Every finding on record at Montezuma Health and Rehabilitation

Based on observations, interview, and the policy titled Storage Areas, the facility failed to ensure food items were properly labeled, dated, and stored under sanitary conditions to prevent foodborne illness. The deficient practice had the potential to affect all 68 residents. Findings include:Review of the policy titled Storage Areas, dated 12/27/2024, documented under Guideline: Items should be covered, sealed, labeled and dated appropriately.The initial kitchen tour with the Dietary Manager (DM) on 1/16/2026 from 8:15 AM through 8:43 AM revealed the following concerns:Reach-in freezer contained a box of turkey sausage patties, and traditional cinnamon roll dough that were not labeled or dated. Walk-in refrigerator contained a bag of opened pub-style battered cod fillets, and a container of pimento cheese that were not labeled or dated.Pantry contained two boxes of expired ketchup.Interview with DM during the tour on 1/16/2026 starting at 8:15 AM, confirmed all surveyor identified concerns. The DM immediately discarded all food items that were not labeled or dated. The DM stated that she is responsible for ensuring all food is labeled with open dates and expired dates.

Based on observation, record review, staff interviews, and review of the facility policy titled Use of Oxygen Therapy, the facility failed to follow Physician's Order for one of one resident (R) (R10) reviewed for receiving oxygen. The deficient practice had the potential to place R10 at risk of adverse clinical outcomes. Findings include:Review of the policy titled Use of Oxygen Therapy, dated 12/27/2024 documented under Intent: To ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. Documented under Guideline: Physician's order for oxygen should be obtained and include Oxygen with liter flow as ordered.Review of the clinical record for R10 revealed the resident was admitted to the facility on [DATE] with diagnoses of but not limited to chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia.R10's most recent Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment. Section O: Special Treatments revealed the resident received oxygen therapy. Review of the physician's orders documented an order for oxygen at three liters per minute (LPM) per nasal cannula with a start date of 03/21/2024.Observation on 1/16/2026 at 10:08 AM revealed that R10's Oxygen was set on 2.5LPM Observation on 1/17/2026 at 9:33 AM revealed that R10's Oxygen was set on 2.5LPMObservation on 1/17/2026 at 2:17 PM revealed that R10's oxygen was set on 2.5LPMInterview on 1/16/2026 at 10:09 AM with R10 revealed that she is not sure what her oxygen should be set on and stated that she does not touch her oxygen control.Interview on 9/3/2025 at 11:15 AM with the Director of Nursing (DON) confirmed resident R10's oxygen was set at 2.5LPM but should have been set on 3LPM. The DON revealed that all nurses should check the oxygen settings throughout the day to make sure the settings are correct.

Based on observations, staff interviews, record reviews, and review of the facility policy titled, Medication Administration-General, the facility failed to ensure the medication error rate was less than 5 percent (%). A total of 28 opportunities were observed, with four errors for two residents (R) (R6 and R11), resulting in an error rate of 14.2 %. This failure had the potential to result in medication not being given in accordance with the physician's orders and had the potential to adversely affect R6 and R11's clinical condition. Findings include: Review of the facility policy titled, Medication Administration-General, dated 2024, revealed the policy guidelines included that medications are to be administered in accordance with a valid prescriber order. The guidelines also instructed the Nurse or Certified Medication Aide (CMA) to read the administration directions on the Medication Administration Record (MAR) and verify the correct medication, dose, and directions for use, prior to medication administration. 1. A review of the clinical record revealed R6 had a physician's order, dated 7/4/2024, for one 81 milligram (mg) tablet of delayed-release aspirin to be administered once per day for a diagnosis of aphasia following cerebral infarction. A review of the electronic Medication Administration Record (eMAR) revealed the aspirin was scheduled to be administered at 9:00 am. Further review of R6's clinical record revealed a physician's order, dated 7/10/2024, for one drop of Artificial Tears 0.5%-0.6% eye drops to be administered to both eyes two times per day for an unspecified disorder of the eye and adnexa. A review of the eMAR revealed the eye drops were scheduled to be administered at 9:00 am and 5:00 pm. There was also a physician's order, dated 8/2/2024, for one 500 mg tablet of divalproex extended release (ER) to be administered orally every 24 hours for a diagnosis of mood disorder. A review of the eMAR revealed the medication was scheduled to be administered at 9:00 am. During an observation of medication pass on 9/4/2024 at 8:32 am, CMA BB failed to administer the delayed-release aspirin as ordered. CMA BB administered a chewable aspirin in error. Observation also revealed CMA BB failed to administer the Artificial Tears eye drops and divalproex oral tablet to R6. During an interview on 9/4/2024 at 10:10 am, CMA BB confirmed she had not administered the eye drops or divalproex medication. 2. A review of the clinical record revealed that R11 had a physician's order, dated 9/2/2024, for one 8.6 mg tablet of senna to be administered every 12 hours for constipation. A review of the eMAR revealed the medication was scheduled to be administered at 9:00 am and 9:00 pm. During an observation of medication pass on 9/4/2024 at 9:15 pm, CMA DD failed to administer the senna as ordered to R11. During an interview on 9/4/2024 at 10:06 am, CMA DD confirmed that R11 should have received the senna during the medication pass.

Based on interviews and record reviews, the facility failed to ensure that the care plan was followed for Activities of Daily Living (ADL) ensuring that care was provided by the appropriate number of staff, to prevent accidents, for one resident (R3), and that the care plan for wound treatments was followed related to treatments being provided as ordered by the physican, for one resident (R5), from a total sample of eight residents. Actual harm was identified to have occurred on 10/9/2023, when a Certified Nursing Assistant (CNA) provided ADL care to R3 by herself, instead of with the required two-person assistance. R3 fell from the bed and sustained a hematoma to the right side of the face. Findings include: 1. Review of the clinical record for R3 revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's, cerebral infarction, and age-related osteoporosis. Review of the care plan revealed that R3 had impaired cognition, a self-care deficit, limited mobility, and was at risk for falls. The fall risk care plan problem included an intervention, dated 1/11/2023, for staff to assist R3 with ADL's and mobility as needed. The limited mobility care plan problem included an intervention, dated 12/17/2021, for staff to provide the appropriate level of assistance to promote the safety of the resident. The self-care deficit care plan problem included an intervention, dated 1/11/2023, for staff to see the ADL POC (plan of correction) for assistance levels. Review of the October 2023 ADL Documentation form revealed that R3 was dependent on staff for bed mobility, transfers, eating, and toilet use. The ADL form also documented that two or more persons physical assistance was provided by staff for the ADL care. Review of the ADL care plan notebook, which was maintained at the North Hall nursing station, revealed that R3 was specified as needing two-person assistance with bed mobility and incontinence care. A review of staff written statements from 10/9/2023 revealed that R3 fell out of bed during the provision of ADL care by one staff person, CNA EE. CNA EE documented in a 10/9/2023 statement that she went to R3's room at 3:00 am for second rounds and R3 was leaning forward and looked uncomfortable. CNA EE decided that R3 needed an adult brief change since she was scratching at the brief. CNA EE raised the bed no higher than the height of her hips and began providing incontinence care to R3 with wipes. The statement documented that CNA EE needed more wipes and when the CNA reached for more wipes with both hands, R3 began slowly moving forward. CNA EE grabbed R3's hip and more wipes and then R3 fell forward (out of bed) towards the door. As R3 was lying on the floor, she was lying on her right side. Review of the 10/9/2023 hospital After Visit Summary documentation revealed that computed tomography (CT) imaging showed a large soft tissue hematoma involving the right scalp and right face. R3 was diagnosed with a traumatic hematoma of the face and returned to the facility on [DATE]. A 10/9/2023 Nurses Note at 6:58 pm documented that R3 had returned to the facility. Swelling and bruising were noted to the right side of the face and right eye. Bruising was noted to the right upper arm and right elbow. During an interview on 11/23/2023 at 10:15 am, the DON confirmed that there was only one person providing care to R3 at the time she rolled out of bed on 10/9/23. When questioned if R3 was supposed to be a two-person assistance for care, DON responded with yes. During an interview on 11/28/2023 at 11:15 a.m., the Director of Nursing (DON) confirmed that the ADL documentation information that was kept in the ADL care plan notebook was also available in an electronic point of care (epoc) form for the CNA's to access via electronic hand-held devices. Cross reference to F689 15650 2. R5 had a care plan with a revision date of 8/31/2023 for skin breakdown: at risk for/actual related to Stage 2 pressure ulcer to left heel with an intervention for treatments/dressings as ordered per physician. Review of the August 2023 eTAR (Electronic Treatment Record) revealed physician's orders on 8/18/2023 to cleanse left heel wound and periwound with normal saline and pat dry, apply skin barrier protective wipe to periwound area, cover with adhesive foam dressing on Monday, Wednesday and Friday. However, there was no documentation that the treatment was done as ordered to the left heel on 8/21/2023, 8/23/2023 and 8/25/2023. Review of the September 2023 eTAR revealed physician's orders for treatment to a pressure ulcer of the sacral region. The order read to clean wound with normal saline, pat dry, clean periwound with skin barrier wipes, apply non-adhesive foam gauze Monday, Wednesday and Friday. However, review of the September eTAR revealed there was no documentation treatment was done as ordered between 9/6/2023 and 9/20/2023 for six of thirteen scheduled days. Review of the October 2023 eTAR revealed the resident had received treatment to the left heel with Di-Dak-Sol 0.0125% topical solution every day from 10/2/2023 through 10/16/2023. There was no documentation treatment was done to the left heel between 10/16/2023 to 10/23/2023. The eTAR indicated a physician's order to cleanse the left heel with normal saline, pat dry, apply skin barrier to periwound, cover with adhesive foam Monday, Wednesday and Friday. Cross refer to F686

Based on interviews and record reviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by the appropriate number of staff, to prevent accidents, for one resident (R3), from a total sample of eight residents. Actual harm was identified to have occurred on 10/9/2023, when a Certified Nursing Assistant (CNA) EE provided ADL care to R3 by herself, instead of with the required two-person assistance. R3 fell from the bed and sustained a hematoma to the right side of the face. Findings include: Review of the clinical record for R3 revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's, cerebral infarction, and age-related osteoporosis. Review of the care plan revealed that R3 had impaired cognition, a self-care deficit, limited mobility, and was at risk for falls. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated that R3 is dependent on staff related to toileting, shower/bathe self, and mobility related to rolling to the left and right, Review of the October 2023 ADL Documentation form revealed that R3 was dependent on staff for bed mobility, transfers, eating, and toilet use. The ADL form included documentation that two or more persons physical assistance was provided by staff for the ADL care. Review of the ADL care plan notebook, which was maintained at the North Hall nursing station, revealed that R3 was specified as needing two-person assistance with bed mobility and incontinence care. Review of Nurses Notes revealed an 10/9/2023 entry that documented Licensed Practical Nurse (LPN) DD was called to R3's room to find the resident lying face down on the floor, on the left side of the bed. Upon examining the right side of her face, bleeding was noted under the eye and the right eye was swollen shut. The cheek bone was also swollen. The nurse's note documented an elevated blood pressure of 184/98 and neurological checks were not within normal limits, with R3 not being able to grasp hand and her pupils were not equal in size. The Nurse Practitioner was notified with orders received to send R3 to the hospital emergency room . Further review of the nurse's note revealed that emergency medical personnel arrived at the facility at 4:15 am and after they examined R3, made a call for R3 to be air-lifted to the emergency room . Review of the 10/9/2023 hospital After Visit Summary documentation revealed that computed tomography (CT) imaging showed a large soft tissue hematoma involving the right scalp and right face. R3 was diagnosed with a traumatic hematoma of the face and returned to the facility on [DATE]. A 10/9/2023 nurse's note at 6:58 pm documented that R3 had returned to the facility. Swelling and bruising were noted to the right side of the face and right eye. Bruising was noted to the right upper arm and right elbow. During an interview on 11/23/2023 at 10:15 am, the Director of Nursing (DON) confirmed that there was only one person providing care to R3 at the time she rolled out of bed on 10/9/2023. When questioned if R3 was supposed to be a two-person assistance for care, the DON responded with yes. During an interview on 11/28/2023 at 11:15 am, the DON confirmed that the ADL documentation information that was kept in the notebook was also available in an electronic point of care (epoc) form for the Certified Nursing Assistants (CNA's) to access via electronic hand-held devices. During an interview on 11/29/2023 at 12:52 pm, LPN DD stated she was at the nursing station and got called into R3's room by CAN EE. Once inside the room, she saw R3 was on the floor, face down. LPN DD stated that she assessed R3, turned her over and saw the blood and called 911 because she knew how serious it was and that R3's blood pressure was elevated. LPN DD stated that it did not take emergency personnel long to get to the facility and once they saw R3 and with her age, they decided to have her air-lifted to the hospital. During an interview on 11/29/2023 at 2:09 pm, CNA FF stated that CNA EE tried to check and change R3 by herself. CNA FF stated that it took two staff members to provide care for R3.

Based on observations, interviews, and record reviews, the facility failed to ensure that pressure ulcer treatments were provided as ordered by the physician for two residents (R1 and R5), and that pressure ulcers were accurately assessed and monitored for two residents (R4 and R5) from a total sample of eight residents. Findings include: 1. Review of the clinical record revealed that R1 was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, type 2 diabetes mellitus, hypertension, cerebral infarction, and peripheral vascular disease. Review of the care plan revealed that R1 had cognitive impairment, limited mobility, a self-care deficit, and skin breakdown. Further review of the clinical record revealed that R1 was hospitalized from 8/27/2023 through 9/11/2023. Review of the electronic August 2023 Treatment Administration Records (TAR's) revealed that prior to the 8/27/2023 hospital admission, R1 had physician ordered wound treatments for a left heel ulcer, left anterior lower leg wound, and excoriated area to the sacrum and buttocks. The left heel ulcer treatment order, dated 8/10/2023, was to cleanse the ulcer and periwound area with normal saline and pat dry. Apply skin barrier protective wipe to the periwound area, apply moist-to-moist gauze dressing to the ulcer, and wrap with roll gauze every Tuesday, Thursday, and Saturday on the day shift. The left anterior lower leg wound treatment order, dated 8/10/2023, was to clean the leg wound and periwound area with normal saline and pat dry. Apply skin barrier protective wipe to the periwound area, apply non-adherent dressing to the wound, and wrap with roll gauze every Tuesday, Thursday, and Saturday on the day shift. The treatment order for the excoriated area to the sacrum and buttocks, dated 8/18/23, was to clean the excoriated area with wound cleanser and normal saline and pat dry. Apply Triad hydrophilic wound dressing every Monday, Wednesday, and Friday on the day shift. Review of R1's Weekly Wound report for July and August 2023 revealed that the left heel ulcer and left leg ulcers were listed as stage 3 pressure ulcers on 7/27/2023. Further review of R1's clinical record, including the electronic August 2023 TAR's revealed that after 8/22/2023, there was no evidence that the wound treatments for the left heel ulcer and left anterior lower leg ulcer were completed as ordered and scheduled on 8/24/2023 and 8/26/2023, prior to the hospital stay on 8/27/2023. There was no evidence that the treatment for the excoriated area to the sacrum and buttocks was completed as ordered and scheduled on 8/23/2023 and 8/25/2023, prior to the hospital stay on 8/27/2023. During an interview on 11/1/2023 at 5:00 pm, Nurse Consultant GG stated that the facility's electronic clinical record system was down from 8/23/2023 through 8/28/2023 and paper TAR's were printed out and used. However, the facility was unable to locate R1's August 2023 printed paper TAR's that would show wound treatments completed prior to R1 going to the hospital on 8/27/23. Nurse Consultant GG also stated that the facility's treatment nurse was out during the time the electronic clinical record system was down, and the charge nurses would have been responsible for providing wound treatments for the residents. During an interview on 11/2/23 at 1:55 pm, Assistant Director of Nursing (ADON) AA stated that she had completed a wound treatment to R1's sacrum before, but she could not remember the exact date and that she might have done a treatment to the sacrum at some point between Monday and Friday (8/21/2023-8/25/23) but could not recall. ADON AA did state that she had never provided wound treatments to R1's legs or feet. During an interview on 11/2/2023 at 2:45 pm, Licensed Practical Nurse (LPN) BB, who was assigned to R1 on the day shift on 8/25/2023 and 8/26/23, stated that he did not provide wound treatments to R1. Further review of R1's clinical record, including the November 2023 electronic TAR's revealed a 11/1/2023 physician's order to clean a wound to the left medial foot with normal saline, apply skin prep to the periwound, and cover the wound with foam dressing every Monday, Wednesday, Friday and as needed on the day shift. Review of the Weekly Wound report for R1 revealed that the left medial foot wound was listed as a stage 2 pressure ulcer on 10/30/2023. During an observation of wound care for R1 on 11/1/2023 at 1:00 pm, a dressing was observed intact to the left medial foot. The treatment nurse stated that she completed the dressing change earlier that morning because the bandage was coming off. During the observation, when R1 was turned and repositioned in bed, and her bed linens changed, the dressing came off the left medial foot ulcer. After the dressing came off, the treatment nurse applied Triad paste to the wound bed and skin prep to the wound edges. She then covered the wound with a foam dressing. However, the physician's ordered treatment for the left medial foot ulcer did not include the use of Triad paste. In addition, the treatment nurse did not clean the wound with normal saline prior to applying the Triad paste, and skin prep, and covering with a foam dressing. 15650 2. Review of the Weekly Wound report for R4 revealed documentation on 7/17/2023 that the resident developed a Stage II pressure ulcer to the left and right buttocks and to the sacrum. Documentation on 8/10/2023 noted the pressure ulcer to the left buttock and the sacrum healed. There was no further documentation of the pressure ulcer to the right buttock since 7/27/2023 when it was described as a Stage II pressure ulcer. On 9/6/2023 the sacrum re-opened as a Stage II that measured 1.6 centimeter (cm) x 2.8 cm x 0.2 cm. However, during an observation of wound care on 11/15/2023 at 10:40 am with the Treatment Nurse, the resident was observed to have two separate Stage II pressure ulcers to the left upper buttock and the right upper buttock. During an interview with the Treatment Nurse on 11/15/2023 at 12:15 pm, she stated the wound measurements on the Weekly Wound report were from the wound on the right buttock. She stated there were no measurements for the left buttock and the wound to the left buttock had been present since October 2023. She also confirmed these wounds were never one wound that had separated into two separate wounds. 3. Review of the Weekly Wound report for R5 indicated the resident developed a Stage II pressure ulcer to the left heel on 8/4/23. Staff continued to document the wound as a Stage II each week through 11/14/2023. However, during an observation of wound care on 11/15/2023 at 11:50 am, the pressure ulcer on the resident's left heel was observed to be an unstageable Pressure Ulcer that was covered with black/gray soft eschar. When the Treatment Nurse was asked if she was staging the wound, she stated the wound was a Stage II. She also stated at that time she thought the dark tissue was the Medi-Honey dressing as she was cleaning the wound and attempted to remove what she thought was the Medi-Honey dressing but was in fact necrotic tissue. During a subsequent interview with the Treatment Nurse on 11/15/2023 at 12:45 pm, she stated that on 11/10/2023 the tissue on the left heel started to look dark. On 11/14/2023 when she measured the wound, she thought the dark tissue was the Medi-Honey dressing. During an interview with the Corporate Wound Nurse on 11/15/2023 at 12:43 pm, she stated the pressure ulcer on the resident's left heel would be considered an unstageable pressure ulcer. Review of the August 2023 Electronic Treatment Record (eTAR) revealed physician's orders on 8/18/2023 to cleanse left heel wound and periwound with normal saline and pat dry, apply skin barrier protective wipe to periwound area, cover with adhesive foam dressing on Monday, Wednesday and Friday. However, there was no documentation that the treatment was done as ordered to the left heel on 8/21/2023, 8/23/2023 and 8/25/2023. Review of the September 2023 eTAR revealed physician's orders for treatment to a pressure ulcer of the sacral region. The order read to clean wound with normal saline, pat dry, clean periwound with skin barrier wipes, apply non-adhesive foam gauze Monday, Wednesday and Friday. However, review of the September eTAR revealed there was no documentation treatment was done as ordered between 9/6/2023 and 9/20/2023 for six of thirteen scheduled days. Review of the October 2023 eTAR revealed the resident had received treatment to the left heel with Di-Dak-Sol 0.0125% topical solution every day from 10/2/2023 through 10/16/2023. There was no documentation treatment was done to the left heel between 10/16/2023 to 10/23/2023. The eTAR indicated a physician's order to cleanse the left heel with normal saline, pat dry, apply skin barrier to periwound, cover with adhesive foam Monday, Wednesday and Friday. During an interview and review of the eTARs with the Treatment Nurse on 11/30/2023 at 10:30 am, she stated that she out sick from 8/19/2023 to 8/30/2023 and the backup Treatment Nurse was out sick during that time as well. She stated the floor nurses would have been responsible for the treatments. She also stated the electronic charting system was down during those dates and they were not able to locate the paper eTARs. She could not give an explanation for the gap in time for the treatment to the sacrum between 9/6/2023 and 9/20/2023. In regards to the lack of documentation for the left heel between 10/16/2023 to 10/23/2023, she was out sick again during that time and the backup Treatment Nurse worked 12 hour shifts and would not be in the facility Monday through Friday. Therefore, the floor nurses would have been responsible for doing the treatments when the backup nurse was not there.

Based on observation, staff interviews, and a review of the facility's policy titled, Cleaning and Sanitizing, the facility failed to demonstrate the proper procedure to wash dishware in the three compartment sink to prevent food borne illness. The facility census was 69, with 67 residents consuming an oral diet. Findings include: Review of the facility policy titled Cleaning and Sanitizing revealed that for three compartment sink, items should be fully submerged in the sanitizer solution per manufacturer guidelines. Review of EcoLab Oasis 146 Multi-Quat Sanitizer Product Specification Document revealed: Expose all surfaces to the sanitizing solution for a period of not less than one minute. Observation on 7/1/2023 at 10:40 a.m. of Dietary Cook BB washing the food processor bowl, blade, and lid in the three compartment sink revealed that she washed the items with soapy water, rinsed and placed all the items in the sanitizing sink for 15 seconds then placed on shelf area to dry. Continued observation revealed a poster hung on the wall in front of the wash sink. The post was labeled EcoLab Wash Procedure, and step five stated to submerge in sanitizer for one minute or as specified by the product label. Interview on 7/1/2023 at 10:40 a.m. with Dietary Cook BB verified that she placed the dishware items in the sanitizing solution for 15 seconds. The cook stated that items are to only be in the solution for 10 seconds. The cook confirmed that the poster hung on the wall for three compartment sink sanitizing indicated submerge for one minute. Interview on 7/1/2023 at 11:00 a.m. with Certified Dietary Manager (CDM) revealed that dishware items should be submerged in the sanitizing solution for 10 seconds. The CDM confirmed that the facility is using EcoLab quaternary sanitizing solution. The CDM did not realize that the manufacturer's recommendation for usage is to submerge items in the sanitizing solution for one minute/60 seconds.

Based on observations, staff interviews, and a review of the facility's policies titled Medication Storage in the Care Center, and Insulin Administration, a review of latanoprost ophthalmic solutions manufacturer packet insert, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored properly for four of five medication carts (South Hall Certified Medication Aide (CMA) cart one, South Hall Nurse cart, South Hall CMA cart two, and North Hall Nurse cart). Findings include: A review of the policy titled Medication Storage in the Care Center, revealed the intent was to ensure medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Guidelines included for medications requiring refrigeration or temperatures between two degrees Celcius (C) (36 degrees Fahrenheit (F) and eight degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. A review of the undated policy titled Insulin Administration, revealed the intent was to ensure insulin is administered correctly and safely. The guidelines included to date all insulin bottles and pens with date of first puncture or date removed from refrigerator and depending on manufacturer's recommendations insulin must be replaced 10 to 56 days after first use. Review of the manufacturer's packet insert for latanoprost ophthalmic solutions revealed that storage instructions were to protect the solution from light and store unopened bottle(s) under refrigeration at two degrees to eight degrees Celsius (C) (36 degrees to 46 degrees Fahrenheit (F)). Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks. Observation on 7/1/2023 at 9:00 a.m. of South Hall Certified Medication Aide (CMA) medication cart one with CMA FF revealed one open container of latanoprost ophthalmic solution 0.005% 2.5 milliliters (ml) (a medication used to treat glaucoma and ocular hypertension) to be stored in the cart without an open or discard date. CMA FF verified there was not an open or discard date on the box or container and revealed she was unsure why the medication was not dated. CMA FF revealed that the nurse who opens the container normally labeled it. She further revealed that all nurses and CMAs should look at the ophthalmic solutions to ensure there was an open or discard date on them prior to administration. Observation on 7/1/2023 at 9:05 a.m. of South Hall Nurse medication cart with Licensed Practical Nurse (LPN) GG revealed one open Novolog Flex Pen 100units/ml (a medication used to treat diabetes mellitus) with an open date of 6/2/2023 and a discard date of 6/30/2023. LPN GG verified the open and discard dates on the Novolog Flex Pen. She revealed she was unsure why the insulin pen was not discarded on the discard date. She revealed that the nurse should check the discard date prior to administering the insulin. Observation on 7/1/2023 at 9:35 a.m. of South Hall CMA medication cart two with CMA AA revealed two containers of unopened latanoprost ophthalmic solution 0.005% 2.5ml to be stored in the medication cart. The label on the box stated to store under refrigeration until opened. CMA AA verified that the ophthalmic drops were not stored under refrigeration according to the manufacturer's recommendations. She revealed that night shift nurses received medications from the pharmacy delivery and stocked the medication carts. Observation on 7/1/2023 at 10:45 a.m. of North Hall Nurse medication cart with LPN HH revealed one open Levemir Flex Touch 300 units/3ml (a medication used to treat diabetes mellitus) to be stored in the cart without an open or discard date. LPN HH verified there was not an open or discard date on the insulin pen. Further observation revealed one open Novolog Flex Pen 100 units/1ml insulin pen with an open date of 5/31/23 and a discard date of 6/29/23. LPN HH verified the open and discard dates on the Novolog Flex Pen. She revealed she was unsure why the Levemir insulin pen did not have an open and discard date on it or why the Novolog insulin pen was not discarded on the discard date. LPN HH further revealed that insulin pens should be dated with an open and discard date when opened and should be discarded on the discard date. She stated that when an insulin pen was opened, the nurse opening the pen should label it. Interview on 7/2/2023 at 9:53 a.m. with the Director of Nursing (DON) revealed her expectations were for medications requiring refrigeration to be stored in the refrigerator as recommended by the manufacturer. She further revealed that her expectations were for ophthalmic medications to be labeled with an open date when opened and discarded on the manufacturer recommended discard date. She revealed her expectations were for insulin to be labeled with an open and a discard date when opened and discarded on the discard date. The DON stated she expected each nurse and CMA to routinely check their assigned medication cart to ensure ophthalmic medications and insulin were labeled appropriately. She further stated that she planned to provide education to nurses and CMAs to ensure ophthalmic medications and insulin were labeled and stored according to the manufacturer's recommendations and were discarded on the discard date. She further revealed that she planned to place identified concerns in the Quality Assurance and Performance Improvement (QAPI).

Based on observation, staff interview, record review, and a review of the facility's policy titled, Intravenous Antibiotic, the facility failed to ensure all nursing staff had the competencies and skill set necessary to provide care for residents receiving intravenous therapy through an Intravenous Infusion Pump for one of two residents (R) (#4) reviewed for intravenous therapy. This failure had the potential for residents to have a decline in health status. Findings include: Review of the undated policy titled, Intravenous Antibiotic, intravenous antibiotics may be administered via a variety of modes, such as: small volume minibags administered intermittently, programmable infusion pumps allowing intermittently intervals, and a keep-vein-open rate between intervals and prefilled disposable antibiotic infusion device. A review of the facility provided Facility Assessment reviewed date 05/22/2023 revealed the facility accepts residents with special treatments - intravenous (IV) medications: Number/Average or Range of Residents - 2. A review of the facility's Skill Checklist - Core Competency form revealed that initials will indicate that the following skills have been successfully demonstrated during peer orientation. These skills represent core nursing competencies and should not be performed until demonstrated to an appropriately trained person. These skills represent those needed for the annual review as well. Intravenous is included on the checklist. A review of the facility's job description for LPN Charge Nurse for Impatient Services revised 3/2022 revealed: Essential Duties and Responsibilities - IV implementation and administration. A review of the facility's job description for RN Nurse Supervisor for Inpatient Services revised 3/2022 revealed: Summary - Responsible for directing nursing care of the patients. Essential Duties and Responsibilities - Monitors the work of other nursing staff care to the unit for thoroughness, makes rounds to provide care to and cleanliness of patients, and implements the educational program. Record review in the Electronic Medical Record (EMR) of the Admission Record for R#4 revealed multiple diagnoses to include infection and inflammatory reaction due to internal right knee prosthesis and Methicillin-resistant Staphylococcus aureus (MRSA) to the right knee. Record review of the admission Minimum Data Set (MDS) for R#4 dated (ARD) of 06/15/2023 revealed a Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating she was cognitively intact, and she had IV medications administered while a resident with a diagnosis as infection and inflammatory reaction due to internal right knee prosthesis. Record review of the care plan in the EMR for R#4 revealed the resident has an infection, new or recently diagnosed administer medications and/or treatment as ordered. Diagnostics as ordered, monitor vital signs, and notify MD. Record review of the Physician's Orders for R#4 revealed an order for R#4 to receive vancomycin 1 gram (gm)/200 milliliters (mL) in dextrose 5 % intravenous piggyback (vancomycin in 5 % dextrose in water) 100 ml intravenously every 24 hours on at 6 a.m. for 37 days. Please allow for the trough to be collected prior to administering medication if the trough is scheduled. Please check the trough schedule prior to administering. Order start date 6/15/2023. A review of the educational in-services provided revealed that the licensed staff did not receive formal training related to the operation/use of intravenous infusion pumps. A review of the Electronic Medication Administration Record (EMAR) revealed that vancomycin 1gm was documented as administered on 7/01/2023 at 6 a.m. Observation and interview on 7/1/2023 at 8:13 a.m. revealed R#4 lying in bed. There was an undated full IV bag of vancomycin 1gm observed hanging on the IV pole. Further observation revealed that the infusion pump was off, and the IV tubing was connected to the resident's Peripherally Inserted Central Catheter (PICC) on the left arm. R#4 stated that the nurse came in and informed her she was starting her IV antibiotic and hung the medicine before the day shift this morning. R#4 further stated that she had surgery on her right knee and now had an infection in the knee, as the reason for the IV medicine she is currently receiving. Interview and observation on 7/1/2023 at 8:30 a.m. with Licensed Practical Nurse (LPN) CC observed LPN CC enter R#4's room, assess her pain level, administer pain medication by mouth, and exit the room. LPN CC returned to R#4's room at 8:41 a.m. and began to disconnect the IV Vancomycin from the PICC line. LPN CC verified that the dose had not been infused, the pump was off, and the IV bag was not dated or timed prior to being hung for administration. LPN CC revealed that the medication was scheduled to be administered at 6 a.m., and she had no idea as to the reason the medication was not infused. LPN CC stated she relieved the night nurse (agency nurse) at 7:15 a.m., but the nurse did not inform her that the medicine was not infused as ordered. LPN CC continues to state she entered R#4's room at approximately 7:45 a.m. but did not notice the antibiotic was not infused and connected to the resident. LPN CC stated that she had received orders on 6/30/2023 from the pharmacy to resume the vancomycin 1gm on 7/1/2023. Interview and observation on 7/1/2023 at 8:44 a.m. with Assistant Director of Nursing (ADON) verified that the vancomycin 1gm still hanging and had not been infused. The ADON reviewed the EMAR and stated that the 6 a.m. dose of vancomycin for 7/1/2023 was documented as administered. The ADON also stated that there was not a progress note to reflect that the medication was not administered and/or that the medical provider was not notified according to the documentation. The ADON revealed that the medication was scheduled to be administered at 6 a.m., and the nurse had one hour before and one hour after the time to administer the dose. The ADON further revealed that the agency night nurse did report to her prior to leaving that she was unable to get the infusion pump to work to administer the dose of IV medication. The ADON stated she was supposed to have checked off on the pump, but she had not done so. ADON stated that she was not sure if the agency nurse knew how to operate the IV pump or had any training in the operation of the infusion pump. In addition, ADON stated that she had worked at the facility since January 2023 and did not have formal training on the use of the IV infusion pump. Interview on 7/1/2023 at 8:54 a.m. with Registered Nurse (RN) EE revealed that she is new to the facility and is shadowing another nurse today. She further stated that she had completed the classroom portion of orientation but had not received any training related to the IV infusion pump at the time of this interview. RN EE stated that she had been a nurse for a long time and was sure she would be able to figure out the operation of the pump. Interview and observation on 7/1/2023 at 9:10 a.m. with Director of Nursing (DON) verified that the IV antibiotic (vancomycin), which was scheduled to be administered at 6 a.m., was still hanging and had not been infused. The DON revealed that the dose should have been dated and timed at the time of being hung for infusion. The DON explained that on 6/29/2023, when the infusion was started, the resident complained of pain at the IV site. The infusion was stopped, and R#4 was sent out to the hospital for further evaluation. The DON revealed that upon return early morning on 6/30/2023, R#4 had a new PICC line in the opposite arm (left), and it was determined the resident had a blood clot in the right arm. The DON further stated that the infusion pump was supplied by the pharmacy, and the nurse had not been trained in the operation of the infusion pump. The DON was unable to program the correct infusion time into the infusion pump for the administration of the medication. After several failed attempts to program the IV infusion pump, DON stated she does not use the pump every day but could Google it or get someone to show her how to operate it. The DON further stated that she had only worked at the facility since October 2022 and was not sure if the nurse had been trained on the operation of the infusion pump. A follow-up interview on 7/01/2023 at 1:04 p.m. with DON revealed that she was not able to locate any documentation of the staff being educated on the usage of the IV infusion pump. The DON provided all the education she had for the night agency nurse and verified that there was no education for the use of the IV infusion pump. The DON also stated that it was her expectation that medications, including intravenous medications, be administered as ordered by the physician. The DON revealed that if the medication was not administered as ordered, the physician should have been notified, and the dose should not have been documented as administered. The DON further revealed that R#4 had MRSA in the right knee, and getting her medication should have been a priority this morning. Interview on 7/2/2023 at 10:54 a.m. with LPN DD revealed that she had worked at the facility for over a year through an agency. LPN DD stated that she had administered IV antibiotics to residents previously at the facility, but the facility did not provide her with any formal education/training for the use of the pump. LPN DD stated that her orientation at the facility consisted of training on electronic records only. Telephone interview on 7/2/2023 at 12:39 p.m. with RN II revealed that she serves as the Educational Coordinator for the facility. She stated that the licensed staff at the facility are nurses who have been hired since she had been at the facility. RN II stated that the licensed staff had been competent in the use of the IV infusion pump by verbalizing the use of the pump. She further stated that there is not always a pump available at the facility to train the staff on its operation physically. RN II revealed there had not been a need to have a representative from the pharmacy conduct an in-service on the use of the pump because there are one-two-three instructions attached to the infusion pump. In addition, RN II stated that she had not observed nurses load the IV tubing or program the infusion pump to ensure compliance with the infusion pump operation. The agency night nurse who worked the night of 6/30/2023 was not available for an interview during this survey.

Based on staff and family member interviews, record review and review of the facility policy titled,Abuse Prohibition the facility failed to ensure that one resident (R A) was free from physical abuse, from a total sample of nine residents. Findings include: The facility had an Abuse Prohibition policy. The policy included a definition of physical abuse as including hitting, slapping, pinching, and kicking. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. During an interview on 9/3/19 at 5:27 p.m., with a family member of RA revealed that the resident (R A) had been hit by a staff member during his stay at the facility and that the facility had terminated the staff member. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/10/18, that documented an allegation of staff to resident abuse. The form included that the allegation involved RA and Certified Nursing Assistant (CNA) A[NAME] A further review of the form revealed the date and time of the incident as occuring on 12/10/18 at 5:45 p.m. and that it was reported at 1:15 p.m. The physician, responsible party and police were notified and CNA AA was suspending pending investigation. A review of the accompanying investigation that included resident interviews, staff statements, body audits and a five day summary conclusion revealed that the allegation was substantiated and CNA AA was terminated on 12/17/18. During an interview on 9/4/19 at 10:30 a.m., the Director of Nursing (DON) confirmed they did terminate CNA A[NAME] The DON stated that LPN BB and CNA AA and that based on what LPN BB stated and what LPN BB demonstrated that she saw they (the facility) terminated CNA A[NAME] Licensed Practical Nurse BB documented in a statement that RA had been going into the hallway in his wheelchair, not cooperating with staff trying to get him to clothe his lower body. The statement documented that the CNA (CNA AA) pushed the resident's wheelchair into his room and the resident raised his hand into the CNA's face. The CNA then balled up her right hand into a fist and hit the resident in the chest. Resident A is documented in the statement as reacting by stating that the CNA was going to jail. LPN BB included that the resident was checked thoroughly and denied any pain and declined further treatment. The Director of Nursing (DON) documented in a written statement that Resident A was interviewed later on 12/10/18 and denied being hit or abused by staff. In addition to terminating CNA AA, the facility implemented additional interventions. A 100% audit with skin assessments was completed on all residents residing on the unit with RA on 12/10/18. Immediate education was provided on patient abuse and proper reporting procedures to the charge nurse and CNA's on 12/10/18. Abuse information was also emailed to the staffing agency that employed LPN BB on 12/11/18 for disbursement.

Based on staff and family interviews, record review, and review of the facility policy titled, Abuse Prohibition policy the faciilty failed to ensure that an allegation of physical abuse was reported timely for one resident (A), from a total sample of nine residents. Findings include: The facility had an Abuse Prohibition policy. The policy included a definition of physical abuse as including hitting, slapping, pinching, and kicking. The policy also included a list of persons included as mandated reporters. The list included employees of public or private agency engaged in professional health related services to elder persons or disabled persons. The Skilled Inpatient Services Reporting and Investigation Abuse policy included that once a complaint or situation is identified involving alleged mistreatment, nelgect, or abuse, the incident will be immediately reported. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. During an interview on 9/3/19 at 5:27 p.m., with a family member of RA revealed that the resident had been hit by a staff member during his stay at the facility and that the facility had terminated the staff member. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/10/18, that documented an allegation of staff to resident abuse. The form included that the allegation involved RA and Certified Nursing Assistant (CNA) A[NAME] A further review of the form revealed the date and time of the incident as occuring on 12/10/18 at 5:45 p.m. However, the form also included that the incident was reported at 1:15 p.m. The physician, responsible party and police were notified and CNA AA was suspended pending the investigation. A review of the accompanying investigation that included resident interviews, staff statements, body audits and a five day summary conclusion revealed that the allegation was substantiated and CNA AA was terminated on 12/17/18. Licensed Practical Nurse (LPN) BB documented in a statement that RA had been going into the hallway in his wheelchair, not cooperating with staff trying to get him to clothe his lower body. The statement documented that the CNA pushed the resident's wheelchair into his room and the resident raised his hand into the CNA's face. The CNA then balled up her right hand into a fist and hit the resident in the chest. Resident A is documented in the statement as reacting by stating that the CNA was going to jail. LPN BB included that the resident was checked thoroughly and denied any pain and declined further treatment. During an interview on 9/4/19 at 2:15 p.m., the Director of Nursing (DON) confirmed that the incident occurred on the night shift (12/9/18 11:00 p.m. to 12/10/18 7:00 a.m.) when LPN BB ( an agency nurse) and CNA AA were working but that she (the DON) was not made aware of the incident until 1:15 p.m. on 12/10/18. The DON stated that LPN BB reported it to LPN CC later that day by phone and LPN CC immediately contacted her. The DON stated that LPN BB told her that she had never been in a situation like that before and did not know what to do. During a subsequent interview on 9/4/19 at 4:50 p.m., the DON stated that LPN BB should have reported the allegation of abuse sooner. A review of testing documentation, dated 4/27/18, provided by LPN BB's staffing agency included questions regarding abuse reporting and examples of abuse, indicating that abuse reporting information had been provided.

Based on observation, record review, and staff interview, the facility failed to store chemicals so that they were inaccessible to cognitively impaired residents in one housekeeping closet on one of two nursing units (Camellia Cove Community). 23 residents resided on the Camellia Cove Community, and the sample size was 30 residents. Findings include: Observation on 10/22/18 at 12:46 p.m. in the Environmental Services Closet between rooms [ROOM NUMBERS] in the locked Camellia Cove Community unit revealed that the closet was unlocked. Further observation revealed that there was a housekeeping cart in the hallway several rooms down, but the housekeeper was not seen in the hall. Continued observation revealed that resident (R) #26 was in his wheelchair outside of his room across from this unlocked closet. Review of R#26's Annual Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 5 (a score of 0 to 7 indicates severe cognitive impairment), and needed extensive assistance for locomotion on the unit. Observations inside the Environmental Services Closet at this time revealed that there were two wire shelf carts which contained four shelves each. Observation of the contents of the cart on the right side of the closet on the top shelf revealed that it contained the following chemicals: -3 full 64-ounce (oz) jugs of Sani-Chem Odor Counteractant -1 full 64-oz jug of Sani-Chem Broad-Cide Plus -1 full 64-oz Sani-Chem Mega Mop jug -2 full 64-oz Osceola Glass Cleaner jugs -1 full 64-oz Sani-Chem Non-Acid Bathroom Cleaner jug -1 full 64-oz Sani-Chem Mega Shield Spray Buff and Floor Restorer jug Observation on the bottom shelf of the cart on the left side of the closet was a plastic bucket without a lid that contained multiple clear plastic wrapped pod-like packages. The labeling on the bucket revealed that it contained: -[MEDICATION NAME] Conditioner/Odor Counteractant, 90 water-soluble packets. The bucket was approximately three-fourths full of these packets. During interview with the Environmental Services Supervisor on 10/22/18 at 12:55 p.m., she verified that the door to the Environmental Services Closet was unlocked, and verified that the closet contained the chemicals listed above. She stated during continued interview that this closet should always be kept locked. She further stated that there was a problem with this closet's lock, because if the door was locked by using a key from the outside of the door, that the door would unlock when the key was turned to remove it from the lock. She stated during further interview that the closet had to be locked from the inside before closing to the door to prevent this from happening. Review of Safety Data Sheets provided by the Environmental Services Supervisor revealed the following cautionary statements: [MEDICATION NAME] Condition/Odor Counteractant: Hazards Identification: Serious eye damage/eye irritation. Broad-Cide Plus: Identification: Quaternary Ammonium Chlorides, disinfectant. Hazards Identification: Toxic, corrosive danger. Causes severe [MEDICAL CONDITION] eye damage. Toxic in contact with skin. Harmful if swallowed. Glass Cleaner: Identification: Multi-Surface cleaner. For industrial use. Hazards Identification: Causes serious eye irritation. Non-Acid Bathroom Cleaner: Hazards Identification: Causes severe skin burn and eye damage. Do not breathe spray or mists. Odor Eliminator: Hazards Identification: Causes serious eye irritation. Causes skin irritation. Mega Mop: Recommended Use: Neutral floor cleaner. For industrial use. Hazard Statements: Causes mild skin irritation. Causes serious eye irritation. Mega Shield: Identification: Water-based alkali detergent. Floor cleaner/restorer. Hazard Statements: Causes serious eye damage and skin irritation. During interview with the Administrator on 10/23/18 at 7:53 a.m., he stated that they replaced the lock on the environment closet on the Camellia Cove Community so that it locked automatically when the door was closed. During interview with the MDS Coordinator on 10/25/18 at 9:10 a.m., she stated that the facility had two units, North and South, and that the South unit was comprised of the locked Camellia Cove Community, which was a dementia care unit. The MDS Coordinator provided a Census Report dated 10/24/18, and stated during interview that the residents circled on the report had a BIMS score of less than 8 indicating cognitive impairment, and that they were independently mobile without staff assistance. Review of this Census report revealed that there were ten residents on the South wing (Camellia Cove Community) that met the criteria for being cognitively impaired and independently mobile, including R#26. During interview with Certified Nursing Assistant AA on 10/25/18 at 9:47 a.m., she stated that R#26 was able to get around without staff assistance.

Based on observation, record review and staff interview, the facility failed to promote care in a manner that maintained dignity related to a care sign posted in one resident (R) (A) room. The sample size was 30 residents. Findings include: Observations on 10/23/18 at 3:05 p.m., 10/24/18 at 8:00 a.m., and 10/24/18 at 1:25 p.m. revealed a sign posted above the bed which read that R A is a patient of hospice care. The sign included the contact information and to contact for all emergency/non-emergency care notification. A card with the chaplain's contact information was posted as part of the hospice sign. Review of the Physician Order's dated 9/4/18 revealed R A with an order for [REDACTED].>Interview with Hospice Registered Nurse (RN) DD on 10/24/18 at 1:25 p.m. revealed that the hospice company placed the sign above R A's bed. RN DD stated that they started hanging the signs above resident's beds because of an issue where some facilities were not communicating well with the hospice team. RN DD removed the sign at this time and revealed that she had not thought about it being an issue of dignity or privacy. During an interview on 10/25/18 at 9:51 a.m., family of R A revealed that if the resident was aware, she would not want a sign hanging above the bed displaying that she was receiving hospice services. Interview with the Assistant Director of Nursing (ADON) on 10/25/18 at 11:02 a.m. revealed that she was not aware that the sign was posted above the bed. ADON stated that she would not expect staff to leave the sign posted in the resident's room and that the sign should be removed. Review of the policy titled Skilled Inpatient Services - A Comprehensive Patients' Rights Program updated (MONTH) (YEAR) revealed Procedural Guidelines - A Comprehensive Patient's Rights program includes: 4. Privacy and confidentiality of information

Based on observation, record review and staff interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided related to shampooing hair for one resident (R) #35. The sample size was 30 residents. Findings include: Review of the clinical record revealed R#35 was admitted with diagnoses, including but not limited to, presence of artificial left hip joint, [MEDICAL CONDITION], heart failure, diabetes mellitus, dementia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#35 Brief Interview for Mental Status (BIMS) score was 3 indicating that resident was cognitively impaired. R#35 was assessed as requiring extensive assistance of 2 persons to physically assist with personal hygiene and bathing. Review of one of the care plans for R#35 related to activities of daily living (ADL's) dated 3/29/18 stated that R#35 required help to perform ADL's related to arthritis, pain in legs, left hip arthroplasty with an intervention including but not limited to provide assistance with ADL's. Review of the Facility's 3-11 Assignment Sheet revealed R#35 bath times are Tuesday, Thursday and Saturday along with nail care and that shaving was to be provided. Review of the Beauty and Barber Services provided at the facility revealed there was no record of services provided for R#35 in (MONTH) of (YEAR) through (MONTH) of (YEAR). Review of the Certified Nursing Assistant (CNA) ADL information from the Plan of Care (COP) documentation revealed that there is no documentation specifically related to R#35 hair being shampooed during bath. Observation on 10/22/18 at 11:45a.m. of R#35 revealed she was sitting up in bed alert and able to communicate verbally with simple questions and answers. R#35 hair was observed as oily, straight, greasy looking and lying flat to her scalp. Interview with R#35 at the same time of this observation revealed she wants her hair shampooed. R#35 continued to state that she usually gets her hair shampooed when the beautician comes to the facility but she has not seen the beautician in 2-3 weeks. R#35 stated she has informed staff that she wants her hair shampooed because it has not been shampooed for several weeks but her hair has not been done yet. Observation on 10/23/18 at 8:30 a.m. and 1:00 p.m. of R#35 revealed that her hair continued to be greasy, straight and lying flat against her head. Interview on 10/24/18 at 10 a.m. with Certified Nursing Assistant (CNA) CC and she stated R# 35 gets her bath on the 3-11shift and should get her hair shampooed at that time unless she refused and if she refused it will be documented. During an Interview on 10/25/2018 at 8:30 a.m. with Registered Nurse, (RN), BB she confirmed that R#35 hair is shampooed by the beautician that comes to the facility. RN, 'BB' continued to state that the beautician has been not been to the facility for weeks and that she cannot say that R#35 hair has been shampooed. She stated that her expectations are for residents to get their hair shampooed on their bath days and as needed and if a resident refuse to get their baths or hair shampooed, the assigned staff should document the refusal with the adl documentation for that shift which will alert the nursing staff. She stated resident is assigned to get baths on the 3:00 p.m. -11p.m. shift on Tuesdays, Thursday and Saturday but could not say for sure that R#35 hair had been shampooed.

Based on observation and staff interviews the facility failed to display and accurately report correct nurse staffing data. The facility census was 68 residents. Findings include: During tour of facility on 10/24/18 at 3:36 p.m. the daily nurse staffing hours could not be found posted in the facility. During an interview and observation on 10/25/18 at 10:37 a.m. with the Staffing Coordinator it was reported that the nurse staffing information should be posted by the time clock. However, observation at the time clock revealed that the staffing information was not posted. During an interview and observation on 10/25/18 at 10:39 a.m. with the Assistant Director of Nursing (ADON), who is also the acting Director of Nursing (DON), revealed that the staff posting information should be by the time clock. However, observation revealed that the staff posting was not posted at the time clock. The ADON reported that she would get copies of staffing information, but the information should have been posted by the time clock. Interview on 10/25/18 at 10:52 a.m. with ADON, revealed that ultimately it is her responsibility to assure that the staffing hours are posted daily. The ADON reported that the staffing information is discussed in the morning meetings daily, but that she failed to post the form. Upon review of the form titled Daily Staffing Census Sheet the form was found to not be complete as it did not have the facility name listed on it.

Based on resident and staff interviews, and review of thefacility Procedure Guidelines titled Patient Trust Fund; section 9 page 1. The facility failed to provide residents who have personal funds accounts, with the facility, with a quarterly financial statement in a timely manner. This deficient practice has the potential to affect all residents who have a personal funds account managed by the facility. The resident census sample was 81. Findings include: Interview with resident (R) # 92 on 10/16/17 at 3:20 p.m. revealed that he has not received a quarterly statement from the financial controller notifying him of his quarterly financial activity. The resident has a Brief Interview for Mental Status (BIMS) score of 15 indicating he is capable of reviewing his personal funds quarterly statement. Interview with the Financial Controller on 10/19/17 at 9:29 a.m. revealed she does not offer the resident a quarterly statement or a financial receipt after he withdraws funds from his account. The financial controller confirmed at this time that she does not offer this resident R92 or any other resident with a personal funds account a quarterly statement or a receipt after financial transactions. During an interview with the Financial Controller on 10/19/17 at 12:05 p.m. the Financial Controller confirmed quarterly statements have not been mailed out to resident family representatives or handed out to residents since June 2016, the financial controller confirmed if a family representative calls and asks for a balance she will verbalize the account balance to the representative and or/resident. The financial controller stated at this time that she does not mail out quarterly statements on a regular basis secondary to being the only person handling finances. Review of the facility Quarterly Statement log book revealed there have not been any quarterly statements printed or mailed out or placed in the quarterly statement log book for review since June 2016. Review of Patient Trust Fund Guidelines revealed quarterly statements must be provided in writing within thirty (30) days after the end of the quarter, statements should be put in a binder in alphabetical order and have the resident sign his/her statement acknowledging accuracy of statement; if the resident is unable to sign, make a copy and mail to the responsible party for signature. Stamp on the original that it was mailed and put the date mailed. The facility failed to provide residents and or resident responsible parties with quarterly financial statements according to patient trust fund guidelines.

Based on record review, review of the facility Diagnostic and Monitoring Services Procedural Guidelines and staff interview, the facility failed to obtain a [MEDICATION NAME] level as ordered by the physician for one (1) resident (R) (R#15) of twenty (20) sampled residents. Findings include: Review of the medical record for R#15 revealed that she developed unavoidable Deep Tissue Injuries (DTIs) on her bilateral heels on 8/1/17. Continued review revealed that the Registered Dietician (RD) assessed the resident on 8/3/17 and recommended that staff obtain a [MEDICATION NAME] level and if the level was abnormally low, to initiate Prostat (a protein supplement) 30 cubic centimeters (ccs.) for thirty (30) days to aid in wound healing. Licensed nursing staff had notified the physician and written the order. However, continued review of the medical record revealed that there was no indication that the [MEDICATION NAME] level was obtained or that the Prostat was initiated. Review of the laboratory tests obtained on 10/3/17 revealed an [MEDICATION NAME] level that was slightly low at 3.3 (normal range was between 3.6-5.7) and a Total Protein level that was normal indicating that the resident had sufficient protein stores for wound healing. Interview with the Director of Nursing (DON) on 10/19/17 at 10:05 a.m. revealed that she had notified the laboratory service and confirmed that the [MEDICATION NAME] had not been obtained as ordered on [DATE]. Continued interview revealed that the licensed nurse who received the order from the physician was responsible for writing it in the Lab Book and the laboratory technician who came the next morning, reviewed the Lab Book and obtained the bloodwork for the lab levels listed in the book. The DON stated that the nurse who received the order from the physician on 8/3/17 no longer worked at the facility. The DON confirmed at that time that the [MEDICATION NAME] level had not been written in the Lab Book. Further interview revealed that the 11:00 p.m. to 7:00 a.m. shift nurse was responsible for checking all of the residents' medical records to ensure that physician orders [REDACTED]. She stated at that time that the Resident Care Coordinator (RCC) was responsible for ensuring that all physician orders [REDACTED]. Interview with Licensed Practical Nurse/Resident Care Coordinator (LPN/RCC) LL on 10/19/17 at 12:17 p.m. revealed that the nurse who received the order from the physician was responsible for writing it in the Lab Book. Continued interview revealed that she was responsible for checking the Lab Book for any laboratory tests that were ordered so that she knew to look out for the results. Continued interview revealed that she did not check the Lab Book daily and if the nurse failed to write the laboratory test in the Lab Book, she would not know to look out for the results. Review of the facility Diagnostic and Monitoring Services Procedural Guidelines revealed that orders for lab and diagnostic services should be carried out as instructed by the physician's orders [REDACTED].>During the survey the resident was observed in bed or in her wheelchair with pressure relieving devices in place.

Based on staff interview and record review, the facility failed to hold a medication per Physician ordered parameters and failed to address constipation as ordered for one resident (#92) from a total sample of thirty-four (34) residents. Findings include: Resident #92 with a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Review of the clinical record, including the Medication Administration Records (MAR's) and interdisciplinary notes revealed that licensed nursing staff failed to hold the [MEDICATION NAME] for a systolic blood pressure SBP) less than 110 on the following dates in May and June 2016: May 2016 5/10/16 at 5p.m. for a systolic blood pressure of 100 5/14/16 at 5p.m. for a systolic blood pressure of 92 5/20/16 at 5p.m. for a systolic blood pressure of 96 5/21/16 at 5p.m. for a systolic blood pressure of 108 5/25/16 at 5p.m. for a systolic blood pressure of 107 5/27/16 at 5p.m. for a systolic blood pressure of 100 June 2016 6/2/16 at 5p.m. for a systolic blood pressure of 103 6/3/16 at 5p.m. for a systolic blood pressure of 109 6/6/16 at 5p.m. for a systolic blood pressure of 100 6/18/16 at 5p.m. for a systolic blood pressure of 101 6/19/16 at 5p.m. for a systolic blood pressure of 90 6/20/16 at 5p.m. for a systolic blood pressure of 105 6/24/16 at 5p.m. for a systolic blood pressure of 107 Resident #92 also had a care plan since 10/27/15 for being at risk for constipation related to medications with an intervention for nursing staff to observe for the frequency of bowel movements and administer medications as ordered. A medical record review of the physician's orders [REDACTED]. The orders included 30 milliliters (ml) of Milk of Magnesia as needed for constipation, up to four doses per month and one 10mg [MEDICATION NAME] suppository as needed for constipation, up to four doses per month. During an interview on 7/7/16 at 11a.m., Licensed Practical Nurse (LPN) BB stated that the nurses reviewed the Bowel Movement Elimination Records daily and if a resident had not had a bowel movement for three days, they would administer a laxative. During an interview on 7/7/16 11:05 a.m., Resident Care Coordinator (RCC) AA also stated that the nurses review the Bowel Movement Records daily and if a resident has not had a bowel movement for three days, the nurse would administer medication on the fourth day. RCC AA also stated that the nurses would document the intervention on the MAR and/or in the nurse ' s notes. A review of the Bowel Movement Elimination Record for resident #92 revealed that the resident did not have a bowel movement for five days in May 2016, from 5/21/16 through 5/25/16. However, there was no evidence in the clinical record that nursing staff addressed and medicated the resident as ordered when there was no evidence that the resident had a bowel movement. Post survey interview during the QA process on 07/13/16 at 3:17 p.m. with LPN DD revealed that DD is the regular LPN for resident #92 on the evening shift and is the nurse usually responsible for administering resident #92 ' s evening medications including the evening dose of [MEDICATION NAME] 6.25mg. Review of the Medication Administration Records (MARs)for the months of May and June with LpN DD confirmed that resident #92 ' s Systolic Blood pressure was less than 110 at 5:00 p.m. for the following dates : 05/10/16, 05/14/16,05/20/16, 05/21/16, 05/25/16, 05/27/16, and 06/02/16, 06/03/16, 06/06/16, 06/18/16, 06/19/16, 06/20/16, 06/24/16 and LpN DD confirmed that [MEDICATION NAME] 6.25mg was documented as being administered for those same dates. LpN DD stated the [MEDICATION NAME] was documented as being administered each of the dates listed but that it should not have been. Continued Post survey interview with LPN DD , at this same time, confirmed that resident #92 did not have a bowel movement from 05/21/16 - 05/25/16. LPN DD confirmed that the facility policy is that if a resident has not had a BM in three days that the nurse administers a laxative per the Physician order [REDACTED].#92 did not had a BM and was not administered a laxative at any time from 05/21/16 - 05/25/16 but that resident #92 should have been administered a laxative. Post survey interview during the QA process on 07/13/16 at 3:53 p.m. with the DON revealed that May and Junes MARs were reviewed with the DON and the DON confirmed that for the following dates: 05/10/16, 05/14/16,05/20/16, 05/21/16, 05/25/16, 05/27/16, and 06/02/16, 06/03/16, 06/06/16, 06/18/16, 06/19/16, 06/20/16, 06/24/16 resident #92 ' s SBP was less than 110 and that [MEDICATION NAME] 6.25 mg was administered when it should have been held. The DON stated that resident #92 did not experience any negative outcomes. DON stated that they do not have a policy or procedure in place for administering anti-hypertensive medication. Continued post survey interview during the QA process with the DON, at this same time, confirmed that resident #92 did not have a bowel movement from 05/21/16 - 05/25/16. The DON confirmed that the facility policy is that if a resident has not had a BM in three days that the nurse administers a laxative per the Physician protocol order. The DON reviewed the MAR for the month of May and confirmed that resident #92 that it was documented that resident #92 did not have a BM at any time from 05/21/16 - 05/25/16 and there was no documentation that the resident had been administered a laxative but that resident #92 should have been administered a laxative.

Based on record review and staff interviews the facility failed to hold a medication per physician ordered parameters as care planned and failed to address constipation as care planned for one resident (#92) from a total sample of thirty-four (34) residents. Findings include: Resident #92 had a care plan since 10/27/15 for being at risk for cardiac complications related to hypertension. The care plan problem included an intervention for licensed nursing staff to check vital signs as indicated and administer medications as ordered. There was a physician's orders [REDACTED]. However, a review of the clinical record revealed that licensed nursing staff failed to hold the [MEDICATION NAME] for a systolic blood pressure less than 110 for six times in May 2016 and seven times in June 2016. This was confirmed by LPN DD on 07/13/16 at 3:17 p.m. and confirmed by the DON on 07/13/16 at 3:53 p.m. Resident #92 also had a care plan since 10/27/15 for being at risk for constipation related to medications. The care plan included an intervention for nursing staff to observe the frequency of bowel movements and administer medications as ordered. However, there was no evidence in the clinical record that nursing staff monitored and medicated the resident as ordered when there was no evidence that the resident had had a bowel movement for five days in May 2016 (5/21/16 through 5/25/16). This was confirmed by LPN DD on 07/13/16 at 3:17 p.m. and confirmed by the DON on 07/13/16 at 3:53 p.m. Cross-refer to F309.

Based on observation, record review, family and staff interviews, it was determined that the facility failed to provide oral/dental care to one resident (Q) from a sample of thirty-four (34) residents. Findings include: Record review for resident Q revealed the facility completed a Quarterly Minimum Data Set (MDS) on 4/6/16 and assessed the resident Q as requiring extensive assistance with personal hygiene including oral and dental care. Resident Q had a plan of care since 2/4/13 requiring assistance with activities of daily living related to Alzheimer ' s, cognitive impairment and limitations in functional status. Although the plan of care did not have specific interventions to address oral or dental care, there was an intervention to assist with activities of daily living, as needed, which includes oral and dental care. During observations of resident Q s dentures on 7/6/16 at 10:34 a.m. and 7/7/16 at 9:15 a.m., food debris and a thick white substance was observed in between the teeth of the dentures. During an interview with the resident Qs family member R on 7/6/16 at 10:34 a.m., the family member stated that the staff do not clean resident Q ' s dentures and that R has to clean the dentures every day when he/she visits because the dentures are so dirty. During an interview with Certified Nursing Assistant (CNA) CC on 7/8/16 at 9:00 a.m., CC stated that when he/she first started taking care of the resident, CC didn't know the resident had dentures. CC stated that the resident's family member usually cleans the dentures when the family member visits the resident. The CNA stated he/she knows what to do for the resident because they have a short meeting every morning discussing what needs to be done for the residents. She stated that there was not a specific place to document oral/dental care. During an interview with the Director of Nursing on 7/8/16 at 10:10 a.m., she stated that she would expect the 3 p.m.-11 p.m. or the 11 p.m. -7 a.m. shift to remove the resident's dentures, clean them and place the dentures in a denture cup to soak overnight. She stated the facility did not have policy and procedure for the care of dentures.