Every finding on record at NHC Healthcare - Lexington

Based on review of facility policy, observation, and interview, the facility failed to ensure medications were not pre-poured prior to administration for 3 of 3 residents observed during medication administration. Findings include:Review of the facility policy titled, Medication Administration Policy dated 01/01/26 revealed, Policy Statement: Medication shall be prepared and administered safely, accurately, and in accordance with physician orders, professional standards of nursing practice, and all applicable federal and state regulation. Medication Preparation. Pre-pouring is permitted ONLY for a single resident.During observation on 04/01/26 at 7:45 AM, of medication administration revealed, in the medication cart drawer were 3 medication cups labeled with residents' last names which contained tablets and capsules. The first medication cup was for Resident (R)137. The second medication cup was for R132 and the third medication cup was for R165. Prior to administering the medications, Registered Nurse (RN)1 provided this surveyor with the empty pill pouches next to each resident's medication cup. This surveyor took the empty pill pouches for each resident to determine the contents in the medication cups. During an interview on 04/01/26 at approximately 7:45 AM, RN1 was asked about pre-pouring medications for multiple residents, RN1 replied, I always prepare my medications this way. It helps me stay on time. RN1 was than asked, how she ensures the medication cups contain the medications she originally put in, RN1 stated, I am the only one with the keys to this cart, so I am the only one who can get into it.During the medication administration observation on 04/01/26 at 7:45 AM, the Director of Nursing (DON) was present, after the DON left, RN1 stated, I think she was telling me I shouldn't have prefilled the medication cups.During an interview on 04/01/26 at 8:15 AM, the DON asked this surveyor how RN1 performed during the medication administration. This surveyor reported there did not appear to be any errors, however, this surveyor expressed concerns about the pre-pouring of the medications. The DON stated, I agree. During a follow-up interview on 04/02/26 at approximately 2:45 PM, the DON stated she had talked with RN1, who denied pre-pouring the medication cups. The DON denied having observed multiple pre-poured medication cups in the medication cart drawer. The DON denied agreeing with the surveyor about pre-pouring medication cups immediately after the medication administration on 04/01/26. The DON verified their policy is to allow pre-pouring of medication for only one resident and again stated RN1 told her that she did not pre-pour multiple resident's medications.

Based on record review, interview, observation and review of facility policy, (1) the facility failed to ensure an ordered medication was secured and not left at Resident (R)40's bedside. Additionally, (2) the facility failed to ensure the correct resident (R23) was transported to an appointment. Specifically, transportation picked up R130 (who did not have an appointment), a cognitively impaired and elopement risk resident, and transported her approximately 15 miles to a medical facility and left the resident unattended. For 3 of 5 residents reviewed. On 03/12/25 at 9:00 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 02/05/25. The IJ was related to 42 CFR 483.25 - Quality of Care. On 03/12/25 at 1:43 PM, the facility provided an acceptable IJ Removal Plan. On 03/12/25 at 2:45 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of D. An Extended Survey was conducted in conjunction with the Recertification Survey for non-compliance at F689, constituting substandard quality of care. Findings include: (1) Review of the facility policy dated 01/09/2019 and titled, Storage of Medication revealed under the policy, Medications and Biolgicals are stored safely, securely, and properly . During an observation on 03/09/25 at 12:30 PM, Nystatin cream was noted at the bedside of R40, with a pharmacy label identifying R40. During an observation and interview on 03/10/25 at 10:18 AM, Nystatin cream was noted still at the bedside of R40. Licensed Practical Nurse (LPN)1 entered the room and confirmed the Nystatin cream was at R40's bedside. LPN1 stated he's been looking for it, the nurse must have left it in here yesterday. It is not supposed to remain in the room, we keep it on the medication cart. Review of R40's Facesheet revealed R40 was admitted to the facility on [DATE], with diagnoses including but not limited to: unspecified dementia, unspecified intellectual disabilities, pruritus, and osteoporosis. Review of R40's Annual Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 02/18/25, revealed R40 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating R40 was severely cognitively impaired. Review of R40's Physician Orders revealed R40 had an order for antifungal cream 1% to apply a small amount to bilateral feet including between toes every shift, dated 03/04/25. During an interview on 03/10/25 at 10:30 AM, Registered Nurse (RN)1 stated she makes room rounds to ensure residents are ok. RN1 stated, We cannot leave treatment items in the rooms. Ambulatory residents can walk in the room and get to it. Once the nurses are done using it, it should be placed back into the treatment cart. During an interview with the Director of Nurses (DON) on 03/11/25 at 4:56 PM, the DON stated, The treatment item is expected to be returned to the treatment cart afterward, not remain in the room. (2) Review of the undated Patient Transportation policy revealed, If the patient and/or family member desires a private transportation company to provide transportation, our facility will arrange for a private transportation company to contact the family regarding transportation costs unless the transportation is a covered service through the patient's Medicare or Medicaid policy. Review of R23's Facesheet revealed R23 was admitted to the facility on [DATE] at 2:16 PM, with diagnoses including, but not limited to: noninfective gastroenteritis and colitis, muscle weakness, hypothyroidism and Parkinson's disease without dyskinesia. Review of R23's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/25, revealed R23 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that R23 was cognitively intact. Review of R23's Progress Notes dated 02/05/25 at 3:20 PM stated, Resident missed appointment d/t [due to] transport picking up incorrect resident. The office is to reschedule. Review of R130's Facesheet revealed R130 was admitted to the facility on [DATE] at 3:13 PM, with diagnoses including, but not limited to: dementia, metabolic encephalopathy, epilepsy, and pulmonary hypertension. Review of R130's Annual MDS with an ARD of 01/13/25, revealed R130 had a BIMS score of 12 out of 15, indicating R130 was moderately cognitively impaired. Furthermore, wandering behaviors were exhibited 1 to 3 days. Review of R130's Elopement Risk assessment dated [DATE], revealed R130 scored a 1.0, indicating R130 was at risk for elopement. During an interview with an ophthalmologist at (local eye clinic) on 03/11/25 at 3:52 PM, revealed R23 in room [ROOM NUMBER] had an appointment on 02/05/25. Transportation dropped a resident off at the appointment. When it was time for the resident to come back, we asked her to verify her name, and she gave us the wrong name stating she was R130. We called the nurse at the facility and told them they sent the wrong resident. The resident that was sent, R130, was demented and crying, asking where she was. The ophthalmologist stated they (the facility) sent the wrong resident to our outpatient facility, and she should have had someone with her, especially with a diagnosis of dementia. Nobody was with her. Transportation came to pick her up within an hour. During an interview with Licensed Practical Nurse (LPN)1, for 200 unit, on 03/11/25 at 4:30 PM, revealed R23 had an appointment on 02/05/25. The transport driver came to the unit, picked up R23's packet and stated she was looking for R23. LPN1 stated he told the transport driver R23 had a room change and she is residing in room [ROOM NUMBER], and stated the patient was in her room. LPN1 stated after he spoke with the transport driver, he left the nurses' station and was going room to room checking on glucometers. LPN1 stated once he left the nurses' station, he did not see the transport driver take the patient. LPN1 stated he got a call from the eye clinic stating they had the wrong resident. LPN1 stated he was unsure how transportation got the wrong resident. LPN1 stated he was unsure where R130 was located, and no one had communicated with him that she was not in the building. LPN1 stated R23 schedules her own appointment and stated he did not notify R130's family in regard to the mishap. LPN1 stated that they should have notified the family. During an interview with LPN2 on 03/11/25 at 5:00 PM, LPN2 stated R23's pick up was supposed to be around 2:00 PM. R130 was out of the facility 30-45 minutes, at the latest. During an interview with the Director of Nursing (DON) on 03/11/25 at 5:29 PM , the DON stated, I was made aware that [R130] was accidentally picked up by transport. [R23] was the resident who was supposed to be picked up. The transportation had gotten into the parking lot and left. Contact was made simultaneously with dispatch of the transport company. When transport came back around to leave, nobody was at the desk. I believe [R23] schedules her appointment and goes alone. Typically, family escorts the resident if they have dementia, if unable, the facility will provide an escort for them. At the same time, the doctor's office was being called, they were calling us. The Administrator was made aware. LPN1 contacted both families. There is no documentation. The day it happened, they were notified. The process for going out to an appointment, transport comes in, confirm the room number, they get the patient. There is a paperwork packet that goes with them. It is usually verified when they get the appointment packet, typically the charge nurse or nurse on the unit at the desk, they lay eyes on the resident. When transport came back around to leave, nobody was at the desk. Two attempts were made to contact R130's Responsible Party (RP) on 03/11/25 at 5:27 PM and 5:54 PM. Both attempts were unsuccessful. A detailed message was left for a return call. During an interview with the ambulance driver (AD)1 on 03/11/25 at 6:19 PM, AD1 revealed that she recalls transporting a resident on 02/05/25 from (the facility) to a doctor's appointment approximately 10 minutes away. AD1 stated she entered the facility and went to the nurse's station on the 200 hall and showed them her phone, which provided the details of the resident she was to pick up. The Charge Nurse told her the resident had moved to room [ROOM NUMBER]. AD1 stated she went to the room and asked the resident if her name was the name that was provided on her documents and asked if she was ready for her appointment, the resident responded Yes to both questions. AD1 further stated she retrieved the resident, provided the charge nurse a thumbs up motion and he provided the same hand gesture as they left the facility. AD1 also included that no one accompanied her to the resident's room and that is normal practice that staff do not accompany her to resident's rooms and she is not responsible for signing any documentation when transporting any resident from the facility. AD1 stated she took the resident to the appointment and she left her there. AD1 then returned to their home location and after she was there for approximately ten minutes, her dispatch contacted her and stated [the facility] contacted them and stated she had transported the wrong resident. AD1 stated that she went to pick the resident up from the doctor's office, of which she was sitting in the lobby unattended, but she was not in distress, she just complained about how cold she was. AD1 concluded she took the resident back to the facility and no one from the facility stated anything to her. The total transport was about one to one and a half hours and never saw the resident that was supposed to have the appointment and be transported. During an interview with R23 on 03/11/25 at 6:25 PM, R23 revealed she makes appointments for herself, sometimes, and was not able to remember if she missed an appointment on 02/05/25 with an eye doctor. R23 was unable to speak verbally, but mouthed the words with Registered Nurse (RN)1 present. RN1 stated R23 has Parkinson's and sometimes you can hear her audibly but in a very low tone. On 03/12/25 at 1:43 PM, the facility provided an acceptable IJ Removal Plan, which included the following: In this incident, resident R23 had an appointment to which R130 was inadvertently picked up by transport and taken to this appointment. There is concern that the R130 was without supervision during the inadvertent transport. The center notified transport for immediate pick up and R130 was returned to the center without any incident. R130 arrived back at NHC Lexington, assessment completed showing no acute distress. All patients have potential to be affected by deficient practice of F689. R130 did not have an appointment, making the concern unique. A review of patient appointments was conducted by the DON on March 12, 2025, showing that no other patients had been affected by this practice. A sign in and out log is implemented as of March 12, 2025, listing date and time out, patient name, responsible person taking the resident, witness of patient leaving, the date and time of return, person returning patent and witness of patient return. This form will be signed by multiple parties to include the nurse or designee during any patient leave of absence to include appointments, family outings, etc. Nursing staff present in facility were educated on this practice on March 12, 2025, and education will continue through March 26, 2025. A review of this practice will be conducted daily by DON or designee for the next thirty days. Then twice weekly for fourteen days, then weekly for fourteen days and ongoing thereafter. Findings will be reported during QA meeting monthly. The facility will monitor this corrective plan monthly during QA until sufficient compliance feels met by the QA committee. March 12, 2025. A QAPI meeting was held on 3/12/2025 with the Administrator, Assistant Administrator, DON, Assistant DON, Nurse Managers, Assistant Regional Nurse, Social Worker Director, HIM Director, Director of Rehab. The Medical Director communicated with via phone. The alleged events were discussed in detail and reviewed and updated processes that will be implemented to assure resident safety from situations of non-supervision are followed up on appropriately. 48835

Based on facility policy review, record review, observation, and interview, the facility failed to ensure respiratory equipment (Bipap, CPAP, and Nebulizer Masks) were functioning, maintained, and stored appropriately for 4 of 4 residents (Resident (R)19, R14, R46 and R59) reviewed for respiratory care out of total sample of 12 residents. The facility's deficient practice increased the resident's risk of respiratory complications. Findings include: Review of the facility policy titled, 306 Respiratory- Respiratory Therapy Equipment with a revision date of February 2025 revealed, 3. Respiratory equipment (i.e., nasal cannula, aerosols, etc.) at bedside will be covered with a plastic bag when not in use. Respiratory therapy services are important in preventing and managing health care acquired infections in the health care setting. The center's Respiratory Therapy Department will follow established guidelines for cleaning, disinfecting and refilling humidifiers and H2O reservoirs. Disposable tubing and refillable reservoirs will be replaced according to center schedule, Suctioning equipment will be disinfected according to center procedures. Review of a document provided by the facility titled Specific Medication Administration Procedures with a revision date of 02/25/25, documented, When equipment is completely dry, store in a plastic bag with resident's name and the date on it. Review of R19's Face Sheet revealed R19 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute recurrent sinusitis, chronic maxillary sinusitis, and mild intermittent asthma. Review of R19's Physician Orders revealed, Prescription ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/; amt: 1 neb; inhalation Twice A Day - PRN, PRN 1, PRN 2 Open Ended with a start date of 02/17/25. Review of R19's Care Plan last revised on 01/13/25, revealed, Complications, at risk for related to disease processes of hypertensive CKD stage 4, iron deficiency anemia, hypothyroidism, primary generalized osteoarthritis, depression, mild intermittent asthma, other chronic pain, GERD, other B12 deficiency anemia, hypokalemia, hypomagnesemia, prurigo nodularis, polyneuropathy, left shoulder pain, chronic sinusitis, insomnia, anxiety disorder, vitamin D deficiency, dysphagia, constipation, hallucinations, difficulty walking, cramp and spasm, localized edema, non-pressure chronic ulcer to left foot, abnormalities of gait and mobility, unspecified lack of coordination, and generalized muscle weakness, [R19] has history of C1 displaced vertebra fracture. Approaches directed staff to, NEBULIZER MASK - CHANGE NEBULIZER TUBING AND MASK EVERY 3 DAYS Edited: 02/02/2024 Nebulizer Care: RINSE MASK AND CHAMBER WITH TAP WATER. LET DRY ON PAPER TOWEL AFTER EACH NEBULIZER TREATMENT Created: 02/02/2024. Observe resident for signs of respiratory distress such as shortness of breath, wheezing, gasping, shallow breathing Created: 08/19/2021. Review of R19's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/25, revealed Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R19's cognition was intact. During an observation and interview on 03/09/25 at 12:58 PM, of R19's room revealed a Medline Nebulizer machine, near the resident's bedside. The Jet nebulizer cap was empty, the adult mask was hooked up to the Jet Nebulizer chamber. The mask was uncovered. The machine was located beside an artificial plant. The artificial plan had dust particles. The tubing on the machine was dated 03/06/25. R19 stated she used the machine as needed. R19 stated she used the machine a few days ago. R19 could not recall the last time staff cleaned the machine or replaced the mask. An observation on 3/10/2025 at 9:09 AM, at 12:18 PM, and on 03/11/25 at 9:09 AM, revealed the Jet nebulizer cap was empty, the adult mask was hooked up to the Jet Nebulizer chamber. The mask was uncovered. The tubing on the machine was dated 03/06/25. During an interview on 03/11/25 at 4:16 PM, Registered Nurses (RN)3 and RN4 confirmed R19 uses her nebulizer PRN (as needed) and that R19 had a treatment a few days ago, however, could not recall the exact date. Both nurses confirmed tubing should have been changed, and confirmed the date on the sticker was the date it was changed, and it was supposed to be changed on the 9th or 10th, even if it's not in use. Both nurses stated it's the nurse's responsibility to ensure nebulizers are covered when not in use, and tubing is changed every 3 days per order. Both nurses confirmed R19 did not have her nebulizer covered until a few minutes ago. 48835 Review of R59's Facesheet revealed R59 was admitted to the facility on [DATE], with diagnoses including but not limited to chronic obstructive pulmonary disease and obstructive sleep apnea. Review of R59's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/27/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R59 was cognitively intact. Review of R59's Physician Orders revealed an order for CPAP, to use CPAP from home at night, pressure 13, at bedtime 9:00 PM. Review of R59's Medication Administration Record (MAR) dated March 2025 revealed nurse signatures were signed every night at 9:00 PM for usage. During an observation and interview on 03/09/25 at 3:30 PM, revealed a CPAP (Continuous Positive Airway Pressure) in R59's room. R59 stated, Something is wrong with it for about 2 weeks. They turned it on last night, it worked for a while then it just cut off. I've been asking about getting it fixed, I need it. No-one has said anything, I'm just waiting. During a follow up interview on 03/10/25 at 2:51 PM, R59 stated, I used the CPAP last night, it cut off twice. There is supposed to be someone coming to look at it. The CPAP is in the drawer. Observation revealed the CPAP machine in R59's dresser drawer. During an interview on 03/10/25 at 4:55 PM, Licensed Practical Nurse (LPN)1 entered R59's room and retrieved the CPAP machine and turned it on. LPN1 stated, It's set for 13 pressure, when it gets to 4 it stops, it runs for 10-15 seconds. LPN1 tried it with the mask on also and confirmed it wasn't working. During an interview on 03/10/25 at 5:02 PM, Registered Nurse (RN)1 stated, The charge nurse was aware. He let the niece know and there is a pulmonology appointment April 24th. We asked her niece to come pick it up. RN1 confirmed that R59 was not able to use the machine. During a phone interview on 03/10/25 at 5:12 PM, R59's niece stated, [R59] has been on the CPAP for years. I thought she was using it at night. I don't recall them telling me that it wasn't working. I've never had it serviced. She was on a CPAP at home. Most of her stuff, the nursing home takes care of. R59's spouse spoke up and stated he was not aware of any problems with the machine. During an interview on 03/10/25 at 5:15 PM, LPN2 stated he checked it an hour or two ago. It popped on and it only went to 4. LPN2 confirmed R59's CPAP was not working correctly. During a follow up interview on 03/10/25 at 5:20 PM, RN1 stated on January 20th, the family was called about the machine needing service. RN2 stated, [R59] has an appointment with Pulmonology April 24th. We asked her niece to come pick up the CPAP. During an interview on 03/10/25 at 6:08 PM, the Nurse Practitioner (NP) stated she's had more issues than we've been successful with it. The mask was replaced at least 2 times. R59 has obstructive sleep apnea and COPD. R59 had a sleep study, her O2 (oxygen) saturation (oxygen in the blood) was dropping in the 80s. The NP further stated, The facility should provide medical equipment. They own one CPAP machine in the facility. When it works it's great. The NP concluded, My preference would be that [R59] use oxygen every night. We knew she didn't use the machine all through the night. She was averaging about 4 hours. During a follow up interview on 03/11/25 at 10:57 AM, LPN2 stated, Aero Care was supposed to call [R59's] family. They called the husband a few months ago, he has advanced Parkinson's. I did not know it [CPAP machine] was broken all this time. There is an appointment for Thursday, I called them first thing this morning. The niece is coming to pick it up and take it to them to fix. I spoke to her yesterday. She said she was not made aware back then. [R59's] husband would not have been able to tell her or remember to tell her with his advanced Parkinson's. During an interview on 03/11/25 at 5:07 PM, the Director of Nursing (DON) stated, I was made aware of [R59's] CPAP machine yesterday. I should have been made aware if they weren't able to get it resolved. Most residents bring there own. My expectations are for me to be notified. 51857 Review of R46's Face Sheet revealed R46 was admitted to the facility on [DATE], with diagnoses including, but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left side, aphasia, obstructive sleep apnea, and morbid obesity. Review of R46's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/24, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating that the resident is cognitively intact. Review of R46's Progress Note dated from January - March 2025 revealed no progress notes related to OSA or breathing difficulties. Review of R46's Medication Administration Record (MAR) reviewed for the months of January-March 2025, revealed the following: that continuous positive airway pressure (CPAP) is ordered to be used at bedtime with start date 10/10/22 to 03/10/25. CPAP care daily- once a day, wash c-pap mask daily with soap and water and air dry. CPAP care weekly- once a day on Sunday. Wash tubing and head gear with soap and water on Sunday and air dry on 7a- 7p. CPAP filters- once a day on Friday every two weeks, change disposable filters. CPAP humidifier- once a day. Empty and refill humidifier daily with sterile/distilled water on 7p-7a. During an observation on 03/09/25 at 11:57 AM, R46's CPAP machine and mask were located at bedside. The CPAP mask was uncovered laying on the nightstand. During an observation on 03/10/25 at 1:07 PM, R46's CPAP facemask was uncovered on the nightstand. Review of Resident (R)14's Face Sheet revealed R14 was admitted to the facility on [DATE], with diagnoses including, but not limited to: chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, hypertension, osteoarthritis, and anxiety disorder. Review of R14's Quarterly MDS with an ARD of 01/07/25, revealed R14 had a BIMS score of 5 of 15, indicating that the resident was severely cognitively impaired. Review of R46's Medication Administration Record (MAR) for the months of January-March 2025, revealed the following: Nebulizer care is performed on every shift- rinse mask and chamber with tap water. Let dry on paper towel after each nebulizer treatment. Nebulizer mask change is once a day every three days- change nebulizer tubing and mask every three days 7p-7a shift. Budesonide suspension for nebulization; 0.5mg/2ml; 1 unit dose; inhalation every 12 hours for COPD. During an observation on 03/09/25 at 12:27 PM, R46's nebulizer mask was uncovered at bedside. During an observation on 03/10/25 at 10:00 AM, R46's nebulizer mask was uncovered on bedside table. During an interview on 03/10/25 at 1:45 PM, Licensed Practical Nurse (LPN)4 stated that there is a protocol in place for CPAP storage. Staff follows the orders in the chart and staff changes the face mask once a week and uses distilled water in the humidifier. LPN4 stated the mask must be washed and cleaned after use and placed on a barrier to allow for drying. LPN4 observed R46's CPAP face mask uncovered at bedside. LPN4 stated that the face mask must be protected from germs when not in use. During an interview on 03/11/25 at 3:31 PM, Registered Nurse (RN)1 stated once the resident is complete with nebulizer or CPAP, the face mask is washed out and laid to dry on a waterproof barrier. RN1 stated when the mask is not in use, it is placed in a bag for infection control purposes. The CPAP face mask and tubing is changed every three months, and the nebulizer is washed in soap and water daily. RN1 stated the tubing is washed weekly, and the filters are changed every two-weeks. RN1 stated the face cushion is changed every month, the mask is placed in a plastic bag after use. During an interview on 03/11/25 at 7:21 PM, the Director of Nursing (DON), stated that she expects respiratory care is being provided per the physician's orders and face masks are stored in their designated storage bags when not in use. The DON encourages patients to utilize the storage bags as well.

Based on observation, interview, and review of facility policy, the facility failed to ensure used Personal Protective Equipment (PPE) was disposed of properly in accordance with professional standards. Specifically, used PPE was observed hanging outside of the resident's rooms who were currently on droplet precautions for 6 of 9 rooms observed. Findings include: Review of the facility's policy titled, 704 Droplet Precautions, documented, Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one patient or both patients are on Droplet Precautions. Review of the CDC Infection Control Summary of Recommendations with a revision year of 2007, states, Slide 10. PPE must be removed at the point of exit; do not reuse face masks. During an observation on 03/09/25 at 10:45 AM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 10:45 AM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 1:15 PM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 1:17 PM, there were used gloves balled up on the handrail outside of room [ROOM NUMBER], a droplet precaution room. During an observation on 03/09/25 at 2:10 PM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 2:31 PM, there was an used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/09/25 at 2:33 PM, there was a used uncovered face mask hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/10/25 at 9:00 AM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/10/25 at 10:08 AM, there were two used uncovered face masks hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an observation on 03/10/25 at 10:14 AM, there was a used uncovered face shield, hanging on room door of room [ROOM NUMBER], a droplet precaution room, near clean PPE. During an interview on 03/09/25 at 1:10 PM, the Director of Nursing (DON) stated that she is the infection control nurse, and the facility now has nine Covid positive patients. The outbreak started on 02/17/25 with 22 positive residents. The facility is maintaining the same staff on the units and reducing community activities to prevent residents from being around others to contain the spread of Covid. During an interview on 03/10/25 at 9:57 AM, the Administrator stated that he would have to get with the nursing department on the mask policy guidelines for masking when Covid is in the building. During a follow up interview on 03/11/25 at 7:24 PM, the DON stated that she expects her staff to don (put on) and doff (take off) their PPE per wherever the isolation is, and PPE should be stored in the bags that are hanging outside the door that contains clean PPE not used PPE. The DON further expects new PPE to be used every time staff enters in a resident's room that is on precautions.

Based on observation, interview, and review of facility policy, the facility failed to ensure call lights were within residents' reach and easily accessible for 2 of 4 residents reviewed for accommodation of needs, Resident (R)126 and R61. Findings include: Review of the facility policy with a revision date of October 2023, titled, Call Light documented, Purpose: To provide a means of communication of needs from the residents to the staff . 8. When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light . 11. Be sure all call lights are placed on the bed at all times and the cords are off the floor. Review of R126's Face Sheet revealed R126 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, psychotic disturbance, anxiety, rhabdomyolysis and a history of falling. Review of R126's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/24, revealed R126 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R126 was cognitively intact. During an observation on 03/09/25 at 11:44 AM, R126's call light was not in reach, the call light was located on the floor behind the bed. During an observation on 03/09/25 at 12:40 PM, R126's call light was on the floor, under the bed. During an observation and interview on 03/10/25 at 12:02 PM, R126's call light was on the floor under the bed. R126 stated that she didn't think that she had a call light anymore. During an interview on 03/10/25 at 1:17 PM, Licensed Practical Nurse (LPN)2 stated that R126 can use their call light and holler for him. LPN2 stated that he conducts routine checks on his residents throughout the day. LPN2 stated that he usually goes to the room when the resident presses the call light. LPN2 further stated he conducts safety checks which consist of providing for the needs of the resident, positioning and ensuring the bedside table is within reach. LPN2 verified that the call light was out of R126's reach. LPN2 picked the call light up off the floor and attached the call light to R126's bed sheet. LPN2 concluded this isn't his normal practice, and there is no reason it should've been missed, staff should've known the call light was out of place. During an interview on 03/10/25 at 1:30 PM, Certified Nursing Assistant (CNA)3 stated the call light is answered by whomever is closest to it. CNA3 stated that routine checks are conducted throughout the day, ensuring call lights are in place, water is at bedside, curtains are pulled, and the room temperature is to the liking of the resident. CNA3 stated R126 takes her call light and throws it on the floor often. CNA3 stated that resident can ambulate, so she notifies them vocally if she can't reach her call light. Review of R61's Face Sheet revealed R61 was admitted to the facility on [DATE], with diagnoses including, but not limited to: dementia, acute embolism and thrombosis of left femoral vein, history of falling, cognitive communication deficit and chronic kidney disease. Review of R61's Quarterly MDS with an ARD of 01/16/25, revealed R61 had a BIMS score of 5 out of 15, indicating R61 was severely cognitively impaired. During an observation on 03/09/25 at 9:00 AM, R61's call light was not visible in the resident's room. During an observation on 03/09/25 at 12:14 PM, R61's call light still could not be located in the resident's room. During an observation on 03/10/25 at 12:02 PM, R61's call light was found on the floor behind the bed by staff. During an interview on 03/10/25 at 1:22 PM, Licensed Practical Nurse (LPN)2 stated that R61 is a closely watched resident. LPN2 stated that R61 doesn't comprehend how to use the call light. R61 vocally expresses herself and is a high fall risk. LPN2 stated there are no excuses warranted, the call light should've been in reach of the resident. LPN2 safety checks consist of providing for the needs of the resident, positioning and ensuring the bedside table is within reach. LPN2 picked the call light off the floor and attached call light to R61 bed sheet so it can be within reach. During an interview on 03/11/25 at 7:23 PM, the DON stated that her expectations of her staff is for all call lights to be answered as prompt as possible and to be able to complete the need if able. Anybody can answer the call lights on the halls, and call lights are to always be in reach of the residents.

Based on observation, record review and interviews, the facility's Consulting Pharmacist failed to assure that the Pharmaceutical service oversight for which it was contracted to provide, continued to identify, evaluate and prevent the improper storage of medications for 3 of 3 medication storage rooms reviewed. There was no immediate action documented which indicated the Pharmacy or facility staff assessed the improperly stored medications at the time of the inspection of the 100, 200, and 300 halls, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure a concern was immediately corrected. The findings included: On 7/30/18 at approximately 3:30 PM, an observation of the Azalea (100) hall medication storage room with Licensed Practical Nurse (LPN) #1 (unit manager) revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F.) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (5) 3 milliliter (ml) [MEDICATION NAME][MEDICATION NAME] 100 units (u)/ ml. 2.) (2) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 3.) (1) Toujeo [MEDICATION NAME] 300 u/ml. insulin pen 4.) (5) vials of [MEDICATION NAME] 10,000 u/ ml. 5.) (2) Prevnar 13 pnuemococcal vaccine 0.5 ml. 6.) (1) container of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 7.) (56) vials of [MEDICATION NAME] 20 mcg. / 2ml. 8.) (2) vials of [MEDICATION NAME], Purified Protein Derivative, 5 TU/0.1 ml. 9.) (1) vial [MEDICATION NAME] 23 vial 10.) (2) [MEDICATION NAME] 70/30 insulin [MEDICATION NAME] 11.) (1) 3 ml. [MEDICATION NAME] 100u/ml. Pens 12.) (1) 3 ml. [MEDICATION NAME]FlexTouch Pen 13.) (2) 3 ml. Humalog insulin KwixPen 100u/ml. 14.) (1) vial [MEDICATION NAME] 70/30 insulin 100u/ml. 15.) (1) vial [MEDICATION NAME] N insulin 100u/ml. 16.) (1) vial [MEDICATION NAME] R insulin 100u/ml. 17.) (3) vial Lorazapam 2 mg. / ml. On 7/30/18 at approximately 3:55 PM, during an interview with LPN #1, s/he was asked by the surveyor if they knew the recommended temperature for the storage of insulin. LPN #1 stated, No. On 7/30/18 at approximately 4:00 PM, an observation of the Magnolia (300) hall medication storage room with Registered Nurse (RN) #1 (unit manager) revealed the 7/30/18 temperature recorded on the medication refrigerator door log was 34 degrees F., which was confirmed by RN #1. The contents of the refrigerator was: 1.) (5) 3 milliliter (ml) [MEDICATION NAME][MEDICATION NAME] 100 u/ ml. 2.) (4) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 3.) (6) Prevnar 13 pnuemococcal vaccine 0.5 ml. 4.) (2) vial [MEDICATION NAME] 23 vial 5.) (2) [MEDICATION NAME] 70/30 insulin [MEDICATION NAME] 6.) (3) 3 ml. [MEDICATION NAME] 100u/ml. Pens 7.) (2) 3 ml. [MEDICATION NAME]FlexTouch Pen 8.) (5) 3 ml. Humalog insulin KwixPen 100u/ml. 9.) (1) vial [MEDICATION NAME] 70/30 insulin 100u/ml. 10.) (1) vial [MEDICATION NAME] N insulin 100u/ml. 11.) (1) vial [MEDICATION NAME] R insulin 100u/ml. 12.) (1) vial Humalog insulin 100u/ml. 13.) (3) vial Lorazapam 2 mg. / ml. On 7/30/18 at approximately 4:22 PM, during an interview with RN #1, s/he was asked by the surveyor if they knew the recommended temperature for the storage of insulin. RN #1 stated, No. On 7/30/18 at approximately 4:26 PM, an observation of the Jasmine (200) hall medication storage room with LPN #2 (unit manager) revealed there was no 7/30/18 temperature recorded on the medication refrigerator door log, and the last recorded temperature on 7/29/18 was 34 degrees F., which was confirmed by LPN #2. The contents of the refrigerator was: 1.) (1) 3 milliliter (ml) [MEDICATION NAME][MEDICATION NAME] 100u/ ml. 2.) (2) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 3) (3) Toujeo [MEDICATION NAME] 300 u/ml. insulin pen 4.) (1) container of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 5.) (32) vials of [MEDICATION NAME] 15 mcg. / 2ml. 8.) (1) vials of [MEDICATION NAME], Purified Protein Derivative, 5 TU/0.1 ml. 9.) (1) vial [MEDICATION NAME] 100u/ml. 10.) (5) vials [MEDICATION NAME]100u/ml. 11.) (1) 3 ml. Humalog insulin KwixPen 100u/ml. 12.) (1) vial [MEDICATION NAME] N insulin 100u/ml. 13.) (3) vial Lorazapam 2 mg. / ml. 14.) (1) [MEDICATION NAME] single injection On 7/30/18 at approximately 5:02 PM, during an interview with LPN #2, s/he was asked by the surveyor if they knew the recommended temperature for the storage of insulin. LPN #2 stated, No. On 7/30/18 at approximately 5:30 PM, a review of the (MONTH) (YEAR) medication refrigerator temperature logs revealed on the Azalea (100) hall (22) days, Jasmine (200) hall (25) days, and the Magnolia (300) hall (22) days were recorded below 36 degrees F. On 7/31/18 at approximately 12:43 PM, during an interview with Consultant Pharmacist #2, a review of the Consultant Pharmacist #1's Jasmine (200) hall (MONTH) (YEAR) medication room refrigerator storage inspection report revealed Consultant Pharmacist #1 marked OK with no concerns mentioned. Following the review of Consultant Pharmacist #1's report, the surveyor asked Consultant Pharmacist #2 if during an inspection of the medication room refrigerator does s/he (Consultant Pharmacist #2) review the refrigerator temperature log. Consultant #2 stated, Yes. (Consultant Pharmacist #1 was unavailable during the days of the survey.) On 7/31/18 at approximately 3:30 PM, during an interview with Pharmacist Consultant #2, a review of the Jasmine (200) hall (MONTH) (YEAR) medication refrigerator temperature log revealed (28) days were recorded below 36 degrees F., with (1) day left blank. Consultant Pharmacist #2 verified (28) days were recorded below 36 degrees F. Also, a review of the May, June, and (MONTH) (YEAR) Executive Summary of Consultant Pharmacist's Medication Regimen Review with Consultant Pharmacist #2 revealed no mention of concerns related to medication room refrigerators. Consultant Pharmacist #2 verified there were no concerns relating to medication refrigerator storage in the inspection reports and indicated that if any concerns were identified with medication room refrigerator temperatures during a Consultant Pharmacist inspection they would be found in the Executive Summary of Consultant Pharmacist's Medication Regimen Review . On 8/1/18 at approximately 6:10 AM, an observation of the Magnolia (300) hall medication storage refrigerator with LPN #3 and the Director of Plant Operations revealed the refrigerator temperature was 32 degrees F. The contents of the refrigerator was: 1.) (4) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 2.) (5) Prevnar 13 pnuemococcal vaccine 0.5 ml. 3.) (1) vials of [MEDICATION NAME], Purified Protein Derivative, 5 TU/0.1 ml. 4.) (1) 3 ml. [MEDICATION NAME]FlexTouch Pen 5.) (2) 3 ml. Humalog insulin KwixPen 100u/ml. 6.) (1) vial [MEDICATION NAME]100u/ml. 7.) (1) vial Humalog insulin 100u/ml. 8.) (3) vials of Lorazapam 2 mg./ml. On 8/1/18 at approximately 6:15 AM, during an interview with the Director of Plant Operations, s/he was asked by the surveyor if the thermometers in the 100, 200, and 300 hall medication refrigerators were checked and working properly on 7/30/18 and on 8/1/18. The Director of Plant Operations stated, Yes, they were checked and work. S/he was then asked if s/he was informed of a problem with the temperatures of the refrigerators or thermometers within the last 6 months, or if the thermostats were adjusted. The Director of Plant Operations stated, No. On 8/1/18 at approximately 6:20 AM, during an interview in the Magnolia (300) hall medication room, LPN #3 was asked by the surveyor if s/he had ever recorded temperatures below 36 degrees of F. on the medication refrigerator storage log. LPN #3 stated, Yes. LPN #3 was then asked, if s/he informed anyone of the temperatures below 36 F. or adjusted the thermostats, LPN #3 stated, No. LPN #3 was then asked if s/he was in-serviced on the correct storage temperature for insulin, LPN #3 stated, No. On 8/1/18 at approximately 6:35 AM, during an interview in the Azalea (100) hall medication room, LPN #4 was asked by the surveyor if s/he had ever recorded temperatures below 36 degrees of F. on the medication refrigerator storage log. LPN #4 stated, Yes. LPN #4 was then asked, if s/he informed anyone of the temperatures or adjusted the thermostats, LPN #4 stated, No. LPN #4 was then asked if s/he was in-serviced on the correct storage temperature for insulin, LPN #4 stated, A long time ago, I think. On 8/1/18 at approximately 6:42 AM, LPN #5 and RN #2 were asked by the surveyor if they had ever recorded temperatures below 36 degrees of F. on the medication refrigerator storage log. LPN #5 and RN #2 stated, Yes. LPN #5 and RN #2 was then asked, if they informed anyone of the temperatures, LPN #5 stated, No, and RN #2 stated, Yes, one time, but could not remember who s/he told. LPN #5 and RN #2 was then asked if they were in-serviced on the correct storage temperature for insulin LPN #5 stated, No, and RN #2 stated, Yes, but could not recall when. On 8/1/18 at 11:25 AM, a review of the facility policy entitled, Medication Storage in the Facility states under policy Medications and biologicals are stored safely, securely, and properly following manufacture's recommendations or those of the supplier . Bullet #7 stated, Medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Review of the manufacture recommendations for insulin, Lorazapam, Lantanoprost, [MEDICATION NAME] 23, Prevnar 13, [MEDICATION NAME], and [MEDICATION NAME] state to store refrigerated between 36-46 degrees F.

Based on observations, interview, review of the facility policy, Medication Storage in the Facility, and review of manufactures recommendations, the facility failed to follow a procedure to ensure that expired medication was removed in 1 of 3 medication storage rooms, and recommended temperatures were maintained in 3 of 3 medication storage rooms reviewed. Expired medication was in the Azalea (100) hall medication storage room refrigerator, and medications were stored on the 100, 200, and 300 hall below the FDA (Food and Drug Administration) approved package inserts and manufacturer package labeling. The findings included: On [DATE] at approximately 3:30 PM, an observation of the Azalea (100) hall medication refrigerator with Licensed Practical Nurse (LPN) #1 revealed (1) 1 milliliter (ml), 10 test, vial of [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) ( Lot # 6) which was opened (,[DATE] empty) with no date of puncture recorded on the vial or packaging box. The pharmacy label on the prescription package had a delivery date to the facility on [DATE]. Following the observation of the PPD vial, LPN #1 verified the vial of PPD was opened with no date of puncture. Review of the [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) packet insert manufacture recommendations #262 stated, A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded. Review of the facility policy, Medication Storage in the Facility, revealed under bullet #9 Outdated, contaminated, frozen or deteriorated medications and those in containers that are cracked, soiled, or without secured closures are removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. The findings included: On [DATE] at approximately 3:30 PM, an observation of the Azalea (100) hall medication storage room with Licensed Practical Nurse (LPN) #1 (unit manager) revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F.) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (5) 3 milliliter (ml) [MEDICATION NAME][MEDICATION NAME] 100 units (u)/ ml. 2.) (2) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 3.) (1) Toujeo [MEDICATION NAME] 300 u/ml. insulin pen 4.) (5) vials of [MEDICATION NAME] 10,000 u/ ml. 5.) (2) Prevnar 13 pnuemococcal vaccine 0.5 ml. 6.) (1) container of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 7.) (56) vials of [MEDICATION NAME] 20 mcg. / 2ml. 8.) (2) vials of [MEDICATION NAME], Purified Protein Derivative, 5 TU/0.1 ml. 9.) (1) vial [MEDICATION NAME] 23 vial 10.) (2) [MEDICATION NAME] ,[DATE] insulin [MEDICATION NAME] 11.) (1) 3 ml. [MEDICATION NAME] 100u/ml. Pens 12.) (1) 3 ml. [MEDICATION NAME]FlexTouch Pen 13.) (2) 3 ml. Humalog insulin KwixPen 100u/ml. 14.) (1) vial [MEDICATION NAME] ,[DATE] insulin 100u/ml. 15.) (1) vial [MEDICATION NAME] N insulin 100u/ml. 16.) (1) vial [MEDICATION NAME] R insulin 100u/ml. 17.) (3) vial Lorazapam 2 mg. / ml. On [DATE] at approximately 3:55 PM, during an interview with LPN #1, s/he was asked by the surveyor if they knew the recommended temperature for the storage of insulin. LPN #1 stated, No. On [DATE] at approximately 4:00 PM, an observation of the Magnolia (300) hall medication storage room with Registered Nurse (RN) #1 (unit manager) revealed the [DATE] temperature recorded on the medication refrigerator door log was 34 degrees F., which was confirmed by RN #1. The contents of the refrigerator was: 1.) (5) 3 milliliter (ml) [MEDICATION NAME][MEDICATION NAME] 100 u/ ml. 2.) (4) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 3.) (6) Prevnar 13 pnuemococcal vaccine 0.5 ml. 4.) (2) vial [MEDICATION NAME] 23 vial 5.) (2) [MEDICATION NAME] ,[DATE] insulin [MEDICATION NAME] 6.) (3) 3 ml. [MEDICATION NAME] 100u/ml. Pens 7.) (2) 3 ml. [MEDICATION NAME]FlexTouch Pen 8.) (5) 3 ml. Humalog insulin KwixPen 100u/ml. 9.) (1) vial [MEDICATION NAME] ,[DATE] insulin 100u/ml. 10.) (1) vial [MEDICATION NAME] N insulin 100u/ml. 11.) (1) vial [MEDICATION NAME] R insulin 100u/ml. 12.) (1) vial Humalog insulin 100u/ml. 13.) (3) vial Lorazapam 2 mg. / ml. On [DATE] at approximately 4:22 PM, during an interview with RN #1, s/he was asked by the surveyor if they knew the recommended temperature for the storage of insulin. RN #1 stated, No. On [DATE] at approximately 4:26 PM, an observation of the Jasmine (200) hall medication storage room with LPN #2 (unit manager) revealed there was no [DATE] temperature recorded on the medication refrigerator door log, and the last recorded temperature on [DATE] was 34 degrees F., which was confirmed by LPN #2. The contents of the refrigerator was: 1.) (1) 3 milliliter (ml) [MEDICATION NAME][MEDICATION NAME] 100u/ ml. 2.) (2) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 3) (3) Toujeo [MEDICATION NAME] 300 u/ml. insulin pen 4.) (1) container of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 5.) (32) vials of [MEDICATION NAME] 15 mcg. / 2ml. 8.) (1) vials of [MEDICATION NAME], Purified Protein Derivative, 5 TU/0.1 ml. 9.) (1) vial [MEDICATION NAME] 100u/ml. 10.) (5) vials [MEDICATION NAME]100u/ml. 11.) (1) 3 ml. Humalog insulin KwixPen 100u/ml. 12.) (1) vial [MEDICATION NAME] N insulin 100u/ml. 13.) (3) vial Lorazapam 2 mg. / ml. 14.) (1) [MEDICATION NAME] single injection On [DATE] at approximately 5:02 PM, during an interview with LPN #2, s/he was asked by the surveyor if they knew the recommended temperature for the storage of insulin. LPN #2 stated, No. On [DATE] at approximately 5:30 PM, a review of the (MONTH) (YEAR) medication refrigerator temperature logs revealed on the Azalea (100) hall (22) days, Jasmine (200) hall (25) days, and the Magnolia (300) hall (22) days were recorded below 36 degrees F. On [DATE] at approximately 12:43 PM, during an interview with Consultant Pharmacist #2, a review of the Consultant Pharmacist #1's Jasmine (200) hall (MONTH) (YEAR) medication room refrigerator storage inspection report revealed Consultant Pharmacist #1 marked OK with no concerns mentioned. Following the review of Consultant Pharmacist #1's report, the surveyor asked Consultant Pharmacist #2 if during an inspection of the medication room refrigerator does s/he (Consultant Pharmacist #2) review the refrigerator temperature log. Consultant #2 stated, Yes. (Consultant Pharmacist #1 was unavailable during the days of the survey.) On [DATE] at approximately 3:30 PM, during an interview with Pharmacist Consultant #2, a review of the Jasmine (200) hall (MONTH) (YEAR) refrigerator temperature log revealed (28) days were recorded below 36 degrees F., with (1) day left blank. Consultant Pharmacist #2 verified (28) days were recorded below 36 degrees F. Also, a review of the May, June, and (MONTH) (YEAR) Executive Summary of Consultant Pharmacist's Medication Regimen Review with Consultant Pharmacist #2 revealed no mention of concerns related to medication room refrigerators. Consultant Pharmacist #2 verified there were no concerns relating to medication refrigerator storage in the inspection reports and indicated that if any concerns were identified with medication room refrigerator temperatures during a Consultant Pharmacist inspection they would be found in the Executive Summary of Consultant Pharmacist's Medication Regimen Review . On [DATE] at approximately 6:10 AM, an observation of the Magnolia (300) hall medication storage refrigerator with LPN #3 and the Director of Plant Operations revealed the refrigerator temperature was 32 degrees F. The contents of the refrigerator was: 1.) (4) Trulicity 1.5 milligram (mg.)/ 0.5 ml insulin cartridges 2.) (5) Prevnar 13 pnuemococcal vaccine 0.5 ml. 3.) (1) vials of [MEDICATION NAME], Purified Protein Derivative, 5 TU/0.1 ml. 4.) (1) 3 ml. [MEDICATION NAME]FlexTouch Pen 5.) (2) 3 ml. Humalog insulin KwixPen 100u/ml. 6.) (1) vial [MEDICATION NAME]100u/ml. 7.) (1) vial Humalog insulin 100u/ml. 8.) (3) vials of Lorazapam 2 mg./ml. On [DATE] at approximately 6:15 AM, during an interview with the Director of Plant Operations, s/he was asked by the surveyor if the thermometers in the 100, 200, and 300 hall medication refrigerators were checked and working properly on [DATE] and on [DATE]. The Director of Plant Operations stated, Yes, they were checked and work. S/he was then asked if s/he was informed of a problem with the temperatures of the refrigerators or thermometers within the last 6 months or if the thermostats were adjusted. The Director of Plant Operations stated, No. On [DATE] at approximately 6:20 AM, during an interview in the Magnolia (300) hall medication room, LPN #3 was asked by the surveyor if s/he had ever recorded temperatures below 36 degrees of F. on the medication refrigerator storage log. LPN #3 stated, Yes. LPN #3 was then asked, if s/he informed anyone of the temperatures below 36 F or adjusted the thermostats, LPN #3 stated, No. LPN #3 was then asked if s/he was in-serviced on the correct storage temperature for insulin, LPN #3 stated, No. On [DATE] at approximately 6:35 AM, during an interview in the Azalea (100) hall medication room, LPN #4 was asked by the surveyor if s/he had ever recorded temperatures below 36 degrees of F. on the medication refrigerator storage log. LPN #4 stated, Yes. LPN #4 was then asked, if s/he informed anyone of the temperatures or adjusted the thermostats, LPN #4 stated, No. LPN #4 was then asked if s/he was in-serviced on the correct storage temperature for insulin, LPN #4 stated, A long time ago, I think. On [DATE] at approximately 6:42 AM, LPN #5 and RN #2 were asked by the surveyor if they had ever recorded temperatures below 36 degrees of F. on the refrigerator storage log. LPN #5 and RN #2 stated, Yes. LPN #5 and RN #2 was then asked, if they informed anyone of the temperatures, LPN #5 stated, No, and RN #2 stated, Yes, one time, but could not remember who s/he told. LPN #5 and RN #2 was then asked if they were in-serviced on the correct storage temperature for insulin LPN #5 stated, No, and RN #2 stated, Yes, but could not recall when. On [DATE] at 11:25 AM, a review of the facility policy entitled, Medication Storage in the Facility states under policy Medications and biologicals are stored safely, securely, and properly following manufacture's recommendations or those of the supplier . Bullet #7 stated, Medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Review of the manufacture recommendations for insulin, Lorazapam, Lantanoprost, [MEDICATION NAME] 23, Prevnar 13, [MEDICATION NAME], and [MEDICATION NAME] state to store refrigerated between ,[DATE] degrees F.

Based on observations, record review and interview the facility failed to develop a plan of care for Resident #4 to include hand splints for 1 of 1 resident reviewed for Position and Mobility. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Observations on 7/30/2018 at approximately 9:30 AM revealed Resident #4 in bed with bilateral hand splints in place. Review on 8/3/2018 at approximately 9:28 AM of the Plan of Care for Resident #4 revealed no goals nor interventions to address the use of bilateral hand splints, for contractures of bilateral hands. Further review on 8/3/2018 at approximately 9:30 AM of the plan of care for Resident #4 revealed interventions which included, restorative nursing, range of motion with contractures. The care plan statesResident will maintain current level of range of motion within disease limitations through next review. During an interview on 8/3/2018 at approximately 9:28 AM with the DON (Director of Nursing) he/she confirmed the splints were on the resident he/she was wearing them each night from 10:00 PM until 6:00 AM. The DON went on to say the splints were originally ordered on [DATE] and were discontinued on 10/25/2017 by accident. The DON stated that therapy has been notified and agreed that Resident #4 still needed to wear the splints nightly. The splints were observed on Resident #4 at 9:00 AM and should have been off at 6:00 AM according to the physician's orders [REDACTED].#4.

Based on record review and interview, the facility failed to ensure a significant change assessment was completed in a timely manner for Resident #82 for 1 of 1 resident reviewed for Hospice. The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Resident # 82 was admitted to Hospice on 5/2/2018. Review on 8/1/2018 at approximately 11:04 AM of the MDS (Minimum Data Set) assessment dated [DATE] which was for the admission to Hospice revealed no information to ensure the significant change assessment included hospice but was transmitted to the state agency. Further review on 8/1/2018 at approximately 11:06 AM of a corrected MDS assessment revealed a correction date of 7/11/2018. The significant change assessment for the admission to hospice had not been submitted to the state agency in a timely manner. During an interview on 8/1/2018 at approximately 11:15 AM with the MDS Coordinator, he/she confirmed the findings, and states, a previous MDS coordinator had left off the fact that the resident was admitted to Hospice. We sent the correction as required by the state agency and as instructed by the RAI (Resident Assessment Instrument) manual.

Based on observations and interviews, the facility failed to ensure dignity and respect for each resident in a manner to maintain and or promote quality of life. Staff failed to allow residents time to give permission to enter rooms after knocking. Staff failed to knock on doors before entering and yelled, knock, knock, on 1 of 2 units observed during the breakfast meal service. The findings included: Observations on 7/30/2018 at approximately 12:48 PM during the lunch meal in the dining room on the 200 Hall and the 100 Hall, revealed staff sitting at the dining room table on the units and feeding 2 residents at the same time. Observations on 8/2/2018 at approximately 8:20 AM revealed staff entering rooms with breakfast trays after knocking but not waiting on residents to give permission to enter the room. Staff were observed on 8/2/2018 at approximately 8:20 AM yelling, knock, knock, and entering rooms with lunch meal trays. During an interview on 8/2/2018 at approximately 9:45 AM with CNA (Certified Nursing Assistant) #2 confirmed that knocking on room doors and not waiting for residents to invite us in, an yelling knock, Knock was not the proper way to enter resident rooms.

Based on review of facility files and interview, the facility failed to ensure all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made. The facility reported an allegation of abuse to the State Agency on 10/20/17. The facility was notified about the incident on 10/18/17. Certified Nursing Assistant (CNA) #1 took a picture of Resident #1 while exposed and posted the picture to social media. The resident's spouse asked that the resident not be told about the picture because of how it may affect him/her. Resident #1 was noted to be alert and oriented and cognitively intact. The picture showed the resident in bed with his/her backside exposed and also included the resident's night stand which contained several items. The angle of a hand in the picture indicated there was another staff member present when the picture was taken. The staff member did not report the incident. One of three resident's reviewed for abuse. The findings included: The facility reported an allegation of abuse to the State Agency for Resident #1 on 10/20/17. CNA #1 took a picture of Resident #1 and posted the picture which was distributed via telephone to a social media app. In an interview with CNA #1 it was determined that the resident in the picture was Resident #1. Review of Resident #1's medical record revealed the resident/legal representative signed the Informed Consent for Photographs/Video/Audio/Outings/Mail Assistance form. The form indicated no for consent to having Resident #1's picture made for posting within the center. The form indicated no for consent to having Resident #1's picture made for release to the general public, inside and outside the building. The form indicated no for consent to having Resident #1's picture made for release digitally through the center's controlled Electronic Media. Review of Resident #1's medical record revealed the Quarterly Minimum (MDS) data set [DATE] coded the resident as having a Brief Interview for Mental Status score of 15 which indicated that the resident was cognitively intact. Review of Resident #1's care plan revealed resident has a [DIAGNOSES REDACTED]. Goals included Resident #1 will continue to participate in decision making related to his/her care and the resident will not have an exacerbation of his/her mood throughout stay at facility. Approaches to this problem area were listed on the care plan and included to promote dignity by ensuring privacy while providing care. Review of Resident #1's History and Physical completed 4/6/17 revealed the resident had severe panic disorder and had been battling this for a long time. The resident was working with psych. Review of the facility's Summary of the Investigation into the incident involving Resident #1 and CNA #1 revealed the facility received a telephone call from a nursing instructor with a technical college. The nursing instructor stated that one of his/her students saw a social media picture taken by CNA #1 that shows a resident's bottom. The nursing instructor forwarded the picture to the facility. The facility interviewed CNA #1 regarding the contents of the picture. CNA #1 admitted to taking the picture with his/her cell phone and sending it to others. CNA #1 informed the facility that the resident in the picture was Resident #1. CNA #1 stated that CNA #2 was present in the room. In an interview with CNA #2, s/he stated s/he had no knowledge that a picture was taken. CNA #2 stated that the picture was of Resident #1 because that was his/her resident to care for. CNA #2 stated that s/he was not in the room the entire time CNA #1 was in the room. CNA #2 could not identify the hand that was in the picture. The facility provided the surveyor with the facility's investigation, which contained one picture. Review of the picture provided to the surveyor revealed the resident turned on his/her side in the bed and their backside exposed. The picture was taken from the foot of the resident's bed. There is a gloved hand that is near the resident's lower back. The picture also includes Resident #1's nightstand which contained several items. There is a caption added to the post that states What kind of butt u call that with five smiley face emojis. CNA #1's facility-obtained statement revealed CNA #1 was shown the picture received from the nursing instructor from a technical college. CNA #1 stated that s/he took the picture. CNA #1 stated that CNA #2 was in the room but that s/he had nothing to do with the picture. CNA #1 stated that the picture was of Resident #1. CNA #2's facility-obtained statement revealed that CNA #2 was interviewed due to the fact that CNA #1 stated that CNA #2 was in the room when s/he took the picture. When CNA #2 was shown the picture, s/he immediately stated that the resident was Resident #1 because that was his/her resident. CNA #2 was asked if s/he knew that the picture was being taken. CNA #2 stated that s/he had no knowledge a picture was taken. During the entrance conference with the administrator on 12/4/17 at approximately 10:00 AM, the facility administrator stated the resident does not know about the photo. The resident's spouse does not want the resident to know because of how it may affect him/her. In an interview with the surveyor on 12/4/17 at approximately 3:15 PM, the facility administrator stated the incident was initially reported by the nursing instructor from a technical college. The nursing instructor called and reported the information and when s/he said s/he had a picture, the administrator asked the nursing instructor to email it. The administrator stated that s/he did not have a copy of the email and had deleted it from their account. The administrator stated that students from that technical college nursing program do not come to the facility. A student at the technical college went to the nursing instructor and told him/her a friend of theirs received the social media picture. The student was disturbed when his/her friend showed him/her the content and reported it to the nursing instructor. CNA #1 admitted to taking the picture. CNA #1 told the administrator the resident in the picture was Resident #1. There is a gloved hand in the upper part of the picture and the angle of the picture indicated someone else was in the room. The administrator asked and CNA #1 said CNA #2 was in the room. The administrator talked with CNA #2 and s/he denied knowing a picture was taken. In a telephone interview with the surveyor on 12/11/17, the nursing instructor stated that the student provided three pictures. The nursing instructor called the facility administrator who asked him/her to email the pictures. The surveyor asked the nursing instructor to forward a copy of the email sent to the administrator. The nursing instructor forwarded the email to the surveyor on 12/11/17. One of the pictures was a screenshot of CNA #1's Facebook page which indicated s/he was a CNA at the facility. The forwarded email included the original email sent to the facility administrator and was stamped as sent on 10/18/17 at 2:12 PM. Review of the facility's Abuse Policy revealed the resident has the right to be free from abuse. The policy indicated the definition of abuse included sexual and mental abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated the definition of mental abuse included staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate regardless of consent or cognitive status. The facility's Reporting Policy indicated any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately, but not later than 2 hours after forming the suspicion.

Based on review of facility files and interview, the facility failed to ensure each resident remained free from abuse. Certified Nursing Assistant (CNA) #1 took a picture of Resident #1 while exposed and posted the picture to social media. The resident's spouse asked that the resident not be told about the picture because of how it may affect him/her. Resident #1 was noted to be alert and oriented and cognitively intact. The picture showed the resident in bed with his/her backside exposed and also included the resident's night stand which contained several items. One of three resident's reviewed for abuse. The findings included: The facility reported an allegation of abuse to the State Agency for Resident #1 on 10/20/17. CNA #1 took a picture of Resident #1 and posted the picture which was distributed via telephone to social media. In an interview with CNA #1, by the facility, it was determined that the resident in the picture was Resident #1. Review of Resident #1's medical record revealed the resident/legal representative signed the Informed Consent for Photographs/Video/Audio/Outings/Mail Assistance form. The form indicated no for consent to having Resident #1's picture made for posting within the center. The form indicated no for consent to having Resident #1's picture made for release to the general public, inside and outside the building. The form indicated no for consent to having Resident #1's picture made for release digitally through the center's controlled Electronic Media. Review of Resident #1's medical record revealed the Quarterly Minimum (MDS) data set [DATE] coded the resident as having a Brief Interview for Mental Status score of 15 which indicated that the resident was cognitively intact. Review of Resident #1's care plan revealed resident has a [DIAGNOSES REDACTED]. Goals included Resident #1 will continue to participate in decision making related to his/her care and the resident will not have an exacerbation of his/her mood throughout stay at facility. Approaches to this problem area were listed on the care plan and included to promote dignity by ensuring privacy while providing care. Review of Resident #1's History and Physical completed 4/6/17 revealed the resident had severe panic disorder and had been battling this for a long time. The resident was working with psych. Review of the facility's Summary of the Investigation into the incident involving Resident #1 and CNA #1 revealed the facility received a telephone call from a nursing instructor with a technical college. The nursing instructor stated that one of his/her students saw a social media picture taken by CNA #1 that showed a resident's bottom. The nursing instructor forwarded the picture to the facility. The facility interviewed CNA #1 regarding the contents of the picture. CNA #1 admitted to taking the picture with his/her cell phone and sending it to others. CNA #1 informed the facility that the resident in the picture was Resident #1. CNA #1 stated that CNA #2 was present in the room. In an interview with CNA #2, s/he stated s/he had no knowledge that a picture was taken. CNA #2 stated that the picture was of Resident #1 because that was his/her resident to care for. CNA #2 stated that s/he was not in the room the entire time CNA #1 was in the room. CNA #2 could not identify the hand that was in the picture. The facility provided a copy of the their investigation into the incident to the surveyor, which contained one picture. Review of the picture provided to the surveyor revealed the resident turned on his/her side in the bed and their backside exposed. The picture was taken from the foot of the resident's bed. There is a gloved hand that is near the resident's lower back. The picture also includes Resident #1's nightstand which contains several items. There is a caption added to the post that states What kind of butt u call that with five smiley face emojis. CNA #1's facility-obtained statement revealed CNA #1 was shown the picture received from the nursing instructor from a technical college. CNA #1 stated that s/he took the picture. CNA #1 stated that CNA #2 was in the room but that s/he had nothing to do with the picture. CNA #1 stated that the picture was of Resident #1. CNA #2's facility-obtained statement revealed that CNA #2 was interviewed due to the fact that CNA #1 stated that CNA #2 was in the room when s/he took the picture. When CNA #2 was shown the picture, s/he immediately stated that the resident was Resident #1 because that was his/her resident. CNA #2 was asked if s/he knew that the picture was being taken. CNA #2 stated that s/he had no knowledge a picture was taken. During the entrance conference with the administrator on 12/4/17 at approximately 10:00 AM, the facility administrator stated the resident does not know about the photo. The resident's spouse does not want the resident to know because of how it may affect him/her. In an interview with the surveyor on 12/4/17 at approximately 3:15 PM, the facility administrator stated the incident was initially reported by the nursing instructor from a technical college. The nursing instructor called and reported the information and when s/he said s/he had a picture, the administrator asked the nursing instructor to email it. The administrator stated that students from that technical college nursing program do not come to the facility. A student at the technical college went to the nursing instructor and told him/her a friend of theirs received the social media picture. The student was disturbed when his/her friend showed him/her the content and reported it to the nursing instructor. CNA #1 admitted to taking the picture. CNA #1 told the administrator the resident in the picture was Resident #1. There is a gloved hand in the upper part of the picture and the angle of the picture indicated someone else was in the room. The administrator asked and CNA #1 said CNA #2 was in the room. The administrator talked with CNA #2 and s/he denied knowing a picture was taken. Review of the facility's Abuse Policy revealed the resident has the right to be free from abuse. The policy indicated the definition of abuse included sexual and mental abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated the definition of mental abuse included staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate regardless of consent or cognitive status. The facility's Reporting Policy indicated any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately, but not later than 2 hours after forming the suspicion.

Based on review of facility files and interview, the facility failed to ensure each resident's personal privacy was respected. Certified Nursing Assistant (CNA) #1 took a picture of Resident #1 while exposed and posted the picture to social media. The resident's spouse asked that the resident not be told about the picture because of how it may affect him/her. Resident #1 was noted to be alert and oriented and cognitively intact. The picture showed the resident in bed with his/her backside exposed and also included the resident's night stand which contained several items. One of three resident's reviewed for privacy. The findings included: The facility reported an allegation of abuse to the State Agency for Resident #1 on 10/20/17. CNA #1 took a picture of Resident #1 and posted the picture which was distributed via telephone to social media. In an interview with CNA #1, by the facility, it was determined that the resident in the picture was Resident #1. Review of Resident #1's medical record revealed the resident/legal representative signed the Informed Consent for Photographs/Video/Audio/Outings/Mail Assistance form. The form indicated no for consent to having Resident #1's picture made for posting within the center. The form indicated no for consent to having Resident #1's picture made for release to the general public, inside and outside the building. The form indicated no for consent to having Resident #1's picture made for release digitally through the center's controlled Electronic Media. Review of Resident #1's medical record revealed the Quarterly Minimum (MDS) data set [DATE] coded the resident as having a Brief Interview for Mental Status score of 15 which indicated that the resident was cognitively intact. Review of Resident #1's History and Physical completed 4/6/17 revealed the resident had severe panic disorder and had been battling this for a long time. The resident was working with psych. Review of Resident #1's care plan revealed resident has a [DIAGNOSES REDACTED]. Goals included Resident #1 will continue to participate in decision making related to his/her care and the resident will not have an exacerbation of his/her mood throughout stay at facility. Approaches to this problem area were listed on the care plan and included to promote dignity by ensuring privacy while providing care. Review of the facility's Summary of the Investigation into the incident involving Resident #1 and CNA #1 revealed the facility received a telephone call from a nursing instructor with a technical college. The nursing instructor stated that one of his/her students saw a picture on social media taken by CNA #1 that shows a resident's bottom. The nursing instructor forwarded the picture to the facility. The facility interviewed CNA #1 regarding the contents of the picture. CNA #1 admitted to taking the picture with his/her cell phone and sending it to others. CNA #1 informed the facility that the resident in the picture was Resident #1. CNA #1 stated that CNA #2 was present in the room. In an interview with CNA #2, s/he stated s/he had no knowledge that a picture was taken. CNA #2 stated that the picture was of Resident #1 because that was his/her resident to care for. CNA #2 stated that s/he was not in the room the entire time CNA #1 was in the room. CNA #2 could not identify the hand that was in the picture. The facility provided a copy of their investigation into the incident to the surveyor, which contained one picture. Review of the picture provided to the surveyor revealed the resident turned on his/her side in the bed and their backside exposed. The picture was taken from the foot of the resident's bed. There is a gloved hand that is near the resident's lower back. The picture also includes Resident #1's nightstand which contained several items. There is a caption added to the post that states What kind of butt u call that with five smiley face emojis. CNA #1's facility-obtained statement revealed CNA #1 was shown the picture received from the nursing instructor from a technical college. CNA #1 stated that s/he took the picture. CNA #1 stated that CNA #2 was in the room but that s/he had nothing to do with the picture. CNA #1 stated that the picture was of Resident #1. CNA #2's facility-obtained statement revealed that CNA #2 was interviewed due to the fact that CNA #1 stated that CNA #2 was in the room when s/he took the picture. When CNA #2 was shown the picture, s/he immediately stated that the resident was Resident #1 because that was his/her resident. CNA #2 was asked if s/he knew that the picture was being taken. CNA #2 stated that s/he had no knowledge a picture was taken. During the entrance conference with the administrator on 12/4/17 at approximately 10:00 AM, the facility administrator stated the resident does not know about the photo. The resident's spouse does not want the resident to know because of how it may affect him/her. In an interview with the surveyor on 12/4/17 at approximately 3:15 PM, the facility administrator stated the incident was initially reported by the nursing instructor from a technical college. The nursing instructor called and reported the information and when s/he said s/he had a picture, the administrator asked the nursing instructor to email it. The administrator stated that students from that technical college nursing program do not come to the facility. A student at the technical college went to the nursing instructor and told him/her a friend of theirs received the social media picture. The student was disturbed when his/her friend showed him/her the content and reported it to the nursing instructor. CNA #1 admitted to taking the picture. CNA #1 told the administrator the resident in the picture was Resident #1. There is a gloved hand in the upper part of the picture and the angle of the picture indicated someone else was in the room. The administrator asked and CNA #1 said CNA #2 was in the room. The administrator talked with CNA #2 and s/he denied knowing a picture was taken.

Based on observation, interview and record review, dietary aid # 1 failed to use proper hand washing techniques while working in the kitchen. Findings included: Observation of kitchen at 11:50 am on 3/29/17 revealed dietary aide #1, placing saran wrap on sandwiches with no gloves on and with splints on both arms from middle of fingers, half of palm and up the arms. Interview with dietary aide #1 at 11:55 am on 3/29 /17 revealed he/she washes their hands with the splints on. Further observation of dietary aide # 1 on 3/29/17 at 12:06 pm revealed he/she removing gloves on over both splints and then washing his/ her hands with both splints on. Interview CDM 12:07 pm verified that dietary aide #1 was not using proper hand washing technique while hand washing while having both splints on. Review of facility safety and sanitation best practice guidelines dated 1/11 revealed hands should be washed using following process: Wet hands and arms - use running water at least 100 degrees or as hot as you can stand. Apply soap - build enough lather. Scrub hands and arms vigorously - scrub for 10 - 15 seconds and clean under fingernails and between fingers. Rinse hands and arms thoroughly. Dry hands and arms. Interview with CDM at 4:30 pm on 3/29/17 revealed dietary aide #1 has worn the splints on both hands since December 2016.

Based on record review and interview, the facility failed to maintain complete and/or accurate records for 1 of 15 residents reviewed. Resident #185 did not have Weekly Wound Assessment Records in the medical record. The findings included: The facility admitted resident #185 with [DIAGNOSES REDACTED]. The resident was admitted from another Long Term Care facility. Review of the medical record revealed the resident was admitted with two unstageable pressure sores. Review of the Care Plan revealed a problem was identified of; Skin integrity, at risk for alteration related to (r/t) weakness, impaired mobility, open wounds on bilateral lower extremities. admitted with DTI (Deep Tissue Injury) to bilateral heels. Review of the Nurses' Notes from 11/29/16 through 1/10/17 revealed the facility monitored the pressure areas, the pressure areas had changes. There was no documentation the resident's Responsible Party (RP) was ever notified of the pressure areas and/or their progression. On 3/29/17 at approximately 9:55 AM, the Director of Nurses (DON) was interviewed by the surveyor. The DON stated that all nurses were responsible for wounds. We have a wound sheet (Weekly Wound Assessment Record) that is kept on the chart, while active may be kept at the desk. Notification should be documented in the nurse's notes or on the back of the wound sheet. During the survey, the facility was unable to locate the Weekly Wound Assessment Records for the resident's wounds of both heels and right buttock.

Based on record review and interview, the facility failed to provide appropriate discharge information to the receiving facility for 1 of 4 discharge records reviewed. Resident #185 was discharged without accurate documentation of wounds. The findings included: The facility admitted resident #185 with [DIAGNOSES REDACTED]. The resident was admitted from another Long Term Care facility. Review of the medical record revealed an Admission Minimum Data Set (MDS) with an Assessment Date of 12/6/16: The MDS was coded the resident required extensive assist with bed mobility, locomotion, toilet use, hygiene. The resident was non ambulatory. The resident was coded to be frequently incontinent of bowel and bladder. S/he was at risk for pressure ulcer (PU), 2 unstageable PU on admission, and skin tears. Pressure reducing devices were in place for bed and chair. The MDS was coded the resident received pressure ulcer care, non-surgical wound care, skin tears, ointments, dressings to feet. Review of the Care Plan revealed a problem was identified of; Skin integrity, at risk for alteration related to (r/t) weakness, impaired mobility, open wounds on bilateral lower extremities. admitted with DTI (Deep Tissue Injury) to bilateral heels. Review of the Nurses' Notes revealed the facility monitored the pressure areas, the pressure areas had changes. On 1/10/2017 the resident was transferred to an Assisted Living facility. Review of the Discharge Summary and Post Discharge Instructions revealed no evidence the Assisted Living facility was notified of the resident's pressure sores or the condition of the pressure sores. There was no indication the resident or family had been instructed on the care/treatment of [REDACTED]. The resident signed the Discharge instructions. Review of the facility Skin Surveillance Form for the week of 12/31/16 through 1/6/17 had documented the resident's wounds: L (left) Heel DTI (Deep Tissue Injury) 1.5 x 1.5. R (right) heel DTI 1.5 x 1.5. Buttocks-Unstageable 2.0 x 2.0. Nurses Notes of 1/3/17. Bilateral heels elevated. Left heel is unstageable with eschar. [MEDICATION NAME] placed to area. R heel [MEDICATION NAME] placed. 1/5/17 Santyl Ointment cleanse area to R buttock with Normal Saline (NS). Apply small amount of Santyl to slough area only. Cover with 2 x 2 gauze and secure with 4 X 5. Change twice a day. Weekly Skin Assessment Progress Note: 1/10/17: Dressing to right buttock changed. Area open, 2 x 2 cm, spotted slough on open area. Cleansed with normal saline, Polymen applied. No signs of infection, no discharge, no odor. Review of the Social Services Notes revealed no documentation of the ALF being aware of the pressure sores or treatments. On 3/29/17 The Director of Nurses (DON) stated the Assisted Living had been out to the facility and assessed the resident. They should have been aware of the wounds. The DON stated the Social Worker (SW) had discussed the wounds and notified the family the day of or the day before the transfer. The DON was unable to provide documentation of the notification of the pressure sores and treatments to the AL or the family. The DON obtained a statement from the Social Worker dated 3/28/17 that stated, on the day of the transfer/discharge to the ALF the SW had discussed with the ALF Admissions Coordinator to confirm the resident was appropriate for admissions to include wound care needs.

Based on record review and interview, the facility failed to notify family members of development and/or progression of pressure sores for 1 of 2 residents reviewed for notification of pressure sores. Resident #185 developed a pressure sore and family was not notified of development or changes in wounds. The findings included: The facility admitted resident #185 with [DIAGNOSES REDACTED]. The resident was admitted from another Long Term Care facility. Review of the medical record revealed an Admission Minimum Data Set (MDS) with an Assessment Date of 12/6/16: The MDS was coded the resident required extensive assist with bed mobility, locomotion, toilet use, hygiene. The resident was non ambulatory. The resident was coded to be frequently incontinent of bowel and bladder. S/he was at risk for pressure ulcer (PU), 2 unstageable PU on admission, and skin tears. Pressure reducing devices were in place for bed and chair. The MDS was coded the resident received pressure ulcer care, non-surgical wound care, skin tears, ointments, dressings to feet. Review of the Care Plan revealed a problem was identified of; Skin integrity, at risk for alteration related to (r/t) weakness, impaired mobility, open wounds on bilateral lower extremities. admitted with DTI (Deep Tissue Injury) to bilateral heels. Review of the Nurses' Notes revealed the facility monitored the pressure areas, the pressure areas had changes. There was no documentation the resident's Responsible Party (RP) was ever notified of the pressure areas and/or their progression. 11/29/16: 3+ [MEDICAL CONDITION] to lower extremities. Right shin skin tear, boggy heels, bilaterally, and redness to coccyx area. Barrier spray ordered. 12/5/16: New orders to D/C [MEDICATION NAME], start [MEDICATION NAME], Daughter aware of new orders. 12/7/16: [MEDICATION NAME] ordered, [MEDICATION NAME] change- family aware. 12/8/16: Weekly skin surveillance: show admission suspected deep tissue injury (sdti) to both heels have no further breakdown, measuring 4 x 4 each. Skin prep continues along with float heels. 12/15/16: Weekly skin surveillance completed for both heels. Continue skin prep to those areas. 12/22/16: Weekly skin surveillance completed for assessment, present on admission, sdti to left/right (L/R) heels. Today they measure 2 x 2, decrease in size, healing, continues. 12/24/16: 10:45 PM- Some bleeding reported from left heel. Examined at 10:00 PM and noted no bleeding. 12/25/16: Certified Nursing Assistant (CNA) alerted nurse to area on resident's R buttocks. Will evaluate for appropriate treatment. Made manager and doctor aware. 12/26/16: Purple and pink area to buttock was examined by doctor (Dr.) and Manager. Will be taken care of as ordered with Z guard crème. Staff made aware. Family made aware. 12/29/16: Weekly skin surveillance completed L and R heels continue with no further breakdown. Float heels and skin prep continue. Sdti to buttocks. Measures 2.5 x 2, discontinued (d/c'd) z guard added skin prep, air mattress, frequent repositioning, q 2 hours and gel cushion. 2:00 PM: Z-guard applied to R buttock, No signs/symptoms (s/s) of bleeding or unusual bruising. Informed Manager about buttock needing to be examined. Applied skin prep to buttocks. 3:51 PM called family member and made aware of new order from doctor. RP voiced understood and had no questions at that time. New Order: Apply skin prep to buttocks every shift. 1/3/17: Bilateral heels elevated. Left heel is unstageable with eschar. [MEDICATION NAME] placed to area. R heel [MEDICATION NAME] placed. 1/5/17: Santyl Ointment cleanse area to R buttock with Normal Saline (NS). Apply small amount of Santyl to slough area only. Cover with 2 x 2 gauze and secure with 4 X 5. Change twice a day. Weekly Skin Assessment Progress Note: 1/10/17: Dressing to right buttock changed. Area open, 2 x 2 cm, spotted slough on open area. Cleansed with normal saline, Polymen applied. No signs of infection, no discharge, no odor. On 3/29/17 at approximately 9:55 AM, the Director of Nurses (DON) was interviewed by the surveyor. The DON stated that all nurses were responsible for wounds. We have a wound sheet that is kept on the chart, while active may be kept at the desk. The manager may be looking at them as well. Every nurse and the managers are responsible for talking to the families about it (wounds). It should be documented in the nurse's notes or on the back of the wound sheet. No policy for preventive skin treatment. We use the weekly skin assessment record. During the survey, the facility was unable to locate the Wound Sheets for the resident's wounds. Although the Nurses' Notes provided documentation the resident's family/RP was notified of changes in Physician Orders, there was no evidence available that the resident's family/RP were notified of the status of the resident's wounds.

Based on record reviews and interviews, the facility failed to develop care plans with measurable goals and interventions to address care and treatment for 2 of 3 residents with limited range of motion (ROM)/contractures. The plans of care for Residents #155 and #197 did not include specific interventions to maintain and/or prevent decline in ROM. Also, based on record reviews and interviews, the facility failed to develop individualized care plans to address interventions to be attempted prior to administration of psychoactive medications for 4 of 7 sampled residents reviewed for unnecessary medications. Care plans for Residents #34, #46, #270, and #378 did not include specific individualized non-pharmacological approaches for preventing, relieving, and/or accommodating distressed behavior. . The findings included: The facility admitted Resident #34 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident required extensive to total assistance with all activities of daily living. Review of the 11-12-14 Annual Minimum Data Set (MDS) Assessment revealed that the resident had functional limitations in both upper and lower extremities. Record review on 2-11-15 at 11:17 AM revealed a 7-9-13 physician's orders [REDACTED]. Give one every 8 hours as needed for anxiety. Record behavior: 1=swinging at staff, 2=kicking at staff, 3=restless, 4=self-inflicted scratches." Review of the 12-14 Medication and Treatment Administration Reports on 2-11-15 at 11:42 AM revealed that Alprazalam was administered on 12-4-14 at 4:28 PM for "scratching self." On 12-5-14 at 5:23 PM, it was given for "restless, pulling...own hair." At 4:20 PM on 12-14-14, Alprazalam was administered for "scratching." On 12-20-14 at 7:56 PM, the medication was given for "hitting and grabbing." On 12-28-14 at 10:06 AM, Alprazalam was given for "hitting/kicking at staff." Review of the 1-15 Medication and Treatment Administration Reports revealed that Alprazalam was administered on 1-11-15 at 11:27 AM for swinging at staff, kicking at staff, and restlessness. On 1-16-15 at 7:41 PM, Alprazalam was given for swinging at staff and restlessness. On 1-24-15 at 4:05 PM, the medication was given for "scratching self." On 1-25-15 at 4:59 PM, the nurse administered Alprazalam for kicking at staff, restlessness, and "scratching self". Review of the 2-15 Medication and Treatment Administration Reports revealed that the medication had been administered on 2-6-15 at 9:16 PM for "hitting." "3 (restless)" and "4 (self-inflicted scratches)" were also noted as behaviors. There was no evidence in the record of assessment/evaluation of the underlying cause of the distressed behavior, no documentation of what was transpiring at the time the behavior occurred, or what interventions were attempted prior to administration of the anti-anxiety medication. Further review revealed physician's orders [REDACTED]. Take one tablet 4 times a day at 9AM, 1PM, 5PM, and 9 PM." "Men-phor Anti-Itch Lotion (Sarna)" was ordered to be applied every shift (7am-7pm) and (7pm-7am). There was no time or frequency specified for the lotion and no evidence that this was attempted prior to administration of the Alprazalam when the reason for administration was "scratching". There was no evidence that an evaluation had been done for an increase in medication or an adjustment in medication times to coincide with any behavior patterns. Review of Social Services notes on 2-12-14 at 10:58 AM revealed that the resident's behaviors occurred "usually when they (the staff) are performing care." During an interview on 2-11-15 at 12:35 PM, Licensed Practical Nurse (LPN) #1 stated that the Alprazalam was given "when (Resident #34) gets anxious, scratches self, or hits staff." S/he stated they "would try other things before meds." The nurse stated that s/he would "sit and talk-just sit with (her/him) and hold (her/his) hand. Sometimes it works, sometimes not. Singing works. Lotion helps." When asked how the surveyor would know what interventions had been attempted prior to medication administration, LPN #1 stated, "It would be documented on the MAR (Medication Administration Record) and in the Nurses Notes." S/he also stated, "It should be on the care plan." On 2-11-15 at 3 PM, review of the Care Plan with the Unit Manager (Director of Nurses in attendance) revealed no specific individualized planned interventions to be attempted prior to psychoactive medication administration. Administration of Alprazalam on an "as needed" basis for anxiety was added to a problem of "Complications, at risk for -related to disease process of: . . . [MEDICAL CONDITION]. . . Dementia..." Another problem indicated that Resident #34 was "known to be combative with staff during ADL's." The only intervention related to exhibited behaviors during care stated:" If (Resident #34) resists care or is combative leave and return at a later time to attempt care." The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Review of the 12-29-14 MDS revealed that the resident's Brief Interview for Mental Status score was "8", indicating moderate cognitive impairment. Record review at 4:17-PM on 2-10-15 revealed a 9-26-14 physician's orders [REDACTED]. May take one tab every 8 hours as needed. 1=crying out, 2=combativeness, 3=restlessness." Review of the 12-14, 1-15, and 2-15 Medication and Treatment Administration Reports on 2-11-15 at 10:28 AM revealed that [MEDICATION NAME] was administered on 12-6-15 at 4:46 PM, 12-8-14 at 7:30 PM, 1-4-15 at 7:51 PM, and 2-2-15 at 7:40 PM for "restlessness". No specific behaviors were noted. Review of Nurses Notes on 2-10-15 at 5:13 PM revealed no reference to behaviors or administration of [MEDICATION NAME] on those dates. The 12-7-14 Monthly Summary noted the resident "(with) episodes of'panic attacks' -does have PRN [MEDICATION NAME] O.5 mg ordered. No inappropriate behaviors or feelings of anxiety this shift." There was no evidence in the record of assessment/evaluation of the underlying cause of the resident's distress, no documentation of what was transpiring at the time the restlessness occurred, or what interventions were attempted prior to administration of the anti-anxiety medication. Minimally, there was no evidence of pain assessment, blood sugar, or oxygen saturation (which were care planned to be done every shift). Review of the Care Plan on 2-10-15 at 4:30 PM revealed no specific individualized planned interventions to be attempted prior to psychoactive medication administration. Administration of [MEDICATION NAME] was noted related to a problem of "Complications, at risk for -related to disease process of: [MEDICAL CONDITIONS]...DM, Dementia,...Arthritis,[MEDICAL CONDITION]" There was no problem listed related to anxiety, restlessness, or behaviors. During an interview on 2-11-15 at 12:35 PM, LPN #1 was unaware that Resident #46 received [MEDICATION NAME] on a PRN basis because s/he "had never given it." After reviewing the MAR, LPN # I stated that the [MEDICATION NAME] was always given in the evening. "I think (s/he) gets more anxious in the evenings. (S/he) wants to go home. During the day, there's a lot of activities going on and (the resident) doesn't notice." S/he stated that before administering the medication, the nurses should attempt other interventions and that this information would be found on the MAR and in the Nurses Notes. The nurse also stated, "It should be on the care plan." The facility admitted Resident #270 with [DIAGNOSES REDACTED]. Record review on 2/11/15 at approximately 11:00 AM revealed Physician order [REDACTED]." Review of the Medication and Treatment Administration Report revealed [MEDICATION NAME] had been administered five times in December 2014 for anxiety and agitation and two times in January 2015 for increased agitation, anxiety, and wandering about the unit. Review of the 12/24/14 care plan revealed there were no interventions listed to implement when the resident became anxious or agitated prior to administration of medications. During an interview on 2/12/15 at 10:05 AM, the MDS (Minimum Data Set) Coordinator stated that, due to the disease process of the resident, the facility was coordinating more concerns into one area of the care plan and stated s/he did not know why there was a delay in updating the care plan for the resident. S/he continued by stating a nurse or anyone on the interdisciplinary team could update the care plan. The facility admitted Resident #155 with [DIAGNOSES REDACTED]. Record review on 2/12/15 at approximately 11:00 AM revealed Resident #155 had been placed on a Restorative Nursing Program to "promote active movement of the lower extremities, increase range of motion of the upper extremities and decrease tone of the lower extremities with stretching goals. These can be addressed during morning care three times per week." Review of the 9/18/14 Significant Change Minimum Data Set (MDS) and the Quarterly MDS indicated both lower extremities had impaired function. Review of the 12/24/14 Care Plan revealed there was no plan developed to address range of motion for lower extremity deficits. During an interview on 2/12/15 at approximately 1:00 PM, Restorative confirmed Resident #155 received services for his/her legs 2-5 times per week for approximately thirty minutes. S/he stated that due to the resident's spasms, it was difficult to perform range of motion and the time frame would vary depending on the condition of the resident. On 2/12/15 at approximately 12:30 PM, after reviewing the resident's care plan, Registered Nurse #5 confirmed there was no care plan to reflect restorative services for range of motion. Based on observation, interview and record review, the facility failed to develop a care plan related to contractures for Resident #197. During the staff interview on 2/10/15 at 12:22 PM, the nurse stated Resident #197 had a contracture of the left hand, but refused to use a hand roll. Observation of the resident during the 4 days of the survey revealed a left hand contracture. On 02/10/2015 at 4:22 PM, the resident was observed sitting in a recliner with a left hand contracture with the ring and little fingers turned inward tight toward the palm of the hand. Review of the clinical record on 2/10/15 did not reveal evidence of a care plan addressing contractures. The nurse responsible for creating care plans stated on 2/11/2015 3:09 PM. "I would not usually list a contracture as a separate problem. I would address it in the first disease plan of care or maybe address with ADLs (activities of daily living) that we are treating currently. I typically would address the refusals of hand rolls due to pain, but the rolls have been DC'd (discontinued) so long ago." The coordinator was asked if contractures had been care planned in previous year. S/he stated s/he would look at the resident's purged file. On 02/11/2015 at 2:23 PM, the Unit Manager stated that Resident #197 refused to wear a hand roll. The surveyor questioned care planning for the contracture and the resident's refusals to wear a hand roll. The Unit Manager stated, "There should be a care plan for the contracture and her (his) refusal to wear hand rolls should be noted on the care plan." On 2/11/15 at approximately 2:45 PM the MDS (Minimum Data Set)/Care Plan Coordinator advised the surveyor that s/he had added contracture to the "disease process" care plan. The Director of Nursing (DON) was interviewed on 2/11/15 at approximately 4:20 PM. S/he stated, "We have never care planned contractures as a problem. They are part of a disease process." On 02/12/2015 at 10:53AM, the nurse responsible for creating care plans stated, "Contracture(s) have been addressed in the problem statements and [DIAGNOSES REDACTED]." The facility admitted Resident #378 with [DIAGNOSES REDACTED]. Review of the medical record for Resident #378 on 2/12/2015 at approximately 8:30 AM revealed a Medication Administration Record (MAR) which included "[MEDICATION NAME] 0.25 mg (milligrams) by mouth every 6 hours as needed for 1.) Fidgety, 2.) Restlessness, and 3.) Crying Out." Further review of the MAR for February 11, 2015 revealed Resident #378 received [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg without any of the behaviors present. Review of the Comprehensive Plan of Care for Resident #378 on 2/12/2015 at approximately 8:42 AM revealed no interventions in place to calm the fidgeting, restlessness or alleviate the crying out before administering the as needed medication, [MEDICATION NAME] 0.25 mg. An interview on 2/12/2015 at approximately 9:15 AM with the Director of Nursing confirmed that the Comprehensive Plan of Care did not include any interventions to try and reduce or alleviate Resident #378's anxiety before administering the as needed dose of [MEDICATION NAME]. On 2/12/2015 at approximately 10:34 AM, review of the 1/20/2015 through 2/12/2015 Nurses Notes revealed no behaviors for which the [MEDICATION NAME] 0.25 mg was needed. There was no evidence in the record of interventions attempted prior to administering the anti-anxiety medication. Review of a 1/26/2015 Clinical Summary on 2/12/2015 at approximately 2:05 PM revealed the following: "Complaints/HPI: This patient's multiple [DIAGNOSES REDACTED]."

Based on observations, record reviews and interviews, the facility failed to provide evidence of non-pharmacological interventions attempted prior to administration of psychoactive medication for 4 of 7 sampled residents reviewed for unnecessary medications (Residents #34, #46, #270, #378). The findings included: The facility admitted Resident #34 with [DIAGNOSES REDACTED]. Observations during the survey and review of the 11-12-14 Annual Minimum Data Set Assessment revealed that the resident required extensive to total assistance with all activities of daily living and had functional limitations in both upper and lower extremities. Record review on 2-11-15 at 11:17 AM revealed a 7-9-13 physician's orders [REDACTED]. Give one every 8 hours as needed for anxiety. Record behavior: 1=swinging at staff, 2=kicking at staff, 3=restless, 4=self-inflicted scratches." Review of the 12-14 Medication and Treatment Administration Reports on 2-11-15 at 11:42 AM revealed that Alprazalam was administered on 12-4-14 at 4:28 PM for "scratching self." On 12-5-14 at 5:23 PM, it was given for "restless, pulling...own hair." At 4:20 PM on 12-14-14, Alprazalam was administered for "scratching." On 12-20-14 at 7:56 PM, the medication was given for "hitting and grabbing." On 12-28-14 at 10:06 AM, Alprazalam was given for "hitting/kicking at staff." Review of the 1-15 Medication and Treatment Administration Reports revealed that Alprazalam was administered on 1-11-15 at 11:27 AM for swinging at staff, kicking at staff, and restlessness. On 1-16-15 at 7:41 PM, Alprazalam was given for swinging at staff and restlessness. On 1-24-15 at 4:05 PM, the medication was given for "scratching self." On 1-25-15 at 4:59 PM, the nurse administered Alprazalam for kicking at staff, restlessness, and "scratching self". Review of the 2-15 Medication and Treatment Administration Reports revealed that the medication had been administered on 2-6-15 at 9:16 PM for "hitting." "3 (restless)" and "4 (self-inflicted scratches)" were also noted as behaviors. There was no evidence in the record of assessment/evaluation of the underlying cause of the distressed behavior, no documentation of what was transpiring at the time the behavior occurred, or what interventions were attempted prior to administration of the anti-anxiety medication. Further review revealed physician's orders [REDACTED]. Take one tablet 4 times a day at 9AM, 1PM, 5PM, and 9 PM." "Men-phor Anti-Itch Lotion (Sarna)" was ordered to be applied every shift (7am-7pm) and (7pm-7am). There was no time or frequency specified for the lotion and no evidence that this was attempted prior to administration of the Alprazalam when the reason for administration was "scratching". There was no evidence that an evaluation had been done for an increase in medication or an adjustment in medication times to coincide with any behavior patterns. Review of Social Services notes on 2-12-14 at 10:58 AM revealed that the resident's behaviors occurred "usually when they (the staff) are performing care." During an interview on 2-11-15 at 12:35 PM, Licensed Practical Nurse (LPN) #1 stated that the Alprazalam was given "when (Resident #34) gets anxious, scratches self, or hits staff." S/he stated they "would try other things before meds." The nurse stated that s/he would "sit and talk-just sit with (her/him) and hold (her/his) hand. Sometimes it works, sometimes not. Singing works. Lotion helps." When asked how the surveyor would know what interventions had been attempted prior to medication administration, LPN #1 stated, "It would be documented on the MAR (Medication Administration Record) and in the Nurses Notes." She also stated, "It should be on the care plan." On 2-11-15 at 3 PM, review of the Care Plan with the Unit Manager (Director of Nurses in attendance) revealed no specific individualized planned interventions to be attempted prior to psychoactive medication administration. Administration of Alprazalam on an "as needed" basis for anxiety was added to a problem of "Complications, at risk for -related to disease process of: . . . [MEDICAL CONDITION]. . . Dementia..." Another problem indicated that Resident 34 "is known to be combative with staff during ADL's." The only intervention related to exhibited behaviors during care stated:" If (Resident #) resists care or is combative leave and return at a later time to attempt care." The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Review of the 12-29-14 MDS revealed that the resident's Brief Interview for Mental Status score was "8", indicating moderate cognitive impairment. Record review at 4:17-PM on 2-10-15 revealed a 9-26-14 physician's orders [REDACTED]. May take one tab every 8 hours as needed. 1=crying out, 2=combativeness, 3=restlessness." Review of the 12-14, 1-15, and 2-15 Medication and Treatment Administration Reports on 2-11-15 at 10:28 AM revealed that [MEDICATION NAME] was administered on 12-6-15 at 4:46 PM, 12-8-14 at 7:30 PM, 1-4-15 at 7:51 PM, and 2-2-15 at 7:40 PM for "restlessness". No specific behaviors were noted. Review of Nurses Notes on 2-10-15 at 5:13 PM revealed no reference to behaviors or administration of [MEDICATION NAME] on those dates. The 12-7-14 Monthly Summary noted the resident "(with) episodes of'panic attacks' -does have PRN [MEDICATION NAME] O.5 mg ordered. No inappropriate behaviors or feelings of anxiety this shift." There was no evidence in the record of assessment/evaluation of the underlying cause of the resident's distress, no documentation of what was transpiring at the time the restlessness occurred, or what interventions were attempted prior to administration of the anti-anxiety medication. Minimally, there was no evidence of pain assessment, blood sugar, or oxygen saturation (which were care planned to be done every shift). Review of the Care Plan on 2-10-15 at 4:30 PM revealed no specific individualized planned interventions to be attempted prior to psychoactive medication administration. Administration of [MEDICATION NAME] was noted related to a problem of "Complications, at risk for -related to disease process of: [MEDICAL CONDITIONS]...DM, Dementia,...Arthritis,[MEDICAL CONDITION]" There was no problem listed related to anxiety, restlessness, or behaviors. During an interview on 2-11-15 at 12:35 PM, LPN #1 was unaware that Resident #46 received [MEDICATION NAME] on a PRN basis because s/he had never given it. After reviewing the MAR, LPN # I stated that the [MEDICATION NAME] was always given in the evening. "I think (s/he) gets more anxious in the evenings. (S/he) wants to go home. During the day, there's a lot of activities going on and (the resident) doesn't notice." S/he stated that before administering the medication, the nurses should attempt other interventions and that this information would be found on the MAR and in the Nurses Notes. The nurse also stated, "It should be on the care plan." The facility admitted Resident #270 with [DIAGNOSES REDACTED]. Record review on 2/11/15 at approximately 11:00 AM revealed Physician order [REDACTED]." Review of the Medication and Treatment Administration Report revealed [MEDICATION NAME] had been administered December 1, 9, 16, 25, and 27, 2014 and on January 10 and 23, 2015 related to anxiety, agitation, and wandering. Review of the Nurse's Notes revealed that on December 1, 2014, the resident was placed on 1:1 supervision for attempting to ambulate. No other interventions were noted in the Nurse's Notes as attempted for the other dates/times prior to administration of the [MEDICATION NAME]. Review of the Medication, Treatment and Task Administration Report (IMAR) for December 2014 and January 2015 did not list any interventions attempted prior to administering the [MEDICATION NAME]. Review of the Psychoactive Medication Therapy 'Evaluation Form for January 2015 revealed that it did not list [MEDICATION NAME] or any other interventions. Review of the pharmacy recommendations revealed a 12/18/14 recommendation to begin psych behavior monitoring in the IMAR, list specific behaviors the resident was expressing, and to list non-drug interventions when needed. This was also recommended on 1/21/15. During an interview on 2/11/15 at approximately 11:00 AM, the Director of Nursing stated behaviors were not documented on the IMAR. The facility admitted Resident #378 with [DIAGNOSES REDACTED]. Observations on 2/9/2015 at 3:07 PM and on 2/10/2015 at 9:38 AM revealed Resident #378 in bed, in pajamas, sleeping. Multiple attempts were made to interview Resident #378, but s/he was not observed out of the bed or awake at any time on 2/9/2015 or 2/10/2015. Review of the medical record for Resident #378 on 2/12/2015 at approximately 8:30 AM revealed a Medication Administration Record (MAR) which included "[MEDICATION NAME] 0.25mg (milligrams) by mouth every 6 hours as needed for 1.) Fidgety, 2.) Restlessness, and 3.) Crying Out." Further review of the MAR for February 11, 2015 revealed Resident #378 received [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg without any of the behaviors present. Further review of the MAR for Resident #378 revealed [MEDICATION NAME] 0.5 mg was administered routinely at 8:00 AM and 8:00 PM. Review of the Comprehensive Plan of Care for Resident #378 on 2/12/2015 at approximately 8:42 AM revealed no interventions in place to calm the fidgeting, restlessness or the crying out before first administering the as needed medication. Review of the 1/20/2015 through 2/12/2015 Nurses Notes on 2/12/2015 at approximately 10:34 AM revealed no behaviors for which the [MEDICATION NAME] 0.25 mg was needed. No documentation could be found in the record that Resident #378 had exhibited any of the fidgeting, restlessness or the crying out behaviors.. Review of a 1/26/2015 Clinical Summary on 2/12.2015 at approximately 2:05 PM revealed under the following: "Complaints/HPI: This patient's multiple [DIAGNOSES REDACTED]."

Based on observations, interviews and review of the facility policy entitled "Medication Storage in the Facility", the facility failed to ensure expired medications were removed from current storage on one of three medication carts on 1 of 3 units and further failed to ensure an expired prescription creme was removed from 1 of 3 treatment carts (one per unit). The findings included: An observation on 2/9/2015 at approximately 12:35 PM revealed a back hall medication cart on the Jasmine Unit with only 4 tablets left on a card of Oxycontin 40 mg (milligrams) lot #WTK32, manufactured by Purdue, which had expired on 1/25/2015. During an interview on 2/9/2015 at approximately 12:25 PM, Registered Nurse (RN) #1 confirmed the expiration date of 1/25/2015 and stated, "I just checked those and did not notice the date to be expired." During an interview on 2/9/2015 at approximately 2:55 PM, Pharmacy Representative #1 stated, "Purdue, the manufacturer for the medication Oxycontin with Lot #WTK32, has verified the medication expiration date should read February 2016." S/he further stated, "The medication was labeled incorrectly by the pharmacy." Review of a statement from Purdue Pharma LP on 2/10/2015 at approximately 12:15 PM revealed: "We are responding to your request for information regarding OxyContin (oxycodone hydrochloride extended-release tablets). Specifically, you (Pharmacy Representative #1) requested the expiration date for OxyContin Lot# WTK32. The expiration date for Lot# WTK32 is 2/2017." The expiration date furnished by the manufacturer did not match with either expiration date furnished by the pharmacy. Review of the policy, "Medication Labels," revealed: "1. Each prescription medication label includes: ...K. Expiration Date... 2. Improperly labeled medications are rejected and returned to the supplier. 3. The provider pharmacy permanently affixes labels to the outside of prescription containers. 6. Only the pharmacist may place a label on the medication container." An observation of the treatment cart on the Jasmine Hall on 2/10/2015 at approximately 10:30 AM revealed 1 bottle of Men-Phor Anti Itch Lotion for topical use, manufactured by Geritrex Corporation with Lot # 9, had expired on 4/2009. During an interview on 2/10/2015 at approximately 10:30 AM, RN #3, Nurse Supervisor of the Jasmine Hall, confirmed the Men-Phor Anti Itch Lotion had expired on 4/2009. Review of the facility policy entitled "Medication Storage in the Facility" revealed: "Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists." During an interview with Pharmacy Consultant #2 on 2/10/2015 at approximately 4:05 PM, the surveyor asked, "What would you expect the nurse to do when giving a medication that had an expired date on the label?" The pharmacist stated, "I would expect the nurse to contact the pharmacy for verification before giving the medication."