Every finding on record at Life Care Center of Banner Elk

Based on observations, record review, and resident and staff interviews, the facility failed to secure an indwelling urinary catheter tubing to prevent tension or trauma for 1 of 2 residents reviewed for urinary catheter (Resident #62).The findings include:Resident #62 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia with urinary obstruction.Review of Resident #62's physician orders dated 02/20/25 revealed an order to secure the catheter tubing with an anchoring device to prevent pulling or trauma.Review of Resident #62's care plan dated 02/20/25 addressed the use of an indwelling urinary catheter related to benign prostatic hyperplasia with obstruction. The goal that he would have no complications due to the urinary catheter would be attained by utilizing interventions that include encouraging the use of a leg strap to reduce pulling and trauma.The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #62's cognition was intact, and he had an indwelling urinary catheter.Review of Resident #62's physician orders dated 07/22/25 revealed an order for a urinary catheter to straight drain for obstructive uropathy.On 08/03/25 at 12:49 PM an observation and interview were conducted with Resident #62. The Resident explained that he has had his urinary catheter since he has been in the facility. The Resident was asked if he had an anchoring device on his catheter tubing and Resident #62 stated he did not and pulled back the sheet and revealed there was no anchoring device on his leg for the catheter tubing. The Resident remarked that sometime the catheter tubing was pulled during care, but he tolerated the pulling.On 08/04/25 at 10:20 AM an observation was made of Nurse Aide (NA) #1 and NA #2 providing catheter care to Resident #62 who did not have an anchoring device for his catheter tubing. Near the completion of the task NA #1 explained that the Resident should have an anchoring device on his thigh to prevent pulling and tugging of the catheter tubing and she informed Nurse #1 yesterday (08/02/25) that Resident #62 did not have an anchoring device for his catheter. NA #1 stated it was the nurses' responsibility to apply the anchoring devices on the residents for their catheters.At 11:10 AM on 08/04/25 an interview was conducted with Nurse #1 who confirmed that she worked with Resident #62 on 08/03/25. The Nurse explained that she removed the anchoring device from Resident #62's catheter tubing on 08/02/25 due to soilage and could not find another one to replace it. The Nurse stated she reported it to Nurse #2 that Resident #62 needed an anchoring device for his catheter tubing. Nurse #1 stated that she did not recall NA #1 informing her that Resident #62 did not have an anchoring device for his catheter tubing.On 08/04/25 at 2:30 PM an interview was conducted with Nurse #2. The Nurse confirmed that she took care of Resident #62 on 08/03/25 7:00 PM to 7:00 AM. Nurse #2 explained that residents who have indwelling urinary catheters should have anchoring devices to prevent from pulling and trauma. The Nurse stated she did not know that Resident #62 did not have an anchor device in place on her shift and Nurse #1 did not inform her that the Resident needed one.During an interview with Nurse #3 on 08/04/25 at 1:10 PM, the Nurse, who was assigned to Resident #62, explained that he had put an anchoring device on Resident #62 after NA reported to him that there was not an anchoring device on Resident #62. An interview was conducted with the Unit Manager on 08/05/25 at 1:44 PM. The Unit Manager explained that all residents with urinary catheters should have anchoring devices in place to prevent them from pulling and trauma unless there was a specific reason why they should not have them. The Unit Manager stated that if that were the case then it should be care planned.On 08/06/25 at 9:00 AM an interview was conducted with the Director of Nursing (DON) who explained that residents with urinary catheters should have an anchor device in place to prevent for pulling and trauma. She stated the hall where Resident #62 resided on was a hectic hall but that was no excuse. The DON indicated that the anchor devices should be made accessible for nurse aides to apply them. [NAME], [NAME] (62) pearson, [NAME] (37280) - RESIDENT NOTE No Notes

Based on observations, record review, and resident and staff interviews, the facility failed to ensure medications were under direct observation by the administering nurse who left medications unattended at the bedside of 1 of 1 resident reviewed for medication storage (Resident #56).Findings included:Resident #56 was admitted to the facility 05/05/23 with diagnoses including diabetes with polyneuropathy (damage of multiple nerves), hypertension (high blood pressure), and depression. Partial review of Resident #56's Physician orders revealed the following:Metformin ER (diabetes medication) 1,000 (milligrams) mg twice a day for diabetes ordered 05/16/23Cholecalciferol (Vitamin D) 2,000 units once a day for supplement ordered 10/26/23Pregabalin (neuropathy medication) 75 mg twice a day for diabetic polyneuropathy ordered 07/23/24Sertraline (antidepressant) 100 mg once a day for depression ordered 09/10/24Empagliflozin (diabetes medication) 25 mg once a day for diabetes ordered 12/24/24Amlodipine (high blood pressure medication) 10 mg once a day for hypertension ordered 04/03/25The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was moderately cognitively impaired and received antidepressant and hypoglycemic (medications that lower blood sugar) medications during the 7-day look back period. An observation of Resident #56's overbed table on 08/03/25 at 12:11 PM revealed a medication cup containing 6 pills of various shapes and sizes. An interview with Resident #56 on 08/03/25 at 12:11 PM revealed he wasn't sure what the pills in the cup were or why they were there. An interview with Nurse #1 on 08/03/25 at 12:13 PM revealed she was caring for Resident #56. She stated the medications in the cup in Resident #56's overbed table were Pregabalin, Sertraline, Vitamin D, Amlodipine, Metformin, and Jardiance. Nurse #1 stated she took the pills to Resident #56 around 9:45 AM and got distracted by the resident's roommate and did not realize Resident #56 did not swallow the medications while she was in the room. She stated she usually stayed with a resident until they swallowed their medication or removed the medication from the room if the resident did not want to take the medication at that time. Nurse #1 stated she had just left Resident #56's room after watching him take all the medications in the cup. An interview with the Director of Nursing (DON) on 08/06/25 at 10:50 AM revealed she expected nurses to stay with residents until all medications were taken or remove them from the room if the resident did not want to take them at the time they were scheduled. She stated Nurse #1 got distracted on 08/03/25 and that was why medications were left unattended in Resident #56's room. An interview with the Administrator on 08/06/25 at 10:55 AM revealed she expected nurses to stay with residents until they completed taking their medication or remove it from the room if the resident did not want to take the medication at the scheduled time.

Based on observation, record review, and staff interviews, the facility failed to implement their infection control policy when Nurse Aide (NA) #2 and the Treatment Nurse did not don (put on) a gown while providing wound care to Resident #47 who required enhanced barrier precautions (EBP) due to the presence of a pressure ulcer (sore). This deficient practice occurred for 2 of 7 staff members observed for infection control practices (Treatment Nurse and NA #2).Findings included:Review of the facility's Enhanced Barrier Precautions policy last revised 03/21/2024 read in part as follows: Policy:The facility should use Enhanced Barrier Precautions (EBP) as an additional MDRO [multi-drug resistant organisms] mitigation [prevention] strategy for residents that meet the following criteria, during high-contact resident care activities; wounds even if the resident is not known to be infected with a MDRO. Wounds generally include chronic wounds. Examples of chronic wounds include pressure ulcers. EBP should be used for any residents who meet the criteria.Definitions:Enhanced Barrier Precautions (EBP)-refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Personal Protective Equipment (PPE)-refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and protect residents from cross-transmission.Procedure:The facility should develop a process to communicate which residents require the use of EBP for all high-contact resident care activities. The facility may choose to post signage on the door or wall outside of the resident room indicating the resident is on Enhanced Barrier Precautions. Examples of high-contact resident care activities requiring gown and glove use include: wound care and changing linens.Review of Resident #47's medical record revealed a nurse's note written by the Director of Nursing (DON) on 07/14/25. The note read in part as follows: Resident noted with unstageable pressure area to sacrum [the triangular bone at the base of the spine]. Measurements 1.5 [centimeters] x 1.7 [centimeters] x 1 [centimeter]. Resident denies pain in area. New orders for treatments in use at this time.An observation of Resident #47's door on 08/04/25 at 8:54 AM revealed no signage indicating he was on EBP, and no shelf or container was present outside the room containing gowns or gloves. A continuous observation of the Treatment Nurse and NA #2 on 08/04/25 from 8:56 AM though 9:02 AM revealed they entered Resident #47's, performed hand hygiene with alcohol-based hand rub (abhr), donned (put on) gloves, and assisted Resident #47 with turning on his left side. NA #2 assisted Resident #47 with staying on his left side and the Treatment Nurse pulled back the brief, removed the dressing from Resident #47's sacrum and placed it in the trash, removed her gloves and placed them in the trash, performed hand hygiene, donned clean gloves, cleaned the wound with wound cleanser, removed her gloves and placed them in the trash, performed hand hygiene, donned clean gloves, measured the wound with a paper tape measure, removed her gloves and placed them in the trash, performed hand hygiene, donned clean gloves, applied medical grade honey gel with a cotton-tipped applicator to the wound bed, covered the wound with a bordered gauze, removed her gloves and placed them in the trash, and performed hand hygiene. The Treatment Nurse and NA #2 did not don gowns while performing wound care for Resident #47.In an interview with the Treatment Nurse on 08/05/25 at 12:12 PM she confirmed on 08/04/25 there was no sign indicating Resident #47 was on EBP and she did not wear a gown while providing wound care. She stated she thought that since the wound did not have a large amount of drainage that Resident #47 did not need EBP. In an interview with NA #2 on 08/05/25 at 2:42 PM she confirmed she did not wear a gown when assisting the Treatment Nurse with positioning Resident #47 for wound care on 08/04/25. She stated since there was no sign indicating Resident #47 was on EBP, she assumed he was not on EBP. An interview with the Infection Preventionist (IP) on 08/06/25 at 10:31 AM revealed Resident #47 should have been placed on EBP when his pressure ulcer was identified. She stated that a miscommunication between herself and the Treatment Nurse was the reason Resident #47 was not on EBP. The IP stated she should have followed up to ensure Resident #47 was placed on EBP and she did not. She stated that placing Resident #47 on EBP fell through the cracks. An interview with the DON on 08/06/25 at 10:42 AM revealed when it was determined that Resident #47 had a pressure ulcer, it was unclear if the wound was open or not. She stated once she determined the pressure ulcer was open, EBP was put in place. The DON stated Resident #47 should have been placed on EBP when the pressure ulcer was identified. An interview with the Administrator on 08/06/25 revealed she thought the reason Resident #47 was not placed on EBP for his pressure ulcer was due to a miscommunication between the IP and Treatment Nurse.

Based on record reviews, facility activity calendars, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 4 of 5 residents reviewed for activities (Resident #7, #22, #28, #21). The findings included: A review of the Resident Council Minutes from July 2023 through July 2024 revealed the following: -July 2023 the residents had discussed trips that might be fun when activities were able to provide group trips. Residents #22 and Resident #7 were in attendance. -September 2023 the residents had discussed wanting to take short trips on the Parkway to see the leaves change. Residents #7, #22, #28, #21 were all in attendance. There was no documented response to the residents request for a group outing. -October 2023 the residents had discussed wanting to take short trips on the Parkway to see the leaves change. Residents #7, #28, #21 were all in attendance. There was no documented response to the residents request for a group outing. -March 2024 the resident had discussed they would like to go on short trips, to the store or Subway, on the van. Activities was going to looking to the dynamics of the van and transportation rules and would report back to Resident Council. Residents #7, #22, #28, #21 were all in attendance. There was no documented response to the residents requests for a group outing. -April 2024 the residents were informed that the Activities Assistant had left his position and that short trips on the van would not be possible until a driver was hired. Residents #7, #22, and #28 were all in attendance. There was no documented response to the residents request for a group outing. -May 2024 residents had discussed they were still wanting to go on day trips and would like for activities to look into renting a party bus so many residents could attend. Resident #7, #22, #28, #21 were all in attendance. There was no documented response to the residents request for a group outing. -June 2024 residents were advised that the facility had looked into party buses and their prices were just too expensive and had called local rafting companies that have large buses, but none were handicap accessible. The residents were informed the Activities Director (AD) had inquired about renting a party bus and the prices were too expensive. The AD had also contacted local rafting companies that had larger buses and none of the buses were handicap accessible. The AD was going to contact the local transportation agency. Residents #22 and Resident #7 were in attendance. There was no documented response to the residents request for a group outing. -July 2024 there was no documented response to the residents request for a group outing. A Resident Council meeting was conducted on 8/21/2024 at 9:59 am with Residents #7, #22, #28, and #21 in attendance. The residents expressed that they had been asking about going on a group outing repeatedly during their Resident Council meetings. The facility staff had responded to the residents that there was no transportation, van/bus driver, and not enough staff to go on group outings at this time. During the Resident Council meeting Resident #7 stated she would like to go to the dollar store and had not been in a store in several years. Resident #22 stated the residents had been told they did not have transportation for group outings. Resident #22 stated not being able to go on group outings felt like being in prison. Resident #21 stated she would love to get out of the facility and go to a store because she wanted to be able to pick out her own stuff, but it with her own money, and feel like an addition to society. An observation was conducted on 8/20/2024 at 12:00 pm revealed the facility was within driving distance of local restaurants (0.8 miles), local stores (6.4 miles), and a park (2.8 miles). a. Resident #7 was admitted to the facility on [DATE]. A review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was cognitively intact, and it was very important to do things with groups of people and to go outside to get fresh air when the weather is good. An interview was conducted on 8/19/2024 at 9:22 am with Resident #7. Resident #7 stated she regularly attended Resident Council and activities at the facility. Resident #7 stated that since she had been admitted , she had never been on an outing and wanted to go. Resident #7 stated the residents had been told there was no transportation to be able to take them on outings. Resident #7 stated she would love to go to a store and stated that not being able to go on outings felt kind of like being in jail. b. Resident #22 was admitted to the facility on [DATE]. A review of a change in condition Minimum Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively intact, and it was very important to do things with groups of people and to go outside to get fresh air when the weather is good. An interview was conducted on 8/18/2024 at 3:49 pm with Resident #22. Resident #22 stated she had been at the facility for a couple of years and was the Resident Council President. Resident #22 stated the residents had not been on a group outing since she was admitted to the facility. Resident #22 stated the residents had expressed wanting to go on group outings just go get out. Resident #22 stated not being able to go on outings really bothered the residents. c. Resident #28 was admitted to the facility on [DATE]. A review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was cognitively intact, and it was very important to do things with groups of people and to go outside to get fresh air when the weather is good. An interview was conducted on 8/19/2024 at 9:28 am with Resident #28. Resident #28 stated he had been at the facility for six years, had regularly attended Resident Council and activities, and had never been on a group outing. Resident #28 stated it made him feel terrible to not be able to go on group outings. Resident #28 stated his family was not able to take him out of the facility and he would just like to go out to a restaurant to eat. d. Resident #21 was admitted to the facility on [DATE]. A review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact, and it was very important to do things with groups of people and to go outside to get fresh air when the weather is good. An interview was conducted on 8/19/2024 at 9:31 am with Resident #21. Resident #21 stated she had been at the facility for four years and had never been on a group outing. Resident #21 stated the only time she had left the facility was to go to doctor appointments. Resident #21 stated the residents had been told the facility did not have a transportation van that was big enough or enough staff to be able to help. An interview was conducted on 8/19/2024 at 10:41 am with the Activities Director (AD). The AD stated she had worked at the facility for four and a half years and transferred to the Activities Director position about a year and a half ago. The AD stated the residents had mentioned wanting to take day trips that were unrealistic because the facility did not have a driver for the van. The AD stated the residents had not been on a group outing since before Coronavirus. The AD stated the facility did not have transportation large enough to support the amount of residents that would want to go, and there was not enough staff to take them. The AD stated most of the residents would require assistance with transfers and toileting, which would require one staff member to one resident for safety purposes. The AD stated she had called local rafting companies about transporting residents on their vans/buses but was told the vans/buses were not handicap accessible. The AD stated she had also reached out to a local transportation agency and stated they would charge if the transportation was not for a medical necessity. The AD stated if she was not able to go out on outings she would feel land locked. The AD stated she did not feel comfortable driving the van in the event something bad happened. The AD stated the van could hold approximately 2 residents in wheelchairs. The AD stated she would have felt bad if she took only 2 out at a time because that would make other residents feel like they were left out and would not be fair. An interview was conducted on 8/19/2024 at 11:18 am with the Administrator. The Administrator stated several of the residents had mentioned wanting to go on group outings but stated that transportation was a huge issue in their county along with the fact that everyone wanted to go. The Administrator stated the facility took the residents outside when the weather was good and provided a variety of entertainment groups. The Administrator stated they started the Resident Council Store which gave the residents an opportunity to feel like they were shopping at a real store. The Administrator stated the AD had made efforts to try to find transportation but that between the lack of a van driver and not having enough staff, it was not feasible to go on outings at this time. The Administrator stated the bus would hold a couple of wheelchairs and several ambulatory residents. The Administrator stated she did not feel comfortable driving the van or bus and being responsible for the residents while they were on an outing if something bad were to happen. An interview was conducted on 8/20/2024 at 9:23 am with the Maintenance Director. The Maintenance Director stated the facility had a transportation van and a bus. He stated the van would hold approximately 2 residents and the bus could hold approximately 3 wheelchairs and several other residents that were ambulatory. The Maintenance Director stated that anyone with a driver's license could drive the van, or the bus and no special credentials were needed. The Maintenance Director stated he occasionally went to the hospital to pick up residents in the van, but primarily was only responsible for maintenance duties in the facility.

Based on record review, and resident and staff interviews, the facility failed to provide a resolution of Resident Council grievances for 1 of 1 monthly Resident Council Meetings (June 2024). The Resident Council had reported they would like to have transportation to go on group outings. The findings included: A review of the Grievance Program policy dated 5/6/2019 stated the facility should make prompt efforts to resolve a grievance and should actively work toward a solution of a complaint/grievance. The facility should follow up with the resident to communicate resolution or explanation and ensure that the issue was handled to the resident's satisfaction. A review of the Resident Council minutes from 6/24/2024 revealed residents requested to take day trips and were advised that the facility had contacted companies regarding party buses for transportation and the prices were too expensive. The Activities Director (AD) had called local rafting companies that had large buses, and none were handicap accessible. The AD was to contact the local transportation agency. A review of a grievance filed on 6/24/2024 by the Activities Director (AD) revealed residents had requested the facility to find transportation to ride around and get lunch. The AD advised residents that she had contacted local rafting companies to see if their bus was handicap accessible and was told they were not. The AD advised the residents that she would contact the local transportation company. The grievance form indicated the facility was not able to resolve the concern at the time it was shared. The Administrator was assigned the grievance. The investigation steps stated, at this time staffing restraints are hindering resident outings. Documented actions taken to resolve/respond to the concerns stated, will continue to try to hire a driver and will also consider ordering special meals in for the residents upon request. There was no documented date, time, findings, or action plan for when the information was shared with the concerned party and the concerned party's response to the action plan/outcome was disappointed. The grievance was signed by the Administrator on 6/27/2024. An interview was conducted on 8/19/2024 at 10:41 am with the AD. The AD stated the resident council met once a month and had requested to go on day trips. The AD stated day trips were not possible at the time because the facility did not have a van driver. The AD stated that she had called the local transportation company in the past and was told that there was a charge for transportation if the reason for transport was not for a medical need. The AD was unsure of when she had reached out to the local transportation agency and stated that when they had used them for a non-medical appointment in the past, it was very expensive. An interview was conducted on 8/20/2024 at 12:33 pm with the Social Services Director. The Social Services Director stated the Grievance Official was the Administrator and that a grievance could be filled out by anyone in the facility. The Social Services Director stated she received all grievances, made a copy of the grievance and wrote the information from the grievance on the grievance log. She stated she gave the grievance to the appropriate department manager and once the grievance was resolved, or if the facility was not able to come to a resolution, the grievance was discussed with the person who filed the grievance, and the Administrator signed the grievance as completed. The Social Services Director stated she was aware members of the Resident's Council had expressed wanting to go on group outings. The Social Services Director stated any interventions, or resolution should have been documented on the grievance form and stated she did not think any interventions or resolutions had been agreed upon. An interview was conducted on 8/20/2024 at 1:18 pm with the Administrator. The Administrator stated anyone at the facility could complete a grievance. The Administrator stated she was the Grievance Official and the Social Services Director was responsible for keeping a log of the grievances and distributed the grievances to the appropriate department manager. The Administrator stated after a grievance was completed, the staff discussed the status of grievances in their morning meetings until the grievance was resolved. The Administrator stated she was under the impression that the residents knew that outings were not feasible at this time due to the facility not having a van/bus driver. The Administrator stated she knew a few months ago the AD had reached out to the local transportation agency and at the time it was too expensive for non-medical trips and the agency did not have a lot of availability. The Administrator stated she had not contacted the local transportation agency or tried to arrange transportation for outings recently, however the facility had advertised for a van/bus driver. The Administrator stated that she should have made sure the residents knew that the grievance could not be resolved, and that the facility would continue to work on hiring a van/bus driver to take the residents on group outings.

Based on observations, record reviews and staff interviews, the facility failed to complete bed rail assessments to determine the need for bed rails for 2 of 9 residents reviewed for accidents (Resident #3 and Resident #45). Findings Included: 1. Resident #3 was admitted to the facility 10/06/22 with diagnoses that included history of repeated falls, status post fracture of the superior rim of the left pubis (a bone of the pelvis) and dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #3 with short and long term memory problems. The MDS also indicated she had functional range of motion impairment on one side of her lower extremity and required substantial to maximal assistance from staff to roll from left to right. The MDS revealed bed rails were not used as a restraint. A review of Resident #3's electronic medical record revealed there had not been a bed rail assessment completed since her admission on 10/06/22. An observation of Resident #3 on 08/18/24 at 4:00 PM revealed she was lying in her bed on her back sleeping with the bilateral quarter bed rails in the up position. During an interview with Nurse Aide (NA) #1 on 08/18/24 at 4:11 PM, the NA explained that Resident #3 had a fall from her bed a while back that fractured some of the bones in her pelvis. The NA stated the Resident was total care with the assistance of two staff but she would attempt to feed herself when sitting up. On 08/19/24 at 2:19 PM an observation was made of Resident #3 lying on her back in her bed with the bilateral quarter bed rails in the up position. During an interview with NA #2 on 08/19/24 at 4:10 PM the NA explained that Resident #3 had a fall from her bed several months ago that broke a bone around her pelvis and since then she seemed to decline. The NA stated Resident #3 required two staff assist to turn in the bed but would hold the bed rail if her hand was put in that position. An interview conducted with Nurse #1 on 08/20/24 at 2:09 PM revealed Resident #3 had declined since she fractured her pelvic bones from a fall. The Nurse explained that the Resident required two staff assist with most of her activities of daily living including rolling from side to side in the bed. She indicated Resident #3 could hold the side rail if you put her hand in that position but could not actively roll herself. Nurse #3 continued that bed rail assessments were completed quarterly but when she reviewed the Resident's electronic medical record for the last assessment, she stated there was no bed rail assessment in the medical record. During an interview with the Director of Nursing (DON) on 08/20/21 at 3:40 PM the DON explained that the bed rail assessments were supposed to be done quarterly along with the MDS assessments. She stated they discovered a glitch in the system that prevented the bed rail assessments from automatically popping up to be completed. 50045 2. Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and dementia. A review of Resident #45's Medical Record revealed an Evaluation for Use of Bed Rails form dated 6/8/2021 which revealed bed rails were not indicated at that time. The Medical Record did not contain a signed consent for the use of bed rails. A review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was severely cognitively impaired and had no behaviors. Bed rails were coded as not used for Resident #45. An observation was conducted on 8/20/2024 at 8:18 am of Resident #45. Resident #45 was observed lying in bed with bilateral upper quarter bed rails raised. An interview was conducted on 8/20/2024 at 8:48 am with Nurse #2. Nurse #2 stated an evaluation for the use of bedrails was performed on admission. Nurse #2 stated bedrails were utilized for mobility purposes or at the request of the resident or resident's family. Nurse #2 stated if a resident required bedrails, there was a quarterly bed rail assessment that had to be completed. Nurse #2 stated there was no evaluation for bed rails in the medical record that indicated Resident #45 needed bed rails, there was no quarterly bed rail assessment, and there was no mention of bed rails in the care plan. Nurse #2 was unsure why there were quarter bed rails used on Resident #45's bed and stated there should not have been. An interview was conducted on 8/20/2024 at 3:42 pm with the Director of Nursing (DON). The DON stated when a resident was admitted to the facility there was an initial assessment for the use of bed rails that was completed by the nurse. The DON stated some residents and/or resident families would request the use of bed rails and signed consent for use. The DON stated if bed rails were used for a resident there should have also been a quarterly assessment for bed rails completed. The DON was unsure why Resident #45 had quarter bed rails on his bed and stated he should not have had bed rails.

Based on observations, record review, and staff interviews, the facility failed to ensure a physician ordered hand splint was placed on a resident as ordered for 1 of 1 resident reviewed for limited range of motion (Resident #22). The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and contracture of left hand. Review of Resident #22's physician orders revealed the following order dated 12/06/22: Apply built-up left hand palm guard with red roll during hand hygiene 7 times a week up to 6 hours a day, indefinitely to prevent further contracture of left hand. One time a day. Review of Resident #22's annual Minimum Data Set (MDS) assessment dated [DATE] revealed her to be cognitively impaired. Resident #22 was coded as requiring extensive assistance with personal hygiene. Resident #22 was coded as not receiving any therapy since her last MDS assessment. An observation made on 05/22/23 at 1:00 PM revealed Resident #22 to be in bed asleep without the placement of her palm guard. Observation of Resident #22's left hand revealed it to be clinched tight with her fingernails pressed against her palm. An observation made on 05/23/23 at 2:10 revealed Resident #22 to be in her bed resting. Resident #22's left hand did not have the physician ordered palm guard in place and her left hand was observed to be clinched tight with her fingernails pressed against her palm. An observation made on 05/24/23 at 9:20 AM revealed resident to be out of bed, in her wheelchair. An observation of her left hand revealed her palm guard to not be in place with her left hand clinched tight with her fingernails pressed against her palm. During an interview with the Restorative Manager on 05/24/23 at 11:00 AM, she reported the facility currently had one Restorative Nurse Aide who was responsible for ensuring splints and palm protectors were in place as ordered. She also verified that Resident #22 was currently on the Restorative Therapy caseload and was ordered to have a palm guard placed on her left hand daily before breakfast and then removed around 2:00 PM. An observation of Resident #22 at 11:15 AM with the Restorative Manager revealed Resident #22 to not have her palm guard on her hand. The Restorative Manager reported it should have been placed on her hand that morning and immediately began providing care and placed the palm guard on Resident #22's hand. An interview with Restorative Aide #1 on 05/24/23 at 11:06 AM revealed she was familiar with Resident #22 and that she had a physician order for a palm guard to be placed in her left hand daily to provide palm protection related to a contracture. She stated Resident #22 was to wear the palm guard 6 hours a day and it was to be placed on Resident #22 before breakfast and then taken off around 1:30 PM or 2:00 PM. She reported she had not been able to work in the capacity of a Restorative Aide on 05/22/23, 05/23/23, or 05/24/23 and instead was working as a nurse aide on a hall. She reported on days that she was not at the facility or had to work as a nurse aide, the restorative aide duties would fall to the nurse aides assigned to the hall. Review of facility assignment sheets revealed Nurse Aide #1 was scheduled to work on 05/22/23 and 05/23/23 on first shift on Resident #22's hall and Nurse Aide #2 and Nurse Aide #3 were assigned to Resident #22's hall on 05/24/23. An interview with Nurse Aide #1 by telephone on 05/24/23 at 11:22 AM was unsuccessful. An interview with Nurse Aide #2 on 05/24/23 at 11:26 AM revealed she was unsure how restorative aide duties were delegated when the restorative aide was not in the facility. She reported she assumed the responsibility of placing splints and palm guards would remain with the restorative department. She reported she had not put any splints or palm guards on Resident #22. During an interview with Nurse Aide #3 on 05/24/23 at 11:34 PM, she reported when Restorative Aide #1 was pulled to the floor, the hall nurse aides or nurses would be responsible for ensuring splints and palm guards were placed on residents. She reported she was aware Resident #22 was admitted to the restorative program and was aware she was supposed to have a palm guard placed on her left hand every day before breakfast. She reported it had been a hectic morning and it was overlooked and not put on Resident #22 on 05/24/23. During an interview with the Director of Nursing on 05/24/23 at 12:09 PM she reported when the Restorative Aide was pulled to the hall, her duties would be delegated to the hall nurse aides. She reported if there was a physician order for a palm guard to be put on Resident #22 then it should be put on as ordered.

Based on record review, observations and staff interviews, the facility failed to prevent a urinary catheter tubing and bag from touching the floor for 1 of 2 residents (Resident #45) reviewed for urinary catheters. The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45's care plan revised on 7/15/21 indicated Resident #45 had an indwelling catheter due to urinary retention. Interventions included catheter care every shift, position catheter bag and tubing below the level of the bladder, check tubing for kinks each shift, may use leg strap or catheter securement device to help hold tubing in place, ensure leg strap or catheter securement device was on and tubing was not placed under leg and check each shift for proper positioning. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 was moderately cognitively impaired, did not exhibit rejection of care behaviors and had an indwelling catheter. Resident #45's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 8/16/21 at 11:35 AM of Resident #45 while he was sitting at the bedside in his wheelchair. Resident #45 had a urinary catheter with the tubing and the urinary catheter bag touching the floor. Another observation of Resident #45 on 8/18/21 at 12:11 PM revealed his urinary catheter bag laying flat on the floor while Resident #45 was lying on his bed. An interview with Nurse Aide (NA) #1 on 8/18/21 at 12:19 PM revealed Resident #45's urinary catheter bag was not supposed to be left laying flat on the floor. During the interview, NA #1 picked up Resident #45's catheter bag and hung it on the bed frame off the floor. NA #1 stated she last saw Resident #45 before 11:00 AM and he was sitting up in his wheelchair with his urinary catheter bag secured on his wheelchair. NA #1 further stated she was not sure if Resident #45 took himself to bed or if another staff member helped him back to bed. An interview with Nurse #2 on 8/18/21 at 12:26 PM revealed he had helped Resident #45 back to bed around 11:00 AM and he hung Resident #45's urinary catheter bag to the metal railing on his bed. Nurse #2 stated the catheter bag might have come unhooked and ended up on the floor. Nurse #2 also stated it was not acceptable for Resident #45's catheter bag to be on the floor. An interview with the Infection Preventionist (IP) on 8/19/21 at 9:31 AM revealed she was familiar with Resident #45 and knew that he had just completed antibiotic therapy for [CONDITION(S)]. The IP stated Resident #45's urinary catheter bag and tubing should have been positioned off the floor when he was in his wheelchair or his bed. An interview with the Director of Nursing (DON) on 8/19/21 at 11:11 AM revealed she was alerted by the IP regarding concerns related to Resident #45's urinary catheter and they found out that Resident #45's wheelchair was lower than the regular wheelchairs. The DON confirmed that they noted Resident #45's urinary catheter bag and tubing were right against the floor whenever he was sitting in his wheelchair and both should be positioned higher up in his wheelchair. The DON stated Resident #45 also often attempted to transfer himself from wheelchair to bed and would take his urinary catheter bag off the wheelchair and either lay it on the floor or on the bed.

Based on observations and staff interviews, the facility failed to store undated and unopened eye drop bottles according to manufacturer's instructions on 2 of 4 medication carts (300 hall medication cart and 400 hall medication cart). The findings included: 1. An observation of the 300 hall medication cart on 8/19/21 at 10:03 AM with Nurse #3 revealed an undated and unopened bottle of [MEDICATION(S)] 0.005% eye drops, a medication used to treat [CONDITION(S)] and ocular hypertension. The bottle was labeled with a sticker that read refrigerate until opened; discard 6 weeks after opening. The undated and unopened bottle of [MEDICATION(S)] belonged to Resident #61. An interview with Nurse #3 on 8/19/21 at 10:05 AM revealed the unopened bottle of [MEDICATION(S)] was filled by the pharmacy and delivered to the facility on [DATE] and must have been placed directly on the medication cart after it was delivered. Nurse #3 stated the [MEDICATION(S)] bottle should have been stored in the refrigerator until it was ready to be opened and used. An interview with the Director of Nursing (DON) on 8/19/21 at 10:23 AM revealed she remembered Nurse #2 telling her that he was going to put the [MEDICATION(S)] bottle on the 300 hall medication cart the day before, after it was delivered from the pharmacy. The DON stated Nurse #2 must have forgotten to throw away the old bottle and open the new bottle of [MEDICATION(S)] and date it. 2. An observation of the 400 hall medication cart on 8/19/21 at 10:14 AM with Nurse #4 revealed an undated and unopened bottle of [MEDICATION(S)] 0.005% eye drops that belonged to Resident #41. The bottle was labeled with a sticker that read refrigerate until opened; discard 6 weeks after opening. The bottle also had a pharmacy label that it was filled on 8/6/21. An interview with Nurse #4 on 8/19/21 at 10:15 AM revealed the unopened and undated bottle of [MEDICATION(S)] should have been kept in the refrigerator until opened because it only lasted for 6 weeks after being taken out of refrigeration. Nurse #4 stated she did not notice the unopened [MEDICATION(S)] bottle because it was due to be given only at night. An interview with the Director of Nursing (DON) on 8/19/21 at 11:11 AM revealed the nurses were supposed to be checking the medication carts weekly for undated medications. The DON stated she was going to call the pharmacy to verify if the [MEDICATION(S)] eye drop bottles were supposed to be refrigerated until they were opened and to check if any of the [MEDICATION(S)] eye drop bottles were still good to be used even though they had not been refrigerated since being sent from the pharmacy.

Based on observations and staff interviews the facility failed to dispose of expired perishable food items in 1 of 2 nourishment room refrigerators (Nourishment room # 1). The findings included: Observation of the resident nourishment room # 1 refrigerator was completed with the Dietary Manager (DM) on [DATE] at 3:40 PM. The observation revealed the following: - 14 containers of yogurt with expiration dates of [DATE] An interview with the DM on [DATE] at 3:41 PM revealed dietary staff were assigned daily to verify expiration dates in resident refrigerators. All outdated / expired items were to be discarded. The DM stated she believed the person who checked it on [DATE] must have forgotten the date. The DM verified items in the refrigerator were available for resident consumption. The Director of Nursing (DON) was interviewed on [DATE] at 11:12 AM. The DON stated checking expiration dates in refrigerators was the responsibility of the dietary department. She revealed her expectation was for expired items not to be available for consumption by residents. The facility Administrator was interviewed on [DATE] at 12:11 PM. The Administrator stated her expectation of dietary staff was to maintain foods ready for distribution to residents within manufacturers expiration dates.

Based on record review, physician, and staff interviews the facility failed to follow physician orders [REDACTED].#17). Findings included: Resident #17 was admitted to the facility 11/16/18 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #17's cognition as being severely impaired. A review of the physician orders [REDACTED].#17 revealed nurses were to administer 12.5 milligrams (mg) of [MEDICATION NAME] (a medication used to treat high blood pressure) by mouth one time a day related to the [DIAGNOSES REDACTED]. Review of Resident #17's (MONTH) 2019 Medication Administration Record (MAR) revealed on 04/20/19 at 10:00 AM Nurse #1 documented Resident #17's systolic blood pressure reading as 94 and initialed she administered [MEDICATION NAME] 12.5 mg. Review of Resident #17's (MONTH) 2019 MAR revealed on: 04/20/19 at 10:00 AM a blood pressure reading of 94/58, 04/21/19 at 10:00 AM a blood pressure reading of 104/62, 04/22/19 at 10:00 AM a blood pressure reading of 90/61. Nurse #1 documented on the MAR she withheld [MEDICATION NAME] using code #3 which read vitals outside of parameters of administration. Review of the nurses' notes for Resident #17 revealed no documentation was entered on 04/20/19. The next documented nurse note revealed on 04/22/19 Nurse #1 withheld [MEDICATION NAME] for a systolic blood pressure reading less than 100. During an interview on 05/01/19 at 3:37 PM the Medical Doctor (MD) revealed parameters were written to guide the nurses to withhold [MEDICATION NAME] when systolic blood pressure readings were less than 100. He was unaware Resident #17's [MEDICATION NAME] medication was administered outside of the parameter. The MD stated if notified he would've directed the nurse to monitor Resident #17 for negative side effects from the medication and possibly discontinue the medication. During an interview on 05/01/19 at 3:49 PM Nurse #1 confirmed on 04/20/19 she initialed [MEDICATION NAME] was administered to Resident #17 on the MAR on 04/20/19. Nurse #1 revealed her routine was to obtain and record the blood pressure reading on the MAR. She then would administer and document the medication was given. Nurse #1 explained on the MAR a code was used to identify when medications were withheld for vital signs outside of parameters and if she withheld a medication she notified her Nurse Supervisor. Nurse #1 couldn't say why she administered [MEDICATION NAME] when the systolic blood pressure was 94. There were other times when this occurred, and she withheld the [MEDICATION NAME] and documented the reasons. She stated when she signed the MAR this meant she had given the medication. She was unable to give a reason why the [MEDICATION NAME] was administered on 04/20/19 and wasn't sure if she did or did not give it that day but was aware the MAR indicated she had. During an interview on 05/01/19 at 4:24 PM the Nurse Supervisor (NS) revealed the computer MAR prompted the nurses to document the reason a medication was held. The NS reviewed Resident #17's MAR which revealed [MEDICATION NAME] was given on 4/20/19 with a systolic blood pressure of 94. She didn't recall being notified [MEDICATION NAME] was administered outside of parameters for Resident #17. She revealed the nurses obtained vital signs prior to administering a medication with parameters. The NS explained it was her expectation if blood pressure medication was administered outside set parameters the nurse would notify her, so she could contact the MD for guidance. The NS revealed it was her expectation the nurse notify her if blood pressures were consistently outside of parameters, so she could notify the MD for guidance and or direction to discontinue the medication. During an interview on 05/01/19 at 4:49 PM the Director of Nursing (DON) revealed it was her expectation physician orders [REDACTED]. After the DON reviewed Resident #17's MAR she confirmed on 04/20/19 there was no documentation showing the [MEDICATION NAME] was withheld. The DON was unaware the [MEDICATION NAME] was administered when parameters directed the nurse to withhold. The DON expected the nurse to notify her after administering the [MEDICATION NAME] outside of those parameters, so the MD and the family could be notified.

Based on record review and staff interviews the facility failed to notify the resident's Responsible Party of a medication change for 1 of 3 residents reviewed for notification of change (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #1 was severely cognitively impaired. Review of the physician order's revealed the following: - 03/13/18 Nudexta, a medication used for uncontrollable crying or laughing, 10 milligrams(mg) once a day for seven days then 10mg twice a day (ok to give at 8:00 AM and 6:00 PM). - 03/30/18 Discontinue Nudexta. An interview conducted on 04/05/18 at 9:30 AM with Resident #1's Responsible Party (RP) revealed she was not notified Resident #1 had been started on Nudexta until she was notified Resident #1 had a bad night and the Nudexta had been discontinued. She stated the Director of Nursing (DON) called her and apologized for not notifying her but she thought the Hospice Nurse had notified her about the Nudexta. An interview conducted on 04/05/18 at 11:12 AM with Nurse #1 revealed Resident #1 had been ordered Nudexta on 03/13/18 to help with her behaviors. She stated when a new medication was ordered it was the nurse that took the order responsibility to notify the family. She stated she did not take the Nudexta order, the Director of Nursing had taken the order. An interview conducted on 04/05/18 at 3:30 PM with the Hospice Nurse revealed the DON and Resident #1's physician had asked her if Hospice would cover the cost for Nudexta and she told them no. She stated thy never informed her Resident #1 was being put on Nudexta and never asked her to inform the RP. She further stated she wasn't aware Resident #1 had been on Nudexta until her RP asked her why she didn't tell her there had been a medication change. An interview conducted on 04/05/18 at 3:52 PM with the DON revealed she and Resident #1's physician had asked the Hospice Nurse if Hospice would cover the cost of Nudexta. The DON stated the Hospice Nurse stated they would not cover the cost of the Nudexta. The DON stated she should have notified Resident #1's RP of the medication change since she took the order.

Based on observations, record review and staff interviews the facility failed to provide oxygen per physician order's for 1 of 3 residents reviewed for respiratory care (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #1 was severely cognitively impaired. Review of the care plan dated 12/08/17 revealed Resident #1 had the potential for respiratory changes related to impaired mobility and aspiration risk. The goal was for Resident #1 to be free of signs or symptoms of respiratory complications through the next review. The interventions included: oxygen as ordered, encourage fluids, and head of bed elevated to facilitate respirations, aspiration precautions. Review of the physician order [REDACTED]. Observations of Resident #1 were as follows: - 04/05/18 9:45 AM Resident #1 sitting in her broad chair in her room with her eyes closed with a nasal cannula (NC) in her nostrils. The oxygen tubing was attached to an oxygen concentrator set at 3 l/min. - 04/05/18 11:05 AM Resident #1 continued to be in her broad chair in her room with NC in her nostrils. The oxygen tubing was attached to an oxygen concentrator set at 3 l/min. - 04/05/18 2:25 PM Resident #1 continued to be in her broad chair in her room with NC in her nostrils. The oxygen tubing was attached to an oxygen concentrator set at 3 l/min. - 04/05/18 3:30 PM Resident #1 continued to be in her broad chair in her room with NC in her nostrils. The oxygen tubing was attached to an oxygen concentrator set at 3 l/min. An interview conducted on 04/05/18 at 11:12 AM with Nurse #1 revealed Resident #1 had an order for [REDACTED].#1's oxygen earlier in the morning and it was on and set at the ordered setting. A follow up interview and observation of Resident #1's oxygen setting with the surveyor was conducted on 04/05/18 at 3:30 PM with Nurse #1. She observed the setting on the oxygen concentrator and agreed it was set at 3 l/min. She stated it should have been at 3.5 l/min per the physician order. She further stated she thought that was high setting and she was going to clarify the order with the physician. An interview conducted on 04/05/18 at 3:40 PM with the Administrator revealed it was her expectation for resident's oxygen to be set at the physician ordered level.

Based on record reviews and staff interviews the facility failed to prevent a significant medication error when a finger stick blood sugar was incorrectly obtained from a resident and the resident was given another resident's long acting insulin for 1 of 3 sampled residents to assure facility was free of significant medication errors (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a physician's admission order dated 01/23/18 indicated there were no MEDICATION ORDERS FOR [REDACTED] A review of a physician's order dated 01/23/18 indicated to obtain blood sugar checks every 4 hours for 24 hours and notify physician of any blood sugars less than 60 and the indication was due to a medication error. A review of a written statement dated 01/23/18 at 10:15 PM by Nurse #2 revealed Nurse #1 was administering medications to Resident #2. The document indicated Nurse #2 was assisting Resident #2's roommate when Nurse #1 reported she had made a medication error when she checked Resident #2's blood sugar and the result was 279 and Nurse #1 had given Resident #2 [MEDICATION NAME] (a long acting insulin). A review of a written statement dated 01/23/18 at 11:00 PM by Nurse #1 revealed when she was administering bedtime medications, she made a medication error when she obtained a blood sugar level and gave Resident #2 [MEDICATION NAME] 25 units on 01/23/18 at 10:15 PM. The statement indicated Resident #2's roommate had orders for the blood sugar check and scheduled insulin and Resident #2 and her roommate had similar first names. The statement revealed the physician was notified of the medication error and orders were received to check blood sugars every 4 hours for 24 hours and notify the physician for blood sugars less than 60. The statement further revealed Nursing Management and Resident #2 were informed of the medication error. A review of nurse's progress notes dated 01/24/18 at 1:06 AM indicated Nurse #1 was administering medications at approximately 10:15 PM on 01/23/18 when she mistakenly obtained a blood sugar level and gave 25 units of [MEDICATION NAME] to Resident #2. The notes revealed Resident #2's blood sugar was 279 prior to the insulin injection. The notes also revealed Resident #2 shared a room with a roommate who was ordered [MEDICATION NAME] and they had similar first names. The notes indicated Nurse #1 notified Resident #2's physician and received physician's orders to check blood sugar levels every 4 hours for 24 hours and notify physician of any blood sugars less than 60. The notes indicated Nurse #1 notified Nursing Management and Resident #2 of the medication error and vital signs were within normal limits and there were no signs or symptoms of low blood sugar but continue to monitor. A review of nurse's progress notes dated 01/24/18 at 4:35 PM by the Director of Nursing (DON) indicated an interdisciplinary team meeting was conducted that morning to discuss an incident when Resident #2 received a dose of 25 units of insulin but had no physician's order for insulin. The notes revealed Nurse #1 had accidentally checked Resident #2's blood sugar and it was 279 so she administered insulin that was meant for her roommate. The notes further revealed Nurse #1 called the physician and received orders to check Resident #2's blood sugar every 4 hours for 24 hours. The notes also revealed Resident #2 had not had any issues from receiving the medication and her blood sugars had not been under 130. The notes indicated the DON checked on Resident #2 and she was alert and oriented and Resident #2 stated she was fine and wanted to go home. The notes further indicated name alerts were placed on Resident #2's Medication Administration Record [REDACTED]. A review of a facility document titled Incident Follow up and Recommendation Form dated and signed by the Director of Nursing on 01/31/18 indicated an incident occurred on 01/23/18 when Nurse #1 accidentally checked Resident #2's blood sugar and gave 25 units of [MEDICATION NAME] to the resident. The document revealed Resident #2's blood sugar was 279 prior to giving insulin and Resident #2 had been upset because she was not discharged to home from the hospital. A section labeled Recommendations and Actions taken revealed physician's orders were obtained to check Resident #2's blood sugar every 4 hours for 24 hours and blood sugars had been good and all were over 130. The document further revealed Nurse #1 would be required to complete rights of medication administration training prior to working again and name alert stickers were placed on Resident #2's medication administration records (MARs) and medications. During an interview on 01/31/18 at 12:39 PM, Physician #1 who was also the Assistant Medical Director stated it was a big deal for a resident to receive insulin who did not have physician's orders for insulin. He explained the key was for the Nurse to let the practitioner know if the insulin was long acting or short acting so they could deal with the acute problem and give orders for how to address it. He stated Resident #2's blood sugar results in the 200 range was no reason to give the insulin without a physician order but it was a good thing her blood sugar was not low. He explained side effects from giving insulin could have long range effects but would depend on the type of insulin that was given. He then explained [MEDICATION NAME] was a long acting insulin and it was good that it was long acting but at the same time not good because it was long acting. During an interview on 01/31/18 at 1:57 PM, the Director of Nursing confirmed a medication error occurred on 01/23/18 at approximately 10:00 PM when insulin was incorrectly given to Resident #2. She stated Nurse #1 had checked Resident #2's blood sugar instead of her roommate by mistake and gave Resident #2 [MEDICATION NAME]. She further stated she was not aware Nurse #2 had made any other medication errors. During a telephone interview on 01/31/18 at 2:08 PM, Physician #2 who was also Resident #2's physician explained he was made aware of the medication error the next day after Resident #2 had received [MEDICATION NAME]. He stated it was a significant medication error because a resident should not be given insulin who was not ordered to receive it. He stated he did not see harm or permanent harm to Resident #2 and since they had been checking her blood sugars she was now getting insulin because her blood sugars were running high. During an interview on 01/31/18 at 2:37 PM, Resident #2 confirmed she had received insulin that she was not prescribed. She explained a nurse had incorrectly given her roommates insulin to her. She stated she did not initially question the injection because she received an injection for one of her medical conditions but it was not insulin. She explained after she received the insulin injection she did not feel bad and she had not had any side effects she was aware of from the insulin injection and Physician #2 had talked with her. During an interview on 01/31/18 at 3:32 PM, the Staff Development Coordinator (SDC) explained she received a telephone call from Nurse #1 between 10:00 PM and 10:30 PM on 01/23/18. She further explained Nurse #1 stated she was giving medications and had checked Resident #2's blood sugar and had given her 25 units [MEDICATION NAME] but the blood sugar check and the insulin was supposed to have been given to Resident #2's roommate. The SDC stated she told Nurse #1 to call the physician on call and Nurse #1 called them and got orders to check blood sugars every 4 hours for 24 hours and she informed the DON and Administrator of the medication error. During an interview on 01/31/18 at 5:25 PM, Nurse #3 who was assigned to Resident #2 stated she was made aware on 01/24/18 that Resident #2 had incorrectly received an insulin injection. She explained they monitored Resident #2's finger stick blood sugars but she had not had any signs or symptoms from receiving the insulin injection. She confirmed they had put name alert stickers on Resident #2's MARs and medications and also on her roommates MARs and medications. During a follow up interview on 01/31/18 at 5:55 PM the DON explained it was her expectations for nurses to verify the resident's name and give the correct dosage of medication according to physician's orders. She stated she talked with Resident #2 after the medication error the next day on 01/24/18 and Resident #2 stated she was fine and had not had side effects from the medication. During an interview on 01/31/18 at 5:58 PM the Administrator stated her expectations were the same as the DONs. She further stated it was her expectation for nurses to verify the resident's identity before they gave them medications. During an interview on 01/31/18 at 6:08 PM, Nurse #2 stated she was helping Nurse #1 on 01/23/18. She explained she was in Resident #2's room assisting her roommate and Nurse #1 was with Resident #2. She stated Nurse #1 told her she had given Resident #2 insulin by mistake and then called the physician and Nursing Administration. She explained they checked Resident #2's blood sugars after she received the insulin and she did not have any signs or symptoms from the insulin injection. During an interview on 01/31/18 at 6:19 PM, Nurse #1 explained Resident #2 had been admitted during the day shift on 01/23/18 and the resident was upset because she had not been sent home from the hospital. She stated is was a busy evening and she had gotten insulin out of the refrigerator for Resident #2's roommate but had not labeled it with the resident's name like she normally did. She stated if she had labeled the insulin with the correct resident's name she might not have made the mistake in giving insulin to Resident #2 later that evening. She explained she was in Resident #2's room after 10:00 PM and checked her blood sugar by mistake but it was 279 so she gave her 25 units of [MEDICATION NAME] subcutaneously. She stated once she gave the insulin she realized Resident #2's roommate was supposed to get the blood sugar check and insulin because she was a diabetic. She explained she informed Resident #2 she had made a mistake and had given her insulin. She stated she called the physician on call who gave her orders to check Resident #2's finger stick blood sugars every 4 hours for 24 hours and to notify the physician if her blood sugars were less than 60 or if she had any other symptoms. She explained she called the SDC who was the manager on call and informed her of the medication error and when she finished her shift after 11:00 PM Resident #2 had not had any side effects from the insulin injection.

Based on observations and staff interviews the facility failed to label resident's personal care items and store them off the floor which included 2 bath basins in resident room #213 and #312 (on 2 of 4 resident hallways), failed to repair smoke prevention doors on the 200 and 400 hallways with broken and splintered laminate and wood on the lower edges of the doors (on 2 of 4 resident hallways), failed to repair doors to the main dining room and to the door of the day room/dining room on the 300 hall with broken and splintered laminate and wood on the lower edges of the doors, failed to repair bathroom doors in 7 resident rooms (room #108, #211, #213, #303, #305, #310 and #312) with broken and splintered laminate and wood on the lower edges of the doors (on 3 of 4 resident hallways), failed to repair a loose toilet with a broken bolt at the base of the toilet in the bathroom of resident room #310, failed to repair an edge guard on a wall in resident room #311 and failed to repair base molding in resident room #305 and between the therapy department and entrance to the 100 hall. The findings included: 1. a. Observations on 01/18/17 at 10:48 AM in resident room #213 revealed a bath basin was sitting on the floor under a sink in the room. The bath basin was not in a plastic bag and there was no resident name visible on the basin. Observations on 01/19/17 at 9:00 AM in resident room #213 revealed a bath basin was sitting on the floor under a sink in the room. The bath basin was not in a plastic bag and there was no resident name visible on the basin. Observations on 01/20/17 at 11:18 AM in resident room #213 revealed a bath basin was sitting on the floor under a sink in the room. The bath basin was not in a plastic bag and there was no resident name visible on the basin. b. Observations on 01/18/17 at 10:27 AM in resident room #312 revealed a bath basin was sitting on the floor under a sink in the room. The bath basin was not in a plastic bag and there was no resident name visible on the basin. Observations on 01/19/17 at 3:09 PM in resident room #312 revealed a bath basin was sitting on the floor under a sink in the room. The bath basin was not in a plastic bag and there was no resident name visible on the basin. Observations on 01/20/17 at 11:26 AM in resident room #312 revealed a bath basin was sitting on the floor under a sink in the room. The bath basin was not in a plastic bag and there was no resident name visible on the basin. During a tour and interview on 01/20/17 at 11:49 with the Director of Nursing (DON) she explained resident care equipment was supposed to be labeled with the residents name with included bath basins. She stated bath basins were not supposed to be stored on the floor in resident rooms but should be stored in the resident's closet. During the tour the DON verified the bath basins in resident room #213 and #312 had no resident name on them and she was not sure why staff had not labeled them and they should not have been left on the floor. 2. a. Observations on 01/17/17 at 12:06 PM revealed the smoke prevention doors on the 200 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/18/17 at 10:50 AM revealed the smoke prevention doors on the 200 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/20/17 at 11:15 AM revealed the smoke prevention doors on the 200 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. b. Observations on 01/17/17 at 12:09 PM revealed the smoke prevention doors on the 400 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/18/17 at 10:55 AM revealed the smoke prevention doors on the 400 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/20/17 at 11:30 AM revealed the smoke prevention doors on the 400 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. 3. a. Observations on 01/18/17 at 11:16 AM revealed 2 doors to the main dining room with broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/19/17 at 11:35 AM revealed 2 doors to the main dining room had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/20/17 at 11:40 AM revealed 2 doors to the main dining room had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. b. Observations on 01/17/17 at 12:02 PM revealed the day room/dining door and the dining room door on the 300 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/19/17 at 11:45 AM revealed the day room/dining door and the dining room door on the 300 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. Observations on 01/20/17 at 11:22 AM revealed day room/dining door and the dining room door on the 300 hall had broken and splintered laminate on the edges of the lower half of the doors that were rough to touch. 4. a. Observations on 01/17/17 at 12:37 PM revealed the bathroom door in resident room #108 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/18/17 at 10:28 AM revealed the bathroom door in resident room #108 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/19/17 at 12:32 PM revealed the bathroom door in resident room #108 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/20/17 at 11:12 AM revealed the bathroom door in resident room #108 had broken and splintered laminate that were rough to the touch on the edges of the lower half of the door. b. Observations on 01/17/17 at 3:10 PM revealed the bathroom door in resident room #211 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/19/17 at 9:20 AM revealed the bathroom door in resident room #211 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/20/17 at 11:18 AM revealed the bathroom door in resident room #211 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. c. Observations on 01/18/17 at 10:47 AM revealed the bathroom door in resident room #213 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/19/17 at 9:24 AM revealed the bathroom door in resident room #213 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/20/17 at 11:19 AM revealed the bathroom door in resident room #213 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. d. Observations on 01/18/17 at 9:59 AM revealed the bathroom door in resident room #303 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/19/17 at 9:25 AM revealed the bathroom door in resident room #303 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/20/17 at 11:23 AM revealed the bathroom door in resident room #303 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. e. Observations on 01/18/17 at 9:45 AM revealed the bathroom door in resident room #305 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/19/17 at 9:30 AM revealed the bathroom door in resident room #305 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/20/17 at 11:24 AM revealed the bathroom door in resident room #305 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. f. Observations on 01/17/17 at 2:35 PM revealed the bathroom door in resident room #310 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/18/17 at 9:56 AM revealed the bathroom door in resident room #310 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/20/17 at 11:28 AM revealed the bathroom door in resident room #310 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. g. Observations on 01/18/17 at 10:27 AM revealed the bathroom door in resident room #312 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/19/17 at 9:37 AM revealed the bathroom door in resident room #312 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. Observations on 01/20/17 at 11:26 AM revealed the bathroom door in resident room #312 had broken and splintered laminate that was rough to the touch on the edges of the lower half of the door. 5. Observations on 01/17/17 at 02:35 PM in the bathroom of resident room #310 revealed a large white vinyl base plate for the toilet had shifted partially out from under the base of the toilet and a bolt at the base of the toilet was broken and the grout around the base of the toilet was cracked. Observations on 01/18/17 at 9:56 AM in the bathroom of resident room #310 revealed a large white vinyl base plate for the toilet had shifted partially out from under the base of the toilet and a bolt at the base of the toilet was broken and the grout around the base of the toilet was cracked. Observations on 01/19/17 at 9:36 AM in the bathroom of resident room #310 revealed a large white vinyl base plate for the toilet had shifted partially out from under the base of the toilet and a bolt at the base of the toilet was broken and the grout around the base of the toilet was cracked. Observations on 01/20/17 at 11:28 AM in the bathroom of resident room #310 revealed a large white vinyl base plate for the toilet had shifted partially out from under the base of the toilet and a bolt at the base of the toilet was broken and the grout around the base of the toilet was cracked. 6. Observations on 01/18/17 at 1:40 PM in resident room #311 revealed a clear guard to protect edges of a wall from damage was located on the edge of a corner wall at the bathroom but was broken off from the top partially down the wall with rough edges to the touch. Observations on 01/19/17 at 9:38 AM in resident room #311 revealed a clear guard to protect edges of a wall from damage was located on the edge of a corner wall at the bathroom but was broken off from the top partially down the wall with rough edges to the touch. Observations on 01/20/17 at 11:25 AM in resident room #311 revealed a clear guard to protect edges of a wall from damage was located on the edge of a corner wall at the bathroom but was broken off from the top partially down the wall with rough edges to the touch. 7. a. Observations on 01/18/17 at 9:45 AM revealed in resident room #305 a section of base molding was missing at a corner next to the bathroom. Observations on 01/19/17 at 9:30 AM revealed in resident room #305 a section of base molding was missing at a corner next to the bathroom. Observations on 01/20/17 at 11:24 AM revealed in resident room #305 a section of base molding was missing at a corner next to the bathroom. b. Observations on 01/18/17 at 10:49 AM between the therapy department and the entrance to the 100 hall the vinyl molding at the floor on a corner was pulled apart from the wall and was slit open. Observations on 01/19/17 at 9:40 AM between the therapy department and the entrance to the 100 hall the vinyl molding at the floor on a corner was pulled apart from the wall and was slit open. Observations on 01/20/17 at 11:11 AM between the therapy department and the entrance to the 100 hall the vinyl molding at the floor on a corner was pulled apart from the wall and was slit open. During an interview and environmental tour on 01/20/17 at 11:59 AM with the Maintenance Director he explained the facility utilized a work order system and there was a clipboard in between the nurse's stations to write things down that needed repair. He stated he had an assistant to help him and they checked the clipboard several times a day and they checked items off when the repair was completed. He further stated he or his assistant were on call for 24 hours a day, 7 days a week and he expected for staff to report everything that needed repair. He explained he did orientation with new employees and oriented them to the work order system and showed them where the work order clipboard was located. He stated they had replaced all resident room doors within the last year but were not doing anything at the present time with repairs to other doors in the facility. He confirmed the smoke prevention doors on the 200 and 400 halls, doors in resident bathrooms and dining room doors had been damaged and needed repair. He explained the missing base molding in resident room #305 had not been reported to him and he had not noticed the damage to the cove molding between the therapy department and the entrance to the 100 hall. He further explained he had not been made aware of the damage to the corner guard on the edge of the bathroom wall in resident room #311. He stated the toilet in the bathroom of resident room #310 looked as if it had been kicked loose and confirmed the base plate that was supposed to be under the base of the toilet was partially out from under the toilet and bolt flange was broken on the base on the right side of toilet and the toilet was loose at the floor and had not been reported to him. During an interview and tour on 01/20/17 at 12:38 PM with the Administrator she stated maintenance staff had started using a maintenance request log for staff to document anytime they saw something that needed repair. She explained maintenance staff checked the log each day and then they brought requests to her for approval if expenses were involved. She stated it was her expectation for staff to report repairs which included damage to doors, toilets, edge guards on walls and base molding to the maintenance staff and she expected for maintenance staff to complete the repairs.

Based on observations and staff interviews the facilities Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in January of 2016. This was for one recited deficiency which were originally cited in December of 2015 on a Recertification survey and subsequently recited on the current recertification survey. The deficiency was in the area of housekeeping and maintenance services. The continued failure of the facility during two federal surveys of record show a pattern of the facilities inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referred to: F 253 Housekeeping and Maintenance Services. Based on observations and staff interviews the facility failed to label resident's personal care items and store them off the floor which included 2 bath basins in resident room [ROOM NUMBER] and #312 (on 2 of 4 resident hallways), failed to repair smoke prevention doors on the 200 and 400 hallways with broken and splintered laminate and wood on the lower edges of the doors (on 2 of 4 resident hallways), failed to repair doors to the main dining room and to the door of the day room/dining room on the 300 hall with broken and splintered laminate and wood on the lower edges of the doors, failed to repair bathroom doors in 7 resident rooms (room [ROOM NUMBER], #211, #213, #303, #305, #310 and #312) with broken and splintered laminate and wood on the lower edges of the doors (on 3 of 4 resident hallways), failed to repair a loose toilet with a broken bolt at the base of the toilet in the bathroom of resident room [ROOM NUMBER], failed to repair an edge guard on a wall in resident room [ROOM NUMBER] and failed to repair base molding in resident room [ROOM NUMBER] and between the therapy department and entrance to the 100 hall. During the recertification survey of 12/04/15 the facility was cited for failure to repair resident doors with broken and splintered laminate and wood on 13 of 59 resident doors (Resident room [ROOM NUMBER], #104, #105, #106, #108, #109, #110, #111, #114, #208, #404, #406 and #415); failed to repair bathroom doors with broken and splintered laminate and wood in 3 of 59 resident rooms (room [ROOM NUMBER], #114 and #403); failed to repair broken and splintered laminate and wood on 4 of 4 central bath doors on 100, 200, 300 and 400 halls; failed to label and cover personal care equipment in 2 resident bathrooms (Resident rooms [ROOM NUMBERS]) on 300 hall and 2 resident bathrooms on 400 hall (Resident rooms [ROOM NUMBERS]) and failed to keep 2 resident wheelchairs clean on 400 hall (Residents #126 and #156). During an interview with the Administrator on 01/20/16 at 4:30 PM she explained after the last recertification survey the plan of correction for environmental and maintenance issues was developed to roll out a little at a time and more work needed to be done. She stated they did incorporate the environmental and maintenance concerns last year in the Quality Assurance and Assessment process but focused on damage to resident room doors and corrected them. She explained they had developed the maintenance work order system and she expected for staff to report damage to doors or other damage on a work order and she expected for maintenance to do repairs. She stated she did not feel there had been a failure to communicate but it was more of a timing issue and they had not been able to get all of the environmental and maintenance problems fixed before the survey was conducted.

Based on observation, record review, and staff interviews the facility failed to remove 10 expired antiemetic suppositories (promethazine) from 1 of 2 medication storage refrigerators. Findings included: A review of the facility policy entitled A Guide to Medication Utilization Expiration Dates and was revised on 06/21/06 indicated drugs including those in the medication carts as well as those in the medication room were to be checked monthly for an expiration date by nursing personnel. If the drug was outdated, it would be disposed of as per state and federal laws. On 01/20/2017 at 08:27 AM 5 Promethazine 12.5 mg (milligram) suppositories with an expiration date of 07/2016 and 5 Promethazine 12.5 mg suppositories with an expiration date of 10/2016 were observed in 1 of 2 medication refrigerators in a clear plastic zip lock bag with an expiration date written on the outside of the bag as 12/2017. On 01/20/16 at 8:30 AM an interview was conducted with Nurse #1 who verified 5 Promethazine 12.5 mg suppositories had expired on 07/2016 and 5 Promethazine 12.5 mg suppositories had expired on 10/2016 and were in the medication refrigerator ready for resident use. Nurse #1 immediately removed the 10 expired Promethazine suppositories from the medication refrigerator. On 01/20/2017 at 9:01 AM an interview was conducted with the Director of Nursing (DON) who verified that 5 Promethazine 12.5 mg suppositories were expired on 07/2016 and 5 Promethazine 12.5 mg suppositories were expired on 10/2016 and were in the medication refrigerator ready for resident use. The DON stated it was the responsibility of the treatment nurse to check the medication refrigerator 3 days a month and it was her expectation that the treatment nurse would have removed the expired Promethazine suppositories from the medication refrigerator. The DON stated it was her expectation that the nursing staff would check for expired medication prior to administering any medication to the resident. The DON stated moving forward the medication refrigerator would be checked on a daily basis and individual medication stored in the refrigerator would be checked for expiration. On 01/20/2017 at 9:13 AM an interview was conducted with the Administrator who stated her expectation was that the DON or her designee would have been responsible to assure that expired medications were not available in the medication refrigerator ready for resident use. The Administrator stated moving forward that any individual medication stored in a plastic bag and labeled with an expiration date on the outside of the bag would be checked by nursing to assure the medication had not expired. On 01/20/2017 at 10:28 AM an interview was conducted with Nurse #2 who stated she was responsible to check the medication refrigerator for expired medication. Nurse #2 stated she checked the medication refrigerator this month and must have missed the expired Promethazine suppositories.

Based on observations and staff interviews the facility failed to repair resident doors with broken and splintered laminate and wood on 13 of 59 resident doors (Resident room #101, #104, #105, #106, #108, #109, #110, #111, #114, #208, #404, #406 and #415); failed to repair bathroom doors with broken and splintered laminate and wood in 3 of 59 resident rooms (Room #108, #114 and #403); failed to repair broken and splintered laminate and wood on 4 of 4 central bath doors on 100, 200, 300 and 400 halls; failed to label and cover personal care equipment in 2 resident bathrooms (Resident rooms 310 and 313) on 300 hall and 2 resident bathrooms on 400 hall (Resident rooms 401 and 402) and failed to keep 2 resident wheelchairs clean on 400 hall (Residents #126 and #156). The findings included: 1. Resident room doors were observed as follows: a. Observations of Room 101 on 12/02/15 at 9:14 AM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 3:58 PM revealed the door of resident room 101 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:20 AM revealed the door of resident room 101 had broken and splintered laminate on the front of the bottom half of the door. b. Observations of Room 104 on 12/02/15 at 3:35 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 3:58 PM revealed the door of resident room 104 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:21 AM revealed the door of resident room 104 had broken and splintered laminate on the front of the bottom half of the door. c. Observations of Room 105 on 12/02/15 at 3:40 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 3:59 PM revealed the door of resident room 105 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:22 AM revealed the door of resident room 105 had broken and splintered laminate on the front of the bottom half of the door. d. Observations of Room 106 on 12/02/15 at 3:39 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:00 PM revealed the door of resident room 106 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:22 AM revealed the door of resident room 106 had broken and splintered laminate on the front of the bottom half of the door. e. Observations of Room 108 on 12/02/15 at 3:41 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:01 PM revealed the door of resident room 108 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:25 AM revealed the door of resident room 108 had broken and splintered laminate on the front of the bottom half of the door. f. Observations of Room 109 on 12/02/15 at 3:45 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:01 revealed the door of resident room 109 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:25 AM revealed the door of resident room 109 had broken and splintered laminate on the front of the bottom half of the door. g. Observations of Room 110 on 12/02/15 at 3:46 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:02 PM revealed the door of resident room 110 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:26 AM revealed the door of resident room 110 had broken and splintered laminate on the front of the bottom half of the door. h. Observations of Room 111 on 12/02/15 at 3:47 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:02 PM revealed the door of resident room 111 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:27 AM revealed the door of resident room 111 had broken and splintered laminate on the front of the bottom half of the door. i. Observations of Room 114 on 12/02/15 3:48 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 4:03 PM revealed the door of resident room 114 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:28 AM revealed the door of resident room 114 had broken and splintered laminate on the front of the bottom half of the door. j. Observations of Room 208 on 12/02/15 at 4:05 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:03 PM revealed the door of resident room 208 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:32 AM revealed the door of resident room 208 had broken and splintered laminate on the front of the bottom half of the door. k. Observations of Room 404 on 12/02/15 at 4:06 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:11 PM revealed the door of resident room 404 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:42 AM revealed the door of resident room 404 had broken and splintered laminate on the front of the bottom half of the door. l. Observations of Room 406 on 12/02/15 at 4:07 PM revealed the door of the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:12 PM revealed the door of resident room 406 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:43 AM revealed the door of resident room 406 had broken and splintered laminate on the front of the bottom half of the door. m. Observations of Room 415 on 12/02/15 at 4:09 PM revealed the door of the resident's room had broken and splintered laminate with a large area of laminate broken off on the front of the bottom half of the door. Observations on 12/03/15 at 4:16 PM revealed the door of resident room 415 had broken and splintered laminate with a large area of laminate broken off on the front of the bottom half of the door. Observations on 12/04/15 at 8:47 AM revealed the door of resident room 415 had broken and splintered laminate with a large area of laminate broken off on the front of the bottom half of the door. 2. Resident bathroom doors were observed as follows: a. Observations of Room 108 on 12/02/15 at 3:41 PM revealed the bathroom door inside the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:01 PM revealed the bathroom door inside resident room 108 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:25 AM revealed the bathroom door inside of resident room 108 had broken and splintered laminate on the front of the bottom half of the door. b. Observations of Room 114 on 12/02/15 at 3:48 PM revealed the bathroom door inside the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:03 PM revealed the bathroom door inside resident room 114 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:28 AM revealed the bathroom door inside of resident room 114 had broken and splintered laminate on the front of the bottom half of the door. c. Observations of Room 403 on 12/02/15 at 4:07 PM revealed the bathroom door inside the resident's room had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/03/15 at 4:10 PM revealed the bathroom door inside resident room 403 had broken and splintered laminate on the front of the bottom half of the door. Observations on 12/04/15 at 8:41 AM revealed the bathroom door inside of resident room 403 had broken and splintered laminate on the front of the bottom half of the door. 3. Observations of the central bath doors were observed as follows: a. Observations on 12/02/15 at 3:39 PM revealed the central bath door on the 100 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/03/15 at 3:59 PM revealed the central bath door on the 100 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/04/15 at 8:23 AM revealed the central bath door on the 100 hall had broken and splintered laminate and wood on the front of the bottom half of the door. b. Observations on 12/02/15 at 4:05 PM revealed the central bath door on the 200 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/03/15 at 4:03 PM revealed the central bath door on the 200 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/04/15 at 8:33 AM revealed the central bath door on the 200 hall had broken and splintered laminate and wood on the front of the bottom half of the door. c. Observations on 12/02/15 at 4:09 PM revealed the central bath door on the 300 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/03/15 at 4:07 PM revealed the central bath door on the 300 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/04/15 at 8:37 AM revealed the central bath door on the 300 hall had broken and splintered laminate and wood on the front of the bottom half of the door. d. Observations on 12/02/15 at 4:19 PM revealed the central bath door on the 400 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/03/15 at 4:16 PM revealed the central bath door on the 400 hall had broken and splintered laminate and wood on the front of the bottom half of the door. Observations on 12/04/15 at 8:47 AM revealed the central bath door on the 400 hall had broken and splintered laminate and wood on the front of the bottom half of the door. During an environmental tour and interview on 12/04/15 at 10:39 AM the Maintenance Director verified all of the resident room doors on the 100 hall had damaged wood and laminate. He explained he and his assistant tried to sand and patch the doors but they had to be careful when the doors were badly damaged and sometimes the doors needed to be replaced. He also verified the doors that had splintered wood and laminate needed to be sanded to remove any splinters or rough edges. He explained all staff had access to work orders and the forms were kept at the nurse's stations. He stated maintenance staff phone numbers were also posted at each nurse's station and they were on call 24 hours a day for 7 days a week to make repairs. He explained he expected for staff to put work orders on a clipboard at the nurse's station and maintenance staff checked it first thing each morning and several times throughout each day. He stated he also asked staff at the nurse's stations if they had any maintenance issues or repairs that needed to be done on a daily basis. He explained he and his assistant started work each day on work orders they received from the night shift then started their big project of the day and the regular preventive maintenance. He stated they tried to work on any new maintenance issues in between the regular preventative maintenance and dealt with big stuff that was broken. He further stated maintenance staff relied on facility staff to tell them what was damaged or broken and he was unaware some of the resident doors and bathroom doors were splintered and so badly damaged. He explained he had sanded all of the central bath doors in the past but when staff bumped lifts and equipment into the edges of the doors it splintered the laminate and wood and they needed to be repaired or replaced. During an interview on 12/04/15 at 1:57 PM the Administrator stated it was her expectation when maintenance staff made their random rounds they should identify damaged doors and get them corrected at the time it was found. She stated maintenance staff had sanded doors in the past but many of the doors needed to be replaced and doors with splintered wood and laminate should be repaired or replaced. 4. Personal care equipment was observed not labeled, covered, clean and/or stored properly as follows: a. Room 310's bathroom, shared by 2 residents, was observed on 12/03/15 at 8:58 AM to have an uncovered, unlabeled wash basin which contained 2 unlabeled emesis basins stacked inside the wash basin located on the back of the commode. There was also a triangular specimen cup with urine residue which was not labeled or covered. On 12/04/15 at 10:51 AM there was an unlabeled uncovered bedpan on the back of the commode. b. Room 313's bathroom, shared by 2 residents, was observed on 11/30/15 at 3:44 PM with 2 unlabeled uncovered urinals on the back of the commode and a seat extender with arm supports located directly on the floor. On 12/01/15 at 8:23 AM observations revealed 1 of 2 urinals wre uncovered and unlabeled on the back of the commode. On 12/02/15 at 11:18 AM the back of the commode was observed with 1 unlabeled uncovered urinal on the back of the commode which had urinal residue inside along with 2 covered urinals. There was a commode seat extender with handrails on the floor at this time. These items remained the same during observations made on 12/03/15 at 2:22 PM and on 12/04/15 at 10:52 AM. c. Room 401's bathroom, shared by 2 residents, was observed on 11/30/15 at 3:19 PM with an unlabeled uncovered wash basin on the back of the commode. The wash basin was observed on the back of the commode, unlabeled and uncovered on 12/02/15 at 11:30 AM, on 12/03/15 at 8:43 AM and at 2:44 PM, and on 12/04/15 at 10:37 AM. d. Room 402's bathroom, shared by 2 residents, was observed on 11/30/15 at 3:25 PM with unlabeled uncovered urinals located on the back of the commode. On 12/01/15 at 9:35 AM the unlabeled, uncovered urinal was observed on the back of the commode soiled with urine residue. On 12/03/15 at 8:48 AM and at 2:44 PM, and on 12/04/15 at 10:35 AM the urinal remained on the back of the commode, unlabeled and uncovered. Interview with Nurse #3 on 12/04/15 at 10:38 AM revealed personal care equipment should be covered with a paper cover which was labeled with the appropriate resident's name. On 12/04/15 at 10:46 AM, Nurse #3 observed the personal care equipment in Rooms 401 and 402. Nurse #3 confirmed the equipment was not stored and labeled correctly. Interview with Nurse Aide (NA) #2 on 12/04/15 at 10:40 AM revealed personal care equipment should be stored in the bathroom, covered and labeled. He confirmed that the urinal in Room 401 was improperly stored and the was basin in Room 401 should not be in the bathroom. On 12/04/15 at 10:54 AM, NA #3 stated personal care equipment was to be covered in bags and labeled with resident names. During observations of equipment on the 300 hall at this time with NA #3, NA #3 stated that the residents in Room 313 used the bathroom independently but the urinals should be covered and labeled and she was unsure if the seat extender was in working order. Interview with the Director of Nursing on 12/04/15 at 12:03 PM revealed personal care equipment should be kept in the bathrooms covered and labeled if not preferred otherwise. In addition she stated the seat extender should not be kept on the floor. 5. Soiled wheelchairs and worn, cracked, vinyl arm rests on the wheelchairs were observed as follows: a. Resident #156's wheelchair was observed on 11/30/15 at 3:10 PM with crumbs and sticky residue on, under and on the sides of the seat cushion. This remained the same when observed on 12/01/15 at 11:39 AM. On 12/03/15 at 8:24 AM, Resident #156 was observed in the dining room in her wheelchair that had dried food spills on the cushion, down the sides of the wheelchair, and on to the wheelchair's tires. The wheelchair was observed soiled with dried food spills on the sides of the wheelchair, food crumbs and dried spills in and around the seat cushion and along the metal supports on 12/03/15 at 2:42 PM and on 12/04/15 at 10:32 AM. In addition, during all these observations the right arm rest of the wheelchair was observed covered in vinyl which was cracked and split exposing the under layer material. b. Resident #126's wheelchair was observed on 12/01/15 at 9:35 AM in his wheelchair which had dried food residue on the front metal supports extending from the arm rests on the left side. On 12/01/15 at 11:27 AM the wheelchair remained soiled and the dried food debris was noted on the seat and on the foot rests of the wheelchair. The wheelchair remained soiled with dried food debris and spills on the cushion, and down the supports, foot rests and calf rests during observations made on 12/02/15 at 11:31 AM, and 12/04/15 at 10:35 AM. On 12/04/15 at 8:05 AM, the Maintenance Director stated he did not keep any work orders as it created too much paperwork. He stated that the maintenance department washed down the wheelchairs by hall every quarter and that the third shift nursing staff were assigned to wipe the wheelchairs down in between. On 12/04/15 at 8:20 AM, the Maintenance Director stated he kept no records of when the last time Residents #126's and #156's wheelchairs were washed by the the maintenance department. As far as a schedule, he stated that the wheelchairs were spread out over the course of the quarter but with no set schedule. On 12/04/15 at 10:38 AM, Nurse #3 stated that wheelchairs were generally cleaned during night shift alone with maintenance washing them. If a staff person sees that a wheelchair was dirty, Nurse #3 stated staff would wipe them down. In addition, if the wheelchair arm rests need to be replaced, a work order should be given for maintenance department who will replace cracked vinyl arm rests. On 12/04/15 at 10:40 AM, Nurse Aide (NA) #2 stated night shift has a schedule that designate when the wheelchairs were to be cleaned. NA #2 stated that nurse aides also were to use disinfectant spray to wash wheelchairs when they saw they needed cleaning. Upon observing the wheelchairs for Residents #126 and #156 at this time, he stated they needed to be cleaned. Interview with the Director of Nursing (DON) on 12/04/15 at 12:03 PM revealed wheelchairs were cleaned by nursing staff per a schedule. In addition, staff were to sign a form indicating they cleaned the wheelchair as scheduled. Review of this schedule showed that Residents #156's and #126's wheelchairs were scheduled to be cleaned by third shift each Monday. The DON was unable to find documentation that the wheelchairs were cleaned on Monday. She further stated nursing staff should wipe down soiled wheelchairs as they find them.

Based on observations, record review, staff and resident interviews, the facility failed to maintain safe water temperatures in residents' sinks on 3 of 4 halls. (Halls 100, 300 and 400); and failed to apply a lap tray using the quick release method of the push buckle attached to the lap tray for 1 of 1 sampled resident with a lap tray. (Resident #130). The findings included: 1. On the first day of the survey, water temperatures were observed in the sinks of resident rooms to be hot to touch and/or measured as follows: *Room 109 on 11/30/15 at 4:26 PM the water in the sink was observed by the surveyor to be too hot to hold her hand under the water. *Room 309 on 11/30/15 at 3:36 PM the water in the the sink was observed to register 120 degrees Fahrenheit with the surveyor's thermometer and was hot to touch. *Room 310 on 11/30/15 at 3:40 PM the water in the room's sink measured 120 degrees Fahrenheit with the surveyor's thermometer and was hot to touch. *Room 315 on 11/30/15 at 3:48 PM the water in the sink was tested with the surveyor's thermometer and measured 122 degrees Fahrenheit and was hot to touch. On 12/01/15 at 11:09 AM Resident #183 who resided in this room denied the water was too hot. *Room 400 on 11/30/15 at 3:10 PM the water temperature in the room's sink with the surveyor's thermometer measured 120 degrees Fahrenheit and was hot to touch. *Room 401 was observed on 11/30/15 at 3:19 PM to have water temperatures in the room's sink to measure 120 degrees Fahrenheit with the surveyor's thermometer and was was noted hot to touch. *Room 402 on 11/30/15 at 3:25 PM the water in the room's sink measured 120 degrees Fahrenheit with the surveyor's thermometer and was hot to touch. *Room 403 on 11/30/15 at 3:29 PM, the water temperature in the room's sink with the surveyor's thermometer registered 120 degrees Fahrenheit and was hot to touch. *Room 411 on 11/30/15 at 3:37 PM the sink in the resident's room felt very hot to the surveyor and the surveyor was unable to keep her hand underneath the running water without her hand becoming very red and hot. On 11/30/15 at 3:29 PM Resident #47 residing in Room 105 stated the water in her sink sometimes got too hot. An interview was conducted with the Assistant Maintenance Director (AMD) on 11/30/15 at 4:01 PM (as the Maintenance Director had gone home with an injury). The AMD stated that maintenance staff check 2 resident rooms per hall and all shower rooms weekly for water temperatures. He stated the rooms generally run between 111 and 113 degrees Fahrenheit. He further stated that the times of the days and locations change each time. On 11/30/15 at 4:05 PM, the surveyor and the AMD checked water temperatures with the calibrated thermometer staff retrieved from the dietary department and found: *Room 306 was 117 degrees Fahrenheit; and *Room 309 was 116 degrees Fahrenheit. On 11/30/15 at 4:09 PM, observations were made of the mixing valve at the boiler and it was noted to be set at 118 degrees Fahrenheit. The AND and surveyor checked more rooms with the staff's thermometer on 11/30/15 at 4:11 Pm and found: *Room 400 was 118 degrees Fahrenheit; *Room 411 was 115 degrees Fahrenheit; *Room 108 was 112 degrees Fahrenheit; and *Room 109 was 114 degrees Fahrenheit. AMD stated he had observed fluctuating temperatures. He reported on 11/30/15 at 4:33 PM that last week the Maintenance Director adjusted the mixing valve due to complaints the water was too cold. Review of the temperature logs revealed weekly temperatures were taken in different rooms but the times were not recorded. The logs showed temperatures ranged from 111 to 113 degrees Fahrenheit. Further interview with the AMD on 11/30/15 at 4:36 PM revealed the highest staff ever turned the mixing valve up to was 120 degrees Fahrenheit. He revealed that the Maintenance Director told him that he turned the mixing valve up after several residents complained their showers were too cold. He stated the water was checked before the adjustment and registered 113 degrees Fahrenheit and after the adjustment the water measured 115 degrees Fahrenheit. AMD stated the temperatures of the water were checked earlier this date and were fine. On 12/01/15 at 7:50 AM AMD stated he readjusted the mixing valve down a few degrees and he would be retesting the water temperatures. With the surveyor's thermometer, water in the sink of Room 400 registered on 12/01/15 at 8:54 AM at 120 degrees Fahrenheit and was too hot for the surveyor to keep her hand under the running water, turning the surveyor's hand red. On 12/01/15 at 9:16 AM the surveyor and AMD went to room 400 and hand tested the water in the sink. The water was too hot for the surveyor to keep her hand under it and AMD agreed the temperature was too hot. With 2 more calibrated thermometers from the dietary department more testing was done in Rooms 412, and 306 on 12/01/15 at 9:50 AM and water ranged from 108 to 110 degrees Fahrenheit. On 12/02/15 at 8:44 PM AMD stated the last time the mixing valve was cleaned with vinegar per manufacturer's recommendations was about 2 months ago, however, there was no documentation of this cleaning. Together the surveyor and AND hand tested the water in Room 400 and noted as the water ran the temperature of the water heated to the point the surveyor's hand turned red. AMD acknowledged the water was getting hotter. With the staff thermometer the water in this room tested at 8:51 AM at 110 degrees Fahrenheit. The water was observed to fluctuate in temperature as the water ran. AMD stated at this time there were pockets of hot and cold water in the pipes causing the fluctuations. On 12/02/15 at 9:04 AM, Nurse Aide (NA) #4 stated that the water fluctuates and sometimes gets very hot. She further stated you have to watch it and keep a close eye on the temperature as you use the water. She stated that if the water temperature rises you added cold water. She has reported the hot water to maintenance and they adjusted it. She stated she had not noticed the water temperatures being hot for a while. NA #5 stated during interview on 12/02/15 at 2:33 PM that the water temperatures fluctuated and if she found the water getting too hot, she adjusted it with cold water. She stated she had told maintenance about the water but it had not been an issue lately. Housekeeping staff #1 stated on 12/02/15 at 10:57 AM that she washed her hands before leaving each resident room. She stated that sometimes the water got hot and she had to add cold water. When this has happened she completed a work order for maintenance to check the water temperatures. The last time she recalled reporting hot water was about a month ago. On 12/04/15 at 8:05 AM, the Maintenance Director stated he did not keep work orders as it got to be too much paperwork. There was no way to determine the last time someone requested the hot water be adjusted. 2. Resident #130 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The initial Minimum Data Set ((MDS) dated [DATE] coded Resident #130 with long and short term memory impairment, being nonambulatory, and requiring extensive assistance with all activities of daily living skills. On 03/18/15 the physician ordered a tabletop to the wheelchair for positioning. The last quarterly MDS dated [DATE] noted Resident #130 had not had any significant changes since the initial MDS. Physician orders [REDACTED]. The care plan for ADLs, last updated on 09/14/15 included the intervention of a high back wheelchair with a table top for positioning. On 12/04/15 at 11:35 AM Resident #130 was observed in a high back wheelchair with a lap tray in place. He was pulling up on the tray repeatedly. Upon further observation, the tray consisted of straps on both sides of the tray with a plastic push button buckle located behind the chair back. The right side strap was tied around the arm support tofu the wheelchair and the left strap dangled behind the wheelchair, unattached. On 12/04/15 at 11:37 AM Nurse #4 stated during interview he will wiggle the lap tray. Observation of the lap tray at this time revealed the left side was not attached and the right side was tied around the right arm support. Nurse #4 proceeded to tie the left strap around the arm support of the wheelchair, leaving the buckle unused. When asked about the buckle, Nurse #4 stated that if the buckle was used, the lap tray would be too tight around his abdomen. While Nurse #4 and the surveyor were examining the lap tray, Resident #130's roommate spoke up and stated the family had been in and left the tray table unattached. On 12/04/15 at 12:15 PM, the Director of Nursing (DON) and surveyor observed the lap tray tied to both arm supports of the wheelchair and the buckle unattached. DON stated the lap tray was not applied correctly with the buckle so that it was able to be immediately removed from the resident. Follow up interview with Nurse #4 on 12/04/15 at 12:26 PM revealed she had not been taught how to apply the lap tray. The Administrator stated on 12/04/15 at 12:38 PM that Nurse #4 had been trained and should have known the lap tray was incorrectly applied when tied to the arm supports of the wheelchair.

Based on record review, observations, and staff interviews the facility failed to follow the care plan to provide repositioning of a resident at risk for skin breakdown for 1 of 3 sampled residents reviewed for pressure ulcers (Resident #34). The findings included: Resident #34 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #34 was moderately cognitively impaired and rarely/never understood and/or understand. Further review of the MDS indicated Resident #34 required extensive assistance with bed mobility and eating, and was totally dependent on staff for transfers, dressing, toileting, personal hygiene, and bathing. Resident #34 was also coded as always incontinent of bowel and bladder. Review of a care plan updated on 11/02/15 revealed Resident #34 was at risk for skin breakdown related to impaired mobility which required 1 to 2 person physical assistance to total care. Further review of the care plan indicated approaches to provide weekly skin assessments, pressure reducing mattress to bed, treatments per physician's orders [REDACTED]. On 11/30/15 at 3:51 PM until 4:03 PM, Resident #34 was observed sitting in the day room in a broda chair with the left side of his body leaned over the left side of the chairs armrest. The resident's armpit was touching the chairs armrest and his left hand was touching the floor. Resident #34 was observed to be incapable of repositioning himself upright in the broda chair. On 11/30/15 at 4:03 PM, Nurse #3 was observed to reposition Resident #34 upright in the broda chair and positioned the resident's left arm on the inside next to the armrest. On 12/01/15 at 8:45 AM, Resident #34 was observed setting in a broda chair and was pushed by Nurse Aide (NA) #6 from the dining room into the hallway outside the resident's room. On 12/01/15 with continuous observations from 8:45 AM until 11:15 AM, Resident #34 remained seated in the broda chair outside his room in the hallway asleep. On 12/01/15 at 11:15 AM, NA #6 was observed to push Resident #34 into his room where he was left setting in the broda chair beside his bed. On 12/03/15 from 8:35 AM until 10:50 AM, Resident #34 was observed lying in the bed and was positioned slightly onto his left side. During the continued observation, Resident #34 was unable to reposition himself in bed. On 12/03/15 at 10:50 AM, NA #6 was observed to complete incontinent care for Resident #34. NA #6 was further observed to change the resident's soiled bed linens, placed green colored sweatpants on the resident, placed a pillow underneath the resident's left side, and stated to Resident #34 I will put your sweatshirt on you before I take you to lunch. On 12/03/15 at 3:00 PM, an interview was conducted with NA #6. She confirmed she was responsible for the care of Resident #34 on 12/03/15 from 7::00 AM until 3:00 PM. She indicated the nurse aides were expected to reposition the residents every 2 hours and/or more often if necessary. NA #6 stated she was aware Resident #34 was susceptible to skin breakdown. She confirmed she had been instructed by the wound nurse at the beginning of her shift that Resident #34 had a reddened area to the left buttock and that he was to be kept off of the area and repositioned at least every 2 hours. NA #6 confirmed she had not repositioned Resident #34 every 2 hours and had no explanation as to why she had not repositioned the resident as she had been instructed at the beginning of her shift. On 12/03/15 at 3:55 PM, an interview was conducted with Nurse #5. She stated she expected the NAs to reposition a resident every 2 hours and/or more often should a resident be at risk and/or have skin breakdown. She further stated she expected the NAs to follow the resident's care plans. On 12/04/15 at 11:50 AM, a telephone interview was conducted with the Wound Treatment Nurse. She indicated she first observed the reddened area on Resident #34's buttocks on 12/02/15. She further indicated the area was considered to be an avoidable stage 1 pressure ulcer. The treatment nurse stated she had instructed the NAs and would have expected Resident #34 to have been repositioned every 2 hours. On 12/04/15 at 1:00 PM, the Director of Nursing (DON) was interviewed. The DON stated she expected the NAs to reposition the residents every 2 hours. The DON further stated she would have expected Resident #34 to have been repositioned every 2 hours per the care plan.