Every finding on record at Mount Notre Dame Health Center

Based on interview, medical record review, and facility policy review, the facility failed to submit a new Level I Pre-admission screening and resident review (PASARR) when required for one (#4) of one sampled resident reviewed for PASARRs. The census was 39. Findings included: Review of an admission record revealed the facility admitted Resident #4 on 03/30/22. According to the admission record, the resident had a medical history that included diagnoses of anxiety disorder (onset 09/16/22), dementia (onset 10/01/22), major depressive disorder (onset 09/21/23), and delusional disorders (onset 11/06/24). Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/07/24, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS assessment revealed the resident had active diagnoses to include anxiety disorder, depression, and psychotic disorder. Review of Resident #4's medical record revealed no evidence to indicate a level I PASARR screening was completed after the resident received new mental illness diagnoses. During an interview on 11/13/24 at 10:51 A.M., Social Worker (SW) #250 indicated she was responsible for resident PASARRs and indicated a resident review was done if there was a significant change or if a mental health diagnosis was added. SW #250 stated the resident review was for updates on the PASARR identification screening form. SW #250 indicated if the resident obtained a new mental health diagnosis, then a new resident review was completed at that time. SW #250 stated she completed a resident review for Resident #4 on 11/12/24 because the resident's prior PASARR did not have the resident's current mental illness diagnoses on it. SW #250 indicated the dates the resident obtained the mental health diagnoses were on the chart on the medical diagnoses list. SW #250 indicated the PASARR should have been resubmitted when the resident was diagnosed with the mental health diagnoses. During an interview on 11/13/24 at 12:27 P.M., the Director of Nursing (DON) indicated SW #250 was responsible for the PASARR process. The DON indicated she did not know much about the PASARR protocols, but if there was a regulation then she expected it to be followed. During an interview on 11/13/24 at 12:56 P.M., the Administrator indicated SW #250 was responsible for the resident PASARRs. The Administrator stated she expected for a Level I PASARR to be submitted when a resident obtained a new mental illness diagnosis. Review of a facility policy titled, PAS/RR [PASARR] Behavioral Health Services, revised 08/2024, indicated, the Social Worker or her designee will initiate a PAS/RR in the [name] system when a [resident] is being admitted to the facility from the community; when a [resident] is admitted to the facility from another facility and this document was not sent in with other transfer documents, or when a [resident] has a significant change in condition (either improvement or decline) and has indications of serious mental illness.

Based on interviews, medical record review, and facility policy review, the facility failed to follow vital sign parameters when administering blood pressure medications for two (#25 and #33) of five sampled residents reviewed for unnecessary medications. The census was 39. Findings included: 1. Review of an admission record indicated the facility admitted Resident #25 on 09/18/23. According to the admission record, the resident had a medical history that included diagnoses of congestive heart failure, hypertension (HTN), and atrial fibrillation. Review of a significant change in status Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/07/24, revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Review of Resident #25's care plan included a focus area, revised 08/01/24, that indicated the resident was at risk for complications related to adverse effects of medications used to treat chronic heart failure and HTN as well as changes in blood pressure. Interventions directed staff to administer medications and to check vital signs per the physician's order and to watch for complications related to a blood pressure below the parameters set by the physician. Review of Resident #25's order summary report which contained active orders as of 11/12/24, revealed an order dated 07/08/24 for metoprolol tartrate (an antihypertensive medication) oral tablet 25 milligrams (mg), give one tablet by mouth two times a day for HTN, with instructions to hold if the systolic blood pressure SBP was less than 110 millimeters of mercury (mmHg) or if the diastolic blood pressure (DBP) was less than 60 mmHg. Review of Resident #25's medication administration record (MAR) for the timeframe of 10/01/24 to 10/31/24, revealed evidence to indicate staff administered metoprolol tartrate to the resident when the resident had a DBP of 56 mmHg on 10/18/24, 57 mmHg on 10/24/24, and 58 mmHg on 10/26/24. Review of Resident #25's MAR for the timeframe of 11/01/24 to 11/30/24, revealed evidence to indicate staff administered metoprolol tartrate to the resident when the resident had a DBP of 54 mmHg on 11/04/24. During an interview on 11/12/24 at 2:50 P.M., Licensed Practical Nurse (LPN) #1 stated if vital sign parameters were included in a medication order, she checked the resident's vital sign prior to administering a medication and held the medication if the resident's blood pressure did not meet the criteria to administer the medication. LPN #1 stated she administered Resident #25's metoprolol tartrate on 10/24/24 because the resident's SBP was within an acceptable range even though the DBP was not. During an interview on 11/13/24 at 9:11 A.M., LPN #2 stated when she administered blood pressure medications with parameters, she checked the resident's blood pressure, and if the reading was below the parameter set by the physician to hold the medication, she did not administer the medication. LPN #2 stated on 11/04/24 she administered Resident #25's metoprolol even though the resident's DBP was below the specified parameter. Per LPN #2, the purpose of including a blood pressure parameter in a medication order that lowered a resident's blood pressure was to make sure the resident's blood pressure did not get too low to where the resident became symptomatic of low blood pressure. 40141 2. Review of an admission record indicated the facility admitted Resident #33 on 04/25/23. According to the admission record, the resident had a medical history that included a diagnosis of HTN. Review of a quarterly MDS assessment, with an ARD of 10/23/24, revealed Resident #33 had a BIMS score of zero, which indicated the resident had severe cognitive impairment. Review of Resident #33's order summary report, that contained active orders as of 11/12/24, contained an order dated 03/06/24, for metoprolol succinate extended release (antihypertensive) 25 mg to administer 12.5 mg by mouth one time a day, with instructions to hold if the resident's SBP was less than 120 mmHg and/or the heart rate was less than 60 beats per minute. Review of Resident #33's MAR for the timeframe 10/01/24 to 10/31/24, revealed documentation that indicated staff administered metoprolol succinate 12.5 mg when the resident's SBP was less than 120 mmHg on 10/11/24, 10/28/24, and 10/30/24. Review of Resident #33's MAR for the timeframe 11/01/24 to 11/30/24, revealed documentation that indicated staff administered metoprolol succinate 12.5 mg when the resident's SBP was less than 120 mmHg on 11/02/24. During an interview on 11/13/24 at 9:11 A.M., LPN #2 stated if the vital signs were under the parameter, then she would hold the medication and document in the progress note that the medication was withheld. LPN #2 indicated it was on the nurse to catch it if the blood pressure was outside of the parameters. LPN #2 reviewed Resident #33's MAR for 10/11/24 and 10/30/24 then indicated she signed the metoprolol succinate 12.5 mg as administered so the medication would have been administered. LPN #2 stated the purpose of the parameter was so the blood pressure did not go too low and the resident become symptomatic of low blood pressure. During an interview on 11/13/24 at 9:44 A.M., Pharmacist #375 stated the purpose of including a parameter with a blood pressure medication order was to ensure a resident's blood pressure stayed within the range the physician felt was safe for the resident. Pharmacist #375 stated metoprolol tartrate acted to lower the blood pressure, and if it was administered when a resident's blood pressure was already low, it could cause tiredness, dizziness, and other unwanted adverse effects. During an interview on 11/13/24 at 11:38 A.M., Physician #300 stated the purpose of including parameters with medications such as metoprolol tartrate that lowered blood pressure was to prevent lowering a resident's blood pressure further to prevent any adverse effects. Per Physician #300, if a resident's blood pressure reading was already low, administering that medication could lower it further, which could cause adverse effects on a resident's desired blood pressure or heart rate. During an interview on 11/13/24 at 12:28 P.M., the Director of Nursing (DON) stated she expected the nurses to hold a medication if the resident's vital signs were outside the parameters outlined in the physician's order. During an interview on 11/13/24 at 12:56 P.M., the Administrator stated she expected nursing staff to follow the policies for following parameters under the guidance of the DON. Review of a facility policy titled, Administering Medication, revised 05/2024, indicated, medications shall be administered in a safe and timely manner, and as prescribed. The policy specified medications must be administered in accordance with the orders, including any required time frame.

Based on observation, staff interview, and review of facility policy, the facility failed to label, date, cover and discard outdated foods items from the walk-in refrigerator and freezer. This had the potential to affect all 36 residents who resided in the facility and receive food from the kitchen. Findings include: On 09/03/19 at 8:16 [NAME]M., an initial tour of the kitchen was conducted with Dietary Supervisor (DS) #100. During the observation the following concerns were verified by DS #100: a. In the freezer there was a bag of steak fries with no date of opened or a use by date. b. In the freezer there was a bag of fish with no date of opened or a use by date. c. In the freezer there was a ham rewrapped with no date or used by date. d. In the freezer there were eight bags of soup vegetables with no date or used by date. e. In the refrigerator there was a tray with 13 slices of apple spice cakes on a cart that were uncovered with no date or used by date. f. In the refrigerator on a tray there were seven cream puffs on a cart uncovered with no date or used by date. g. In the refrigerator there were a bag of carrots with a prep date of 08/25/19 and a used by date of 09/01/19 Interview on 09/03/19 at 8:30 [NAME]M., DS #100 stated foods should be covered, labeled and dated. 2. Observation on 09/04/19 at 3:00 P.M., revealed Dietary Cook (DC) #200 took off plastic gloves and placed them on the counter to get a spatula for the pureed desert. DC #200 placed the spatula on top of the plastic gloves and proceeded to use the edge of the spatula to cut a piece of pie and place in the blender. Interview on 09/04/19 at 3:05 P.M., DC #200 reported she did not realize she had placed the spatula on top of the plastic gloves. DC #200 verified findings. 3. Observation on 09/04/19 at 5:10 P.M., revealed Dietary Aide (DA) #300 brought in the kitchenette six cups of ice uncovered. There was an ice machine in the hallway across from the finance and medical records office. The ice machine was also located down the hall from the bathrooms. Interview on 09/04/19 at 5:11 P.M., DA #300 reported she did not know she was supposed to cover the cups of ice. DA #300 verified findings of not covering cups of ice while traveling in the hall way then to the kitchenette. Review of the facility policy titled, Food Storage, no date, revealed all foods must be covered, labeled and dated.

Based on record review and interview, the facility failed to ensure care was provided in accordance with a resident's plan of care for one of 17 residents whose care plans were reviewed (Resident #40), out of a facility census of 39. Findings include: Review of the medical record for Resident #40 indicated she was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 04/08/16, indicated she was moderately cognitively impaired, and required supervision for transfers, walking in room and personal hygiene and limited assistance for dressing and toilet use. The assessment indicated the resident had fallen. The resident's plan of care, initiated on 10/15/15, included the potential for falls and/or injury related to history of falls and being new to the unit. The goal was for the resident to have no injuries related to falls. Interventions included: keep call light in reach at all times, make sure resident is wearing proper fitting shoes, sign in room to remind resident to use walker at all times, nurse call pressure alarm on at all times when in bed and when in the recliner - make sure alarm is on and working, staff to stay with resident during toileting task and safely ambulate her to the recliner or her wheelchair for meals or activities. Nursing notes on 12/29/15 at 10:58 P.M. indicated the resident was observed on the floor in a sitting position in front of the closet in her room. Staff had heard a banging noise coming from the North hall, and ran to find the resident sitting on floor. The resident was rolling the wheelchair back and forth to hit door to alert the staff of her incident. The note indicated the STNA was educated on the proper use of the nurse alarm activation. The resident did not have any injuries from the fall. Nursing notes on 2/23/16 at 8:20 A.M. indicated the resident was found sitting on the floor in the bathroom. The note indicated at 5:37 A.M. the nurse assisted the resident to the bathroom using a rolling walker. The nurse told the resident to pull the white string on the wall to her left for the emergency light to come on when she was finished, and wait for some one to come and assist her. The note indicated the nurse stepped out to assist another resident. Then, at 5:40 A.M., a Stated tested Nursing Assistant (STNA) came and notified the nurse the resident was on the floor. The STNA had heard the resident screaming for help. There were no injuries noted at the time, and the resident did not have any pain. Interview with the Director of Nursing (DON) on 04/14/2016 at 9:48 A.M. indicated the STNA did not have the alarm in place when the resident fell on [DATE], as care planned. The DON confirmed the intervention to stay with the resident in the bathroom was initiated on the care plan on 01/08/16, and the nurse left the resident unattended in the bathroom when the resident fell on [DATE].

Based on observation, record review and interview, the facility failed to ensure nursing staff implemented interventions to prevent falls for one of three residents reviewed for falls (Resident #40) of 25 residents identified by the facility as high risk for falls, out of a facility census of 39. Findings include: Resident #40 was observed on 4/11/16 at 3:20 P.M. in her room, sitting in her recliner with an alarm pad in place to her recliner. She stated she had fallen, and staff want her to ask for help more. A sign was observed hanging on the wall in the resident's room to remind her to use four wheeled walker at all times. Review of the medical record for Resident #40 indicated she was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 04/08/16, indicated she was moderately cognitively impaired, and required supervision for transfers, walking in room and personal hygiene and limited assistance for dressing and toilet use. The assessment indicated the resident had fallen. The resident's plan of care, initiated on 10/15/15, included the potential for falls and/or injury related to history of falls and being new to the unit. The goal was for the resident to have no injuries related to falls. Interventions included: keep call light in reach at all times, make sure resident is wearing proper fitting shoes, place sign in the room to remind resident to use walker at all times, nurse call pressure alarm on at all times when in bed and when in the recliner - make sure alarm is on and working, staff to stay with resident during toileting task and safely ambulate her to the recliner or her wheelchair for meals or activities. The plan of care also included documentation to indicate the resident was moved to a room closest to the nurses' station on 12/02/15, obtained a physical therapy evaluation on 12/26/15, the physician reviewed medications related to falls on 01/05/16, and a restorative toileting program was initiated on 01/14/16. The record indicated the resident had multiple falls, including the following: 12/29/15 found sitting on the floor in room 02/23/16 found on floor in bathroom 03/09/16 found on floor in room, 04/04/16 found on floor in room Nursing notes on 12/29/15 at 10:58 P.M. indicated the resident was observed on the floor in a sitting position in front of the closet in her room. Staff had heard a banging noise coming from the North hall, and ran to find the resident sitting on floor. The resident was rolling the wheelchair back and forth to hit door to alert the staff of her incident. There were no injuries. The note indicated the State tested Nursing Assistant (STNA) was educated on the proper use of the nurse alarm activation. Nursing notes on 2/23/16 at 8:20 A.M. indicated the resident was found sitting on the floor in the bathroom. The note indicated at 5:37 A.M. the nurse assisted the resident to the bathroom using a rolling walker. The note further revealed the nurse told her to pull the white string on the wall, to her left, for the emergency light to come on when she's finished, and wait for some one to come and assist her. The note indicated the nurse stepped out to assist another resident. Then, at 5:40 A.M., a STNA came and notified the nurse the resident was on the floor. The STNA had heard the resident screaming for help. There were no injuries noted at the time, and the resident did not have any pain. Interview with the Director of Nursing (DON) on 04/14/2016 at 9:48 A.M. indicated the STNA did not have the alarm in place when the resident fell on [DATE], as care planned. The DON indicated the STNA was educated after this incident. The DON confirmed the intervention to stay with the resident in the bathroom was initiated on the care plan on 1/08/16, and the nurse left the resident unattended in the bathroom when the resident fell on [DATE].

Based on personnel file review, interview, and policy review, the facility failed to ensure policies pertaining to pre employment screening of applicants included independent contractors and employees hired from employment companies. This affected three of three independent contract employee files reviewed form a total of 12 employee files reviewed. This had a potential to affect all 36 residents. Findings include: Review of the personal file for Employee # 1 revealed the employee had a hire date of 05/13/97. The employee was not on the criminal record background check log. Interview with Employee # 20 on 10/22/13 at 1:05 P.M. revealed the facility did not do a criminal records background check on the individual as the employee was an independent contractor and not a direct employee of the facility. Review of the personal file for Employee # 12 revealed the employee had a hire date of 06/04/11. The employee was not on the criminal record background check log. Interview with Employee # 20 on 10/22/13 at 1:05 P.M. revealed the facility did not do a criminal records background check on the individual as the employee was an independent contractor and not a direct employee of the facility. Review of the personal file for Employee #11 revealed the employee had a hire date of 04/01/13. The employee was not on the criminal record background check log. Interview with Employee # 20 on 10/22/13 at 1:05 P.M. revealed the facility did not do a criminal records background check on the individual as the employee hired through a separate staffing company. The only criminal records check that had been done had been by a local police department located in another county.. Review of the facility policy Background Screening Investigations with a Revised date of August 2007 revealed the policy only indicate background checks will be done only on a person making an application for employment with the facility. The policy does not address ensuring independent contractors or staff hired through a staffing company have background checks completed as part of the employment process.

Based on resident and staff interviews, record review and facility policy review, the facility failed to investigate and report residents allegations of mistreatment by staff. This affected one (#20) of three Stage 2 sampled residents reviewed for abuse out of a total facility census of 38. Finding include: Review of the medical record of Resident #20 revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact without short or long term memory problems. No behavior problems were indicated. The resident was identified with mood problems that included trouble falling and staying asleep or sleeping too much, feeling tired and having little energy, and trouble concentrating on things. The resident's psychosocial care plan did not indicate the resident had behaviors with staff. The resident's mood care plan stated the resident had frequent concerns of clothing, placement and level of mobility. The resident also had generalized complaints regarding her present situation to those in her past. The resident was identified as easily redirected with mood issues. Care planned interventions included to provide empathy, offer reassurance, and problem solve as necessary. The care plan stated that staff should allow the resident opportunity to express her feelings, concerns, and and the staff would provide reassurance to the resident. During interview on 07/10/12 at 11:06 A.M., Resident #20 stated a nurse talked rudely to her and was mean. The resident stated she reported this to the Director of Nursing (DON) who spoke with the nurse. Resident #20 stated the nurse stated to her she was a registered nurse and she knew what she was doing. Interview with the Administrator on 07/12/12 at 8:12 A.M. revealed she was unaware Resident #20 had reported a nurse being mean. Further interview with the Administrator later revealed there was an incident with Resident #20 and it had been reported to the Director of Nursing. The Administrator stated a facility Self Reported Incident report was not initiated or sent to the State survey agency. Interview with the Director of Nursing on 07/12/12 at 8:58 A.M. verified Resident #20 reported a nurse had talked to her in a mean tone. The DON stated Registered Nurse (RN) #17 and the resident had argued about how the nurse was doing a treatment and it was at that time RN #17 allegedly spoke to the resident in a mean tone. The DON provided an Employee Incident Report dated 05/25/12 that stated Resident #20 complained to her that a nurse had talked to her in a mean tone. The Report stated the incident was discussed with RN #17 and the nurse denied using a mean tone. RN #17 stated the resident did not like the way she dressed her toe. RN #17 stated she checked the physician's orders [REDACTED]. RN #17 affirmed she told Resident #20 she was following the physician's orders [REDACTED].#17 had ever spoken to them in a mean, rough, or rude manner, revealed she had not. The DON indicated the incident was not verbal abuse and a thorough investigation was not completed. Review of the facility's policy for Reporting Sister Abuse with a revised date of May 2008, revealed the policy stated when a suspected incident of Sister abuse was reported a member of management would investigate the alleged incident. The Administrator would provide the person in charge of the investigation a completed copy of the "Resident Abuse Report Form" and any supporting documents relative the the alleged incident. The policy stated the individual conducting the investigation would at a minimum review and interview ten items which included interviewing other Sisters to whom the accused employee provides care. The policy also stated the individual in charge of the investigation would consult daily with the Administrator concerning the progress/finding of the investigation.

Based on observation, record review and staff interview, the facility failed to ensure plans of care were revised to reflect the current care needs and abilities of a resident with repeated falls. This affected one (#20) of two residents sampled for accidents out of total facility census of 38. Findings include: Review of the medical record of Resident #20 revealed the resident was admitted to the facility on [DATE] and had current [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] identified the resident with severe cognitive deficit, no behaviors, required extensive assistance of one staff member for bed mobility and dressing, and limited assistance of one staff for toileting. The resident needed standby assistance only for transfers and ambulation. The assessment indicated the resident had an unsteady balance but was able to stabilize with staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfers. The resident had no functional limitations and used a rolling walker for ambulation. The resident was frequently incontinent of bladder and occasional incontinent of bowel. One fall without injury was identified. A Fall Assessment: Predisposition for Falling indicated the resident was identified at high risk for falls. Review of the resident's care plan for Fall and Dizziness/[MEDICAL CONDITION] revealed interventions included nurse call pressure alarm on the bed at all times, remind the resident to keep her hands on her walker at all times and to keep it with her, non-skid shoes and sock, keep path clear and clutter free, call light in reach, supervise resident with walker and provide cues for proper technique, and give the resident reminders to call for assistance before showers. Review of nursing notes revealed Resident #20 sustained a fall on 12/01/11 at 4:30 A.M. The notes stated the resident was found on the floor near her bed with the rocker turned over. An external risk factor of dementia was identified. Steps taken to prevent recurrence stated the resident was to call for assist prior to getting up. On 04/27/12 at 8:31 A.M., the resident transferred herself into a chair without her walker and lost her balance falling back into her chair. The notes stated the resident was reminded by staff to ask for assistance and to keep her walker with her. The post fall intervention was to re-educate the resident. On 06/09/12 at 3:55 P.M., Resident #20 was observed on the floor in the lounge of the East wing in the corner near the bookshelf. The post fall intervention was to check the resident frequently with staff attempting to keep the resident in the common areas for observation. The note stated the resident was noncompliant and walking without her walker more. On 06/22/12 at 8:59 A.M., a housekeeper witness the resident fall on the floor in her room. The resident stated she was bending down to put on her shoes and she grabbed the rocking chair, it gave way and she fell to the floor. The notes stated the resident was reeducated to sit down before putting her shoes on. After the 06/22/12 fall, investigation teaching was done and the resident reeducated on the use of assistive devices, safe transfer techniques, the use of call lights, and to ask staff assistance with shoes as needed. On 07/07/12, the resident fell in a common area and sustained a skin tear to the right hand and forehead. The notes stated the resident was reeducated to call for assistance. Staff were to monitor the resident while in common areas. After the 07/07/12 fall teaching was done to instruct the resident on the safe use of assistive devices, the use of the call light, and to wait for staff assist before getting up. Steps taken to prevent recurrence was re-education. On 07/11/12 at 10:53 A.M., Resident #20 was observed seated in regular chair at a table in the common lounge, on the second floor with her rolling walker behind her. The resident was wearing appropriate footwear. A large bruise with a laceration closed with steristrips, was observed over the resident's left eye. At 12:35 P.M., Resident #20 was observed seated in the main dining room eating lunch with her rolling walker beside her. During interview on 07/11/12, the Director of Nursing stated the resident's current fall trend had been discussed with the nursing staff to try to develop interventions to prevent further falls. The DON affirmed many care planned post fall interventions were to re-educate the resident which was not the most effective intervention for a resident with short term memory loss.

Based on observation of testing the sanitizer levels and staff interview the facility failed to ensure the sanitizer was at the proper concentration for the three compartment sink and the sanitizer bucket in th kitchen. This had the potential to affect all 39 residents in the facility who had an oral diet. Findings included: Observation on 03/25/11 at 8:20 A.M., during the initial tour of the kitchen, the three compartment sink sanitizer was tested . The sanitizer is a Quaternary solution sanitizer. The solution was tested with the facility test strips. The test strip was held in the solution for the manufactures recommended 10 seconds. The first test strip tested less than 100 parts per million ( ppm). The second test strip tested at 100 ppm. Interview with the Dietary Supervisor #2 at 8:27 A.M. revealed the sanitizer sink had been set up at 7:00 A.M. A new box of sanitizer strips was provided. The test strip remained at less than 100 ppm. The sink was drained and refilled by Dietary Supervisor #2 and the sanitizer dial turned on. The new solution was tested with the new strips. The sanitizer was 100 ppm. The sanitizer bucket was tested . The sanitizer bucket registered less than 100 ppm. Interview with Dietary Supervisor #2 at that time revealed, the sanitizer bucket solution was filled at the same time the first sink solution. The manufactures guidelines and the facility posted instructions for the proper strength of sanitizer was 200 ppm. The Dietary Supervisor confirmed the improper sanitizer strength during the above interviews and observations.

Based on review of medicare liability notices and interview the facility failed to ensure notice was given at least two days before the residents services ended for four residents ( #30, #43, #44 ,and #45) of six reviewed with medicare coverage. The facility identified two residents currently receiving medicare coverage. Findings include: 1. Review of the Utilization Review Determination of Continued Stay for Resident #30 revealed the resident was notified on 2/28/11 that coverage would be discontinued the next day, 3/1/11. 2. Review of the Utilization Review Determination of Continued Stay for Resident #42 revealed the resident was notified on 1/3/11 that there would be no coverage after 1/3/11. 3. Review of the Utilization Review Determination of Continued Stay for Resident #44 revealed the resident was notified on 9/16/10 that there would be no coverage after 9/16/10. 4. Review of the Utilization Review Determination of Continued Stay for Resident #45 revealed the resident was notified on 12/25/10 there would be no coverage after 12/25/1 and again on 1/3/11 that there would be no coverage after 1/3/11. Interview with the Director of Nursing on 03/27/11 at 8:50 A.M. confirmed the notices were not sent/given to the residents within the required time frames.

Based on record review, review of reports of bruises of unknown origin and staff interview the facility did not ensure bruises of unknown origin were thoroughly investigated and reported to the State agency. One of the three reports was not reported to the State Agency. This involved two of three Self Reported incidents reviewed and affected two residents (#35,#27) of two residents reviewed for bruises of unknown origin. The facility census was 39. Findings include: 1. Record review of the accumulative [DIAGNOSES REDACTED]. Review of the Self Reported Incident Form dated 01/03/11 noted a State tested Nurse Aide (STNA) noticed a bruise on the resident's right shoulder. The conclusion was the etiology of the bruise was unable to be determined. The facility interviewed one aide and one nurse on each shift who worked on the unit the resident resided on. No other staff were interviewed. Interview with the Director of Nursing (DON) on 03/26/11 at 1:40 A.M. revealed the report was reviewed with her at this time. She stated she interviewed one STNA and one nurse who worked on that unit for each shift. She stated all STNA's and nurses in the facility assist each other with turning and reposition, toileting, transfers when needed and covers the other staff when they are at lunch. She confirm no other staff were interviewed. The DON affirmed the facility did not complete a thorough investigation. 2. Record review of the accumulative [DIAGNOSES REDACTED]. The minimum data set assessment dated [DATE] noted the cognitively impaired resident and had behaviors daily. Review of a facility report for Resident #27 regarding a bruise located on the upper chest of unknown origin dated 09/25/10 revealed the resident was found in bed with a three inch by two inch purple bruise to the right upper chest by a STNA. The report noted the resident had numerous behaviors and she will grab and pinch the staff. One STNA was interviewed on each shift one one nurse on the day and evening shift was interviewed. No other staff were interviewed. The report was reviewed during an interview with the DON on 03/26/11 at 1:40 P.M. She stated she interviewed one STNA and one nurse who worked on that unit for each shift. She stated all STNAs and nurses in the facility assist each other with turning and reposition, toileting, transfers when needed and covers the other staff when they are at lunch. She confirm no other staff were interviewed. The DON affirmed the facility did not complete a thorough investigation of the bruise of unknown origin. Interview with the DON on 03/27/11 at approximately 8:15 A.M. confirmed she didn't send in a report to the state agency and the origin of the bruise was not thoroughly investigated.

Based on observation, record review and staff interview the facility did not ensure one resident had a dressing in place per physician's orders. This affected one resident (#10) of ten sampled residents. The facility census was 39. Findings include: Record review of the accumulative [DIAGNOSES REDACTED]. The minimum data set assessment dated [DATE] indicated the resident required extensive assistance from the staff for all functional tasks including toileting and personal hygiene. Review of physician's orders dated 02/21/11 noted to apply a foam dressing, [MEDICATION NAME] dressing to the middle back and change once a week. Review of nurses notes dated 02/23/11 at 4:30 P.M. revealed the area to mid spine remained closed, [MEDICATION NAME] dressing remains in use for protection. Observation on 03/25/11 at 6:05 P.M. Register Nurse (RN) #8 and State tested Nurse Aide (STNA) #16 transferred the resident back to bed for personal care and to administer a treatment to her back. The resident was incontinent of urine and stool. STNA #16 provided perineal care. As the resident was repositioned on her left side, the [MEDICATION NAME] dressing was not on the resident's back. RN #8 looked in the resident's clothing, bed linens and chair and no dressing was noted. The resident was not scheduled for a shower until later in the evening. RN #8 placed the [MEDICATION NAME] on the prominent curvature located on the mid spine and noted to be pink in color. Interview with RN #8 revealed the [MEDICATION NAME] dressing was to be changed every three days. If the STNAs noticed the dressing was not on her back they were to inform the nurse. The resident had been up in the chair for most of the day. RN #8 stated she worked 12 hours and no one had informed her the dressing wasn't in place.

Based on observation, record review, review of the facility's policy on Perineal Care, and staff interview the facility did not ensure for one resident with a history of urinary tract infection received services that placed the resident at risk for another infection. This affected one resident (#30) of four residents reviewed for incontinence. The facility identified 29 residents for incontinence. Finding include: Review of the facility's policy on Perineal Care revised 11/08 noted the purpose of the procedure was to provide cleanliness and to prevent infections. Record review of the accumulative [DIAGNOSES REDACTED]. The minimum data set assessment dated [DATE] indicated the resident required extensive assistance from the staff for all functional tasks including toileting and personal hygiene. Observation on 03/25/11 at 6:05 P.M. Register Nurse (RN) #8 and State tested Nurse Aide (STNA) #16 transferred the resident back to bed for personal care and to administer a treatment to her back. The resident was incontinent of urine and stool. STNA #16 provided perineum care using moisten disposable cloths she cleansed the perineal area front to back. The resident was positioned on her left side. STNA #8 wiped front to back and a large amount of stool was on the disposable wipe and the STNA's gloves. STNA #16 partially folded the contaminated cloth and cleansed the perineum front to back with the stool covered cloth. Her gloves were visibly soiled with stool. She partially fold the disposable wipe and grossly contaminated gloves started to cleanse the perineum again when the STNA was stopped and informed of her contaminated gloves and cloth. She threw away the cloth and took a new disposable wipe and wiped her own gloves off but not thoroughly and using the same soiled gloves continued with care. Interview with RN #8 directly after care was provided confirmed the technique the STNA used for care placed the resident at risk for another infection and confirmed the STNA didn't wash her hands.

Based on observation, review of the facility's policy on Storage of Medications, and staff interview the facility did not ensure drugs and biologicals were consistently monitored for expiration dates. This affected one of one storage room for drugs and biologicals and had the potential to affect any resident that required that medication from a facility census of 39. Findings include: Review of the facility's policy on Storage of Medications dated 07/07 revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. No discontinued, outdated, or deteriorated drugs or biologicals are available for use in the facility. Observation on 03/25/11 at 10:45 A.M., accompanied by License Practical Nurse (LPN) #8, of the medication room that also was a storage area for extra medications revealed the following medications were found that remained on the shelf past the expiration date. 1. Four packages of 12 capsules each of an anti-diarrhea medication Lopramaine with an expiration dated of 12/10. 2. One bottle 237 milliliters liquid of an anti-suppressant cough medication, DM-Tuss Syrup with an expiration date of 12/10. 3. One bottle of 473 milliliters of a laxative Milk of Magnesia with an expiration date of 12/10. 4. One container of chem test strips with an expiration date of 02/11. Interview with License Practical Nurse (LPN) #11 on 03/25/11 at this confirmed all medications listed were expired. Interview with the Director of Nursing on 03/26/11 at 3:30 P.M. stated the nurses are responsible to rotate the stock and send back expired medications.

Based on observation, record review, review of the facility's policy on Hand washing/Hand Hygiene, and staff interviews the facility did not ensure the staff cleanse their hands after their gloves were visibly contaminated with stool placing a resident at risk for an urinary tract infection. This affected one resident (#24) of four residents reviewed for incontinence care. the facility identified 29 residents with incontinence. Findings include: Record review of the accumulative [DIAGNOSES REDACTED]. The minimum data set assessment dated [DATE] indicated the resident required extensive assistance from the staff for all functional tasks including toileting and personal hygiene. Observation on 03/25/11 at 6:05 P.M. Register Nurse (RN) #8 and State tested Nurse Aide (STNA) #16 transferred the resident back to bed for personal care and to administer a treatment to her back. The resident was incontinent of urine and stool. STNA #16 provided perineum care using moisten disposable cloths she cleansed the perineal area front to back. The resident was positioned on her left side. STNA #8 wiped front to back and a large amount of stool was on the disposable wipe and the STNA's gloves. STNA #16 partially folded the contaminated cloth and cleansed the perineum front to back with the stool covered cloth. Her gloves were visibly soiled with stool. She partially fold the disposable wipe and grossly contaminated gloves started to cleanse the perineum again when the STNA was stopped and informed of her contaminated gloves and cloth. She threw away the cloth and took a new disposable wipe and wiped her own gloves off but not thoroughly and using the same soiled gloves continued with care. Interview with RN #8 directly after care was provided confirmed the technique the STNA used for care placed the resident at risk for another infection and confirmed the STNA didn't wash her hands. Review of the facility's policy on Infection Control Hand washing/Hand Hygiene revised 07/09 note the facility considers hand hygiene the primary means to prevent the spread of infections. The procedure includes for staff to wash their hands when hands are visibly dirty or soiled with blood or other body fluids.