Every finding on record at NHC Healthcare, Chattanooga

Based on facility policy review, medical record review and interview, the facility failed to accurately code a Preadmission Screening and Resident Review (PASRR) level 2 on the Minimum Data Set (MDS) assessment for 3 residents (Resident #35, Resident #81 and Resident #84) of 7 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, PRE-ADMISSION SCREENING & [and] Resident Review (PASRR), revised 11/2016, revealed .requires all centers to screen patients .to determine if they have Mental Illness, Intellectual or Developmental Disability .those patients found nursing facility appropriate under Level II [2] review, the Center [facility], should incorporate .PASRR Level II determination .into the patient's assessments (MDS) . Resident #35 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Failure to Thrive, Bipolar Disorder, Hallucinations and Insomnia. Review of Resident #35's PASRR submission dated 6/27/2023, revealed the resident was considered by the state designated agency to have a level 2 outcome. Review of Resident #35's significant change MDS assessment dated [DATE], revealed the resident was not coded as a resident currently considered by the state to have a level 2 outcome. Resident #81 was admitted to the facility on [DATE], with diagnoses including, Bipolar Disorder, Anxiety, Emotional Liability and Nicotine Dependence. Review of Resident #81's PASRR submission dated 7/19/2024, revealed the resident was considered by the state designated agency to have a level 2 outcome. Review of Resident #81's significant change MDS assessment dated [DATE], revealed the resident was not coded as a resident currently considered by the state to have a level 2 outcome. 36003 Resident #84 was admitted to the facility on [DATE], with diagnoses including Non-Alzheimer's Dementia, Anxiety, Depression and Psychotic Disorder. Review of Resident #84's PASRR submission dated 9/5/2024, revealed the resident was considered by the state designated agency to have a level 2 outcome. Review of Resident #84's admission MDS assessment dated [DATE], revealed the resident was not coded as a resident currently considered by the state to have a level 2 outcome. During an interview on 10/17/2024 at 5:50 PM, the MDS Supervisor stated Resident #35, Resident #81 and Resident #84 were currently determined by the state designated agency to have a level 2 outcome and confirmed Resident #35, Resident #81 and Resident #84 were not accurately coded for a PASRR level 2 on the MDS assessment.

Based on facility policy review, medical record review and interview, the facility failed to implement a person centered comprehensive care plan intervention related to falls for 1 resident (Resident #51) of 3 residents reviewed for falls. The findings include: Review of the facility's policy titled, Documentation Guidelines, revised 6/2023, revealed .Care Plan Approaches [interventions] are specific, individualized steps partners [staff] and patients will take together to assist the patient to achieve the goal .Approaches serve as instructions for patient care . Review of the facility's undated policy titled, [Named facility] FALLS PROGRAM, revealed .to reduce the patients' risk of falling .implement appropriate interventions .Evaluate effectiveness of the interventions . Review of the facility's undated policy titled, L.A.M.P (Look at me please), revealed .L.A.M.P is a program initiated within the facility .means of communication to alert the staff of the individual's specific fall intervention needed . Medical record review revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Low Blood Pressure While Standing, Bradycardia, History of Falls, Dementia and Osteoporosis. Review of the facility's document for Resident #51 titled, POST FALL INVESTIGATION, dated 9/12/2024, revealed the resident had a witnessed fall while ambulating in the hallway on 9/12/2024, and the L.A.M.P program was listed as the facility's post fall intervention. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 was unable to complete the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review of the Significant Change MDS revealed the resident had falls at the facility since admission. Review of a comprehensive care plan for Resident #51 revised 10/13/2024, revealed .At risk for falls .Approach .pt [patient] to be a participant on the L.A.M.P. program . During an observation on 10/14/2024 at 2:00 PM, Resident #51 was in her room, sitting in her wheelchair. No signage was posted on the doorway, or in the resident's room related to falls or the L.A.M.P program. During an observation on 10/17/2024, at 9:00 AM, Resident #51 was not in the room, and no signage was posted on the doorway, or in the resident's room related to falls or the L.A.M.P. program. During an interview on 10/17/2024, at 9:20 AM, LPN F stated .The L.A.M.P program is a picture of a lamp or sign on the resident's door frame intended to remind staff prior to entering the resident's room. The Lamp stands for look at me please and reminds staff to pay special close attention to the resident regarding falls while in the room. The sign is kept on the doorframe and not in the room and not in the closet . During an interview on 10/17/2024, at 9:30 AM, CNA G stated .The L.A.M.P program is picture that goes only on the resident's door or door frame to let us know to pay close attention to them for falls risk and there is a number written on the picture to tell you which resident is on the L.A.M.P program . During an observation and interview on 10/17/2024, at 9:35 AM, LPN F and CNA G observed the door and door frame for Resident #51's room and confirmed there was no L.A.M.P signage in use for the resident. During an interview on 10/17/2024, at 10:00 AM, the Care Plan Coordinator H stated the L.A.M.P program signage was to be placed on the resident's door or the resident's door frame and confirmed the L.A.M.P. program fall intervention was not implemented.

Based on facility policy review, medical record review and interviews, the facility failed to ensure the medical record was accurate and complete for 1 resident (Resident #117) of 5 residents reviewed for blood glucose monitoring. The findings include: Review of the facility's policy titled, Introduction to Documentation for Inpatient Medical Records, dated 11/2023, revealed .It is the responsibility of each health care center to .maintain comprehensive records .accurately .Professional Standards of Documentation .evaluations, treatments .responses are accurately recorded .Information is recorded as near to the time of the occurrence . Resident #117 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Long term use of Insulin, Hyperglycemia and Adult Failure to Thrive. Review of the Part A PPS (Prospective Payment System) Discharge Item Set Minimum Data Set (MDS) assessment for Resident #117 dated 9/30/2024, revealed the resident had received insulin in the 7 day look back review. Review of the comprehensive care plan for Resident #117 dated 8/24/2024, revealed .Type II Diabetes .Perform fingersticks as ordered . Review of a Physician Order for Resident #117 dated 8/24/2024, revealed the order for blood sugar checks before meals and at bedtime (07:30 AM, 11:00 AM, 04:30 PM, 09:00 PM). Review of a Physician Order for Resident #117 dated 9/18/2024, revealed .Hyperglycemic Protocol .Any blood sugar 401 or greater, administer insulin per sliding scale and recheck in 2 hours. If still 401 or higher, notify medical staff for further orders . Further review of the medical record revealed Resident #117 had orders for long acting insulin (started 8/26/2024) and sliding scale insulin orders were added 10/11/2024. Review of the Medication Administration Record (MAR) for Resident #117 dated 9/1/2024-9/30/2024, revealed a blood sugar check was performed on 9/23/2024 at 4:30 PM with results of 434 mg/dl (milligram/deciliter-unit of measure). Continued review of the MAR revealed the Hyperglycemic Protocol dated 9/23/2024 had been omitted for the entire day. A repeat blood sugar should have performed 2 hours after the initial elevated blood sugar. Review of the Vitals Report for Resident #117 dated 9/23/2024, revealed the resident had a blood sugar recorded at 5:09 PM which resulted 434 mg/dl and the next blood sugar recorded at 8:01 PM which resulted 264 mg/dl (3 hours and 8 minutes later). During an interview on 10/17/2024 at 1:57 PM, Nurse Practitioner (NP) D was hesitant to increase Resident #117's insulin or order sliding scale insulin. Resident #117 was a new admission, and she was not familiar with the resident and sensitivity of his blood sugars to insulin. The NP was aware outside food was brought in by family for the resident and the resident snacked frequently. During an interview on 10/17/2024 at 2:24 PM, Medical Doctor (MD) E reviewed Resident #117's blood sugars for 9/23/2024 and had no issues with the single elevated blood sugar; the next blood sugar was not elevated and had come down. Resident #117 did not have to be sent to the hospital for the elevated blood sugar and had no negative outcomes. During interviews on 10/17/2024 at 4:34 PM, the Assistant Director of Nursing and the Director of Nursing confirmed Resident #117's medical record dated 9/23/2024, was incomplete and not accurate.

Based on review of facility job descriptions, medical record review, observation and interview, the facility failed to ensure 1 coffee cup was clean prior to resident use of 5 coffee cups observed. The findings include: Review of the facility job description titled, Dishwasher, revised 11/2020, revealed duties and responsibilities included, .Assists in maintaining the FNS [Food Nutrition Services] department in a .sanitary manner .Responsible for scraping .washing, and sanitizing dishes .utensils .Assembles meal trays on tray line and checks trays for .quality . Review of the facility job description titled, Food and Nutrition Services (FNS) Aide, revised 11/2020, revealed duties and responsibilities included .Assists in maintaining the FNS department in a .sanitary manner .Responsible for scraping .washing, and sanitizing dishes .utensils .Assembles meal trays on tray line and checks trays for .quality . Review of the medical record revealed Resident #94 was admitted to the facility on [DATE], with diagnoses including Mild Dementia with Anxiety, Delusional Disorders and Chronic Obstructive Pulmonary Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #94 scored 13 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. The resident did not require assistance with eating. During observation and interview on 10/15/2024, at 8:52 AM, Resident #94 requested this surveyor look at the rim of her coffee cup. Observation revealed a dark substance on the rim of the coffee cup. The dark substance was easily removed when the resident wiped a small area with a tissue. The substance on the tissue was wine colored. In reference to a clock face, the handle of the coffee cup was sitting on the over bed table with the handle at 3 o'clock and the dark substance was at 12 o'clock. Resident #94 was not wearing lipstick at the time of the observation. During observation and interview on 10/15/2024, at 9:05 AM, the Director of Nursing confirmed the rim of the resident's coffee cup had a dark substance and confirmed the cup had not been properly cleaned prior to resident use. During an interview on 10/15/2024, at 11:30 AM, the Administrator stated dietary staff were expected to inspect dishes, cups, and eating utensils for cleanliness prior to serving food and drinks to residents.

Based on review of facility policy, observation, and interview the facility failed to maintain a clean environment in 1 of 1 kitchen observed with the potential to affect 162 of 174 residents in the facility. The findings include: Review of the facility policy titled, Safety & Sanitation Best Practice Guidelines, revised 11/2017 showed .Equipment must be cleaned and/or sanitized after every use .Cleaning shall be done during periods when the least amount of food is exposed such as after closing . During the initial kitchen observation and interview on 1/10/2022 at 10:30 AM, with the Dietary Supervisor showed dried brown food debris on the meat slicer. Continued observation showed a deep fryer with brown food debris present in the oil and a large pool of oil present of the floor beside the deep fryer. The Dietary Supervisor stated the meat slicer and deep fryer were used the day before and should have been cleaned after its use. During an observation of the kitchen on 1/10/2022 at 12:00 PM, showed the Dietary Supervisor sprayed water on the oil in the floor, next to the deep fryer, during food preparation. During an interview on 1/11/2022 at 11:00 AM, the Certified Dietary Manager (CDM) stated she is responsible to over see the kitchen. The CDM stated the Dietary Supervisor should not clean equipment during food preparation and serving. The CDM stated the meat slicer and deep fryer should be cleaned after each use.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 4 residents (#28, #65, #92, and #96) of 34 residents reviewed for dignity. The findings include: Review of the facility's undated policy titled, Patient Dignity, showed Each resident shall be cared for in a matter that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Staff shall maintain an environment in which confidential clinical information is protected .Signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (e.g. [for example], taped to the inside of the closet door) . Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) significant change assessment dated [DATE], showed Resident #28 was sometimes able to make self understood and had moderate cognitive impairment. During observations on 1/10/2022 at 11:22 AM and 4:00 PM, 2 signs were located above Resident #28's bed. One sign read, Please make sure that Pressure-Relieving Boots are on patient's feet while in bed. Thank You! The other sign read, Please do not put a brief on patient while in bed .Please try to feed .Hospice .No Brief .Dependent diner. The signs were visible to residents, staff, and visitors that entered the room. During an observation and interview on 1/10/2022 at 4:42 PM, in Resident #28's room, Unit Manager #1 confirmed the signage was present above Resident #28's bed and was visible to other residents, staff, and visitors who entered the room. During a telephone interview on 1/11/2022 at 6:18 PM, Resident #28's responsible party stated he was unaware of any signage placed in the resident's room and had not requested any signage be placed in Resident #28's room. Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS quarterly assessment dated [DATE], showed Resident #65 had unclear speech and severe cognitive impairment. During observations on 1/10/2022 at 12:05 PM and 3:25 PM, 3 signs were located above Resident #65's bed. One sign read, Keep [Resident #65] bed against the wall! This is care planned. DO NOT MOVE BED. One sign read, Hospice shaves [Resident #65] face on Thursdays . The other sign read, [Resident #65] is to be on continuous O2 [oxygen]. Please do not remove resident's nasal cannula. Thank-you. The signs were visible to residents, staff, and visitors who entered the room. During an observation and interview on 1/10/2022 at 4:46 PM, in Resident #65's room, Unit Manager #2 confirmed the signage was present above Resident #65's bed and was visible to other residents, staff, and visitors who entered the room. Resident #92 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 5-day scheduled assessment dated [DATE], showed Resident #92 had moderate cognitive impairment. During an observation on 1/10/2022 at 3:48 PM, 1 sign was located above Resident #92's bed which read, NO DIAPERS WHILE IN BED .NO MILK .NO ICE CREAM .NO YOGURT .NO APPLE JUICE .NO COFFEE . The sign was visible to residents, staff, and visitors who entered the room. During an observation and interview on 1/10/2022 at 3:35 PM, in Resident #92's room, Certified Nursing Assistant (CNA) #2 confirmed the signage was present above Resident #92's bed and was visible to other residents, staff, and visitors who entered the room. Resident #96 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 5-day scheduled assessment dated [DATE], showed Resident #96 had unclear speech, was sometimes able to make self understood, and had severe cognitive impairment. During an observation on 1/10/2022 at 11:34 AM, 2 signs were located above Resident #96's bed. One sign read, PLEASE REVIEW BEFORE PROVIDING LIQUIDS OR SOLIDS and the other sign read, NPO [nothing by mouth] !! RISK FOR ASPIRATION PNEUMONIA! The signage was visible to residents, staff, and visitors who entered the room. During an observation and interview on 1/10/2022 at 4:05 PM, in Resident #96's room, Licensed Practical Nurse (LPN) #3 confirmed the signage was present above Resident #96's bed. During a telephone interview on 1/11/2022 at 7:50 PM, Resident #96's emergency contact confirmed he was unaware of any signage posted in the resident's room and had not requested any signage be placed in Resident #96's room. During an interview on 1/12/2022 at 5:28 PM, the Director of Nursing (DON) stated it would be the expectation of the facility to follow the facility policy. Further interview confirmed that signage posted above a resident's bed that had not been requested by the resident or family was a failure to follow the facility's policy. During an interview on 1/12/2022 at 6:41 PM, the DON confirmed no documentation showed Residents #28, #65, #92, and #96 or their families had requested any signage to be placed in their rooms.

Based on facility policy review, medical record review, and interviews the facility failed to develop and implement comprehensive care plans for 4 residents (#24, #41, #150, and #156) of 34 residents reviewed for care plans. The findings include: Review of the facility policy titled, NHC Care Plan Development, undated showed .center will ensure an interdisciplinary and comprehensive approach to the development of the patient's plan of care .Care Plan Approaches are individualized . Resident #24 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) annual assessment dated [DATE] showed Resident #24 required extensive assistance with bed mobility, dressing, toileting, personal hygiene, and bathing; Impairment of bilateral lower extremities. Further reivew showed frequent incontinence. MDS showed (1) stage 2 pressure ulcer present on admission; (1) stage 3 pressure ulcer present on admission; (1) stage 3 pressure ulcer present on admission and moisture associated skin damage. Review of the care plan dated 10/21/2021 showed the care plan did not address Resident #24's pressure ulcers or staging of pressure ulcers to buttocks. Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physical Therapist (PT) Progress & (and) Discharge Summary dated 10/14/2021 showed .Patient received PT evaluation and initial treatment. Patient with orders for bedrest and inability to attempt sitting at edge of bed .severity of sacral wound .recommend nursing ROM [range of motion] to BLE's [bilateral lower extremities] with ADL [activities of daily living] care . Review of an Minimum Data Set (MDS) admission assessment dated [DATE] showed the resident was cognitively intact, required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for personal hygiene and toilet use and had bilateral upper and lower extremity impairment. Review of Resident #41's care plan dated 10/26/2021 showed no documentation the resident was to receive range of motion with ADL care and did not address pressure ulcers or staging of pressure ulcers to sacrum. Resident #150 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan dated 10/14/2021 showed no documentation of a prosthetic device. Review of the MDS quarterly assessment dated [DATE] showed no documentation of a limb prosthesis for Resident #150. Resident #156 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 12/16/2021 showed a potential for skin integrity/wound at risk compromise. The care plan did not identify the resident had multiple pressure ulcers. Review of the MDS admission assessment dated [DATE] showed Resident #156 required extensive assistance of 2 staff for bed mobility and transfers; extensive assistance of 1 staff for dressing, toileting, and personal hygiene. Further review showed (3) stage 4 pressure ulcers and (2) unstageable pressure ulcers. During an interview on 1/12/2022 at 11:00 AM, the Director of Nursing stated physician orders drive the care plans and nurse managers work with MDS coordinators to develop the care plans. During an interview on 1/12/2022 at 3:00 PM, Licensed Practical Nurse #2 stated care plans are not individualized. During an interview on 01/12/2022 at 3:45 PM, the Wound Care Nurse stated care plans are generic and not person centered.

Based on medical record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 residents (#84, #150, and #164) of 34 residents reviewed for MDS assessments. The findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS quarterly assessment dated [DATE] showed Resident #84 had no documentation of a stage 4 pressure ulcer. During an interview on 1/12/2022 at 5:26 PM, the MDS coordinator confirmed the MDS dated [DATE] was not coded correctly and did not document the stage 4 pressure ulcer. Resident #150 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS quarterly assessment dated [DATE] showed no documentation of a limb prosthesis for Resident #150. During an interview on 1/12/2022 at 4:16 PM, the MDS coordinator confirmed the MDS dated [DATE] showed no documentation Resident #150 had a limb prosthesis. Resident #164 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS discharge assessment dated [DATE] showed Resident #164 had a planned discharge to acute hospital. Review of a Nurse Progress Note dated 11/9/2021 showed Resdient #164 discharged home at 2:25 PM with family. During an interview on 1/12/2022 at 3:50 PM, the MDS Coordinator confirmed the MDS dated [DATE] was not coded correctly. The discharge should have been planned, return to the community.

Based on medical record review , Physical Therapy (PT) recommendations, observation and interview the facility failed to ensure 1 resident (#41) received appropriate services to prevent further decrease in range of motion for 3 residents reviewed for limited range of motion. The findings include: Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a PT Progress & (and) Discharge Summary dated 10/14/2021 showed .Patient received PT evaluation and initial treatment. Patient with orders for bedrest and inability to attempt sitting at edge of bed .severity of sacral wound .recommend nursing ROM [range of motion] to BLE's [bilateral lower extremities] with ADL [activities of daily living] care . Review of a Minimum Data Set (MDS) admission assessment dated [DATE] showed the resident was cognitively intact, required extensive assistance of 2 staff for bed mobility, extensive assistance of 1 staff for personal hygiene and toilet use and had bilateral upper and lower extremity impairment. Review of Resident #41's care plan dated 10/26/2021 showed no documentation the resident was to receive range of motion with ADL care. During an observation and interview on 1/10/2022 at 3:45 PM, showed Resident #41 lying in bed. Resident #41 stated she is unable to move her legs and she has little movement of her upper extremities. She stated physical therapy does not work with her and nursing staff do not complete range of motion with her during ADL care. During an interview on 1/12/2022 at 10:15 AM, PT #1 stated Resident #41 was discharged from PT services in 10/2021 due to a severe pressure ulcer and the inability to sit at the bedside. PT #1 stated PT recommended nursing to complete passive ROM to extremities with ADL care.That's standard care . Further interview confirmed Resident #41 did not experience decline in range of motion. During an interview on 1/12/2022 at 11:00 AM, the Director of Nursing stated there was no documentation ROM had been completed for Resident #41. During an interview on 1/12/2022 at 11:15 AM, Certified Nursing Assistant (CNA) #1 stated she had not completed and was not aware Resident #41 required ROM during ADL care. During an interview on 1/12/2022 at 11:20 AM, Licensed Practical Nurse (LPN) #1 stated she was not aware Resident #41 required and had not completed ROM during ADL care.

Based on facility policy review, medical record, observation and interview the facility failed to implement a new intervention after a fall for 1 resident (#43) of 3 residents reviewed for accidents. The findings include: Review of the facility policy titled, FALLS POLICY, undated showed .Initiate a new intervention to keep patient safe and pertains to this fall . Resident #43 was admitted to the facility on [DATE] with diagnoses including Displaced Upper Arm Fracture, Non-Displaced Neck Fracture, Depression and Diabetes. Review of a Minimum Data Set (MDS) admission assessment dated [DATE] showed Resident #43 required extensive assistance for bed mobility and toileting. Review of a Post Fall Investigation dated 1/7/2022 showed Resident #43 had a fall with no injury in the resident's bathroom.pt [patient] using restroom .light In hand .CNA [Certified Nursing Assistant] lowered pt to floor . Review of Resident #43's care plan showed no new fall intervention implemented on the care plan after the resident's fall on 1/7/2022. During an observation and interview on 1/10/2022 at 12:25 PM, with Resident #43 showed the resident was seated in a wheelchair in her room. Resident #43 stated she had a previous fall. A CNA had assisted her from the toilet and she had fell in the bathroom. During an interview on 1/12/2022 at 8:00 AM, Registered Nurse (RN) #1 stated she was responsible to oversee falls in the facility. RN #1 stated Resident #43 required 1 staff to assist with transfers and did not sustain any injuries after the fall. RN#1 stated she did not feel there was unsafe behavior by the resident or the CNA. Continued interview confirmed RN #1 did not implement a new intervention to prevent further falls for Resident #43.

Based on review of the facility policy, medical record review, and interview, the facility failed to notify the physician in a timely manner of a malfunction of a Percutaneous Endoscopic Gastrostomy (PEG) tube (flexible feeding tube inserted through the abdominal wall and into the stomach for nutrition, fluids, and medications) for 1 resident (#2) of 3 residents reviewed for PEG tubes. The findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 5/9/19 revealed Resident #2 was care-planned for Infection Potential related to Feeding Tube, and Nutritional Status, Dependent on Tube Feed with interventions including (caloric, fiber fortified nutritional tube feeding) at 60 milliliters an hour for 18 hours, assess for changes in condition and notify medical staff, and MD (medical doctor) to replace PE[NAME] Medical record review of the Resident Progress Notes dated 9/1/19 at 1:38 PM, for Resident #2 revealed .in am, previous shift .nurse reported perforation to PEG tube. Noted large hole at end of catheter. Removed without difficulty and replace with new 24F (French) 20 cc (cubic centimeters) tube .restarted without concerns per supervisor .Husband updated, left message with NP (Nurse Practitioner) . Further review revealed no documentation the physician or the NP was made aware of the PEG tube perforation and the removal and reinsertion of a new PEG tube. Medical record review of the Physician's Orders on 9/1/19 revealed no documentation of an order to reinsert the PEG tube. Medical record review of an untitled typed letter, dated 10/14/19, and signed by the Unit Supervisor RN revealed .pt. (patient) had a removable gastric tube in place that had perforated and some of the balloon was visible from tube site entrance .nurse notified house supervisor .replaced with facility gastric tube . Interview with the Compliance Registered Nurse (RN) (former Unit House Supervisor) on 1/2/20 at 12:15 PM, in the Conference Room, confirmed she was the supervisor on duty on 9/1/19 when the Licensed Practical Nurse (LPN) (no longer employed at the facility), notified her of the perforated PEG tube. Continued interview confirmed she and the LPN removed the perforated PEG tube, reinserted a new PEG tube without notifying the physician. Interview with the Compliance RN, the Director of Nursing, and the Corporate Consulting RN on 1/2/20 at 1:50 PM, in the Conference Room, confirmed the facility did not notify the physician or NP of the PEG perforation and removal and reinsertion of the PEG tube.

Based on review of facility policy, medical record review, observation, and interview the facility failed to obtain a physician's order for an indwelling urinary catheter for 1 resident (#459) of 3 residents reviewed for urinary catheters of 49 sampled residents reviewed. The findings included: Review of the facility policy, Electronic Health Record IMAR System, dated 4/24/15 revealed .admission orders [REDACTED]. Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of hospital discharge orders dated 3/9/18 revealed .MD (Medical Doctor) order for (urinary catheter) .Catheter this admission: yes . Medical record review of Physician's Orders dated 3/9/18 revealed no order for an indwelling urinary catheter. Observation of Resident #459 on 3/18/18 at 11:00 AM and 2:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Observation of Resident #459 on 3/19/18 at 9:25 AM and 3:00 PM, in the resident's room, revealed the resident had an indwelling urinary catheter. Interview with Licensed Practical Nurse (LPN) #1 and LPN #2 at 3:30 PM, the 400 hall nursing station, revealed they were unaware Resident #459 had an indwelling urinary catheter and there was no physician's order. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed the admitting nurse failed to properly reconcile admission orders [REDACTED]. Continued interview confirmed .We missed it .

Based on medical record review and interview, the facility failed to develop a baseline care plan to address the care and treatment of [REDACTED].#459) of 49 sampled residents reviewed for baseline care plans. The findings included: Medical record review revealed Resident #459 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge orders dated 3/9/18 revealed Resident #459 was discharged with an indwelling urinary catheter. Medical record review of a baseline care plan dated 3/9/18 revealed no care plan for the care and treatment of [REDACTED]. Interview with the Director of Nursing on 3/20/18 at 7:22 AM, in the conference room, confirmed Resident #459's care plan failed to address the treatment and care of the indwelling urinary catheter.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide new interventions after a fall for 1 resident (#40) of 6 residents reviewed for falls of 49 residents reviewed. The findings included: Review of the facility's NHC FALLS PROGRAM undated revealed .Purpose: To identify patients at risk for falling and to implement the appropriate interventions .3) Implement appropriate interventions 4) Evaluate the effectiveness of the interventions . Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 1 staff to transfer, dress, toilet, complete personal hygiene, and the resident was non-ambulatory and total assistance of 1 staff for bathing. Review of the POS [REDACTED]. The new intervention was to keep the resident in high traffic areas. Review of the POS [REDACTED]. The new intervention was to educate staff to keep the resident in high traffic areas. Observation and interview with Resident #40 on 3/20/18 at 9:15 AM in the dining area revealed he was sitting in his geri chair (in the down position) at the table finishing his breakfast. States he falls because he is clumsy. I'm 96, old people fall Observation of Resident #40 on 3/20/18 at 2:30 PM, in the dining area revealed the resident sitting in the geri chair asleep, with the chair reclined. Interview with the Licensed Practical Nurse (LPN) Risk Manager on 3/20/18 at 2:45 PM, in the conference room revealed after reviewing the 9/21/17 and 10/8/17 Post Falls Investigations confirmed the new intervention for the 9/21/17 fall was to keep the resident in a high traffic area, this would include educating the staff of the new intervention, and would be added to the Certified Nurse Assistant work sheet. Continued interview confirmed Resident #40 received a hematoma to his forehead with the 10/8/17 fall, and the resident was in his room, which is not in a high traffic area. Further interview confirmed the new intervention to educate staff to keep the resident in a high traffic area was not a new intervention.

Based on review of facility policy, review of pest control records, observation, and interview, the facility failed to maintain sanitary conditions and failed to safely store canned foods in the dietary department in 1 of 1 observations made. The findings included: Review of the facility policy Safety and Sanitation, last revised 10/2014, revealed .if dent is not on side seam top or bottom .no leakage .before placing .acceptable dented cans back on the storeroom shelf for usage, label 'OK' at the site of acceptable dent, date and initial . Review of pest control records revealed the dietary department was serviced for a roach infestation in the dishwasher drain in April 2016 and was serviced by the pest control company for treatment of [REDACTED]. Observation of the dietary department on 10/25/16 between 1:40 PM and 2:15 PM, in the food preparation areas and dishwashing areas, revealed the following: 1. A dead roach atop the edge of the wall trim on the south wall adjacent to the stored cereals and steam kettle. 2. A dead roach on the floor behind the reach in cooler near the stove. 3. Food debris atop the floor drain grate behind the steam kettle. 4. Damp dry wall between the faucet and sink adjacent to the ice maker. 5. Dirt and debris on the floors in the food prep areas at the corners, behind, and beneath large appliances. Continued observation of the dietary department on 10/25/16 between 2:15 PM and 2:25 PM, in the dry storage area, revealed: 1. A 106 ounce can of whole corn dented and stored available for resident use, unmarked as reviewed for safety. 2. A 112 ounce can of chocolate pudding dented and stored available for resident use, unmarked as reviewed for safety. 3. Two 6 pound 9 ounce cans of crushed tomatoes stored dented available for resident use, unmarked as reviewed for safety. 4. A 112 ounce can of tomato ketchup stored dented and available for resident use, unmarked as reviewed for safety. 5. A 28 ounce can of unpeeled tomatoes stored dented and available for resident use, unmarked as reviewed for safety. 6. A 49.75 ounce can of clam chowder stored dented and available for resident use, unmarked as reviewed for safety. 7. Four steam table lids stored with brown debris and food residue on the inner and outer surfaces available and ready for use. Continued observation of the dietary department on 10/25/16 at 2:25 PM, in the walk in cooler, revealed a loose aluminum floor panel located on the floor of the cooler. Further observation revealed when stepped on, the distal end of the panel arose from the floor of the cooler. Continued observation of the dietary department at 2:30 PM, revealed a resident water pitcher labeled with the room and bed number lying in the floor behind the utensil rack. Further observation revealed 2 #16 scoops stored ready for use, stored wet with visable food debris inside the scoops. Interviews with 4 dietary staff members during tour of the kitchen on 10/25/16 between 1:40 PM and 2:15 PM, in the dietary department, revealed the 4 staff members confirmed they had seen live roaches in the kitchen on 10/23/16. Futher interview confirmed the staff had seen roaches near the dishwasher drain, on the floor near the stove, and on the wall near the walk in freezer. Continued observation revealed Dietary Worker #1 confirmed he saw live roaches on 10/22/16 emerge from the wall behind the soap dispenser and paper towel dispenser, located beside the ice maker. Interview with the Kitchen Supervisor on 10/25/16 at 2:35 PM, outside the dietary department, revealed the facility's contracted pest control service had implemented a regimen to eliminate roaches in the dietary department in April 2016 and efforts were ongoing. Continued interview revealed roaches continued to be present in the dietary department. Further interview revealed on two occasions, after power washing food service carts outside the building, the Kitchen Supervisor and dietary staff found roaches on the carts themselves when they were brought back inside the kitchen. Continued interview confirmed the roach infestation was not resolved. Further interview confirmed the dented cans were stored and available for use, the facility failed to properly inspect the dented cans, and the facility failed to follow facility policy.

Based on review of facility policy, medical record review, review of a facility investigation, and interview, the facility failed to maintain control of the controlled substance inventory for 1 resident (#3) of 3 residents reviewed for controlled substance use reviewed. The findings included: Review of the facility Controlled Substance policy, effective date 6/2016, revealed .Accurate accountability of all controlled drugs is maintained at all times .when a dose of a controlled medication is removed from the container for administration .or not given for any reason .it must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose .when a controlled medication is administered .the licensed nurse immediately enters the following information on the accountability record .date and time of administration .amount administered .signature of the nurse . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Medication Administration Record [REDACTED].Lorazepem (Ativan) 2 mg (milligrams per) ml (milliliter) .inject . 2 mg .every 4 hours as needed . Medical record review of the Narcotic Inventory Record (documentation of narcotic administration and waste) dated 9/13/16 at 7:30 PM, revealed Licensed Practical Nurse (LPN) #12 documented waste of 2 ml of Ativan (2 doses) on a single line on the document. Continued review revealed the waste was countersigned by LPN #2. Review of the facility investigation dated 9/13/16 revealed during the 7:00 PM narcotic reconciliation count LPN #2 determined Resident #3 had 2mls of injectable Ativan was unaccounted for. Continued review of the facility investigation revealed LPN #12 reported to LPN #2 the missing Ativan had been wasted though no Nurse had witnessed the waste and LPN #12 documented both doses of the missing Ativan as wasted on a single entry into the record. Continued review of the facility investigation revealed on 9/13/16 around 8:30 PM, LPN #12 (who was off duty and had remained in the facility in a nursing office adjacent to the nursing station) exhibited symptoms of altered mental status, slurred speech, and a brief period of unresponsiveness witnessed by a number of the Nurses on duty. Further review revealed EMS was called to the facility, LPN #12 refused EMS assessment or to undergo compulsory urine drug screening, and LPN #12 fled the facility. Continued review of the facility investigation revealed the facility determined LPN #12 had diverted the missing doses of Ativan and LPN #2 had failed to follow the Controlled substances policy, which required two nurses to witness narcotic waste, to immediately document wasted narcotic doses, and to document each wasted dose individually on the applicable controlled substance inventory documents. Interview with LPN #2 on 10/25/16 at 5:20 PM, by telephone, revealed on 9/13/16 around 7:30 PM, LPN #2 discovered the irregularity in the narcotic count for Resident #3's Ativan and initially refused to accept control of the medication cart. Continued interview revealed LPN #12 corrected the narcotic count and informed LPN #2 the missing Ativan had been wasted, at which time LPN #12 documented the waste in a single entry on the Narcotic Control Inventory and LPN #2 the waste. LPN #2 confirmed she did not witness waste of the missing Ativan and confirmed she accepted control of the medication cart. Further interview confirmed she did not immediately notify her supervisor of the irregularity in the medication count, but did report the situation after she and a number of other nurses on duty witnessed LPN #12 become impaired with symptoms consistent with drug ingestion a short time later. Interview with LPN #12 on 10/26/16 from 3:22 PM to 4:28 PM, by telephone, confirmed she informed LPN #2 she wasted the missing Ativan during the narcotic reconciliation count on 9/13/16. Continued interview revealed LPN #12 confirmed she had deliberately documented the alleged waste via a single entry into the record in violation of facility policy and no licensed nurse witnessed the waste of the missing Ativan in violation of facility policy. Further interview revealed LPN #12 denied diversion of the medication. Interview with the Administrator and Director of Nursing (DON) on 10/25/16 at 6:10 PM, in the conference room, confirmed LPN #2 and LPN #12 failed to follow the facility controlled substances policy for waste of narcotics and failed to report irregularities in narcotic reconciliation counts immediately to the nursing supervisor. Further interview confirmed the facility investigation determined the missing Ativan from Resident #3 was diverted by LPN #12 and the facility failed to maintain control of the controlled substance inventory for Resident #3.

Based on review of facility policy, review of temperature logs, observation, and interview, the facility failed to monitor and record freezer temperatures for 8 of 8 resident freezers for 4 of 4 nursing stations, monitor a thermometer for 1 of 10 resident refrigerators for 1 of 4 nursing stations, and to complete temperature logs for 2 of 10 nourishment refrigerators/freezers for 2 of 4 nursing stations that could have affected 178 residents. The findings included: Review of facility policy, Safety and Sanitation Best Practice Guidelines, Refrigerator and Freezer Storage, revised 1/2011 revealed .thermometers .recorded upon opening and in the late afternoon .temperatures not within these ranges, 32 degrees F (Fahrenheit) to 41 degrees F or less .for refrigerator and between - (symbol for negative) 10 degrees F to 0 degrees F .for freezer, should be reported . Observation with Licensed Practical Nurse #1 on 3/29/16 at 9:05 AM in the Station 4 Kitchen/Ice Machine Room in the Non-NHC Refrigerator/Freezer, revealed no thermometer in the freezer. Observation with Registered Nurse #1 on 3/29/16 at 9:20 AM in the Station 3 Kitchen Room in the Non-NHC Refrigerator/Freezer, revealed no thermometer in the freezer. Observation with the Registered Dietician (RD) on 3/29/16 at 9:25 AM, at the Station 2 Non-NHC Refrigerator/Freezer revealed no thermometer in the freezer. Further review in the NHC Secured Refrigerator revealed 24, 4 oz (ounce) dairy snacks with no thermometer and no posted temperature control log sheet. Observation with the RD on 3/29/16 at 9:30 AM, at the Station 1 Refrigerator/Freezer at the Secured Refrigerator revealed 24, 4 oz dairy desserts (high calorie ice creams) with no freezer thermometer. Further review revealed no posted temperature control log sheet. Continued review of the Station 1 Non-NHC Refrigerator revealed no freezer thermometer. Observation with the RD on 3/29/16 at 9:40 AM,at the Station 3 Secured Refrigerator/Freezer revealed 27, 4 oz dairy desserts with no freezer thermometer. Observation with the RD on 3/29/16 at 9:50 AM, at the Station 4 Secured Refrigerator/Freezer revealed no freezer thermometer. Interview with the RD on 3/29/16 at 10:30 AM, in the RD office confirmed the facility failed to maintain and monitor freezer temperatures for 8 freezers, maintain a thermometer for 1 refrigerator, and to maintain temperatures logs for 2 refrigerators.

Based on medical record review and interview, the facility failed to prevent a fall for 1 resident (#350) of 3 residents reviewed for falls of 34 residents reviewed. The findings included: Medical record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 3/19/15 revealed the resident was at risk for falls due to a history of falls, weakness, abnormality of gait, osteoarthritis, cervical and thoracic [DIAGNOSES REDACTED], with goals of (Resident #350) will be kept safe AEB (as exhibited by) no falls with injury resulting in hospitalization . Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident needed extensive assistance with bed mobility, transfers, toilet use, and personal hygiene, with the assistance of 2+ persons. The MDS rated the resident needed total assistance with locomotion on unit with the assistance of one person. Review of a facility fall investigation dated 4/12/16 revealed the resident had been toileted in his bathroom on the evening of 4/8/16 with the assistance of CNA #1. The CNA stated . she was transferring the resident from the commode to the wheelchair when the wheelchair tipped backward into her body . she lowered the resident onto the floor of the bathroom . She said that he did not hit anything and stated she thought he was fine . The CNA opened the bathroom door and asked the roommate's family member to help her return the resident to his wheelchair .the family member assisted the CNA to transfer the resident back into his wheelchair and back to his bed. The CNA intended to report the fall to the Nurse on duty Licensed Practical Nurse (LPN) #5, got busy with other residents and forgot to report the fall . Review of a note from the Director of Nursing on 3/29/16 at 9:10 AM, in the conference room revealed .the facility had no falls policy, the facility had guidelines they use to keep patients safe, and the patients are individually assessed . Interview with the Administrator on 3/29/16 at 4:18 PM, in the Administrator's office confirmed CNA #1 should have prevented the fall and reported the resident's fall to her superior immediately after the fall, did not report it until questioned about it at a later date.

Based on review of medical records, [MEDICAL TREATMENT] clinic flow sheets, observation, and interview, the facility failed to assess the correct [MEDICAL TREATMENT] site and update the care plan to reflect the current [MEDICAL TREATMENT] in use for one resident (#186) of thirty-seven residents reviewed. The finding included: Resident #186 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident was independent in cognitive skills for decision making. Medical record review of the nurse's notes and [MEDICAL TREATMENT] clinic flow sheets revealed the nurses documented post [MEDICAL TREATMENT] assessments of the left upper extremity and check of the bruitt & thrill dated January 31, 2015, February 2, 2015, and February 3, 2015. Review of the [MEDICAL TREATMENT] flow sheets obtained from the [MEDICAL TREATMENT] center dated January 29, 2015, January 31, 2015, and February 3, 2015, indicated use of the venous [MEDICAL TREATMENT] catheter access in right chest wall instead of the left upper arm access. Medical record review of the care plan dated December 29, 2014, revealed the residents [MEDICAL TREATMENT] access was located in the left upper extremity. Interview with Registered Nurse (RN) #1 on February 10, 2015, at 8:30 a.m., in the nurses station 2 hallway, confirmed RN #1 was not aware of which access was being used for [MEDICAL TREATMENT]. Interview with the Assistant Director of Nursing (ADON) on February 10, 2015, at 8:45 a.m., at nurses station 2, confirmed the ADON was not sure which site was in use for [MEDICAL TREATMENT]. Interview with Licensed Practical Nurse (LPN) #1, on February 10, 2015, at 9:00 a.m., in the nurses station 2 unit manager's office, confirmed the right chest wall [MEDICAL TREATMENT] access was being used. Coninued interview with LPN #1 revealed the [MEDICAL TREATMENT] clinic had notified LPN #1 by telephone of the use of the right chest wall catheter for [MEDICAL TREATMENT]. Interview with the ADON on February 10, 2015, at 9:00 a.m., in the station 2 unit manager's office, confirmed the care plan was incorrect. Observation and interview with the resident on February 11, 2015, at 8:00 a.m., in the resident's room confirmed the right wall [MEDICAL TREATMENT] catheter was present and used for [MEDICAL TREATMENT].

Based on observation and interview, the facility failed to store food in a sanitary manner to prevent cross-contamination between resident food items and non-food items for three of seven refrigerator/freezers designated for resident snacks, on two of four units observed. The findings included: Observation with Licensed Practical Nurse (LPN) #4 on February 10, 2015, at 12:55 p.m., of the station 1 nourishment refrigerator/freezer, revealed individual servings of ice cream for resident use stored in the freezer. Continued observation revealed three ice packs had been stored on the door rack of the freezer (one freezer gel pack and two solid ice packs). Observation with LPN #3 on February 10, 2015, at 1:00 p.m., of the station 4 nourishment refrigerator/freezer located in the Kitchen/Ice Machine room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one solid ice pack had been stored on the door rack of the freezer. Observation with LPN #3 on February 10, 2015, at 1:05 p.m., of the station 4 nourishment refrigerator/freezer located in the Med (medication) Prep (preparation) Room, revealed individual servings of ice cream for resident use had been stored in the freezer. Continued observation revealed one gel freezer pack had been stored in the freezer next to the resident's ice cream. Interview with LPN #2 on February 10, 2015, at 2:15 p.m., at nurse's station 4, confirmed the ice packs were not to be stored with the food items. Interview with the Registered Dietician on February 10, 2015, at 4:15 p.m., in the Parkwood Dining Room, confirmed non-food items were not to be stored with the resident's snacks.