Every finding on record at MS Care Center of Raleigh

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be treated with dignity and respect by failing to protect a resident from unnecessary exposure when the resident was observed exposed in the shower room and visible from the hallway for one (1) of (19) sampled residents. Resident # 19. Findings Include:A review of the facility's Privacy Policy, undated, revealed, It is the policy of this facility that .all staff will observe the resident's right of privacy.By providing privacy to the resident for all treatments and/or care rendered 1. Pull shower curtains.A record review of the admission Record revealed the facility admitted Resident #19 on 12/07/21 with diagnoses including Age-related Osteoporosis without Current Pathological Fracture. A record review of Quarterly Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 05/26/2026 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 03 indicating severe cognitive impairment.On 06/25/2026 at 09:50 AM, during an observation while walking down the Central Unit hallway, the door to the shower room was open and Resident #19 was sitting in a shower chair. She was exposed with no covering from her waist up. On 06/25/2026 at 09:55 AM, during an interview with Certified Nursing Assistant (CNA) #1, she stated that the shower room door was left open by another employee, and she did not realize it until Resident #19 was out of the shower stall. CNA #1 confirmed that the protocol for bringing a resident from the shower stall is to have the resident covered with a towel, or pull the curtain, in case another person is in the room or the door was accidentally left open. CNA #1 affirmed that the purpose of keeping the residents covered or the door closed is to protect the residents' privacy.On 06/25/2026 at 10:08 AM, during an interview with the Director of Nursing (DON) she stated that not only should the shower room door have been closed but Resident #19 should have had a towel or blanket around her just in case the door was left open. The DON explained that there are also two curtains that can be drawn to allow additional opportunities to maintain the residents' privacy. The DON reported that a reasonable person would not want to be exposed without clothing for a passerby to view them from the hallway. She explained the purpose of protecting the residents' privacy is to help maintain their dignity.

Based on observation, interviews, record review, and facility policy review, the facility failed to label and date prepared foods in the refrigerator and freezer and failed to prevent the possible spread of infection when a kitchen staff member failed to wear a beard guard while preparing plates for the dining hall for one (1) of four (4) days of kitchen observation. Findings include: A review of the facility's Food Storage Labeling policy, revised 8/24, revealed, .Procedure .2. All food items that are not in their original container must be labeled with the common name of the food and the use by date. 3. Foods that are prepared and stored for later service must be labeled and dated . A review of the facility's Employee Work Practices policy, revised 10/17, revealed, .Procedure .2. Proper Work Attire .c. The food service employee observes the following dress standards .iii. Food handlers with facial hair wear a beard restraint . On 02/10/2025 at 10:24 AM, during an initial tour with the Dietary Manager (DM), an observation was made of the refrigerator of one (1) pot of peas and carrots, one (1) pan of uncooked beef burger patties, one (1) pan of yeast rolls, mashed potatoes, beef fingers, cooked rice, and corn-all covered in aluminum foil without a preparation date, description, or use-by date. The DM confirmed that the food items were not labeled with the date, description, or use-by date as required by facility policy. On 02/10/2025 at 11:25 AM, during an observation, a male kitchen worker was observed preparing meal trays for residents without wearing a beard guard. On 02/11/2025 at 9:57 AM, during an interview, a kitchen staff worker stated that staff had recently been in-serviced regarding food dating and labeling. On 02/12/2025 at 10:00 AM, during an interview, the Registered Dietitian (RD) stated that the facility's policy for food preparation required all stored food to be labeled with a date and description on the outside of the container. The RD confirmed that staff were required to wear hair restraints while in the kitchen and stated that the male kitchen worker had forgotten to put on a beard restraint. The RD further stated that the expectation for staff was to follow policy and prepare food according to proper food safety guidelines. On 02/13/2025 at 11:56 AM, during an interview, the Administrator stated that the expectation for kitchen staff was to follow facility policies to safely prepare food and prevent the spread of infection among residents. The Administrator stated that food safety measures were essential to ensuring that residents received meals that met their preferences and nutritional needs.

Based on observation, staff interview, and facility policy review, the facility failed to provide a safe, functional, sanitary, and comfortable environment as evidenced by resident rooms with excessive rust on the ceiling grids for two (2) of nine (9) resident rooms observed on the North Hall. rooms [ROOM NUMBERS] Findings Included: A review of the facility's policy, revised 9/2022, revealed, It is the policy of this facility to provide services based on the following regulation .Safe/Functional/Sanitary/Comfortable Environment .The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public . On 9/12/24 at 11:15 AM, in an observation of room [ROOM NUMBER] and room [ROOM NUMBER] on the North Hall, the metal ceiling grids were excessively discolored with rust. The rusted areas were more excessive over the beds that were near the windows in the room. On 9/12/24 at 12:10 PM, in an interview and observation of room [ROOM NUMBER] with Housekeeper #1, she confirmed the ceiling grids were excessively rusted. She explained she had worked on the North Hall for approximately one (1) month and had not noticed the rusted ceiling grids. On 9/12/24 at 2:15 PM, in an interview and observation of rooms [ROOM NUMBERS] with the Maintenance Director, he confirmed the ceiling grids were rusted and was unsure why the grids were more rusted in the two rooms above the beds than other places throughout the facility. He stated he felt like the rust was caused by using aerosol disinfecting products during the COVID-19 pandemic. He explained he would repair the grids and that he had not gotten to it yet. On 9/12/24 at 4:15 PM, in an interview with the Administrator, she explained she was not aware of the rusted ceiling grids in the rooms but acknowledged the facility utilized aerosol disinfectant during COVID-19.

Based on observation, interview, and facility policy review, the facility failed to ensure a resident's privacy as evidenced by posting of clinical care signage on the resident's wall for one two (2) of 20 sampled residents. Resident #32 and Resident #10. Findings Include: Review of the facility's policy, Personal Privacy/Confidentiality of Record, undated, revealed the document did not address clinical care signage in resident rooms. Resident #32 On 08/01/23 at 10:40 AM, an observation revealed there were signs posted on the resident's wall over the bed as follows: 1. When resident is in the bed ensure bed is in its lowest position with fall mat beside bed before exiting. 2. Nectar thickened liquids. 3. 201B Meal Instructions 1. Assist with all meals, 2. Slow rate, 3. Give one sip then swallow, 4. Give small bites/small sips, 5. Keep upright during meals and 30 min after meals. In an interview on 08/01/23 at 01:35 PM, Licensed Practical Nurse (LPN) #1 revealed that she acknowledged the signage was posted in resident's room but was unsure of who had placed it. She stated she believed it was possibly the hospice company. Resident #10 On 08/01/23 at 01:35 PM, an observation revealed there were signs posted on the resident's wall over the bed as follows: 1. When resident is in the bed ensure bed is in its lowest position with fall mat beside bed before exiting. 2. Keep head of bed elevated at all times On 08/01/23 at 02:02 PM, an interview with Registered Nurse (RN) #1 Charge Nurse, revealed the signage had been posted due to the removal of bed rails and the staff placed the signs as a reminder to place the beds in the lowest position. The charge nurse removed the signage during the interview and stated that reminders could be placed on the kiosks used by the Certified Nursing Aides (CNAs). On 08/01/23 at 02:41 PM, in an interview with the Director of Nurses (DON), she acknowledged the posted signage and stated the facility would remove the signs or place them so that only staff could view the information. 43283 48181

Based on observation, interview, and facility policy review it was determined the facility failed to serve food in a safe and sanitary condition to prevent the possible spread of infection and contamination, during one (1) of two (2) kitchen observation. The identified concerns placed all residents receiving food/nourishment from the kitchen at risk for foodborne illnesses. Findings include: A review of the facility's Food Service Operational Standards For Purchasing, Cooking and Storage policy, undated, revealed: This facility stores, prepares, distributes, and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. Avoid overloading cooking surfaces. Wash, rinse, and sanitize all equipment and utensils before and after each use. Review of the facility's Hand Washing Policy, undated, revealed, handwashing would be done by all staff throughout their shift, and to reduce the transmission of organisms from resident to resident, and from the staff to the resident. A review of the facility's Cleaning and Sanitizing Equipment policy, undated, revealed: All equipment is kept clean and food contact surfaces are cleaned and sanitized. Remove food and soil from under and around the equipment. Remove detachable parts and manually wash, rinse, and sanitize or run through dish machine. Allow to air dry. Wash and rinse fixed food contact surfaces, then wipe or spray with a chemical sanitizing solution. Review of the facility's training record, titled Safety and Dietary Procedures, dated 02/26/2020, revealed the dietary staff was in-serviced on Food Storage, Food Preparation, Food Service/Sanitation, Safety, Food Temperature and other Safety Measures, which included cross contamination, handwashing, cleaning surfaces and proper refrigeration of leftovers. A review of the facility's Employee Sanitation Practices policy, undated, revealed, gloves are worn to protect food by creating a barrier between the hands and food. Gloves should be changed as soon as they become soiled or torn and before beginning a different task. An observation, during the initial tour of the kitchen, on 03/03/2020 at 9:15 AM, revealed the conventional oven was dirty with build-up of food on the inside walls of the oven. The aluminum foil, in the bottom of the oven, was dirty with food build up. The two (2) small ovens had food build up on the inside walls and on the aluminum foil in the bottom of the ovens. The door of the oven had food build up on it as well. During an interview, on 03/03/2020 at 9:35 AM, the Dietary Manager (DM) stated that all the ovens were dirty. The DM stated she had a schedule for when the ovens are supposed to be cleaned, and they were apparently not cleaned according to the schedule. The DM stated the food build-up on the ovens looked to be from several days of cooking. A review of the Cleaning Schedule #1, dated February 2020-March 01, 2020, revealed the small ovens were initialed as being last cleaned on February 27, 2020. The large oven was initialed as being last cleaned on February 29, 2020. During an observation, on 03/04/2020 at 10:56 AM, Dietary Worker #2 knocked a piece of white sandwich bread, that was in a paper sleeve, off of a serving cart onto the floor. Dietary Worker #2 picked the sleeve with the piece of bread in it, up off the floor, and placed it back on top of the cart with the other pieces of sandwich bread in sleeves. The sleeve with the piece of bread that had fallen to the floor, was taken off of the cart; however, the other sleeves of bread were served to the residents. Dietary Worker #2 did not remove her gloves or wash her hands after picking the sleeve of bread off the floor and placing it back onto the cart. Dietary Worker #2 went back to the food serving line, wearing the same gloves that she used to pick the bread up off the floor. During an observation, on 03/04/2020 at 11:02 AM, the Dietary Manager (DM) was assisting Dietary Worker #3 in calibrating the thermometer to check food temperatures. The DM, without wearing gloves, picked up the foam cup that was being used for calibration, went to the ice maker and dipped the foam cup into the ice machine to obtain more ice. During an interview on, 03/04/2020 at 11:04 AM, the DM stated that she used the foam cup to obtain ice from the ice machine, instead of using the scoop. The DM stated she shouldn't have done it, and that it was contamination. The DM revealed they did not discard the ice from the ice machine, nor did they clean the ice machine. During an interview, on 03/04/2020 at 11:06 AM, Dietary Worker #2 confirmed she picked up the paper sleeve containing the piece of sandwich bread, from the floor and placed it back on top of the cart with the other sleeves of bread. Dietary Worker #2 stated she was not supposed to do that. Dietary Worker #2 stated she should have thrown it away. Dietary Worker #2 revealed she threw the sleeve of bread away, but it was after she had sat it on the other sleeves of bread, on the cart. Dietary Worker #2 stated they still served the other sleeves of bread to the residents for lunch, and they should have thrown it away. On 03/04/2020 at 11:29 AM, during an interview, the Dietary Manager (DM) stated that she saw Dietary Worker #2 drop the sleeve, with the piece of bread in it, pick it up, and put it on top of the cart with the other sleeves containing the bread. The DM confirmed she saw Dietary Worker #2 throw away the sleeve of bread that had fallen on the floor, but it was after she had placed the contaminated bread back on the cart. The DM stated she told Dietary Worker #2 not to put it back on the cart, but she did it anyway. The DM stated what Dietary Worker #2 had done was contamination. She stated that Dietary Worker #2 should have discarded the whole cart of bread, after she laid the contaminated bread back onto the cart. During an interview, on 03/04/2020 at 1:25 PM, the DM stated that it was ultimately her responsibility to make sure the equipment was cleaned as scheduled. The DM stated that it was also her responsibility to make sure that the contaminated food was not served. On 03/06/2020 at 9:14 AM, during an interview, with the DM, revealed she saw Dietary Worker #2 go back to the serving line, without washing her hands and changing gloves, after picking the bread up off of the floor. During an interview, on 03/06/2020 at 11:47 AM, the Administrator stated that she considered it an infection control issue, with the staff not following the cleaning schedule for cleaning the oven and back splash on the oven. The Administrator stated the Dietary Manager getting the ice from the ice machine without gloves on, and without using the scoop, was an infection control issue. She stated that the Dietary Manager not washing her hands and changing gloves, after picking the bread up off the floor, and before returning to the serving line, was an infection control issue. The Administrator stated Dietary Worker #2 should not have placed the bread back on the cart. She stated the tray of bread, on the cart, should have been discarded since it was contaminated, and fresh bread should have been brought out to be served. The Administrator stated Dietary Worker #2 contaminated the other bread on the serving cart, when she placed the bread that was picked up off of the floor, back onto the serving cart. A review of the facility's training record, dated 02/26/2020, revealed the Dietary Manager and Dietary Worker #2 were in-serviced on Food Safety and Dietary Procedures.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain soiled trash and linen in a manner to prevent cross contamination for one (1) of three (3) incontinent care observations, Resident #4. Findings Include: Resident #4 A review of the facility's policy entitled Clean and Dirty Policy, not dated, reads: Dirty linen will not be placed on the bed, over bed table, floor, or any other clean surface. Review of the facility's Communication: Process of Exchange Information With Others, not dated, reads: Never place any soiled linens, briefs, or any other soiled objects on floor or bedside chair/tables, etc. On 10/04/17 at 3:10 PM, observation of Certified Nursing Assistance (CNA) #1 and CNA #2 performing incontinent care, on Resident #4, revealed CNA #2 placed the plastic bag with soiled trash on the floor in Resident #4's room. CNA #1 asked CNA #2 to get the soiled plastic bag off the floor. CNA #2 picked the soiled plastic bag off the floor and placed it in Resident #4's chair, that had no barrier. After CNA #2 removed the soiled pad from underneath Resident #4, she placed it in Resident #4's chair, which had no barrier. On 10/05/17 at 3:15 PM, interview with CNA #1 revealed she told CNA #2 to pick up the soiled trash bag off the floor, because nothing should be on the floor, clean or dirty, nothing should be on the floor. She stated nothing should be on the floor because of contamination. On 10/05/17 at 3:45 PM, interview with the Director of Nursing (DON) revealed staff had been trained no to put soiled trash or anything on the floor and thought the CNAs were just nervous. When asked about the soiled pad being placed in Resident #4's chair with no barrier, she stated, I know for a fact that they are trained on that. That's just a huge no, no. The DON stated this was an infection control issue. During an interview on 10/05/17 at 4:00 PM, CNA #2 stated, I was trying to remember to wash my hands, I was just nervous. She stated that she usually placed the soiled items in a bag, but was just nervous and put the soiled pad in the chair. A review of the facility's Face Sheet revealed the facility admitted Resident #4 on 04/26/12, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/17/17, revealed staff assessed Resident #4 with moderately impaired cognition.

Based on observation, staff interview, record review and facility policy review, the facility failed to maintain effective pest control in the kitchen area as evidence by observation of a live cockroach on the kitchen floor for one (1) of three (3) kitchen observations. Findings include: A review of the facility's Pest Control policy, not dated, provided by the Administrator, revealed a pest management program is used to prevent pest from entering the food service department and to implement measures to eliminate any pest that infest it. An observation in the kitchen on 1/18/2017 at 9:15 AM, revealed a live cockroach crawling across the kitchen floor from the hand washing station toward the stove area. Dietary worker #2 removed the cockroach when it was brought to her attention. During an interview on 1/18/2017 at 9:15 AM, the Dietary Manager (DM) confirmed that a cockroach was swept up by Dietary Worker #2. The DM stated there had not been any recent reports of roaches in the kitchen area. The DM stated, Our exterminator recently inspected and sprayed the kitchen about a week or so ago. During an interview on 1/19/2017 at 11:10 AM, Dietary Worker #2 confirmed she had removed a live cockroach from the kitchen area with a broom and dust pan. During an interview on 1/19/2017 at 11:15 AM, The Dietary Manager (DM) revealed she notified the Environmental Services Director (ESD) of the live cockroach sighted in the kitchen. The DM stated the ESD is the person who notifies the exterminator of any pest concerns when he comes for an inspection visit. An interview on 1/19/2017 at 12:05 PM, with the Environmental Services Director (EDS), confirmed she does notify the pest control exterminator of any pest concerns in all areas of the facility. The ESD stated the exterminator had made a visit a week and a half prior. During an interview on 1/19/2017 at 12:20, with the Administrator, it was confirmed that a visit had been made on 1/12/2017 by the exterminator. The Administrator stated she had not been notified of any pest concerns at that time or since then. A telephone interview on 1/20/2017 at 12:30 PM, with the exterminator who serviced the facility, confirmed a visit on 1/12/2017. He stated he had not been notified of any current pest concerns. He stated he had inspected the kitchen area and it was negative for any actual pest sightings and provided the usual type of treatment and services. He confirmed he talks to the ESD on each visit to enquire of any problems between visits. A review of the invoice, dated 1/12/2017, for the contracted exterminator visit, revealed an interior kitchen area inspection and treatment.

Based on observation, record review, staff interview, and policy review, the facility failed to follow the Care Plan for incontinence care for one (1) of 23 care plans reviewed, Resident #14. Findings include: Review of the facility's Total Care Plan Policy, undated, revealed the care plan must be resident specific, identify problems that affect the resident and his/her care needs, and identify the discipline responsible for performing the intervention. A review of Resident #14's care plan, with an initial date of 7/23/15, revealed Resident #14 was frequently incontinent of bowel and bladder due to Alzheimer's Dementia. The goal on the Care Plan: Resident #14 will have no more than one (1) UTI (urinary tract infection) develop through 3/2/2017. The intervention on the care plan noted: assist with incontinence care as needed. Observation on 01/19/2017 at 4:00 PM, revealed Certified Nurse Aide (CNA) #1 washed Resident #14's middle vaginal area with soapy water from back to front. C N A #1 also washed resident #14 buttocks from back to front when she performed incontinent care. During an interview on 1/19/2017 at 4:30 PM, CNA #1 confirmed that she failed to follow the care plan by not cleaning Resident #14 from front to back. CNA #1 said she has been in-serviced on the correct way to clean the residents during incontinent care. CNA #1 also said she was nervous. Review of the Face Sheet revealed the facility admitted Resident #14 on 04/19/2013, with [DIAGNOSES REDACTED]. A review of the current quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/16, revealed Resident #14 scored 3 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent care in a manner to prevent the potential for urinary tract infections for one (1) of six (6) incontinent care observations, Resident #14. Findings Include: A review of the facility's Peri Care Policy, undated, revealed that the resident's perineal area should be washed from front to back for females and the purpose was to aid in prevention of urinary tract infections. An observation of incontinent care on 1/19/2017 at 4:00 PM, revealed Certified Nursing Assistant (CNA) #1 washed Resident #14's perineal area from back to front with a soapy towel. CNA #1 also washed Resident #14's buttocks from back to front, instead of front to back. During an interview on 1/19/17 at 4:30 PM, CNA #1 confirmed that she failed to cleanse Resident #14's perineal area from front to back as taught. CNA #1 said she was nervous. During an interview on 1/19/2017 at 4:45 PM, the Assistant Director of Nursing (ADON) stated CNA #1 failed to prevent the possible spread of infection by not cleansing Resident #14's perineal area from front to back. The ADON also said CNA #1 was trained with return demonstration by the Staff Development Nurse on incontinent care. A review of the facility's face sheet revealed the facility admitted Resident #14 on 4/19/13, with [DIAGNOSES REDACTED]. A review of Resident #14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/04/2017, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired.

Based on observation, staff interview, facility policy review, and record review, the facility failed to serve a component of a therapeutic diet for two (2) of three (3) meals observed (Resident #11). Findings Include: Review of facility policy entitled Diet Order Policy (no revision date) revealed, It is the policy of the facility that each resident will be served a diet with specific physician's orders [REDACTED]. Record review of physician's orders [REDACTED].#11 to have a pureed diet with extra gravy on meats, and ice cream to be served with lunch and supper. Meal observation on 11/23/15 at 11:45 AM revealed Resident #11 was served puree hamburger patty (no extra gravy) cream potatoes(no gravy) puree peas, puree bread, pudding, tea and water and apple sauce. There was no ice cream on his plate. The resident's tray contained a menu card reminder that read, Puree w (with)/extra gravy on meat. Apple sauce cup and ice cream with lunch and supper. After questioning, Certified Nursing Assistant (CNA) #1 retrieved the ice cream and the resident ate all of the ice cream. During an interview on 11/23/15 at 11:45, CNA #1 confirmed that the ice cream and gravy was missing from the tray. She went to get the ice cream, but was unable to retrieve the gravy because the facility did not prepare gravy that particular day because the hamburger was the alternate meal and the spaghetti was the main meal. She stated she was aware of the sign on the tray but was not sure if it was for both ice cream and applesauce or just one of the two. Meal observation on 11/24/15 at 12:00 PM revealed Resident #11 was served Puree meat(with gravy) puree turnip greens, puree bread ,apple sauce and pudding. CNA #2 stated the ice cream was missing and went to retrieve. Resident # 11 was then observed eating all of his ice cream. During an interview on 11/24/15 at 12:00 PM, CNA #2 confirmed the ice cream was missing from the tray but did not know why. During an interview on 11/24/15 at 1:45 PM, Dietary Worker #1 stated that nurses write out a diet order and dietary puts it on a card for the dietary staff to see. The person on the other side of the steam table is responsible for checking the tray to make sure it is correct. She said she doesn't know why she missed Residents # 11's ice cream twice but she would find out. That person has left for the day. Dietary Worker #1 confirmed the facility was out of gravy the day the gravy was missing from the tray. During an interview on 11/25/15 at 16:15 PM, the Assistant Director of Nursing (ADON) stated the CNAs were responsible for double-checking the resident's trays. The CNAs have their own Plan of Care for each resident. The ice cream and extra gravy was never put on the CNA plan of care. The ADON stated that was the problem. Resident #11 was admitted to the facility 10/06/09 with [DIAGNOSES REDACTED].

Based on record review and staff interview, the facility failed to develop a care plan to include activities for Resident #8 for one (1) of 22 care plans reviewed. Findings Include: Record review of Resident #8's Care Plans revealed no Activities Care Plan. Staff interview on 11/24/2015 at 11:48 AM with Activity Therapy Staff #1 revealed, an Activity Admission Note is completed and given to the MDS/Care Plan Nurse, who then creates an Activity Care Plan for the resident. On 11/24/2015 at 11:55 AM staff interview with Registered Nurse (RN) # 3 revealed, the Activity Therapist submits a note with the admission note and a care plan. I must have shredded the care plan. I don't usually create the care plans on the computer until it's time for an MDS (Minimum Data Set), so it's not on the computer. Review of the facility's Face Sheet revealed, the facility admitted the resident on 9/24/2015. Resident #8's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 10/02/2015 revealed Resident's BIMS (Brief Interview for Mental Status) score was 0 (zero) indicating Resident #8 had severe cognitive impairment.

Based on record review, staff interview and facility policy review, the facility failed to obtain a Pre-[MEDICATION NAME] level as ordered by the physician for one (1) of 17 residents reviewed for labs; Resident #3. Findings include: Review of the facility's policy entitled, Lab Work Policy, (undated), revealed it is the policy of the facility that lab work will be drawn as per physician's orders [REDACTED]. Resident #3 A review of Resident #3's cumulative physician orders [REDACTED]. A review of the lab results for Pre-[MEDICATION NAME] levels revealed lab reports missing for October 2015 and July 2015. Interview on 11/24/15 at 4:35 PM with Registered Nurse (RN) #1, revealed the person responsible for ordering the labs is the charge nurse and sometimes it is me. RN #1 revealed that she did not see any Pre-[MEDICATION NAME] levels for the months requested in Resident #3's chart . Interview on 11/24/15 at 5:20 PM with RN #1 confirmed Pre-[MEDICATION NAME] levels for October 2015 and July 2015 were not drawn. RN #1 stated I can't tell you why they weren't done. I've looked everywhere and I can't find them. Interview on 11/19/15 at 4:40 PM with the Director of Nursing (DON) revealed the facility used an old system of index cards to keep up with labs and now they have a computer system. The DON stated she is trying to put the labs into the computer so it will trigger each month when they are due. A review of the Face Sheet revealed the facility admitted Resident #3 on 02/18/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/15 revealed Resident #3 scored 12 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility failed to maintain a clean and homelike environment as evidenced by an unsanitary toilet in one (1) of three (3) resident shower rooms and faded, stained and marred floors, brown stains around base of toilets in nine (9) of 61 resident bathrooms observed. Findings Include: Facility policy entitled Bathing Tubs/Showers did not address the cleaning and sanitation of commodes or maintaining bathroom floors. Observation on 11/24/15 at 2:30 PM revealed the toilet in the North hall shower room had red stains resembling blood spatters on the toilet seat, feces inside the toilet, and unboxed body wipes sitting on the toilet tank. During an interview on 11/24/15 at 3:00 PM, Housekeeper #3 confirmed the findings and said she knew the shower room was cleaned between 11:30 AM and 12:00 PM when resident bathing was complete. She confirmed the cleaning of that particular shower room was the responsibility of the North hall housekeeper on that side of the facility. Housekeeper #3 stated the North hall housekeeper's shift ended at 2:30 PM and the person had left for the day. Housekeeper #3 stated the North hall housekeeper should have checked it before she left, but she could not say whether she did. The facility did not have documentation of housekeeping assignments and completion of duties Observations of the residents' personal restrooms on 11/22/15 at 2:30 PM and 11/24/15 from 2:30 to 3:15 revealed the following: The bathroom in room 209 had scuffs on the walls and stained floor tiles around the toilet area. The caulking around the base of the toilet was black with stains. The bathroom in room 210 had cracked and stained floor tiles and peeling paint on the walls around the toilet area. The caulking at the base of the toilet was black, dirty and stained. The bathroom in room 225 had scuffed, stained and faded floor tiles around the toilet area. The caulking around the base of the toilet was black, dirty and stained. The bathroom in room 226 had scuffed, stained and faded floor tiles and loose vinyl baseboard on right side of toilet. Caulking at base of toilet was black, dirty and stained. The bathroom in room 227 had dirty, stained and faded floor tiles surrounding toilet. The caulking surrounding the base of the toilet was black, dirty and stained. The bathroom in room 229 had dirty, stained and faded floor tiles surrounding toilet. The caulking surrounding the base of the toilet was black, dirty and stained. The bathroom in room 230 had dirty, stained and faded floor tiles surrounding toilet. The caulking surrounding the base of the toilet was black, dirty and stained. The bathroom in room 231 had dirty, stained and faded floor tiles surrounding toilet. The caulking surrounding the base of the toilet was black, dirty and stained. The bathroom in room 232 had dirty, stained and faded floor tiles surrounding toilet. The caulking surrounding the base of the toilet was black, dirty and stained. During an interview on 11/24/15 at 2:50 PM, Maintenance #1 stated he was aware of the condition of the toilets. The facility had just finished remodeling that area of the facility and they had not gotten to the restrooms with their remodeling. He stated that the floors had been stripped and cleaned several times, and that is one reason they look so bad. He said the floors would have to be replaced. The scuffed walls on the side of the toilets were from wheelchairs bumping the walls and have been repainted several times. During an interview on 11/24/15 at 3:00 PM, Housekeeper #3 also confirmed the areas of the floor have been mopped, stripped and polished several times and the floors would not come clean. Housekeeper #3 stated the floors would have to be replaced.

Based on observation, staff interview, and facility policy review, the facility failed to follow a care plan related to following a therapeutic diet for Resident #11, the administration of oxygen for Resident #2 and #19, and obtaining lab tests as ordered for Resident #3, for four (4) of 22 resident care plans reviewed. Findings Include: Review of facility policy entitled Total Care Plan Policy (no revision date) revealed that a interdisciplinary care plan would be completed by the interdisciplinary team including the Director of Nursing, Charge Nurse, Social Services, Activity, Dietary, Licensed Practical Nurse, Certified Nursing Assistants, Therapist, Physical Therapy, Occupational Therapy, Speech Therapy, Physician, and Administrator. The care plan would be updated as the resident's condition or plan of care changes. The plan of care would identify problems that affect the resident and his care needs and identify interventions related to a specific problem and goals to be maintained. Resident #11 Record review of Resident 11's plan of care read, Resident is at risk for weight loss 2nd (secondary) to poor dentition. One of the goals for this problem was to serve the resident ice cream with lunch and supper. The revision date for this action was 10/22/15. Meal observation on 11/23/15 at 11:45 AM revealed Certified Nursing Assistant (CNA) #1 feeding Resident #11 a pureed hamburger patty (no extra gravy) cream potatoes (no gravy), pureed peas, pureed bread, pudding, apple sauce, tea and water. There was no ice cream on his plate. Resident #11 seemed disinterested and was not eating. After being questioned about the ice cream, CNA #1 retrieved the ice cream, and the resident ate all of the ice cream. Review of the resident's tray card reminder revealed, Puree w/extra gravy on meat. Apple sauce cup and ice cream with lunch and supper. Meal observation on 11/24/15 at 12:00 PM revealed CNA #2 fed Resident #11 Puree meat (with gravy), puree turnip greens, puree bread, apple sauce, and pudding. Resident #11 seemed disinterested in the food and was not eating. After questioning, CNA #2 stated the ice cream was missing and went to retrieve. Resident # 11 ate all of the ice cream. During an interview on 11/24/15 at 3:40 PM, the Assistant Director of Nursing (ADON) stated a Plan of care is for the nurses to be able to refer to when providing care for the residents. The plans of care are updated by the nurses according to new orders. The Certified Nursing Assistance (CNA) refer to a separate plan of care for them. Record review of the CNA plan of care revealed that the notation for the gravy with all meats and the ice cream with lunch and supper were never transcribed onto the plan of care. The ADON stated that was the problem. The facility admitted Resident #11 on 10/06/09 with [DIAGNOSES REDACTED]. Resident #19 Record review of Resident #19's care plan revealed a care plan for potential for SOB (Shortness of Breath) r/t (related to) dx (diagnoses) of [MEDICAL CONDITION] and hx (history) of asthma. An intervention for this care plan listed oxygen at two liters per minute by nasal cannula routinely for shortness of breath. Record review of Resident #11's physician's orders [REDACTED].@ 2L/min (two liters per minute) via (by) nasal cannula routinely (SOB) Shortness of Breath. Observation of Resident #19 on 11/23/2015 at 3:30 PM with Registered Nurse (RN) #2 present revealed the resident sitting in geriatric chair with oxygen tubing intact to resident's nares, and oxygen (O2) tank on the back of Resident #19's geriatric chair. Observation revealed the portable oxygen tank on back of the chair was empty. RN #2 obtained an O2 saturation level. Resident #19's O2 level was 96 percent (%) on room air. Review of the facility's Face Sheet revealed, the facility admitted the resident on 9/05/2015. Resident #19's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 9/14/2015 revealed Resident's BIMS (Brief Interview for Mental Status) score of 99, indicating Resident #19 had severe cognitive impairment. Resident #2 Record review of Resident #2's care plan revealed a care plan for At risk for Acute Respiratory distress 2nd (secondary) to Dx (diagnosis) of [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS]. Interventions included O2 at 4 liters per minute by nasal cannula and (O2 SAT PRN) oxygen saturation as needed. Observation on 11/22/15 at 2:35 PM, 11/22/15 at 5:02 PM, 11/23/15 at 8:40 AM, 11/23/15 at 9:50 AM, 11/23/15 at 11:45 AM, and 11/23/15 at 3:04 PM (six observations) revealed Resident #2's oxygen delivery was set at 2 liters per minute instead of 4 liters per minute as ordered and care planned. On 11/23/15 at 4:05 PM, interview with the Director of Nurses (DON) and the Assistant Director Nurses (ADON) revealed the care plans are to be updated with every change in an activity of daily living (ADL). The nurse receiving an order is responsible for transcribing the order to the care plan. The DON stated daily, the care plan nurse, RN #5, is responsible for reviewing the care plans and the Minimum Data Set (MDS) nurse Licensed Practical Nurse (LPN) #3 double checks to ensure any care plan changes are reflected in the next review. Review of the facility's face sheet revealed the facility admitted the resident on 4/10/15. Resident #2's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 9/29/15 revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #3 A review of Resident #3's care plan revealed a problem related to Stage IV ulcer with an approach listed to monitor Pre-[MEDICATION NAME] monthly as ordered. A review of Resident #3's cumulative physician orders [REDACTED]. A review of the lab results for Pre-[MEDICATION NAME] levels revealed lab reports missing for October 2015 and July 2015. Interview on 11/24/15 at 4:35 PM with Registered Nurse (RN) #1 revealed Resident #3's care plan listed an approach to monitor Pre-[MEDICATION NAME] monthly as ordered. RN #1 revealed the person responsible for ordering the labs is the charge nurse and sometimes it is me. Interview 11/24/15 at 5:20 PM with RN #1 confirmed Pre-[MEDICATION NAME] levels for October 2015 and July 2015 were not drawn. RN #1 stated I can't tell you why they weren't done. I've looked everywhere, and I can't find them. A review of the Face Sheet revealed the facility admitted Resident #3 on 02/18/11 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/15 revealed Resident #3 scored 12 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment.

Based on observation, staff interview, and record review, and facility policy review, the facility failed to administer oxygen as ordered for two (2) of five (5) residents with physician's orders [REDACTED].#2 and #19. Findings Include: Review of the facility's policy revealed Oxygen Policy undated, It is the policy of this facility that oxygen will be utilized as follows: 1) With specific physician's orders [REDACTED]. Documentation: If continuous document on the MAR (Medication Administration Record). Resident #2 Observation revealed on 11/22/15 at 2:35 PM, during initial facility tour, Resident #2 was lying in bed with the head of the bed slightly elevated, using oxygen by nasal cannula bi-prong at two liters per minute (2L/M)delivered by an oxygen concentrator. The concentrator humidification container was empty of fluid and contained condensation particles within the container. On 11/22/15 at 5:02 PM, observation revealed Resident #2's oxygen continued at 2L/M with fluid in the humidification bottle. Record review of Resident #2's physician's orders [REDACTED]. On 11/23/15 at 8:40 AM, observation revealed Resident #2 watching television in her room with O2 at 2 Liters instead of 4 liters per minute as ordered. On 11/23/15 from 9:50 AM through 10:25 AM, observation during wound care revealed Resident #2's respiration rate increased from 18-20 breaths per minute to 24 breaths per minute with pursing of lips. Observation revealed the O2 administration continued at 2L/M per NBP. Resident looked at and moved about the oxygen tubing frequently during the care observation. On 11/23/15 at 11:45 AM, observation and interview of Resident #2 revealed the oxygen administration remained at 2L/M per NBP. The resident stated she could not remember the last time the nurse check her O2 SAT. On 11/23/15 at 3:04 PM after being questioned about the O2 order and setting, Registered Nurse (RN) #4 looked on the computer and revealed the oxygen order for administration per NBP at 4 L/M for [MEDICAL CONDITION] and O2 Sat readings PRN. She then reviewed in the electronic Medication Administration Record [REDACTED]. Observation and interview of Resident #2's O2 SAT by RN #4 while the resident received oxygen at 2L/M revealed the resident's O2 sat reading was 88 %. RN #4 increased the oxygen flow to 4L/M and reported she thought the machine was not working correctly. RN #4 then changed to a new oxygen concentrator and changed the tubing. Resident #2 then said, I can feel it coming out now. RN #4 then repeated the O2 sat check and obtained a reading of 95 %. Resident #2 said she was breathing easy. Interview on 11/23/15 at 3:04 PM with RN #4 revealed it would be the medication nurse assigned to the resident and then the charge nurse's responsibility to check the oxygen on each resident and it should be documented on the eMAR upon rounds made by the nurse at least at the beginning of each shift. A review of the nursing notes revealed the last documentation of an observation of Resident #2's respirations was 11/1/15 at 3:17 PM. The last documentation of oxygen administration was on 10/1/15 at 4:03 AM by LPN #1 when it was documented to be infusing at 2L/M via NC. On 11/23/15 at 4:05 PM, an interview with the Director of Nurses (DON) and the Assistant Director Nurses (ADON) revealed areas requiring a nurse's performance are transcribed to the eMAR. Each time a medication or treatment is due, the computer flags it notifying the nurse. The medication nurse then performs the administration or procedure and documents into the eMAR as completed. On 11/24/15 at 1:45 PM, an interview with the DON and the ADON was revealed the oxygen should have been at 4L/M, but it was at 2L/M. The DON replied the medication nurse and the charge nurse are responsible for checking the O2 each shift and making rounds on every resident on their assigned unit. Review of the facility's face sheet revealed the facility admitted the resident on 4/10/15. Resident #2's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 9/29/15 revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #19 Observation of Resident #19 on 11/23/2015 at 3:30 PM with RN #2 revealed the resident in geriatric chair with oxygen (O2) tubing intact to resident's nares and a portable oxygen tank on the back of Resident #19's geriatric chair. The O2 tank was empty. RN #2 obtained oxygen saturation level. The O2 saturation reading was 96 % on room air. Record review of Resident #11's physician's orders [REDACTED].@ 2L/min (two liters per minute) via (by) nasal cannula routinely (SOB) Shortness of Breath. On 11/23/2015 at 3:30 PM, staff interview with RN #2 revealed facility staff hooked resident up to the portable oxygen tank. The resident had an oxygen concentrator available in her room. RN #2 said the oxygen is checked every shift by the nurse. Staff Interview on 11/23/2015 at 6:30 AM with the Assistant Director of Nurse (ADON) revealed, a physician's orders [REDACTED]. There needs to be a better system in place. We need to double check our system and in-service the nurses on paying better attention. Staff interview on 11/24/2015 at 4:05 PM with the DON (Director of Nursing) revealed the nurse assigned to administer medications is responsible for checking the resident's oxygen and initialing the check on the MAR. Review of the facility's Face Sheet revealed, the facility admitted the resident on 9/05/2015. Resident #19's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 9/14/2015 revealed Resident's BIMS (Brief Interview for Mental Status) score of 99, indicating Resident #19 had severe cognitive impairment.