Every finding on record at Mclean Health Center

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure the resident and physician/APRN were notified timely when a medication was not administered in accordance with physician orders. The findings include: Resident #1's diagnoses included depressive episodes and anxiety disorder. The Resident Care Plan (RCP) dated 4/8/2026 identified Resident #1 had anxiety and insomnia. Interventions directed to administer antianxiety medications as ordered by the physician, and maintain consistent schedule with daily routine. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented. Review of hospital discharge paperwork dated 4/7/2026 directed start 4/8/2026 Clonazepam (Klonopin, used to treat anxiety) 0.25 mg (milligrams) disintegrating tablet take one tablet by mouth nightly. A physician order dated 4/7/2026 directed Clonazepam oral tablet disintegrating 0.25 mg give one (1) tablet by mouth at bedtime for anxiety, start 4/8/2026. Review of the April MAR (Medication Administration Record) directed Clonazepam oral tablet disintegrating 0.25 mg give one (1) tablet by mouth at bedtime, scheduled for 9 PM, for anxiety. The box to sign for 4/8/2026 was blank, with no entry to identify the medication was administered. Record review failed to identify that the resident or physician/APRN were notified that Clonazepam 0.25 mg was not administered on 4/8/2026. a. Physician order dated 4/9/2026 directed Clonazepam oral tablet disintegrating 0.50 mg give one (1) tablet by mouth at bedtime for insomnia. Review of April MAR (Medication Administration Record) directed Clonazepam oral tablet disintegrating 0.50 mg give one (1) tablet by mouth at bedtime, scheduled for 9 PM, for anxiety. The box for the nurse to sign for 4/9/2026 was marked with a 9 (other/see progress notes). Record review failed to identify that the resident or physician/APRN were notified that Clonazepam 0.25 mg was not administered on 4/9/2026. b. Physician order dated 4/13/2026 directed Clonazepam oral tablet disintegrating 0.25 mg give three (3) tablets by mouth at bedtime for anxiety. Review of April MAR (Medication Administration Record) directed start date 4/13/2026 Clonazepam oral tablet disintegrating 0.25 mg give three (3) tablets by mouth at bedtime, scheduled for 8 PM, for anxiety. Further review identified on 4/20, 4/21, 4/22/2026 as 9 (other/see progress notes). Record review failed to identify a nursing note for 4/20/2026. Nursing note (late entry) dated 4/21/2026 identified the pharmacy was called to verify Klonopin (Clonazepam) 0.25 mg, give three (3) tabs, equaling 0.75 mg total, and a prescription was electronically sent by APRN and would be sent this afternoon. Confirmed with pharmacy the script was received, and the unit nurse and DNS updated. Nursing progress note dated 4/22/2026 by RN #2 indicated the Clonazepam 0.25 mg three (3) tabs was not available for administration; awaiting delivery from the pharmacy. Review of RN #1 written statement dated 4/25/2026 identified the Clonazepam was not given to Resident #1 due to unavailability on 4/20, 4/21 and 4/22/2026. Record review failed to identify that the resident or physician/APRN were notified that Clonazepam 0.25 mg three (3) tablets were not administered on 4/20, 4/21 and 4/22/2026. On 7/7/2026 at 12:11 PM interview with RN #2 identified that a resident should be notified if a medication was unavailable, and it should be documented in the resident's record. On 7/7/2026 at 12:42 PM interview with RN #1 identified if a medication was unavailable the resident should be notified. Interview, record review and facility policy review on 7/7/2026 at 2:26 PM with the DNS indicated the facility should have had Resident #1's Clonazepam upon admission, and if the medication was not administered, the resident and physician/APRN should be notified. Interview failed to identify why the resident and physician/APRN were not notified. Notification to a family should be completed if the resident was not alert and oriented. Review of facility Change of Resident's Condition Policy directed in part; when a resident has a change of condition, timely notification of physician and family occur.

Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #1's diagnoses included depressive episodes and anxiety disorder. The Resident Care Plan (RCP) dated [DATE] identified Resident #1 had anxiety and insomnia. Interventions directed to administer antianxiety medications as ordered by the physician, and maintain consistent schedule with daily routine. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 was alert and oriented. Review of hospital discharge paperwork dated [DATE] directed start [DATE] Clonazepam (Klonopin, used to treat anxiety) 0.25 mg (milligrams) disintegrating tablet take one tablet by mouth nightly. A physician order dated [DATE] directed Clonazepam oral tablet disintegrating 0.25 mg give one (1) tablet by mouth at bedtime for anxiety, start [DATE]. Physician order dated [DATE] directed Clonazepam oral tablet disintegrating 0.50 mg give one (1) tablet by mouth at bedtime for insomnia. Physician order dated [DATE] directed Clonazepam oral tablet disintegrating 0.25 mg give three (3) tablets by mouth at bedtime for anxiety. Review of the April MAR (Medication Administration Record) identified the 4/8 Clonazepam nurse signature box was blank (not signed to identify the medication was administered). Additional review identified the signature box for 4/9, 4/20, 4/21 and [DATE] were marked 9 to indicate see progress notes. Nursing note review failed to identify why the 4/8, 4/9 and [DATE] doses of Clonazepam were not administered. Nursing note dated [DATE] identified the Clonazepam was not available and a call was made to the pharmacy. The pharmacy confirmed a script was received and it would be sent to the facility this afternoon. Nursing note dated [DATE] by RN #2 indicated the Clonazepam 0.25 mg three (3) tabs were not available for administration; awaiting delivery from the pharmacy. Facility incident report dated [DATE] identified Resident #1 did not receive Clonazepam as ordered on 4/20, 2/21 and [DATE] because the medication was not available in resident supply and was not available in facility emergency supply. Review of RN #1 written statement dated [DATE] identified the Clonazepam was not given to Resident #1 due to unavailability on 4/20, 4/21 and [DATE]. Review of facility emergency medication stock machine Transactions by Item/Procedure report date range 4/1 to [DATE] identified Clonazepam 0.5 mg tablet quantity/supply on 4/4 was 0 and on [DATE] was 40. Although requested, the facility was unable to identify any additional emergency stock level of Clonazepam 0.5 mg in emergency stock throughout [DATE]. Interview, record review and facility policy review on [DATE] at 2:26 PM with the DNS identified she was not aware Resident #1's Clonazepam was not received timely from the pharmacy to ensure administration. The DNS stated the facility emergency supply should have included Clonazepam 0.5 mg during April. The DNS stated the facility had not been regularly stocking the Clonazepam in the emergency supply as it often expired before use, and she had corrected the supply issue. The DNS stated if she was notified, she would have ensured required steps were taken for the resident supply or the emergency supply, to ensure the medication was administered as ordered. Review of facility Medical Administration/Management Policy directed in part; to ensure that medications are safely and accurately administered and managed. Review of facility Agreement for Omnicell Automated Dispensing System directed in part; the purpose of the emergency supply of medication is to ensure the residents will have access to pharmaceutical care in a manner that provides for the appropriate initiation and continuation of drug therapy.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure responsible party was notified timely of medication changes. The findings included: Resident #1's diagnoses included pneumonitis, neuropathic bladder and cognitive communication disorder. Record review identified Resident #1 was self-responsible until 12/20/2025, and Resident #1 had two (2) designated Responsible Parties. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine out of fifteen, indicative of moderate cognitive impairment, was dependent with ADLs, and had indwelling urinary catheter. The Resident Care Plan (RCP) dated 11/26/2025 identified Resident #1 had a wound, had a foley catheter, and had an alteration in ADL self-care performance. Interventions directed wound care as ordered, notify the physician of changes in the wound, medication as ordered, foley catheter monitor for signs of infection and notify the physician as indicated, and provide assistance with personal hygiene. APRN note dated 1/2/2026 at 1:04 PM indicated Resident #1 was seen for complaint of a sore throat. Resident #1 indicated the sore throat started on 1/1/2026. Denied pain with swallowing, denied rhinorrhea, occasional cough, and no fever. Currently up in wheelchair in room with complaints of pain when sitting in chair. Has sacral wound, recently completed antibiotic, no hematuria noted in foley bag, urine cloudy, appetite fair, drinking well, working with therapy, blood sugars stable. Vital signs reviewed and stable, medications, labs and progress notes reviewed, lungs clear, sore throat. Plan start Acetaminophen twice a day for three (3) days. Physician/APRN order dated 1/2/2026 directed Acetaminophen tablet 325 milligrams (mg) give two (2) tablets two times a day for sore throat until 1/5/2026. Review of record failed to identify that the responsible party was notified by facility staff of a medication change. APRN note dated 1/7/2026 at 10:46 PM identified a follow up visit to evaluate Resident #1's sacral wound not improving and pain related to the sacral wound. Resident #1's responsible party called nursing this morning and requested pain medication prior to wound treatment. Resident #1 reported pain when sitting in chair, but responsible party insists he/she be up in the chair. APRN recommended that Resident #1 spend short time in chair and more time in bed on his/her side for wound healing. On oxycodone scheduled twice a day and as needed every six (6) hours, but with the schedule he/she will not receive as needed except overnight. Physician/APRN order dated 1/7/2026 directed Acetaminophen tablet 500 mg, give two (2) tablets by mouth every 8 hours for pain. Record review failed to identify the facility staff notify the responsible party of new order for Acetaminophen tablet 500 mg give two (2) tablets by mouth every 8 hours for pain. Nursing note dated 1/12/2026 titled Communication with Family indicated a call was placed to family at his/her request. Labs were reviewed, a copy was provided, and updated urinary catheter was changed without incident. APRN order dated 1/12/2026 directed on Acetaminophen oral tablet 325 mg give three (3) tablets every eight (8) hours for pain management. Review of record failed to identify the responsible party was notified of the new Acetaminophen orders dated 1/12/2026 that directed to administer 325 mg, give three (3) tablets every eight (8) hours for pain management. APRN note dated 1/21/2026 indicated Resident #1 was seen for follow up and lab review. [NAME] blood cell count was elevated, no fever and the sacral wound was unchanged. An MRI was scheduled for next week to rule out osteomyelitis, urinary catheter remains in place, chronic milky appearing urine despite flushing twice daily, recent catheter change, and urine culture was negative. Nursing note dated 1/22/2026 indicated new onset change in level of consciousness, temperature 97.8 degrees, brief episode of non-responsiveness, the responsible party returned Resident #1 to his/her room. Resident #1 was tired and sleepy but arousable, transferred back to bed and became more awake. The APRN was notified and assessed Resident #1. Physician order dated 1/22/2026 directed to obtain a urinalysis with culture, and to administer Doxycycline Hyclate (antibiotic) oral tablet 100 mg give 100 mg mouth two (2) times a day for leukocytosis for seven (7) days, to start after urine culture was obtained. The order further directed to administer Acidophilus (probiotic) oral capsule, give two (2) capsules by mouth three (3) times a day for gut health while on antibiotics for 7 (seven) days. Record review failed to identify the responsible party was notified of the new orders obtained on 1/22/2026 that directed to administer Doxycycline Hyclate oral and Acidophilus. Interview and record review on 3/16/2026 at 2:33 PM with the DNS identified initially the resident was self-responsible and was later evaluated by psychiatry who identified he/she was unable to demonstrate decisional capacity. Although the DNS stated any resident's responsible party should be notified of new physician orders, the DNS was unable to provide documentation that Resident #1's responsible party was notified of the medication changes that occurred on 1/2, 1/7, 1/12, and 1/22/2026. The DNS stated the nurse on each shift should have notified and documented the notification in the clinical record. Review of facility Change of Resident's Condition Policy directed in part, to assess changes of conditions and to notify the physician, and family (representative/responsible party). Clearly document the date, times, physicians/personnel/family (representative/responsible party) of notification and any pertinent information in the nurses' notes.

Based on review of clinical records, interviews, and review of facility documentation and policy for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident was safely transferred using a mechanical lift. The findings included:Resident #1 was admitted to the facility March 2021 with diagnoses of hemiplegia and hemiparesis, major depressive disorder, and anxiety disorder. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and indicated Resident #1 was cognitively intact. The MDS further identified Resident #1 was dependent with toilet hygiene, personal hygiene, and transfersReview of Resident #1's Care Plan dated 6/20/25 identified an activity of daily living, self-care performance deficit related to confusion and hemiplegia. Interventions directed to utilize the maxi lift (Hoyer lift) with an assist of two (2) and use of an extra-large blue sling. Review of Resident #1's Care Card dated 6/30/25 (utilized by nursing staff which listed Resident #1's specific care needs) identified transfer instructions directing staff to utilize the Maxi Lift (Hoyer) with an assist of two (2) staff and use of the extra-large blue sling (pad used to safely and securely transfer the resident) into the custom tilt in space wheelchair. Review of the Department of Public Health Facility Licensing and Investigation Section Reportable Event form dated 7/28/25 at 5:500 PM identified Resident #1 had slid out of her sling while being transferred in his/her room, had pain to the back of his/her head and left side heaviness, and that the incident was witnessed by NA#1 and NA#2.Review of Resident #1's hospitalization summary dated 7/28/25 identified both the C6 and C7 spinous processes were fractured with some edema surrounding them.Interview with NA #2 on 8/19/25 at 10:58 AM identified he/she participated in transferring Resident #1 from his/her wheelchair back to bed with the assistance of NA #1 on 7/28/25. NA #2 indicated he/she and NA #1 were only able to secure three (3) of the four (4) sling straps to the Maxi-Lift as each time they attempted to secure the fourth strap, Resident #1 would indicate he/she was in pain. NA #2 identified it was then that he/she thought the sling may have been the wrong size for the resident. NA #1 and NA #2 transferred Resident #1 with only three (3) straps secured to the Maxi-Lift, with one of them manually supporting the unstrapped/unsupported lower extremity during the transfer. While Resident #1 was suspended partially over his/her bed, NA #2 was unable to progress the lift forward as the wheel came into contact with a cord that was underneath Resident #1's bed. NA #2 indicated he/she chose to push the Maxi-Lift wheel over the cord, and after doing so, Resident #1 slid out of the sling and fell onto the floor. Interview with the Director of Nursing Services (DNS) on 8/20/25 at 12:00 PM identified the facility's standard of practice for a safe transfer utilizing a Maxi-Lift was to employ two (2) staff members to perform the task, assess the sling color (for integrity and to ensure the color matches the care card instruction), proper positioning of the sling under the resident, ensure the area was clear for the transfer, and to ensure that all four straps (via clips) were securely attached to the Maxi-Lift prior to initiating the transfer. The DNS further indicated any issues, concerns or questions regarding the transfer should be brought to the attention of the floor nurse prior to the transfer taking place.Review of the Transfers/Safe Resident Handling/Mechanical Lifting and Transfer Devices policy directed staff members were expected to maintain compliance with safe handling/transfer practices, and resident lifting and transferring would be performed according to the resident's individual plan of care.[JA1] The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance as of July 30, 2025.Staff education: to ensure the safety of residents who require mechanical transfers. Staff members must look at the care card before performing the transfer, ensure the proper sling size is used, and ensure correction positioning. The facility completed lift orientation / competencies for all staff.Weekly Care audits were conducted to ensure proper lift and transfer of residents.

Based on review of clinical records, interviews, and review of facility documentation and policy for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure new staff were competent to properly and safely administer mechanical lift transfers. The findings included:Resident #1 was admitted to the facility March 2021 with diagnoses of hemiplegia and hemiparesis, major depressive disorder, and anxiety disorder. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of fifteen (15) and indicated Resident #1 was cognitively intact. The MDS further identified Resident #1 was dependent with toilet hygiene, personal hygiene, and transfersReview of Resident #1's Care Plan dated 6/20/25 identified an activity of daily living, self-care performance deficit related to confusion and hemiplegia. Interventions directed to utilize the maxi lift (Hoyer lift) with an assist of two (2) and use of an extra-large blue sling. Review of Resident #1's Care Card dated 6/30/25 (utilized by nursing staff which listed Resident #1's specific care needs) identified transfer instructions directing staff to utilize the Maxi Lift (Hoyer) with an assist of two (2) staff and use of the extra-large blue sling (pad used to safely and securely transfer the resident) into the custom tilt in space wheelchair. Review of the Department of Public Health Facility Licensing and Investigation Section Reportable Event form dated 7/28/25 at 5:500 PM identified Resident #1 had slid out of her sling while being transferred in his/her room, had pain to the back of his/her head and left side heaviness, and that the incident was witnessed by NA#1 and NA#2.Interview with NA #2 on 8/19/25 at 10:58 AM identified he/she participated in transferring Resident #1 from his/her wheelchair back to bed with the assistance of NA #1 (an agency hire that was new to the facility) on 7/28/25. NA #2 indicated he/she and NA #1 were only able to secure three (3) of the four (4) sling straps to the Maxi-Lift and transferred Resident # 1. The transfer was initiated; Resident #1 was suspended in air and partially over his/her bed when the lift wheel encountered a cord underneath Resident #1's bed. NA #2 indicated he/she chose to push the Maxi-Lift wheel over the cord, and after doing so, Resident #1 slid out of the sling and fell onto the floor, with the back of her head hitting the metal base of the lift. Review of Resident #1's hospitalization summary dated 7/28/25 identified both the C6 and C7 spinous processes were fractured with some edema surrounding them.Interview with NA #1 (an experienced agency nurse's aide of 12 years) on 8/19/25 at 9:45 AM identified 7/28/25 was his/her first day at the facility, that he/she was new to its practices, and that he/she had followed NA #2's instructions on how to transfer Resident #1 via mechanical lift that day. [JA1] Although requested, the facility was unable to provide documentation identifying NA #1 was skilled checked for mechanical transfers.Interview with the Director of Nursing Services (DNS) on 8/19/25 at 12:20 PM identified NA #1 was not educated or skill checked for mechanical transfers prior to performing Resident #1's mechanical transfer on 7/28/25. The DNS indicated the focus for agency staff (nurse's aides) on their first day of work was to familiarize them with the residents' care needs, diet orders, and transfer statuses as the expectation was that they were already educated and skilled on how to properly perform mechanical transfers. The DNS further indicated that as mechanical transfers were a two person assist, a competent mentor (NA #2, a non-agency nurse aide hired by the facility) would guide them and ensure the correct procedure was followed and did not mandate agency staff to be skill checked for mechanical transfers prior to participating/performing them. Since Resident #1's accident on 7/28/25, the facility has changed its practice and all new agency staff are now educated/skill checked prior to participating in or performing mechanical transfers. Interview with NA #2 on 8/19/25 at 2:21 PM identified that he/she was not assigned to mentor/oversee NA #1 and that he/she just participated in assisting NA #1 with Resident #1's transfer on 7/28/25. Review of the Transfers/Safe Resident Handling/Mechanical Lifting and Transfer Devices policy directed staff would be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually, and as the need arises or changes in equipment occur. The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance as of July 30, 2025.Staff education: to ensure the safety of residents who require mechanical transfers. Staff members must look at the care card before performing the transfer, ensure the proper sling size is used, and ensure correction positioning. The facility completed lift orientation / competencies for all staff.

Based on observation, review of the clinical record, facility documentation and interview for 1 resident (Resident #39) who utilized eye drops, the facility failed to assess the resident for Self-Administration of Medication and obtain a physician's orders for the resident to self-administer eye drops. The findings include: Resident #39's diagnoses included anxiety, depression, glaucoma, hearing loss, hypertension, diabetes mellitus, atrial fibrillation and acute myocardial infarction. The annual MDS dated [DATE] identified Resident #39 had intact cognition. The corresponding care plan identified Resident #39 had a self -care performance deficit related to impaired mobility. Interventions included: the resident was independent with upper body bathing and required minimum assist when needed with lower body bathing, to ambulate with rollator and noted the utilization of wheelchair. Review of physician's orders dated 3/1/25 through 4/30/25 directed to administer Brimonidine Tartrate 0.2 % drops one drop in the left eye twice a day for glaucoma, Brinzolamide 1 % drop suspension one in left eye two times a day for glaucoma. Review of the April 2025 MAR identified to administer Brimonidine Tartrate 0.2 % drops one drop in the left eye twice a day for glaucoma, Brinzolamide 1 % drop suspension one in left eye two times a day for glaucoma. Observation of Resident #39 on 4/30/25 at 11:15 AM identified the resident self-propelling in a wheelchair to the nurse's station with two eye drop bottles in her/his hand. Resident #39 indicated to the surveyor, (I am looking for the nurse so I can give her back the drops I took). Review of the clinical record and facility Electronic Medical Record (EMR) failed to identify a Self-Administration of Medication Assessment and/or a physician's order for Resident #39 to self-administer the eye drops. Interview with RN #2 on 4/30/25 at 11:30 AM identified she believed Resident #39 could self-administer the eye drops and thought the resident was assessed to self-administer the eye drops. Record review and interview with the DNS and the Quality Educator (RN #1) on 4/30/25 at 11:25 AM identified the resident was cognitively intact with no memory problems. However, they were unable to provide evidence of a Self-Administration Assessment form and/or a physician's order for Resident #39 to self-administer the eye drops. After inquiry, on 4/30/25, a Self-Administration of Medication Assessment was started by the licensed staff. The facility policy for Self-Administration of Medication identified any resident who can safely administer his/her medication will be allowed to do so. A self-Administration assessment will be completed by a nurse. If the assessment shows the resident is competent, continue. The label must include: the name of the medication, dose, when it should be taken, the route it should be taken, the treatment number and the name of the physician who prescribed the medication. All medication must be stored in a lock unit. Residents and the facility must have access to the unit.

Based on review of the clinical record, facility policy, and interviews for 1 of 2 residents, (Resident #4), reviewed for a general skin condition, the facility failed to follow a physician order for an antiplatelet (prevents blood clots) medication. The findings include: Resident #4's diagnoses included atrial fibrillation, diastolic congestive heart failure, and hypertension. The quarterly MDS dated [DATE] identified Resident #4 had no cognitive impairment and required partial/moderate assistance with upper body dressing, substantial/maximal assistance with lower body dressing, and required supervision or touching assistance with transfers. The care plan dated 3/26/25 identified the resident received antiplatelet therapy. Interventions included to administer the antiplatelet medication as ordered by the physician. Review of the current physician's orders failed to identify antiplatelet medication use. Interview with LPN #1 on 4/30/25 at 10:40 AM identified that the care plan indicated antiplatelet use, but she was unable to find a current physician's order for an antiplatelet medication. Reinterview with LPN #1 on 4/30/25 at 12:10 PM identified that Resident #4 should have been receiving Aspirin (antiplatelet medication) 81 mg according to the physician orders dated 3/25/25, but that it was missed when the facility changed electronic medical record software systems. Subsequent to surveyor inquiry, a medication error report was generated, the physician was notified, and Resident #4's Aspirin was reinstated.

Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 5 residents, (Resident #1 and 32) reviewed for unnecessary medications, the facility failed to limit as needed (PRN) psychotropic drugs to 14 days without a rationale documented in the resident's medical record. The findings include: 1. Resident #1's diagnoses included chronic respiratory failure, calorie malnutrition, pharyngoesophageal dysphagia, acute metabolic encephalopathy, Parkinson disease, seizure disorder, hypertension, atrial fibrillation, depression, anxiety, and chronic pain. The physician's order dated 1/26/25 directed to administer Lorazepam (anti-anxiety) 0.5mg PRN for 30 days. The physician's order dated 2/25/25 directed to administer Lorazepam 2 mg/ml concentrate (0.25 ml/0.5 mg by mouth/sublingual every 4 hours PRN for anxiety or agitation (no stop dated). The [DATE]/25/25 through 3/12/25 noted Lorazepam 2 mg/ml concentrate (0.25 ml/0.5 MG) by mouth /sublingual twice a day 9:00 AM and 5:00 PM for anxiety or agitation with no stop date. A Pharmacy Consultation Report dated 3/11/25 identified PRN (when needed) order for ant-anxiety haS been in place for greater than 14 days without stop date. Additionally, the report also noted Centers for Medicare and Medicaid Services (CMS) requires PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days. Record review and review of the pharmacy consultation report dated 3/11/25 with the DNS on 4/30/25 at 2:10 PM identified she believed there was a 30 day stop order on the Lorazepam 1/26/25, Lorazepam 0.5 MG, but when the physician's orders were changed on 2/25/25 there was no stop date. The DNS further indicated this error was picked up by the pharmacy 3/11/25. The DNS also indicated the 11:00 PM - 7:00 AM licensed staff are responsible for checking medication every 24 hours for dates and renewal. The Use of Psychotropic Medication policy identified physician's orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). 2. Resident #32 was admitted to the facility in April 2023 with diagnoses that included Alzheimer's disease and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #32 had short and long term memory problems and severely impaired cognition. The corresponding care plan identified an alteration in mood state with interventions that included to refer to Geri psych as needed and monitor for increased anxiety. Physician's order dated 8/16/24 directed to administer Ativan/Lorazepam (antianxiety medication) 0.5mg every 6 hours prn anxiety, restlessness and tearfulness for 30 days. A pharmacy consult form dated 9/12/24 identified a prn Lorazepam order was reissued on 8/16/24 for 30 days. Pharmacy recommendations identified as per CMS regulations, when re-issuing a psychotropic, please document the indication for use and the rationale for the extended time period. The physician's response on the form, undated, identified ongoing LT use; to maintain stability, however failed to document the required information. Physician's order dated 11/3/24 directed to administer Ativan 0.5mg every 6 hours prn anxiety, restlessness and tearfulness for 30 days the reassess with physician. Physician's order dated 12/3/24 directed to administer Ativan 0.5mg every 6 hours prn anxiety, restlessness and tearfulness for 60 days. A psychiatric evaluation and consultation dated 12/6/24 identified the resident was seen for medication management to follow up on prn Ativan extended by medical provider. Documentation identified anxiety disorder, currently on prn Ativan 0.5mg every 6 hours for anxiety. Effective use of prn. Staff nurse reports the resident has remained stable with no acute psychiatric or behavioral concerns. Continue current dose of medication and monitor for worry, panic, restlessness. Resident with chronic psychiatric illness, stable on current regimen. A pharmacy consult form dated 12/16/24 identified a prn Lorazepam order was reissued on 12/3/24 for 60 days. Pharmacy recommendation identified as per CMS regulations, when re-issuing a psychotropic, please document the rationale for the extended time period. The physician's response on the form dated 12/31/24 identified comfort measures only (CMO). Physician's order dated 2/3/25 directed to continue Ativan 0.5mg every 6 hours prn for 60 days. The annual MDS dated [DATE] identified Resident #32 had short and long term memory problems and severely impaired cognition. Physician's order dated 4/13/25 directed to continue Ativan 0.5mg every 6 hours prn for 60 days. Review of the clinical record failed to reflect that the physician documented a rationale for extending the PRN Ativan more that 14 days between 8/16/24 to current. Review of the use of psychotropic medication policy directed PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition, that is documented in the clinical record and for a limited duration, (i.e. 14 days). If the attending physician or prescriber believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the residents medical record and indicate the duration for the PRN order.

Based on tour of the Dietary Department and staff interview, the facility failed to ensure stored food included an expiration date, was dated when opened and failed to ensure refuse was covered near food items. The findings include: Tour of the Dietary Department on 9/11/23 at 11:30 AM with the Director of Dining Services identified the following in the HC-HC Reach in Refrigerator: a. a 1 gallon container that was 1/3 full of Vinaigrette dressing was dated as opened 8/18/23, but the container or labeling failed to include an expiration date. b. a 1 gallon container that was 3/4 full of Italian dressing was dated as opened on 9/6/23 but failed to identify an expiration date either on the container or labeling. c. a 1 gallon container that was 1/2 full of Ranch dressing was dated as opened on 9/6/23, but the expiration date on the container was illegible due to the label being faded. d. a 1 gallon container that was almost full of Honey Mustard failed to identify the date opened. e. a 32 ounce bottle of Balsamic Vinaigrette that was 1/2 full was dated as opened on 9/10/23, but failed to include an expiration date on the label or bottle. f. a 1 gallon bottle of Toasted Sesame dressing that was 1/4 full was dated as opened on 4/19/23, but failed to include an expiration date on the label or bottle. g. a 1 gallon container of Tuscan Caesar dressing that was 3/4 full was dated as opened on 4/14/23, but failed to include an expiration date on the label or container. h. a 1 gallon container of Tuscan Caesar dressing that was 1/4 full was dated as opened on 11/2/23 (date has not occurred as of yet), and failed to include an expiration date on the label or container. Additionally, there was an uncovered plastic garbage bin that was 1/2 full of garbage and located proximal to an opened dessert cart that contained assorted bakery items (the bakery items were individually covered with plastic wrap). Furthermore, observation of the Cooks Reach-In-Refrigerator at that time with the Director of Dining Services identified the following: a. a 48 ounce container of Dijon mustard with an opened date of 4/5/23, and an expiration date of 9/2/23 (9 days past the expiration date). b. a 4.5 ounce bottle that was 1/2 full of Salted Caramel sauce, which failed to include a date opened. c. a container of Teriyaki sauce that was 1/4 full with an opened date of 5/3/23, but failed to include an expiration date either on the label or container. Additionally, tour of the Dry Storage room identified the following: a. a bulk flour bin (approximately 5 gallons), that was 1/2 full of flour, failed to include a date as to when the flour was emptied into the bulk bin. b. a 2 pound (lb) opened bag of spaghetti that was 1/2 used, was wrapped in plastic wrap, but lacked a date when opened. c. a 4 lb opened bag of elbows that was 1/2 used was knotted by the bags top, was 1/2 full, lacked a date when opened. d. a plastic storage container containing Asian dry noodles was 3/4 full, with a discard by date of 1/11, but did not identify the year to discard. Interview with the Director of Dining Services at that time identified the expiration dates were on the original box/case the containers came in, and when they were removed, the expiration date should have been written on the container from the person who removed them from the case. Additionally, the Director of Dining Services identified the Sous Chef or Chef is responsible for periodic checking food items for expiration and dates opened. Although he identified there wasn't a specific time frame for checking, he stated it should be done weekly.

Based on clinical record review, observations, review of facility documentation, review of facility policy and interviews for 1 of 1 sampled resident (Resident #38) reviewed for accidents, the facility failed to complete a Neurological Assessment and a re-admission nursing assessment following an emergency room (ER) visit for a fall with injury. The findings include: Resident #38's diagnoses included dementia, late onset Alzheimer's without behavioral disturbance, repeated falls, and an unspecified lack of coordination. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 had severe cognitive impairment, was independent with eating and required assistance with set up, required supervision and no assist from staff with bed mobility, and transfer, and need limited assistance with dressing and extensive assistance with personal hygiene. No falls were identified since the last MDS. A Resident Care Plan dated 6/2/23 identified a problem with being at risk for falls with interventions that included: leaving the resident's door open when assistance was not being provided, assisting with toileting/incontinent care per facility policy, assisting with toileting on arising, and assisting with chair management/seating in the dining room. Nursing notes dated 6/17/23 at 11:09 AM indicated Resident #38 was found on the floor on at 7:50 AM by a Nurse Aide who was ambulating another resident in the hallway when he/she heard Resident #38 hit the floor from the hallway and after opening Resident #38's door, the resident was found on the floor lying on his/her back. Nursing notes dated 6/17/23 at 8:37 AM indicated a physician order directed to send Resident #38 to the hospital status post fall secondary to pain in the neck, back, left upper extremity and left thigh. Resident #38 returned from theER on [DATE] at 5:00 PM. Physician progress notes dated 6/19/23 indicated Resident #38 fell and was transported to the ER for evaluation as the resident was in pain. Resident #38 was diagnosed with a left ulnar fracture. A Neurological Flow Sheet failed to reflect neurological assessments were completed from 6/17/23 at 5:00 PM (upon return from the ER) through 6/18/23 at 3:00 AM. Review of Neurological Flow Sheet and interview with the Registered Nurse (RN) #2 on 9/15/23 at 11:10 AM indicated the Neurological Flow Sheet following Resident #38's fall on 6/17/23 was incomplete. RN #3 further identified there was not a readmission assessment completed by a RN upon Resident #38's return from theER on [DATE] at 5:00 PM. A review of the facility fall policy indicated that the following documentation must be completed post fall: document every shift for 72 hours on post-fall and document on Neurological Flow Sheet if unwitnessed or with a head injury.

Based on observation, review of the clinical record, facility documentation and interviews for 1 of 5 sampled resident (Resident #468) reviewed for dining, the facility failed to supervise Resident #468 for meals per recommendations by the Speech Language Pathologist (SLP). Resident #468's diagnoses included acute right cerebral stroke, right sided weakness and diabetes mellitus type II. The admission Resident Care Plan (RCP) dated 9/1/23 identified Resident #468 had chewing/swallowing difficulty requiring SB6 (soft and bite sized) diet consistency with interventions that included to treat as indicated by speech therapy. Interventions also included Resident #468 had the potential for self-care deficit requiring a full set up for meals including an inner lip dish, built-up fork/spoon and supervised eating in the day room. A physician's order dated 9/1/23 directed the diet included carbohydrate controlled, heart healthy, soft and bite size consistency with thin liquids. Review of the physician's orders failed to indicate assistive devices used for meals, as well as supervision status. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #468 was cognitively intact and required extensive assist with 2 persons for bed mobility, transfers and dressing, and extensive assist with a 1 person for eating. Observation on 9/12/23 at 10:22 AM identified Resident #468 was still in bed with a meal (breakfast) on the bedside table within Resident #468's reach, uneaten with no staff person present in the room. Observation on 9/13/23 at 1:03 PM identified Resident #468 was sitting at the bedside in his/her wheelchair eating the lunchtime meal from the bedside table unassisted with no staff person present in the room. Observation on 9/14/23 at 12:40 PM identified Resident #468 was sitting at the bedside in his/her wheelchair being assisted with the lunchtime meal by his/her significant other, with no staff person present in the room. Review of Nurse Aide (NA) documentation from 9/1/23 to 9/14/23 identified Resident #468 ate his/her meal independently with set-up help only eleven times since admission. Interview with the Speech Language Pathologist (SLP) on 9/15/23 at 11:50 AM identified that she expected Resident #468 to be set-up and supervised by staff at all meals, meaning that Resident #468 should be within eye sight of staff at all times. If Resident #468 refused to eat in the day room, then he/she should be set-up in the doorway within sight and staff should be readily available to help and cue Resident #468 to take smaller bites and take bites of his/her meal in general. SLP indicated Resident #468's significant other was not trained by the facility in feeding and confirmed that the significant other should not have been feeding the resident, nor did she count that as a supervising staff. Interview with DNS on 9/15/23 at 12:23 PM identified she did not expect meal supervision to be a physician's order, but instead a therapy recommendation which she would expect the nursing and aide staff to follow. Additionally, the DNS indicated that therapy had access to update the care plans, which then carry over to the Nurse Aide care card for direction.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #468) reviewed for respiratory care, the facility failed to ensure that oxygen tubing was properly stored, labeled and dated. The findings include: Resident #468's diagnoses included acute right cerebral stroke (8/29/23), hypertension, urinary tract infection and hyponatremia. An Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #468 was cognitively intact and required extensive assistance of 2 for bed mobility, transfers and dressing. A physician's order dated 9/8/23 directed nursing staff to apply a nasal cannula at 2.0 liters of oxygen to maintain oxygen saturation greater than 92%. Observation on 9/12/23 at 10:22 AM identified Resident #468's oxygen nasal cannula tubing was unlabeled, undated and hanging on the concentrator, not bagged. Observation on 9/13/23 at 1:03 PM identified Resident #468's oxygen nasal cannula tubing was unlabeled, undated and hanging on the concentrator, not bagged. Observation on 9/14/23 at 12:40 PM of Resident #468's oxygen nasal cannula tubing was unlabeled, undated and hanging on the concentrator, not bagged. Interview with RN #1 on 9/14/23 at 1:59 PM identified she was unsure when the oxygen tubing was last changed, stating it was the responsibility of the 11:00 PM to 7:00 AM shift nurse to change oxygen tubing, however, the task did not show up on the Medication Administration Record or Treatment Administration Record to document on. RN #1 identified the facility policy was to change the oxygen tubing weekly and/or when soiled or filled with water, as well as label with the date and time and bag the tubing for infection control. She could not identify if it was a physician's order or a nursing protocol. RN #1 identified Resident #468 was not aware the tubing was unlabeled and unbagged. Subsequent to surveyor inquiry, RN #1 stated she would discard and change the tubing. Review of the Care of Respiratory Equipment policy Reviewed June 2013 directed changing disposable cannulas, tubing is to be changed every Thursday on 11-7 shift. Night nurse to tag and date each change and document in ECS Medication Administration Record (MAR).

Based on observation, clinical record review, review of facility documentation, and interviews for one sampled resident (Resident #27) who required assistive devices for dining, the facility failed to provide a lipped plate per the resident's plan of care. The findings include: Resident # 27's diagnoses included dementia, essential hypertension, and chronic obstructive pulmonary disease. The annual MDS assessment dated [DATE] identified Resident #27 had severe cognitive impairment, required extensive assistance with bed mobility, dressing, personal hygiene, and was independent with eating with set up help from the staff. The Resident Care Plan (RCP) dated 7/27/23 identified Resident #27 was at risk for unplanned weight changes due to his/her small meal intakes and advancing Alzheimer's dementia and advanced age. Interventions included to set up meals, provide feeding assistance, monitor meal intake daily and a lipped plate at meals. Observation on 9/14/23 at 12:00 PM identified Resident #27 was eating in the second floor dining room, Resident #27's food was on a regular plate without the benefit of a lipped plate being provided per the RCP. Resident #27's dining ticket also identified that a lipped plate should be utilized for all meals. Interview and observation with the Dietary Aid (DA) #1 on 9/14/23 at 12:15 PM identified Resident #27 did not have a lipped plate. DA #1 identified that she did have a stock of lipped plates in the second floor dining room and she showed that there were lipped plates available. She also provided a copy of Resident #27's menu which indicated Resident #27 should have a lipped plate at all meals. DA #1 was not able to provide a reason Resident #27 was not provided a lipped plate. Facility policy on adaptive equipment indicated that Food & Nutrition Services will store the adaptive equipment and provide to the resident for use during meals.

Based on clinical record review, observations, facility policy review, and interviews for 2 residents (Resident #13 and Resident #31) the facility failed to store urinals, bath basins and bed pans in a sanitary manner and in accordance with the facility policy. 1. Resident #13's diagnoses included bladder cancer, urinary incontinence, incomplete bladder emptying, and a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves. A physician order dated 6/19/23 directed Resident #13 be placed on enhanced barrier precautions every shift for having an indwelling urinary catheter. An Annual MDS assessment dated [DATE] identified Resident #13 was cognitively intact, had an indwelling urinary catheter and required extensive assistance with one person assist for dressing, toilet use and hygiene. A Resident Care Plan dated 8/9/23 identified Resident #13 experienced incontinence and alterations in urinary output, and urinary retention related to chronic incontinence and impaired mobility. Interventions included to assist with toileting/incontinence care, empty catheter every shift, and monitor intake/output. A physician's order dated 9/9/23 directed to send a urine sample for analysis and to test for bacteria 2. Resident #31's diagnoses included dementia, muscle wasting, abnormalities of gait and mobility, osteoarthritis, and major depressive disorder. A Resident Care Plan dated 6/6/23 identified Resident #31 experienced episodes of urinary incontinence related to mobility deficit. Interventions included to assess for urinary tract infection, provide incontinence care, assist with toileting and toilet every 2 hours and as needed. An Annual MDS assessment dated [DATE] identified Resident #31 was cognitively intact, required total dependence of one for toilet use, personal hygiene, extensive assistance of two with bed mobility and dressing, and was independent with set-up for meals. Observation on 9/11/23 at 11:00 AM identified room [ROOM NUMBER]-A and room [ROOM NUMBER]-A's bathroom was shared by 2 residents (Resident #13 and Resident #31). The bathroom contained one bath basin with one bedpan inside, both unbagged and unlabeled, on the bottom shelf of a white dresser to the left of the sink, 2 urinals were unlabeled and unbagged behind the toilet seat. An additional observation and interview on 9/12/23 at 11:09 AM with Nurse Aide (NA) #5 identified room [ROOM NUMBER]-A and room [ROOM NUMBER]-A's bathroom was shared by 2 residents (Resident #13 and Resident #31). The bathroom contained 1 unlabeled/unbagged bedpan on the bottom shelf of a white dresser to the left of the sink and 2 unlabeled/unbagged urinals behind the toilet seat. Interview with NA #5 at that time indicated the bedpan was used for Resident #31 and that the urinal was used to empty Resident #13's indwelling catheter bag. NA #5 also indicated that she would expect the urinal and bedpans to be labeled, bagged, and placed in the bottom drawer of the side table in each resident's room and not left in the shared bathroom. An additional observation on 9/14/23 at 6:30 AM identified room [ROOM NUMBER]-A and room [ROOM NUMBER]-A's bathroom was shared by 2 residents. The bathroom contained 1 unlabeled/unbagged urinal behind the toilet seat and 1 bath basin unlabeled/unbagged on the bottom shelf of a white dresser to the left of the sink. Observation and interview on 9/14/23 at 11:50 AM with the Infection Prevention Nurse (IP) identified room [ROOM NUMBER]-A and room [ROOM NUMBER]-A's bathroom was shared by 2 residents. The bathroom contained 1 unlabeled/unbagged urinal behind the toilet seat and 1 bath basin unlabeled/unbagged on the bottom shelf of a white dresser to the left of the sink. The IP nurse indicated that she would expect the bath basin and the urinal to be labeled with each resident's room number, dated, be placed in a bag and placed in the bottom drawer of each resident's bedside table. Policy review for the cleaning of patient wash basins and bedpans indicated that each urinal, wash basin and bedpan should be marked with a date, room number and placed in a bag, each item should be returned to the appropriate room.

Based on observation and staff interview, the facility failed to ensure the daily nurse staffing information was posted in a prominent place, readily accessible to residents and visitors. The findings include: On 9/14/23 at 12:30 PM interview and observation with the Director of Nursing (DNS) noted the nurse staff posting to be taped to the window of the outside door at the primary entrance, visible only to incoming personnel/visitors/residents entering the facility from the outside. Interview with the DNS on 9/14/23 at 12:30 PM identified she thought nurse staffing information was also posted by the staffing board/time clock, but observation with the DNS at that time failed to identify the posting was located by the staffing board/time clock. The DNS further indicated that she did not believe the nurse staffing information was posted on any other units throughout the facility. Additionally, the DNS identified it was the responsibility of the 11:00 PM to 7:00 AM Nursing Supervisor to complete and post nurse staffing information and identified it should be updated each shift as needed.

Based on observation, review of the clinical record, facility policy, and staff interviews for 1 of 2 residents (Resident #49) reviewed for pressure ulcers, the facility failed to complete a comprehensive wound assessment by a Registered Nurse for newly identified blisters to Resident #49's feet. The findings include: Resident #49 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #49 had severely impaired cognition and a range of motion impairment to the lower extremities. Additionally, the MDS identified Resident #49 required two-person physical assistance for bed mobility and was totally dependent on staff for personal hygiene. Additionally, the MDS identified that Resident #49 was at risk for pressure ulcers and had no current, unhealed stage 1 or higher pressure ulcers. A Braden score (an assessment that measures the risk for developing a pressure ulcer) dated 11/16/21 identified Resident #49 was at moderate risk for the development of pressure sores. A Resident Care Plan (RCP) dated 11/23/21 identified Resident #49 was at moderate risk for skin impairment. Interventions included to encourage turning and repositioning, keep skin clean and dry, provide adequate nutrition and hydration, assess skin condition during care and notify the nurse of any redness, open areas, blisters, rashes and/or discolored areas. Additional interventions indicated to use moisturizer for dry skin including intact heels, offload heels when in bed as resident tolerates and pressure relieving devices for the bed. Nurse's notes from Licensed Practical Nurse (LPN) #1 and dated 12/14/21 at 11:41 AM identified Resident #49's skin was intact and a fluid-filled, non-tender, blister was noted to the inner aspect of his//her bilateral feet. Skin prep was applied, and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, LPN #1's nurse's not further identified Resident #49's shoes were newer. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse's note dated 12/14/21 at 6:29 PM identified Resident #49 had all skin intact, heels offloaded on pillows and skin prep applied to the inner foot heels. The RCP was updated on 12/14/21 and identified fluid-filled, non-tender blisters to the inner aspect of Resident #49's bilateral feet. The RCP further identified per Resident #49's family, Resident #49's shoes were newer. Interventions included to apply skin prep to blisters as ordered, no shoes for 7 days and when in bed to position Resident #49's feet so that they are not touching together. Nurse's notes from RN #3 and dated 12/15/21 at 4:04 PM identified intact blisters with no drainage and treatment as ordered. Nurse's note from RN #1 and dated 12/16/21 at 8:07 AM identified a skin problem to blisters on the right medial heel and left medial foot. The right medial heel was 3.2 cm in length by 1.9 cm in width, all skin intact, clear fluid filled blister that was reabsorbing, yellow with some pink areas around the edges of the blister and no drainage. The left medial foot was 3 cm in length by 2 cm in width, all skin intact, clear fluid filled blister that was reabsorbing, dark pink at the edges on the blister and no drainage. Resident #49 denied pain, skin prep was applied to both blisters as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1's nurse's note further identified the APRN was aware of the skin issue. Interview with the DNS on 12/21/21 at 10:03 AM failed to identify Resident #49's foot blisters were assessed and areas measured by an RN from 12/14/21 when LPN #1 observed the blisters until RN #1's assessment on 12/16/21. The DNS further identified the Wound RN had been out of the facility the past few weeks and the Nursing Supervisors of the units were following and monitoring the wounds. Interview and record review with RN #1 (Unit Supervisor) on 12/22/21 at 9:45 AM identified LPN #1 observed the newly identified pressure ulcers on 12/14/21 and thought they were blisters. RN #1 further identified that although RN #3 wrote a note in the electronic record later that day on 12/14/21, RN #3 failed to measure or include a description of the pressure ulcers/blisters. Additionally, record review with RN #1 identified Resident #49's bilateral foot blisters were not assessed by an RN until 12/16/21 (2 days after the development of the heel blisters). She identified the Wound RN was normally in the facility on Saturdays to review the wounds and would notify the Nursing Supervisors when wounds needed to be measured. RN #1 further identified that newly identified pressure areas would typically be measured right away and Resident #49's foot blisters appeared to be re-absorbing and the skin had deflated down. She further identified the cause of the pressure ulcers were most likely from Resident #49's new shoes because the blisters lined up with the Velcro straps on the shoes. Interview with RN #2 on 12/22/21 at 11:40 AM identified she observed Resident #49's pressure ulcers on 12/14/21. She further identified it was a blister and they were not considered pressure ulcers because they were not opened. She stated it was clearly caused from the resident's new shoes and she took the shoes off as an intervention. She further identified she did not take measurements. Follow up interview with the DNS on 12/22/21 at 12:30 PM identified a blister can be a pressure ulcer and Resident #49's blisters appeared to be caused from the pressure of the Velcro on his/her new shoes, but it was difficult to confirm if the cause was from pressure or friction. She further identified her expectations for a newly identified pressure ulcer or skin concern was to be measured within the first day or two. The Pressure Ulcer Treatment Stage II Policy and Procedure identified blisters as a Stage II pressure ulcer. It further identified to document initial findings and measurements in a nursing note and complete a wound assessment in ECS (the electronic medical record).

Based on observation during a tour of the kitchen, a review of the facility policy, and staff interviews, the facility failed to ensure food was stored in a safe manner and/or failed to ensure kitchen equipment was maintained in a clean and/or sanitary manner. The findings included: a. Observations with the Director of Dietary Services on 7/22/19 at 9:40 AM identified one opened gallon of feta blue cheese dressing dated 3/29/19, one opened gallon of toasted sesame dressing that was illegibly labeled, one opened orange marmalade container dated 8/19/18, one opened vanilla low fat yogurt with a manufacturer expiration date of 7/13/19 were stored in the refrigerator with food items for resident consumption. Interview with the Director of Dietary Services on 7/22/19 at 9:40 AM noted the feta blue cheese dressing, and toasted sesame dressing, orange marmalade and the yogurt should not have been stored in the refrigerator as they were outdated. Additionally, the Director of Dietary Services identified the facility practice was to date items when received. The Director of Dietary indicated when staff opens a food container, a label with an open date should be identified to ensure the food was utilized only when it was safe to consume. The Director of Dietary identified all staff are expected to check the refrigerator for outdated food items and discard them according to food storage guidelines. Although the Director of Dietary was not certain why the food items were stored in the refrigerator past the expiration dates, she believed the items may have been in the refrigerator because they had been stored in the back of the refrigerator unit and were only utilized to prepare specialty food items. Review of the food product shelf life guidelines provided by the Director of Dietary identified bottled salad dressings should be refrigerated after opened and kept for three months. Opened jellies and jams would be kept for six months. Review of Facility policy on Food Storage directed all foods would be appropriately labeled and dated based on food storage guidelines. All foods would be labeled, dated, and used by the dates identified and this process would be monitored and followed. b. Observations with the Director of Dietary Services on 7/22/19 at 9:40 AM identified an operating wall mounted oscillating fan in the kitchen pointed toward the left side of the dishwashing conveyor belt where clean dishes emerged from the machine. The wire cage of the fan was observed to have blackish- grayish debris on the front and back sides of the grille of the fan. Interview with Director of Dietary Services on 7/22/19 at 9:40 AM identified although the fan was to be cleaned monthly as part of the cleaning schedule by housekeeping, it needed to be cleaned again and the Director of Dietary Services had not noticed it. The Director of Dietary Services identified it was her responsibility to ensure the fan was clean. Facility documentation of the fan cleaning was reviewed on 7/23/19 and identified the fan had been cleaned last on 6/10/19. Subsequent to surveyor inquiry the fan was cleaned on 7/23/19. Interview with Director of Housekeeping on 7/24/19 at 6:30 AM identified housekeeping was responsible for cleaning the fans in the kitchen monthly and was late in cleaning the kitchen fan this past month. The Director of Housekeeping indicated it was important to clean the fans in the kitchen to maintain a clean area to prepare resident food. The Director of Housekeeping identified the fan near the dishwasher blew on the clean dishes and that was why the fan should be kept clean. Review of facility building service procedure identified fans would be cleaned once every calendar month for a total of twelve times/year.

Based on an observation, a review of the facility policy, and staff interviews, the facility failed to ensure one of three resident nourishment rooms was maintained in a clean and sanitary manner. The findings include: Observations on 7/23/19 at 2:20 PM identified seven residents in the day room adjacent to the nourishment station on one of the resident units. Five different colored, non labeled, water and or liquid containers were observed on the back of the counter of the resident's nourishment station. Interview and observation of the resident nourishment station with Director of Dietary on 7/23/19 at 2:38 P identified there were multiple colored water and or liquid containers on the nourishment station countertop. Additionally, the Director of Dietary identified the containers were not placed on the resident's counter by dietary nor were they facility containers. Interview and observation of the resident nourishment station with LPN #1 , charge nurse, on 7/23/19 at 2:44 PM identified although the nourishment station was for the resident's, the containers belonged to the nursing staff. LPN #1 indicated the nursing staff was not to have the containers on the nursing unit and although there was a nearby staff refrigerator, the staff left the bottles/ containers on the nourishment counter as it was closer to the nursing unit. LPN #1 identified there was a staff breakroom, however, staff was not comfortable leaving their liquid containers far away from the unit. LPN #1 indicated the resident nourishment area was not an acceptable place for staff to leave water bottles as it would be possible for resident's to access them and/or it could pose an infection control issue. Interview with the Director of Nursing (DON), acting as the infection control nurse on 7/23/19 at 3:05 PM identified nursing staff was not allowed to have water bottles/liquid containers on the nursing unit or in resident nourishment areas as residents could access them and it could pose an infection control issue. Review of facility policy related to staff rest and meal breaks identified managers were responsible for scheduling meal and rest breaks. The policy further identified a designated area in the facility with a refrigerator was made available for staff to utilize for meal and rest breaks.

Based on a clinical record review, staff and resident interviews for one of three sampled residents reviewed for physical therapy and/or activities of daily living (Resident #18), the facility failed to ensure the care plan was comprehensive to include behaviors of refusing care. The findings include: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] identified Resident #18 was cognitively intact and required extensive assistance of two for bed mobility, dressing, toilet use and personal hygiene. A Resident Care Plan (RCP) dated 10/10/18 identified a problem with requiring assistance for activities of daily living with interventions that included to utilize a stretcher (secondary to decreased ability to sit up), wash upper body, perform peri-care, and to lotion the upper body. Interview with NA #1 on 7/22/19 at 11:45 AM identified Resident #18 refused showers and only allowed a bed bath to be provided. An interview and review of physical therapy notes with the Director of Physical Therapy (DPT) on 7/23/19 at 1:20 PM identified although physical therapy had been provided from 10/3/18 through 7/4/19, Resident #18 often refused to sit on the edge of the bed, refused to get out of bed, and/or refused to ambulate which resulted in therapy being discontinued on 7/4/19. The DPT further identified that Resident #18 refused to have certain therapists provide therapy to him/her. Interview with the Director of Nursing (DON) on 7/23/19 at 2:07 PM indicated Resident #18 refused to have certain staff care for him/her and was accusatory to staff. Additionally, review of the RCP with the DON failed to identify a care plan was developed to reflect Resident #18's behavior of refusing showers, refusing care from particular staff, and being accusatory, and therefore no interventions were in place to address these behaviors. Further interview with the DON indicated resident care plans were developed by either the MDS Coordinator or herself, and could not identify why the facility failed to ensure a comprehensive plan of care with interventions to reflect Resident #18's behaviors of refusing care and/or accusatory behavior.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #70) reviewed for pressure ulcers, the facility failed to ensure the dietitian completed an accurate initial dietary assessment, which included measures to promote healing of an open area. The findings include: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/6/19 identified to turn and reposition every 2 - 3 hours, provide adequate nutrition and hydration, use moisturizer for dry skin, and protective skin care ointments. A wound report dated 4/6/19 identified Resident #70 had a 2.0 centimeter cm by 2.0 cm moisture slit in the coccyx. Triad was applied as ordered, waffle overly and equagel cushion in place. A dietary note dated 4/8/19 identified Resident #70 was at low risk for skin breakdown with intact skin, leaves 25% of food uneaten, and was on a therapeutic diet. (The note failed to reflect the open area on the coccyx). The 5 day PPS MDS dated [DATE] identified Resident #70 had moderately impaired cognition, required extensive assistance for bed mobility and transfers, was frequently incontinent of bowel and bladder, and had a stage I pressure ulcer with moisture associated skin damage (MASD). A wound report dated 4/13/19 identified Resident #70 had a 2.2 cm by 1.8 cm by 0.1 cm a partial thickness loss of skin layers that presents as an abrasion or blister (stage II pressure ulcer). The wound bed was pink with yellow [MEDICATION NAME] visible prior to cleaning, removed after cleansing. Surrounding tissue with blanchable redness. A new treatment order was obtained. The clinical record identified Resident #70 was transferred to the hospital on [DATE] and returned on 4/16/19 to rule out a stroke. A wound report dated 4/20/19 identified Resident #70 has full thickness skin loss, exposing the subcutaneous tissues, presents as a deep crater, (pressure ulcer stage III). The area measured 2.8 cm by 1.6 cm by 0.1 cm 50% pink, 50% yellow. A dietary note dated 4/20/19 identified Resident #70 has a stage III pressure ulcer with increased nutritional needs. Recommendations included to ensure 100% meal intake and start mighty shakes 120 ml daily. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Intermittent observation on 7/24/19 between 11:00 AM to 12:00 PM identified Resident #70 was seated in a wheelchair with a Roho cushion. Observation at 12:00 PM identified staff transferred Resident #70 from the wheelchair into bed. Observation at that time indicated the Roho did not appear to be properly inflated. Interview with the Dietitian on 7/24/19 at 11:00 AM identified when a resident is newly admitted , she looks in the notes and gets a weekly report from the Infection Control Nurse regarding pressure ulcers. If a resident comes in with a pressure ulcer the Dietitian indicated she would assess calorie and protein needs, and request bloodwork if none was available from hospital. Although Resident #70 had an open area on admission 4/5/19, which deteriorated by 4/13/19, and was present on readmission 4/16/19 (stage III), the Dietitian indicated she was not aware of the pressure ulcer until 4/22/19, 6 days after the resident was readmitted , when she saw the resident for a readmission assessment. The Dietitian indicated it would be a good standard of practice to have asked for an [MEDICATION NAME] and [MEDICATION NAME] when Resident #70 was first admitted on [DATE] with a 2.0 cm by 2.0 cm moisture slit in the coccyx, was at high risk for breakdown and had no recent available bloodwork. The policy on skin breakdown directed that nutrition documentation of stage II or above should be completed monthly or more frequently. The note should include open area, stage, location, size and if healing has occurred of not. If this is a new open area, calculate how many calories/protein are provided by current diet interventions. This will justify not initiating additional measures, or will show reason for initiating of a supplement. Evaluate need for multiple vitamin with minerals, additional vitamin c or additional zinc. Nutrition and skin care plans are updated to reflect current nutrition interventions. Although Resident #70 was admitted to the facility on [DATE] and required extensive assistance with bed mobility, was frequently incontinent and had a 2.0 cm by 2.0 cm moisture slit in the coccyx, the dietitian's assessment dated [DATE] identified Resident #70 was at low risk for skin breakdown and had intact skin. Subsequently, the dietitian failed to ensure measures were immediately implemented to address the resident's increased nutritional needs related to the open area on the coccyx, which later deteriorated on 4/13/19 to a 2.2 cm by 1.8 cm by 0.1 cm partial thickness loss, stage II pressure ulcer.

Based on clinical record reviews and interviews for two of six sampled residents ( Resident #24 and Resident#136) reviewed for pressure ulcers, the facility failed to ensure that heels were offloaded to prevent pressure sore development in residents who were at risk due to orthopedic surgery of the lower extremities. The findings include: 1. Resident #24's [DIAGNOSES REDACTED]. A nurse's note dated 3/2/15 noted the resident's heels had intact skin and a surgical incision on the right hip. The physician orders [REDACTED]. The care plan dated 3/3/15 identified a risk for impairment of skin integrity with interventions which included elevating heels off of the bed as resident allows. Review of the clinical record identified a Braden assessment dated [DATE] with a score of 15, which represents a mild risk for the development of pressure ulcers. A nurse's note dated 3/6/15 identified Resident #24's heels were red and painful; the resident was educated on maintaining floating of heels and skin prep the use of a heel manager (device used to elevate heels) when in bed to the right foot and skin prep every shift to right heel. The weekly wound monitoring dated 3/7/15 identified a suspected unstageable deep tissue injury to the right heel that measured 2.4 cm by 2.4 cm and appeared as intact skin with a dark purple center and surrounding redness. Review of the clinical record and treatment record failed to identify documentation that the resident's heels were elevated/pressure offloaded prior to the development of heel pain on 3/6/15. Further review of the weekly wound monitoring identified that on 3/14/15 the right heel appeared as a 3.0cm by 3.0cm fluid filled blood blister and on 3/28/15 the wound bed measured 3.5cm by 3.4 with a wound bed that covered by slough and/or eschar. Interview and review of the clinical record with the DNS on 5/14/15 at 2:03 PM failed to provide documentation that the resident's heels had been offloaded as identified in the care plan prior to development of the unstageable pressure sore on 3/6/15. The DNS identified it was not the practice of the facility to document offloading of heels or a system in place for ensuring that the nurse aides carried out heel elevation and/or what amount of pillows were used to elevate the heels. He/she further indicated that once the resident developed heel pain and the physician ordered the heel manager, that information was placed on the resident's treatment record and the licensed staff were responsible for ensuring the heel manager was in place by signing for it in the treatment record. 2. Resident#136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse's notes dated 3/5/15 at 10:21PM identified intact skin except for a surgical incision at the right hip. A Braden scale dated 3/5/15 identified a score of 13 which indicated that the resident was at a moderate risk for pressure ulcer development. The physician orders [REDACTED]. An initial care plan dated 3/7/15 directed nurses' aides to elevate the resident's heels off the bed as the resident allows. The physician orders [REDACTED]. The nurse's notes dated 3/12/15 at 11:00PM identified a red, purple area on the right heel that was tender to touch. The area was covered with Skin Prep and a message was left for the supervisor and the wound nurse. The physician orders [REDACTED]. The nurse's notes dated 3/14/15 at 10:52PM identified the presence of a fluid filled blister on the right heel. The nurse's notes dated 3/21/15 at 10:06PM identified a left heel flat blister was observed and skin prep was applied. On 3/29/15, the left heel blister was reabsorbed; however, the right heel blister persisted until 5/1/15. Clinical record review and interview with the DNS on 5/14/15 at 11:30AM identified that nurse aides were given directions to elevate the resident's heels off the bed, however the clinical record lacked documentation that a mechanism was in place to ensure the interventions of offloading of the heels was implemented between admission on 3/5/15 and 3/12/15 when the pressure sore developed.

Based on observations, clinical record review, review of facility documentation and interviews, for 2 of 3 sampled residents reviewed for accidents, ( Resident #178 and Resident # 59 ), failed to ensure proper techniques were used during a mechanical lift tranfer which resulted in a fall with an injury and/or failed to provide adequate supervision to prevent an accident . The findings include: 1. Resident # 178's [DIAGNOSES REDACTED]. The care plan dated 1/29/14 identified a self-care deficit with interventions which included the use of a mechanical lift for transfers. A review of facility documentation dated 4/2/14 at 2:00PM identified the NA ' s were transferring the resident from the chair to the bed with the maxi-lift (a mechanical lift device) when the sling detached from the mechanical lift which resulted in the resident slipping out of the sling. The NA ' s supported Resident # 178's body and lowered him/her to the floor. A review of the facility investigation identified a statement from NA # 3 following the incident which identified that Resident #178 was on his/her assignment on 4/2/14 and he/she had transferred the resident out of bed with the mechanical lift following morning care. NA#3 ' s statement further identified that he/she was providing care to another resident at the time of the incident when he/ she entered the room after hearing a noise, Resident #178 was noted on the floor lying across the base/legs of the mechanical lift. The nurse ' s notes dated 4/2/14 at 3:01PM identified Resident #178 was assessed following the incident and no injuries were noted however, the physician directed to obtain an X-ray of the spine due to complaints of back pain. The radiology report dated 4/2/14 identified moderate osteoporotic compressions involving T11 vertebrae. The age of the compression is old or indeterminate. Further review of nurses noted dated 4/3/14- 4/5/14 identified Resident #178 received Tramadol 50mg three times as needed for back pain with some relief on 4/3/15, and two times on 4/4/14. MD #1 evaluated the resident on 4/4/14 at 2:30PM due to continued complaints of pain and poor appetite with recommendations to monitor appetite and ensure supplements are consumed if meal intake continues to be compromised. A review of the nurse's notes dated 4/5/14 at 12:45AM identified Resident #178 was transferred to the emergency roiagnom on [DATE] at 10:05PM due to decreased oral intake, decreased mobility and mental status changes. Review of the hospital discharge summary dated 4/12/14 identified Resident #178 was transferred to the acute care setting from the skilled nursing facility with increasing lethargy following a fall on 4/2/14 from a mechanical lift. A CT scan which was completed during Resident #178 ' s hospitalization identified an almost complete collapse of the right upper and lower lobe of the lung and the physician felt the resident had a right pneumothorax likely related to the earlier fall on 4/2/14. Resident #178 was treated at the hospital and required the insertion of a chest tube to drain the hemothorax. The final [DIAGNOSES REDACTED]. Interview with NA # 1 on 5/10/15 at 11:30 AM identified he/she assisted NA # 2 attach the resident to the lift and then was at the controls of the maxi lift. He/she started to raise the resident out of the chair with the lift when the canvas sling detached from the lift on the left side and the resident slid out of the sling. Both NA ' s supported the resident and lowered him/her to the floor with the lift. NA # 1 identified the cause of the fall was the sling being too large for the resident and was unable to identify who had secured the sides of the canvas sling. NA #1 could not recall if he/she had checked to ensure that the clips were fully in position prior to utilizing the mechanical lift. Interview with the Director of Nurses on 5/11/15 at 10:30 AM identified the investigation following the fall determined the clip had detached from the lift causing the resident to slide out of the sling during transfer. He/she further identified that prior to this incident the facility did not have a policy/procedure in place to assess resident's to determine what size sling should be used for a mechanical lift transfer. Interview with RN # 1 on 5/11/15 at 1:30 PM who was supervising on 4/2/14 at the time of the incident identified that he /she was called to the room because the resident had slipped from the sling because the clip gave way, and the resident was lowered to the floor by NA # 1 and NA # 2. Interview and review of the clinical record with MD #1 on 5/12/15 at 11:30 AM identified he/she recalled the incident and remembered being informed by the Nursing Supervisor that the fall had been caused as a result of the sling clip detaching from the mechanical lift. Interview with the representative from the Arjo lift company who manufactures the maxi lift on 5/13/15 at 11:45 AM identified following a review of the incident, he/she believed Resident #178 fell from the mechanical lift as the clips were not securely attached to the sling. Review of the maxi lift instructions identified to always check that all the sling attachment clips are fully in position before and during the lifting cycle. 2. Resident #59's [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] identified intact cognition, required supervision of one staff member for eating and functional limitation in range of motion in bilateral UE. The physician orders [REDACTED]. The nurse ' s notes dated 6/29/14 at 6:20PM identified the resident was in his/her room and spilled tea on his/her hand. No injuries were noted. The care plan following the incident identified to reinforce to nurse aides and nurse's to supervise the resident with hot beverages as directed in the physician orders. Interview with the DNS on 5/14/15 at 10:40AM identified that the mug did contain a cover; however the nurse aide did not follow the plan of care and provide supervision with hot beverages. Interview with NA#4 on 5/14/15 at 3:30PM identified that Resident #59 was on her assignment on 6/29/14 3:00PM-11:00PM shift. NA#4 set up the supper tray per request of the resident in his/her room. The meal tray contained a hot beverage which was covered by a lid. Shortly after leaving the room, the resident rang the call bell indicating that the tea had spilled. NA#4 identified that although he/she read the care card which identified the resident required supervision with hot beverages, he/she left the resident unattended during the meal.