Every finding on record at Marsh's Edge

Based on observations, staff interviews and review of the facility's policy titled, Medication Labeling and Storage, the facility failed to discard expired syringes stored in one of one medication storage rooms. The deficient practices created the potential to use expired syringes. The facility had a census of nine residents. Findings include: Review of the facility's undated policy titled, Medication Labeling and Storage under the Medication Storage section revealed, 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Under the Medication Labeling section revealed, 2. The medication label includes, at a minimum: medication name (generic and/ or brand; prescribes dose; strength; expiration date, when applicable; resident's name; route of administration; and appropriate instructions and precautions. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding or destroying these items. Interview and observation on [DATE] at 1:40 pm of the medication storage room with the Registered Nurse Supervisor (RNS) revealed a sealed zip lock bag of syringes with expiration date of [DATE]. RNS confirmed the date on the bag was [DATE] and that the syringes were expired. During an interview on [DATE] at 12:34 pm with the Director of Nursing (DON) revealed that the RNS was about to destroy the syringes when she asked what she was doing. She stated that the RNS informed her that the syringes were expired, and she was about to destroy them. DON stated she took the bag and partially opened it and removed the label. DON also stated that the bag of syringes was inside of another bag and the RNS removed it prior to bringing it to her. She stated that she took the bag and contacted the pharmacy for clarification on the expiration date. During an observation and interview on [DATE] at 2:00 pm, the DON presented a bag of syringes without a label that was opened on the side. DON insisted that this was the bag observed the day before and that she removed this bag from the original bag and had cleaned up the bag a bit. DON stated that she used the lot number to contact the pharmacy for clarification and had gotten a letter stating the syringes were not expired. During a follow up interview on [DATE] at 2:30 pm with the RNS revealed that she did not in fact remove the syringes from another bag prior to giving it to the DON. RNS admitted that the sealed bag of syringes was handed to the DON as observed the day before. She also stated that she normally check the expiration dates listed on the packages delivered by the pharmacy and would contact them if there was any doubt or if she had questions but had not contacted them about this situation (expired syringes). During a telephone interview on [DATE] at 8:00 pm with the Director of Clinical Services (DCS) for the pharmacy revealed, that she was aware that at some point everything expires and stated that the pharmacy computer generates labels with expiration dates automatically for items especially the ones removed from their original packaging. The DCS stated that she was only given a lot number and was not sure if that was for the item (syringes) in question. The DCS revealed that she contacted the manufacturer about the lot number she was given and that she was still awaiting a response.

Based on observations, staff interviews, and review of the facility policy titled, Food Receiving and Storage the facility failed to ensure that items were labeled and dated in the satellite kitchen refrigerator, freezer, and dry storage area and in the dry storage area in the main kitchen. This deficient practice had the potential to affect 14 of 14 residents receiving an oral diet. Findings include: Review of the facility policy titled, Food Receiving and Storage, revised November 2022 revealed the following: Dry Food Storage: 4. Dry foods that are stored in bins are removed from the original packaging, labeled and dated (use by date). Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage 1. All food stored in the refrigerator or freezer are covered, labeled, and dated (use by date). 7. Refrigerated foods are labeled, dated, and monitored so that are used by their use-by date, frozen, or discarded. Initial tour on 1/27/2023 at 8:07 a.m. of the satellite kitchen began with dietary staff present. It was reported that the dietary manager had not made it to the facility for the day. The following was observed: 1. In the freezer there was one box containing ice cream sandwiches that was opened but there was no open date or expiration dates on the box or ice cream bars. 2. In the reach in cooler here was one key lime pie that had been opened (partially eaten) that did not have an open or expiration date on it. 3. There was a pound cake wrapped in clear wrap that did not have an open or expiration date. 4. On the shelves behind the steam table there were 19 small boxes of various cereal that did not have an expiration date. 5.There were two partial loaves of bread that did not have an open or expiration date on them. During an interview and observation on 1/27/2023 at 3:13 p.m. with the Certified Dietary Manager (CDM) AA he reported that he had already removed the pie and from the refrigerator after surveyor's initial tour. CDM AA reported that both items were from the day before. The ice cream sandwich bars remained in the freezer and did not have an open date or an expiration date. The cereal remained on the shelves and CDM AA reported that he put the cereal in the kitchen and rotated them first in and first out. However, there were no dates on the boxes of cereal and he reported that he would have to contact the company to determine when the items expire because they have codes on them. CDM AA confirmed that the loaves of bread did not have an expiration date. A brief tour on 1/27/2023 at 3:37 p.m. of the main kitchen was conducted with CDM AA and the following was observed during the tour: 1. There was one #10 can of sliced jalapenos noted to be dented. 2. There was one #10 can of tomatoes noted to be dented and without an expiration date. 3. There were six cans of sweet potatoes, six cans of dark kidney beans, and 10 cans of roasted red peppers that did not have expiration dates or received date. There were codes on the can, but the CDM AA was not able to identify the expiration date. During an interview on 1/29/2023 at 12:21 p.m. with CDM AA revealed that each staff member is responsible for labeling and dating items on their shift. He acknowledged that he discarded the cereal because they did not have a date on them, and he was the person that had placed them in the satellite kitchen. It was reported that the Director of Dining and CDM were responsible to make sure the use by date is made known to staff. CDM AA reported that the ice cream sandwich bars were taken from the original box and the expiration date was on that box. Lastly, he reported that the bread came from the freezer in the main kitchen and should have had an expiration date when placed in the satellite kitchen. Continued interview with CDM AA also revealed that dented cans were typically identified during delivery and returned to the vendor by the driver. Interview on 1/27/2023 at 1:03 p.m. with the Administrator who acknowledged that an in-service had been provided to staff earlier in January 2023 related to meal service which included labeling and dating items. He reported that this information has not been incorporated into the Quality Assurance Program yet, but they would be meeting soon. The Administrator then provided documentation of education provided to staff on 1/27/2023 related to labeling and dating of items.

Based on observations, interviews and record reviews, the facility failed to label opened multi-dose containers/vials in accordance with currently accepted professional standards and their own internal policy and procedure for three of four medication storage areas (two medication carts and one medication refrigerator). Findings include: 17 multidose containers in three of four medication storage areas were open and in use without any label indicating when the container/box was opened. 1. One of one refrigerators in the medication room was observed on 11/20/17 at 11:47 a.m. with Registered Nurse (RN) AA. It contained one vial of purfified protein derivative used for TB testing; the vial was opened but not labeled with the date when it was opened. An interview with RN AA on 11/20/17 at 11:47 a.m. confirmed the vial was opened and had been used, but was not labeled with the date it was opened. 2. One of two medication carts was observed on 11/20/17 a 12:00 p.m. with RN AA. It contained the following opened multidose containers without any labeling indicating when they were opened: a) R#14 had an opened vial of Flonase Nasal spray with the date filled of 8/28/17; it was ordered for use twice daily routinely; there was no date of opening. Interview with RN AA confirmed the absence of an opening date. b) Two open multidose vials of Lidocaine (a local anesthetic), one dated as opened on 10/13/17 and the other with an unclear notation of either 8 or 9 2017. Interview with RN AA confirmed the date on the vial of 10/13/17 but was unable to determine what date the second vial was opened. The United States Pharmacopeia (USP) General Chapter 797 recommends if multidose vials have been opened or accessed (e.g. needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. c) One open multidose vial of sterile water (H20) without any labeling of date when opened; RN AA confirmed the absence of an opening date. d) R#10 had an opened multidose container of Prednisone eye drops with no date of opening; the container was labeled as filled on 9/15/17 with directions of one drop right eye daily; RN AA confirmed the absence of an opening date; e) R#7 had an opened multidose container of over the counter (OTC) eye drops labeled as Refresh Optive Lubricant. There was no date opened listed on the container and there was no bag or box with a pharmacy label providing directions/orders for use. Interview with RN AA reveals the family of R#7 brought the OTC eye drops in for the staff to utilize. f) R#7 had an opened multidose container of OTC eye drops labeled as Blink Contacts Lubricant Eye Drops. There was no date opened listed on the container and there was no bag or box with a pharmacy label providing directions/orders for use. Interview with RN AA reveals the family of R#7 brought the OTC eye drops in for the staff to utilize. g) R#10 had an opened multidose tube of eye ointment labeled as Pred-G ointment with a fill date of 6/30/17. There was no date of opening listed on the container. Interview with RN AA confirms the absence of an opening date. h) R#23 was discharged from the facility 10/31/17. There was an opened container of Milk of Magnesia in the medication cart labeled with R#23's name. There was no opening date listed on the label of the medication. Interview with RN AA confirmed the discharge of R#23 and the absence of an opening date. She stated the medication should have been removed from the cart when the resident was discharged . i) R#1 had a box containing albuterol inhalation solution labeled with a pharmacy expiration date of 10/31/18. The box contained silver foil pouches containing the solution vials. One foil pouch was opened with no date of opening noted. RN AA confirmed the absence of an opening date on the opened foil pouch. The facility Vice-President of Clinical Analytics provided a document from Med-Pass (a forms company) stating it is a reference they utilize detailing information about use of multidose medications. The form states Albuterol should be used within one week of opening foil pouch. 3. The second of two medication carts was observed on 11/20/17 a 12:20 p.m. with RN AA. It contained the following opened multidose containers without any labeling indicating when they were opened: a) R#4 had an opened multidose vial of Flonase Nasal spray with no opening date on the label; it had a fill date listed as 10/9/17. Interview with RN AA confirmed the absence of an opening date. b) R#17 had an opened multidose inhaler of Symbicort with no opening date listed. It had a fill date listed on the label of 6/8/17. Interviw with RN AA confirmed the absence of an opening date. c) R#18 had three opened multidose containers of eye drops without any labeling indicating when they were opened. The labels listed fill dates of 10/25/17 and 10/23/17. Interview with RN AA confirmed the absence of an opening date. d) R#19 had an opened multidose container of Lactulose filled 9/19/17. There was no opening date on the label. It was listed for routine daily use (30 mls daily). Interview with RN AA confirmed the absence of an opening date. Interview with the VP of Clinical Analytics 11/21/17 at 12 noon after requesting a policy on the opening and dating or labeling of mutidose vials or containers provided a policy dated effective July 2009 entitled Preparation and general guidelines IIA3: Vials and Ampules of injectable medications. The procedure states the date opened and the initials of the first person to use the vial are recorded on multidose vials (on the vial label or an accessory label affixed for that purpose).

Based on observations, interviews and record review, the faciilty failed to asess one of four residents, Resident (R) # 17 to determine if they were safe to self-administer drugs before they started the self-administration process. The interdisciplinary team also failed to determine where the drug would be stored and who would be responsible for the drug and did not include this information in the resident's plan of care. . Findings include: Review of a quarterly MDS with an assessment reference date of 9/15/17 reveals R#17 has a BIMS score of 14, [DIAGNOSES REDACTED]. R#17 also is noted to have adequate vision. R#17 has a physician's orders [REDACTED]. During a medication administration pass observation conducted on 11/21/17 at 8:25 a.m., R#17 was in possession of a [MEDICATION NAME] multidose inhaler. An interview with R#17 conducted on 11/21/17 at 8:25 a.m. revealed she carries the inhaler with her throughout the facility keeping it on her person during the day and at her bedside at night. During an interview conducted 11/21/17 at 11:47 a.m., Registered Nurse (RN) AA stated that R#17 keeps a [MEDICATION NAME] multidose inhaler at bedside and with her to use as a rescue inhaler. RN AA stated R#17 uses the inhaler if she is short of breath. RN AA was not aware of documentation evaluating the resident for safe self-administration of medications. An interview conducted on 11/21/17 at 9:05 a.m. with the Vice-President of Clinical Analytics revealed the facility does have an assessment tool for evaluation of residents to determine if they are safe to self-administer medications. The VP also stated that there was not an assessment completed in the computer system but the Assistant Director of Nursing (ADON) was in the process of completing the assessment at that time. Review of the care plan on 11/21/17 at 9:15 a.m. for R#17 reveals a problem for resident at risk for shortness of breath due to [MEDICAL CONDITIONS]. There were no interventions listed related to the as needed use of a [MEDICATION NAME] inhaler or self-administration of the same medication.

Based on observation, staff interview, and review of the facility's policy on handwashing it was determined that the facility failed to ensure that food items in two (2) of two (2) reach-in coolers in the main kitchen were dated and labeled and that dietary staff washed hands after handling soiled items and prior to storing clean plates in the pantry. The census was fourteen (14) residents. Findings include: 1. During the initial tour of the main kitchen beginning on 1/9/17 at 8:30 a.m., there was a covered unidentifiable cooked meat in the reach-in cooler #1 that did not have a date when it was cooked or a label that identified the food item. The Director of Dining Services (DDS) stated at that time that the item was a chicken breast. There was also a small metal pan of an unidentified pureed food that did not have a date or label. Observation of the reach-in cooler #2 revealed an uncovered pan of fish fillets which the DDS identified as Snapper, two plastic bags of salmon fillets, a plastic container of an unidentified food item, a plastic container of gravy, a plastic-wrapped beef fillet and a container of chicken wings that were not dated or labeled. The unlabeled and undated food items were removed by the DDS at that time. Interview with the DDS on 1/9/17 at 8:45 a.m. revealed that the Sous Chef was responsible for ensuing that all food items in the coolers and freezers were dated and labeled. Continued interview revealed that the Sous Chef had worked the previous evening and should have identified and removed the unlabeled and undated food items from the coolers. 2. On 1/11/17 at 9:10 a.m. Dietary Staff AA placed dirty breakfast plates in a dish rack and then placed the rack in the dishwasher. After turning on the dishwasher, AA left the pantry and then returned several minutes later. Without washing or sanitizing his hands, AA obtained the rack of clean plates from the dishwasher and stored them individually in the plate warmer rack. AA then rinsed food debris from some soiled plates/dishes, placed them in the rack and then placed the rack in the dishwasher for washing. On 1/11/17 at 9:20 a.m. Dietary Staff AA obtained a broom and swept a small area of the pantry floor prior to leaving the pantry for several minutes. AA returned to the pantry with two soiled glasses, a broom, a dustpan and a soiled linen napkin. AA placed the soiled napkin in the linen bag, placed the broom and dustpan in the corner of the room and placed the soiled glasses on the sink counter. Without washing or sanitizing his hands, AA then removed the rack of clean plates/dishes from the dishwasher and stored them individually in the plate warmer rack. Interview with the DDS on 1/11/17 at 5:40 p.m. revealed that dietary staff should wash their hands after touching potentially contaminated items and prior to handling clean dishes. Review of the facility's Dietary Policy and Procedures Manual: Handwashing, revealed that staff should wash their hands after handling soiled equipment or utensils and during food preparation to prevent cross contamination when changing tasks.

Based on record review and staff interview, the facility failed to provide documentation that a Quality Assessment and Assurance (QAA) meeting was held in the second quarter of 2016, and that there was Director of Nursing (DON) representation at the February meeting in 2016. The current facility census was fifteen residents, and the sample size was fourteen residents. Findings include: Review of the QAA attendance sign-in sheets revealed that for the first quarter in 2016, the only meeting held was on 2/25/16. Further review of this sign-in sheet revealed that there was no DON in attendance. Further review of the QAA sign-in sheets revealed that there were no attendance sheets provided between the February meeting until 7/21/16. During interview with the DON, who was also the QAA Coordinator, on 1/11/17 at 12:17 p.m., she stated that she took the QAA program over in August of 2016, and increased the frequency of the meetings from quarterly to monthly at that time. During interview with the DON on 1/11/17 at 12:42 p.m., she verified that there was no DON in attendance during the first quarter QAA meeting in February. During further interview, she stated that she was not able to find documentation that a QAA meeting was held in the second quarter of 2016 (from April to June).

Based on record review and staff interview, the consultant pharmacist failed to make a recommendation for a gradual dose reduction (GDR) for a hypnotic given routinely for over a year for one Resident (R) Q. The sample size was fourteen residents. Findings include: Review of R Q's physician's orders [REDACTED]. Review of the facility's consultant pharmacist monthly drug regimen reviews from July 2016 to November 2016 revealed that no recommendation was made to consider a GDR for the temazepam. During interview with the Director of Nursing (DON) on 1/12/17 at 10:23 a.m., she stated that R Q was receiving the temazepam for insomnia. During interview with the DON on 1/12/17 at 11:42 a.m., she stated that she had reviewed the consultant pharmacist recommendations from January of 2016 to the present time, and did not see where a gradual dose recommendation had been made for the temazepam. Cross-refer to F 329

Based on record review, resident and staff interview, the facility failed to consider a gradual dose reduction (GDR) for a hypnotic given routinely for over a year for one Resident (R) Q, and failed to document non-pharmacological attempts to address the resident's [MEDICAL CONDITION]. The sample size was fourteen residents. Findings include: Review of R Q's clinical record revealed that she was admitted to the skilled nursing unit on 12/7/15, and had [DIAGNOSES REDACTED]. Review of her physician's orders [REDACTED]. Review of R Q's care plans revealed that one had not been developed for the routine hypnotic use, nor did any of the care plans address her [MEDICAL CONDITION] and possible non-pharmacological interventions that could be used to help her sleep. During interview with the Director of Nursing (DON) on 1/12/17 at 10:23 a.m., she stated that R Q was receiving the [MEDICATION NAME] for [MEDICAL CONDITION]. She further stated that [MEDICATION NAME] was a hypnotic, and she verified that she had not developed a care plan for it's use. During interview with Licensed Practical Nurse (LPN) BB on 1/12/17 at 10:37 a.m., he stated that he had never known R Q to have complaints of [MEDICAL CONDITION]. He further stated that there was an area in the facility's computerized Medication Administration Records (MAR) to document non-pharmacological interventions, but the interventions had to be selected from a drop-down box and he was not able to find that any non- pharmacological interventions had been documented to address [MEDICAL CONDITION] on R Q's January MAR. During interview with Registered Nurse CC at this time, she stated that because R Q's [MEDICATION NAME] was routine and not prn (as needed), that they didn't need to try non-pharmacological interventions to help the resident sleep before giving the [MEDICATION NAME]. During interview with R Q on 1/12/17 at 10:57 a.m., she stated that as soon as she laid her head on her pillow at night, that she was out and slept very well. During further interview, she stated that at one time, years ago, she had difficulty sleeping and had to take a sleeping pill. During interview with the DON on 1/12/17 at 11:42 a.m., she stated that she did not see where a gradual dose recommendation had been done for the past year for the [MEDICATION NAME]. Review of R Q's MARs revealed that the resident had received [MEDICATION NAME] nightly from 12/7/15 (her original admitted ) through the current date of 1/11/17. Review of R Q's November and December 2016 and January 2017 computerized MARs revealed that non-pharmacological interventions for the [MEDICATION NAME] were documented as no behaviors this shift, with nothing specified to address the [MEDICAL CONDITION] other than the administration of the [MEDICATION NAME].

Based on observation, record review, resident and staff interview, the facility failed to develop care plans for antipsychotic, hypnotic, and denture use for one Resident (R) (Q). The sample size was fourteen residents. Findings include: 1. Review of R Q's Admission Minimum Data Set ((MDS) dated [DATE] revealed that she had inflamed or bleeding gums or loose natural teeth, mouth or facial pain, discomfort or difficulty with chewing. Review of the Care Area Assessment Summary (CAAS) for this MDS revealed that Dental Care triggered as a concern with the decision to care plan. Review of her Quarterly MDS dated [DATE] revealed that she had a broken or loosely fitting full or partial denture, and she had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of her Annual MDS dated [DATE] revealed that she was assessed as having a broken or loosely fitting full or partial denture. Review of the CAAS for this MDS revealed that Dental Care triggered with the decision to care plan, and noted that the resident needed a new partial bridge fixed, loose fit, daughter aware. Review of all of R Q's care plans revealed the only mention of dentures was a self-care deficit problem with an intervention to ensure mouth and denture care was given as needed or requested, and a mechanically altered diet care plan with an intervention to insert dentures prior to meals. Review of Care Plan Updates revealed a care plan problem developed 12/27/16 for a cracked upper denture, with intervention to change the diet to mechanical soft. Further review of the care plan revealed that it was revised on 12/30/16 to note the denture was repaired and diet upgraded to regular. During review of all the care plans revealed there was nothing that addressed the missing teeth or loosely fitting dentures. During observations on 1/9/17 at 1:48 p.m., and 1/11/17 at 9:59 a.m., R Q was observed to be missing several teeth on the upper left side. During observation on 1/12/17 at 10:57 a.m., R Q removed her top full denture, and it was observed that there were several missing teeth on the left side. During interview with the resident at this time, she stated the dentures had been that way for ages, and that this top plate was also loose. During interview with the Director of Nursing (DON), who was also the MDS Coordinator, on 01/12/17 at 11:42 a.m., she stated that R Q's top denture had cracked during a meal on 12/27/16, was sent out for repair, and that she updated the care plan on 12/30/16 to reflect a change in the resident's diet due to her denture repair, but that was the only care plan developed that was related to dental. During interview with the DON on 1/12/17 at 12:40 p.m., she stated that she found a dental intervention in the care plan for a mechanically altered diet that noted to insert dentures prior to meals. During interview with Certified Nursing Assistant DD on 1/12/17 at 2:27 p.m., she stated that R Q's dentures fit a little loose, so they had to put extra adhesive on them. 2. Review of R Q's physician's orders [REDACTED]. Review of her Quarterly MDS dated [DATE] revealed that she had trouble falling or staying asleep, or sleeping too much, and had no behaviors. Review of the Annual MDS dated [DATE] revealed that she received an antipsychotic and hypnotic all seven days of the assessment period, and [MEDICAL CONDITION] Drug Use triggered on the CAAS. Review of R Q's care plans revealed that no care plans were seen for the antipsychotic or hypnotic use. During interview with the DON on 1/12/17 at 10:23 a.m., she stated that she care planned the [MEDICATION NAME] within the antidepressant use care plan, because there was an intervention to observe the resident for changes in mood and behavior, such as sleep patterns. During further interview, she verified that [MEDICATION NAME] was a hypnotic, and verified no care plan was developed for hypnotic use including non-pharmacological interventions to address the [MEDICAL CONDITION]. During further interview, the DON verified that R Q was on aripiprazole, but not care planned for antipsychotic use. The DON further stated that either she or the staff nurses were supposed to update the care plans when a new drug order was received. Cross-refer to F 329.

Based upon observation and staff interviews the facility failed to maintain safe water temperature to prevent accidents for seven (7) of twelve (12) resident bathroom sinks on one (1) of one (1) hall. Findings include: Observation on 5/4/15 at 9:15 a.m. with Director of Facilities revealed the following hot water temperature to be equal or greater than one hundred and twenty (120) degrees Fahrenheit (F) for the following rooms with the facility thermometer: Room 154 bathroom sink revealed the hot water temperature of 120 F Room 155 bathroom sink revealed the hot water temperature of 124 F Room 157 bathroom sink revealed the hot water temperature of 120 F Room 161 bathroom sink revealed the hot water temperature of 121 F Room 162 bathroom sink revealed the hot water temperature of 123.5 F Room 163 bathroom sink revealed the hot water temperature of 122 F Room 165 bathroom sink revealed the hot water temperature of 121.5 F An interview on 5/4/15 at 9:25 a.m. the Director of Facilities verified that the laser thermometer was calibrated. An interview on 5/4/15 at 9:30 a.m. the Administrator was informed of the bathroom sinks temperature above 120 F and stated that he/she would have the Director of Facilities turn off and drain the hot water tanks. And the hot water temperatures would be adjusted to a safe range. He/She implemented a plan of correction for the hot water problem. An interview on 5/6/15 at 11:45 a.m. the Director of Nurse (DON) verified that eleven (11) of twelve resident were able to independently use their bathroom sinks.

Based on record review and staff interview the facility failed to complete a comprehensive assessment within fourteen (14) calender days after admission for nine (9) residents (#27,#29,#4,#3,#20,#35,#22,#33 and #31) from a eighteen (18) sampled residents. Findings include: Record review revealed admitted s for the following residents: #29 on 12/10/2013, #4 on 12/18/2013, #3 on 1/8/2014, #20 on 10/21/2013, #35 on 12/31/2013, #22 on 11/6/2013, #33 on 12/30/2013, #27 on 11/1/2013 and #31 on 1/8/2014. However, facility staff had failed to complete an Admission Minimum Data Set (MDS) assessment within the required timeframe. An interview with the Administrator on 1/30/2014 at 9:24 a.m. revealed that staff had failed to complete the admission MDS assessment for the above residents within the fourteen (14) day timeframe.

Based on record review and staff interview the facility failed to assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare Services (CMS) not less than once every three (3) months for two (2) residents (#7 and #19) of eighteen (18) sampled residents. Findings include: Record review revealed that Resident #7 last quarterly Minimum Data Set (MDS) assessment was completed on 9/12/2013 and Resident #19's last quarterly MDS assessment was 10/23/2013. An interview with the Administrator on 1/30/2014 at 9:24 a.m., she revealed the quarterly assessments had not been completed within the required timeframe.

Based on record review and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments for nine (9) residents to the Centers for Medicare and Medicaid (CMS) database system in the required time period. Findings include: An offsite review of a Georgia Minimum Data Set (MDS) 3.0 Missing OBRA Assessment report dated 1/28/14 revealed that the facility had a total of nine (9) resident assessments which had not been submitted to the Centers for Medicare and Medicare (CMS) database system . The late MDS assessments were for a time period of 05/10/13 to 11/13/13. An interview with the Administrator on 1/30/14 at 9:24 a.m. confirmed that the Minimum Data Set assessments were not being completed and transmitted on some residents as required.

Based on record review and staff interview the facility failed to administer medications as ordered for five (5) (#4, #3, #20, #30 and #36) of eighteen (18) sampled residents. Findings include. 1. Review of the physician orders [REDACTED]. On 12/20/13 the physician wrote an order for [REDACTED]. However staff failed to clarify with the physician the specified coverage for a blood sugar range of 351-400. Review of the 12/2013 Medication Administration Record (MAR) revealed the following blood sugars: 12/24/13 at 4:30 p.m. the blood sugar was 393 and staff gave 8 units of [MEDICATION NAME], on 12/26/13 at 4:30 p.m. the blood sugar was 352 and staff gave 6 units of [MEDICATION NAME] and on 12/29/13 at 4:30 p.m. the blood sugar was 365 and staff gave 6 units of [MEDICATION NAME]. An interview with the physician on 1/29/14 at 2:25 p.m. confirmed the 12/20/13 sliding scale order was incomplete and revealed that he would expect the nurses to call him to clarify the order. Review of the physician order [REDACTED].=2 251-300=4 301-350=6 351-400=8 call the physician if above 400. However review of the MAR from 1/20/14- 1/27/14, there were nine (9) times when the resident should have been covered with sliding scale insulin but there was no documentation that it was given. An interview with the Director of Nursing on 1/29/14 at 11:00 a.m. revealed the 12/20/13 physician's orders [REDACTED]. She could not provide any documentation that the sliding scale insulin was given from 1/27/14-1/27/14 when indicated. An interview with the Nurse consultant 1/30/14 at 2:00 p.m. revealed that she would expect the nursing staff to document the amount of insulin that was given to the resident on the MAR. Review of the Physician order [REDACTED]. Review of the 12/2013 and 1/2014 MAR revealed that on 12/27/13, 12/28/13, 12/29/13,12/31/13, 1/3/14, 1/4/14,1/10/14, 1/11/14 and 1/12/14 staff documented the medication was not given because it was not available or could not locate the medication. An interview with the Director of Nursing on 1/29/14 at 11:00 a.m. revealed that the staff may not have been able to locate the medication but she did confirmed that the pharmacy had sent the eye drops to the facility on [DATE]. She revealed that the eye drops were stored in the top drawer, with other eye drops, and that the nurse probably overlooked them. 2. Review of the clinical record for resident #30 revealed a [DIAGNOSES REDACTED]. Record review of the Physician orders [REDACTED]. Review of the residents Medication Administration Record (MAR) revealed that six (6) times in December 2013 the blood sugar results documented, per staff, were 200 or above. However, there was no evidence that staff had administered the insulin as ordered. 3. Review of resident #3 physician order [REDACTED]. Review of the resident's MAR for September 2013 revealed documentation by the nurses that the medication was not administration on 9/1/13, 9/2/13 and 9/3/13 at 7 p.m. due to the medication not being available. 4. Review of the physician order [REDACTED]. Review of the resident's October 2013 MAR revealed the nurse documented the medication was not administered on 10/22/13 because the medication was not available. The resident also had a physician order [REDACTED]. However, the nurse documented on the MAR medication was not administered as ordered on [DATE] due to the medication not available. An interview with the Director of Nursing on 1/30/14 at 2:31 p.m. revealed that the medications were not administered as ordered. Further interview at 2:45 p.m. revealed that when a resident is admitted the medications are ordered from the pharmacy and are usually received that night. However, the facility had a back up pharmacy to use to obtain any medications needed for the residents. She confirmed that residents should receive medications as ordered. 5. Review of the physician orders [REDACTED].=1 unit, 201-250=3 units, 251-300=5 units, 301-350=7 units, greater than 350=8 units and notify MD. Review of the 1/2014 MAR revealed 34 times where no insulin was documented as given per the sliding scale coverage as follows: 6:30 a.m. Blood Sugars: 1/12 the Finger Stick Blood Sugar (BS)=164 with no evidence that insulin given; 1/14 the BS=180 no evidence that insulin given; 1/17 the BS=166 with no insulin documented;1/18 the BS=153 no insulin documented;1/19 the BS=156 with no insulin documented;1/20 the BS=185 with no insulin documented; 11:00 a.m. Bloodsugars: 1/6/14 the BS=180 with no insulin documented;1/16 the BS=188 with no insulin documented;1/18 the BS= 200 with no insulin documented;1/19 the BS=166 with no insulin documented;1/26-BS=196 with no insulin documented;1/27 the BS=154 with no insulin documented 4:30 p.m. Blood Sugars: 1/6 the BS=212 with no insulin documented; 1-11 BS=167 with no insulin documented; 1/16 the BS=179 with no insulin documented;1/18 BS=165 with no insulin documented; 1/19 the BS=152 with no insulin documented;1/20 the BS= 229 with no insulin documented;1/25 the BS=170 with no insulin documented;1/27 the BS=244 with no insulin documented; 1/28 the BS= 204 with no insulin documented 9:00 p.m. Blood Sugars: 1/6 the BS=187 with no insulin documented;1/8 the BS= 201 no insulin documented; 1/11 the BS=240 with no insulin documented; 1/14 the BS=181 with no insulin documented; 1/17 the BS=216 with no insulin documented; 1/18 the BS=186 with no insulin documented; 1/19 the BS=185 with no insulin documented; 1/22 the BS=159 with no insulin documented; 1/23 the BS=173 with no insulin documented; 1/24 the BS=202 with no insulin documented; 1/27 the BS=201 with no insulin documented; 1/28 the BS=223 with no insulin documented. An interview with Licensed Practical Nurse "AA" on 1/30/14 at 12:00 p.m. revealed that she just initialed the insulin was given and did not write the amount of insulin that was given.

Based on observation and staff interviews the facility failed to ensure that three (3) of twenty (20) commodes were clean. Findings include: Dried feces was observed on the inner rim of the toilet bowl, elevated commode seat and on the bathroom floor in front of the toilet for resident #4 on 1/27/14 at 2:30 p.m., 4:00 p.m., on 1/28/14 at 8:15 a.m., 10:45 a.m. and 4:00 p.m., 1/29/14 at 8:15 a.m., 10:30 a.m., 2:15 p.m. and 4:00 p.m. Observation on 1/30/14 at 10:40 a.m. in room 161 had dried feces on the inside of the toilet bowl and room 164 had dried feces on the rim of the toilet bowl and the underside of the toilet seat. An interview on 1/30/14 at 1:55 p.m. with the Administrator confirmed the toilets needed cleaning. She stated if staff noticed the toilets were dirty then they should call housekeeping to come and the clean immediately.

Based on record review and staff interview the facility failed to accurately assess a pressure ulcer for one (1) resident (#1) on the Minimum Data Set (MDS) assessment of eighteen (18) sampled residents. Findings include: Review of the resident #1 admission form revealed the resident was admitted to the facility on [DATE]. Review of the physician progress notes [REDACTED]. The physician noted a Stage 3 left heel ulcer and a Stage 2 versus a callous on the right mid-forefoot. However,staff failed to assess the pressure ulcers on the Admission MDS which was completed on 9/30/13. An interview with the nurse consultant on 1/30/14 at 4:15 p.m. revealed the staff assessed the wounds as a diabetic ulcer because the wound care clinic doctor noted the wound as diabetic, pressure ulcer and arterial wounds. She stated the staff should have clarified with the doctor exactly how the areas should have been assessed and did not.

Based on record review and staff interview the facility failed to develop a comprehensive plan of care which included measurable objectives and timetables for one (1) resident (#27) of eighteen (18) sampled residents. Findings include: Review of resident #27 admission form revealed the resident was admitted to the facility on [DATE]. The facility developed an interim care plan dated 11/1/2013 and as of 1/30/2014 the facility was still using the interim plan of care for the resident. An interview with the Director of Nursing on 1/28/14 at 3:20 p.m. revealed that the resident's Interim Care Plan had not been updated. She further stated they were late completing the MDS assessments and resident care plans. She stated this resident's care plan should have been completed in twenty one (21) days of admission.

Based on record review and staff interview the facility failed to develop a comprehensive plan of care within seven (7) days after the completion of the comprehensive assessment for one (#1) of eighteen (18) sampled residents. Findings include: Review of the admission form for resident #1 revealed the resident was admitted to the facility on [DATE] and had an admission minimum data set (MDS) completed on 9/30/13. However, the facility did not develop a comprehensive plan of care for the resident. An interview with the nurse consultant on 1/30/2014 at 4:15 p.m. she revealed the resident should have had a comprehensive care plan developed in a timely manner.

Based on record review, staff and resident interview the facility failed to implement care plan interventions for catheter care for one (1) resident (Z) with an indwelling catheter of eighteen (1) residents. Findings include: Review of resident ("Z")'s interim care plan dated 1/24/14 revealed a problem to address his/her indwelling catheter with an intervention for catheter care for every shift. An interview with Licensed Practical Nurse staff "BB" on 1/29/14 at 10:00 a.m. revealed that the staff do catheter care every shift and document it on the Treatment Administration Record(TAR). She further stated that the Certified Nursing Assistant(CNA) does this procedure and then records it on the TAR. However, review of the treatment record revealed no documentation for the Foley care. During interview with resident ("Z") on 1/29/14 at 10:15 a.m. revealed that he/she doesn't recall any catheter care since his admission on 1/23/14. Cross to F315

Based on observation, clinical record review, staff interview, and resident private caregiver interview, the facility failed to provide care in accordance with the written plan of care, as related to turning and repositioning, the provision of incontinence care, and the application of a pressure sore dressing, for one (1) resident (#10) who had a pressure sore, of twelve (12) sampled residents. Findings include: Record review for Resident #10 revealed an Annual Minimum Data Set assessment of 02/20/2014 in which Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented urinary and bowel incontinence, and Section G - Functional Status indicated total dependence for bed mobility and toilet use. Section M - Skin Conditions documented that Resident #10 had no pressure sores at that time, but was at risk for pressure sores. Resident #10's Care Plan Report documented an entry, originally dating from 02/24/2014, which identified that the resident was at risk for an alteration in skin integrity related to decreased mobility and incontinence. This Care Plan Report referenced Interventions, also dated 02/24/2014, which included, but were not limited to, staff assisting Resident #10 with turning and repositioning as needed, checking the resident for incontinence, and changing the resident if wet or soiled three (3) times daily and as needed. A 03/16/14 Nurse's Notes entry for Resident #10 documented the identification of a coccyx pressure sore measuring 0.5 centimeter (cm) by 0.5 cm, and a 03/16/14 Physician/Prescriber Telephone Orders form specified the cleansing of this coccyx pressure sore and the application of [MEDICATION NAME] dressing every three (3) days and as needed until healed. Further review of Resident #10's Care Plan Report revealed a Care Plan update dated 03/16/2014 (the date of the physician's orders [REDACTED]. However, during an interview with Resident #10's private caregiver conducted in the resident's room on 04/05/2014 at 3:40 p.m., the private caregiver stated that nursing staff had not repositioned the resident and had not provided incontinence care since the caregiver's arrival at 9:00 a.m. that morning. During interview with Certified Nursing Assistants (CNAs) "SS" and "TT" conducted on 04/05/2014 at 4:00 p.m., CNAs "SS" and "TT" acknowledged that they had neither checked Resident #10 for incontinence, nor repositioned the resident, since earlier that morning at 8:00 a.m. This represented an eight (8) hour period of time (extending from 8:00 a.m. until the 4:00 p.m. staff interview) during which facility staff had failed to check Resident #10 to determine the need for incontinence care and had failed to turn and reposition the resident from side-to-side, as specified by the Care Plan Report Interventions referenced above. Observation of Resident #10 at the time of this interview revealed the incontinence brief to be saturated with urine, and in addition, revealed that the resident's coccyx pressure sore was not covered with a dressing as ordered, but rather was open to air. During an interview conducted on 04/05/2014 at 4:05 p.m., the Medication Nurse acknowledged that Resident #10's coccyx pressure sore was not covered with a dressing as ordered. Cross refer to F314 for more information regarding Resident #10.