Every finding on record at Life Care Center of Sparta

Based on facility policy review, medical record review, meal tray ticket review, observations, and interviews, the facility failed to ensure the resident had an adaptive device placed properly for 1 resident (Resident #5) of 2 residents reviewed for adaptive devices. The findings include: Review of the facility's policy titled, Assistive Devices - Special Eating Equipment, revised 4/25/2023, revealed .facility provides residents with special eating equipment and assistive devices as deemed necessary .ensure .resident .properly use .devices when consuming meals .installing plate guards .provide .appropriate staff assistance .to ensure .residents .use the assistive devices when eating . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Epilepsy, and Hypertension. Review of a Nutrition: Assessment/Nutritional Data Collection for Resident #5 dated 7/29/2026, revealed .Resident requires .plate guard with meals to promote independence and QoL [Quality of Life] . Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of a comprehensive care plan dated 8/6/2026, for Resident #5 revealed .resident has an ADL [Activities of Daily Living] self-care performance deficit .plate guard . Review of an Occupational Therapy Note for Resident #5 dated 8/11/2026, revealed .assessment of self feeding and potential need for plate guard .Patient able to complete self feeding with use of plate guard at 6 pm [plate guard to be positioned at 6:00 PM on plate closest to resident] of plate . During an observation on 8/11/2026 at 7:45 AM, Resident #5 was sitting up in bed with breakfast tray with plate guard on side of plate away [Noon position on tray] from resident. During an observation on 8/11/2026 at 12:30 PM, Resident #5 was sitting up in bed with lunch tray in front of her and with plate guard away from resident. During an interview on 8/11/2026 at 12:35 PM, Certified Nursing Assistant (CNA) B stated plate guard was placed away from Resident #5 to allow the resident to scoop food. During an interview on 8/12/2026 at 10:45 AM, the Director of Nursing (DON) confirmed the plate guard for Resident #5 was placed incorrectly.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to properly store a nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for 1 resident (Resident #1) of 4 residents reviewed.The findings include:Review of the facility policy titled, Oxygen Administration (Infection Control, Safety, & Storage), reviewed 3/3/2026, revealed, .To ensure that oxygen is administered and stored safely .Infection Control .Store oxygen and respiratory supplies in a bag labeled ( i.e., resident name) when not in use .Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, and Pneumonia. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of a comprehensive care plan for Resident #1 dated 6/8/2026, revealed .resident has COPD, chronic respiratory failure .nebulizer treatments as ordered .Review of the Physician's Orders for Resident #1, dated 8/1/2026 - 8/31/2026, revealed an order with a start date of 6/3/2026, for .ipratropium-albuterol solution [medication used to open narrowed airways] for nebulization; 0.5 mg [milligrams]-3 mg [2.5 mg base]/3 mL [milliliters]; amt [amount]:1 vial; inhalation .inhale orally four times a day .During an observation in Resident #1's room on 8/10/2026 at 9:55 AM, a nebulizer mask and tubing was observed, uncovered, not stored in a bag, sitting on the bedside table near the resident's bed.During an observation and interview in Resident #1's room on 8/11/2026 at 8:52 AM, a nebulizer mask and tubing was observed, uncovered, not stored in a bag, sitting on the bedside table near the resident's bed. Registered Nurse (RN) A confirmed the nebulizer mask and tubing was undated and uncovered, not stored in a bag, sitting on the bedside table near the bed. RN A stated the nebulizers should be stored in a plastic bag and was unable to find a bag in Resident #1's room. RN A left Resident #1s room and returned with a plastic bag and placed the mask in the bag. During an interview on 8/12/2026 at 8:50 AM, the Director of Nursing (DON) confirmed the nebulizer mask should be stored in plastics bags.

Based on facility policy review, medical record review, observation and interview, the facility failed to implement appropriate infection prevention and control practices related to hand hygiene during medication administration for 1 resident (Resident #44) of 5 residents observed for medication administration.The findings include:Review of the facility's policy titled, Hand Hygiene, dated 6/1/2026, revealed .Hand hygiene will be followed by staff .Associates perform hand hygiene .After contact with objects and surfaces in the resident's environment . Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Aphasia, Dysarthria, and Heart Failure. Review of a Physician's Order for Resident #44 dated 6/25/2026, revealed .Clopidogrel Bisulfate Tablet [medication used for prevention of blood clots] 75 MG [milligram] .1 tablet by mouth one time a day .During an observation and interview of medication administration on 8/11/2026 at 7:55 AM, revealed Registered Nurse (RN) A sanitized hands with alcohol-based solution and began preparing oral medications for Resident #44. Clopidogrel to be retrieved from the [Medication dispensing machine] located on another wing of the facility. RN A returned to medication cart and continued preparing medications for Resident #44 without washing or sanitizing her hands after touching multiple surfaces. RN A entered resident's room and administered medications and had not washed or sanitized her hands. During an interview on 8/11/2026 at 8:25 AM, RN A confirmed she failed to follow proper infection control practices during the medication administration.

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure the call light was within reach for 1 resident (Resident #4) of 74 residents observed.The findings include: Review of the facility's policy titled, Resident Call System, revised 1/4/2023, revealed .the call light should be positioned within reach of the resident .The call system must be accessible to residents while in bed . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Dementia, Left Femur Fracture, and Syncope. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and was dependent on staff for ADL's (Activities of Daily Living) and personal hygiene. Review of a comprehensive care plan for Resident #4 revised 6/15/2026, revealed .resident has an ADL self-care performance deficit .Encourage the resident to use bell to call for assistance . During multiple observations on 8/10/2026 at 10:10 AM and 2:10 PM, Resident #4 was lying in bed, and soft call light was on the nightstand and out of reach of Resident #4. During an interview on 8/10/2026 at 2:15 PM, Certified Nursing Assistant (CNA) C confirmed Resident #4's soft call light was on the nightstand and out of resident's reach. During an interview on 8/10/2026 at 2:17 PM, Licensed Practical Nurse (LPN) D confirmed Resident #4's soft call light was on the nightstand and out of resident's reach. During an observation on 8/11/2026 at 7:35 AM, Resident #4 was lying in bed with soft call light on the nightstand and out of resident's reach. During an interview on 8/11/2026 at 7:38 AM, LPN E confirmed Resident #4's soft call light was on the nightstand and out of resident's reach. During an interview on 8/12/2026 at 8:00 AM, the Director of Nursing (DON) confirmed call lights should be within resident's reach and Resident #4's call light was not accessible for resident use.

Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including Dementia, Atrial Fibrillation, and Heart Failure. Review of the comprehensive care plan for Resident #69 dated 2/4/2025, revealed .discharge plan .wishes to return home . Review of a Progress Note for Resident #69 dated 4/3/2025, revealed .Resident discharging home at this time in the care of her daughter. Discussed discharge instructions with resident and daughter. No questions or concerns voiced . Review of a discharge MDS assessment dated [DATE], revealed Resident #69 had a planned discharge to an acute care hospital. During an interview on 5/13/2025 at 7:52 AM, the DON confirmed Resident #69 was discharged home and the discharge MDS assessment dated [DATE] was inaccurate. Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, observations, and interviews, the facility failed to accurately complete an MDS assessment for 2 residents (Resident #21 and Resident #69) of 19 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual dated 10/2024, revealed .discharge assessment .must be completed when the resident is discharged from the facility .SECTION A .discharge status .this item documents the location to which the resident is being discharged at the time of discharge .steps for assessment .review the medical record including the discharge plan and discharge orders for documentation of discharge location .coding instructions .Code Home/Community: if the resident was discharged to a private home .SECTION P . RESTRAINTS AND ALARMS .intent of this section is to record the frequency that the resident was restrained by any of the listed devices .was used at any time during the day or night, during the 7-day look-back period .Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories .Code 1, used less than daily: if the item met the definition and was used less than daily during the observation period .Trunk restraints include any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot easily remove . Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Diabetes Mellitus, and Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #21 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review of the quarterly MDS assessment revealed the resident had a trunk restraint used less than daily. Review of the comprehensive care plan for Resident #21 revised 3/17/2025, revealed the resident's plan of care did not include any limb restraints. During an observation and interview on 5/12/2025 at 12:00 PM, revealed Resident #21 lying in bed. Resident was able to move his lower extremities and there was no trunk restraint observed. The resident stated he had not used a trunk restraint at the facility. During an observation on 5/13/2025 at 8:15 AM, revealed Resident #21 was lying in bed and there was no trunk restraint observed in use. During an interview on 5/14/2025 at 7:50 AM, the Director of Nursing (DON) confirmed Resident #21 did not have a trunk restraint and the MDS assessment dated [DATE] was inaccurate.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene were followed during meal service when 1 staff member failed to offer hand hygiene assistance to 2 residents (Resident #10 and Resident #50) of 14 residents observed during meal tray distribution on 1 of 6 hallways. The findings include: Review of the facility's policy titled, Hand Hygiene for Residents, Families, and Visitors, revised 6/13/2023, revealed .the facility should assist either physically or through reminders to residents to perform hand hygiene .before meals . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Left-Sided Hemiplegia, Muscle Weakness, and Tremors. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident required partial or moderate assistance with personal hygiene. Review of the comprehensive care plan for Resident #10 revised 4/2/2025, revealed .self care deficit .assist with ADLs [activities of daily living] . Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including Abnormalities of Gait and Mobility, Polyosteoarthritis, and Unsteadiness on Feet. Review of a quarterly MDS assessment dated [DATE], revealed Resident #50 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident required supervision or touching assistance with personal hygiene. Review of the comprehensive care plan for Resident #50 revised 4/21/2025, revealed .limited physical mobility .assist with ADLs . During an observation on 5/12/2025 at 12:29 PM, in Resident #10's room, revealed Certified Nursing Assistant (CNA) A brought Resident #10's tray into the room and placed the meal tray in front of the resident. CNA A opened the resident's silverware and opened the plate warming dome from the plate of food. Resident #10 picked up his fork and began eating the meal. Continued observation revealed CNA A failed to offer Resident #10 hand hygiene assistance prior to the resident eating the lunch meal. During an interview on 5/12/2025 at 12:30 PM, Resident #10 stated the staff did not offer hand hygiene assistance prior to the lunch service. During an observation on 5/12/2025 at 12:31 PM, in Resident #50's room, revealed CNA A brought Resident #50's tray into the room and placed the meal tray in front of the resident. CNA A opened the resident's silverware and opened the plate warming dome from the plate of food. Resident #50 picked up her fork and began eating the meal. Continued observation revealed CNA A failed to offer Resident #50 hand hygiene assistance prior to the resident eating the lunch meal. During an interview on 5/12/2025 at 12:33 PM, Resident #50 stated the staff did not offer hand hygiene assistance prior to the lunch service. During an interview on 5/12/2025 at 12:34 PM, CNA A confirmed she failed to offer hand hygiene to Resident #10 and Resident #50 prior to serving the lunch meal. During an interview on 5/14/2025 at 7:54 AM, the Director of Nursing (DON) stated the staff were to offer hand hygiene assistance to all residents before meal service. The DON confirmed infection prevention and control practices were not maintained during the lunch meal service on 5/12/2025 when CNA A failed to offer Resident #10 and Resident #50 hand hygiene assistance prior to the lunch meal service.

Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to obtain a physician's order for the use of an orthotic device (immobilizer) to include skin monitoring under the orthotic device for 1 resident (Resident #43) of 3 residents reviewed for orthotic devices. The findings include: Review of the facility's policy titled, Splints and Braces-Lower Extremity, dated 9/20/2024, revealed .the facility will provide .splints and braces .in accordance with professional standards of practice . of the patients affected body part .as ordered by practitioner .collaborate with the practitioner to help determine each device application . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Left Femur Fracture, Diabetes, and Muscle Weakness. Review of an admission Braden Scale Assessment for Resident #43 dated 2/17/2025, revealed .Immobilizer to LLE [left lower extremity] . Review of an Order Summary Report dated 2/17/2025 through 2/24/2025, revealed Resident #43 did not have a physician's order for the immoblizer. Review of a Skilled Nursing Note for Resident #43 dated 2/18/2025, revealed .Immobilizer worn on L [Left]-leg . Review of a Skilled Nursing Note for Resident #43 dated 2/19/2025, revealed .Immobilizer worn on L-leg . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 14 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. The resident had impairment of one side of the lower extremity. The resident was total dependent upon staff assistance with personal hygiene, lower body dressing, and transfers. Review of a Skilled Nursing Note for Resident #43 dated 2/20/2025, revealed .Immobilizer worn on L-leg . Review of a Skilled Nursing Note for Resident #43 dated 2/21/2025, revealed .Immobilizer worn on L-leg . Review of a Skilled Nursing Note for Resident #43 dated 2/22/2025, revealed .Immobilizer worn on L-leg . Review of a Skilled Nursing Note for Resident #43 dated 2/23/2025, revealed .Immobilizer worn on L-leg . Review of a Skilled Nursing Note for Resident #43 dated 2/24/2025, revealed .Immobilizer worn on L-leg . During an interview on 5/13/2025 at 12:17 PM, Certified Nursing Assistant (CNA) B stated she was familiar with Resident #43. CNA B stated when the resident was first admitted to the facility an immobilizer was worn on the left leg. The CNA also stated the immobilizer was not used currently. During an interview on 5/13/2025 at 12:22 PM, CNA C stated she was familiar with Resident #43. CNA C stated Resident #43 used to wear an immobilizer to her left leg (unsure of exact dates) and the resident no longer used the immobilizer. During an interview on 5/13/2025 at 12:32 PM, the Wound Care Nurse stated she was familiar with Resident #43. The resident was admitted to the facility from the hospital after surgical repair of a fracured left femur and had an immobilizer in place to the left leg. During an interview on 5/13/2025 at 12:41 PM, the Rehabilitation Director (RD) stated she was familiar with Resident #43 and when the resident was admitted to the facility she had an immobilizer in place to the left leg. During an interview on 5/13/2025 at 12:55 PM, PTA D stated he was familiar with Resident #43 and when the resident was admitted to the facility she had an immobilizer in place to the left leg. During an interview on 5/13/2025 at 1:43 PM, Resident #43's daughter stated Resident #43 wore an immobilizer to the left leg when she was admitted to the facility. She also stated the immobilizer had been discontinued on 2/24/2025. During an interview on 5/13/2025 at 1:47 PM, the Director of Nursing (DON) stated Resident #43 was admitted to the facility with an immobilizer in place to the left leg. The DON confirmed the nursing staff failed to obtain a physician's order for Resident #43's use of the immobilizer. The DON stated the facility identified the deficient practice of failing to obtain a physician's order to continue the use of the immobilizer and had taken actions to address the non-compliance. The DON stated a Performance Improvement Plan (PIP) was initiated on 2/24/2025. The DON further stated a 100% audit had been completed for all residents with orthotic devices to ensure physician orders were in place for the orthotic device. The DON stated the alleged date of compliance was 3/5/2025. A plan of correction was developed from 2/24/2025- 3/5/2025 to address the deficient practice identified. The corrective actions were validated on-site by the surveyor on 5/12/2025- 5/14/2025 through interviews and review of facility documents. The facility's Plan of Correction for obtaining a physician's order for orthotic devices was presented to the survey team and documented the following corrective actions were implemented: Review of a Witness Interview/ Statement form dated 2/24/2025, revealed .staff completed a 100% audit of all residents to verify who had any devices .orders verified . Review of a Witness Interview/ Statement form dated 2/25/2025, revealed .100% current residents assessed for braces and splints .All residents had MD [medical doctor] orders for device being used . On 2/25/2025 through 2/27/2025, the 90 active employees received education to address orthotic devices. 1. Audits for any orthotic devices of sampled residents were completed by the DON on 2/24/2025-2/25/2025 and confirmed there were no issues observed with orthotic devices. 2. During an interview on 5/13/2025 at 1:47 PM, the DON confirmed the facility had not had concerns with residents' who admitted to the facility with an orthotic device having a physician's order since the facility identified the deficient practice on 2/24/2025. 3. Surveyor interviewed multiple staff members (in various departments) from 5/13/2025-5/14/2025 for knowledge of the in-services provided in the corrective action plan, and no knowledge deficits were identified. The deficient practice was cited as past noncompliance for F-684 and the facility is not required to submit a plan of correction.

Based on facility policy review, observation and interview the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) before entering a resident's room on transmission based precautions for 1 resident (#66) reviewed for infection control and prevention of 23 sampled residents. The findings include: Review of the facility policy, Transmission-Based Precautions and Isolation Procedures, revised 11/28/16 revealed .Contact Isolation Procedures .PPE .Wear a gown and gloves on room entry . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 12/11/18 at 7:45 AM, in Resident #66's room revealed a sign on the resident's door indicating the resident was on Contact Precautions and to .wear a gown when entering . Further observation revealed Resident #66 sitting on the edge of his bed and the Speech Therapist (ST) was at the resident's bedside wearing gloves. Continued observation revealed the ST did not have a protective gown on while at the resident's bedside. Interview with the Director of Nursing on 12/11/18 at 7:50 AM, in the 300 hallway confirmed Resident #66 was on Contact Precautions [MEDICAL CONDITION] in the sputum and the ST did not wear the appropriate PPE while in the resident's room.

Based on medical record review and interview, the facility failed to resubmit a Level 1 Pre-Admission Screening and Resident Review (PASARR) change of status when the resident was diagnosed with [REDACTED].#31) of 23 sampled residents. The findings include: Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Level 1 PASARR assessment dated [DATE] revealed Resident #31 did not have a [DIAGNOSES REDACTED]. Medical record review of a [DIAGNOSES REDACTED].Major [MEDICAL CONDITION] .onset date .6/6/09 .Unspecified mood (affective) disorder .onset date 4/6/11 . Medical record review of Resident #31's Annual Minimum Data Set ((MDS) dated [DATE] revealed she had a Brief Interview for Mental Status score of 14, indicating Resident #31 was cognitively intact. Further review revealed Resident #31 had current [DIAGNOSES REDACTED]. Medical record review of a Psychotherapy Note dated 11/12/18 revealed .Psychotherapy services are medically necessary and appropriate based on the patient's [DIAGNOSES REDACTED]. This potential for decompensation poses a threat to the patient's overall well-being and stability which supports the need for ongoing psychological services . Medical record review of a Psychiatric Visit Note dated 11/29/18 revealed . (Resident #31) . with hx (history) anxiety, depression, and [MEDICAL CONDITION] disorder . Interview with MDS Coordinator #1 on 12/10/18 at 2:32 PM in the Orchid charting room confirmed the facility failed to resubmit a Level 1 PASARR change of status.

Based on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 resident (#72) of 6 residents reviewed for accidents, of 18 residents reviewed. The findings included: Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE], revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers and toileting. Medical record review of Resident #72's Care Plan dated 7/24/17, revealed no intervention to include the resident required 2 person physical assist with transfers. Review of a facility fall investigation dated 9/29/17 revealed .While assisting resident to bathroom, resident was standing + (and) had hold of grabbar when her knees gave out + she was assisted by staff sat in floor .abrasion noted to resident's back .(increase) assistance (with) transfers from 1 to 2 . Interview with Certified Nursing Assistant #1 on 12/6/17 at 8:35 AM, at the Orchid Nurses station, confirmed she was alone when assisting Resident #72 to the restroom on 9/29/17 at the time of the fall. Interview with Registered Nurse #1 on 12/6/17 at 8:30 AM, in the chart room, confirmed Resident #72's MDS dated [DATE] was accurate and the resident was a 2 person physical assist for transfers and toileting. Interview with the Director of Nursing (DON) on 12/6/17 at 9:55 AM, in the DON office, confirmed, the care plan should reflect the MDS comprehensive assessment. Continued interview confirmed the facility failed to develop a comprehensive care plan that addressed the functional needs of a 2 person physical assist for transfers and toileting for Resident #72.

Based on facility policy review, medical record review, and interview, the facility failed to ensure the safety of 1 resident (#72) of 6 residents reviewed for accidents, of 18 residents reviewed. The findings included: Review of the Facility Policy Fall Management dated 11/16 revealed, .To promote patient safety .reduce falls by proactively identifying, care planning and monitoring of patient's fall indicators .based on comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan . Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #72's Annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers and toileting. Medical record review of Resident #72's Care Plan dated 7/24/17, revealed no intervention to include the resident required 2 person physical assist with transfers. Review of a facility fall investigation dated 9/29/17 revealed .While assisting resident to bathroom, resident was standing + (and) had hold of grabbar when her knees gave out + she was assisted by staff sat in floor .abrasion noted to resident's back .(increase) assistance (with) transfers from 1 to 2 . Interview with Certified Nurses Assistant #1 on 12/6/17 8:35 AM, at the Orchid Nurses station, confirmed she was alone when assisting Resident #72 to the restroom on 9/29/17 at the time of the fall. Interview with the Director of Nursing (DON) on 12/6/17 9:55 AM, in the DON office, confirmed the facility's failure to ensure the safety for Resident #72 resulted in a fall on 9/29/17.

Based on facility policy, medical record review, and interview the facility failed to notify the physician and the resident's responsible party of a critically abnormal laboratory value for 1 (Resident #32) of 26 residents reviewed. The findings included: Review of an undated facility policy, Changes in Resident's Condition or Status, revealed .Nursing services will be responsible for notifying the resident's attending physician when: .There is a need to alter the resident's treatment or medications significantly .Deemed necessary or appropriate in the best interest of the resident . Continued review revealed .Nursing services will be responsible for notifying the resident, his/her next of kin, or representative (sponsor) as each case may apply, when: .there is a change in the resident's physical, mental, or emotional status . Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged from the facility on 7/2/15. Medical record review revealed a physician order [REDACTED].#32: Complete Metabolic Panel, Complete Blood Count with Differential, and a Urinalysis. The indication for the order was documented as symptoms of infection. Medical Record review of a laboratory results printout dated 7/1/15 for Resident #32 revealed a potassium level of 7.6 (normal value 3.5-5.1). The potassium level was documented as a critically high abnormal value. Continued review revealed the laboratory services documented the facility (Licensed Practical Nurse #1) was notified of the critical potassium value on 7/1/15 at 18:41 (6:41 PM). Continued review revealed a handwritten documentation at the bottom of the laboratory results printout Called to Dr. Clark 7/2/15. Interview with the Director of Nursing (DON) on 12/1/15 at 8:35 AM, in the conference room, when asked about the laboratory results for Resident #32 which were obtained on 7/1/15, stated the physician ordered lab work for Resident #32 on 7/1/15 due to the resident not feeling well.The laboratory notified the facility by telephone of a critical high potassium level result. (Licensed Practical Nurse #1) received the report of the potassium level but failed to report it to the physician. The facility did not notify the physician or the resident's responsible party of the abnormal laboratory results until 7/2/15 at which time an order was received to transport the resident to a hospital for evaluation and treatment. The DON confirmed the facility failed to notify the physician and responsible party in a timely manner concerning the resident's abnormal laboratory values.

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and dated on 1 of 3 medication carts. The findings included: Review of the facility's Policies for Medication Administration .Medication Storage & Security in the Facility with a revision date of 6/2006 revealed .medications that are discontinued or medications that are left at the facility when the resident is discharged are removed from the medication cart . Observation on 12/2/15 at 10:15 AM at the Magnolia long hall medication cart, along with Licensed Practical Nurse (LPN) #1 revealed an open multidose vial of Lidocaine 1% without an open date. Interview with LPN #1 on 12/2/15 at 10:18 AM beside the medication cart, when asked about the policy for opened vials, stated .they're supposed to be dated when opened .actually that shouldn't be on the cart because the resident was discharged . Continued observation of the Magnolia long hall medication cart revealed an open multidose FloVent Diskus 250 mcg (micrograms) without an open date. Interview with LPN #1 on 12/2/15 at 10:21 AM beside the medication cart, when asked about the policy for open inhalation diskus, confirmed the the diskus should have an open date and a discard date. Interview with the Director of Nursing (DON) on 12/2/15 at 3:15 PM in the DON's office, when asked about the policy for dating multidose vials or inhalers and for medications left for residents who have been discharged , confirmed the medication for the discharged resident should have been removed and the facility failed to date the medications when opened.

Based on medical record review and interview, the facility failed to obtain a laboratory test as ordered by a physician and obtained a laboratory test not ordered by the physician for one (#101) of thirty-one residents reviewed in Stage 2. The findings included: Resident #101 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Review of the laboratory results dated [DATE], revealed the CBC and CMP were completed as ordered by the Physician. Continued review revealed the [MEDICATION NAME] Acid level ordered by the Physician was not competed. Further reveiw revealed a Hemoglobin A1C (used to determine the average blod glucose level in the blood0 was complated without a physician's orders [REDACTED]. Interview on October 1, 2014, at 10:10 a.m., with the Director of Nursing and Licensed Practical Nurse #1 confirmed the Hemoglobin A1C was completed in error instead of the [MEDICATION NAME] Acid level ordered by the Physican.

Based on observation and interview, the facility failed to post nurse staffing information daily with the current date. The findings included: Observation on September 3, 2013, at 9:35 a.m., in the facility lobby revealed a Nurse Staffing posting dated September 1, 2013. Interview with the Assistant Director of Nursing on September 3, 2013, at 9:50 a.m., confirmed the date was not current.

Based on observation and interview, the facility dietary department failed to maintain dietary equipment in a sanitary manner. The findings included: Observation on September 3, 2013, at 2:30 p.m., and interview with the Dietary Manager present during the observation confirmed the following: 1.)The range top, back splash and shelf had an accumulation of blackened debris. 2.)The grill, connected to the range top, had an accumulation of blackened debris. 3.)The can opener slot had sticky blackened debris present.

Based on observation and interview, the facility failed to follow guidelines to prevent the spread of infection for thirteen out of twenty-seven residents. The findings included: Observation on September 3, 2013, at 12:00 p.m., in the main dining room revealed an ice scoop in the ice cooler. Further observation revealed the Certified Nursing Assistant (CNA #1) removed the ice scoop from the ice chest, scooped the ice, touched the scoop to the resident's water cup, and returned the ice scoop to the ice chest. Further observation revealed CNA #1 repeated the same procedure for thirteen out of twenty-seven residents served in the main dining room. Interview with CNA #1 on September 3, 2013, at 12:05 p.m., in the main dining room confirmed the ice scoop was stored in the ice cooler. Further interview with CNA #1 confirmed "...this is how...always do it..." Interview with the Dietary Manager on September 3, 2013, at 12:20 p.m., in the main dining room confirmed the ice scoop was not to be stored in the ice cooler.

Based on medical record review, observation, and interview, the facility failed to follow the care plan for padded side rails for one resident (#36) of twenty-nine residents reviewed. The findings included: Resident #36 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on September 3, 2013, at 12:26 p.m., in the resident's room revealed bruised areas to the top of both hands. Interview at the time of the observation revealed the bruised areas "were normal wear and tear, if it gets bumped will bruise." Further interview revealed the resident was on anti-coagulant medication. Observation on September 3, 2013, at 3:03 p.m., of the resident in the bed in the resident's room revealed the side rail was in the raised position. Further observation revealed the side rail was not padded. Medical record review of the August 2013 Physician's Recapitulation Orders revealed the resident was receiving [MEDICATION NAME], an anti-coagulant medication. Review of the Care Plan dated February 6, 2013, and updated on July 10, 2013, revealed "...at risk of alteration in skin integrity due to impaired mobility, incontinence and use of medication...APPROACHES:...7/10/13 add padding to side rail..." Interview with the Assistant Director of Nursing, on September 5, 2013, at 8:55 a.m., in the resident's room confirmed the side rails were not padded. Further interview confirmed the facility had failed to follow the Care Plan for the padded side rails.

Based on medical record review and interview, the facility failed to notify the physician timely of significant changes in a resident's (#46) condition for one resident of twenty-nine residents reviewed. The findings included: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nursing Notes dated August 17, 2013, at 8:10 a.m., revealed "Late Entry for 8-17-13 @ (at) 5 am (5 a.m.) Upon entering the res.'s (resident's) room to adm. (administer) am (morning) meds (medications) and check BS (blood sugar), noted the resident to be unresponsive...checked BS -meter reading LOW (Equal to or below 40) Standing Order Utilized...Vital signs temp (temperature) 99.3 Pulse 32/min (thiry two beats per minute) Resp. Rate 22/min ( Respiratory rate twenty two breaths per minute) Blood Pressure 144/115...MD (Medical Doctor) notified (no time documented), and new order noted to send to...hospital for eval and tx (evaluation and treatment)...EMS (Emergency Medical Services) here for transport @ 5:40 am and EMT (Emergency Medical Technician) assessed res. (resident) and found res to be without pulse and respiration..." Medical record review of the County EMS Run Sheet dated August 17, 2013, revealed "Arrived patient 8/17/2013 5:44:00...Notes/Narrative...Pt was found unresponsive, no pulse, no respirations...taken to ambulance...asystole (without electrical activity in the heart) 08/17/13 05:49:00 in 3 leads...pt was tx (transported) to...ER (emergency room ) to be pronounced..." Medical record review of the Nursing Home to Hospital Transfer Form, undated and untimed revealed the resident was transferred to the "...hospital, with vital signs of temperature of 99.3, pulse of 32, respiratory rate of 22 and an oxygen saturation of 88% (percent) with oxygen at 4 liter via NC (nasal cannula)..." Telephone interview with the resident's Physician on September 5, 2013, at 10:18 a.m., confirmed the resident was "very compromised" with end stage [MEDICAL CONDITION], on [MEDICAL TREATMENT] three times weekly, and the facility had called regarding the resident but could not remember the time of the call. The Physician confirmed "I would expect to be informed immediately if the patient's pulse rate were 32 beats per minute..."

Based on medical record review, review of facility policy, and interview, the facility failed to have a justification for the use of an indwelling catheter for one resident (#26) of twenty-nine residents reviewed. The findings included: Resident #26 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone Order dated July 23, 2013, revealed "...Insert...foley catheter...indication/[DIAGNOSES REDACTED]. Review of facility policy, Indwelling Catheters, revealed "Policy...A client who enters (named facility) without an indwelling catheter shall not be catheterized unless the person's clinical condition demonstrates that catheterization is necessary...Intent:...An indwelling catheter shall not be used unless there is a valid medical justification...Procedures: 3. b. Insert urinary catheter only when justified medically and ordered by the attending physician...4. Perform a comprehensive assessment that addresses those factors that predispose the resident to the development of urinary incontinence and/or use of an indwelling catheter. A comprehensive assessment should include: a. The risks and benefits of an indwelling...catheter...c. factors supporting medical justification for the initiation of, and continuing need for the catheter use..." Interview with the Minimum Data Set Coordinator and Licensed Practical Nurse #3, at the Orchid nursing station on September 4, 2013, at 3:24 p.m., confirmed the foley catheter was inserted on July 23, 2013, and the facility had failed to complete the catheter assessment. Further interview confirmed the facility did not have medical justification for the use of the catheter at the time of the insertion on July 23, 2013, and the facility had failed to follow the facility policy.