Every finding on record at Mountain City Care & Rehabilitation Center

Based on facility policy review, medical record review, and interview the facility failed to prevent a fall for 1 resident (Resident #59) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Falls Policy, dated 7/19/2022, revealed .The intent of this policy is to ensure the facility provides an environment that is free from accident hazards over which the facility has control to prevent avoidable falls .Interventions are to be revised as indicated . Resident #59 was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)], [CONDITION(S)], Chronic Kidney Disease, and Muscle Weakness. Record review of a nursing progress note for Resident #59 dated 7/26/2022, revealed .CNA (certified nursing assistant) was assisting resident to the toilet when resident's leg became weak .CNA eased resident to the floor . Record review of the comprehensive plan of care revealed .Problem .resident is at risk for falls due to [CONDITION(S)], weakness .Approach Start Date: 7/26/2022 .2 [staff] assist with all transfers . Review of a facility investigation dated 7/26/2022, revealed .Evaluation Notes: Resident was being assisted to toilet by CNA. Resident became weak and was lowered to the floor .Reviewed with therapy staff and they agree safer to transfer with assist of 2 at all times. Staff educated on transfer assist of 2 at all times . Record review of a nursing progress note for Resident #59 dated 9/20/2022, revealed .During transfer with CNA from chair to bed, resident lost footing, CNA was assisting resident with transfer and CNA lowered resident to the floor sitting with bottom down on floor .Resident stated .my feet just went out .no injuries observed and resident reports no pain or discomfort .Resident was then assisted to bed by staff x [times] 2 . During a telephone interview on 10/19/2022 at 12:48 PM, with the Director of Nursing (DON) present, CNA #1 confirmed she worked on 9/20/2022 when Resident #59 sustained a fall .CNA #2 was transferring resident by herself when resident had fall . CNA #1 also stated the Charge Nurse asked her to help CNA #2 assist the resident back to bed after the fall. During an interview with the DON on 10/19/2022 at 12:58 PM, confirmed the facility policy on falls was not followed.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to report an allegation of abuse to the state agency and other officials in accordance with state law for 1 resident ( Resident #1) of 4 residents reviewed for abuse. The findings include: Review of the facility's Policy titled, Abuse, Neglect and Misappropriation of Property last revised 5/8/19 showed .Allegation of Abuse Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse .is occurring, has occurred, or .might have occurred .Immediately All alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made .all allegations and incidents of abuse .as defined in this policy, will be reported 'immediately' . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 3 indicating the resident had severe cognitive impairment. Review of Resident #1 's plan of care start date 12/14/2020 showed .Resident resists care and can be combative with others . Review of facility's investgation showed on 4/26/2022 at approximately 4:27 PM Certified Nursing Assistant (CNA) #1 informed the Administrator and Director of Nursing (DON) of an allegation of abuse. A statement was obtained from CNA #1 related to an alleged incident which involved Resident #1 and CNA #2. CNA #1 stated she walked Resident #1 towards the resident room when she was met by CNA #2. CNA #2 then reported to CNA #1, Resident #1 had grabbed her by the top of the head and then demonstrated how and pulled Resident #1's hair. The facility documentation showed Resident #1 screamed .ouch you pulled my hair you stupid [OBSCENITY] . and CNA #2 replied .yea well Karma's a [OBSCENITY] and walked out . During an interview on 6/21/2022 with the Director of Nursing (DON) at 10:01 AM, the DON stated .The SSD [Social Service Director] brought her [CNA #1] to us [DON and Administrator] . The DON stated .We didn't substantiate abuse [allegation of abuse on 4/26/2022] .we [facility] didn 't report it . During an interview on 6/21/2022 with the Staff Development Coordinator (SDC) at 11:59 AM, the SDC stated she was aware of the allegation of abuse made by CNA #1, completed the Teachable Moment with CNA #2 and treated the alleged incident on 4/26/2022 as an allegation of abuse. During an interview and review of the facility abuse policy on 6/21/2022 at 1:04 PM, the Administrator stated he was aware of the alleged abuse incident on 4/26/2022 related to Resident #1 and CNA #2. The administrator stated he was aware of the facility's abuse policy .I did not report it [the allegation of abuse on 4/26/2022] because within 1 hour .I did not substantiate the abuse .

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to prevent abuse for 1 resident (#1) of 4 residents reviewed for abuse. The findings include: Review of the facility's Policy titled, Abuse, Neglect and Misappropriation of Property last revised 5/8/19 showed .willful infliction .Abuse includes .verbal abuse .willful means non-accidental .the individual must have acted deliberately .Allegation of Abuse Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse .is occurring, has occurred, or plausibly might have occurred . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 99 indicating the resident had severe cognitive impairment. Review of the facility's investigation showed on 2/9/2022 Certified Nurse Assistant (CNA) #1 explained to the Director of Nursing (DON) that she thought Licensed Practical Nurse (LPN) #1 had verbally abused Resident #1. An investigation was initiated, LPN #1 was suspended pending outcome of the investigation and a statement was obtained from CNA #1 stating Resident #1 was at the nurses station yelling because he wanted a coke LPN #1 yelled back at him I ain't giving you no coke .nope that's why you ain't getting one, you're acting like an[OBSCENITY] a statement from LPN #1 showed .I did say some things. I do not recall exactly what was said .venting out loud. It was a poor lapse in judgment . LPN #1 was terminated for the above verbal abuse. During an interview on 1/3/2022 at 1:45 PM, the DON stated .we concluded based on her [LPN #1's] statements and [CNA #1's] statement that she [LPN #1] had acted outside of our code of conduct, and she was terminated . During a telephone interview on 3/1/2022 at 2:45 PM, CNA #1 stated he [Resident #1] was up at the nurse's station, and he was acting up because he wasn't getting more attention than his roommate .he wanted a coke .I heard her [LPN #1] say 'I ain't giving you no coke .nope that's why you ain't getting one, you're acting like an[OBSCENITY] . Facility corrective actions included: Resident #1 was assessed including a skin assessment on 2/9/22 by the charge nurse with no concerns. Investigation was immediately implemented upon notification 2/9/22 and was completed on 2/11/22 by the Chief Executive Officer (CEO) and Director of Nursing (DON). Staff member was suspended 2/9/22 by the CEO and DON pending outcome of investigation. Staff member was terminated by facility upon completion of investigation. All residents were assessed for any signs and symptoms of abuse/neglect. Residents with Brief Interview for Mental Status (BIMS) score greater than 8 were interviewed by Social Services Director on 2/9/22 without any new allegations. All residents with BIMS less than 8 were physically assessed on 2/9/22 by nursing administration without any concerns identified. Staff were re-educated on 2/10/22 on the abuse policy and procedure to include requirement to report abuse allegations immediately and was completed with certified letters sent out on 2/14/22 to remaining prn (as needed) staff, staff on vacation, or FMLA staff. Post test administered and 100 percent score obtained to evaluate competency. If an employee did not score 100 percent, then employee will be immediately re-educated and Post test re-administered. Staff abuse post test regarding abuse was administered daily starting 2/14/22 by the CEO, DON, Nursing Supervisors, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Business Office Manager, Social Services Director, or Rehab Manager to 5 different staff members on both shifts daily until 2/18/22. Then total of 5 staff on varying shifts will be administered abuse post test weekly x 4 weeks to ensure continued understanding of the abuse/neglect policy and procedure and reporting abuse/neglect. In the event of any new report of alleged abuse, neglect or misappropriation of property either the Signature Care Consultant or Vice President of Operations will be contacted within 24 hours to review the initial abuse investigation and then again within 5 days to review the 5-day completed abuse investigation. An Ad hoc Quality Assurance (QA) meeting was held on 2/15/22 and action plan formulated and implemented at that time. Results of the staff abuse post test will be reported to the QA committee to determine if need continued education or revision of the plan. Facility alleges compliance on 2/18/22

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to follow their abuse policy for reporting allegations of abuse immediately and failed to report allegations of abuse to the State Survey Agency within the federally required time frame of 2 hours for 1 resident (Resident #1) of 4 residents reviewed for abuse. The findings include: Review of the facility's Policy titled, Abuse, Neglect and Misappropriation of Property last revised 5/8/19 showed .willful infliction .Abuse includes .verbal abuse .willful means non-accidental .the individual must have acted deliberately .Allegation of Abuse Means a report, complaint, grievance, statement, incident, or other facts that a reasonable person would understand to mean that abuse .is occurring, has occurred, or plausibly might have occurred .Immediately All alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made .all allegations and incidents of abuse .as defined in this policy, will be reported 'immediately' as defined in this paragraph . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 99 indicating the resident had severe cognitive impairment. Review of the facility's investigation showed on 2/9/2022 at approximately 11:40 AM Certified Nurse Assistant (CNA) #1 called the Director of Nursing (DON) and ask if she could come in and talk to her, at approximately 2:00 PM on 2/9/2022 CNA #1 arrived at the facility, and she explained to the DON that she thought Licensed Practical Nurse (LPN) #1 had verbally abused Resident #1 the night before. A statement was obtained from CNA #1 stating Resident #1 was at the nurses station yelling because he wanted a coke LPN#1 yelled back at him I ain't giving you no coke .nope that's why you ain't getting one, you're acting like an[OBSCENITY] a statement from LPN #1 showed .I did say some things. I do not recall exactly what was said .venting out loud. It was a poor lapse in judgment . During an interview on 3/1/2022 at 1:45 PM, the DON stated .it should have been reported immediately it happened around midnight [2/9/2022], and it was around 2 PM [2/9/2022] when she [CNA #1] came and reported it . During a telephone interview on 3/1/2022 at 2:45 PM, CNA #1 stated he [Resident #1] was up at the nurse's station, and he was acting up because he wasn't getting more attention than his roommate .he wanted a coke .I heard her [LPN #1] say 'I aint giving you no coke .nope that's why you aint getting one, you're acting like an[OBSCENITY] ' it was around 1:00 in the morning [2/9/2022] I left right after that because my shift ended .I didn't want to call the DON at 1:00 in the morning .yes they did do education with me it I should have called someone as soon as it happened . Facility corrective actions included: Resident #1 was assessed including a skin assessment on 2/9/22 by the charge nurse with no concerns. Investigation was immediately implemented upon notification 2/9/22 and was completed on 2/11/22 by the Chief Executive Officer (CEO) and Director of Nursing (DON). Staff member was suspended 2/9/22 by the CEO and DON pending outcome of investigation. Staff member was terminated by facility upon completion of investigation. All residents were assessed for any signs and symptoms of abuse/neglect. Residents with Brief Interview for Mental Status (BIMS) score greater than 8 were interviewed by Social Services Director on 2/9/22 without any new allegations. All residents with BIMS less than 8 were physically assessed on 2/9/22 by nursing administration without any concerns identified. Event manager was reviewed on 2/11/22 by Regional nurse to ensure that all events for the past 30 days were reviewed for potential allegations and to ensure appropriate reporting. No issues were identified. All resident progress notes for the past 30 days were reviewed on 2/11/22 by Regional nurse for potential allegations and to ensure appropriate reporting. No issues were identified. All grievances for the past 30 days were reviewed by the CEO to determine if any items documented were a reportable event. None were identified. Staff were re-educated on 2/10/22 on the abuse policy and procedure to include requirement to report abuse allegations immediately and was completed with certified letters sent out on 2/14/22 to remaining prn (as needed) staff, staff on vacation, or FMLA staff. Post test administered and 100 percent score obtained to evaluate competency. If an employee did not score 100 percent, then employee will be immediately re-educated and Post test re-administered. Staff abuse post test regarding abuse was administered daily starting 2/14/22 by the CEO, DON, Nursing Supervisors, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Business Office Manager, Social Services Director, or Rehab Manager to 5 different staff members on both shifts daily until 2/18/22. Then total of 5 staff on varying shifts will be administered abuse post test weekly x 4 weeks to ensure continued understanding of the abuse/neglect policy and procedure and reporting abuse/neglect. In the event of any new report of alleged abuse, neglect or misappropriation of property either the Signature Care Consultant or Vice President of Operations will be contacted within 24 hours to review the initial abuse investigation and then again within 5 days to review the 5-day completed abuse investigation. The Administrator or Director of Nursing will review grievances, progress notes and events daily starting 2/10/22 until 2/18/22 to determine if there are reportable allegations that have not been identified. Director of Nursing will report to Administrator any identified allegations of abuse, neglect or misappropriation immediately after the review. The Administrator will report any allegations of abuse, neglect or misappropriation to the Tennessee Department of Health, Adult Protective Services and Ombudsman. An Ad hoc Quality Assurance (QA) meeting was held on 2/15/22 and action plan formulated and implemented at that time. Results of the staff abuse post test will be reported to the QA committee to determine if need continued education or revision of the plan. Facility alleges compliance on 2/18/22

Based on facility policy review, medical record review, and interview the facility failed to address or act timely upon the Pharmacist recommendations for 3 residents (#18, #84, and #94) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy, [MEDICAL CONDITION] Medications, last revised 9/5/18, revealed .The facility will make every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications .Reviews reports from the pharmacist consultant .If the physician determines there is to be no change in the medication; the physician will document the rationale in the resident's medical record . Review of the facility policy, Medication Monitoring Medication Regimen Review and Reporting, dated 9/2018, revealed .the consultant pharmacist incorporates federally mandated standards of care .the consultant pharmacist .gather pertinent information related to the resident's status .communicated to .the medical director .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days .For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document .rationale of why the recommendation is rejected in the resident's medical record . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Medication Regimen Review for Resident #18 dated 12/22/18 revealed .This resident is on [MEDICATION NAME] (an antianxiety medication) .consider adding a stop date . Continued review revealed no documentation the physician had addressed the recommendation. Medical record review of a physician's order dated 2/12/19 revealed .[MEDICATION NAME] .x (times) 14 d (days) . (52 days after the recommendation by the pharmacist) Medical record review of a Pharmacist Medication Regimen Review for Resident #18 dated 12/22/18 revealed .The following medication(s) has/have not been used in this resident since 12/1/18 .[MEDICATION NAME]-DM (a medication used for cough) Please consider evaluation of continued need or discontinuation . Continued review revealed no documentation the physician had addressed the recommendation. Medical record review of a physician's order dated 9/28/19 revealed .[MEDICATION NAME]-DM ([MEDICATION NAME]) .DC (discontinue) date .9/28/19 . (280 days after the recommendation by the pharmacist) Interview with the Director of Nursing (DON) on 10/02/19 at 10:17 AM, in the conference room, confirmed the pharmacy recommendations dated 12/22/18 had not been addressed timely by the physician for Resident #18. Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's recapitulation orders dated 12/20/18 revealed [MEDICATION NAME] (an anti-anxiety medication) 0.5 milligram (mg) every 12 hours as needed (PRN) without a stop date documented. Medical record review of the Pharmacist Medication Regimen Review for Resident #84 dated 1/25/19 revealed a recommendation for the evaluation of the continued need for the [MEDICATION NAME] 0.5 mg every 12 hours PRN beyond the 14 days. Continued review revealed the Physician did not provide or document a rationale for the continued use of the PRN [MEDICATION NAME] beyond the 14 days. Medical record review of a Physician's .Active Order .As Needed . form dated 2/28/19 revealed [MEDICATION NAME] 0.5 mg PRN at bedtime without a stop date documented. Medical record review of the Pharmacist Medication Regimen Review for Resident #84 dated 3/14/19 revealed a recommendation for the evaluation of the continued need for the PRN [MEDICATION NAME] beyond the 14 days. Continued review revealed the Physician did not provide or document a rationale for the continued use of the PRN [MEDICATION NAME]. Interview with the DON on 10/2/19 at 3:00 PM, in the DON's office, confirmed the Pharmacist recommendation had not been addressed or acted upon by the Physician for Resident #84. Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Pharmacist Medication Regimen Review for Resident #94 dated 12/19/18 revealed .This resident is receiving a statin (a medication used to treat high cholesterol). Please consider baseline and annual LFTs (liver function test) to monitor for side effects of atorvastatin (a medication used to treat high cholesterol) . Continued review revealed no documentation the physician had addressed the recommendation. Medical record review of the Physician Order Report dated 9/1/19- 10/1/19 revealed an order dated 8/13/18 .atorvastatin tablet .1 TABLET ORALLY AT BEDTIME . Interview with the DON on 10/02/19 at 12:22 PM, in the conference room, confirmed the physician had not addressed the recommendation dated 12/19/18 for liver function tests for Resident #94.

Based on facility policy review, medical record review, and interview the facility failed to provide a rationale for the continued use of an as needed (PRN) anti-anxiety medication beyond 14 days for 1 resident (#84) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy, [MEDICAL CONDITION] Medications, last revised 9/5/18, revealed .The facility will make every effort to comply with state and federal regulations related to the use of [MEDICAL CONDITION] medications .A [MEDICAL CONDITION] drug .include .Anti-anxiety .the physician will review the medical record, medical history, and related factors .Documents rationale and [DIAGNOSES REDACTED].e., times 2 weeks) and only for specific clearly documented circumstances . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #84 scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Continued review revealed the resident received Antianxiety, and Antipsychotic Medications. Medical record review of the Physician's recapitulation orders dated 12/20/18 and 1/1/19 to 1/31/19 revealed [MEDICATION NAME] (anti-anxiety medication) 0.5 milligram (mg) every 12 hours PRN without a stop date documented. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed Resident #84 received the PRN [MEDICATION NAME] for a total of 42 days (28 days beyond the 14 days). Medical record review of a Physician's .Active Order . form dated 2/28/19 revealed [MEDICATION NAME] 0.5 mg PRN at bedtime without a stop date documented. Medical record review of the MAR's dated from 2/2019 through 7/2019 revealed Resident #84 received the PRN [MEDICATION NAME] 4 months beyond the 14 days without a rationale documented by the Physician. Medical record review of a Physician's Order dated 7/1/19 revealed the PRN [MEDICATION NAME] was discontinued (4 months after the recommended 14 day stop date). Interview with the Director of Nursing (DON) on 10/2/19 at 3:00 PM, in the DON's office, confirmed the Physician had not provided or documented a rationale for the continued use of a PRN [MEDICAL CONDITION] medication beyond the 14 days.

Based on facility policy review, medical record review, observation, and interview, the facility failed to correctly administer medications for 1 resident (#1). The facility had a total of 2 medication errors of 35 opportunities resulting in a 5.71% (percent) medication error rate. The findings include: Review of the facility policy Medication Administration dated 9/2018 revealed .If it is safe to do so, medication tablets may be crushed .when a resident has difficulty swallowing .Long-acting, extended release or [MEDICATION NAME] coated (coated with a substance that prevents the medication from being released until it reaches the small intestine) dosage forms should generally not be crushed: an alternative should be sought . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician Order Report dated 9/1/19-10/1/19 revealed an order dated 9/16/19 .aspirin (a medication used to treat pain or thin the blood) tablet, delayed release . Continued review revealed an order dated 9/16/19 .[MEDICATION NAME] (a medication used to treat high blood pressure) tablet extended release 24 hr (hour) . Observation of medication administration with Licensed Practical Nurse (LPN) #1 on 10/1/19 at 8:48 AM, outside Resident #1's room, revealed LPN #1 crushed the [MEDICATION NAME] extended release, and crushed a chewable aspirin, mixed the medications with applesauce, and administered the medications to Resident #1. Interview with LPN #1 on 10/1/19 at 10:46 AM, at the 100 hall nurses station, confirmed Resident #1's aspirin order was for a delayed release tablet and the aspirin administered was a chewable aspirin. Continued interview confirmed the [MEDICATION NAME] order was an extended release tablet and it had been crushed for administration .it's the only way she can swallow it . Interview with the Director of Nursing on 10/01/19 at 2:52 PM, in the linen room, confirmed it was her expectation for delayed release medications to not be crushed. Continued interview confirmed it was her expectation for nurses to notify the physician to obtain an order for [REDACTED].

Based on facility policy review, observation, and interview, the facility failed to maintain infection control practices during 3 of 9 medication administration observations. The findings include: Review of the facility policy Cleaning and Disinfection of Resident-Care Items and Equipment revised 10/2018 revealed Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection .Reusable items are cleaned and disinfected or sterilized between residents . Observation of medication administration on 10/1/19 at 8:38 AM, on the 100 hallway, with Licensed Practical Nurse (LPN) #1 revealed LPN #1 entered a resident's room, placed a pulse oximeter (device placed on the fingertip used to measure the oxygen level in the blood) on the resident's finger, took the pulse oximeter off the resident's finger and laid it on the over bed table while administering the medications to the resident, then placed the pulse oximeter into her pocket and exited the resident's room. Continued observation revealed LPN #1 did not clean or sanitize the pulse oximeter after use. Further observation revealed LPN #1 entered another resident's room, placed the pulse oximeter on the resident's finger, then removed the pulse oximeter and exited the resident's room. Continued observation revealed LPN #1 did not clean or sanitize the pulse oximeter after use. Further observation revealed LPN #1 re-entered the first resident's room, placed the pulse oximeter onto the resident's finger, then removed the pulse oximeter and exited the room. Continued observation revealed LPN #1 placed the pulse oximeter onto the medication cart without cleaning or sanitizing it after use. Interview with LPN #1 on 10/1/19 at 9:04 AM, in the 100 hallway, confirmed the LPN did not clean the pulse oximeter after resident use .not unless their hands are dirty . Interview with the Director of Nursing on 10/2/19 at 1:48 PM, in the conference room, confirmed it was her expectation for the pulse oximeter to be cleaned with disinfecting wipes after use with each resident.

Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan for the use of an indwelling urinary catheter (a tube inserted into the bladder to drain urine from the body) for 1 resident (#71) of 5 residents reviewed for indwelling urinary catheters. The findings include: Review of the Facility's Comprehensive Care Plan Policy, last revised date 7/19/18, revealed .A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Medical record review revealed Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].CATH (indwelling urinary catheter) . Medical record review of a Resident's Progress Note dated 8/27/19 revealed, .catheter placed . Medical record review of a physician's orders [REDACTED].CATH CARE EVERY SHIFT . Medical record review of the Comprehensive Care Plan revealed no documentation for the use of an indwelling urinary catheter. Interview with the Minimum Data Set Coordinator #1 on 10/2/19 at 9:16 AM, in the conference room, confirmed the facility had not developed a comprehensive care plan for the use of an indwelling urinary catheter for Resident #71.

Based on medical record review, review of a facility investigation, and interview, the facility failed to prevent abuse for 1 resident (#1) of 5 residents reviewed for abuse. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 3 (severe cognitive impairment) on the Brief Interview for Mental Status. Continued review revealed the resident had no physical behaviors towards others and verbal behaviors of 1 to 3 times during the assessment period. Review of a facility investigation dated 5/29/19 at 8:22 PM revealed Licensed Practical Nurse (LPN) #1 and LPN #2 witnessed a visitor to the facility holding Resident #1's cane perpendicular across Resident #1's chest and pushing Resident #1 across the hall. Continued review revealed the visitor was escorted to the front office by the Social Worker (SW) and the police were called. Further review revealed the visitor was charged with simple assault. Continued review revealed the resident had no injuries. Telephone interview with LPN #1 on 9/17/19 at 12:00 PM revealed she witnessed the visitor holding Resident #1's cane perpendicular across Resident #1's chest and pushing him across the hall. Continued interview revealed the visitor had not been allowed back into the facility. Telephone interview with LPN #2 on 9/17/19 at 12:05 PM revealed she saw the visitor holding Resident #1's cane perpendicular across Resident #1's chest and pushing him across the hall. Interview with the SW on 9/17/19 at 12:10 PM revealed .I saw the visitor with the resident (Resident #1) at the wall .saw the visitor had his (Resident #1's) cane across his (Resident #1's) body holding him against the wall .took the visitor up front .police showed up .the visitor is not allowed back in the building . Interview with the Director of Nursing (DON) on 9/18/19 at 9:00 AM, in the conference room, revealed .I heard a loud noise .went out into the hall and when I looked down the hall the visitor had (Resident #1) up against the wall with his (Resident #1's) cane held to him (Resident #1) at chest level .I called the police .the visitor has not been allowed in the building .

Based on review of facility policy, medical record review, observation, and interview, the facility failed to implement isolation precautions for 2 of 2 isolation rooms observed, affecting 3 residents (#80, #25, #85) of 39 sampled residents. The findings include: Review of the facility's policy Isolation - Categories of Transmission-Based Precautions, revised (MONTH) 2012, revealed Gloves and Handwashing .wear gloves .when entering room .Gown .wear a disposable gown upon entering the Contact Precautions room . Medical record review revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #80's Care Plan dated 10/7/18 revealed VRE ([MEDICATION NAME] resistant [MEDICATION NAME] - superbugs in the urine that have become resistant to the antibiotic [MEDICATION NAME]) in urine with an intervention to observe contact precautions. Observation on 10/9/18 at 1:26 PM, on the 100 unit hall, revealed Maintenance Worker #1 in Resident #80's room wearing no personal protective equipment (PPE), gown, or gloves, performing maintenance on the air conditioner. Maintenance Worker #1 then exited the room without performing hand hygiene. Interview with Maintenance Worker #1 on 10/9/18 at 1:29 PM, on the 100 unit hall, confirmed he did not wear PPE or gloves while in Resident #80's room, and did not perform hand hygiene before leaving or after exiting the room. Observation on 10/9/18 at 9:17 AM, on the 100 unit hallway, revealed Certified Nursing Assistant (CNA) #3 in Resident #80's room without PPE and gloves. CNA #3 exited the room with a dirty food tray and put the food tray in the tray cart without performing hand hygiene. Interview with CNA #3 on 10/9/18 at 9:18 AM, on the 100 hall, confirmed she was in Resident #80's room and did not put on PPE or gloves. Resident #25 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED]. Medical record review of Resident #25's Care Plan dated 10/3/18 revealed .problem .scabies . Observation on 10/9/18 at 6:59 PM, on the 100 unit hallway, revealed Resident #85 was wandering and self-propelled into Resident #25's room. Interview with Licensed Practical Nurse (LPN) #6 on 10/9/18 at 7:00 PM, on the 100 unit hallway, confirmed Resident #85 was confused and wandered inside Resident #25's room. Interview with Registered Nurse #2 on 10/9/18 at 7:16 PM, on the 100 unit hallway, revealed .anyone should gown and glove in the hallway before entering contact precaution room . Interview with LPN #4 on 10/11/18 at 6:30 PM, in the Admissions Office, confirmed the facility failed to follow their infection control policy by not wearing gloves and gowns in the isolation rooms.

Based on medical record review, observation, and interview, the facility failed to implement oxygen therapy according to accepted professional standards for 1 Resident (#62) of 8 residents receiving oxygen of 35 residents reviewed. The findings include: Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum (MDS) data set [DATE] revealed the resident had moderate cognitive impairment and received oxygen therapy. Medical record review of the Physician's Recapitulation Orders dated 10/1/18 to 10/31/18 revealed .02 (oxygen) up to 6 LPM (liters per minute) to try to maintain SATS (oxygen saturation) > (greater than) 88% (percent). Observation on 10/8/18 at 11:35 AM, in the resident's room, revealed an oxygen concentrator (medical device to deliver oxygen) in the resident's room. Further observation revealed the oxygen concentrator was not turned on and the oxygen tubing was on the floor. Interview and observation with Licensed Practical Nurse (LPN) #3 on 10/8/18 at 11:40 AM, in the resident's room, revealed the oxygen was to be administered continuously. LPN #3 checked the resident's oxygen saturation and the results were 94% on room air. The LPN wet a paper towel with water, wiped the oxygen tubing off, placed the tubing in the resident's nostrils, and turned the oxygen concentrator to 2 liters per minute. Interview with LPN #3 revealed .I should have went and got new tubing instead of wiping it off with a wet paper towel . Interview with the Director of Nursing on 10/11/18 at 4:14 PM, in the admission office, confirmed the facility failed to follow accepted professional standards for oxygent therapy for Resident #62.

Based on medical record review, observation, and interview, the facility failed to monitor interventions to reduce behaviors of dementia for 2 (#87 and #26) of 5 residents reviewed for dementia care of 39 sampled residents. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's care plan dated 3/14/18 revealed the resident was care planned for yelling out for help with an intervention to monitor and record behavior. Medical record review of Resident #87's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. Further review of the MDS revealed Resident #87 had an active [DIAGNOSES REDACTED]. Medical record review of Resident #87's Medication Administration Record [REDACTED]. Multiple observations conducted daily during the annual Recertification survey 10/8/18 - 10/11/18, revealed Resident #87 frequently called out help me. Interview with Certified Nursing Assistant (CNA) #2 on 10/11/18 at 6:42 PM, at the 100 unit nurses station, revealed .it's all the time he hollers 'help me' .he hollers 'help me, help me' all night . Interview with Licensed Practical Nurse (LPN) #1 on 10/11/18 at 6:33 PM, at the 100 unit nurses station, revealed .he hollers out 'help me' it'd be an all the time thing if we charted it every time . Interview with the Director of Nursing on 10/11/18 at 7:34 PM, in the Conference Room, revealed .it would be there on the MAR; and if it's not, then it's not been documented . Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of Resident #26's Care Plan reviewed on 8/2/18 revealed .wandering will attempt to get out doors and has entered other rooms .Monitor and record behavior . Medical record review of the Medication Administration Records from 5/1/18 - 10/10/18 revealed no documentation of monitoring for wandering. Interview with the Social Services Director on 10/11/18 at 10:23 AM, at the 300 hall Nurses Station, confirmed there was no documentation of monitoring for exit seeking or wandering for Resident #26. Interview with the Director of Nursing on 10/11/18 at 5:26 PM, in the conference room, confirmed the social worker was responsible for initiating monitoring sheets. Continued interview confirmed exit seeking or wandering monitoring sheets were not implemented.

Based on facility policy review, medical record review, observation, and interview, the facility failed to complete an interdisciplinary team (IDT) assessment for self-administration of medications for 1 resident (#2) of 5 residents reviewed for medication administration of 37 residents sampled. The findings include: Review of facility policy Medication Administration General Guidelines dated 5/16 revealed .Medications are to be administered at time they are prepared . Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations .The resident is always observed after administration to ensure that the dose was completely ingested . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's current care plan dated 1/27/17 revealed the resident was not documented to self-administer prescribed medications. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Medical record review of Resident #2's physician's orders [REDACTED].>Medical record review of facility revealed Resident #2 was not reviewed by the Interdisciplinary (IDT) team for self-administration of medications. Observation on 10/8/18 at 11:00 AM, in the resident's private room, revealed the resident was lying in bed watching television alone. Continued observation revealed a 30 ml (milliter) clear plastic medication cup with 10 pills sitting on the resident's bedside table. The cup contained the following medications: [REDACTED] *One Carvedilol 25 milligram (mg) tablet (medication used to treat high blood pressure) *One [MEDICATION NAME] 5 mg tablet (medication to treat high blood sugar) *One Chewable Aspirin 81 mg tablet (medication to prevent blood clots) *One [MEDICATION NAME] 5 mg tablet (medication to treat high blood pressure) *One [MEDICATION NAME] 50 mg tablet (medication used to treat high blood pressure) *One Potassium CL (chloride) ER (extended release) 20 meq (milliequivalent) (medication to treat low blood levels of potassium) *One Calcium Acetate 667mg (medication to prevent high blood phospate) *One [MEDICATION NAME] 120 mg (medication used to treat swelling and high blood pressure) *One Multiple Vitamin with minerals formula (supplement used to improve health) Interview with Resident #2 on 10/8/18 at 11:00 AM, in the resident's room, revealed, .I usually take them (pills at bedside) with lunch .when they are busy they leave them (pills at bedside) . Interview with Licensed Practical Nurse #7 on 10/8/18 at 11:05 AM, outside of Resident # 2's room, confirmed .I did not watch her take all of her pills .I don't leave any meds (medications) but hers (Resident #2) .those were her 9:00 AM meds . Interview with the Director of Nursing on 10/11/18 at 2:20 PM, in the conference room, confirmed .Absolutely not (resident to give own medications) unless self-administration .they (nurses) should not leave medications at bedside .she knew it wasn't policy .

Based on observation and interview, the facility failed to maintain an effective pest control program in 1 hallway of 3 hallways observed during the survey, affecting 1 resident (#7) of 39 sampled residents. The findings include: Review of facility policy, Pest Control dated 1/2015, revealed .Our facility shall maintain an effective pest control program .to ensure that the building is kept free of insects . Observation on 10/8/18 at 11:00 AM, in Resident #2's room, revealed the resident lying in bed with a fly strip ribbon hanging from the ceiling above the resident. Continued observation revealed several small dead black insects on the hanging fly strip ribbon. Interview with the Maintenance Director on 10/10/18 at 5:14 PM, in the 300 nursing station, confirmed .issues with gnats within last 3 months .Have had residents complain about gnats . Observation and interview with the Maintenance Director on 10/10/18 at 5:19 PM, outside of Resident #7's room, confirmed .I installed fly trap (fly strip ribbon in the resident's room) for gnats .Does not seem sanitary (fly strip hanging above the resident's bed) . Observation on 10/11/18 at 8:35 AM, outside of Resident #2's room, revealed the resident lying in bed with the fly trap ribbon hanging from the ceiling above the resident's bed. Continued observation revealed several small dead black insects on the hanging fly strip ribbon. Further observation revealed a Certified Nursing Assistant delivered the resident's breakfast tray and placed the tray on the bedside table. Interview with the Director of Nursing on 10/11/18 at 2:26 PM, in the conference room, confirmed the fly ribbon was not sanitary to hang in a resident's room and the facility failed to follow the pest control policy.

Based on medical record review, observation, and interview, the facility failed to maintain a complete and accurate medical record for 1 resident (#85) of 39 sampled residents. The findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #85's current care plan dated 4/12/18 revealed the resident was care planned for wandering with interventions .Monitor and record behavior . Review of Resident #85's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. Further review of the MDS revealed the resident was coded as wandering that occurred 1 to 3 days. Review of Resident #85's Medication Administration Record [REDACTED]. Multiple observations conducted daily during the annual Recertification survey 10/8/18 - 10/11/18, revealed Resident #85 wandered daily. Interview with Certified Nursing Assistant (CNA) #1 on 10/8/18 at 1:00 PM, on the 100 unit hall, confirmed Resident #85 was wandering. Further interview with CNA #1 revealed She's usually in and out of rooms. Interview with CNA #2 on 10/11/18 at 8:04 AM, on the 100 hall, revealed She is in and out of rooms. She gets around the building. Interview with Licensed Practical Nurse (LPN) #1 on 10/11/18 at 2:35 PM, at the 100 unit nurses station, revealed Resident #85 had dementia, did not know where she was, and she wandered. Interview with LPN #2 on 10/11/18 at 2:58 PM, at the 100 unit nurses station, confirmed the monitoring sheet indicated the resident had no wandering behavior this month. Further interview with LPN #2 revealed the resident had wandered this week. Further interview revealed Maybe they are just so used to her wandering that it is normal rolling around in her house and they aren't charting it as wandering. Interview with the Director of Nursing on 10/11/18 at 5:28 PM, in the Conference Room, revealed I'd agree it is not being coded correctly; the coding means it's not being documented correctly.

Based on medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (#68) of 4 residents reviewed for falls of 37 sampled residents. The findings include: Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #87's Care Plan revised 9/7/18 revealed .At risk for falls .Floor Mat . Observation on 10/9/18 at 8:04 PM, in Resident #87's room, revealed the resident was lying in bed and there was not a floor mat beside the bed. Observation on 10/10/18 at 2:45 PM, in Resident #87's room, revealed the resident was lying in bed and there was not a floor mat beside the bed. Interview with Registered Nurse #3 on 10/10/18 at 4:25 PM, on the 100 hallway, revealed proper fall risk interventions for Resident #87 included a floor mat on the left side of the bed. Continued interview on 10/10/18 at 4:28 PM, in the resident's room, confirmed the floor mat was not positioned in the floor next to the bed and the facility failed to implement the falls intervention for Resident #87

Based on observation and interview the facility failed to ensure expired medications were not available for use in 1 of 1 medication rooms observed. The findings included: Observation and interview on 10/5/16 at 10:07 AM, in the 100 Hallway medication room with Licensed Practical Nurse (LPN) #2 revealed 2 of 5 vials of lorazepam (prescribed to treat seizures which are not responding to other forms of treatment) 2 milligrams (mg)/milliliters(ml) vials in the locked medication refrigerator with expiration date of 10/1/16. Continued observation and interview with LPN #2 confirmed the medication was expired and available for use in the medication refrigerator. Interview with the Director of Nursing (DON) on 10/5/16 at 1:05 PM, in the medication room, revealed the DON was aware of the expired medication and stated, .didn't know what to do . with the expired medication due to the return bin to the pharmacy was full. Continued interview confirmed the medications were in the medication refrigerator and were available for resident use.

Based on facility policy review, medical record review, and interview the facility failed to obtain pre and post (before and after) [MEDICAL TREATMENT] vital signs (VS) for 1 resident (#9) of 1 resident reviewed for [MEDICAL TREATMENT] of 24 sampled residents. The findings included: Review of the facility policy, [MEDICAL TREATMENT] Monitoring, not dated, revealed .Vital signs to include blood pressure monitoring will be assessed and documented in accordance with the physician's orders and [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) protocol (pre and post [MEDICAL TREATMENT]) . Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Recapitulation Order dated 9/28/16 revealed .[MEDICAL TREATMENT] EVERY MON (Monday), WED (Wednesday), AND FRI (Friday) . Medical record review of [MEDICAL TREATMENT] Communication Records and electronic Vitals Report with 300 Hall Unit Supervisor for dates 7/1/16 through 10/3/16 revealed no documentation of pre [MEDICAL TREATMENT] VS for 2 of 35 [MEDICAL TREATMENT] treatments. Continued review revealed no documentation of post [MEDICAL TREATMENT] VS for 22 of 35 [MEDICAL TREATMENT] treatments. Interview with the 300 Hall Unit Supervisor on 10/5/16 at 8:34 AM, on the 300 Hall nursing station, confirmed VS are obtained before and after [MEDICAL TREATMENT] treatment. Continued interview confirmed the facility failed to obtain pre and post [MEDICAL TREATMENT] VS per facility policy for Resident #9.

Based on review of facility policy, medical record review, observation, and interview the facility failed to follow physician's orders for administration of insulin for 1 resident (#176) of 1 resident observed for insulin administration of 5 residents observed during medication administration observation. The findings included: Review of the facility policy, Medication Administration Subcutaneous Insulin, dated 2007 revealed, .To administer subcutaneous insulin as ordered . Medical record review revealed Resident #176 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physicians Order dated 9/26/16 revealed, .[MEDICATION NAME] 100 unit/ml (milliliter) vial (insulin [MEDICATION NAME]) accuchecks (finger stick to test blood glucose level) before meals. inject 26 units [MEDICATION NAME] SUBQ (subcutaneously) Before meals. DX (diagnosis): DM (diabetes mellitus). Frequency 0800, 1200, 1700 (8 AM,12 PM, 5PM) . Medical record review of the Medication Administration Record [REDACTED]. Further review revealed Resident #176's blood sugar was less than 100 on 1 of 49 times tested . Medical record review of the History and Physical dated 9/2/16 revealed XXX[AGE] year-old male with type 2 diabetes, CKD ([MEDICAL CONDITION]) .admitted with .sepsis secondary to pneumonia and [MEDICAL CONDITION] with blood glucose in 300s. BG (blood glucose) since admission has been running in 300s .Hemoglobin A1c (test to determine average blood sugar over a 3 month period) on this admission is 11.9% . Medical record review of lab results dated 9/13/16 revealed .Hemoglobin A1C 11.1 H (high) 4.6-5.6% (normal range) . Observation of Licensed Practical Nurse (LPN) #2 on 10/5/16 at 8:20 AM, in Resident #176's room revealed, LPN #2 administered [MEDICATION NAME] (a type of fast acting insulin) 26 units subcutaneous (under the skin) in the resident's left arm. Further observation revealed Resident #176 had finished eating his breakfast. Interview with LPN #2 on 10/5/16 at 8:30 AM, in the 100 hallway, confirmed the physician's order was to administer the insulin before meals. Continued interview confirmed Resident #176's blood sugar was 172 before breakfast. Further interview confirmed she gave the insulin after breakfast and it .has become a habit she has got into in case the resident does not eat . Interview with the Director of Nursing on 10/5/16 at 12:35 PM, in the conference room, confirmed nurses are expected to administer medications as ordered by the physician. Continued interview confirmed if the medication is ordered before a meal it should be given before the resident eats.