Every finding on record at Meridian Nursing Home

Based on record review and interview, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. A Resident Census and Conditions of Residents form documented 33 residents resided in the facility. Findings: On 10/27/22 at 3:05 p.m., the corporate nurse reviewed staffing reports which documented four or more shifts in the 3rd quarter without a licensed nurse on duty. The nurse stated there was an error in reporting, as the facility always had a licensed nurse on duty every shift. The nurse stated there might have been a few shifts without RN coverage, but stated the facility was never without a licensed nurse on duty. On 10/27/22 at 4:02 p.m., the corporate nurse supplied facility hand-written daily staffing reports for the specific days identified as having no coverage. All of the identified days documented licensed nursing staff to be on duty. There were two days, 04/23/22 and 05/10/22, which were not provided to show an RN was on duty at least eight hours. The corporate nurse again stated she would not be surprised if there were days with no RN coverage. The nurse reported an LPN would frequently work double shifts on the weekends, and she believed the double shifts might have been missed and could be the reason for data be incorrectly reported. On 10/27/22 04:33 p.m., the corporate nurse reported the DON was currently the only full-time RN on staff. She stated the facility had at least one other part-time, PRN RN, but this was not someone who covered weekend shifts on a regular basis. The corporate nurse stated she was in the facility one day a week and occasionally she would fill the need for an RN, but for the most part the RN position was covered only by the DON. She stated the facility had advertised for the RN position and was actively interviewing and attempting to hire another RN to cover weekend shifts. On 10/27/22 at 4:49 p.m., the DON reported the facility had not had a weekend RN since at least July 2022. The DON reported occasionally there might be PRN coverage but for the most part, she had been the only RN on staff. The DON reported she worked Monday through Friday, as well as taking call to ensure there was always a licensed nurse on duty.

Based on observations, interview and record review, it was determined the facility failed to ensure ~fluids had been provided throughout the day between meals and, ~the physician had been notified for significant weight loss for one (#28) of two residents who were reviewed for hydration/nutrition. This had the potential to affect all 44 residents. Findings: Resident #28 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/18/18, documented the resident's cognition was severely impaired. She required extensive assistance with all of activities of daily living. She was always incontinent of bowel and bladder. The resident's (MONTH) (YEAR) dietary consult documented the resident was to have fluids encouraged for hydration. The (MONTH) (YEAR) dietary consult documented the resident had an 8.8% decrease in her weight in the past three months. The dietician had recommended to increase 2.0 calorie nutrition supplement to 120 milliliters three times daily. The current physician's orders [REDACTED]. Observations were made numerous times through out the survey of the resident lying in her bed either sleeping or just lying there. There had not been any fluid at her bedside on (MONTH) 30, (YEAR), (MONTH) 1, (YEAR) and (MONTH) 2, (YEAR). On (MONTH) 30, (YEAR) at 9:05 a.m., the resident's roommate stated, We hardly ever get fresh water like we are supposed to get. On (MONTH) 1, (YEAR) at 3:15 p.m., certified nurse aide (CNA) #1 was asked how often fluid was provided for the residents. She stated, Each shift and as needed. On (MONTH) 2, (YEAR) at 11:25 a.m., CNA #2 was asked why the resident had no fluid by her bedside. She stated, I just noticed that today, I'll go get her some right now. At 11:35 a.m., licensed practical nurse #1 was asked if she knew why the resident had not had any fluid by her bedside. She stated, I did not know why. She was asked if anyone offered her fluid through out the day. She stated, They are supposed to. On 05/02/18 at 11:37 a.m., the administrator was asked why the resident was not given any water for three days. She stated, Everyone else has theirs, I don't know why she doesn't have any. On 05/03/18 at 10:48 a.m., corporate nurse #1 was asked if the (MONTH) (YEAR) dietary consult had been sent to the physician. She stated, I can't find where it had been sent.

Based on observation, record review and interview, it was determined the facility failed to follow the care plan for use of incontinent products for one (#37) of fourteen residents whose care plans were reviewed. This had the potential to affect all 44 residents. Findings: Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 04/05/18, documented the resident was severely cognitively impaired . It documented she was totally dependent with transfers with two or more person assistance, totally dependent with dressing, toilet use, hygiene and bathing with one person assistance, extensive assistance with bed mobility and eating with one person assistance. It documented she had no range of limitations and was always incontinent of bowel and bladder. A care plan, dated 08/12/16, documented the resident had bowel/bladder incontinence and was at risk for odors and infection. Interventions included she was to have been checked for incontinent episodes at least every 2 hours and no incontinence products where to be used on her while she was in bed. On 04/30/18 at 11:15 a.m., the resident was observed in bed with briefs on. On 05/02/18 at 10:00 a.m., staff was observed to have transferred the resident to her bed and provided incontinent care to the resident and placed a brief on the her, leaving her in bed. At 10:17 a.m., certified medication aide (CMA) #1 was asked what incontinent products are used. He stated the facility used wipes, sprays and briefs. CMA #1 was asked when briefs were used for the resident. He stated he always puts briefs on the resident because she was incontinent. On 05/03/18 at 10:58 a.m., the director of nursing was asked what type of incontinent products the facility used. She stated they had peri wash spray, wipes, and briefs. She was asked if the resident's care plan had been followed when the resident had been placed in briefs while in bed. She stated it had not been.

Based on record review and interview, it was determined the facility failed to ensure records were complete and accurate for dietary intake for one (#1) of three residents whose records were reviewed. This had the potential to affect 38 residents who received food from the kitchen as identified by the director of nurses (DON). Findings: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An initial assessment, dated 06/08/17, documented the resident was severely cognitively impaired. It documented the resident needed total assistance with bed mobility, dressing and bathing with two or more person assistance, total assistance with hygiene with one person assistance, extensive assistance with eating with one person assistance. It documented the resident had a range of motion limitation on side in the lower extremities, had a catheter for bladder elimination, and was always incontinent of bowel. The dietary records for 08/2017 contained fifteen missed opportunities for dietary intake and supplement amounts to have been documented. On 12/07/17 at 2:05 p.m., the DON was asked if the resident's dietary records represented a complete and accurate record. She stated it had not.

Based on record review and interview, it was determined the facility failed to provide the correct dosage of medication for one (#1) of three residents whose records were reviewed. This had the potential to affect all 43 residents. Findings: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's weight was 90 pounds. An initial assessment, dated 06/08/17, documented the resident was severely cognitively impaired. It documented the resident needed total assistance with bed mobility, dressing and bathing with two or more person assistance, total assistance with hygiene with one person assistance, extensive assistance with eating with one person assistance. It documented the resident had a range of motion limitation one side in the lower extremities, had a catheter for bladder elimination, and was always incontinent of bowel. A progress note, dated 07/12/17 at 11:21 a.m., documented the resident weighed 83 pounds, her current meal intake was 25-50%, and the resident had a poor appetite. A physician's orders [REDACTED]. The 07/2017 and 08/2017 medication administration records documented the resident had received 400 mg of [MEDICATION NAME] every day. A resident progress note, dated 08/16/17, documented the resident weighed 82 pounds. The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. On 12/0717 at 11:45 a.m., the director of nurses was asked if the physician's orders [REDACTED]. She stated it had not been followed.

Based on record review and interview, it was determined the facility failed to have a clinical justification for catheter use for one (#1) of three residents whose records were reviewed for catheter use. This had the potential to affect five residents with catheters as identified by the director or nurses (DON). Findings: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An initial assessment, dated [DATE], documented the resident was severely cognitively impaired. It documented the resident needed total assistance with bed mobility, dressing and bathing with two or more person assistance, total assistance with hygiene with one person assistance, extensive assistance with eating with one person assistance. It documented the resident had a range of motion limitation on one side in the lower extremities, had a catheter for bladder elimination, and was always incontinent of bowel. A urine culture, dated [DATE], documented a urinary tract infection with >100,000 colony forming units/ml of Escherichia coli. A care plan, dated [DATE], documented the resident required a catheter related to a femur fracture, immobilization, and was bedfast. Interventions included the facility was to change the catheter as ordered by the physician, and to provide catheter care every shift and as needed. A nurses's note, dated [DATE], documented a fax was sent to the physician requesting to discontinue the catheter. A nurses's note, dated [DATE], documented the catheter remained in place and the physician had not responded to the fax. Progress notes dates, [DATE], [DATE] and [DATE], documented the resident continued to have an indwelling urinary catheter. The resident was transferred to the hopsital on [DATE] with [DIAGNOSES REDACTED]. The resident expired in the hospital on [DATE]. The hospital discharge summary documented, .-Hospital Course .The cause of death is [MEDICAL CONDITION] from urinary tract infection . On [DATE] at 2:05 p.m., the DON was asked if there was a justification for the resident's catheter. She stated after the initial first six weeks of admission there was not a justification for the catheter. She was asked if the catheter should have been discontinued. She stated it should have been.

Based on record review and interview, it was determined the facility failed to accurately assess one of one (#44) residents reviewed for hospice services. This had the potential to effect one other hospice resident as identified by the director of nurses. Findings: Resident #44 was admitted to hospice services 11/08/16 with [DIAGNOSES REDACTED]. A significant change assessment, dated 11/18/16, documented the resident had received hospice services and had not documented she had a prognosis of a life expectancy of less than 6 months. On 02/16/17 at 1:52 p.m., an interview with the minimum data set coordinator was conducted. She reviewed the significant change assessment and agreed it had not documented the resident had a life expectancy of less than six months and should have.

Based on observation and interview, it was determined the facility failed to ensure the two facility's ovens in the kitchen were kept clean. This had the potential to affect 38 residents who received their meals from the kitchen according to the dietary manager (DM). Findings: At 03/23/16 at 9:34 a.m., both ovens in the kitchen were inspected. Both ovens had a build up of burnt debris in the bottom. At 9:36 a.m., the DM was interviewed and asked what the facility's cleaning schedule for the ovens were. She stated, Every Saturday or Sunday. She was asked if the facility's weekly cleaning schedule for the ovens had been followed. She stated, No. At 9:45 a.m., the director of nursing was informed of the above findings. She stated she would talk to the kitchen staff about the ovens needing to be cleaned.

Based on interview and record review, the facility failed to maintain accurate and complete clinical nutritional intake records for two (#24, and #53) of three sampled residents whose records were reviewed for nutrition. This had the potential to affect all 48 residents who resided in the facility. Findings: 1. Resident #24 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 03/19/15, documented the resident was cognitively intact. She was independent with mobility, transfer, and eating. The clinical record documented the resident had a 7.7 % weight loss during the month of January 2015. The January 2015 dietary intake record had not documented 37 of 90 opportunities of the resident's intake amount. On 05/28/15 at 2:43 p.m., certified nurse assistant (CNA) #1 was asked the process for documenting a resident's dietary intake record. She stated you are to put the percentage amount a resident eats on their paper record and then put the information into the computer system. She was asked if the resident refused or did not eat anything what would put in the computer. She stated refused or none. She was asked if the record would be left blank. She stated no, there should be something in there. On 05/28/15 at 2:50 p.m., CNA #2 was asked the process for documenting a resident's dietary intake record. She stated you are to put the percentage amount a resident eats on their paper record and then put the information into the computer system. She was asked if the resident refused or did not eat anything what would put in the computer. She stated refused or none. She was asked if the record would be left blank. She stated no, there should be something in there. On 05/28/15 at 3:16 p.m., the director of nursing was asked what a resident's dietary intake record should contain. She stated it should have the percentage amount of how much a resident had eaten for the meal, the amount of any supplements consumed, and the amount of snack they had. She was shown the January 2015 dietary intake records and was asked if the record contained a complete and accurate amount of a resident's intake. She stated it did not. 2. Resident #53 was admitted on [DATE] [DIAGNOSES REDACTED]. An admission assessment, dated 01/02/15, documented the resident was cognitively intact. She needed supervision for mobility and eating. The clinical record documented the resident had a 11 % weight loss 60 days after admission. The January 2015 dietary intake record had not documented 55 of 93 opportunities of the resident's intake amount. On 05/28/15 at 2:43 p.m., CNA #1 was asked the process for documenting a resident's dietary intake record. She stated you are to put the percentage amount a resident eats on their paper record and then put the information into the computer system. She was asked if the resident refused or did not eat anything what would put in the computer. She stated refused or none. She was asked if the record would be left blank. She stated no, there should be something in there. On 05/28/15 at 2:50 p.m., CNA #2 was asked the process for documenting a resident's dietary intake record. She stated you are to put the percentage amount a resident eats on their paper record and then put the information into the computer system. She was asked if the resident refused or did not eat anything what would put in the computer. She stated refused or none. She was asked if the record would be left blank. She stated no, there should be something in there. On 05/28/15 at 3:16 p.m., the director of nursing was asked what a resident's dietary intake record should contain. She stated it should have the percentage amount of how much a resident had eaten for the meal, the amount of any supplements consumed, and the amount of snack they had. She was shown the January 2015 dietary intake records and was asked if the record contained a complete and accurate amount of a resident's intake. She stated it did not.

Based on observation, record review, and interview it was determined the facility failed to justify the continued use of an indwelling foley catheter for one (#56) of three sampled residents. This had the potential to effect five residents with indwelling foley catheters according to the Residents Census and Conditions of Residents report. Findings: Resident #56 was admitted to the facility with [DIAGNOSES REDACTED]. The admission assessment, dated 03/10/15, documented the resident's cognition was moderately impaired. He was dependent on staff for all activities of daily living, was frequently incontinent of bowel and had an indwelling foley catheter. The resident's care plan documented the resident required an indwelling urinary catheter related to failure of catheter removal at the hospital prior to admission to the facility. A physician's orders [REDACTED]. A nurse's note, dated 04/18/15, documented the foley catheter was patent and changed that day with immediate urine return noted. On 05/29/15 at 10:05 a.m., the director of nurses stated the resident had been admitted with an indwelling foley catheter. She was in agreement there was no documentation of medical justification for the continued use of the catheter. On 05/29/15 at 10:16 a.m. the resident was observed in bed with the foley bag secured under the bedframe.

Based on record review and interview it was determined that the facility failed to provide the appropriate liability and appeal notices for 2 (#24, #55) of 2 residents that were Medicare beneficiaries discharged in the last 6 months. The director of nurses (DON) identified no other Medicare residents as being discharged in the past 6 months. Findings: Resident #24 was admitted to the skilled services on 12/26/14 and discharged on [DATE]. Resident #55 was admitted to skilled services on 01/06/15 and discharged on [DATE]. There was no documentation found in the clinical records for resident #24 and #55 the facility provided a notice of liability when discharged from skilled services. On 05/28/15 at 3:45 p.m., a request was made to the DON to provide the notices of liability and appeal for resident #24 and #55. She stated, I know we're suppose to have them. But the residents left in an emergency situation and we didn't have time to get the liability and appeal form signed.

Based on interview and record review, it was determined the facility failed to obtain physician ordered laboratory (lab) tests for one (#39) of five residents whose records were reviewed for unnecessary medications. This had the potential to affect all 48 residents who resided at the facility. Findings: Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A careplan, dated 04/24/15, documented the resident takes [MEDICATION NAME] and is at risk for increased bleeding and bruising. It documented interventions which included to obtain labs as ordered. A physician's orders [REDACTED]. There were no lab results for a PT/INR the week of 05/07/15, which would have been two weeks after the order. On 05/28/15 at 11:26 a.m., licensed practical nurse #1 was asked if a PT/INR had been drawn for resident #39 for the month of May 2015. She stated she could not find any. A review of the physician order [REDACTED]. She stated it should have been. On 05/28/15 at 11:51 a.m., the director of nursing was asked if a PT/INR was done for resident #39 for the week of 05/07/15. She stated it had not been done. A review of the physician order [REDACTED]. She stated it should have been.

Based on observation and interview, it was determined the facility failed to ensure comfortable, safe temperature levels were maintained in the main dining room and the assisted dining room/activities room. The Census and Condition Report, dated 05/20/13, documented 45 residents resided in the facility. Findings: On 05/20/13 at 6:30 p.m., the air temperature of the assisted feeding/activities room was measured to be 67.1? F (Fahrenheit). Residents were observed dressed in heavy clothing and covered with blankets. Residents were heard asking for additional coats and blankets. On 05/21/13 at 10:30 a.m., a group meeting was held in the assisted dining/activities room with eight residents. During the meeting complaints were voiced concerning the room temperatures in the activities room and the main dining room. More than half of the residents had on heavy jackets, coats or blankets. At 2:44 p.m. the air temperature of the main dining room was measured to be 65.6? F. The thermostat in the main dining room was located to the left of the ice machine. The exhaust air coming out of the ice machine was measured at 71.8? F. The temperature reading of the thermostat read 79? F. It appeared as if the thermostat may have been giving a false room temperature reading of 79? F due to the warm exhaust air coming from the ice machine. This resulted in the room air temperature of 65.6? F. At 11:25 a.m., the director of nursing was told of the low temperatures in the main dining room and the assisted dining/activities rooms. She was told of the exhaust air from the ice machine possibly affecting thermostat. She stated, "We will check on that."

Based on observation, record review and staff interviews, it was determined the facility failed to provide dignity during meal service for two (#1 and #9) of five sampled residents observed during meal service who required assistance with eating. The Residents Census and Condition, dated 05/20/13, documented 16 residents required assistance with eating. Findings: The policy, Nursing Responsibilities at Meal Service, documented, "...Arrange seating to accommodate individual resident needs...Adapt space and equipment to assist residents maintaining independent functioning, dignity, well-being, and self determination...Provide appropriate feeding assistance to all residents..." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The annual resident assessment, dated 04/04/13, documented the resident required total assistance with feeding. The care plan, dated 04/04/13, documented, "...Total assistance with feeding in assisted dining room. Hand feed..." On 05/20/13 at 12:15 p.m., the resident was seated in the assisted dining room for lunch. She had three glasses of fluids in front of her with the plastic wrap on them. She received her tray of pureed food. The two LPNs (licensed practical nurse) in the dining room did not set up the resident's tray or start to feed her. Both LPNs were standing to feed residents. At 12:20 p.m., the resident had pushed herself back from the table. At 12:22 p.m., LPN #2 pulled the resident back up to the table. She continued to feed the resident seated to the left of resident #1. At 12:26 p.m., LPN #2 removed the plastic wrap off of the tea glass and gave the resident a drink. She then gave her a bite of meatloaf. The resident's tray had sat in front of her for ten minutes before she was offered a bite of food. At 12:27 p.m., LPN #2 stated, "I'm short so I have to stand to feed." At 6:00 p.m., the resident was seated in the assisted dining room for dinner. At 6:05 p.m., the resident received her tray. The LPN asked for silverware for the resident. At 6:07 p.m., the resident had to be pulled back up to the table. At 6:08 p.m., silverware was provided. At 6:09 p.m., the resident received her first bite of food from LPN #3. The LPN, who was standing to feed, then preceded to move around the two horseshoe shaped tables giving a bite of food to three other residents besides resident #1. At 6:12 p.m., the DON (director of nursing) came into the assisted dining room and told LPN #3 to sit down to feed. At 6:14 p.m., LPN #3 was observed attempting to feed five residents at a time, one bite at a time. At 7:00 p.m., resident #1 was finished with eating fifty-five minutes after she received her tray. 2. Resident #9 had [DIAGNOSES REDACTED]. She required extensive assistance of one person with her meals. On 05/20/13 at 6:10 p.m., the evening meal was observed. Resident #9 was seated in the assisted dining room on the outside of a horseshoe shaped table in a geri-chair. CNA #1 was observed standing on the inside of the horseshoe shaped table while she fed the resident. On 05/21/13 at 2:45 p.m., the DON was informed of the observations. She stated, "I've told them to sit down."

Based on observation, record review and interview, it was determined the facility failed to provide feeding assistance to dependent residents for two (#1 and #9) of five sampled residents who required assistance with eating. The Census and Conditions, dated 05/200/13, documented 16 residents required assistance with eating. Findings: The policy, Nursing Responsibilities at Meal Service, documented, "...Arrange seating to accommodate individual resident needs...Adapt space and equipment to assist residents maintaining independent functioning, dignity, well-being, and self determination...Provide appropriate feeding assistance to all residents..." 1. Resident #2 had [DIAGNOSES REDACTED]. She received more than 50% of her nourishment from a feeding tube, but was allowed pleasure feedings of a regular diet with finger foods. On 05/20/13 at 12:20 p.m., the resident was observed at the noon meal. She was in the assisted dining room in a geri-chair with a lap tray in place. She was positioned away from the tables and other residents. She had a weighted spoon in one hand and was picking at her food with the other hand. Food had been dropped and smeared across the top of the tray. The resident was observed taking bites of the food she would pick up. At 12:30 p.m., the resident dropped the spoon on the floor. She appeared to begin crying. The staff did not turn to observe the resident. At 12:40 p.m., the resident dropped her water glass, with a small amount of water and ice in it, on the floor. She appeared to begin crying. LPN #4 (licensed practical nurse) and CNA #2 (certified nurse aide) turned and looked at the glass on the floor and kept feeding the other residents. The resident returned to picking at the food scattered across the tray and taking small bites. At 6:10 p.m., the resident was observed at the evening meal. She was in the assisted dining room in a geri-chair with a lap tray in place. She was positioned away from the tables and other residents. A tray with two glasses of fluids was positioned beside the geri-chair. She was observed playing with the food on her plate and taking a bite at times. She dropped and smeared food across the top of the tray. Her water glass was empty and she was observed numerous times to tip the glass up in an attempt to get another drink. She appeared to begin crying. At 6:25 p.m., the DON (director of nursing) cleared the tray of the food and plate, and gave the resident some juice and a fresh cookie. The resident poured some of the juice out onto the cookie. During both meals the staff was not observed to monitor the resident or to attempt to get the resident to focus on the task of eating, except the DON at 6:25 p.m. On 05/21/13 at 1:50 p.m., the DON was asked for the rationale on placing the resident away from the tables and other residents. She stated the resident would try to take food from other residents' plates and this allowed the resident to be monitored while she ate. She was informed of the above observations. The DON stated she thought there was too much food on the plate which overstimulated the resident. She stated she had tried to refocus the resident by removing the tray and offering her only a cookie and juice, but it was too late. The DON was asked if she thought the resident needed more supervision during the meals. She stated, "Probably." 2. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The annual resident assessment, dated 04/04/13, documented the resident required total assistance with feeding. The care plan, dated 04/04/13, documented, "...Total assistance with feeding in assisted dining room. Hand feed..." On 05/20/13 at 12:15 p.m., the resident was seated in the assisted dining room for lunch. She had three glasses of fluids in front of her with the plastic wrap on them. She received her tray of pureed food. The two LPNs (licensed practical nurse) in the dining room did not set up the resident's tray or start to feed her at that time. At 12:20 p.m., the resident had pushed herself back from the table. At 12:22 p.m., LPN #2 pulled the resident back up to the table. She continued to feed the resident seated to the left of resident #1. At 12:26 p.m., LPN #2 removed the plastic wrap off of the tea glass and gave the resident a drink. She then gave her a bite of meatloaf. The resident's tray had sat in front of her for ten minutes before she was offered a bite of food. At 6:00 p.m., the resident was seated in the assisted dining room for dinner. At 6:05 p.m., the resident received her tray. The LPN asked for silverware for the resident. At 6:07 p.m., the resident had to be pulled back up to the table. At 6:08 p.m., silverware was provided. At 6:09 p.m., the resident received her first bite of food from LPN #3. The LPN, who was standing to feed, then preceded to move around the two horseshoe shaped tables giving a bite of food to three other residents besides resident #1. At 6:12 p.m., the DON came into the assisted dining room and told LPN #3 to sit down to feed. At 6:14 p.m., LPN #3 was observed attempting to feed five residents at a time, one bite at a time. At 7:00 p.m., resident #1 was finished with eating fifty-five minutes after she received her tray.

Based on record review and interview, the facility failed to develop comprehensive careplans for two (#7 and #11) of 12 sampled residents. The Census and Condition, dated 05/20/13, documented 45 residents resided at the facility. Findings: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The CAA (care area assessment), dated 02/18/13, on the annual comprehensive MDS (minimum data set) identified the following areas were triggered and would be care planned: Communication; Mood and [MEDICAL CONDITION] Drug Use. The care plans for Communication, Mood and [MEDICAL CONDITION] Drug Use were not located in the medical record. On 05/22/13 at 9:00 a.m., the ADON was asked if she could locate the missing care plans in the medical record. She stated "No, I missed doing them." 2. Resident #7 had [DIAGNOSES REDACTED]. The CAAs narrative on annual resident assessment, dated 03/05/13, documented a comprehensive care plan for incontinence, nutrition and pain would be developed. Care plans for incontinence, nutrition and pain were not located in the medical record. On 05/21/13 at 1:50 p.m., the ADON was asked if she could locate the care plans for incontinence, nutrition and pain. After reviewing the record and the computer, she stated, "I don't know why, but I didn't do them."

Based on observation and staff interview, it was determined the facility failed to ensure there were no expired medications in the medication refrigerator. The facility identified one medication room and one medication refrigerator. The policy, Drug Destruction, documented, "1. When a medication has passed its expiration date or is otherwise deteriorated, or has been discontinued, or for a resident no longer residing at the facility, it should be removed from the medicaiton cart as soon as possible and accounted for and kept under lock and key in the facility approved location...." On 05/21/13 at 8:55 a.m., the medication refrigerator was observed. One baggie with six Annucort suppositories which had an expiration date of 02/12/13 was found. This was given to LPN #1 who took it to the DON. On 05/21/13 at 9:15 a.m. the DON and ADON were asked if the Annucort should have been in the refrigerator. They both stated, "No". The DON stated the staff usually pulled expired medications 30 days before their expiration date, log it in and put the medications in her office to be locked up before destruction.

Based on observation, record review and interview, it was determined the facility failed to ensure there was nursing supervision of the CMAs (certified medication aides) administering PRN (as needed) medication dosages which required nursing assessment for one (#3) of 11 sampled residents for whom medications were reviewed. The Resident Census and Condition, dated 03/19/12, documented 47 residents resided in the facility. Findings: Resident #3 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The MAR (medication administration record) for PRN medications documented the resident was administered: ~ 03/11/12 at 7:25 a.m., one [MEDICATION NAME] tablet for complaints of right hip pain, ~ 03/12/12 at 8:45 a.m., one [MEDICATION NAME] due to increased anxiety and one [MEDICATION NAME] for complaints of general pain, ~ 03/14/12 at 7:15 a.m., two tablets of [MEDICATION NAME] for complaints of pain and a [MEDICATION NAME] due to anxiety, ~ 03/18/12 at 9:00 a.m., two tablets of [MEDICATION NAME] for complaint of right hip pain, ~ 03/19/12 at 10:00 a.m., two tablets of [MEDICATION NAME] due to increased anxiety and two tablets of [MEDICATION NAME] due to signs and symptoms of pain and ~ 03/20/12 at 8:10 a.m., two [MEDICATION NAME] tablets due to increased anxiety and two [MEDICATION NAME] for signs and symptoms of pain. The above entries, on the front and the back of the MAR, were initialed by the CMA. No nurses' signatures or initials were located with these entries. The Behavior Monitoring sheets, dated March 2012, documented no behaviors for the antianxiety medications on all three shifts from 03/15/12 through 03/20/12. On 03/20/12 at 2:30 p.m., CMA #1 was asked what was the procedure on deciding the dosage when a PRN medication was ordered for one or two tablets as needed. She stated she would ask the resident how many they wanted or she would ask the charge nurse. On 03/21/12 at 8:20 a.m., CMA #2 was asked how she decided how many [MEDICATION NAME] or [MEDICATION NAME] she gave to resident #3 since the order read one or two tablets as needed. She stated she asked the charge nurse and gave what the nurse told her to give. She was asked if the charge nurse documented that she had told her how many to give. She stated, "Sometimes I write, LPN aware." She was asked, "Aware of what?" She stated aware of how many tablets she gave. At 8:30 a.m., the ADON (assistant director of nursing) and the corporate RN (registered nurse) were asked if there was a policy on how a CMA decided how many pills to dispense if the order read, one or two. The corporate nurse stated she did not think there was a written policy. The ADON stated she did not know of a written policy, but the CMAs were to go to the charge nurses before giving any PRN medications. The nurse was then to assess the resident and tell the CMA whether or not to give a PRN medication, or one or two tablets. The nurse was to initial the back of the MAR for PRN medications along with the CMA. They were asked if it was in the scope of the CMAs practice to decide whether to give one or two tablets when the dosage was not specified. The ADON stated, "No." The ADON was shown the March MAR for PRN medications for resident #3. She was asked if the nurse had co-signed the entries with the CMA. After reviewing the documentation she stated, "No." At 8:40 a.m., after looking through the policy manuals, the corporate RN stated, "There is no written policy on that."

Based on record review and interview, it was determined the facility failed to obtain physician ordered laboratory (lab) tests for four (#6, 8, 9, and #10) of 12 sampled residents who had orders for lab tests to be conducted in November of 2011 and January of 2012. The facility identified 37 residents had lab tests ordered for November and January. Findings: 1. Resident #6 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The clinical records contained no documentation the test was obtained. On 03/20/12 at 10:00 a.m., the assistant director of nurses (ADON) was asked if the test had been obtained. At 11:00 a.m., the ADON and corporate nurse stated the test was not obtained. 2. Resident #8 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The clinical record contained no documentation the test was obtained. On 03/20/12 at 3:15 p.m., the ADON was asked if the test had been obtained. At 3:30 p.m., she stated it had not been obtained. 3. The March 2012 monthly physician's orders [REDACTED]. "...11/02/11 CBC (complete blood count) monthly..." There was no documentation to show the lab test had been obtained. On 03/21/12 at 8:45 a.m., the corporate RN (registered nurse) was asked to locate the January 2012 lab test. At 9:15 a.m., the ADON stated, "There was no lab drawn in January." The corporate RN stated, "I QA'd (problem was identified) this in January during a mock survey." She was asked to provide the supporting documentation to show how the problem with the lab tests had been identified. At 2:10 p.m., the corporate RN provided an action plan, dated 01/17/12, which documented, "Area of Concern Routine Lab work not being drawn timely Action Taken Review all residents orders for routine labs to be drawn monthly, quarterly, semi-annually, or annually Person Responsible DON MDS (minimum data set) Date of Correction 4/15/2012 Follow Up Recommendations DON/MDS will monitor all resident" 4. Resident #10 had [DIAGNOSES REDACTED]. The March 2012 monthly physicians orders, documented, "...07/19/2010 Pro-BNP (B-type naturiuretic peptide) and HgbA1c (hemoglobin A1c) every 3 months, JUL-OCT-JAN-APR..." Pro-BNP is used to help determine heart failure or to monitor effects of therapy for heart failure. HgbA1c can be an indicator of heart failure among individuals without diabetes. The clinical records contained no documentation for Pro-BNP or HbgA1c for January 2012. On 03/21/12 at 10:00 a.m., the corporate RN was asked to locate the lab tests for January 2012. At 1:00 p.m., the ADON was asked to locate the lab tests for January 2012. No documentation for these labs was provided.

Based on record review and interview, it was determined the facility failed to: ~ ensure the dosage of Seroquel (an anti-psychotic drug) and Reglan (an anti-emetic drug) were reduced as ordered for one (#8) of 11 sampled residents for whom medications were reviewed and ~ ensure there was nursing supervision of the CMAs (certified medication aides) administering PRN (as needed) medication dosages which required nursing assessment for one (#3) of 11 sampled residents for whom medications were reviewed. The Resident Census and Condition, dated 03/19/12, documented 17 residents received anti-psychotic medications. Findings: 1. Resident #8 had [DIAGNOSES REDACTED]. On 10/20/11, the consulting pharmacist's Medication Regimen Review sheet documented the pharmacist recommended the Reglan order be changed to read Reglan 5mgs (milligrams) two times a day before meals. The order currently read Reglan 5mgs two times a day. The certified nurse practicer agreed and signed the document. The director of nurses signed the document on 10/25/11. The quarterly resident assessment, dated 02/02/12, documented she was severely impaired in cognition and had verbal behaviors toward others. She was able to self-propel her wheelchair throughout the facility. On 02/10/12, a physician's orders [REDACTED]. It also documented, "May resume 50mgs dose in the morning if her behaviors increase." and 2.) Reduce Reglan to 5mgs per mouth each evening. A physician's progress note, dated 02/10/12, documented, "Seroquel 50mgs BID (two times a day) REDUCE AS A TRIAL to 25mgs QAM (every morning) and 50mgs QPM (every evening). If she has increased behaviors during the day we can order that back to 50mgs BID." At the bottom of the page a staff member wrote by hand the document was noted on 02/14/12. On 02/16/12, the consulting pharmacist's Medication Regimen Review sheet documented, "The physician okay'd to change Reglan BID AC (before meals). However, it is still ordered BID." The February and March 2012 monthly physicians orders, documented the resident had continued to be administered: ~ Seroquel 50mgs two times a day and ~ Reglan 5mgs two times a day. The February and March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The time for administration of Reglan was changed on the MARS on 02/22/12. The time was changed from 7:30 a.m. and 5:00 p.m. to 7:00 a.m. and 5:00 p.m. The MARS were not updated to reflect the physician's orders [REDACTED]. The change was Reglan 5mgs 1 per mouth BID before meals. The MARS continued to read Reglan 5mgs per mouth BID. On 03/20/12 at 4:00 p.m., the ADON (assistant director of nurses) and the corporate nurse were asked if the doses of Seroquel and Reglan had been reduced. They stated, "No." The ADON stated the physician had been notified of the failure to reduce the doses. He stated not to change anything now. He wanted to evaluate the resident on his next visit. The corporate nurse stated the time on the MARS had been changed on 02/22/12. The times of 7:00 a.m. and 5:00 p.m. would be before meals but the way the order read had not been changed. 2. Resident #3 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The MAR (medication administration record) for PRN medications documented the resident was administered: ~ 03/11/12 at 7:25 a.m., one Norco tablet for complaints of right hip pain, ~ 03/12/12 at 8:45 a.m., one Valium due to increased anxiety and one Norco for complaints of general pain, ~ 03/14/12 at 7:15 a.m., two tablets of Norco for complaints of pain and a Valium due to anxiety, ~ 03/18/12 at 9:00 a.m., two tablets of Norco for complaint of right hip pain, ~ 03/19/12 at 10:00 a.m., two tablets of Ativan due to increased anxiety and two tablets of Norco due to signs and symptoms of pain and ~ 03/20/12 at 8:10 a.m., two Ativan tablets due to increased anxiety and two Norco for signs and symptoms of pain. The above entries, on the front and the back of the MAR, were initialed by the CMA. No nurses' signatures or initials were located with these entries. The Behavior Monitoring sheets, dated March 2012, documented no behaviors for the antianxiety medications on all three shifts from 03/15/12 through 03/20/12. On 03/20/12 at 2:30 p.m., CMA #1 was asked what was the procedure on deciding the dosage when a PRN medication was ordered for one or two tablets as needed. She stated she would ask the resident how many they wanted or she would ask the charge nurse. On 03/21/12 at 8:20 a.m., CMA #2 was asked how she decided how many Ativan or Norco she gave to resident #3 since the order reads one or two tablets as needed. She stated she asks the charge nurse and gives what the nurse tells her to give. She was asked if the charge nurse documented that she had told her how many to give. She stated, "Sometimes I write, LPN aware." She was asked, "Aware of what?" She stated aware of how many tablets she gave. At 8:30 a.m., the ADON (assistant director of nursing) and the corporate RN (registered nurse) were asked if there was a policy on how a CMA decided how many pills to dispense if the order reads, one or two. The corporate nurse stated she did not think there was a written policy. The ADON stated she did not know of a written policy, but the CMAs were to go to the charge nurses before giving any PRN medications. The nurse was then to assess the resident and tell the CMA whether or not to give a PRN medication, or one or two tablets. The nurse was to initial the back of the MAR for PRN medications along with the CMA. They were asked if it was in the scope of the CMAs practice to decide whether to give one or two tablets when the dosage was not specified. The ADON stated, "No." The ADON was shown the March MAR for PRN medications for resident #3. She was asked if the nurse had co-signed the entries with the CMA. After reviewing the documentation, she stated, "No." At 8:40 a.m., after looking through the policy manuals, the corporate RN stated, "There is no written policy on that."