Every finding on record at NHC Healthcare, Johnson City

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide dental services for 1 resident (Resident #29) of 21 sampled residents. The finding include: Review of the facility policy Patient Rights, Dental Services, dated 1/2018, showed .the center will assist patients in obtaining routine and emergency dental services from an outside source .assist if necessary or requested in making appointments . Review of the medical record showed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 13, indicating intact cognition. Review of the Care Plan for Altered Nutritional Status, updated 3/13/2022, revealed .dental consult as warranted . Review of the medical record revealed no documentation a dental referral was scheduled for Resident #29. Observation and interview with Resident #29 on 5/9/2022 at 10:45 AM, revealed brown stained lower teeth. The resident stated she had upper dentures and did not want lower dentures. She was not having pain, but was having problems with her lower teeth, and wanted to see a dentist. Continued interview confirmed she had not been asked by the facility to help her with a dental consult. During an interview on 5/10/2022 at 2:55 PM, the Social Service Director (SSD) stated she was responsible for scheduling resident dental visits. She stated the nurses either contacted her with concerns, made resident rounds, or she called family for the quarterly dental visits. A dental visit had been scheduled for 3/22/2022, but the dental group rescheduled for 5/25/2022. The SSD confirmed Resident #29 was not on the dental appointment list for 3/22/2022 or 5/25/2022; the facility did not have a consent or decline for dental services for Resident #29.

Based on facility policy review, review of the Lippincott Nursing Center, medical record review, facility documentation review, observation, and interview the facility failed to correctly administer medications for 1 resident (#335) of 6 residents reviewed for unnecessary medications. The findings include: Review of the undated facility policy Administering Medications revealed .3. Medications must be administered in accordance with the orders .4. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Method of identifying the resident checking photograph attached to the electronic medical record .5. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication .6. The following information must be check/verified for each resident prior to administering medications: [REDACTED]. Vital signs, if necessary . Review of the Lippincott Nursing Center 8 Rights of Medication Administration dated 5/27/11 revealed the 8 rights of medication administration included the right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response. Medical record review revealed Resident #335 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making was modified independence indicating the resident had some difficulty in new situations only. Review of facility documentation dated 7/17/18 revealed Resident #335 received the medications of another resident during the 9:00 AM medication pass. Continued review revealed the medications were administered incorrectly to Resident #335 based on mistaken identity. Medical record review of Resident #335's Electronic Medication Administration Record [REDACTED]. Medical record review of a nurses' note dated 7/17/18 and timed 10:30 AM revealed the resident's blood pressure was 196/87; Heart rate was 60 beats per minute; respiratory rate was 18 breaths per minute and the Oxygen saturation (amount of oxygen in the blood) was 98% (percent). Continued review revealed the resident was alert and oriented. Medical record review of a Nurse Practitioner's note dated 7/17/18 revealed .Pt (patient) was given morning meds (medications) that were prescribed to another pt. He had not received his own meds at the time. Medications were reviewed. His own morning blood pressure medication was held due to medicines he received. Pt was seen approx (approximately) 2 hours after receiving medications. He was alert and oriented. No adverse affects have occurred at this time. Discussed with patinet (patient) and daughter that he may have some drowsiness. Vital signs checked per staff and were stable . Medical record review of a nurses' note dated 7/17/18 and timed 1:45 PM revealed the resident's blood pressure was 151/76 and the resident was alert and oriented. Medical record review of nurses' notes dated 7/17/18 from 1:54 PM through 2:30 PM revealed the resident complained of nausea with some .thin watery emesis . Continued review revealed the resident remained alert, oriented and had some complaints of dizziness and sleepiness. Medical record review of a nurses' note dated 7/17/18 and timed 3:00 PM, revealed the resident had no further emesis. Continued review revealed the resident reported he was feeling .a little better . and wanted to go to his doctor's appointment. Medical record review of a nurses' note dated 7/17/18 and timed 3:30 PM, revealed the resident was out of the facility for a doctor's appointment. Medical record review of a Provider Note dated 7/18/18 revealed .patient received wrong medications including [MEDICATION NAME] (medication for [MEDICAL CONDITION]), Requip (medication for restless leg syndrome), [MEDICATION NAME] (medication for depression), Vitamin D (calcium), Risaquad (medication to balance good bacteria in the digestive system), [MEDICATION NAME] (blood pressure medication), and [MEDICATION NAME] (blood pressure medication) . Observations of Resident #335 from 7/23/18 through 7/25/18 revealed the resident was participating in physical therapy and talking with other residents in the hallway. Interview with Resident #335 and the residents' daughter on 7/23/18 at 11:30 AM, in the resident's room revealed the resident had received another resident's medication on 7/17/18. The residents' daughter reported Resident #335 received 2 blood pressure medications, an antidepressant, medication for [MEDICAL CONDITION], and a vitamin in error. Interview with Nurse Practitioner (NP) #1 on 7/24/18 at 3:05 PM, in the Station 4 Chart Room confirmed Resident #335 received another resident's medications on 7/17/18. Further interview revealed the resident complained of nausea for a couple of hours and vomited 1 time. Continued interview revealed the resident's vital signs remained stable, all of the labs were normal and there were no adverse side effects. Interview with Resident #335 on 7/24/18 at 3:41 PM, in the resident's room revealed the resident had received the medications in the hallway as the resident was going to therapy. The resident reported he had gotten sleepy while in therapy, had nausea and vomiting, and was light headed. Interview with Licensed Practical Nurse (LPN) #1 on 7/24/18 at 3:41 PM, in the Infection Control Office revealed she thought Resident #335 came out of room [ROOM NUMBER]. LPN #1 confirmed she gave Resident #335 the medication for the resident occupying room [ROOM NUMBER]. Interview with the Director of Nursing on 7/24/18 at 4:27 PM, in the Station 4 Resident Care Coordinator's Office confirmed Resident #335 received the incorrect medication on 7/17/18 and confirmed the facility failed to follow the facility policy for medication administration.

Based on medical record review and interview the facility failed to ensure an accurate Minimum Date Set (MDS) for one resident (#89) of 43 sampled residents. The findings include: Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day MDS dated [DATE] revealed .Section P .physical restraints .used in chair or out of bed .1 (indicating used less than daily) . Observation of the residents on 7/26/18 at 1:02 PM, in the resident's room, revealed resident alert and verbal sitting in wheelchair in room. Continued observation of the resident room revealed no restraint in place to resident or in resident room. Interview with the MDS coordinator on 7/25/18 at 8:50 AM, in the MDS office, confirmed the MDS dated [DATE] was not accurate and the resident had not used a physical restraint.

Based on facility policy review, observation, and staff interviews, the facility failed to distribute meals in a sanitary manner and failed to disinfect the hands to prevent contamination during meal service on 1 of 3 dining areas observed. The findings included: Review of policy and procedure on Handwashing, dated 10/2014, revealed, .Hands should be washed before starting to work; after break time; after using the rest room; after touching hair, face, or body .after touching anything that might contaminate hands .Sanitizing gel may ONLY be used as an added measure after washing hands to minimize bacteria, but not in place of handwashing . Observation on 05/22/17 at 11:53 AM, during meal service near the 300 hall, revealed Certified Nurse's Assistant (CNA) #5 picked up an uncovered plate of multiple food items from the hot bar (serving line), and carried it to an adjacent dining area across the hallway. Observation of CNA #6 revealed the CNA picked up an uncovered plate of multiple food items and carried the tray across the hallway into another dining area. Continued observation revealed the Dietary Aide (DA) #1 was plating food, without wearing gloves, wiping his face and adjusting his glasses, then touching the plate surfaces with bare fingers and placing resident's food on the plates to be served to the residents. Continued observation revealed DA #1 failed to wash his hands or use hand sanitizer after touching his face or glasses. Observation on 05/24/17 at 7:50 AM, during the breakfast meal service observation near the 300 hall, revealed CNA #8 picked up an uncovered breakfast plate from the tray line, walked across the hallway to the dining room and served Resident #102. Continued observation revealed CNA #9 also picked up an uncovered breakfast plate, carried the plate of food across the hallway to the dining room, and served Resident #105. On 05/24/17 at 8:04 AM, interview with the Dietary Manager (DM) #1, confirmed when staff are walking trays into another room from the serving line, the plated food should be covered. When asked if gloves are required when touching food surfaces, she confirmed that they were.

Based on medical record review, observation, and interview the facility failed to honor individual choices for daily schedules for 2 residents (#84, #211) of 21 residents interviewed. The findings included: Medical record review revealed Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #84 had a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment. Review of the medication record completed on 5/23/2017 at 3:48 PM revealed Resident #84 had a blood pressure medication ordered with parameters to hold the medication based on the resident's current blood pressure. The medication is set for an 8:00 AM administration schedule. Resident #84 also had an order for [REDACTED]. Observation and interview with Resident #84 on 5/22/2017 at 1:26 PM, in the resident's room confirmed she had not been given the opportunity to choose the time she preferred to be awakened in the morning nor the type of bathing she received. They wake me up at 5 (AM) but I don't get breakfast till 9 (AM). I would like to get up at 7 (AM) .I go (to the shower) on Tuesday and Friday. I didn't choose those days. An interview was completed with Activity Assistant (AA) #1 on 5/23/2017 at 2:10 PM. AA #1 stated, On admission, we fill out an assessment .We don't ask about what time they want to get up in the morning. On 5/23/2017 at 2:55 PM, an interview was completed with Certified Nursing Assistant #1 (CNA). CNA #1 stated she was familiar with Resident #84. I come in at 6:30 (AM). She is usually sleeping then. I go in to get her vitals (blood pressure, temperature, pulse) about 7 (AM). They get done every day. I ask if she wants to get up and she usually gets started with her day at that time. Breakfast comes out about 7:45 AM. Sometimes she says she doesn't want to get up at 7. Observation on 5/24/2017 at 7:05 AM, revealed staff checking vital signs. Observation on 5/24/2017 at 7:50 AM, revealed the breakfast tray was delivered to Resident #84. On 5/24/2017 at 8:05 AM an interview was completed with LPN #1. LPN #1 stated the activities staff ask residents about bedtimes, but not morning wake up times, and LPN #1 was unable to find any documentation in the record indicating Resident #84's preferred time to get up in the mornings. On 5/24/2017 at 8:05 AM, a review of the CNA Point of Care data noted no information about the time Resident #84 preferred to get up in the mornings. Medical record review revealed Resident #211 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #211 had a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. On 5/22/2017 at 2:53 PM, an interview was completed with Resident #211. Resident #211 stated she was not able to choose the time she was awakened in the morning. They get me up about 8:30 (AM). I prefer 9:00 (AM) or later. On 5/23/2017 at 3:00 PM, an interview was completed with CNA #1 who stated she was familiar with Resident #211. (Resident #211) eats about 7:45 (AM). She likes to sleep in. She will say, I don't feel like it and I want to wait awhile. She gets vital signs each morning around 7:00 (AM) and she will usually say she doesn't want to get up; she wants to wait till after breakfast. Review of the medication record on 5/23/17 at 3:45 PM noted no medications that required vital sign parameters before administering the resident's prescribed medication. On 5/23/2017 at 4:09 PM, an interview was completed with LPN # 2 who stated she was familiar with Resident #211. We get everyone's vital signs every day. We would get Resident #211's vitals each shift. On day shift they would start getting vital signs at 7:00 AM. On 5/24/2017 at 7:48 AM, Resident #211's breakfast tray was noted delivered. On 5/24/2017 at 8:05 AM, a review of the Nursing Assistant Point of Care data noted no information about the time Resident #211 preferred to get up in the mornings. An interview was completed with LPN #1 on 5/24/2017 at 8:05 AM, who stated activities staff ask residents about bedtimes, but not morning wake up times, and that she couldn't find any documentation in the record indicating Resident #211's preferred time to get up in the mornings.

Based on Centers for Disease Control (CDC) guidelines, medical record review, observation and interview, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) when entering a resident's room and to follow proper infection control standards for 1 resident (#418) of 4 residents reviewed for infection control of 26 residents reviewed. The findings included: Review of the CDC guidelines for residents with Clostridium Difficile dated 2007 revealed, .Use gloves when entering patients' rooms and during patient care .Use gowns when entering patients' rooms and during patient care . Medical record review revealed Resident #418 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a lab dated 05/21/16 revealed Resident #418 had a positive stool culture (Stool specimen tested for toxin) positive for Clostridium difficile (infectious bacteria that can cause symptoms ranging from diarrhea to life threatening inflammation of the colon). Medical record review of a physician's orders [REDACTED]. Observation of Resident #418's room on 5/31/16 at 11:50 AM, revealed a contact precaution sign located outside of the resident's door. Continued observation revealed gowns, gloves, and masks hanging from a plastic apron located on the outside of the resident's door. Observation of a meal tray delivery for Resident #418 on 5/31/16 at 11:52 AM, revealed the Certified Nursing Assistant (CNA) #1 had not donned personnel protective equipment (PPE) which consists of gown and gloves, before entering Resident #418's room to deliver a meal tray. Interview with CNA #1 on 5/31/16 at 11:52 AM, in the 100 hallway, confirmed CNA #1 entered Resident #418's room without donning personal protective equipment. Interview with the Director of Nursing on 6/2/16 at 8:56 AM, in the conference room, confirmed the facility failed to ensure staff donned appropriate PPE when entering Resident #418's room, who was on contact precautions, and failed to follow proper infection control standards for Resident #418.

Based on review of facility policy, observation, and interview, the facility failed to administer medications in a sanitary manner for 1 of 4 medication carts and the facility failed to feed residents in a sanitary manner for 1 of 3 dining rooms. The findings included: Review of facility policy, Medicine Handling, undated revealed .1. If oral medicine is dropped from its packaging onto the top of the med cart while being removed for administration, use gloved hand to pick up and discard. Observation on 6/22/15 at 10:30 AM, near the 100 nursing desk revealed Licensed Practical Nurse (LPN) #1 prepared Resident #231's medications. Continued observation revealed LPN #1 dropped a [MEDICATION NAME] Bisulfate 75 mg onto the contaminated medication cart, put gloves on and put the pill into a medication cup, prepared the remaining medications placing them into the same medication cup, and administered the contaminated medications to Resident #231. Interview with LPN #1 on 6/22/15 at 10:45 AM, near room [ROOM NUMBER] confirmed the dropped pill was contaminated and should have been discarded. Review of facility policy, Hand Hygiene, revealed, Hands shall be washed.whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such, and before eating.In the absence of visible soiling of hands, alcohol-based hand rubs are preferred for hand hygiene. Observation of the dining area at station 2 on 6/22/15 from 12:05 PM to 12:10 PM, revealed Certified Nursing Assistant (CNA) #3 was feeding 3 residents while standing over them, holding/touching the backs of their chairs. Continued observation revealed CNA #3 moved from one resident to another touching their eating utensils without sanitizing the hands. Interview with CNA #3, on 6/22/15 in the dining room, confirmed I didn't wash my hands after touching the chair. Interview with the Director of Nursing (DON) and the Administrator on 6/24/15 at 10:42 AM, in the DON's office confirmed yes they should have washed their hands between touching the chair and feeding the residents.

Based on medical record review, observation, and interview, the facility failed to ensure an unnecessary medication was not administered to 1 resident (#80) of 5 residents reviewed for unnecessary medications. The findings included: Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Consultant Pharmacist's Recommendation to Physician form dated 6/2/15 revealed .This resident is receiving the antipsychotic agent [MEDICATION NAME] but lacks an allowable [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication, Treatment and Task Administration Record Report for June 2015 revealed the resident received Quetiapine ([MEDICATION NAME]) 25 mg (milligrams) daily at 9:00 PM, 6/1/15 through 6/23/15. Observation on 6/24/15 at 12:20 PM revealed the resident lying on the bed, in the resident's room, talking with a staff member. Interview with Resident Care Coordinator #1 on 6/24/15 at 8:10 AM, at the nursing station confirmed the resident continued to receive the [MEDICATION NAME] through 6/23/15 and the physician's orders [REDACTED].

Based on medical record review, observation, and interview, the facility failed to honor bathing preferences for 1 resident (#231) of 3 residents reviewed for activities of daily living. The findings included: Medical record review revealed Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact/independent with daily decision making and was totally dependent with one person assist for bathing. Observation on 6/23/15 at 7:45 AM revealed the resident lying awake on the bed. Interview with the resident, at this time, revealed the resident received 2 showers weekly. Continued interview revealed the resident had oily hair and would like a shower daily. Further interview revealed Resident #231 had told her Certified Nursing Assistant (CNA) she would like to receive a shower more often than twice a week. Interview with CNA #1 (CNA usually assigned to care for the resident), in the hallway on 6/23/15 at 1:15 PM confirmed the resident had voiced would like a shower daily. Continued interview revealed the CNA had not reported the resident's request to the nursing supervisor. Interview with Resident Care Coordinator #1 on 6/23/15 at 1:40 PM, at the nursing station confirmed the resident's request/choice to receive a shower more often than 2 times a week had not been honored.

Based on observation and interview, the facility failed to assist residents with eating at mealtime, in a dignified manner, for 5 residents observed in 1 dining of 3 dining areas observed. The findings included: Observation of the station 2 dining area on 6/22/15 at 12:03 PM revealed Certified Nursing Assistant (CNA) #2 feeding two residents while standing over them. Observation of the station 2 dining area on 6/22/15 at 12:05 PM revealed CNA #3 feeding three residents while standing over them and moving from one resident to another. Interview with CNA#2 on 6/22/15 at 12:16 PM, in the dining room confirmed Don't suppose to stand up and feed residents. Interview with CNA#3 on 6/22/15 at 12:19 PM, in dining room confirmed I'm not to stand and feed residents. Interview with the Director of Nursing (DON) and the Administrator on 6/24/15 at 10:42 AM, in the DON's office confirmed the CNAs are not suppose to stand over the residents when assisting with feeding.

Based on observation and interview the facility failed to ensure tube feedings were properly labeled for one resident (#169) of twenty-six residents reviewed. The findings included: Resident #169 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on March 17, 2014, at 2:52 p.m., in the resident's room, revealed the resident lying in the bed with [MEDICATION NAME] 1.5 calorie (tube feeding) infusing at 65 milliliter (ml) per hour per the Percutaneous Endoscopic Gastrostomy (PEG) feeding tube. Continued observation revealed the tube feeding was not labeled with a start date or time. Interview with the Director of Nursing (DON) on March 17, 2014, at 3:22 p.m., in the resident's room, confirmed the facility failed to label the tube feeding with a date or time.

Based on medical record review and interview, the facility failed to evaluate the bladder incontinence status of one resident (#162) of twenty-six residents reviewed. The findings included: Resident # 162 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the current care plan for the resident indicated that the resident was at risk for alteration in skin integrity due to urinary incontinence, with an intervention of assisting the resident with toileting as needed. Medical record review revealed two forms entitled Incontinence Screening, one dated November 8, 2013, and the other dated November 18, 2013. Both forms were complete on page one, Both forms indicated Resident # 162 "scored a five on the incontinence screening and is a candidate for a bowel/bladder program at this time and is willing and/or able to participate in a continence program". Further review of the Incontinence Screening form dated November 8, 2013, revealed Resident # 162 "actively wants to regain bladder control". Continued review of both Incontinence Screening forms revealed the second page to be blank and the section of the forms "Complete the following algorithm to determine the appropriate incontinence management program" was not completed. Further review revealed the section " After completing the management algorithm, the program best suited to meet the patient's needs was:" had not been completed and a bladder training program had not been identified on the form for the resident. Interview with Licensed Practical Nurse (LPN) #1 on March 18, 2014, at 1:57 p.m., at Nurse Station Two, revealed Resident #162 was incontinent of urine mostly at night and occasionally during the day. Continued interview revealed the resident was not on a scheduled toileting program. Further interview revealed "We offer to take... to the bathroom at least every two hours. The facility standard for residents who need assistance with toileting is to offer every two hours." Interview with MDS (minimum data set) Coordinator #1 on March 19, 2014, at 10:12 a.m., revealed the incontinence screening form, both page one and two, were to have been completed by the MDS coordinator. An incontinence training program for the resident was to have been identified on the form. The information on the form was then to be relayed to the Resident Care Coordinator at the resident's station. Further interview with the MDS Coordinator #1 confirmed page two of the incontinence screening forms dated November 8, and November 18, 2013, for Resident #162 had not been completed and no incontinence program had been identified.

Based on observation, medical record review, and interview, the facility failed to assess for the use of a restraint prior to starting a potential restraint for two residents (#164,#152) of twenty-six residents reviewed. The findings included: Resident #164 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on March 17, 2014, at 2:30 p.m., and March 18, 2014, at 3:12 p.m., revealed resident #164 on the 300 hall in a reclined wheelchair. Medical record review of a care plan dated February 5, 2014, revealed "...11/27/13 resident placed in gerichair...1/3/14 resident to be up in rocking wheelchair (type of reclined wheelchair) during the day as tolerated..." Medical record review of a physical restraint review dated January 28, 2014 revealed, "...pt (patient) is up to gerichair daily..." Interview on March 18, 2014, at 1:44 p.m., with Resident Care Coordinator (RCC) #1 at the 300 hall nurse's desk, revealed the resident was placed in the gerichair on November 27, 2013, and a restraint assessment was not completed till January 28, 2014, "two months later." Continued interview revealed the recline wheelchair was not assessed prior to placing the resident in the wheelchair on January 3, 2014. Interview on March 19, 2014, at 9:23 a.m., in the RCC office confirmed the facility failed to assess the gerichair and rocking wheelchair prior to starting for a potential restraint. Resident #152 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident in the resident's room on March 17, 2014, at 1:42 p.m., revealed the resident sitting in a Broda chair (type of reclining chair). Review of the Interim Care Plan dated February 12, 2014, revealed "...2/21/14, Broda chair d/t (due to) fall..." Continued review of the medical record revealed the facility failed to complete a Pre-Restraint Assessment for the Broda chair until March 4, 2014, a delay of eleven days. Interview with the Station one Resident Care Coordinator (RCC) on March 18, 2014, at 11:45 a.m., at the Station one Nurse's Station confirmed the facility failed to perform a Pre-Restraint Assessment prior to initiating use of the Broda chair.

Based on medical record review, observation, and interview, the facility failed to maintain an accurate clinical record for one (#172) of fifty sampled residents. The findings included: Resident #172 was admitted to the facilty on June 25, 2012, with diagoses including [MEDICAL CONDITIONS], Long-Term [MEDICATION NAME] Therapy, [MEDICAL CONDITIONS], Acute Anxiety, Dementia, Depression, and [MEDICAL CONDITION]. Medical record review revealed a physician's orders [REDACTED]. every twelve hours for anxiety. Medical record review of a Medical Psychiatry Evaluation dated October 10, 2012, revealed the resident was currently on [MEDICATION NAME] 0.5 mg. twice daily for anxiety. Further review revealed, "...add PRN (as needed) of [MEDICATION NAME] 0.5 mg. every 12 hours for increased anxiety." Medical record review of the November Physician's Recapitulation (recap) Orders revealed the order for [MEDICATION NAME] 0.5 mg. every 12 hours as needed (PRN) for acute anxiety however, the physician's orders [REDACTED]. twice daily. Further review of the Physician's Recap Orders for December 2012 and January 2013, revealed no order for the routine order for [MEDICATION NAME] 0.5 mg. twice daily. Review of the Medication Administration Records (MAR) for October, November, December 2012 and January 2013, revealed the resident continued to receive [MEDICATION NAME] 0.5 mg. every 12 hour at 8:00 a.m. and 8:00 p.m. documented as "every 12 hours as needed" with no further dosages given. Medical record review of a physician's orders [REDACTED]. bid PRN due to disuse." Review of the MAR indicated [REDACTED]. on January 4, 2013, at 8:00 a.m., and the medications was then discontinued. Interview with the Psychiatric Nurse Practitioner at the 200 Hall Nursing Station on January 9, 2012, at 2:30 p.m., confirmed the resident was to have remained on [MEDICATION NAME] 0.5 mg. twice daily and only the PRN dosages were to be discontinued. Telephone interview with the Pharmacist on January 10, 2013, at 10:00 a.m., confirmed the Physician's Recap Orders are sent to the facility by the pharmacy and the MARs are printed from the Physician's Recap Orders. Further interview confirmed no order had been received to discontinue the routine [MEDICATION NAME] 0.5 mg. twice daily, and the order should have been included on the Physician's Recap Orders and the MARs in November and December 2012 and January 2013. Interview with the 300 Hall Resident Care Coordinator on January 10, 2013, at 10:10 a.m., confirmed the resident's Physician's Recap Orders and MARs for November and December 2012 and January 2013 were incorrect

Based on medical record review and interview, the facility failed to obtain a laboratory test as ordered by the physician timely. The findings included: Resident #172 was admitted to the facilty on June 25, 2012, with diagoses including [MEDICAL CONDITIONS], and Long-Term [MEDICATION NAME] Therapy. Medical record review revealed a [MEDICATION NAME] was obtained on November 28, 2012, with INR (International Normalized Ratio) result of 5.3. Orders received were to hold [MEDICATION NAME] for two days and start alternating dosage, every other day of 2.0 mg. and 2.5 mg., and recheck INR in two days. Medical record review revealed no documentation the [MEDICATION NAME] was obtained on November 30, 2012, as ordered. Further review revealed the next [MEDICATION NAME] was obtained on December 5, 2012, (seven days from order received on November 28, 2012). Medical record review of the December 5, 2012, [MEDICATION NAME]/INR result was 2.8, with orders to hold [MEDICATION NAME] for one day and repeat lab in one week. Interview with the 300 Hall Licensed Practical Nurse Supervisor at the 300 Nursing Station on January 9, 2013 at 2:15 p.m., confirmed the [MEDICATION NAME] had not been obtained as ordered by the physician.

Based on observation, review of facility policy, and interview, the facility failed to ensure staff disinfected hands during the ice pass to the residents. The findings included: Observation on January 9, 2013, revealed on the 200 hall several residents had a virus and the facility was using isolation precautions for everyone. Observation on January 9, 2012, at 9:30 a.m., in the 200 hall, revealed two CNA's (certified nursing assistant) filling the resident's water pitchers with ice. Continued observation revealed CNA #1 entered room [ROOM NUMBER], obtained resident A bed's water pitcher, returned to the ice chest, filled the water pitcher with ice, returned to the resident's room, retrieved B bed's water pitcher, returned to the ice chest, placed the water pitcher on the ice chest, filled the water pitcher with ice, and returned the water pitcher to the B bed's room. Continued observation revealed CNA #2 went into room [ROOM NUMBER], obtained the water pitcher and continued to proceed in the same procedure as CNA #1. Continued observation revealed CNA #1 and #2 entered room [ROOM NUMBER] with one resident and enter 204, with one resident, entered room [ROOM NUMBER], with one resident, entered room [ROOM NUMBER], with two residents. Continued observation revealed the CNA's did not disinfect the hands after each resident's water pitcher was filled with ice. Review of facility policy, Handwashing/Hand Hygiene, revealed "...e. before and after entering isolation precaution setting...6. i. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident..." Interview with the CNA #1 and #2 on January 9, 2013, at 9:45 a.m., in the 200 hallway, confirmed the CNA's had not disinfected the hands after each resident's water pitcher was filled with ice. Interview with the Assistant Director of Nursing on January 10, 2013, at 10:15 a.m., in the 400 hallway, confirmed the staff are to disinfect hands after each patient. Continued interview confirmed staff are not to place the resident's water pitchers on the ice chest.

Based on medical record review, observation, and interview, the facility failed to ensure the accurate acquiring, receiving, dispensing and administering of a medication for one (#172) of fifty sampled residents. The findings included: Resident #172 was admitted to the facilty on June 25, 2012, with diagoses including Parkinson's Disease, Coronary Artery Disease, Long-Term Coumadin Therapy, Congestive Heart Failure, Chronic Renal Failure, Acute Anxiety, Dementia, Depression, and Insomnia. Medical record review revealed a physician's orders [REDACTED]. every twelve hours for anxiety. Medical record review of a Medical Psychiatry Evaluation dated October 10, 2012, revealed the resident was currently on Clonazepam 0.5 mg. twice daily for anxiety. Further review revealed, "...add PRN (as needed) of Clonazepam 0.5 mg. every 12 hours for increased anxiety." Medical record review of the November Physician's Recapitulation (recap) Orders revealed the order for Clonazepam 0.5 mg. every 12 hours as needed (PRN) for acute anxiety however, the physician's orders [REDACTED]. twice daily. Further review of the Physician's Recap Orders for December 2012 and January 2013, revealed no order for the routine order for Clonazepam 0.5 mg. twice daily. Review of the Medication Administration Records (MAR) for October, November, December 2012 and January 2013, revealed the resident continued to receive Clonazepam 0.5 mg. every 12 hour at 8:00 a.m. and 8:00 p.m. documented as "every 12 hours as needed" with no further dosages given. Medical record review of a physician's orders [REDACTED]. bid PRN due to disuse." Review of the MAR indicated [REDACTED]. on January 4, 2013, at 8:00 a.m., and the medication was then discontinued. Observation on January 9, 2013, at 2:00 p.m., revealed the resident sitting quietly in a broda chair in the resident's room. Interview with the Psychiatric Nurse Practitioner at the 200 Hall Nursing Station on January 9, 2012, at 2:30 p.m., confirmed the resident was to have remained on Clonazepam 0.5 mg. twice daily and only the PRN dosages were to be discontinued. Telephone interview with the Pharmacist on January 10, 2013, at 10:00 a.m., confirmed the Physician's Recap Orders are sent to the facility by the pharmacy and the MARs are printed from the Physician's Recap Orders. Further interview confirmed no order had been received to discontinue the routine Clonazepam 0.5 mg. twice daily, and the order should have been included on the Physician's Recap Orders and the MARS in November and December 2012 and January 2013. Interview with the 300 Hall Resident Care Coordinator on January 10, 2013, at 10:10 a.m., confirmed the resident had not received Clonazepam 0.5 mg. since January 4, 2013, at 8:00 a.m.

Based on medical record review, observation, and interview, the facility failed to implement interventions including assistive devices to reduce the risks of an accident that were consistent with the needs and plan of care for one resident (#108) of fifty residents reviewed. The findings included: Resident # 108 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated March 31, 2012, revealed "...Bed in low position, bed alarm, and mat on floor..." Continued medical record review of the Care Plan dated December 6, 2012, revealed "...Bed in low position, bed alarm and mat on floor..." Medical record review of a Physician's Telephone Order dated April 1, 2012, revealed "...Bed/WC (wheel chair) Alarms, low bed (with) floor mat..." Observation of the resident in bed on January 9, 2012, at 2:10 p.m., with LPN #1 revealed no bed alarm in place and the bed in a raised position and not in the low position. Continued observation on January 10, 2013, at 8:05 a.m., revealed the resident in bed with the bed in a raised position. Interview with LPN #1 on January 9, 2013, at 2:20 p.m., in the upstairs conference room confirmed the bed alarm was not in place. Interview with LPN #1 on January 10, 2013, at 8:05 a.m., in the resident's room confirmed the bed was not in the low position.

Based on medical record review, observation, and interview, the facility failed to ensure residents were free from restraints for one resident (#108) of fifty residents reviewed. The findings included: Resident #108 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record Review of the Care Plan dated December 6, 2012, revealed no interventions for restraint use. Further review of the Care Plan dated December 6, 2012, revealed no interventions for siderails and "...bed to be in the lowest position with mat on floor..." Continued medical record review revealed no documentation of a physician's orders [REDACTED]. Observation on January 9, 2013, at10:40 a.m., revealed four side rails in the up position with siderail covers in place. Further observation revealed the resident lying on the left side against the right upper siderail. Interview with Certified Nurse's Assistant #3 and Certified Nurse's Assistant #4, on January 10, 2012 at 8:10 a.m., confirmed the resident was able to roll in the bed and the siderails prevented the resident from rolling out of the bed. Interview with the Resident Care Coordinator (RCC #2), on January 9, 2013, at 10:40 a.m., in the resident's room, confirmed the four siderails were in the up position and the resident was not able to volunatarily able to get out of the bed. Further interview with RCC #2 confirmed the bed was to be in the low position with a mat on the floor at bedside. RCC #2 confirmed the bed was not in the low position. Interview with the Director of Nursing (DON) in the upstairs conference room on January 10, 2013, at 9:45 a.m., revealed the DON stated "...four side rails on the bed were not restraints...the side rails prevented the resident from coming out of the bed...the side rails were split and the resident could get out of the bed between the rails..." Continued interview revealed the DON was not able to say how much distance was between the lower and upper rails. Further interview with the DON confirmed when the definition of a restraint according to federal regulations were explained, the DON confirmed the side rails were a restraint.

Based on medical record review and interview, the facility failed to complete a comprehensive assessment for incontinence for one resident (#209) of fifty residents reviewed. The findings included: Resident #209 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Urinary Incontinence Assessment and Evaluation Form dated September 6, 2012, revealed "Pt (patient) is frequently incontinent of bladder. Will consult (named incontinence experts)." Additional review of the Urinary Incontinence Assessment and Evaluation Form on September 18, 2012, revealed "Incontinence Management referral to evaluate and treat as needed..." Medical record review revealed a consult was performed on November 1, 2012, by the incontinence group and electronically signed on November 15, 2012. The plan included "perform voiding diary, obtain a void volume with post void residual." Medical record review revealed an order to discontinue the incontinence group on November 15, 2012. Medical record review of the monthly Nursing Summary dated November 28, 2012, revealed, "unable to retrain d/t (due to) impaired cognition." Interview with Certified Nursing Assistant (CNA# 5), on January 9, 2013, at 12:37 p.m., in nursing station 1, revealed the resident was not capable of physically moving to the bathroom independently, never expressed the need to urinate, and was always incontinent of bowel and bladder. Interview with the Director of Nursing (DON) and the Resident Care Coordinator (RCC #1), on January 9, 2013, at 12:40 p.m., in the conference room, revealed November 1, 2012, was the first visit from the incontinence group and on November 2, 2012, the resident was started on void therapy but "there is no record of it" with the only note being the one dated November 15, 2012. Interview with the DON and RCC #1 on January 9, 2013, at 1:29 p.m., at the Station 1 nursing station, confirmed a comprehensive assessment for bladder incontinence was not completed.

Based on medical record review, observation, and interview, the facility failed to ensure adequate supervision for two (#12, #21) and failed to ensure safety devices were in place for three residents (#3, #5, #9) of thirty residents reviewed. The facility's failure resulted in actual harm to resident #12. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed, "...moving on and off toilet...not steady, only able to stabilize with human assistance" Medical record review of the resident Care Plan dated March 3, 2011, revealed "...Problem...Impaired mobility and self care deficit with left sided [DIAGNOSES REDACTED] making pt (patient)...increased risk for falls...Approaches...Observe for unsafe actions..." Medical record review of facility investigation documentation provided by the facility dated April 23, 2011, at 4:00 p.m., revealed, "...This nurse was alerted by staff that resident was in the floor in the bathroom...sent to ER (emergency department)..." Medical record review of a hospital Consultation Report dated April 23, 2011, revealed, "...yesterday...was up to commode nursing apparently stepped away...was complaining of pain in...shoulder and arm...Impression:...left clavicle fracture..." Interview and statement review completed at the time of the fall with Certified Nursing Assistant (CNA) # 1 on June 8, 2011, at 9:20 a.m., by phone confirmed that CNA #1 turned their back for a few seconds after putting the resident on the toilet. Interview with the Director of Nursing in the facility conference room on June 8, 2011, at 10:30 a.m., confirmed the resident was not to be left unobserved while in the bathroom and confirmed the CNA turned their back away from the resident resulting in a fall/fracture. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated May 5, 2011, revealed, "problem...pt (patient) at risk for falls...approaches...use wedge when pt (patient) in bed for positioning..." Medical record review of documentaion provided by the facility dated May 28, 2011, at 8:00 p.m., revealed, "Certified Nursing Assistant (CNA) heard resident's bed alarm sounding...wedge cushion not on bed...found in closet..." Interview with Resident Care Coordinator #1 on June 7, 2011, at 1:15 p.m., in the station two chart room, confirmed the wedge cushion was not on the bed at the time of the fall on May 28, 2011. Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan updated January 13, 2011, revealed, "...problem...Impaired mobility related to Parkinson's with a history of falls and [DIAGNOSES REDACTED]; making patient at risk for falls...Approaches...Provide assistance with transfers..." Medical record review of a nurse's note dated January 14, 2011, at 3:15 p.m., revealed, "...Pt (patient) taken to bathroom per CNA. Was left to check on another resident...found resident sitting on buttocks on floor facing...chair...no injuries..." Continued medical record review of a nurse's note dated February 25, 2011, revealed, "...resident reported that...was on...way back from the bathroom and fell ...no injuries..." Medical record review of the January 14, 2011, post fall interventions revealed, "...intervention after fall...resident not to be left alone in bathroom..." Interview with the Resident Care Coordinator #2 on June 8, 2011, at 9:45 a.m., confirmed the resident was left unattended at the time of the fall on the January 14, 2011, and February 25, 2011. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with two persons physical assist for transfers, and extensive assistance with two persons physical assist for toilet use. Medical record review of the post falls nursing assessment dated [DATE], revealed, "...CNA (certified nursing assistant) was transferring resident to bathroom when...legs gave way. The CNA lowered...to the floor...(no injuries) Inservice staff on gait belt (and) 2 assist..." Medical record review of the post falls nursing assessment dated [DATE], revealed, "...CNA was transferring resident from the toilet to (named brand) chair when...has to slide (resident)...to the floor (until) help came ...(no injuries)" Observation on June 6, 2011, at 4:15 p.m., revealed the resident lying on the bed. Interview on June 7, 2011, at 4:10 p.m., at the nursing station, with Resident Care Coordinator #1, confirmed a gait belt or two person assistance had not been used when transferring the resident at the time of the fall on April 19, 2011. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the high risk patient selection form dated March 1, 2011, revealed the resident had three falls in February 2011 and had poor safety awareness. Medical record review of the care plan dated May 26, 2011, revealed, "...use bed cushion alarm..." Observation on June 7, 2011, at 12:45 p.m., revealed the resident lying on the bed with the pressure pad alarm cord hanging down the side of the bed with no alarm box. Interview on June 7, 2011, at 12:45 p.m., in the resident's room, with Resident Care Coordinator #1, confirmed the alarm box was not attached to the pressure pad alarm.