Medication Administration Record (MAR) dated 11/2022, failed to direct the use of an antipsychotic medication. During an interview on 11/30/22 at 11:51 AM, Staff Registered Nurse (RN) reported, Resident # 9 never received an antipsychotic medication. Interview 11/30/22 at 3:19 PM, the MDS Coordinator, reported she coded Resident # 9 for an antipsychotic medication. The MDS Coordinator, confirmed the resident took an antidepressant 4. The MDS for Resident # 17 dated 10/19/22, included diagnoses of non-Alzheimer's dementia and psychotic disorder. The MDS showed Resident # 9 took a medications in the drug classification of antianxiety medication for the 7 days in the reference period. The MAR dated 11/17/22, failed to include a medication in the drug classification of antianxiety medication. Interview 11/30/22 at 3:19 PM, the MDS Coordinator, reported Resident # 17 is on antipsychotic medication and she coded it incorrectly on the MDS dated [DATE]. During an interview on 12/01/22 10:54 AM the DON states the expectation is the MDS will be completed timely and accurately.

Based on observation, staff interview and policy review the facility failed to maintain a clean environment with 1 out of 4 bathrooms observed with brown substance on walls, floor and baseboard. The facility reported a census of 44 residents. Findings include: During an observation on 11/29/22 at 09:08 AM in room [ROOM NUMBER] bathroom noted a build up of a brown substance on the floor around the base of the toilet. The wall has a smeared brown substance behind the handrail next to the toilet and on the baseboard behind the toilet. During an interview on 11/29/22 09:41 AM with Staff B, housekeeper stated no housekeeper or supervisor at this facility. I am the only housekeeper in the building today so after cleaning the general areas I will have to clean all the bathrooms and rooms. The toilets should be cleaned every day and I would say they are not getting done every day but maybe every other day. I cleaned them yesterday and they definitely were not very clean and you could tell they needed more attention. During an observation on 11/30/22 at 8:01 AM the brown substance remains on the wall, baseboard and at the base of the toilet in the bathroom of room [ROOM NUMBER]. During an interview on 12/01/22 at 8:14 AM the Administrator stated I would expect the bathrooms to be cleaned daily. During an observation on 12/01/22 at 8:26 AM the surveyor showed the administrator the bathroom she confirmed the bathroom was dirty and had an odor. Review of the undated Housekeeping Schedule - 1 housekeeper provided by the facility the document directed staff When cleaning the room you want to: 1. Clean the bathroom - mirror, sink, grab bar, towel bars, paper towel dispenser, toilet , wood shelf, step-on can/flower pot 2. Empty garbage's in the room and bathroom 3. Sweep and mop room floor and bathroom floors- move all small furniture, get under the bed and behind furniture and doors. 4. Must remain in the area while floors are wet from mopping 5. Check bathroom supplies- paper towels, cups, soap, 2 spare toilet paper, garbage bags, gloves. The Housekeeping Daily Cleaning Schedule Task to Do Form undated provided by the facility directed staff in resident bathroom to spot clean walls beside toilets, sinks, and sides of cabinets and dispensers.

Based on clinical record review, staff interviews and facility policy review the facility failed to address a diuretic medication in 1 out of 5 resident reviewed for unnecessary medication (Resident # 9). The facility reported a census of 44 resident. Findings included; The Minimum Data Set (MDS) Assessment for Resident # 9 dated 11/9/22, included diagnoses of anemia and cancer. The MDS listed the Resident's Brief Interview for Mental Status (BIMS) as 15 (intact cognition). The MDS showed Resident # 9 took a medications in the drug classification of diuretic for 7 days in the reference period. The Medication Administration Record (MAR) dated 11/2022, directed bumetanide (diuretic) 1 milligram (mg) daily for edema. The Care Plan for Resident # 9 dated 10/25/22, failed to address the use of the diuretic and failed to address what the staff are expected to monitor for the medications effectiveness. On 12/01/22 at 10:58 AM the Director of Nursing (DON) stated she expected diuretics addressed on the Care Plan. The facility provided a policy titled Goals and Objectives, Care Plan dated 4/2009, directed at point #1; Care plan goals and objectives are defined as the desired outcome for a specific resident problem.

Based on clinical record review, physician and staff interviews, the facility failed to notify the physician for one of one residents reviewed with abnormal vital signs on multiple occasions. (Resident # 46) The facility census was 46 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #46 had [DIAGNOSES REDACTED]. The care plan revised 5/17/18, included no problem related to hypertension or cardiac output. Clinical record review revealed blood pressure measurement on 6/21/18 at 8:00 p.m. as 199/70 lying, right arm; at 8:30 p.m. as 206/78, lying, right arm; at 8:45 p.m. as 194/73, lying, right arm; at 10:00 p.m. as 185/79, lying, right arm; at 10:30 p.m. as 180/76, lying, right arm & at 11:00 p.m. as 181/75, lying, right arm. On 6/22/18 at 8:00 a.m. the blood pressure was 208/74, sitting, right arm; at 12:23 p.m., 180/72, sitting, right arm and at 2:26 p.m., 186/71 Nurse note dated 6/23/18 at 11:15 a.m., documented writer called to beauty parlor to assess resident's left shoulder pain and bulging fistula in upper left arm. Good thrill noted. Shirt removed and new bruising noted to back of left arm, left side, and right forehead dark purple in color. Left hand reddish red color. No range of motion to left arm. Rating pain 10 with facial grimacing noted, stating it comes and goes. Upper left shoulder, front and back shows emerging blue blood vessels. Family requesting shoulder x-ray, and desire to take her to emergency room per self. Physician notified. Nurse note dated 6/23/18 at 12:30 p.m., documented resident transported to emergency room per family. Nurse note dated 6/23/18 at 3:46 p.m., documented the resident's blood pressure both systolic and diastolic very elevated in emergency room and 5 medications given but has not lowered it. X-Ray of right shoulder done. New bruise noted by family to left knee. At present, fistula appears to be operating properly. An emergency room report dated 6/23/18, documented the assessment/plan had been #1 uncontrolled hypertension. The note documented apparently on several occasions blood pressures were found to be above target values. Resident with long standing history of hypertension. Fallen on a couple of occasions. Presented to emergency department earlier today with left upper arm pain. On 7/19/18 at 6:52 a.m., the Director of Nursing (DON) stated the staff should have notified the physician of high blood pressure. The nephrology (kidney) specialty clinic nurse stated during interview on 7/19/18 at 8:30 a.m., they would expect notification of the elevated blood pressures because hypertensive emergency could result in death. The nurse verified the clinic nephrologist provided care for the resident when hospitalized with the hypertensive emergency. On 7/19/18 at 9:28 a.m., the residents primary physician stated he would expect the facility to notify the physician of elevated blood pressures if there was more than one elevated pressure. On 7/19/18 at 9:30 a.m., the DON stated the expectation would have been for the physician to be notified of blood pressures on 6/21 and 6/22 that were over 200 systolic.

Based on clinical record review and staff interview, the facility failed to coordinate Level II Pre-Admission Screening and Resident Review (PASRR) recommended services with the plan of care for two of two residents reviewed. (Resident #6 & #18) The facility census was 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #6 with [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident was admitted to hospice level of care 4/10/17 for progression of [MEDICAL CONDITION] and weight loss. A Level II PASRR was completed on 2/19/16. PASRR-identified support and services were: ongoing psychiatric services, a behaviorally-based treatment plan to include both routine and crisis related behavioral supports, socialization/leisure/recreation activities, facilitation of family involvement, supportive counseling from nursing facility staff, obtain archived psychiatric records to clarify history, and an evaluation for a [DIAGNOSES REDACTED]. The current care plan, (pages 1-12, 15-17)) with a target date of 7/25/18, failed to address or incorporate any PASRR-identified services and did not identify any proposed alternative methods for meeting the Resident's needs for behavioral health and specialized services. A Consultation/Clinic Referral document dated 3/9/17 with an order to follow up in 4 months is the last documentation regarding the resident's [MEDICAL CONDITION] and dementia. The document does not refer to her [DIAGNOSES REDACTED]. During interview on 7/17/18 at 10:30 a.m., the Director of Nursing (DON) stated the resident's family refused to take her out to any more appointments and services. During interview on 7/17/18 at 1:50 p.m., the Social Services designee stated the Interdisciplinary Team was waiting for the physician to see the resident on 7/18/18 and address the mental health needs of the resident since she is now on hospice. The Social Services Designee stated documentation of this plan was in her office on her notepad and acknowledged it is not documented in the resident's electronic health record or paper chart. On 7/17/18, the DON presented the surveyor with an updated PASRR care plan (pages 13-14) with a revision date of 7/17/18 that incorporated interventions suggested in (YEAR). 2. The Minimum Data Set (MDS) assessment for Resident #18 dated 5/9/18, documented [DIAGNOSES REDACTED]. A document titled Medical Director-Report of Irregularities documented the patient received [MEDICATION NAME] and the physician directed the [DIAGNOSES REDACTED]. The current PASARR dated 6/10/2015, was a negative level 1 and showed no mental health diagnosis. During an interview on 7/17/18 at 1:46 p.m., the Social Services Designee reported the PASARR process was an Interdisciplinary team process and when a new mental health [DIAGNOSES REDACTED].

Based on observation and staff interview the facility failed to properly sanitize a kitchen food preparation area by ensuring the quaternary sanitizer was an an effective level. The facility census was 43. Findings include: During observation in the kitchen on 5/9/17 at 10:18 a.m., Staff A, Cook used a rag from a red bucket and wiped a kitchen counter after pureeing pork chops. At 10:25 a.m., the Dietary Manager confirmed the liquid in the red bucket had been for sanitizing. The surveyor requested the Dietary Manager check the level of sanitizing solution in the bucket. The Manager dipped a test strip in the bucket for several seconds and it did not change color. The Dietary Manager then dumped the solution and placed fresh solution in the bucket. The solution again checked at 150 ppm. The Dietary Manager stated they would have maintenance check the solution dispenser. On 5/10/17 at 10:20 a.m., the surveyor requested the Dietary Manager check the sanitizing level of the quaternary solution in a red bucket which sat in the kitchen. The Dietary Manager verified the solution had been used to sanitize kitchen items and dipped a strip in the bucket for several seconds. The Dietary Manager confirmed the solution had again been about 150 ppm. At that time the Dietary Manager stated they had not had anyone check the solution dispenser the previous day.

Based on clinical record review and staff interview the facility failed to notify the physician of an adverse change in a residents condition for one of seven residents reviewed. (Resident #4) The facility census was 43. Findings include: The Minimum Data Set (MDS) assessment for Resident #4 dated 2/22/17, included [DIAGNOSES REDACTED]. A progress note dated 4/14/17 at 4:58 a.m., documented the resident had a small emesis, brown sputum during the night. Clinical record review revealed no physician notification of the brown emesis. A nurses note dated 4/15/17 at 12:10 a.m., documented the resident had a coffee ground emesis in a basin at 10:10 p.m [MEDICATION NAME] (anti-emetic/nausea)given at this time. No further emesis noted. Clinical record review revealed no physician notification of the coffee ground emesis. A progress note dated 4/20/17 at 1:15 p.m., documented staff in room with resident, writer summoned to resident room. When entering room another nurse and certified nurse aide, CNA in room. Resident sitting in recliner with feet up and looking forward without blinking. A set of vitals were taken. Nurse reports that had just been talking with resident at 1:15 p.m. when entered room to do skins. CNA reports had just toileted resident at 1:00 p.m CNA stated that resident exhausted and ready to sit in recliner. Resident unresponsive and no response to sternum rub. Another set of vitals taken and Director of Nursing, DON aware and called to MD to give update. Resident then about 1:50 p.m. started to attempt to talk and move right arm. Did grip with the right but unable with the left hand. Would move left at the shoulder level. Blood sugar 300. Resident pale and clammy. Heart rate regular. Resident refused to smile and then stated going to get sick. MD called back at 2:08 p.m. and wants sent to the ER for eval ant treat. Oxygen started at 2 liters per nasal cannula. A hospital discharge summary dated 4/28/17, documented the resident had been admitted on [DATE]. The [DIAGNOSES REDACTED]. a. Hemorrhagic shock b. Upper [MEDICAL CONDITION] with massive transfusion requirement 10 units packed red blood cells c. Bleeding penetrating [DIAGNOSES REDACTED] ulcer, gastro[DIAGNOSES REDACTED] artery aneurysm requiring coil embolization d. Penetrating [DIAGNOSES REDACTED] ulcer complicated by [MEDICAL CONDITION] e. [MEDICAL CONDITION] of [MEDICAL CONDITION] f. Chronic diarrhea g. [MEDICAL CONDITION] proctitis h. Weight loss During an interview with the Director of Nursing on 5/10/17 at 11:30 a.m., she stated she would have expected the physician to be notified of the coffee ground emesis and more follow-up completed.

Based on record review, interviews, and facility policy, the facility failed to immediately separate a staff after an allegation of alleged abuse and failed to timely report the alleged abuse to the Department of Inspections and Appeals for 1 of 4 residents (Resident #1). The facility identified a census of 44 residents. Finding include: According to the nurses notes for Resident #1 dated 02-26-16 at 4:30 p.m. the Director of Nursing spoke with Resident #1 who stated a female nursing assistant (Staff C) had hit him/her in the chest. Resident #1 described what the staff looked like and what had occurred. During an interview with Staff A, certified nursing assistant (CNA) on 03-14-16 at 5:13 p.m. she stated on the evening shift of 02-23-16, Resident #1 told her a woman on the first shift had hit him/her. Staff A reported being the only staff aware of the incident. Staff A stated she reported the alleged incident to the charge nurse (Staff B) but did not think Staff B did anything. Staff B told her she would look into the incident but the evening got hectic. An interview on 3/5/16 at 10:18 a.m. with Staff B, Registered Nurse (RN)/charge nurse she reported on 2/23/16 at approximately 3:00 p.m., Staff A told her Resident #1 said Staff C allegedly pushed him/her. Staff B stated she knew at the time that it was an allegation of alleged abuse and had been taught to report this type of allegation to the Administrator and State agency; however she did not report the alleged incident. Staff B reported she completed a treatment for [REDACTED]. Staff B stated she received a written warning and deserved it as she let the resident down. During an interview with Resident #1 on 3/14/16 at 4:40 p.m., Resident #1 reported staff had been rough when helping him/her out of bed. Resident #1 stated if their spouse had grabbed his/her arm like that he/she would have said it was rough and it hurt. Resident #1 reported the incident occurred once and denied being hit by anyone. Resident #1 reported the staff did not work here anymore (Staff C) but stated the CNA (Staff C) worked with him/her the following days after the incident. Resident #1 stated she had no concerns or was not fearful when Staff C worked with him/her after the incident. According to documentation in the facility employee punch report Staff C continued to work on 02-25-16 from 5:42 a.m. to 2:04 p.m. and on 02-26-16 from 5:42 a.m. to 2:02 p.m. According to investigation summary for Resident #1, Staff A reported the alleged abuse incident to Staff B (charge nurse) on 2/23/16. Staff A also reported the incident to the Director of Nursing on 02-26-16 at 3:45 p.m. The facility immediately started an investigation and identified Staff C worked with Resident #1 on 2/25/16 and early on 2/26/16. On 3/2/16, the facility completed their investigation and called Staff C into the facility. Staff C had been educated and informed the Director of Nursing would be monitoring her interaction with residents. The facility completed their internal investigation and determined no abuse occurred, however Staff C was no longer employed at the facility as of 3/3/16. During an interview on 12-30-15 at 11:20 a.m. the Director of Nursing confirmed the incident had not been reported to Department of Inspections and Appeals as required with in a 24 hour period following the incident. Review of the facility policy titled Dependent Adult Abuse reviewed December 2015, indicated all allegations of Resident abuse should be reported immediately to the charge nurse. The charge nurse shall separate the alleged abuser from the resident and complete a head to toe assessment to rule out any injury. The charge nurse is responsible for immediately reporting the allegations of abuse to the Director of Nursing, Administrator, or designated representative with 24 hours to the Department of Inspections and Appeals via phone, fax, email or web.

Based on clinical record review and staff interview, the facility failed to respect the resident's right to receive services in the facility with a reasonable accommodation of individual needs and sleeping preferences for one of seven residents reviewed (Resident #5). The facility census was 43 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool dated 4/29/15, documented Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with all aspect of activities of daily living. The Initial Activity assessment dated [DATE], documented the resident liked to get up in the morning at 8:00 a.m. The Interdisciplinary Progress Notes dated 5/28/15 at 4:30 a.m., documented staff collected urine specimen for analysis, culture and sensitivity via female catheter. During an interview on 7/15/15 at 2:30 p.m., the facility Director of Nursing stated the facility expectation would be for staff to collect the specimen (via female cath) after 6:00 a.m. or after the resident awakens.

Based on observation, clinical record review and staff interview, the facility failed to provide complete incontinence care to prevent odor, infection and skin breakdown for one of three incontinent residents observed (Resident #2). The facility reported a census of 43 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 6/10/15, Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two staff for bed mobility and transfer. The care plan dated 6/4/15, documented the resident as at risk for skin breakdown related to immobility and incontinence and frequently incontinent of bladder. The care plan directed staff to assist with incontinence cares. During an observation on 7/13/15 at 11:20 a.m., Staff A (Certified Nurse Aide, CNA) and Staff B (CNA) assisted the resident to a toilet in the central bath. Staff A removed the resident's visibly soiled incontinent brief. The brief was visibly with urine and emitted a foul urine odor. After Resident #2 finished using the toilet, both staff lifted the resident using an E-Z stand lift. Staff A used one disposable wipe and wiped once over the resident's rectal area, then applied a new incontinence brief. Staff A stated the resident's pants were wet as well. Staff B then changed the resident's pants. Staff A then informed Staff B a soaker pad on the resident's wheel chair was wet and told Staff B to change it. Staff B removed the soiled soaker pad and placed a dry one on the wheel chair. Staff A and Staff B then transferred the resident to the wheel chair. Staff B wheeled the resident to the dining room for lunch. During an interview with the facility Director of Nursing on 7/16/15 at 11:20 a.m., they stated they would expect staff to do more thorough incontinence care than had been done on the resident and staff knew that because audits had recently been done.

Based on record review and staff interview, the facility failed to document a clinical contraindication for the lack of a Gradual Dose Reduction for 1 of 10 active residents reviewed (Resident #5). The facility reported a census of 43 residents. Findings included: 1. According to the Minimum Data Set (MDS) assessment tool dated 4/29/15, Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with aspects of daily living. The MDS also documented the resident receiving an antidepressant medication in the last 7 days. A facsimile note dated 3/12/15, requested the physician to consider decreasing [MEDICATION NAME] (depression medication) 20 milligrams every day from 30 milligrams every day, unless clinically contraindicated. Nursing comments documented, at this time, continue with [MEDICATION NAME] 30 milligrams. The physician responded, please implement the following dose reduction (decrease [MEDICATION NAME] 30 mg to 20 mg daily. A signed Physician order [REDACTED].>Resident #5's Medication Administration Record [REDACTED]. During an interview on 7/15/15 at 2:40 p.m., the facility director of nursing stated that she documents in the nursing comment section and the physician will agree or disagree with her regarding whether the medication should be decreased or remain the same.

Based on observation, record review and interview the facility failed to notify the physician in a timely manner of two falls, one with injury for 1 of 3 residents observed (Resident #3). The facility reported a census of 40 residents. Findings included: According Minimum Data Set (MDS) assessment tool dated 2/16/15, Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident as cognitively intact and revealed the he/she required extensive to total assistance of one staff for bed mobility and surface to surface transfers. The resident's care plan with a target date of 05/26/15 revealed the resident was at risk for falls and instructed one staff to assist with ambulation, remind the resident to ask for assistance, use a motion sensor alarm at all times, and utilize a floor mat alarm when in bed. The care plan indicated the resident had been unstable on his/her feet and did not remember to ask for help. The resident's physician order [REDACTED]. An incident report dated 2/13/15 at 10:00 a.m. documented staff found Resident #3 laying on his/her right side in the lobby, next to a wheelchair with the alarm sounding. The incident report documented staff notified the resident's physician of the incident by electronic fax on 02/15/15 at 12:40 p.m. (over 48 hours after the fall). A fax dated with a return date of 2/19/15 from the physician indicated the acknowledgement of the fall (six days later). A second incident report dated 2/19/15 at 10:00 p.m., documented staff found the resident on the floor in his/her doorway on his/her right side. The incident report also documented Resident #3 sustained two abrasions to the right elbow and two abrasions to the back of his/her head. The incident report revealed staff notified the physician of the fall by electronic fax on 02/20/15 at 4:30 p.m. (sixteen hours after the fall). There were no return faxes indicating the physician acknowledged the incident. On 03/25/15 at 9:30 the resident's physician stated he had been notified by fax of the resident's fall on 02/13/15. He said he did not recall getting a fax regarding the fall on 02/19/15 and/or possible head injury. On 03/25/15 at 7:30 a.m. Staff A, LPN stated that she did not notify the primary physician of the fall on 02/19/15, because his/her head wound appeared stable. Staff A stated the normal procedure for physician notification is to notify the physician the following day shift unless the resident is injured enough to go the emergency room , then call and notify the attending physician immediately. On 03/25/15 at 8:55 a.m. Staff B, LPN stated the normal procedure for physician notification would be for staff to send a fax to the physician's office unless there was an issue like an injury, or a need for the emergency room then they would call the office or the physician if after office hours. On 03/25/15 at 11:05 a.m. Staff C, RN stated that her responsibilities included sending faxes to the physician's office for notifications of changes and for orders. She stated the normal procedure would be for the staff nurse to put problems that needed to be addressed on a task list, she would then fax the physicians and wait for responses and then write orders on the resident charts. She stated the normal procedure would be to call the doctor and family if there is an injury or the resident hits their head, if the fall is unwitnessed it would be treated as a possible head injury and doctor notified immediately. Staff C stated she had not been working when the 02/13/15 fall occurred and the nurse involved had placed it on the task list so she could notify the doctor. She stated she did fax the doctor on 02/15/15, but received a return fax 02/19/15 acknowledging the fall from the 13th (6 days after that fall). Staff C stated that she did not have anything on the task sheet indicating she needed to notify the doctor regarding the fall on 02/19/15. She stated she had not been aware that the doctor had not been notified of it until he called the facility on 02/20/15 at 5:35 p.m.

Based on observation, staff interview and facility policy review, the facility failed to ensure medications were kept in a secured area, and failed to ensure staff responded to a door alarm in a timely manner. The facility reported a census of 44. Findings include: 1. On 5/14/14 at 8:03 a.m., the facility Director of Nursing (DON) office door stood open. Observation revealed three pill bottles sitting on a shelf and visible from the 200 hallway. No staff had been present in or near the office. The DON stood at the far side of the nurses station with their back to the office. At that time, the surveyor noted a large bottle of Ibuprofen, and smaller bottles of Tylenol and Aspirin accessible with no staff supervision of the medications. At 8:10 a.m., the medications remained unattended and the surveyor notified the DON. At that time the DON moved the medications to a secure area and stated they had just given a staff person some Tylenol. At 8:28 a.m., the facility Administrator stated they would expect medications to be locked up if unattended. 2. During the facility environmental tour on 5/14/14 at 8:46 a.m., the surveyor sounded an alarmed exit door. The facility Administrator verified the door led to the out doors. At 8:50 a.m., no staff had responded to the door alarm. At that time the administrator stated staff should have responded to the door alarm by that time. During the same tour, observation revealed a medication cup near the top of a garbage can on an unattended medication cart, and easily accessible. The can had been attached to the lower part of the medication cart. The medication cup had what appeared to be crushed medications in applesauce. At that time the surveyor pointed the cup out to the facility DON, who then removed the bag and stated it looked like medications in the cup. The DON verified the medications should not have been left that way. At 9:42 a.m., Staff B (Licensed Practical Nurse, LPN) verified the medications had belonged to Resident #12 and the resident had refused the medication. Staff B stated they should have disposed of the medication in a biohazard container. Staff B provided the surveyor with a list of medications in the cup which included: a. Naproxen 220 milligrams (mg)-anti-inflammatory b. Metoprolol Tartrate 25 mg-blood pressure medication c. Allopurinol 100 mg-gout medication d. Digoxin 125 micrograms-heart medication e. Potassium Chloride 20 milliequivelant f. Omeprazole 20 mg-decreases stomach acid g. Colace 100 mg-stool softener h. Lasix 80 mg-diuretic On 5/15/14 at 10:21 a.m., the facility corporate QA nurse stated the facility had four residents that wore wanderguard bracelets.

Based on observation, clinical record review and staff interview, the facility failed to utilize appropriate infection control techniques during resident treatments for two of three residents reviewed. The facility also failed to sanitize glucometers in a manner to prevent the spread of infection and according to manufacturer guidelines. (Resident #7 & #5) Findings include: 1. The Minimum Data Set (MDS) assessment for Resident # 7 dated 2/26/14, documented [DIAGNOSES REDACTED]. The MDS documented the resident required no assistance for bed mobility or ambulation. An office procedure report dated 5/8/14, documented the resident had a wide local re-excision of left forearm squamous cell [DIAGNOSES REDACTED] with two layer closure. The care plan updated 5/9/14, contained no information regarding the surgical wound or potential for infection. An emergency department physician note dated 5/13/14, documented the resident seen for non-traumatic soft tissue swelling over the dorsal aspect of the left forearm. The report documented the resident had a cancerous tumor removed from the left forearm the previous Wednesday with the area stitched. However, started having infection to the wound and swelling to the left hand. Had been seen the previous Friday and received shot of antibiotic, was then started on oral antibiotics. A radiology consultation dated 5/13/14, documented the resident had a nonhealing sore of forearm, history of skin cancer. On 5/14/14 at 4:45 p.m., Staff A (Registered Nurse, RN) asked the resident to stand in the medication room. Staff A donned a pair of gloves with no handwashing observed. Staff A completed a dressing change to an incision on the residents left forearm. During the dressing change, a sling that had been removed from the residents arm dropped onto the floor. Staff A picked up the sling and placed it on a binder on a counter in the medication room. Upon completion of the treatment, Staff A placed the same sling back on the residents left arm. During interview with the facility Director of Nursing (DON) on 5/15/14 at 9:10 a.m., they stated they would not expect a sling to be placed back on the arm of a resident with a surgical wound after it had fallen to the floor. 2.The Minimum Data Set (MDS) for Resident #5 revealed the rescompleted 4/1/14, indicated current Stage 2 pressure ulcers. The care plan updated 4/9/14, revealed that resident at risk for skin breakdown related to incontinence and immobility. Care plan directed staff to administer treatment as ordered by physician. The resident's physician's orders [REDACTED]. During observation on 5/13/14 at 4:00 p.m., Staff A (Registered Nurse) directed resident into bathroom. Staff A opened up the treatment book. Staff A continued by placing wound cleaner and a paper towel on top medication cart, placing 4x4 gauze and medicated ointment on top paper towel. Staff A then moved the paper towel to on top of the resident's toilet tank. Staff A used hand sanitizer and donned gloves, lowered resident's pants and brief to reveal open areas of growth on resident's buttock. Staff A removed gloves and donned new gloves. Staff A dispensed wound cleaner onto 4x4 gauze and cleansed open area. Again with a new wipe dispensed wound cleaner onto 4z4 gauze and cleansed 2nd open area. Staff A removed gloves placed paper towel on the seat of resident's wheelchair placing a small amount of medicated ointment on top. Staff A donned new gloves, obtained ointment on 1st finger and applied to 1st open area. They continued by obtaining ointment onto the 2nd finger and placed onto 2nd open area, removed gloves and pulled up residents brief and pants. Staff A dropped cap to ointment onto resident's wheelchair seat, picked up and placed on to ointment tube. Staff A assisted resident to sit down in wheelchair. Staff A cleaned up area, bagged garbage, washed hands then wiped off the ointment tube, wound cleanser bottle and placed back into medication cart. Staff A then cleaned the top of the medication cart. 3. During an observation on 5/13/14 at 6:15 a.m., Staff C (Licensed Practical Nurse) placed glove on top of medication cart along with a paper towel. Staff C donned gloves, wiped off glucometer with Caviwipes then placed glucometer on glove lying on top of medication cart. Staff C placed alcohol swab, lancet and syringe onto paper towel. Staff C wiped of Resident #2 finger with the alcohol swab, poked with lancet and tested resident's blood sugar. Staff C removed gloves, wiped glucometer off with Caviwipes and placed back onto glove setting on top medication cart. Staff C donned new gloves, rolled insulin [MEDICATION NAME] 70/30, wiped top off with alcohol swab, drew up insulin and administered insulin in resident's leg then removed gloves. Staff C continued on to Resident #13 room at 6:30 a.m. with medication cart. Staff C used hand sanitizer, donned gloves. Next Staff C wiped off glucometer with Caviwipes and placed back onto the same glove on top medication cart. Staff C placed alcohol swab, lancet and syringe onto paper towel. Staff C wiped off resident's finger with the alcohol swab, poked with lancet and tested resident ' s blood sugar. Staff C removed gloves, wiped glucometer off with Caviwipes and placed back onto glove setting on top medication cart. Staff C donned new gloves, rolled insulin [MEDICATION NAME] 70/30, wiped top off with alcohol swab and drew up insulin then administered insulin in resident's leg then removed gloves. Staff C continued on to Resident #14 room, used hand sanitizer, donned gloves at 6:43 a.m., wiped glucometer with caviwipes set on same glove on top medication cart. Staff C wiped resident's finger with alcohol. At 6:44 a.m., placed test strip in to glucometer and tested resident's blood sugar. At 6:45 a.m. put glucometer on paper towel, removed gloves and wiped glucometer with Caviwipes. Staff C proceeded to shut resident's door, donned gloves, wiped off Humalog insulin with alcohol then drew up insulin and administered in resident's left buttock. Staff C removed gloves, picked up glucometer off paper towel and placed on top tray that contained alcohol swabs, gauze and lancets then placed tray in drawer of medication cart. During an interview on 5/13/14, at 7:10 a.m. Staff A revealed the facility used the same glucometer for testing all the resident's blood sugars. Staff A acknowledged that is why they clean the glucometer with Caviwipes between each use. They set it onto a barrier and let dry at least a couple of minutes. The front of the facilities treatment book instructed staff to wrap the glucometer in Caviwipes and the machine must stay wet for 3 minutes. The facilities hand washing procedure recommendation for hand washing/ hand sanitizer after glove removal.

Based on record review and staff interview the facility failed to follow physicians orders for 2 of 10 residents reviewed (Residents #2 & #5). The facility census was 44 residents. Findings include: 1. Review of the current Physicians Order Sheet for Resident #2 signed in March 2014 revealed an order for [REDACTED]. During an interview 5/14/14 at 3:35 pm the facility D.O.N. (Director of Nursing) verified the physicians order directed staff to administer the calcium with vitamin D 2 times a day, but the MAR indicated [REDACTED]. 2. The Minimum Data Set (MDS) for Resident #5 completed 4/1/14, included [DIAGNOSES REDACTED]. The MDS also indicated the resident took an anticoagulant (blood thinner). A physician order [REDACTED]. The resident's medical record failed to contain any documentation that indicated staff drew an INR drawn for the resident since 4/16/14. During an interview with the DON on 5/14/14 at 4:15 p.m., the DON acknowledged the facility failed to draw an INR.

Based on observation, clinical record review and staff interview the facility failed to complete a thorough assessment for two of three residents reviewed with areas of altered skin integrity, and failed complete an assessment for one of one residents reviewed with weight loss. (Resident #7, #9 & #5) The facility reported a census of 44. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident # 7 dated 4/16/14, documented [DIAGNOSES REDACTED]. The MDS also documented the resident required extensive assistance of two for bed mobility and transfer. The care plan included a problem of potential for skin breakdown (no date) related to immobility and incontinence. The problem included an intervention to check skin with baths and cares, notify nurse of any reddened areas. On 5/12/13 at 12:07 p.m., the resident sat in a wheel chair in the dining room. Observation revealed a dark reddish scab-like area on the right temple, quarter sized. At 12:39 p.m., the resident sat in a lounge area across from the nurses station. Observation revealed the residents lower shins to have multiple dark blue bruises on them from quarter to fifty-cent piece sized. A review of the skin assessments for the resident revealed no assessment completed for any of the areas on either the temples or the lower legs. During interview on 5/15/14 at 8:00 a.m., the facility Director of Nursing verified there had been no assessments of the areas, with no explanation why. 2. The MDS for Resident # 9 dated 2/26/14, documented [DIAGNOSES REDACTED]. The MD'S documented the resident to be independent with ambulation and bed mobility. A physician office procedure report dated 5/8/14, documented the resident had been seen by a surgeon for squamous cell [MEDICAL CONDITION] on the left forearm. The report documented the resident had a wide local re-excision of the left forearm squamous cell carcina, which had been sutured. A nurses note dated 5/8/14 at 2:00 p.m., documented the resident returned from a physician visit with sutures in the left forearm. Order to remove sutures 5/29/14. The entry included no assessment of the incision. The care plan updated 5/9/14, included no problem of altered skin integrity. A nurses note entry on 5/9/14 at 9:30 p.m., documented the left forearm sutures had been intact. Mild [MEDICAL CONDITION] with no exudate or [DIAGNOSES REDACTED]. The entry included no other assessment of the area. An entry on 5/10/14 at 10:00 a.m., documented the resident had 2+ non-[MEDICAL CONDITION] to the left arm near the wrist and fingertips, the dressing had been wrapped a little tight, put new dressing on resident, denies any pain, sutures intact, scant amount serous drainage. The entry included no measurement of the wound/incision. An entry on 5/12/14 at 3:30 a.m., documented the residents left forearm and left hand were swollen into the fingers. On 5/12/14 (no time) a late entry had been made for 5/9/14 at 2:00 p.m.. The entry documented the resident had requested the dressing be removed. Sutures intact, suture line without any indication of problems or signs/symptoms of infection. The entry included no measurements. An entry on 5/12/14 at 7:10 a.m., documented the resident requested their hand be assessed. The entry documented the resident had 4 + [MEDICAL CONDITION] to the hand and fingers. The entry included no wound/incision measurement. An entry on 5/12/14 at 7:00 p.m., documented the dressing had been changed and included no measurement. An entry on 5/13/14 at 4:30 a.m., documented the residents left hand remained [MEDICAL CONDITION]. At 7:00 a.m., an entry documented the resident requested an assessment of the arm. The assessment included frank red blood on the old dressing. At lease 3 sutures not fully visible. Incision line closest to hand slightly eviscerated with gray colored center. Left hand and area above bandage to elbow with multiple degrees of [MEDICAL CONDITION]. The entry included no wound/incision measurement. At 10:30 a.m., an entry documented orders received to take to the emergency room . Clinical record revealed no skin assessment sheet for the area, with no documentation of number of sutures, or size of the incision. During interview on 5/15/14 at 10:10 a.m., the facility corporate QA nurse stated the facility did not do skin assessments on surgical wounds which would include measurement. At that time the facility Director of Nursing stated they did not know how many sutures the resident had because it had not been in the surgical report. A review of a facility form for non-pressure skin assessment, revealed the form included a box to check for surgical wounds. The surveyor pointed this out to the QA nurse at that time, who did not respond. 3. The MDS for Resident #5 completed 4/1/14, included [DIAGNOSES REDACTED]. The MDS also indicated the resident needed supervision and set up for eating. The care plan dated 3/25/14 included the potential for weight loss related to history of dementia. The care plan instructed staff to weight resident per protocol and to allow resident ample time to consume food. The nurse's notes lacked detailed documentation of an assessment including lung sounds and [MEDICAL CONDITION] on 4/6/14 and 5/13/14. On those dates the residents showed a weight gain of more than 5 pounds in one week. The nurse's note on 4/6/14 documented lungs adventitious and no mention about [MEDICAL CONDITION]. The weight record showed on 4/6/14 at 10:32 a.m., 145.80 pounds and on 4/5/14 at 11:32 a.m., showed 136.4 pounds. The nurse's note on 5/13/14 lacked any assessment documentation with reference to lung sounds or [MEDICAL CONDITION]. The weight record showed on 5/13/14 at 1:31 p.m., 150.00 pounds and then at 1:32 p.m., 147.2 pounds. The previous weight on 5/6/14 at 11:25 a.m., showed 136.4 pounds. During an interview on 5/15/15 at 7:17 a.m., the DON indicated the Certified Nursing Assistant (CNA) weighed the resident's. If a change in weight they would notify the nurse on duty. DON further indicated the nurse would be expected to do an assessment. The nurse listened to lung sounds and checked for [MEDICAL CONDITION]. During an interview on 5/15/14 at 8:50 a.m., Staff B(Licensed Practical Nurse) indicated that if a resident had a weight change the CNA would notify them. The CNA's had parameters and they thought it was 5 pounds in one week. Staff B also acknowledged that when they logged in to computer to chart a red flag would pop up alerting them to a weight change.

Based on record review and and staff interview the facility failed to ensure all residents were seen by a physician as required by Medicaid for 1 of 10 residents reviewed (Resident #8). The facility census was 44 residents. Findings include: Review of the medical record for Resident #8 revealed physician visits documented on 3/11/13 then not again until 10/24/13 then not seen again until 1/9/14 when the resident went to the hospital, per Medicare/Medicaid requirements Resident #8 should have been seen every 60 days or 2 months. During an interview on 5/15/14 at 7:15 a.m. the facility D.O.N. (Director of Nursing) verified that there was no documentation for physician visits for Resident #8 between the dates of 3/11/13 and 10/24/13.