Every finding on record at Mission at Nephi Nursing and Rehabilitation

Based on interview and medical record review, it was determined, for 1 of 27 sampled residents, that the facility did not revise the comprehensive care plan. Specifically, the resident sustained two falls with no new interventions implemented on the care plan. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, dementia, and depression. Resident 17's medical record was reviewed 5/27/25 through 5/29/25. A Quarterly Minimum Data Set (MDS) Assessment, dated 2/20/25, indicated, [Section] C1000. Cognitive Skills for Daily Decision Making . Moderately impaired-decisions poor, cues/supervision required . The Care Plan indicated a Focus, [Resident 17] is at risk for falls r/t [related to] Unaware of safety needs, hx [history] of dementia, unsteady on feet. [Resident 17] is impulsive to stand on his own. [Resident 17] is forgetful of own limitations of balance. [Resident 17] will at times attempt to walk without required assistance. [Resident 17] will often slide from his chair/bed onto the floor on his bottom. A review of progress notes indicated resident 17 sustained falls on 3/31/25 and 5/20/25. No new interventions were implemented on the care plan. On 5/29/25 at 10:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated it had been difficult to prevent resident 17 from falling. The DON stated it was the expectation to implement a new intervention after each fall.

Based on observation, interview, and record review, it was determined for 1 of 27 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the resident sustained two falls with no new interventions implemented and did not have a non-alarming pressure pad on their bed and wheelchair as indicated on the care plan. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, dementia, and depression. On 5/28/25 at 1:12 PM, an observation was made of resident 17's bed and resident 17 sitting in his wheelchair. His bed had no alarm pad in place. A concurrent interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated resident 17 was a high fall risk and was supposed to have an alarm pad on his bed, but it had been broken for about 2 weeks. CNA 1 stated that same alarm pad would be used on his wheelchair if it was functioning and that it was not currently on his wheelchair. CNA 1 stated the alarm pad notified the nurse if resident 17 were to get up. Resident 17's medical record was reviewed 5/27/25 through 5/29/25. A Quarterly Minimum Data Set (MDS) Assessment, dated 2/20/25, indicated, [Section] C1000. Cognitive Skills for Daily Decision Making . Moderately impaired-decisions poor, cues/supervision required . A Fall Risk Evaluation, dated 2/12/25 at 1:47 AM, indicated resident 17's mobility status was, Ambulates WITH problems and WITH devices (gait is unsteady, slow, lurching). It further indicated resident 17's balance while standing, sitting, and during transitions was, Not steady, only able to stabilize WITH physical assistance. A Fall Risk Evaluation, dated 5/18/25 at 9:05 PM, indicated resident 17's mobility status was, Not able to attempt without physical assistance. It further indicated resident 17's balance while standing, sitting, and during transitions was, Not able to attempt without physical help. The Care Plan indicated a Focus, [Resident 17] is at risk for falls r/t [related to] Unaware of safety needs, hx [history] of dementia, unsteady on feet. [Resident 17] is impulsive to stand on his own. [Resident 17] is forgetful of own limitations of balance. [Resident 17] will at times attempt to walk without required assistance. [Resident 17] will often slide from his chair/bed onto the floor on his bottom. Interventions included, non alarming pressure pad to be used in bed and wheelchair for monitoring of movement. Date Initiated: 03/11/2025. Revision on: 04/01/2025. A review of progress notes indicated resident 17 sustained falls on 3/31/25 and 5/20/25. No new interventions were implemented on the care plan. On 5/28/25 at 1:51 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 17 did not have an alarm pad on his bed or wheelchair because it was broken. LPN 1 stated if the resident adjusted their seat or stood up, the alarm pad would alert the nurse on a device that the nurse carried around and they could go check on him. On 5/29/25 at 10:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated it had been difficult to prevent resident 17 from falling. The DON stated there was supposed to be an alarm pad in place so the nurses could go visualize him when it went off. The DON stated it was the expectation to implement a new intervention after each fall.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a staff member was observed to prepare a residents meal and did not change gloves or use hand hygiene after touching multiple kitchen appliances. Findings include: On 6/1/23 at 12:30 PM, an observation of lunch tray line was performed. The following observations were made: a. An observation was made of the Dietary Manager Assistant (DMA) leave the active lunch tray line to find other kitchen utensils. On return to the tray line the (DMA) was observed to pick up the food scoop and start to scoop food. The DMA was then reminded to change her gloves by the Corporate Dietary Director (CDD). b. An observation was made of the DMA. The DMA was observed to open the refrigerator door with gloved hands. A plastic container filled with meat was retrieved from the refrigerator and placed on the metal table. The DMA took a bowl and filled it with the meat that was in the plastic container and placed it in the microwave. The DMA was then observed to obtain four slices of bread, hold the bread and spread mayonnaise on two of the four slices of bread and place them on a plate. Some of the meat was observed to fall onto the metal table, the DMA was observed to pick up the meat with the same gloved hands and place the meat on the bread. The sandwiches were then taken to the dining room to the resident. The DMA did not change gloves or use hand hygiene during the observation. On 6/5/23 at 11:15 AM an interview was conducted with the Dietary Manager (DM). The DM stated the dietary staff are expected to offer the residents a presentable plate, follow the correct portion size, and be aware of the residents likes and dislikes. The DM stated the dietary staff are expected to keep the area in the kitchen clean, use hand hygiene, and to not touch the kitchen appliances and then touch the resident's food without washing their hands or changing gloves.

Based on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 19 sampled residents, a staff member was observed to touch a resident medications with bare hands with each medication administration. Also medications were dropped on and in the medication cart and then administered to the residents. Resident identifiers: 15 and 79. Findings include: On 6/1/23 at 7:30 AM, during morning medication pass the following was observed: a. At 7:50 AM Registered Nurse (RN) 2 was observed to drop a medication into the bottom of the narcotic drawer. RN 2 then picked up the medication with a glove and placed it in the medication cup with the other medications for resident 79. RN 2 was then observed to administer the medications to resident 79. b. At 8:30 AM, RN 3 was observed to not use hand hygiene prior to medication pass. RN 3 was observed to take a drink from a mug, touch the computer, the medication cart, the medication cart keys and was then observed to push the medications through the back of the pill pack into her bare hand, then place the medications into the medication cup. RN 3 was observed to pour out many tablets from an over the counter (OTC) medication bottle into her ungloved left hand, pick up one tablet with her ungloved right hand then return the rest to the original bottle. RN 3 was observed to drop a medication on top of the medication cart, pick up the medication with a bare hand and place it in the medication cup. There were ten observations where RN 3 touched the medications with bare hands. No hand hygiene was used and no gloves were observed to be worn. All medications were then administered to resident 15 . On 6/1/23 at 8:10 AM, an interview was conducted with RN 2. RN 2 stated it is necessary to keep everything clean when passing medications to residents. RN 2 stated the medications should not touch the medication cart or anything that may be dirty to prevent the residents from getting sick. On 6/1/23 at 2:20 PM an interview was conducted with the Director of Nursing (DON). The DON stated the nurses in the facility are expected to use good hang hygiene when passing medications, know the 5 rights of the residents and know what medications they are administering so they can do it correctly. The DON stated the nurses are also expected to follow the parameters that had been ordered by the medical doctor and know what those parameters are before they administer any medication. The DON stated if a vital sign is out of the parameters that have been set by the doctor the nurse is expected to hold the medication and make the provider aware. The DON stated the nurses are expected to not touch the medications with bare hands when they are preparing them for the residents.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 19 sampled residents, a resident's hypotensive medication used to treat low blood pressure was not monitored according to the physician's ordered parameters. Resident identifier: 17 and 23. Findings include: 1. Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included osteomyelitis of the right ankle and foot, chronic ulcer of the right foot, gastroesophageal reflux disease, atrial fibrillation, type II diabetes, edema and athlersclerotic heart disease. Resident 17's medical record was reviewed on 5/31/23. A physician's order dated 5/28/23 documented, Spironolactone Oral Tablet Give 12.5 mg (milligram) by mouth one time a day related to EDEMA, UNSPECIFIED Hold if SBP (Systolic Blood Pressure) < (less than) 100. The May 2023 Medication Administration Record (MAR) was reviewed and the following were documented when the Spironolactone was administered outside of the physician's ordered parameters. a. On 5/28/23, no SBP was documented and the Spironolactone was administered b. On 5/29/23, no SBP was documented and the Spironolactone was administered A physician's order dated 5/29/23 documented, Furosemide Oral Tablet Give 40 mg orally one time a day for Edema HOLD if SBP <100. The May 2023 Medication Administration Record (MAR) was reviewed and the following were documented when the Furosemide was administered outside of the physician's ordered parameters. a. On 5/28/23, no SBP was documented and the Furosemide was administered b. On 5/29/23, no SBP was documented and the Furosemide was administered A physician's order dated 12/20/22 documented, Sotalol HCl (Hydrochloride) Oral Tablet Give 20 mg by mouth two times a day for hypotension and bradycardia Hold if SBP <100 or HR (heart rate) <55. The May 2023 Medication Administration Record (MAR) was reviewed and the following were documented when the Sotalol was administered outside of the physician's ordered parameters. a. On 5/5/23, no SBP documented and AM (morning) dose of Sotalol was administered b. On 5/6/23, no SBP documented in AM and Sotalol was administered, SBP 86/49 at 3:40 PM and evening dose of Sotalol was administered. c. On 5/10/23, SBP 95/57 AM dose was administered d. On 5/18/23 no SBP documented and morning dose was administered e. On 5/21/23 no SBP documented and morning dose was administered f. On 5/24/23, SBP 95/56 AM and PM doses were administered g. On 5/28/23, no SBP documented and morning dose administered, SBP 88/53 at 3:20 and PM (evening) dose was administered. h. On 5/30/23, SBP 89/69 at 1:59 PM and PM was dose administered 2. Resident 23 was admitted to the facility on [DATE] with diagnoses which included dementia, cardiac arrhythmia, atrial fibrillation, major depressive disorder, anxiety, and protein calorie malnutrition. Resident 23's medical record was reviewed on 5/31/23. A physician's order dated 4/1/23 documented, Metoprolol Succinate ER (extended release) Oral Tablet 24 Hour Give 12.5 mg by mouth one time a day related to CARDIAC ARRHYTHMIA, UNSPECIFIED Hold for SBP <110 or HR <60. The May 2023 Medication Administration Record (MAR) was reviewed and the following were documented when the Metoprolol was administered outside of the physician's ordered parameters. a. On 5/2/23, no HR was documented and Metoprolol was administered b. On 5/4/23, SBP 105/80; No HR documented and Metoprolol was administered c. On 5/8/21, no HR was documented and Metoprolol was administered d. On 5/10/23, no HR was documented and Metoprolol was administered e. On 5/11/23, no HR was documented and Metoprolol was administered f. On 5/12/23, no HR was documented and Metoprolol was administered g. On 5/15/23, SBP 101/54 and Metoprolol was administered h. On 5/16/23, SBP 106/60; No HR documented and Metoprolol was administered i. On 5/21/23, no HR documented and Metoprolol was administered On 6/1/23 at 7:10 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the B/P was taken in the morning by the aides and then given to the nurse and they put it in the computer. RN 2 stated it was important to follow the parameters set by the doctor and a medication that had a parameter should not be given until B/P or HR was obtained. On 6/1/23 at 11:15 AM and interview was conducted with RN 1. RN 1 stated the nurses found the parameters for any medication in the orders of the medical record. RN 1 stated the nurses were the ones who documented the vital signs in the medical record after the Certified Nursing Assistants (CNAs) provided the information. RN 1 stated it was a double check, the nurses could read what the vital sign level was then put it into the computer before the medication was administered. On 6/1/23 at 2:20 PM an interview was conducted with the Director of Nursing (DON). The DON stated the nurses in the facility were expected to use good hang hygiene when passing medications, know the 5 rights of the residents and know what medications they administered so they did it correctly. The DON stated the nurses were also expected to follow the parameters that had been ordered by the medical doctor and know what those parameters were before they administered any medication. The DON stated the nurses were to obtain what vital signs they needed prior to administering a medication with a parameter. If a vital sign was out of the parameters the nurse was expected to hold the medication and make the provider aware.

Based on observation and interview it was determined, for 5 of 22 sampled residents that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including [CONDITION(S)]-CoV-2. Specifically, soiled Person Protective Equipment (PPE) was observed to be stored on top of a cart containing clean PPE, signage was not on resident doors that required PPE, staff were observed to touch food with bare hands and food was transported through the halls uncovered. Resident identifiers: 18, 19, 21, 81 and 181. Findings include: 1. Resident 181 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/21 at 11:11 AM, an observation was made outside of resident 181's room. There were no signs outside resident 181's room to indicate resident 181 required PPE or Transmission-based Precautions (TBP). An observation was made of resident 81's room across from resident 181. Resident 81's room was observed to have signage that revealed droplet precautions. There was a plastic container with PPE that was outside resident 81's room. On 8/30/21 at 11:32 AM, an observation was made outside of resident 181's room. Certified Nursing Assistant 1 (CNA 1) was observed handing a large mug to CNA 2 from inside resident 181's room. CNA 1 was observed to be wearing a gown, gloves, N95 mask and face shield. CNA 2 was wearing a surgical mask and eye protection. CNA 1 was interviewed and stated the mug was resident 181's. CNA 1 was observed to place the mug onto a wheeled utility cart that was containing other used mugs. CNA 2 was not observed to perform hand hygiene after touching resident 181's mug. On 8/30/21 at 11:55 AM, an observation was made of the Director of Nursing (DON) placing TBP signage outside resident 181's room. On 8/30/21 at 12:04 PM, an observation was made of soiled PPE in a ball on top of a cart containing new PPE outside resident 181's room. On 8/30/21 resident 181's medical record was reviewed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order further revealed resident 181 was to stay in room and resident 181 was to wear a mask when others entered the room or if he left his room. The order revealed that resident 181's door was to be closed. On 8/31/21 at 1:32 PM interview an interview with resident 181. Resident 181 stated that he felt the quarantining process and TBP were .more of a sequestration than a quarantine. Staff don't remember to follow the guidelines half the time anyway. It's a waste of time. 2. On 8/31/21 at 12:32 PM, an observation was made of CNA 1. CNA 1 was observed to removed meal trays from the meal cart and deliver the meal trays to resident room. CNA 1 was not observed to perform hand hygiene between rooms and meal trays. On 8/31/21 at 12:33 PM, an observation was made of CNA 2 removing food covers from plates containing food. CNA 2 was observed to walk through the halls with plates uncovered and food exposed. CNA 2 was also observed to have long fingernails. CNA 2 was observed to touch resident 21 and 181's food with her fingernails. 3. On 8/30/21 at 11:20 AM, an observation was made of a Licensed Practical Nurse (LPN) 1 and CNA 2 and CNA 3 in resident television lounge area with face shield up on top of the head, not covering the face. Staff were observed within 3 feet of resident 18. On 8/30/21 at 12:56 PM, an observation was made of CNA 3 sitting at desk in communal resident television room with mask down around chin and face shield on top of head. On 8/30/21 at 1:57 PM, an observation was made of LPN 1 within 1 foot of resident 18. LPN 1 was observed with a face shield on top of head and masked pulled down under chin to speak to resident 18. On 8/30/21 at 2:00 PM, an observation was made of LPN 1. LPN 1 was walking in north hallway past residents with her face shield on top of her head. On 8/31/21 at 1:54 PM, an observation was made of LPN 1 and CNA 3 with face shields on top of the their heads and surgical masks down around chin when exiting the staff lounge directly into the resident communal television area that was occupied by resident 18 and resident 19. 4. On 8/30/21 at 12:35 PM, an observation was made of a meal tray being walked down the hallway to resident 19 who was in the communal television room, cake and vegetables not covered. On 8/30/21 at 12:40 PM, an observation was made of cake on small plates, vegetables in small bowls and pureed foods in small bowls. The food was observed to be transported through the north hallway uncovered. On 8/31/21 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated newly admitted resident's that were vaccinated did not require a 14 day quarantine period. The DON stated that unvaccinated residents were to be quarantined with droplet precautions for 14 days. The DON stated that staff were to wear an N95 mask, gown, gloves and a face shield when entering a resident's room that required droplet precautions. The DON stated that resident rooms that required droplet precautions had signage outside the rooms. The DON stated that she did not know where the signs had gone that was outside resident 181's room. The DON stated that she had placed signage outside resident 181's room multiple times. The DON stated that her corporate team told her that the dish machine killed anything, so resident's requiring quarantine did not require paper products for their food. The DON stated that staff tried to carry used meal trays to the kitchen so that the trays were not placed back into the food carts. The DON stated that resident 181's mug should have been taken to the kitchen and hand hygiene performed. On 9/01/21 at 10:15 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that resident's that required a 14 day quarantine period after admission required their food to be on paper if they were unvaccinated from COVID-19. The DM stated that there were no residents that required their food to be on paper products. The DM stated that nurses provided specification on a dietary memo provided to the kitchen after a resident was admitted . The DM stated that resident 81 was on isolation but they were Doing things differently with him. The DM stated that resident 81 was not provided food on paper products. The DM stated that the garbage on resident 81's tray should have been disposed of in the garbage in his room. The DM stated there were no other residents in the facility on isolation or quarantine. The DM further stated that food was to be covered while transporting it through the hallways. The DM stated that the food cart was to be moved through the hallway outside each resident's room so that a tray was not transported through the hallway with uncovered foods.

Based on interview and record review it was determined, for 5 of 22 sampled residents, that the facility did not assess each resident using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services not less frequently than once every three months. Specifically, quarterly Minimum Date Set (MDS) assessments were not completed no later than 14 days after the assessment reference date (ARD). In addition, quarterly MDS assessments were not completed and submitted in a timely manner. Resident identifiers: 1, 5, 6, 8 and 9. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/1/21 resident 1's medical record was reviewed. A quarterly MDS assessment with a target Assessment Reference Date (ARD) of 6/20/21, had an in progress status and had not been completed. A Quarterly MDS assessment dated [DATE], was the last submitted MDS assessment located in resident 1's medical record. 2. Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/1/21 resident 5's medical record was reviewed. A quarterly MDS assessment with a target ARD of 7/7/21, had an in progress status and had not been completed. A quarterly MDS assessment dated [DATE], was the last submitted MDS assessment located in resident 5's medical record. 3. Resident 6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/1/21 resident 6's medical record was reviewed. A quarterly MDS assessment with a target ARD of 7/16/21, had an in progress status and had not been completed. A quarterly MDS assessment dated [DATE], was the last submitted MDS assessment located in resident 6's medical record. 4. Resident 8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/1/21 resident 8's medical record was reviewed. A quarterly MDS assessment with a target ARD of 7/16/21, had an in progress status and had not been completed. A quarterly MDS assessment dated [DATE], was the last submitted MDS assessment located in resident 8's medical record. 5. Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/1/21 resident 9's medical record was reviewed. A quarterly MDS assessment with a target ARD of 6/24/21, had an export ready status and had not been completed. A quarterly MDS assessment dated [DATE], was the last submitted MDS assessment located in resident 9's medical record. On 9/01/21 at 10:45 AM, an interview was conducted with the MDS coordinator. The MDS coordinator stated in a residents medical chart, export ready meant the MDS was done but had not been submitted and in progress meant that MDS still required information to be entered. The MDS coordinator stated the facility had been behind on completing the MDS section of the medical record. The MDS coordinator stated her time was split between being the Assistant Director of Nursing (ADON) and the MDS coordinator. The MDS coordinator stated a new process had been put into place where Thursdays were set aside to only work on MDS's. The MDS coordinator stated she had been the MDS coordinator for the past 2 years.

Based on observation, interview, and record review it was determined, for 1 of 22 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident who utilized a Continuous Positive Airway Pressure ([CONDITION(S)]) machine did not have orders for maintenance of their [CONDITION(S)] equipment, and there was no resident monitoring for the use of the devices in place. Resident identifier: 30 Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/30/21 at 11:00 AM, an interview was conducted with resident 30. Resident 30 stated his [CONDITION(S)] machine had only been cleaned one time since he was admitted to the facility. Resident 30 stated the cleaning had occurred the evening prior. Resident 30 stated he could breathe better and his voice was not so horse since the [CONDITION(S)] had been cleaned. Resident 30 stated he cleaned his [CONDITION(S)] regularly with soap and water before he came to the facility. Resident 30 stated he had asked the staff weeks ago to clean his machine but nothing had happened. On 8/31/21 resident 30's medical record was reviewed. Review of resident 30's physician orders dated 7/26/21 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . No specific level of humidification ordered. There were no physician orders in place for the cleaning of the [CONDITION(S)] machine. Review of resident 30's July 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation for the cleaning of the resident 30's [CONDITION(S)] machine. Review of resident 30's August 2021 MAR and TAR revealed no documentation for the cleaning of the resident's [CONDITION(S)] machine. On 4/28/21 resident 30's care plan revealed no focus area for respiratory care, [CONDITION(S)] cleaning or maintenance. Review of the facility Policy and Procedure for Cleaning of [CONDITION(S)]/[CONDITION(S)] equipment stated: 1. [CONDITION(S)]/[CONDITION(S)] machines and equipment should be cleaned routinely to minimize the risk of contamination. 2. The [CONDITION(S)] machine will be cleaned on a weekly basis with warm soapy water using a mild dish detergent or baby shampoo. 3. Cleaning will be performed in the morning to allow time for any washed parts to air dry prior to reuse. The policy also stated how to clean each individual part of the [CONDITION(S)] machine, what solutions not to use when cleaning the parts of the [CONDITION(S)] and proper storage of the [CONDITION(S)] machine. On 8/31/21 at 2:00 PM, an interview was conducted with a Liscensed Practical Nurse (LPN) 1. LPN 1 stated resident 30 had a [CONDITION(S)] and the facility was working on getting the machine cleaned. LPN 1 stated staff were unsure on how to clean the [CONDITION(S)] so they were waiting for instruction as to not ruin the [CONDITION(S)] machine. LPN 1 stated the resident had asked for some dish detergent to clean the [CONDITION(S)] machine himself so he was provided with some. LPN 1 stated the [CONDITION(S)] was cleaned weekly by the CNA's but there was not a place in the medical record to document the [CONDITION(S)] cleaning. LPN 1 stated staff just knew when it was done or when it needed to be done, there was no process. LPN 1 stated [CONDITION(S)] orders for use and cleaning were found in the order section of the medical record. On 8/31/21 at 4:02 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the [CONDITION(S)] machines was cleaned weekly, and the [CONDITION(S)] orders and maintenance were in the physician's orders of the medical record. The DON stated the facility had an action plan started that morning that focused on [CONDITION(S)] maintenance. The DON stated she wanted [CONDITION(S)] cleaning to be charted in the orders using a check mark system. The DON stated she recognized there was a gap in the system and they had started to address it.

Based on observation and interview, it was determined for 4 of 27 sampled residents that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, there were strong odors present on a resident hall, there was sheetrock damage in two resident rooms, two bedside tables were stained and dirty, a resident's privacy curtains were broken, and a resident's catheter bag was leaking. Resident identifiers: 10, 20, 21, 23, and 29. Findings include: 1. An initial tour of the facility was conducted on 5/20/19 at 11:50 AM. Strong odors were present on the north hallway upon entrance and throughout the day. 2. On 5/20/19 at 2:00 PM resident 10's room was observed to have sheetrock damage on the east wall next to the resident's bed. Resident 10 stated, It's always been like that. At 2:40 PM resident 21's room was observed to have deep gouges in the sheetrock on the west wall next to the resident's bed. Resident 21 was unaware of how long the damage had been there. 3. On 5/20/19 at 2:40 PM resident 20 and 21's room was observed. Both bedside tables were covered with debris and dried liquid spills. The bedside tables remained dirty throughout the duration of the survey. 4. On 5/20/19 at 2:55 PM resident 23's privacy curtains were observed to be loose and coming out of the ceiling. Resident 23 stated, I don't close my curtains because I'm afraid it will fall on my head. 5. On 5/21/19 at 9:00 AM a slow drip was observed coming from resident 29's bedside catheter bag, resulting in a small puddle underneath the resident bed measuring approximately 2 feet by 2 feet round. Observations were made at 9:30 AM, 10:00 AM, and 11:45 AM. Each time the catheter bag was observed leaking and the resulting puddle was getting larger, with the final size observed approximately 3 feet by 4 feet round. At 12:05 PM it was observed that the catheter bag was no longer leaking and the puddle of liquid underneath the resident's bed was no longer there. At 3:19 PM Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated, We check catheter bags at 0600 (6:00 AM) and 1400 (2:00 PM). That's when we're alerted to do it in our charting. The N[NAME] (nocturnal/graveyard) shift will empty them before they leave. When asked about the leaking catheter bag and accompanying large puddle of liquid, CNA 1 stated the N[NAME] shift had not tightened the cap on the catheter bag when they had emptied it and that was the cause of the leak. When asked if that was something they should have noticed, CNA 1 stated, probably. 6. On 5/23/19 at 10:55 AM, odors were present upon entrance to the special needs unit on 5/20/19 at 11:50 AM. The odors of urine and fecal matter were present throughout the day.

Based on interview and record review, the facility did not ensure that pharmacist recommendations were acted upon 5 of 27 sample residents. Resident identifiers: 4, 6, 7, 25, and 37. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 5/20/19. Resident 4's physician orders [REDACTED]. A pharmacy recommendation sheet dated 10/18/18 indicated that resident 4 received [MEDICAL CONDITION] replacement therapy, but a recent serum TSH ([MEDICAL CONDITION] stimulating hormone) concentration is not available in the resident record. Please consider monitoring a serum TSH concentration on the next convenient lab day and then annually. This was not signed by the physician until 12/10/18. The physician checked the box indicating that he agreed with the pharmacist's recommendation, and that the recommendation should be implemented. The sheet indicated that the Director of Nursing (DON) had signed it but did not date it. A pharmacy recommendation sheet dated 12/13/18 indicated that (Resident 4) receives [MEDICATION NAME], but does not have a TSH concentration documented in the medical record within the past 6 months. There is an order for [REDACTED]. It was not implemented until 5/21/19. No documentation could be located to indicate that the resident's TSH was checked between the pharmacist's initial recommendation on 10/18/18 and 5/21/19. On 5/22/19 at 10:30 AM, an interview was conducted with Corporate Resource Nurse (CRN) 1. When asked why the pharmacist recommendations were not followed so that appropriate monitoring of resident 4's [MEDICATION NAME] could occur, CRN 1 stated that she had discovered a drawerful of lab results yesterday that the DON had not acted upon. 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's medical record was reviewed on 5/20/19. Resident 6's physician orders [REDACTED]. A pharmacy recommendation sheet dated 10/18/18 indicated that resident 6 receives lipid-lowering therapy with [MEDICATION NAME]. Please consider monitoring a fasting lipid panel on the next convenient lab day and annually thereafter. The physician signed it but did not date it. The physician checked the box indicating that he agreed with the pharmacist's recommendation, and that the recommendation should be implemented. The recommendation was not signed by the facility staff until 5/21/19. No documentation could be located to indicate that the resident's fasting lipid panel was checked between the pharmacist's initial recommendation on 10/18/18 and 5/21/19. 3. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 5/20/19. Resident 7's physician orders [REDACTED]. The Nursing (YEAR) Drug Handbook indicated that [MEDICATION NAME] had a black box warning, and that Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV disease or infection (Wolters Kluwer, pages 1215 - 1218). The Pharmacy Recommendation Report given to the facility by the consultant pharmacists from (MONTH) (YEAR) to (MONTH) 2019 indicated that the pharmacist had reviewed resident 7's medication and did not have any recommendations for the physician, including listing an appropriate [DIAGNOSES REDACTED]. 4. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pharmacy recommendation sheet dated 3/20/19 stated the following regarding resident 25's medication: a. Comment: (Resident name) has not had an assessment of renal function and is receiving [MEDICATION NAME] each day. [MEDICATION NAME] use should be monitored by a serum creatinine. b. Recommendation: Please consider monitoring serum creatinine on the next convenient lab day and every 6 months thereafter so that appropriate staging can be assigned from the Glomerular Filtration Rate (GFR) and appropriate dosing adjustments can be made based upon estimated creatinine clearance (CrCl). This recommendation was signed by the physician on 3/23/19. The physician checked a box stating, I accept the recommendation(s) above, please implement as written. The recommendation was not signed by the Director of Nursing or implemented until 5/21/19. 5. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pharmacy recommendation sheet dated 1/21/19 stated the following regarding resident 37's medication: a. Comment: (Resident name) receives Atorvastatin, and does not have a fasting lipid panel documented in the medical record in the previous 12 months. b. Recommendation: Please order a fasting lipid panel on the next day convenient lab day and every day 12 months thereafter. This recommendation was signed by the physician on 3/25/19. The physician checked a box stating, I accept the recommendation(s) above, please implement as written. The recommendation was not signed by the Director of Nursing or implemented until 5/21/19.

Based on interview and record review, the facility did not ensure that each drug regimen was free from unnecessary drugs for 4 of 27 sample residents. An unnecessary drug is any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, residents were receiving medications without adequate monitoring. Resident identifiers: 4, 6 25, and 37. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 5/20/19. Resident 4's physician orders [REDACTED]. A pharmacy recommendation sheet dated 10/18/18 indicated that resident 4 received [MEDICAL CONDITION] replacement therapy, but a recent serum TSH ([MEDICAL CONDITION] stimulating hormone) concentration is not available in the resident record. Please consider monitoring a serum TSH concentration on the next convenient lab day and then annually. This was not signed by the physician until 12/10/18. The physician checked the box indicating that he agreed with the pharmacist's recommendation, and that the recommendation should be implemented. The sheet indicated that the Director of Nursing (DON) had signed it but did not date it. A pharmacy recommendation sheet dated 12/13/18 indicated that (Resident 4) receives [MEDICATION NAME], but does not have a TSH concentration documented in the medical record within the past 6 months. There is an order for [REDACTED]. It was not implemented until 5/21/19. No documentation could be located to indicate that the resident's TSH was checked between the pharmacist's initial recommendation on 10/18/18 and 5/21/19. On 5/22/19 at 10:30 AM, an interview was conducted with Corporate Resource Nurse (CRN) 1. When asked why the pharmacist recommendations were not followed so that appropriate monitoring of resident 4's [MEDICATION NAME] could occur, CRN 1 stated that she had discovered a drawerful of lab results yesterday that the DON had not acted upon. 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's medical record was reviewed on 5/20/19. Resident 6's physician orders [REDACTED]. A pharmacy recommendation sheet dated 10/18/18 indicated that resident 6 receives lipid-lowering therapy with [MEDICATION NAME]. Please consider monitoring a fasting lipid panel on the next convenient lab day and annually thereafter. The physician signed it but did not date it. The physician checked the box indicating that he agreed with the pharmacist's recommendation, and that the recommendation should be implemented. The recommendation was not signed by the facility staff until 5/21/19. No documentation could be located to indicate that the resident's fasting lipid panel was checked between the pharmacist's initial recommendation on 10/18/18 and 5/21/19. 3. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pharmacy recommendation sheet dated 3/20/19 stated the following regarding resident 25's medication: a. Comment: (Resident name) has not had an assessment of renal function and is receiving [MEDICATION NAME] each day. [MEDICATION NAME] use should be monitored by a serum creatinine. b. Recommendation: Please consider monitoring serum creatinine on the next convenient lab day and every 6 months thereafter so that appropriate staging can be assigned from the Glomerular filtration Rate (GFR) and appropriate dosing adjustments can be made based upon estimated creatinine clearance (CrCl). This recommendation was signed by the physician on 3/23/19. The physician also checked a box stating, I accept the recommendation(s) above, please implement as written. The recommendation was not signed by the Director of Nursing or implemented until 5/21/19. 4. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pharmacy recommendation sheet dated 1/21/19 stated the following regarding resident 37's medication: a. Comment: (Resident name) receives Atorvastatin, and does not have a fasting lipid panel documented in the medical record in the previous 12 months. b. Recommendation: Please order a fasting lipid panel on the next day convenient lab day and every day 12 months thereafter. This recommendation was signed by the physician on 3/25/19. The physician checked a box stating, I accept the recommendation(s) above, please implement as written. The recommendation was not signed by the Director of Nursing or implemented until 5/21/19.

Based on interview and record review it was determined for 3 of 27 sample residents that the facility did not ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, residents were prescribed an anti-psychotic medication without a supporting clinical diagnosis. Resident identifiers: 7, 26, and 31. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 5/20/19. Resident 7's physician orders [REDACTED]. The Nursing (YEAR) Drug Handbook indicated that [MEDICATION NAME] had a black box warning, and that Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV disease or infection (Wolters Kluwer, pages 1215 - 1218). The Pharmacy Recommendation Report given to the facility by the consultant pharmacists from (MONTH) (YEAR) to (MONTH) 2019 indicated that the pharmacist had reviewed resident 7's medication and did not have any recommendations for the physician, including listing an appropriate [DIAGNOSES REDACTED]. 2. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 26's medical record was reviewed on 5/20/19. Resident 26's physician orders [REDACTED]. The Nursing (YEAR) Drug Handbook indicated that [MEDICATION NAME] had a black box warning, and that Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV disease or infection (Wolters Kluwer, pages 1215 - 1218). 3. Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 31's medical record was reviewed on 5/20/19. Resident 31's physician orders [REDACTED]. The Nursing (YEAR) Drug Handbook indicated that [MEDICATION NAME] had a black box warning, and that Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV disease or infection (Wolters Kluwer, pages 1215 - 1218). On 5/22/19 at 2:45 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that he had been attempting gradual dose reductions on the residents for whom it was appropriate but that it was at least a 6 month process to wean the residents off of some antipsychotics. The MD was not aware that he needed to indicate in the clinical record the reason for the ongoing use of antipsychotic medications in residents with dementia. On 5/23/19 at 10:40 AM, Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 stated that she had indicated to the former Director of Nursing (DON) that any [MEDICAL CONDITION] drugs administered to residents needed to be addressed by the physician to support their use, as well as have the appropriate diagnosis, but that the issue had not yet been corrected.

Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies for the two previous recertification surveys. Findings include: An annual recertification survey was completed 4/5/18, during which the facility received a total of 23 deficiencies. Quality of care, assistance with activities of daily living, prompt physician notification of laboratory results, and medical record accuracy were again identified as areas to be cited, in addition to system failures with regard to infection control, antibiotic stewardship, pharmacy services, [MEDICAL CONDITION] medications, quality assurance and laboratory services. During the recertification survey completed on 5/23/19, the facility received a total of 10 deficiencies. Quality of care/proper catheter care and appropriate pressure ulcer treatments were again cited. In addition, system failures were again cited with regard to pharmacy services, medication monitoring, quality assurance, and [MEDICAL CONDITION] medication reviews.

Based on interview and record review, the facility did not maintain a quality assessment and assurance committee that identified and corrected issues with respect to which quality assessment and assurance activities are necessary. In addition, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Findings include: An annual recertification survey was completed 4/5/18, during which the facility received a total of 23 deficiencies. Quality of care, assistance with activities of daily living, prompt physician notification of laboratory results, and medical record accuracy were again identified as areas to be cited, in addition to system failures with regard to infection control, antibiotic stewardship, pharmacy services, [MEDICAL CONDITION] medications, quality assurance and laboratory services. During the recertification survey completed on 5/23/19, the facility received a total of 10 deficiencies. Quality of care/proper catheter care and appropriate pressure ulcer treatments were again cited. In addition, system failures were again cited with regard to pharmacy services, medication monitoring, quality assurance, and [MEDICAL CONDITION] medication reviews.

Based on observation and interview, it was determined for 2 of 27 sample residents that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, a resident was not given a soda when one was requested and another was not given adequate privacy when their brief was changed. Resident identifiers: 21 and 89. Findings include: 1. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/22/19 at 3:45 PM resident 21 was observed in her room wringing her hands and crying while seated in her wheelchair. When asked what was wrong resident 21 stated, I really want to get a Diet Coke with my bingo bucks but don't know what to do. (Note: Residents were able to win and accumulate paper slips called bingo bucks to be redeemed for drinks and snacks). Certified Nursing Assistant (CNA) 2 was asked for assistance by the surveyor, to which CNA 2 replied, The bingo bucks shop is only open on Fridays. Resident 21 continued to cry and repeat that she wanted a Diet Coke. CNA 2 was asked by this surveyor if the facility allowed residents to have drinks from the vending machines. CNA 2 stated, I'll have to go find the activities director and ask. This surveyor and resident 21 waited for 30 minutes, however, CNA 2 never returned. During the 30 minute continous observation of resident 21, the resident continued to cry and repeat that she wanted a Diet Coke. At approximately 4:30 PM, CNA 2 was observed to be seated at the nurse's station with Registered Nurse (RN) 1. At that time, CNA 2 was asked about redeeming bingo bucks on days other than Fridays. RN 1 stated residents were free to get drinks from the vending machine at their leisure. She also stated that resident 21 had a personal refrigerator in her room that was stocked with Diet coke. 2. Resident 89 was admitted to the facility on [DATE] with [MEDICAL CONDITION], dysphagia, cognitive communication deficit, dementia, urinary tract infection, pain, and muscle weakness. On 5/22/19 at 2:30 PM, resident 89 was observed having her brief changed in her room by CNAs 3 and 4. CNA 3 closed the resident's door and CNA 4 pulled the bed's privacy curtain halfway around the bed. The bedroom window, however, was observed to be open with the shades pulled up. The window was left open with the shades pulled up during the brief change, allowing a full view of the exposed resident to a yard crew working in the cemetery next door.

Based on interview and record review, it was determined for 1 of 27 sample residents that the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident had a urine sample that was not obtained in accordance with professional standards of practice or the facility's policy and procedures manual. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/22/19 at 9:30 AM, Licensed Practical Nurse (LPN) 1 was observed administering morning medication. LPN 1 stated that she needed to obtain a urine sample for analysis from resident 38. While in resident 38's room, LPN 1 was observed taking an empty urine sample cup and going to the far side of the resident's bed, stooping down, then rising with a now full cup of urine. When asked how that sample of urine was obtained, LPN 1 stated, I just drained it from the bag. (Note: Resident 38 had a suprapubic catheter with a bag that collected the urine). LPN 1 stated she did not know if there was a facility procedure for obtaining a urine sample from a closed drainage system, that she would just open the spout on the urine collection bag and collect a sample from there. On 5/22/19 at 10:30 AM resident 38 was interviewed. Resident 38 stated that LPN 1 had obtained the urine sample that morning by opening the drainage spout on the urine collection bag and catching the urine in a cup. Resident 38 stated that some staff did it that way while others would use a needle and withdraw urine from the speci-port. On 5/22/19 at 10:45 AM, LPN 2 was interviewed. She stated she was not aware if there was a facility policy for obtaining a urine sample from a closed system such as a suprapubic catheter. On 5/22/19 at 11:30 AM Registered Nurse (RN) 1 was interviewed. She stated that the facility policy for obtaining a urine sample from a resident with a catheter was to use a needle and withdraw urine from the catheter tubing's speci-port. She stated urine from the collection bag should not be used as it could collect sediment, change temperature, and the port itself may be contaminated. The facility policy and procedures manual was reviewed and detailed the following procedure for obtaining an uncontaminated urine specimen from a resident with a catheter: a. Close clamp on drainage tube below the speci-port. b. Cleanse speci-port with alcohol swab. c. Insert needle into the speci-port. Pull gently back on the plunger to obtain the required amount of urine. On 5/22/19 at 1:30 PM Corporate Resource Nurse (CRN) 2 was interviewed. She stated the correct procedure for obtaining a urine specimen from a resident with a catheter was to draw it from the speci-port, as documented in the company policy guide.

Based on interview, observation and record review, the facility did not ensure that 2 of 27 sample residents received the appropriate care to prevent and treat pressure ulcers. Specifically, a resident was not repositioned for a period of 4 hours, putting her at risk of developing a pressure ulcer, and a second resident did not receive the physician-prescribed dressing for his pressure ulcer. Resident identifiers: 38 and 89. Findings include: 1. Resident 89 was admitted to the facility on [DATE] with [MEDICAL CONDITION], dysphagia, cognitive communication deficit, dementia, urinary tract infection, pain, and muscle weakness. On 5/22/19, a continuous observation was made of resident 89. The following was observed: a) At 9:51 AM, resident 89 was observed to be seated in her wheelchair in the main seating area of the special needs unit. Resident 89 remained in the same position in her wheelchair until 11:57 AM. b) At 11:57 AM, resident 89 was observed to be wheeled from the main seating area of the special needs unit to the main dining room. c) At 12:32 PM, a staff member was observed to tilt the back of resident 89's wheelchair up approximately 15 degrees prior to assisting the resident with dining. No other attempt was made at repositioning resident 89 prior to the meal. d) At 12:43 PM, a staff member was observed to wheel resident 89 in her wheelchair back to the main seating area of the special needs unit, where the resident was in front of the television. At no time during the observation was resident 89 observed to attempt to reposition herself. e) At 2:12 PM, more than four hours since the observation had begun, the surveyor requested staff to reposition resident 89. At that time, an observation was made of resident 89's buttocks and legs. The back of resident 89's legs where the wheelchair seat had been in contact with the resident were noted to have dark red indentations. Resident 89 was observed to have some redness in the coccyx area. Interviews were immediately conducted with the two staff members assisting the resident, Certified Nursing Assistants (CNAs) 3 and 4. CNA 3 stated that resident 89 was supposed to be repositioned in bed every one to two hours, and that the resident was unable to reposition herself while in bed or in the wheelchair. When asked how often resident 89 was supposed to be repositioned while in her wheelchair, CNA 3 stated that we try to not have her in her wheelchair for too long. CNA 3 stated that staff just try to keep an eye on her (resident 89). Resident 89's medical record was reviewed on 5/20/19. Resident 89's care plan dated 10/15/18 indicated that resident 89 was at risk for skin impairment due to immobility, poor nutritional status and incontinence. The care plan indicated that resident 89 had a history of [REDACTED]. Resident 89's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that resident 89 required 2 person extensive assistance for bed mobility. 2. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19 resident 38's medical record was reviewed and found to contain the following order: a. 5/13/19. Stage II Pressure injury to coccyx: Cleanse with NS (normal saline), pat dry. Apply hydrogel, cover with foam border dressing. Change Qday (every day) and PRN (as needed) for draingage (sic), dislodgement, soilage (sic). On 5/21/19 at 2:40 PM, Licensed Practical Nurse (LPN) 1 was observed performing wound care on a stage 2 pressure injury located on resident 38's coccyx. Upon entering the resident's room LPN 1 stated, Just so you know, I've never been trained on how to do wound care. When asked what the doctor's order was LPN 1 stated, I don't know, I haven't looked at the order. I just look at what dressing was previously on the wound and use that. LPN 1 removed the previous dressing, cleaned the area with NS, and then placed a [MEDICATION NAME] Dressing (Thin) directly on the wound with the adhesive sticking directly to the wound bed. No hydrogel was applied. On 5/22/19 at 1:30 PM Corporate Resource Nurse (CRN) 2 and the Medical Director were interviewed. The Medical Director stated a [MEDICATION NAME] Dressing (Thin) should not have been placed on the wound, hydrogel should have been applied, and a foam border dressing should have been used. CRN 2 stated if a nurse was not aware of the order or procedure they should stop and check the order and if they were still unsure they should ask for help from their nursing supervisor.

Based on observation and interview it was determined that the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions and the expiration date when applicable. Specifically, a resident's multi-dose vial of insulin had no open date or expiration date. Findings include: On [DATE] at 10:30 AM an observation was made of a medication cart on the south hall. The cart contained the following: a. [MEDICATION NAME] 100 unit/milliliters (ml) vial opened with no open date or expiration date. Registered Nurse (RN) 1 was immediately interviewed and stated that the vial should not have been in use and proceeded to discard it in the sharps container. On [DATE] at 10:05 AM, Licensed Practical Nurse (LPN) 1 was interviewed. When asked about insulin expiration and open dates, LPN 1 stated she was unaware that there was a time limit on when insulin expired.

Based on observation and interview, it was determined for 2 of 27 sample residents that the facility did not assure full visual privacy. Specifically, two residents did not have ceiling suspended curtains which extended around the bed to provide total visual privacy in combination with adjacent walls and curtains. Resident identifiers: 20 and 30. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 an initial tour of the facility was conducted. It was observed that resident 20's bed only had one curtain attached to the ceiling. Other dual occupancy resident rooms had two curtains. The single curtain was insufficient to provide privacy from her roommate or from staff entering the room to assist resident 20's roommate. 2. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 an initial tour of the facility was conducted. It was observed that resident 20's bed only had one curtain attached to the ceiling. Other dual occupancy resident rooms had two curtains. The single curtain was insufficient to provide privacy from her roommate or from staff entering the room to assist resident 30's roommate. On 5/21/19 at 3:16 PM Certified Nursing Assistant (CNA) 1 was interviewed regarding resident 30's privacy curtain. CNA 1 stated the curtain provided sufficient privacy because, I always have to pull them back when I bring her meals. She's never complained or asked for them to be drawn but they cover her if needed. On 5/22/19 at 9:09 AM resident 30 was interviewed. She stated her privacy curtain, doesn't really give me enough privacy.

Based on observation, interview and record review it was determined for 1 of 8 sampled residents that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, transmission-based precautions and isolation precautions were not followed for a resident identified as having been diagnosed with [REDACTED]. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 2/26/19 at 9:15 AM, resident 2 was observed sitting in his wheelchair in his room. Resident 2 was observed to be sleeping while sitting in his wheelchair. Resident 2 was observed with 2 dressings on his left leg. Resident 2 was observed receiving oxygen through nasal canula. It was observed that resident 2 had one pillow underneath his left arm and one pillow on the bedside table. Observations were made of dressings, an isolation gown and open tube of Venelex cream on a bed next to resident 2. It was observed there was not an isolation precautions sign on the door of resident 2's room or PPE avaialable at the entrance. On 2/26/19 at 9:20 AM, resident 2 was interviewed. Resident 2's main language was Spanish, but he was able to understand and respond to questions in simple English. Resident 2 stated that he did not have any problems with his care at this facility. Resident 2 stated that he was in the hospital recently because he had an infection in his wounds. Resident 2 stated that the staff treated his wounds, but that he did not know if the wounds were getting better or worse. Resident 2 stated that the staff wore gloves when they provided his care. On 2/26/19 at approximately 10:00 AM, the medical records for resident 2 were reviewed. Medical records revealed that resident 2's physician wrote the following orders regarding resident 2's wounds: a. Cleanse area with wound cleanser, cover with [MEDICATION NAME] and foam dressing; one time a day related [MEDICAL CONDITION] and unspecified organism. b. Venelex Ointment (Balsam Peru-Castor Oil)-apply to open wound of lower back topically every shift. c. Hydrogel and foam boarder dressing-change one time daily related to pressure ulcer of sacral region. d. Left lower leg wounds: Cleanse with Normal Saline (NS) or wound cleanser. Apply Iodine to wound bed, cover with secure foam dressing-one time a day. Medical records revealed that the facility created resident 2's care plan on 6/11/18 with a revision date of 2/11/19. Per the care plan: Resident 2 has stage two pressure ulcer on right and left side of coccyx related to (r/t) Immobility and he was at risk for impaired skin integrity r/t diabetes, [MEDICAL CONDITIONS], [MEDICAL TREATMENT], surgical wound, Arteriovenous (AV) Fistula. Nursing notes revealed following: a. 2/12/2019 at 4:31 AM: Patient is here for long term care. He was recently readmitted to the facility following hospitalization [MEDICAL CONDITION] due to infection of wounds on left lower extremity. b. 2/17/2019 at 0:14 AM: .Resident is here [MEDICAL CONDITION] in his left leg; is on precautions and isolation. c. 2/17/2019 at 9:35 AM: . Resident is currently on isolation r/[MEDICAL CONDITION] infection. d. 2/19/2019 at 12:50 PM: Resident [MEDICAL CONDITION] and recently finished his IV antibiotics. Resident has been sleeping often and does not come out of his room due to [MEDICAL CONDITION]. e. 2/22/2019 at 7:04 AM: Here for long term care, recently readmitted following hospitalization [MEDICAL CONDITION]. No longer on any antibiotics. Continues to have a Peripherally inserted central catheter (PICC) to left upper arm which flushes well. Medical Doctor (MD) does not want this removed until after follow up appointments. He has two wounds to his left lower leg, dressings changed, top wound is black in wound bed, bottom wound is white in wound bed. Wounds do not appear to be healing. On 2/26/19 at 10:36 AM it was observed that there was not a sign on resident 2's door or PPE at the entrance of resident 2's room. An oberservation was made of a housekeeper that entered into resident 2's room and emptied the garbage can. The housekeeper was observed to walk into resident 2's bathroom, clean the sink and toilet. It was observed that the housekeeper had gloves on her hands and no gown. It was observed that after she cleaned the bathroom, she discarded her glover into a trash recepticle on her housekeeping cart that she pushed throughout the facility. On 2/26/19 at 10:49 AM, an observation was made of resident 2's room with an isolation precautins sign on the door and no PPE at the entrance to his room. Resident 2 was observed sitting in his wheelchair asleep. On 2/26/19 at 10:53 AM, the Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated the he positioned resident 2 this morning after breakfast. CNA 3 stated that he would use gloves and gown when providing care to resident 2. CNA 3 stated that resident 2 [MEDICAL CONDITION] in his wounds and that he was on isolation precautions. CNA 3 stated that he did not know where the isolation sign and the isolation cart with PPE were placed. CNA 3 stated that there was a sign on the door few days ago. On 2/26/19 at 11:11 AM, resident 2 was observed to be sitting in his wheelchair. It was observed that he did not have seat cushion underneath him on his wheelchair. On 2/26/19 at 12:20 PM, the Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 2 [MEDICAL CONDITION] infection on his wounds. She stated that his next appointment with the doctor would be on 2/27/19 to determine if resident 2 could be cleared his isolation precautions. RN 1 stated that all staff upon entering resident 2's room should wear gown and gloves when providing care because resident 2 still [MEDICAL CONDITION] infection in his wounds. RN 1 stated that the isolation sign and the cart should be at the entrance of resident 2's room. RN 1 stated that because resident 2 had 2 pressure sores on his buttocks, he should be repositioned every 2 hours and that resident 2 should have a seat cushion on his wheelchair to prevent further skin breakdown. On 2/26/19 at 12:30 PM, CNA 2 was interviewed. CNA 2 stated that she did not see any isolation precaution signs on resident 2's door and that she thought that he was cleared. CNA 2 stated that she would wear a gown and gloves because she knew that he [MEDICAL CONDITION] in his wound. CNA 2 stated that resident 2 had wounds on his buttocks and that he should have a seat cushion. CNA 2 stated that she did not see the cushion on his wheelchair for a while. CNA 2 was observed feeding resident 2. CNA 2 was observed to wear a gown and gloves while feeding resident 2. On 2/26/19 at 1:02 PM, the Director of Nursing (DON) was interviewed. The DON stated that resident 2 still [MEDICAL CONDITION] in his wound and that he was on isolation precautions. The DON stated that there was an isolation sign on his door before, but that someone took it down. The DON stated that they had an isolation cart at the entrance of resident 2's room with all necessary equipment and that someone took that away as well. The DON was not sure what happened with the isolation cart and isolation sign. On 2/26/19 at 1:40 PM, the maintenance/supply director was observed in resident 2's room to change his mattress. The maintenance/supply director was observed to adjust the new mattress without donning gloves and gown. Resident 2's old mattress along with an air pump was observed in the hallway outside of resident 2's room. Resident 2's soiled linens were observed on a recliner in his room. A black seat cushion was observed on the clean bed next to resident 2's wheelchair and recliner. The maintenance/supply director stated that he removed used bedding from the old air-mattress with gloves on his hands. He stated that this bedding would be taken to laundry in a yellow bag and would be washed twice. He stated that housekeeping did regular cleaning of resident 2's room and he was not sure if they wore gloves and gowns. He stated that the DON found resident 2's deflated seat cushion in resident his closet, and he took it into the maintenance area to reinflate it. He stated the seat cushion was not washed before he took it to reinflate it. The maintenance/ supply director stated that he was not sure if resident 2 was still on isolation precautions or if he had been cleared.

Based on observations, interviews, and record review it was determined that the facility failed to ensure that a resident received adequate supervision to prevent accidents for 1 of 27 sample residents. Specifically, the facility failed to provide adequate supervision after a resident eloped from the facility and sustained multiple falls which resulted in a laceration that required staples. Additionally, the hot water temperatures in eight resident restrooms ranged between 121 to 140 degrees Fahrenheit (F) which placed residents at an increased risk for injury. Resident identifiers: 28 and 39. Findings include: 1. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 39's medical record was reviewed on 12/12/16. On 9/20/16 a fourteen day Minimum Data Set (MDS) assessment was completed by the facility staff. Resident 39 was assessed as having a BIMS (Brief Interview for Mental Status) of 1 which indicated that resident 39 was severely cognitively impaired. The facility staff assessed resident 39 as requiring extensive assistance of two people for transfers and ambulation. Review of the Fall Risk Assessment form that was completed at the time of admission revealed that resident 39 was given a score of 12 which placed him at high risk for falls. On 9/19/16, the facility staff developed a care plan for resident 39 entitled ADL (Activities of Daily Living) & (and) Risk for falls. The facility staff documented the problems which included (resident 39's) strength and mobility have deteriorated. (Resident 39) needs assistance with some of the things that he used to do on his own. (Resident 39) also does not want to fall or have any other injury this quarter. The goal developed was (Resident 39) will function at a level that he satisifed (sic) with and not have any falls this quarter. The approaches that were developed to achieve the goal included: (a) Listen to input from resident about completing his daily activities; (b) Provide resident with adaptive equipment as needed; (c) Encourage resident to perform as many tasks as he can; (d) Provide/assist resident with a clutter free room and living environment that is free of trip hazards; (e) Provide supervision and or assistance with hygiene tasks including oral care, nail care, and grooming; and (f) Encourage resident to use call light when he requires assistance with ADLs. On 9/14/16 at 3:58 PM, a licensed nurse documented Resident fell in the dining room on the unit. He stated to the nurse that he got up and his legs quit working causing him to fall. He had shoes on his feet, the lighting was good and the floor was dry. His briefs were dry. He was lying on his left side with his legs stretched out and his arms were to his side. He was alert and oriented x 1 (to person only). No changes to LOC (level of consciousness) at this time. Neuro (neurological) checks were started due to fall being unwitnessed. Resident denied hitting his head at this time. Family was notified, PCP (Primary Care Physician) was notified via fax, unit manager was notified in person. He was educated on allowing staff to assist him with ambulation. No injuries were observed when assessed by this nurse at this time. He is also being monitored for a sore to his left index finger. No s/s (sign or symptoms) of infection was observed by this nurse. WCTM (Will Continue To Monitor). Resident 39's Fall Risk Assessment was updated on 9/14/16 with a score of 15, which placed resident 39 at a higher risk for falls than when first admitted to the facility. Review of the incident report, dated 9/14/16 at 12:45 PM, revealed no documentation that the incident was thoroughly investigated as to the root cause of the incident. On 9/15/16, the Falls - Risk for Injury care plan was updated to include the following approaches (a) Call bell within reach, remind resident to use; (b) Answer call light promptly & assist resident; (c)Assess for B&B (Bowel and Bladder) program; and (d) Staff to continue to monitor for (changes). (Note: There was no documentation available for review to indicate the the facility staff assessed resident 39's bowel and bladder program.) On 9/20/16 the facility Director of Nursing (DON) documented in the Fall Committee Meeting Minutes that the facility staff were educated to assist resident 39 when ambulating. On 10/3/16 at 12:42 AM, a licensed nurse documented (Resident 39) was trying to get out of bed without assistance was found lying supine on bedroom floor by (Certified Nurse Assistant (CNA) 4) at 2330 (11:30 PM) on 10/2/16. He states he hit his head but states he has 0/10 pain. (Resident 39) LOC is normally AXO (alert and oriented) to person only and he is confused. He was assessed he has reddness (sic) on the posterior occiput. No other injuries are noted at this time. Neruo (sic) checks were started. He was added to alert charting. Dr. notified. Will have AM nurse notify family. (Note: This was resident 39's second fall since admission to the facility.) Resident 39's Fall Risk Assessment was updated on 10/2/16, score remained at 15. Review of the incident report, dated 10/2/16 at 11:30 PM, revealed no documentation that the incident was thoroughly investigated. On 10/3/16, the Falls - Risk for Injury care plan was updated to include the following approaches (a) have staff check q (every) round; (b) orient resident to environment; (c) bed kept in low position; (d) (question) NOC (night time) meds possibly making him more drowsy. Staff education to assist to bed shortly (after) meds given. On 10/10/16 at 12:21 AM, a licensed nurse documented (Resident 39) fell at 2010 on 10/9/16 in the living room area. The floor in the living room area was dry and clean. (Resident 39) was wearing shoes. (Resident 39) likes to move furniture around it appears that he stumbled and fell and hit his head on the dinning (sic) room door. He was assessed neuro checks were started. (Resident 39) is A&O to person only this is resident's normal LOC. Pupils equal and reactive to light bilaterally. Grip equal bilaterally. No s/s of injuries on his head. When asked resident stated he had no pain. He has a bruise on R (right) upper arm. Skin tear on R posterior elbow is 1.5 cm (centimeters) in length with skin flap. Contacted wound nurse (Registered Nurse (RN) 1) got orders for skin tear: clean with NS (normal saline). Apply moistened collagen cover with padded tegaderm. Change Q M,W,F (every Monday, Wednesday, and Friday). Followed orders for skin tear. Put on alert charting, contact Dr. Will continue to monitor. (Note: This was resident 39's third fall since admission to the facility.) Resident 39's Fall Risk Assessment was updated on 10/9/16 with a score of 16. Review of the incident report, dated 10/9/16 at 8:10 PM, revealed no documentation that the incident was thoroughly investigated. On 10/10/16, the Falls - Risk for Injury care plan was updated to include the following approaches (a) Round more frequently; (b) staff to redirect him when they see him moving furniture. (Note: There was no documentation available for review to indicate how often the staff were to observe resident 39.) On 10/21/16 at 6:53 PM, a licensed nurse documented At 1745 (5:45 PM) (Resident 39) was reported missing by the CNA. He was last seen at 1730 (5:30 PM) my (sic) the nurse and the administrator on the unit in the common area. The staff searvched (sic) all the rooms and bathrrom (sic) on the unit and off the unit. The administrator and a nurse went and drove around to find him. He was found down the street two houses. He has no apparent injuries at this time. He was happy upin (sic) arrival back to the facility. DON was notified of situation at 1815 (6:15 PM). The wife was notified of situation at 1850 (6:50 PM) via phone call. Staff will continue o (sic) monitor and encourage fluids. Call light is within reach. MD (medical doctor) notifird (sic) via fax. On 10/21/16 at 7:01 PM, the facility staff documented, Addendum: Staff believes he was let off the unit by another resident d/t (due to) there was no alarms set off at time of disappearance. Staff believes he got off unit walked out the south west door and around to the building. Review of the incident report, dated 10/21/16 at 6:53 PM, revealed no documentation that the incident was thoroughly investigated. On 11/8/16 at 3:55 PM, a licensed nurse documented Resident was found on the floor by the aide. He was laying on his right side with his legs straight and his arms were by his side. He stated to the nurse that he was petting the dog. He was assessed for injury and none was apparent at the time. He was able to bear weight when assisted to standing position at this time. Floor was clean and dry, lighting was adequate, he had shoes on his feet at the time. Briefs were clean and dry. During next few neuro checks his BP (blood pressure) was low and this nurse pushed fluids and notified PCP. PCP sent order for UA (urinary analysis) and to continue to push fluids at this time. Neuro checks are being continued and there continues to be no changes to LOC at this time. Staff to continue to anticipate his needs and we are currently trying to obtain urine culture. WCTM. (Note: This was resident 39's fourth fall since admission to the facility.) On 11/8/16, the Fall Risk Assessment was updated with a score of 13, a lower score than resident 39's previous assessment. Review of the incident report, dated 11/8/16 at 3:55 PM, revealed no documentation that the incident was thoroughly investigated. On 11/15/16 the Falls - Risk for Injury care plan was updated to include the following approaches (a) open curtains daytime; (b) (question) if he thought dog was his and playing with it; (c) Staff will continue to monitor for (changes) and placing self on floor to play with pets. On 11/14/16 at 6:49 PM, a licensed nurse documented (Resident 39) is being monitored for an unwitnessed fall reported today that occurred approximately 1515 hours (3:15 PM) in his resident room. (Resident 39) was watching television while standing and reported becoming dizzy. He stated he stepped back and fell on his back hitting his head on the floor. I was informed of the fall via (CNA 5). She stated (resident 39)'s roommate found (resident 39) lying on the floor talking. I entered the room after receiving the information regarding the fall and immediately began a patient assessment. (Resident 39) demanded to stand up and appeared agitated that we were asking so many questions regarding him falling onto his back. There were no complaints of pain other than to his occipital lobe where a reddened (sic) area that was approzimately (sic) 2x2 inches was found. Not once did he rub his head but he did state he fell backwards. No s/s of any other injuries. Patient was immediately put on a Neuro watch for any changes. (Resident 39) was instructed to rest in his room while we assessed him over the next hour. Resident desired to watch the television and the staff continually monitored to observe for changes. Call light was within reach. Family was notified. Physician office was notified via phone call and fax message. (Note: This was resident 39's fifth fall since admission to the facility.) Resident 39's Fall Risk Assessment was updated on 11/14/16 with a score of 10, a lower score than his previous assessment. Review of the incident report, dated 11/14/16 at 3:15 PM, revealed no documentation that the incident was thoroughly investigated. On 11/15/16, the Fall - Risk for Injury care plan was updated to include the following approaches (a) encourage to participate in meaningful activities; (b) assess for medication changes monthly; (c) Evaluate for deficits and Refer for appropriate consultation-HOH (hard of hearing), eyes, psych. (d) med (medication) eval (evaluation) d/t (due to) dizziness sent to MD (medical doctor). (e) UA (urinary analysis). (Note: There was no documentation available for review to indicate that the medication evaluation or the urinalysis was completed as care planned.) On 11/15/16 the facility DON documented in the Fall Committee Meeting Minutes to monitor resident's behavior, placing self on floor. On 11/22/16 at 9:54 PM, a licensed inures documented (Resident 39) was standing in the hallway when he lost his balance and fell . Nurse witnessed fall, he did not hit his head. He was on his right side. Nurse helped him up and to the couch. She assessed him for any injuries. No injuries. MD notified 11/22/16 at 2236 (11:36 PM). Nurse was unable to get a hold of family. Fluids encouraged, call light within reach. staff WCTM. (Note: This was resident 39's sixth fall since admission to the facility.) Resident 39's Fall Risk Assessment was updated on 11/22/16 with a score of 10. Review of the incident report, dated 11/22/16 at 7:00 PM, revealed no documentation that the incident was thoroughly investigated. On 11/23/16, the Falls - Risk for Injury care plan was updated to include the following approach Med list sent to MD for review. (Note: There was no documentation available for review which indicated that the physician reviewed resident 39's medications.) On 11/28/16 at 8:55 PM, a licensed nurse documented (Resident 39) was found on the floor with no apperent (sic) injury VS (vital signs) and neuros started. Dr. and family notified. He is now sleeping in his bed with call light within reach. Will continue to monitor. (Note: This was resident 39's seventh fall since admission to the facility.) Review of the incident report, dated 11/28/16 at 6:30 PM, revealed no documentation that the incident was thoroughly investigated. Resident 39's Fall Risk Assessment was updated on 11/28/16 with a score of 11. On 11/30/16, the Falls - Risk for Injury care plan was updated to include the following approach Ask MD if staff could obtain labs. On 11/28/16 the facility DON documented in the Fall Committee Meeting Minutes to contact the MD for recommendation for a medication review and labs. On 12/5/16 at 6:59 PM, a licensed nurse documented During nursing shift change, (Resident 39) was eating in the north unit dining room with his roommate. (Resident 39) finished and stood up from the table falling backwards. He hit his head against the bedside table near the wall. CNA reported the fall having occurred at 1800 hours (6:00 PM). This nurse and a second nurse gave first aid via patient assessment and neuros. Family notified. Doctor notified. Wound Nurse notified. Staff will continue to monitor for any changes. Fluids encouraged. Call light is within reach. (Note: This was resident 39's eighth fall since admission to the facility.) On 12/5/16 at 10:30 PM, a licensed nurse documented . Pt has a small abrasion to mid upper back, no other injuries noted. Resident 39's Fall Risk Assessment was updated on 12/5/16 with a score of 17. Review of the incident report dated 12/5/16 at 6:00 PM, revealed abrasion on the back is 5 centimeters. There was no documentation that the incident was thoroughly investigated. On 12/5/16, the Falls - Risk for Injury care plan was updated to include orthostatic BP's (blood pressures) BID (twice a day) x (times) 1 week. (Note: The orthostatic blood pressures were not initiated until the morning of 12/7/16.) On 12/6/16 at 3:46 PM, a licensed nurse documented At 1322 hours (1:22 PM) (resident 39) was found by (CNA 3) in his room face down with blood on his head. This nurse and second nurse responded and found (resident 39) A& O x 1 with confusion but WNL (within normal limits) of his dx (diagnosis). (Resident 39) could not remember what happened or that he had a head injury. A laceration was located on the top of his head which was 6 cm long and 0.02 cm wide. (Resident 39) was immediately placed on neuros and patient assessment completed. First aid provided by this nurse and second nurse. (Resident 39) was transported to the hospital by (Restorative Nurse Assistant (RNA) 1) to the (local hospital) ER (emergency room ) to evaluate the laceration. Family and doctor were notified. (Note: This was resident 39's ninth fall since admission to the facility.) On 12/7/16 at 3:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1stated that resident 39 was to be kept in direct line of sight of staff. On 12/12/16 at 10:40 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 39 needed assistance with transfers and ambulation and required one on one supervision to prevent wandering. On 12/12/16 at 10:45 AM, an interview was conducted with CNA 6. CNA 6 stated that resident 39 needed assistance while standing at all times. CNA 6 stated that resident 39 was to be kept in line of sight at all times. On 12/12/16 at 10:50 AM, an interview was conducted with CNA 7. CNA 7 stated that resident 39 required assistance when walking and that she was to keep an eye on him. On 12/12/16 at 1:30 PM, an interview was conducted with the Corporate Nurse. The Corporate Nurse was unable to provide documentation that resident 39's physician conducted a medication review prior to 12/1/16. 2. On 12/5/16 at 1:30 PM, water temperatures were taken in resident restrooms as follows: (Note: All temperatures were in degrees Fahrenheit.) a. Room 40/42 - 140.5 degrees within 20 seconds; b. Room 25 - 133; c. Room 32/34 - 128; d. Room 36/38 - 130; e. Room 26/28 - 124; f. Room 37 - 121; g. Room 6/8 - 134.5 in 1 minute 15 seconds; h. Room 22/24 - 126.2 in 47 seconds; i. Room 14/16 - 130.1 in 30 seconds. On 12/5/16 at 1:45 PM, an observation was made of the hot water heater. The temperatures were in degrees Fahrenheit. The mixing valve temperature was 120. The hot water heater tank was 128. The broiler was set at 205-210. An interview was immediately conducted with the Maintenance Director (MD). The MD stated that he did not check resident restroom water temperatures. The MD stated that he checked the temperatures of the hot water heater, mixing tank and broiler. The MD stated that he did not know what the temperature regulations were. The MD stated that the staff complained of cold water but there were no complaints of hot water. On 12/5/16 at 1:50 PM, an interview was conducted with CNA 8. CNA 8 stated that the water had been really hot before. CNA 8 stated that she added cold water to the hot water. CNA 8 stated that she told the maintenance director. On 12/5/16 at 1:33 PM, an interview was conducted with resident 28. Resident 28 resided in room 40 where the water temperature was 140.5. Resident 28 stated that the water had been really hot at different times.

Based on observation, interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 3 of 31 sample residents. Specifically, (1) There was a delay in timely notification of critical laboratory values that resulted in a resident being hospitalized , and (2) Two residents were not treated for [REDACTED]. Resident identifiers: 1, 24, and 56, Findings include: 1. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 56's medical record was reviewed on 7/11/13. The electronic "Departmental Notes" were reviewed. The licensed nursing staff documented: a. 6/19/13 at 7:15 PM: "...This afternoon she had a very dark, tarry stool. Order was obtained from (Medical Doctor) to obtain fecal occult test. The test did return positive. He was contacted again and ordered the following: 1. Draw CBC (Complete Blood Count) now and in am. (results need to be in prior to 12 PM). 2. Start [MEDICATION NAME] 20 mg (milligrams) po (by mouth) q (every) day. 3. d/c (discontinue) [MEDICATION NAME]. ...Lab was drawn and sent to (local) lab. Awaiting results. Will continue to monitor for changes in condition." b. 6/19/13 at 8:10 PM: "Received results from CBC lab draw. Faxed to MD (Medial Doctor). Awaiting response." c. 6/20/13 at 2:03 PM: "...Resident transported to (local hospital) ER (emergency room ) request d/t (due to) decreased hemo globin (sic). Daughter (name redacted) called at 0905 (9:05 AM) verbal message left, she called back and the situation was explained. ER called at 1400 (2:00 PM) reported (resident 56) was being transported to (another hospital)..." The laboratory values obtained for resident 56 were reviewed. The following abnormal laboratory values were obtained: a. 6/14/13 (prior to admission to the facility): hemoglobin 11.9 g/dl (grams per deciliter) with a hematocrit of 38% (percent). (Note: The laboratory company documented a normal hemoglobin was 12-16 g/dl and a normal hematocrit of 35-46%.) b. 6/19/13 at 6:21 PM: Red Blood Cells (RBCs) low at 2.16 (normal value 6 million cells per microliter), Hemoglobin critically low at 6.3 g/dl with a hematocrit of 20.6%. The laboratory company documented on the laboratory report "Critical Alert Comments: repeated to verify. Reported to (Licensed Practical Nurse (LPN) 2) at (facility). Critical results released (6/19/13 (at 6:32 PM)." (Note: Resident 56's hemoglobin was significantly lower than the laboratory results that were obtained on 6/14/13, five days prior to admission to the facility.) On 7/11/13 at 9:20 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that she was resident 56's nurse on 6/20/13 when she was sent to the hospital for an evaluation. RN 1 stated that resident 56 was "very pale" and that the Director of Nursing (DON) had told her on 6/20/13 at approximately 8:30 AM, to send resident 56 to the emergency room for an evaluation related to her laboratory results that were obtained on 6/19/13. On 7/11/13 at approximately 9:30 AM, the facility Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 56 was not sent to the emergency room for an evaluation until 6/20/13 because the laboratory company faxed the laboratory results to an office that was not checked by the nursing staff after hours. On 7/11/13 at approximately 9:45 AM, LPN 2 was interviewed via telephone. LPN 2 stated that she was assigned to care for resident 56 on 6/19/13. LPN 2 stated that resident 56 developed black tarry stools. LPN 2 stated that she contacted resident 56's primary care physician and received orders for a guaiac test and to check her CBC. LPN 2 stated that she "remembered" the laboratory company called her about the abnormal labs but did not actually see the laboratory results. LPN 2 stated that she verbally notified the next shift that resident 56 had an abnormal laboratory result and "passed it on to the night shift nurse to deal with." On 7/11/13 at approximately 9:50 AM, the facility DON was interviewed. The DON stated that she received the abnormal laboratory values from the facility fax machine on 6/20/13. The DON stated that after reviewing the laboratory results, she notified the day shift nurse to have resident 56 sent to the hospital to be evaluated. The DON was not aware that the laboratory company documented that LPN 2 was verbally notified of the abnormal laboratory values on 6/19/13 at 6:32 PM. Resident 56's "emergency room Report" for 6/20/13 was reviewed. The hospital physician documented that resident 56's blood pressure was 96/59 with a hemoglobin of 6.4 g/dl and hematocrit of 20.6%. Resident 56 received a liter of normal saline intravenously and "her first unit of packed red (blood) cells" before being transfered to another hospital for a higher level of care. (Note: Resident 56's care was delayed for 14 1/2 hours before receiving treatment for [REDACTED]. 2. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/10/13 a medical record review was conducted for resident 24. An "Initial Pain Assessment" completed 12/24/13 and re-assessed on 3/29/13, revealed that the facility staff assessed resident 24 as having joint, bone and incisional pain. The facility staff assessed resident 24 expressed pain with verbalization, grimacing, groaning, frowning, guarding and resistance to cares. Review of the care plans developed on 1/2/13 and revised on 4/13/13 for resident 24 revealed a care plan for generalized pain related to a left [MEDICAL CONDITION]. The goal that was developed for resident 24 was "Resident will demonstrate relief of s/sx (signs and symptoms) of pain with current regimen each time administered through next review" and "Resident will have no unreported adverse side-effects r/t (related to) his/her pain management regimen." The approaches for resident 24 included: "a. Observe for verbal and non-verbal s/sx of pain. Watch for grimacing, groaning, guarding, increased expression of anger, agitation, tearfulness, withdrawal, etc. b. Administer pain medications as ordered. Give prior to treatments, therapies or other activities identified to cause resident pain, as possible. c. Ensure proper body alignment and position for comfort, as possible. d. Notify physician of increased intensity of pain and/or that which is not adequately controlled with current pain regimen, as needed." A review of the facility electronic "Departmental Notes" revealed the following enteries: 1. 1/25/13 at 4:40 AM: "...Res (resident) bed alarm ringing. Aide went to res and found her supine on the bedside floor mat with her posterior up in the air. Aide walkie talkied nurse and nurse assessed head, neck and spine. Finiding (sic) no injuries. Rolled res to prone position and sat her up. Then lifted her up onto her bed that was in the bed to floor position. Rolled res toward the wall and place (sic) pillow under her bed pads. Made sure bed alarm was inplace (sic) and working. Res has been reaching both arms out as if to hug someone then claps her hands. Also has been knocking on the wall. Vitals were taken. (The primary care physician was) notified on his voice mail. Day nurse asked to notify family." 2. 1/27/13 at 5:37 AM: "Res has been anxious and in pain this noc (night)...." 3. 1/27/13 at 5:54 AM: "Res has shown confusion this noc, but she has not shown any adverse reactions to recent FOF (fall on floor) incidents. Will continue to monitor for changes." 4. 1/28/13 at 12:05 PM: "Resident is scheduled to have [MEDICATION NAME] changed today. She is out of patches. I contacted the pharmacy r/g (regarding) to this. They stated that they are waiting on a signed script from (the primary care physician). (Assistant Director of Nursing) called to his office regarding this. They asked to have a med (medication) list faxed to them. Unabel (sic) to fax at this time d/t (due to) phone lines down. Will see if (transportation) can take it to the clinic." 5. 2/5/13 at 4:45 PM: "Hsopice (sic) nurse notified and a new order for Tylenol 325 milligrams (mg), 2 tabs (tablets) PO (by mouth) Q (every) 6 hours prn (as needed) fever was given. (NOTE: Resident 24's temperature was recorded as 100.2 degrees Farenheit (F).) 6. 2/5/13 at 7:05 PM: "Res has a swollen L (left) leg and hip. Skin at hip is very tight to the touch. No redness noted. Res c/o (complains of) pain in area, when moved. PRN oxy ([MEDICATION NAME]) was given for pain. Will continue to monitor for any changes. DON (Director of Nursing) notified. Temp (temperature) was reported this evening. DON notified. Passed on to noc shift. Personal alarms are on." 7. 2/6/13 at 4:38 AM: "(Resident 24) has been showing s/s (signs and symptoms) of pain to her L hip. It is swollen and painful to the touch. She favors this side when leg is moved or when rolled onto that side. PRN pain meds given for pain. Tylenol given last noc for fever with good results. Fluids are encouraged. Will continue to monitor for changes in condition." (NOTE: Resident 24's temperature was recorded as 100.6 degrees F.) 8. 2/6/13 at 6:03 PM: "Res has pain in left hip/leg. New order from hospice DR (doctor) for Roxinol that they are sending via hospice pharmacy." (NOTE: Roxinol was ordered approximately twenty three hours after pain was increased.) 9. 2/7/13 at 9:04 PM: "(Resident 24) has been displaying s/s of pain to her L hip, it is swollen and painful to the touch. She favors this side when her leg is moved or when rolled onto her L side. PRN pain meds given for pain, tol. (tolerated) well with good effect. Fluids are encouraged. Cont. (continue) to mont (monitor) and assist as needed. Monitor for s/s of changes in condition." 10. 2/10/13 at 6:55 PM: "CNA's (Certified Nurse Assistants) reported to me this AM (morning) that (Resident 24) was having increased pain to her left hip. Prior to admit to HH (home health and hospice) she had surgery to the left hip. Upon assessment it was noted to be red and swollen, hot to touch et (and) very tender. She has been favoring this leg/hip for several days now. She also had a low grade fever. PRN Tylenol given for fever et PRN MS ([MEDICATION NAME]) given for pain, PRN [MEDICATION NAME] given for increased anxiety r/t (related to) pain. All meds were effective. She was given 2 more doses of MS et 1 more dose of Tylenol throughout today, effective. She has been in the living area all afternoon resting quietly in the chair. She is DNR (Do Not Resuscitate) et hospice status at this time. I contacted (DON) regarding hip. New order obtained: Keflex 500 mg PO BID (twice daily) x 7 days. Dx (diagnosis): [MEDICAL CONDITION]. Four doses of Keflex taken from e-kit (emergency kit) et 1st dose given with yogurt. Tolerated well. I contacted her daughter (resident 24's daughter). Assisted wtih (sic) et encouraged fluids. Will continue to monitor for any change in condition." (NOTE: The primary care physician was not notified of resident 24's fever, pain in the left leg and hip, or the swollen area to the left leg and hip for 5 days, at which time an order for [REDACTED]. 11. 2/11/13 at 12:27 AM: "While getting (resident 24) ready for bed, it was noticed that a great deal of fluid was found on her pants, w/c (wheelchair), and floor. The incision on her L hip had eviscerated at approx (approximately) distal 2 inches. Pus, liquid and blood were moderately flowing. Wound was bandaged to keep from seeping onto clothing. She was c/o pain to the area, so MS and [MEDICATION NAME] given with good effect. The site continues to be red and oozing. (Resident 24) not transferred to ER (emergency room ) d/t being on hospice, per (DON). Family was notified and they said they would visit in the AM. (Resident 24) is resting quietly this noc and not c/o further pain. She received abt (antibiotic) for [MEDICAL CONDITION] and is not showing any adverse reactions to tx (treatment). Infection report completed." (NOTE: The primary care physician was not notified of the surgical wound that had reopened.) On 7/10/13 at 3:55 PM, an interview was conducted with the DON. The DON stated that there was no documentation that resident 24's family did not want resident 24 sent to the hospital for evaluation after sustaining a fall with increased pain. The DON stated that the facility licensed nursing staff should have notified resident 24's primary care physician after resident 24 experiened an increase in pain, when resident 24 developed signs and symptoms of infection of a surgical wound, and when resident 24's surgical wound dehisced. 3. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/11/13 at 8:12 AM, an observation was made of morning medications being administered by RN 1 to resident 7 during a medication pass. Resident 7 was moaning and told RN 1 that her ankle was swollen and that she was in pain. Resident 7 asked RN 1 for a pain pill. RN 1 told resident 7 that she would get her an [MEDICATION NAME] and would "be right back." On 7/11/13 at 8:26 AM, an interview was conducted with RN 1. RN 1 stated that she had not administered the [MEDICATION NAME] to resident 7 yet. On 7/11/13 at 8:35 AM, an observation was made of RN 1 as she prepared the [MEDICATION NAME] for resident 7. On 7/11/13 at 8:39 AM, RN 1 administered the [MEDICATION NAME] to resident 7. RN 1 asked resident 7 what her pain level was and resident 7 reported that it was "10" on a scale of 1 to 10 with 1 being the least amount of pain and 10 being the worst amount of pain. (Note: Resident 7 waited for 27 minutes before RN 1 administered the requested pain medication.)