Every finding on record at Mountain Vista Health Park

Based on observations, record review, and physician and staff interviews, the facility failed to implement their Infection Control Policy for transmission-based precautions when Nursing Assistant (NA) #1 and NA #2 failed to perform hand hygiene, apply a face mask prior to entering a room with droplet precautions in place and failed to complete hand hygiene upon exiting the room. This was for 2 of 5 staff members observed for infection control practices (NA #1 and NA #2).The findings included:Review of the droplet precautions sign with a revision date of 1/20/22 revealed instructions for entering the room including:Everyone must clean hands before entering and leaving the roomEveryone must wear a surgical/procedure mask when entering the room and remove after exiting the room.Additional personal protective equipment (PPE) may be required per Standard PrecautionsPPE: apply in this order: alcohol-based handrub or wash with soap and water (if visibly soiled); mask (cover nose, mouth, and chin)Take off and dispose of in this order: mask (do not grasp front of the mask when removing); alcohol-based handrub or wash hands with soap and water if visibly soiled.The facility policy Isolation: Categories of Transmission-based Precautions with a revision date of 9/2022 specified droplet precautions were implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. The policy indicated an individual should be placed in a private room if possible, but when a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors, or on a case-by-case basis after considering infection risks to other residents. The policy specified that masks were worn when entering the room, gloves, gown, and goggles were worn if there was a risk of spraying respiratory secretions.An observation was conducted on 4/27/26 at 12:16 PM. Resident #45's door frame had the sign droplet precautions with instructions to perform hand hygiene and apply a face mask prior to entering the room. NA #1 entered Resident #45's room to deliver a lunch tray to Resident #45 (Resident #52's roommate). Resident #45 was sitting in a chair, and her bed was closest to the door. NA #1 did not perform hand hygiene prior to entering the room. NA #1 was noted to move the over-the-bed tray closer to Resident #45 and remove the lid from the plate of food. NA #1 did not perform hand hygiene after leaving the room. An alcohol-based handrub dispenser was noted on the wall beside the door.NA #1 was interviewed on 4/27/26 at 12:19 PM immediately after she exited the room and she reported she did not think she had to perform hand hygiene or apply a face mask to deliver a meal tray because the droplet precautions were in place for Resident #52 but not Resident #45. NA #1 reported she saw the droplet precautions sign.NA #2 was observed entering Resident #52's room with a lunch tray on 4/27/26 at 12:17 PM. Resident #52's door frame had the sign droplet precautions with instructions to perform hand hygiene and apply a face mask prior to entering the room. NA #2 did not perform hand hygiene or apply a face mask prior to entering the room. No face mask was applied by NA #2 before she entered the room. NA #2 was observed setting up Resident #52's lunch tray and adjusting the over-the-bed tray. NA #2 exited the room and did not perform hand hygiene. An alcohol-based handrub dispenser was noted on the wall beside the door.NA #2 was interviewed on 4/27/26 at 12:21 PM immediately after she exited the room and she reported she was aware Resident #52 had droplet precautions in place. NA #2 reported she had applied a face mask earlier in the shift to assist Resident #52 with grooming and dressing but did not think she had to perform hand hygiene or apply a face mask for tray delivery. NA #2 reported she saw the droplet precautions sign.On 4/27/26 at 2:49 PM, the Director of Nursing was interviewed with NA #1 and NA #2 present. Both NAs stated they had received education on precautions and PPE but could not recall the dates. NA #1 reported she became confused about the precautions in place and did not realize she needed to wear a face mask when delivering a tray to Resident #45, who was not on droplet precautions, and said she was nervous because she was being observed. NA #2 reported she knew Resident #52 was on droplet precautions but, due to nervousness, did not think to perform hand hygiene or apply a face mask before delivering a meal tray. Both NAs stated they were told during morning report on 4/27/26 that Resident #52 tested negative for COVID, influenza, and RSV, and they thought the droplet precautions sign was going to be removed; they also said they did not recall touching anything in the room that would have required hand hygiene. The DON stated both NAs had infection control education in the past and should have performed hand hygiene and worn a face mask before entering a room with droplet precautions, and she acknowledged that Resident #52 had a negative PCR test but remained on droplet precautions, adding that she expected staff to read and follow posted precaution signs and apply required PPE before entering the room.An interview was conducted with the Infection Control Preventionist (IP) on 4/29/26 at 9:03 AM. The IP reported Resident #52 had signs and symptoms of respiratory infection and special droplet precautions were implemented. The IP explained Resident #52 was tested for COVID, influenza, and RSV. The IP explained the rapid test was negative for COVID, and the PCR was negative for COVID, influenza, and RSV, but because Resident #52 had a cough, the facility kept her on droplet precautions and discontinued the special droplet precautions. The IP explained that if one resident was on droplet precautions in a room, the roommate was considered exposed and on droplet precautions. The IP explained that this meant the facility staff should wear a surgical mask when entering the room to provide care, as well as perform hand hygiene before and after care, including delivering meal trays to the resident under droplet precautions and their roommate.The Administrator was interviewed on 4/29/26 at 2:08 PM. The Administrator reported she and the DON discussed the incident and determined because NA #1 and NA #2 had been told in morning report on 4/27/26 that Resident #52 was negative for COVID, influenza, and RSV, they thought Resident #52 was going to be taken off droplet precautions, and it was okay to deliver the meal tray without performing hand hygiene or applying a face mask. The Administrator reported she expected all staff to follow the instructions on precaution signs posted on a resident's door.The facility Physician was interviewed on 4/29/26 at 2:46 PM. The Physician reported he had ordered loratadine (used to treat allergy symptoms) for Resident #52 based on her symptoms and medical history, but he had not examined her on 4/26/26. The Physician reported that the rapid and PCR test for COVID, influenza, and RSV were negative and Resident #52 remained on droplet precautions due to a cough, which he felt the allergy medication would help. The Physician reported he was concerned about the potential for infectious disease spread when he learned NA #1 and NA #2 did not follow the droplet precaution sign instructions by not performing hand hygiene or applying a face mask prior to delivering a meal tray to Resident #45 and Resident #52.

Based on observations, record review, staff interviews, Medical Director interview and oxygen vendor interview the facility failed to administer oxygen (02) as ordered by the physician for 1 of 2 residents reviewed for oxygen (Resident #46). The findings included: Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had cognitive impairment, used supplemental 02 and had a one sided impairment on the upper and lower extremities. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 62.5 micrograms/actuation powder for inhalation, 1 puff daily for wheezing and shortness of breath dated 7/18/22 -02 at 5 liters per minute (l/min) via nasal cannula continuously for dependence on supplemental 02 dated 8/10/22 Resident #46's Care plan updated on 8/9/22 revealed Resident #46 had impaired respiratory status and required supplemental 02. The goal was Resident #46 would be free of respiratory infection and would have adequate 02 exchange. The interventions included monitor 02 sat every shift, 02 at 5L/min continuously to maintain 02 sat (measurement of the level of oxygen in the blood) above 89%, administer medication ([MEDICATION(S)]) as ordered. An observation was made of Resident #46 on 8/30/22 at 8:28 AM, the resident was lying in his bed with his nasal cannula in place in his nares. The nasal cannula tubing was connected to the 02 concentrator and the 02 concentrator was set at 6L/min. The resident did not appear to be in any distress. On 8/30/22 at 3:42 PM Resident #46 was observed in the dining room near the window. His nasal cannula was in place in the resident's nares and connected to the portable 02 tank. The resident's portable 02 tank was set on 8L/min and the 02-gauge needle was in the red, which indicated it was empty. The resident was in no respiratory distress. During an interview with Nurse Aide (NA) #3 on 8/30/22 at 4:07 PM revealed nurses were responsible for adjusting the residents 02 to the correct rate. NA's could apply the resident's nasal cannula and turn on the 02 concentrator or apply nasal cannula from the portable 02 tank to the resident, but the nurse was responsible for turning on the 02 tank. NA #3 demonstrated how she turned on the 02 concentrator. When turned on it was at 6L/min. She stated she did not think it was right and would notify the nurse. An interview was conducted on 8/30/22 at 4:20 PM with the Director of Nursing (DON). She stated Resident #46's 02 order in the electronic medical record (EMR) was 5L/min continuously. On 8/30/22 at 4:25 PM until 4:34 PM a continuous observation was conducted by this surveyor and the DON of Resident #46. During the observation an interview was conducted with the DON. Resident #46 was observed self-propelling in his wheelchair (WC) exiting from the activity room. The resident's 02 tank was held in a fabric sleeve attached to the back of his WC. The DON observed and indicated the dial on the 02 tank was set at 8L/min and adjusted the 02. When she was done, this surveyor asked that she view the 02 gauge. The 02 gauge was observed in the red, which indicated the tank was empty. The DON removed the nasal cannula tubing from the 02 tank, there was no sound of air escaping the 02 tank observed when the tubing was removed. The DON removed the 02 tank from the sleeve and stated she would get another 02 tank. Resident #46 was in no distress and continued to propel himself across the hall to the dining room. At 4:28 PM the DON returned with an 02 tank and placed it in the sleeve on the back of the resident's WC. This surveyor asked the DON if she had a pulse oximeter to check the resident's 02 sat. It took the DON approximately one minute to retrieve the pulse oximeter and at 4:29 PM the pulse oximeter was applied and the residents 02 sat was 74%. Resident #46 was in no respiratory distress; his breathing was normal, and his color was good. When asked if he felt ok, he nodded yes. At 4:30 PM the nasal cannula tubing was attached to the 02 tank by the DON. At 4:33 PM the Resident #46's 02 sat was 86% and at 4:34 PM the 02 sat was 92%. Resident #46 did not show any signs of distress at any time during the observation. During an interview and observation on 8/30/22 at 4:46 PM Nurse #2 explained, resident's that used 02 had their 02 sats measured every shift by either the nurse aide or nurse. If the 02 sat was below 90% it should be reported to the nurse. She further explained Resident #46 used 02 at 5L/min and she had not checked Resident #46's 02sat or tank yet because he was not in his room. She stated the resident was mobile in his WC and she would have to find him to check his 02 sat. Nurse #2 revealed she received report from Nurse #1 and Nurse #1 had changed resident #46's 02 tank and checked his 02 sat sometime before her shift ended. Nurse #2 stated she was not aware that the resident's 02 tank was set on 8L/min or that the in room concentrator was set on 6L/min. An observation was made with Nurse #2 of the 02 concentrator. Nurse #2 indicated the concentrator was set too high and she had adjusted it back to 5L/per min. She stated she did not know how that happened. An interview was conducted on 8/30/22 at 5:05 PM with the DON, who indicated she was not aware that Resident #46's 02 concentrator was set at 6L/min. She indicated nurses were responsible for ensuring their residents were receiving 02 at the ordered rate. During an interview on 8/31/22 at 11:00 AM Nurse #1 revealed she cared for Resident #46 during dayshift on 8/30/22. She further revealed the resident wore 5L/min and that she changed his 02 tank and turned the tank on 5L/min around 12:30 PM on 8/30/22. On 8/31/22 at 1:43 PM an interview was conducted with the oxygen vendor that supplies 02 tanks for the facility. The vendor revealed the facility used E sized tanks. An E sized tank that was completely full and had 02 running at 5L/min would be empty in 2 hours (hr) and 16 minutes (min). He further revealed if the E sized tank was completely full and had 02 running at 8L/min the tank would be empty in 1hr 25min. During an interview on 8/31/22 at 1:14 PM The Medical Director revealed he was familiar with Resident #46 and his need for 02 use. He indicated if the resident's 02 sats were lower than 88% he expected the staff to ensure the resident was wearing the 02 or encourage the resident to wear the 02 then recheck the 02 sat. If the 02 sat remained low, he expected to be notified. He further indicated he expected the nursing staff to use the ordered dose of 02. If there was a concern that the resident needed a change in the 02 dose, staff should call for a new order. The Medical Director stated he was aware of the events that took place with Resident #46 on 8/30/22 and did not believe the that it had any significant adverse effects on the resident.

Based on record review, and interviews with staff and Pharmacy Consultant, the facility failed to ensure a Medication Regimen Review was completed for 2 of 7 residents (Resident #10 and #11) reviewed for unnecessary medications. Findings Included: A review of the policy dated 11/28/12 titled Pharmacy Record Reviews read in part, the pharmacist shall be responsible to review the medication regimen of all residents at least on a monthly basis. 1.Resident #10 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia, major depressive disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10's cognition was severely impaired. Resident #10 was administered antianxiety medication and anticoagulant medication 7 of 7 days, antidepressant medication 6 of 7 days and opioid medication 5 of 7 days of the look back period. A review of the pharmacy consultant record sheet for resident #10 revealed the pharmacist reviewed the medications on 4/26/21. There was no review of resident #10's medication regimen for the month of March 2021. A review of the pharmacy consultation sheet showing one entry for April 2021 was shared with the Director of Nursing (DON) on 5/25/21 at 5:30 PM who stated when the pharmacist comes for her reviews she is given a census list and signs off on that census sheet that the medication regime review was completed. The Pharmacist then completes the Pharmacy Consultant Record sheet on each resident. The DON presented the documented signed off census sheet dated 3/31/21 showing the medication regimen review was completed by the Pharmacist. Resident #10 was listed on the census sheet. An interview was completed with the Pharmacist on 5/25/21 at 6:01 PM who reviewed the pharmacy consultant record sheet and stated she must have forgot to enter a note. The Pharmacist stated that she receives a census sheet, so she knows who she needs to review and then reviews the labs to see if there were any problems with the lab results. The Pharmacist stated she then reviews the resident's medications to see if there were any medication changes. If changes are needed, the Pharmacist will fill out a change form. If there are no recommendations, she will write no recommendations on the pharmacy consultation sheet for each resident. An interview was completed with the DON on 5/26/21 at 5:23 PM who stated that it is her expectation for the pharmacist to follow the policy and to review the medications monthly and document in the resident's medical record and submit her recommendations. The DON stated that her recommendations are hand delivered to the DON or will fax the report. A telephone interview was conducted with the medical director on 5/26/21 at 5:39 PM who stated that monthly reviews are helpful, and he was not aware some reviews were not completed. The medical Director stated that he reviews the recommendations when it is put in his box and if one did not show up, he would not be aware that a review was not completed. A phone interview as completed with the Pharmacist on 5/27/21 at 9:02 AM who agreed there was no entry on the consultant sheet for March for resident #10. The Pharmacist stated that if it is not on the pharmacy consultation sheet then she could not say a medication review was completed. The Pharmacist stated that going forward she will be printing the census in order of the halls and room numbers so nothing is omitted. An interview was completed with the administrator on 5/27/21 at 9:33 AM who stated that she would expect the pharmacist would conduct monthly reviews and document them in the medical record. 2. Resident #11 was admitted to the facility on [DATE]. His diagnoses included a progressive neurological condition, [CONDITION(S)], shortness of breath, hypertension, anxiety, [CONDITION(S)], [CONDITION(S)] and a history of stroke. The Quarterly Minimum Data Set (MDS) assessment completed on 02/25/21 indicated Resident #10 was not cognitively intact. Review of the medical record for the monthly Medication Regimen Review (MRR) for Resident #11 revealed the review was not completed in January 2021 or February 2021. An interview was conducted with the Pharmacist on 05/25/21 at 6:02 PM regarding the MRR. She stated she usually completed the medication reviews on each resident monthly. She stated if there was a recommended change, the Pharmacist completed the change form in addition to signing the pharmacy consultant record sheet in the patient record. A follow-up interview was done with the Pharmacist on 05/25/21 at 6:29 PM after she reviewed the records of concern that were missing the monthly MRR. She stated she must have missed Resident #11 during her monthly reviews. An interview with the Director of Nursing (DON) was done on 05/25/21 at 6:03 PM. She stated the MRR was supposed to be recorded in the chart monthly. An interview was conducted on 05/26/21 at 5:22 PM with the Director of Nursing regarding the Pharmacist's role with MRR. The DON noted the Pharmacist was to review the resident's information monthly and document the recommendations for the physician on the pharmacy consultant record. An interview was done on 05/26/21 at 5:39 PM with the Medical Director. The physician stated monthly medication reviews are helpful and he was not aware that the reviews had not been completed. He noted he reviewed the recommendation when it was put in his box and if one did not show up, he would not be aware that a review had not been completed. On 05/27/21 at 9:01 AM the Pharmacist was interviewed by phone regarding the Medication Regimen Review process that had been occurring monthly. She stated her monthly she had been reviewing resident records and would sign a census when she was done. The pharmacist gave the signed census to the DON. She noted in the future printing the census by room number may be more helpful. She said she understood that the census signature sheet was not sufficient, and she needed to document in the resident's record, as that was not meeting the requirements. The pharmacist noted she was going to work on a plan for the future, so no residents were omitted. An interview was conducted on 05/27/21 at 9:33 AM with the administrator regarding the Medication Regimen reviews that had not been done. She stated the monthly review of the medications should be completed and documented in the medical record.

Based on observation, record review and staff interviews, the facility failed to assess a resident for self-administration of medication for 1 of 1 resident (Resident #154) reviewed for self-administration of medication. Findings included: Review of facility policies entitled Self-Administration of Medication and Medication for Bedside Use read in part: Any resident who desires that they self-medicate will have the appropriate assessment form completed. If any resident self-medicates, this shall be included in the care plan. The interdisciplinary team shall be responsible for the assessment and compliance of any self-medicating resident. The facility shall complete a general assessment per request if resident desires for self-administering medications. Any medication dispensed to a patient for bedside use will bear all proper labeling as described in previous policy. In addition, the doctor will indicate in the orders that his medication is for bedside use. The label provided for this medication will state (MONTH) be kept at bedside. Any medication found in patient's room with this label will be removed. The medication will only be allowed if the self-medication for is completed the interdisciplinary team so indicates. The patient will have means for the bedside medications to be locked for security purposes. The patient will be taught proper administration and documentation if bedside meds are ordered and allowed. Resident # 154 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's most recent comprehensive MDS dated [DATE], and coded as an admission assessment, revealed the facility assessed the resident as having moderately impaired cognition. A review of the resident's baseline care plan dated 7/12/19 revealed there was no care plan in place for resident to self-administer her medications. A review of Resident #154's Medication Administration Record [REDACTED]. On 07/24/19 at 04:39 PM, Nurse #1 was observed administering medication to resident #154. During the observation, it was noted that there was a bottle of Latanoprost .005% ophthalmic solution, a bottle of artificial tears in a cup and a 100-gram tube of [MEDICATION NAME] Sodium 1% topical gel sitting on top of the bedside table. Immediately after the observation an interview was conducted with Nurse #1. During the interview she stated the medications that were in the room were used at home and brought in by the family. She further stated the resident's family was coming to pick up the medications. An interview was conducted with the Director of Nursing (DON) on 07/24/19 at 04:46 PM. She stated that families are told that all medications are to be given to the nurse. She further stated that the home medications are to be put up on the medication cart and sent back. The DON stated that she felt the family member had brought in the medications for the nurse to follow up with physician. The DON immediately went to the resident's room and removed the medications.

Based on record review, resident interview, and staff interviews the facility failed to record a grievance and failed to provide a written grievance summary for 2 of 2 residents reviewed for grievances (Resident #20 and Resident #27). Findings include: 1. Resident #20 was most recently readmitted on [DATE] and was originally admitted on [DATE]. Resident #20's cumulative [DIAGNOSES REDACTED]. Review of Resident #20's most recent Minimum Data Set (MDS) revealed a quarterly assessment with an Assessment Reference Date (ARD) of 4/12/18. The resident was coded as having been cognitively intact. The resident was coded as having had no hallucinations or delusions and did not display any abnormal behavior. An interview was conducted with Resident #20 on 6/4/18 at 3:09 PM. Resident #20 stated he had 2 shirts which were missing, University of South Carolina (USC) shirts, one black and one garnet colored. The resident stated he had reported it to a staff person at the facility and he had been told by a facility staff person the shirt had been looked for but shirt could not be located. Review of the facility grievances since 3/1/18 revealed no recorded grievances in regards to Resident #20 alleging he was missing any items. An interview was conducted on 6/6/18 at 4:41 PM with the Activities Director (AD) and Resident #20. The resident stated he was missing three USC shirts, one was garnet and the other two were black. The AD looked into the resident's closet and found one garnet USC shirt. The resident stated the shirt was not the shirt which was missing. The AD continued to look for the alleged missing shirts and she was unable to locate them. The AD informed the resident she was going to look for his alleged missing shirts. An interview was conducted on 6/7/18 at 11:59 PM with the AD. The AD stated she had ordered three shirts for the Resident #20 to replace the alleged missing shirts. The AD stated she told the Administrator about the alleged missing shirts. An interview was conducted on 6/7/18 at 12:18 PM with the AD. The AD stated she had completed a Missing/Damaged Item Form for the alleged missing shirts of Resident #20. The AD stated she had not completed a grievance/complaint form for the resident's alleged missing shirts. An interview conducted on 6/7/18 at approximately 12:30 PM was conducted with the Housekeeping Director (HD). The HD stated she had not completed a grievance form for missing clothing articles. The HD stated the process usually was to write a note and pin it on the bulletin board if a resident informed her of missing clothing items. An interview was conducted with the Administrator on 6/7/18 at 1:52 PM. The Administrator stated the facility had not been completing grievance forms for missing items such as clothing. The Administrator stated grievance forms were available at the nurses' station and it was the responsibility of the nurses give out or fill out a grievance form. The Administrator stated it was her expectation to complete a grievance form if an item was established as missing. 2. Resident #27 was admitted to the facility on [DATE]. Resident #20's admission [DIAGNOSES REDACTED]. Review of Resident #27's most recent Minimum Data Set (MDS) revealed a comprehensive admission assessment with an Assessment Reference Date (ARD) of 4/20/18. The resident was coded as having had moderately impaired cognition. The resident was coded as having had no hallucinations or delusions and had not displayed any abnormal behavior. An interview was conducted with Resident #27 on 6/4/18 at 10:38 AM. Resident #27 stated she had had some money come up missing. Review of the facility grievances since 10/1/17 revealed no recorded grievances in regards to Resident #27 alleging she was missing any items. An interview was conducted with the AD and Resident #27 on 6/7/18 at 12:05 PM. The resident informed the AD she had some missing money. The AD stated to the resident she would discuss the missing money with the resident's nurse. The AD looked in the resident's night stand and discovered a wallet with a $5 bill in it. The resident stated her husband had recently placed the $5 bill in the wallet to replace the money which was missing. An interview was conducted with the AD on 6/7/18 at 12:06 PM with the AD. The AD stated she would follow up with the resident's nurse because some residents had made allegations of missing money but the residents actually had not had money. The AD further explained residents were sometimes confused and had alleged to have had missing money but had not actually had money or money which was missing. The AD also stated she was going to inform the Administrator. The AD added the resident's husband was supposed to be visiting the facility in the afternoon and she would discuss the alleged missing money with him when he arrived. The AD stated she would not fill out a grievance form for the alleged missing money. An interview was conducted with Nurse #1 on 6/7/18 at 12:08 PM. The nurse stated she would tell the Social Worker (SW) about the missing money Resident #27 had alleged was missing. The nurse stated if the SW was not at the facility then she would look for the money herself. The nurse added she would tell oncoming nurses about the alleged missing money in the shift report. The nurse stated she would not fill out a grievance form the alleged missing money. An interview was conducted with the Administrator on 6/7/18 at 1:52 PM. The Administrator stated the facility had not been completing grievance forms for missing items. The Administrator stated a grievance form had not been completed for Resident #27's alleged missing money because the facility staff was in the midst of investigating if the alleged money was really missing. The Administrator stated grievance forms were available at the nurses' station and it was the responsibility of the nurses give out or fill out a grievance form. The Administrator stated it was her expectation to complete a grievance form if an item was established as missing.

Based on record review and staff interviews, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form CMS- to the facility residents prior to discharge from Medicare Part A Services for 2 of 3 residents (# 6 and # 107) reviewed. Findings included: A. Resident # 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of records revealed Resident # 6 Medicare Part A Services began on 2/2/2018 and terminated on 3/12/2018. Resident # 6 was discharged from Medicare Covered Part A stay with benefit days remaining. The SNFABN Form CMS was not provided to Resident # 6 by the facility. B. Resident # 107 was admitted to the facility on [DATE] with general weakness, hypertension and dementia. Record review revealed Resident # 107 Medicare Part A Services began on 2/12/2018 and terminated on 3/10/2018. The SNFABN Form CMS was not provided to Resident # 107 representative by the facility. An interview with the business officer manager on 6/7/2018 at 10:45 AM revealed she did not issue the SNFABN to Resident # 6 and Resident # 107. She further revealed she did not know that the SNFABN Form CMS was required if the resident was issued a Notification of Medicare Non-Coverage (NOMNC) Form CMS . The business office manager revealed that she has never issued the SNFABN to residents. An interview with the administrator on 6/7/2018 at 11:05 AM revealed she expected the business office manager to issue the SNFABN Form CMS to residents who received Medicare Part A Services prior to discharge. The administrator acknowledged that the facility had failed to provide the form to the facility residents.

Based on observations, record reviews and staff interviews, the facility failed to provide a clean and comfortable interior environment for 4 of 5 rooms (Rooms # 48, 52, 55 and 61) and 1 of 2 hallways (Spring Hall) reviewed. Findings included: 1. An observation in Room # 61 on 6/4/2018 at 10:20 am revealed: a. Wallpaper to the left of the window was torn off in an approximate 3 feet by 3 feet square with sheetrock exposed. b. The filter to the package terminal air conditioner (PTAC) contained a moderately thick layer of dust, lint and debris. c. Loose and peeling joint tape on the ceiling above the doorway. d. A follow up observation in Room # 61 on 6/5/2018 at 4:30 pm revealed the filter contained a moderately thick layer of dust, lint and debris. Review of the facilities maintenance room audits dated (MONTH) (YEAR), the only audit log on file, did not reveal any concerns to the areas observed in Rooms # 48, 52, 55 and 61. Review of the facilities housekeeping log revealed that the vents and PTAC filters in Rooms # 48, 52, 55 and 61 were cleaned on 4/15/2018 and 5/3/2018. During an interview with the Maintenance Director and Administrator on 6/6/2018 at 8:59 am both parties observed the wallpaper to the left of the window that was torn off in an approximate 3 feet by 3 feet square with sheetrock exposed in Room # 61. The Maintenance Director revealed that he was not aware of the walls condition. The Administrator revealed that she was aware of the walls condition and it had been in that state for an extended time. 2. An observation in Room # 55 on 6/4/2018 at 2:31 pm revealed: a. Wallpaper torn in a scaling pattern to the left of the window. b. Brown water stains to the ceiling in the corner next to the window. An interview with Aide #1 on 6/5/2018 at 4:17 pm revealed that she was frequently assigned to Rooms # 48, 52, 55 and 61. She revealed that all staff could submit maintenance requisitions for work orders. Aide # 1 reported that a copy of the maintenance requisition went to the administrator and the other copy was placed in a mailbox centrally located for the maintenance director. She further revealed that she was not sure who cleaned the vents and filters but housekeeping washed the privacy curtains. Aide # 1 was assigned to Room # 55 and was aware of the torn wallpaper and brown water stains on the ceiling but had not completed any work orders to maintenance. 3. An observation in Room # 52 on 6/6/2018 at 10:48 am revealed: a. Dark brown dried substance on the privacy curtain of the bed near the door. b. The plastic corner protector at the bathroom entrance was cracked and broken at the top. 4. An observation in Room # 48 on 6/6/2018 at 10:50 am revealed: a. The plastic corner protector at the bathroom entrance was cracked and broken at the top. b. Peeled and hanging wallpaper near the right side of the overhead light by the bed next to the window. An interview with Housekeeper # 1 on 6/6/2018 at 10:43 am revealed she regularly was assigned to Rooms # 48, 52, 55 and 61. She further revealed that housekeeping staff reported work orders to maintenance, filter cleaning was done by maintenance and the housekeeping supervisor was responsible for cleaning the privacy curtains. Housekeeping #1 had not completed any work orders to maintenance for Rooms # 48, 52, 55 or 61. An interview with the Housekeeping Supervisor on 6/6/2018 at 12:36 pm revealed that housekeeping staff cleaned the PTAC filters monthly and mattresses and privacy curtains biannually or when residents depart or are removed from isolation. The Housekeeping Supervisor further revealed that there was no formal method of checking or auditing the condition of the rooms. She reported that she relied on the facility staff to notify when housekeeping is needed. The Housekeeping Supervisor provided an informal log of handwritten notes as the cleaning log. 5. An observation of the ceiling on Spring Hall near the nurse's station on 6/5/2018 revealed: a. An approximately 4 feet by 3 feet oval area of brown water stained celling with three 6-inch pieces of dangling sheetrock. b. Loose and peeling joint tape. During an interview with the Maintenance Director and Administrator on 6/6/2018 at 8:59 am both parties observed the approximately 4 feet by 3 feet oval area of brown water stained celling with three 6-inch pieces of dangling sheetrock on the Spring Hall near the nurse's station. The Administrator revealed that she was aware of condition of the ceiling but there were no current work orders to repair the area. An interview with the Maintenance Director and Administrator on 6/6/2018 at 8:59 am revealed the Administrator assumed responsibility of maintaining the facility's maintenance system. The Administrator revealed that was no formal maintenance process, as the staff submitted the work orders she prioritized which order needed to completed first. The Administrator further revealed that she kept all records of the maintenance work order requisitions. An interview with the Administrator on 6/7/2018 at 11:05 am revealed that she expected all the residents in the facility to have a clean and comfortable environment free from disrepair. She further revealed that she expected all staff to submit work orders to the maintenance box for conditions that needed to be repaired.

Based on record review, observations and staff interview the facility failed to remove expired medications from 2 of 2 medication carts checked for medication storage (summer medication cart and spring medication cart). The findings included: Review of the FDA recommended storage instructions dated 2012 for Ipratropium Bromide/Albuterol Sulfate revealed the vials should be protected from light before use. Therefore, keep the unused vials in the foil pouch or carton. Do not use after the expiration date printed on the carton. An observation of the summer hall medication cart on 8/3/16 at 10:07 AM revealed a foil package of Ipratropium Bromide/Albuterol Sulfate that was opened and was not labeled or dated when it was opened. The foil package was not sealed shut. The expiration date on the back of the package was dated 07/16. Four of the individual plastic vials were also dated 07/2016. Continued observation of the summer hall medication cart revealed a box of MAPAP 325 milligrams (mg) (used for Tylenol) tablets labeled for Resident # 31 had a hand written expiration date on it of 6/2016. Five individual MAPAP pills packages had the expiration date of 6/16 and two MAPAP pill packages had an expiration date of 5/16. Resident #31 ' s Medication Administration Record [REDACTED]. An observation of the spring hall medication cart on 8/3/16 at 10:34 AM revealed a box of acetaminophen suppositories available for use and labeled for Resident #24. The box contained an expiration date of 7/2016. There were six suppository bullets inside the box. Resident #24 ' s MAR indicated [REDACTED]. Nurse #1 was interviewed on 8/3/16 at 11:08 AM. She stated it varied who checked the medication carts .It was based on whomever had the time. If a medication had expired then they would send it back to the pharmacy to be replaced. Nurse #2 was interviewed on 8/3/16 at 12:36 PM. She stated the nurses are supposed to check the medications and it depends on whomever had the time to check it. She stated she was unaware about the dating or storage of the ipratropium/albuterol solution. Nurse #3 was interviewed on 8/3/16 at 12:38 PM. She stated she called the company about information on the ipratropium/albuterol medication. She stated if the vials of ipratropium/albuterol solution were in the foil pack and were folded over and sealed with a piece of tape then the vials were good until the expiration date on the carton. If the vials were not in the foil package and exposed to light then they had to be used within a week. The Director of Nursing was interviewed on 8/4/16 at 1:29 PM. She stated if a physician stopped or discontinued a medication then it would be returned to pharmacy. She stated she had talked to the administrator about getting a new process for checking the medications. The pharmacist came every month and checking for expired medications was on her list of things to do. The nurse that pulled the medication should also check that it is in date. The expectation was the medications that are stored in the medication carts to be in date. The staff pharmacist was interviewed on 8/4/16 at 2:12 PM. She stated for the nursing home side of the building, she checked the emergency medication box, reviewed resident ' s charts and wrote recommendations for the physician. She also checked for out of date drugs in the cabinets and refrigerator. She stated she does not check the medication carts. She does not have the key to the medication cart.

Based on record review, observation and staff interview, the facility failed to wear a hairnet and to completely cover the hair with a hairnet, failed to air dry the dome lids, failed to date and label food and to discard outdated food in the refrigerator, failed to wash hands consistently between dirty and clean dishes and failed to operate the dishwashing machine properly. The findings included: 1. The facility's policy on hair restraints (undated) was reviewed. The policy read in part " food employees shall wear hair restraints such as hats, hair covering or nets, beard restraints and clothing that cover body hair that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens, unwrapped single-service and single use articles. " On 7/14/14 at 11:15 AM, initial tour of the kitchen was conducted with administrative staff #1. Administrative staff #1 was observed not wearing a hairnet during the tour. On 7/15/14 at 1:40 PM, kitchen observation was conducted with administrative staff #1. Again, administrative staff #1 was not wearing a hairnet. On 7/15/14 at 4:30 PM, observation of the tray line was conducted with the administrative staff #1. Again, she was observed not wearing a hairnet. Dietary Aide #2 was also observed assisting on the tray line with a hairnet on but the hairnet did not completely cover the hair above her forehead. On 7/16/14 at 11:30 AM, administrative staff #1 was interviewed. She provided a copy of the facility's policy on hair restraints. She stated that the policy indicated that all dietary employees should be wearing a hairnet and she should be wearing it also. She indicated that she had a hairnet in her office and she will be wearing it from now on. She added that she had in-serviced the dietary staff on 7/15/14 regarding the use of the hair restraints including dietary aide #2. Dietary aide #2 was instructed to completely cover her hair with the hairnet. 2. On 7/14/14 at 11:15 AM, initial tour of the kitchen was conducted. There were 2 large plastic containers observed in the refrigerator that were not labeled and dated. There was also a plastic container of cottage cheese with an open date of 6/30/14 and the use by date was 7/6/14. The manufacturer ' s expiration date (use by date) listed on the container was 7/11/14. Upon interview with the administrative staff #1 at 11:25 AM, she stated that the label and date on the 2 large plastic containers had sweated off. She revealed that one plastic container was a mayonnaise and the other container was a home made ranch dressing. She also stated that the cottage cheese was expired and should have been discarded. 3. On 7/15/14 at 1:40 PM, kitchen observation was conducted. There were eight dome lids observed inside the storage bin that were stocked wet. Upon interview with the administrative staff #1 at 1:50 PM, she indicated that the dietary staff members were instructed to make sure the dishes were dry before putting them in the storage bin. 4. On 7/15/14 at 1:40 PM, dietary aide #1 was observed operating the dishwashing machine. The final rinse temperature was observed between 156-168 degrees. Dietary aide #1 was interviewed. She stated that she was assigned to wash the dishes after breakfast and lunch. She indicated that the final rinse temperature was always on the 180 degrees centigrade (C) and she did not know why it was not reaching that temperature. She also stated that there was a leak at the back of the machine and that might be the reason why the temperature was not reaching 180 degrees. She indicated that the maintenance was aware of the leak and had ordered the parts. At 1:50 PM, administrative staff #1 came to observe the dishwashing machine and agreed that the temperature was not reaching 180 degrees. She indicated that she would call the maintenance staff. At 1:55 PM, maintenance staff member came to observe the dishwashing machine. He also agreed that the temperature was not reaching 180 degrees. Dietary aide #1 was operating the dishwashing machine during the entire observation. The dietary aide was observed opening the machine before the final rinse cycle was completed. At 2:10 PM, the maintenance staff member indicated that he will check the machine and will get back with me. At 4:15 PM, the maintenance staff member revealed that the dishwashing machine was working properly and reaching more than 180 degrees during the final rinse cycle. He indicated that dietary aide #1 was not waiting for the final rinse cycle to complete before opening the machine and that was the reason why the temperature was not reaching 180 degrees. On 7/15/14 at 4:30 PM, the dishwashing machine was observed. The final rinse temperature was 184 degrees at this time. On 7/16/14 at 11:30 AM, administrative staff #1 was interviewed. She indicated that she had in-serviced all dietary aide including dietary aide #1 on how to operate the dishwashing machine properly. 5. On 7/15/14 at 1:40 PM, dietary aide #1 was continuously observed operating the dishwashing machine. She was observed washing the dirty dishes with no gloves on and was loading them in the dishwashing machine. After loading the dirty dishes, she handled the clean dishes. She was observed handling the dirty and clean dishes five times and had washed her hands only twice. At 1:50 PM, dietary aide #1 was interviewed. She stated that she was aware that she had to wash her hands between dirty and clean. On 7/16/14 at 11:30 AM, administrative staff #1 was interviewed. She stated that she had in-serviced all dietary staff including dietary staff #1 to wash hands between dirty and clean dishes on 7/15/14.

Based on observation, medical record review and staff interviews, the facility failed to check a gastrostomy tube for residual as ordered prior to medication administration for one of two residents observed for medication administration via a gastrostomy tube (resident # 17). The findings included: A record review for the undated Policy and Procedures for Medication Administration via Gastrostomy Tube was conducted. The policy stated "The nurse shall follow facility accepted policies unless otherwise specified in a physician order" . The policy also stated to "Check the tube for residual by the use of a piston syringe aspiration-standard to withhold medication administration if more than 2 hours of feeding aspirated-hold or check physician orders [REDACTED]. Resident # 17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. Hold if residual > (greater than) 150 cubic centimeters." Nurse # 3 was observed administering medication to resident # 17 via a peg tube on 7/15/14 at 10:13 AM. Nurse # 3 did not check the peg tube for residual by the use of a piston syringe aspiration prior to medication administration. An interview was conducted on 7/16/14 at 2:32 PM with Nurse # 3. Nurse # 3 stated she did not check the resident's peg tube for residual on 7/15/14 at 10:13 AM because the resident did not have residual when it was checked in the past. Nurse # 3 stated the last time she checked the resident's peg tube for residual was sometime during the previous week. An interview with Administrative Staff # 2 was conducted on 7/16/14 at 3:20 PM. Administrative Staff # 2 stated the nurses were expected to check for residual prior to administering medication via a peg tube.

Based on observation and staff interviews, the facility failed to discard expired medication (Phenergan injection) and failed to date one Advair diskus and three bottles of Pro-Stat (protein supplement) when opened on two of two medication carts. The findings included: 1. The Manufacturer's insert for Advair Diskus read, in part, "Safely discard ADVAIR DISKUS 1 month after you remove it from the foil pouch, or after the dose indicator reads "0", whichever comes first. Take ADVAIR DISKUS out of the box and foil pouch. Write the "Pouch opened" and "Use by" dates on the label on top of the Diskus. The "use by" date is 1 month from date of opening the pouch." On 7/15/14 at 11:00AM, an observation of the medication cart for summer hall was conducted and revealed one Advair Diskus 500/50 mcg. Thirty six (36) doses remained in the diskus. No date was noted to indicate when the diskus had been opened. On 7/15/14 at 11:00AM, Nurse #1 stated they did not date the Advair diskus when opened and there was not a policy regarding dating the Advair diskus when they opened it. She said she was not aware it should be dated. On 7/15/14 at 4:31PM, the pharmacist stated there was not a policy to date the Advair diskus because the medication was scheduled to be used one capsule twice a day and did not need to be dated. She said if it was used in a home situation, it might be dated to ensure the drug was used twice a day and within 30 days but, in a long term care setting, the drug was ordered BID (twice daily) and was given BID as scheduled and would be empty at the end of thirty days. 2. The manufacturer's specifications for Pro-Stat read, in part, "Storage Instructions: Discard 3 months after opening. Record date opened on bottle of container." An observation of the Spring Hall medication cart on 7/16/14 at 10:56 AM revealed three opened 30 ounce bottles of Pro-Stat. No date was noted to indicate when the three bottles had been opened. An interview with Nurse #2 was conducted on 7/16/14 at 11:00 AM. Nurse #2 stated the facility did not require the date of opening to be placed on bottles of Pro-Stat. An interview with Administrative Staff #2 was conducted on 7/16/14 at 3:20 PM. Administrative Staff #2 stated the opening date was not expected to be recorded on a bottle of Pro-Stat because the entire bottle is generally administered before a three month period. 3. An observation of the Spring Hall medication cart on 7/16/14 at 10:56 AM was conducted. Three unopened ampules of phenergan 25 milligrams per milliliter with an expiration date of 4/20/14 were observed in the medication cart. An interview with Nurse #2 was conducted on 7/16/14 at 11:00 AM. Nurse #2 stated the nursing staff was expected to check the expiration date of medications prior to administration. The nursing staff was not expected to routinely check the medication carts for expired medications. No facility staff was assigned to routinely check the carts for expired medication. An interview with Administrative Staff #2 was conducted on 7/16/14 at 3:20 PM. Administrative Staff #2 stated the pharmacist was expected to check the medication carts on a monthly basis and to remove all expired medication from the carts. The nurses were expected to check the expiration date of medication prior to drug administration. If an expired medication was found, the nurses were expected to remove it from the cart immediately.

Based on medical record review and staff interview, the facility failed to accurately code for prognosis of life expectancy less than six months for three of seven residents with a coded prognosis of less than six months on the Minimum Data Set assessment (Resident #47, Resident #38 and Resident #26). The findings included: 1. Resident #47 was admitted to the facility 9/17/12. Cumulative [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #47 had a condition or chronic disease that may result in a life expectancy of less than 6 months. A review of the medical record revealed the Terminal Illness Progress Note had checked Terminal illness that because of its nature can be expected to cause a resident to die--usually chronic diseases for which there is no cure. On 5/29/14, it was noted as terminal dementia. A physician's progress note dated 7/9/14 stated clinical impression: Dementia. The physician did not indicate that this was a [DIAGNOSES REDACTED]. The statement "Approaching or close to death in clinical symptoms" was not checked. On 7/16/14 at 12:07 PM, an interview with MDS Coordinator #1 revealed that the MDS Coordinators looked at the [DIAGNOSES REDACTED]. MDS Coordinator #1 acknowledged that physician documentation was required for this section. She also indicated that that the word terminal in front of a [DIAGNOSES REDACTED]." Yes" . MDS Coordinator #1 indicated that they did not look for documentation from the physician of life expectancy or of end of life clinical symptoms and potential care considerations. The Terminal Illness Progress form was reviewed with MDS Coordinator #1. She acknowledged that the definition on the form for Terminal illness did not necessarily indicate a life expectancy of less than 6 months. She also was not certain if the physician intended that each resident in the facility with a terminal or end stage [DIAGNOSES REDACTED]. On 7/16/14 at 4:40 PM, a telephone interview with the physician revealed that when he documented a condition, illness or disease as terminal he did not necessarily mean that they were nearing the end of life clinically or that their life expectancy may be less than 6 months. He stated that what he meant by terminal was that it was not curable and that it eventually would contribute to or be the cause of their death. 2. Resident #38 was last admitted to the facility 8/1/12. Cumulative [DIAGNOSES REDACTED]. A Quarterly MDS dated [DATE] indicated Resident #38 had a condition or chronic disease that may result in a life expectancy of less than 6 months. A review of the medical record revealed the Terminal Illness Progress Note had checked Terminal illness that because of its nature can be expected to cause a resident to die--usually chronic diseases for which there is no cure. Also checked was final stage of illness. A date of 1/15/14 indicated end stage [MEDICAL CONDITION]. A physician's progress note dated 7/9/14 stated clinical impression: end stage [MEDICAL CONDITION]. The physician did not indicate that this was a [DIAGNOSES REDACTED]. The statement "Approaching or close to death in clinical symptoms" was not checked. On 7/16/14 at 12:07 PM, an interview with MDS Coordinator #1 revealed that the MDS Coordinators looked at the [DIAGNOSES REDACTED]. MDS Coordinator #1 acknowledged that physician documentation was required for this section. She also indicated that that the word terminal in front of a [DIAGNOSES REDACTED]."Yes" . MDS Coordinator #1 indicated that they did not look for documentation from the physician of life expectancy or of end of life clinical symptoms and potential care considerations. The Terminal Illness Progress form was reviewed with MDS Coordinator #1. She acknowledged that the definition on the form for Terminal illness did not necessarily indicate a life expectancy of less than 6 months. She also was not certain if the physician intended that each resident in the facility with a terminal or end stage [DIAGNOSES REDACTED]. On 7/16/14 at 4:40 PM, a telephone interview with the physician revealed that when he documented a condition, illness or disease as terminal he did not necessarily mean that they were nearing the end of life clinically or that their life expectancy may be less than 6 months. He stated that what he meant by terminal was that it was not curable and that it eventually would contribute to or be the cause of their death. 3. Resident #26 was admitted to the facility 3/10/12. Cumulative [DIAGNOSES REDACTED]. A review of the medical record revealed the Terminal Illness Progress Note had a check mark next to the following statement: "Terminal illness that because of its nature can be expected to cause a resident to die--usually chronic diseases for which there is no cure." The statement "Approaching or close to death in clinical symptoms" was not checked. " Terminal MS " was handwritten on the form and dated 8/8/12 and 2/6/13. A Significant Change Minimum Data Set (MDS) assessment dated [DATE], a Quarterly MDS dated [DATE] and a Significant Change MDS dated [DATE] indicated Resident #26 had a condition or chronic disease that may result in a life expectancy of less than 6 months. The monthly physician's progress notes from 1/4/14 to 7/9/14 were reviewed and under clinical impression they all had a hand written [DIAGNOSES REDACTED]. On 7/16/14 at 12:07 PM, an interview with MDS Coordinator #1 revealed that the MDS Coordinators looked at the [DIAGNOSES REDACTED]. MDS Coordinator #1 acknowledged that physician documentation was required for this section. She also indicated that that the word terminal in front of a [DIAGNOSES REDACTED]." Yes " . MDS Coordinator #1 indicated that they did not look for documentation from the physician of life expectancy or of end of life clinical symptoms and potential care considerations. The Terminal Illness Progress form was reviewed with MDS Coordinator #1. She acknowledged that the definition on the form for Terminal illness did not necessarily indicate a life expectancy of less than 6 months. She also was not certain if the physician intended that each resident in the facility with a terminal or end stage [DIAGNOSES REDACTED]. On 7/16/14 at 4:40 PM, a telephone interview with the physician revealed that when he documented a condition, illness or disease as terminal he did not necessarily mean that they were nearing the end of life clinically or that their life expectancy may be less than 6 months. He stated that what he meant by terminal was that it was not curable and that it eventually would contribute to or be the cause of their death. He added that he did not think that Resident #6 was nearing the end of her life clinically or that she may have less than a 6 month life expectancy.

Based on observation and staff interviews the facility failed to equip 2 of 2 corridors with firmly secured handrails (summer corridor, spring hall corridor). The findings include: Observation on 4-4-12 at 1:00pm revealed 13 loose handrails on 2 of 2 corridors. 1 handrail located outside of the facilities utility room revealed 1 exposed nail as evidenced by a bracket screw being exposed. Further observation revealed 1 handrail with the metal exposed located across from the nursing station. Loose handrails were observed outside resident rooms (spring corridor) 48, 49, 53, 55, 58, 59 and out side resident rooms (summer corridor) 60, 62, 64, 71, and 73. During an interview on 4-4-13 at 1:15pm, the Maintenance Director indicated he was made aware of needed repairs by work orders submitted by staff or requests from residents. The Maintenance Director further indicated he had not observed any work orders in regards to loose handrails. The Maintenance Director revealed that he periodically checked corridor handrails to identify potential maintenance concerns. On 4-4-13 at 1:16pm, the Maintenance Director observed handrails and indicated they were loose. The Maintenance Director further indicated that handrails may have become loose by furniture that was moved throughout the facility. The maintenance director provided examples of hospital beds and other medical devices that are repeatedly pushed up against the handrails. During an interview on 4-4-13 at 3:54pm, the Administrator revealed handrails were a part of the facility Quality Assurance Review process. The Administrator indicated that the Maintenance Director performed his own Quality Assurance Review on the facility handrails. On 4-4-13 at 4:00pm, the Administrator observed handrails and indicated that not many residents use the handrails. The Administrator identified the handrails as a "A little loose. " The Administrator further indicated that items pushed up against the handrails could be the cause for handrails to become loose.

Based on observations, staff interview, pharmacy consultant interview and policy review the facility failed to maintain temperatures in the medication refrigerator between 36 degrees Fahrenheit to 46 degrees Fahrenheit to prevent compromise of the integrity of the insulins. The facility failed to have a door covering the freezer with insulins stored in the top shelf compartment to the refrigerator door. This was for one of one medication refrigerators. The findings included: Review of a document " Medication Storage and Security " which was not dated, gave instructions on medication storage. " Medications that require refrigeration will be kept in the medication room refrigerator. The temperature shall be maintained at 36-46 degrees F. (Fahrenheit) ... " Observations on 4/2/13 of the refrigerator in the medication room at 11:00 AM revealed multidose insulin vials were stored on the shelf compartments on the inside of the refrigerator door. The freezer was frosted with ice accumulation and had no door to block the freezer air from the insulins on the inside of the refrigerator door. The top shelf was near the freezer compartment when closed. There were five opened multidose insulins stored in this top shelf compartment. Review of an insert for one of the insulins revealed manufacturer ' s recommendations were to keep the insulin from freezing temperatures. The refrigerator temperature control logs for the months of March 2013 and April 2013 were posted on the wall of the medication room. Review of the recorded temperature checks revealed the following: 3/1/13 , 3/9 and 3/14/13 temperatures were 32 degrees F, 3/2, 3/3, 3/5, 3/7, 3/12, 3/13/13 temperatures were 34 degrees F; and on 4/1/13 temperature was 34 degrees F. There were three days in March with no recorded temperature checks. The remaining days had temperatures in the specified ranges. Interview with nurse #3 on 4/1/13 at 11:05 AM revealed she was not aware the medication refrigerator temperature should be at 36 degrees. Further interview revealed she was not aware insulin multidose vials should not be kept at freezing temperatures or the medication would be compromised. Follow up interview with Administrative nursing staff #1 on 4/2/13 at 1:45 PM revealed she had checked the policy for medication storage and the temperature and it was supposed to be 36 degrees Fahrenheit to 46 degrees Fahrenheit. She was not aware the refrigerator temperatures had been too cold. An interview was conducted by phone on 4/4/13 at 9:52 AM with the pharmacy consultant regarding medication storage in the refrigerator. The consulting pharmacist does check the temperatures of the medication refrigerator during her visits. She had not noticed temperatures being out of range at her monthly visits to the facility. The pharmacy consultant was not sure the exact range of the temperatures but freezing would be too cold.

Based on observations, staff interviews, and policy review one of five nurses failed to wash her hands between tasks that involved invasive procedures and medication administration observed during medication administration (Resident #41) and a direct care staff member failed to wash her hands between resident to resident care during dining (Resident #50 and #30) and after touching soiled clothing protectors and returning to assist with feeding. The findings include: 1. Review of the policy with instructions for hand washing included: " Methods of Compliance " no date. " A. Work Practices .... #2. Hand washing - This facility ensures that all employees wash hands using soap, running water and friction in the following situations: b. Immediately after or as soon as feasible following contact with blood or other potentially infectious materials (other skin should be washed with soap and water and mucous membranes flushed with water after such contact); c. Immediately or as soon as feasible after removal of gloves or other personal protective equipment. During medication pass on 4/2/13 at 3:45 PM with Nurse #4 observations of a finger stick blood sugar was performed on Resident # 41. Nurse #4 returned to the medication cart, disposed of the glucose strip and lancet, stored the glucometer in its container, removed her gloves and began to prepare the insulin injection. After the insulin was administered to Resident #41, nurse #4 disposed of the syringe, removed her gloves and started to proceed with the next resident ' s finger stick blood sugar check. Interview with nurse #4 at 3:49 PM on 4/2/13 revealed she usually uses the hand sanitizer, but was nervous being watched during med pass. Nurse #4 stopped, washed her hands before proceeding with the next finger stick blood sugar check. Interview with Administrative nurse staff #1 on 4/4/13 at 2:35 PM revealed the nurse should have washed her hands after the finger stick was completed and after the injection was administered. Her hands should be washed after any invasive procedure. 2. The facility's infection control policy related to hand washing procedures, which was undated, indicated that employees are expected to wash their hands using soap, running water and friction immediately after, or as soon as feasible, following contact with potentially infectious materials and immediately, or as soon as feasible, after removal of gloves or other personal protective equipment. It further indicated that hand washing facilities are " readily accessible to employees at the facility " including in the kitchen and activity room. On 4/3/13 at 1:20 pm, Nursing Assistant (NA) #1 was observed during the lunch meal in the dining room. She was wearing gloves and feeding Resident #50 a peanut butter and jelly sandwich and soup. NA#1 wiped the mouth of Resident #50 with the resident's bib. NA #1 patted Resident #50 on the shoulder, walked to Resident #30's table, picked up Resident #30's cup by the mouth of the cup and moved it closer to the resident. She did not change gloves or wash her hands in between the residents. A hand washing area was located in the dining room, to the right side of the door leading from the dining room into the kitchen. On 4/3/13 at 1:25 pm, NA #1 picked up dirty trays, plates, cups, and utensils from various tables in the dining room and placed the dirty items in the food cart. She did not change gloves or wash her hands after handling the dirty items. On 4/3/13 at 1:27 pm, NA #1 walked back to Resident #30. She picked up the resident 's ice cream cup, picked up her spoon, placed it in the ice cream cup and handed it to the resident. She did not change gloves or wash her hands before handling the resident's ice cream cup or spoon. On 4/3/13 at 1:30 pm NA #1 was interviewed and indicated she washes her hands in between residents and after feeding them. On 4/4/13 at 10:00 am the DON was interviewed regarding infection control. She indicated that she was the infection control representative for the facility. She indicated that staff wear gloves when feeding residents and are trained to change gloves and wash hands in between feeding residents. .

Based on observations, medical record review and staff interviews the facility failed to identify the use of a table top tray on a geri chair as a restraint, and provided no medical symptom for the restraint use. and did not assess the table top tray as a restraint for one (Resident #48) of four sampled residents with restraints. The findings included: Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an assessment dated [DATE] for the use of side rails revealed one side rail was used and Resident #48 was " up ad lib " (as desired). There were no other assessments of potential restraints. Review of Nursing Annual/Update assessment dated [DATE] revealed functional abilities for ambulation by "self" and "travels" by "self" and Transfers - "self". No assistance was required for these Activities of Daily Living (ADLs). Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #48 had short and long term memory impairment and severe impairment in daily decision making abilities. Resident #48 required total assistance by staff with eating, personal hygiene and toileting. Resident #48 could transfer and walk in the hallway with supervision, and could walk in her room independently. The use of a chair that prevents rising as a restraint was not assessed on the MDS. Review of the care plan updated 3/13/13 revealed a problem of dysphagia and ongoing weight loss due to refusal/poor meal intake related to terminal Alzheimer's and anorexia. The approaches included for staff to ensure she was out of bed to a reclining chair for all meals. This required the use of Geri-chair with a table top tray (attached tray on chair) for meal times to maintain resident in sedentary position for improved intake. Staff were to ensure the tray was removed after meal completion. Review of the medical record revealed, no restraint assessment for the use of the table top tray attached to the geri chair and no identified medical necessity or [DIAGNOSES REDACTED]. During initial tour on 4/1/13 at 10:45 AM Resident #48 was observed in a geri chair with a table top tray attached to the chair. Observations on 4/1/13 at 12:33 PM revealed Resident #48 was being wheeled by a direct care staff member down the hall. An administrative nursing staff member stopped the direct care staff and informed her Resident #48 could walk. Resident #48 walked with hand held assistance of one staff to the dining room. In the dining room, Resident #48 sat in the geri chair. The table top tray was attached over the resident ' s lap. The resident was unable to rise from the chair. She was observed tapping her foot, scooting herself away from the table and putting her head down on the tray. She remained seated in the geri chair with the table top tray in place from 12:40 PM to 1:16 PM. The staff in the dining room had not served her tray, or attempted to feed her. The tray was served at 1:16 PM by a direct care staff member. The food was not placed on the lap buddy. Resident #48 refused to eat and did not attempt to feed herself. The table top tray was removed from the geri chair after the refusal to eat. Observations on 4/3/13 at 12:30 PM revealed Resident #48 walked from her room to the dining room with hand held assistance of one staff member. Resident #48 walked approximately 120 feet. At 12:35 PM Resident #48 sat in the geri chair and direct care staff placed the table top tray on the chair. No food or drink was provided for this resident until she received her food tray at 1:12 PM. The food and drink was removed from Resident #48 and the direct care staff proceeded to assist another resident. Resident #48 remained in the geri chair with the table top tray in place on the chair. Observations on 4/4/13 at 8:55 AM revealed she was sitting in her room in the geri chair, with an aide feeding her breakfast. Resident # 48 was holding her head upright and accepting the food. The geri chair tray was not in use during this meal time. Observations on 4/4/13 at 12:49 PM revealed resident #48 ambulated with hand held assistance of one staff into the dining room. At 12:52 PM the resident sat in the geri chair and the tray was placed on the chair. The chair was scooted up to the table. Direct care staff #1 served the tray and attempted to feed the resident from 1:02 PM to 1:04 PM. The food was removed from the table top tray on the geri chair and direct care staff #1 began feeding another resident. Resident #48 remained in the geri chair with the table top tray table in place Interview with direct care staff #2 on 4/4/13 at 1:30 PM revealed she had provided care for Resident #48 on 4/1/13. Direct care staff #2 explained the tray table was to keep Resident #48 in the geri chair at meal time. The resident would get up and leave during the meal. She could not get up and leave with the tray over the chair. The tray was to be removed after a meal. Interview with MDS nurse #2 on 4/4/13 at 1:35 PM revealed the most current care plan was in front of the nurse's notes. That care plan gave instructions for Resident #48 to have a tray placed on the geri chair. She further explained the tray table on the geri chair was for meal times only. The MDS nurse and floor nurse went to the dining room to view Resident #48. Both nurses stated the tray table should have been removed after the resident had eaten. The floor nurse spoke to the direct care staff #3. The floor nurse stated the aide was going to try and feed her some more. Both nurses stated the table top tray would be a restraint if it was not removed after the meal. Interview on 4/4/13 at 1:40 PM with direct care staff #1, who provided meal assistance on 4/4/13, revealed the table top tray was to keep Resident #48 in the geri chair during meals. She stated she knew the table top tray was supposed to be removed and she had not done that. Interview with MDS nurse #2 on 4/4/13 at 2:00 PM revealed the tray would not be a restraint if a resident would be able to feed themselves. The most recent MDS was reviewed with MDS Nurse #2 which assessed Resident #48 as requiring total assistance with eating. MDS Nurse #2 explained Resident #48 did vary in her physical functioning, but would hold a spoon, sometimes her liquids, or she would do her own cups. If she feeds herself a few bites and the staff follow up and complete the meal, the MDS would be coded as total assistance. The interview continued with questions regarding a decline since the 3/5/13 MDS assessment. Observations were shared with the MDS nurse #2 of the resident not attempting to eat or drink or of staff not offering food or drink while seated with the table top in place. MDS nurse #2 was not able to state if Resident #48 had experienced a decline or had stop feeding herself.

Based on observations, staff interview, and record review the facility failed to post accurate daily staff postings in a clear and readable format for 6 consecutive days. Findings included: On 4/1/13 at 10:00am an initial tour of the facility was conducted. The daily staff posting was posted at the nurse's station between Spring and Summer halls. Staff posting was listed for the dates 3/30/13 - 4/1/13. It was noted that on each day the total and actual number of staff hours, for licensed and unlicensed staff, was not listed on the posting. The posting listed the resident census, the nursing hours per patient day (NHPPD), and full-time equivalents (FTE's). On 4/2/13 - 4/4/13 the daily staff postings did not list the total and actual number of staff hours. The Director of Nursing (DON) was interviewed on 4/4/13 at 1:52pm regarding the posting of staff hours. She indicated that she monitors to be sure that the form is posted, does not complete it herself, and that it is completed daily by the "nurse supervisor on the Spring hall. Today is was (Registered Nurse (RN) #1)." She stated, "I remember when we first started doing this form and my thoughts are, 'Who can really understand these numbers anyway?'" The DON indicated that she was not aware that the total and actual number of staff hours should be listed on the posting in a clear and readable format. On 4/4/13 at 2:15pm, RN#1 was interviewed and indicated that she completed the staff posting on the days that she works. She indicated that she was not aware that the total and actual number of staff hours should be listed on the posting in a clear and readable format.

Based on observations and staff interviews, the facility failed to ensure sanitary conditions in the kitchen by not eliminating food items from the dry storage area floor; by not removing a dented can from available food storage; by not securing tops to two opened food items, when not in preparation; by failing to label 3 beverage containers and remove 2 expired beverage pitchers in stand up refrigerator; and for failure to contain loose hair under caps or hairnets for three of six dietary staff employees observed during meal preparation. The findings include: A kitchen tour was conducted on 12/20/10 at 8:04 am. The Dietary Manager was not present. Items were examined in the stand up refrigerator and revealed an unlabled and opened pitcher of a reddish-orange substance, dated 12/6; an unlabeled and opened pitcher of a purple substance, dated 10/23. Three additional pitchers of a brown beverage, were unlabeled. A tour was next conducted of the dry storage area. There were five empty mouse traps on the floor. Two sealed single serving containers of cereal were observed next to two of the mouse traps. Other items on the floor were a dented can of sliced apples; 2 small individual packs of sugar, a short stack of empty clear food storage containers, a dented can of cranberry sauce and dried loose onion skins. A can of dented pink Salmon was observed on the shelf in the available food area. On the counter in the food preparation area, a container of mashed potato granules was observed with the lid not tightly secured. On another counter, a large opened can of Pork 'N' Beans was observed with an ice cream scoop spoon, inserted in the can. There were no staff at either counter, preparing food. A second visit was made to the kitchen on 12/21/10 at noon. The can of mashed potato granules was observed on the same counter, with the lid not secured. The beverage containers in the stand up refrigerator remained unlabeled. The cook and two aides were positioned at the steam table, preparing meal trays for lunch. Dietary aide #1 was observed with a baseball cap on her hair, which was gathered in a pony tail. On the left side of her head, a small section of loose hair, fell over her right ear. Dietary aide #2 was assigned to the dishroom. He wore a baseball cap and had long hair pinned under the baseball cap, with the back of his hair exposed. He was observed moving items from the dishroom to the kitchen, on several occasions. Dietary aide #3 assisted the cook with calibrating a thermometer on the tray line. She wore a hair net on her scalp, positioned behind her ears, with a large section of bangs exposed. The Dietary Manager was interviewed on 12/21/10 at 5:10pm. She stated food should be used within three days, once assigned a date by dietary staff. She explained that as a practice, they do not label the unsweetened in the stand up refrigerator because it has a high turnover for use. She shared that she had an expectation for items to be covered to ensure that they are not contaminated. The Dietary Manager shared that she has witnessed dietary staff to attempt to multi-task and believed that an aide might have lost his focus on preparing the Pork 'N' Beans while assisting in other areas of the kitchen. She then commented that staff have been trained to keep items off of the dry food storage area floors and to keep dented cans out of circulation.