Every finding on record at NHC Healthcare, Scott

Based on policy review, record review, facility document, and interview, the facility failed to submit a five-day investigative summary to the State related to an allegation of neglect for 1 (Resident #1) of 3 sampled residents reviewed for abuse/neglect. Findings included: 1. A review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, with an original date of 08/01/2001 and revised date of 2023, revealed, It is the policy of this facility that 'abuse' allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. 2. Medical record review of the Resident Face Sheet revealed the facility admitted Resident #1 on 04/25/2022, with diagnoses that included Conduct Disorder, Cognitive Communication Deficit, Mild Vascular Dementia with Mood Disturbance, and Recurrent Severe Major Depression with Psychotic Symptoms. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2022, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with toilet use and was frequently incontinent of bowel and bladder. Review of an incident report dated 08/22/2022, indicated on 08/20/2022, Resident #1 informed a certified nursing assistant of an allegation of neglect. Per the incident report, the resident stated their incontinence brief had not been changed since 08/19/2022. A review of facility documents revealed no evidence a five-day investigative summary report had been submitted to the state agency. During an interview on 10/13/2023 at 3:18 PM, the Director of Nursing (DON) said the Administrator was responsible for reporting issues to the state agency. During an interview on 10/12/2023 at 4:47 PM, the Administrator stated he reported Resident #1's concerns to Adult Protective Services (APS), the state agency, the local police department, and the Ombudsman. The Administrator stated he had not filed a five-day report with the state because APS investigated and stated there were no issues, and because the allegations were unsubstantiated. In a follow-up interview on 10/13/2023 at 5:29 PM, the Administrator stated he was unaware a five-day report had to be submitted to the state agency.

Based on Centers for Disease Control and Prevention (CDC) guidelines, policy review, Work Summary Report review, Screening Log review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained to ensure all staff who enter the facility completed the screening process for the prevention and potential spread of COVID-19 when 26 of 174 staff members (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, #2, #3, and #4, Respiratory Therapist (RT) #1, Social Worker #1, Maintenance #1, Receptionist #1 and #2, Physical Therapist Assistant (PTA) #1, #2, and #3, Occupational Therapist Assistant (OTA) #1 and #2, Physical Therapist (PT) #1, Certified Nursing Assistant (CNA) #1, #2, #3, #4, and #5, Temporary Nurse Assistant (TNA) #1 and #2, and Dietary Staff #1, #2, and #3) failed to complete the screening log prior to working 4 of 6 days (3/1/2022, 3/4/2022, 3/5/2022, and 3/6/2022) reviewed; and when 1 of 3 nurses (LPN #5) failed to perform hand hygiene for 1 of 4 sampled residents (Resident #32) observed during medication (med) administration. This had the potential to affect the 56 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) guidelines document titled, Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so they can properly manage .a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 .symptoms of COVID-19, or .who meets criteria for quarantine or exclusion from work .Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility . Review of the facility's Staff/Visitor/Vendor Screening Log and the facility's Work Summary Report dated from 3/1/2022-3/6/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 3/1/2022 - TNA #1, OTA #1 and #2, PTA #1, #2, and #3, and Dietary Staff #3. b. 3/4/2022 - LPN #1, #2, and #3, Maintenance #1, CNA #1, PTA #1 and #3, OTA #1, and Dietary Staff #1 and #2. c. 3/5/2022 - LPN #4, CNA #2 and #3, TNA #2, and Receptionist #1. d. 3/6/2022 - Social Worker #1, RT #1, LPN #4, PT #1, PTA #2, CNA #4 and #5, TNA #1, and Receptionist #1 and #2. During an interview on 3/16/2022 at 3:05 PM, the Infection Preventionist was asked about the staff failing to screen prior to entering the facility. The Infection Preventionist stated, .I audit weekly or twice a week .I don't know how I failed to catch those staff that didn't screen .I think it has to do with the time clock . Review of the facility's undated policy titled, Hand Washing and Hand Sanitizer, revealed .Hand hygiene is the primary means to prevent the spread of infection .Wash or sanitize hands after removal of gloves . Review of the facility's policy titled, Administration Procedures for All Medications, dated 1/1/2019, revealed .Cleanse hands .before beginning a med pass, before handling medication, and before contact with a resident . Observation at the 100 Hall Medication Cart on 3/15/2022 at 8:12 AM, revealed LPN #5 failed to perform hand hygiene before she prepared Resident #32's medications. LPN #5 disposed of the medication packages in a trash bag, touching the inside of the trash bag with her bare hands. LPN #5 failed to perform hand hygiene before she removed the cap to Resident #32's eye medication. Observation at the 100 Hall Medication Cart on 3/15/2022 at 11:56 AM, revealed LPN #5 failed to perform hand hygiene, donned gloves and cleaned the blood glucose meter. LPN #5 doffed her gloves and donned clean gloves without performing hand hygiene. LPN #5 went to Resident #32's room, wearing the same gloves, and checked the resident's blood glucose. LPN #5 did not remove her gloves, perform hand hygiene, and don clean gloves prior to checking the resident's blood glucose level. Observation at the 100 Hall Medication Cart on 3/15/2022 at 12:12 PM, revealed LPN #5 failed to perform hand hygiene and prepared insulin. LPN #5 did not perform hand hygiene, donned clean gloves, went to Resident #32's room, and administered the insulin. During an interview on 3/16/2022 at 1:30 PM, the Director of Nursing (DON) confirmed staff should wash their hands prior to administering medications.

Based on policy review, observation, and interview, the facility and failed to ensure meal trays were served under sanitary conditions when 3 of 7 (Certified Nursing Assistant (CNA) # 1, #2, and #3) staff members failed to perform proper hand hygiene during dining. The findings include: The facility's undated Hand Washing and Hand Sanitizer policy documented, .Hand hygiene is the primary means to prevent the spread of infection . Observations in Resident #3's room on 4/29/19 at 11:57 AM, revealed CNA #1 delivered Resident #3's meal tray into her room. CNA #1 repositioned Resident #3. CNA #1 and CNA #2 then pulled Resident #3 up in the bed. CNA #1 opened the meal tray, poured Resident #3's milk, touched items on the tray, opened Resident #3's straw, touched the straw with his bare hands, and inserted it into Resident #3's drink without performing hand hygiene. Observations in Resident #5's room on 4/30/19 at 7:32 AM, revealed CNA #3 delivered Resident #5's meal tray, moved a garbage can, then set up the meal tray, and stirred the food with the utensils, without performing hand hygiene. Observations in Resident #21's room on 4/30/19 at 7:39 AM, revealed CNA #3 delivered Resident #21's meal tray, pulled Resident #21 up in the bed, opened the silverware, opened the juice, and put the straw into the juice, without performing hand hygiene. Observations in Resident #23 and Resident #6's room on 4/30/19 at 8:01 AM, revealed CNA #3 and CNA #2 pulled Resident #23 up in the bed. CNA # 2 then removed her gloves and went to Resident #6 and set up her meal tray, opened her jelly and spread it on her food, opened the juices, opened the straw and put it into Resident #6's drink, without performing hand hygiene. Observations in Resident #303's room on 4/30/19 at 8:05 AM, revealed CNA #3 delivered Resident #303's meal tray, raised the head of the bed, adjusted Resident #303's oxygen on her face, moved a cord on the floor under the bed, moved the over-bed table in front of the resident, opened and sprinkled sweetener over the food, opened the carton of milk, opened the straw and put it into the drink, without performing hand hygiene. Interview with the Director of Nursing (DON) on 4/30/19 at 9:36 AM, in the Community Room, the DON was asked if it was appropriate to reposition residents, touch articles in the room such as garbage cans and things on the floor, then set up meal trays without performing hand hygiene. The DON stated, They should perform hand hygiene before setting up the tray.

Based on policy review, medical record review, observation, and interview the facility failed to store an ice scoop under sanitary conditions for 1 of 2 (200 Hall) ice storage areas and failed to ensure practices were followed to maintain infection control for 1 of 1 (Resident #25) sampled residents observed during perineal care. The findings include: 1. The facility's Safety & (and) Sanitation Best Practice Guidelines policy dated 11/2017 documented .the handle of the scoop must be stored so that it does not touch the ice . 2. Observations in the 200 Hall nourishment room on 4/29/19 at 11:30 AM and at 3:39 PM, revealed the ice scoop was stored inside the portable ice bin on top of the ice. Interview with the Director of Nursing (DON) on 4/30/19 at 11:40 AM. in the 100 Hall, the DON was asked if it was acceptable for the ice scoop to be stored inside the ice bin. The DON stated, No. 3. The facility's undated Perineal Care policy documented, .To provide cleanliness and comfort to the patient .prevent infections .Remove gloves and discard. Wash and dry your hands . 4. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #25's room on 4/29/19 at 11:37 AM, revealed Certified Nursing Assistant (CNA) #2 provided perineal care to Resident #25. CNA #2 did not remove the soiled gloves used during the perineal care. After performing the perineal care, CNA #2 assisted the resident to sit on the bedside, took the resident's hairbrush, and began brushing and touching Resident #25's hair. Interview with the DON on 4/30/19 at 9:36 AM, in the Community Room, the DON was asked if it was appropriate to perform perineal care and wear the same gloves to brush a resident's hair. The DON stated, No.

Based on policy review, observation and interview, the facility failed to ensure the environment was free from accident hazards as evidenced by unsecured and accessible chemicals and needles stored in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's .Storage of Hazardous Chemicals policy documented, Hazardous chemicals are to be stored out of the reach of patients. Examples of hazardous materials are .[MEDICATION NAME] . 2. The facility's .EQUIPMENT AND SUPPLIES FOR ADMINISTERING MEDICATIONS policy documented, .The following equipment and supplies are .maintained by the facility for the proper storage, preparation and administration of medication .needles . 3. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed a bottle of nail polish remover ([MEDICATION NAME]), 4 bottles of shave cream labeled Keep out of Reach of Children, 5 bottles of anti-perspirant deodorant labeled, Keep out of Reach of Children, 3 denture cleanser tablets, (9) 24-gauge needles, and (2) 23-gauge needles, all unsecured. Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the nail polish remover, the items labeled Keep out of reach of children, or the needles. The DON stated, No. The DON confirmed the chemicals and sharps were not secured.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 1 (Clean Utility Room) clean utility rooms. The findings included: 1. The facility's MEDICATION STORAGE IN THE FACILITY policy documented .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . 2. Observations in the unlocked Clean Utility Room on 6/18/18 at 6:45 AM, 7:43 AM, 12:19 PM, and 2:34 PM, revealed 5 unsecured syringes containing 5 milliliters of [MEDICATION NAME] 100 units/milliliter (an anticoagulant medication). Interview with the Director of Nursing (DON) on 6/18/18 at 2:42 PM, in the Clean Utility Room, the DON was asked if the residents should have access to the [MEDICATION NAME] syringes. The DON stated, No. The DON confirmed the medication was not secured.

Based on policy review, observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by black sticky buildup on a skillet, expired food and staff members observed in the kitchen with hair not completely covered on 2 of 3 (7/6/16 and 7/7/16) days of the survey. The facility had a census of 55 with 53 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's MANUAL WARE WASHING documented, .Use a brush, cloth, or scrubber to loosen remaining soil . Observations in the kitchen on 7/6/16 at 3:20 PM, revealed black sticky build up on a large skillet. Observations in the kitchen on 7/6/16 at 3:25 PM, revealed 4-bags of 48 ounce (oz) cheese cake bake with best by date of 30 June 2016. Interview with the Dietary Manager (DM) on 7/6/16 at 3:22 PM, in the kitchen, the DM was shown the dirty skillet and was asked should the skillet look like this. The DM stated, .looks like we didn't get it cleaned good . The DM was shown the expired cheese cake bake mix and was asked should there be expired food in the kitchen. The DM stated, No, Ma'am . 2. The facility's HYGIENIC & SAFETY PRACTICES policy documented, .Dietary partners shall wear hair restraints .that are designed and worn to effectively keep their hair from contacting exposed food . Observations in the kitchen on 7/6/16 at 9:25 AM, revealed the Dietary Manager (DM), Dietary Staff #1 and Dietary Staff #2 standing in the kitchen with their hair not completely covered. Observations in the kitchen on 7/6/16 at 4:50 PM, revealed Dietary Staff #3 with her hair not completely covered while she was preparing plates to be served to residents. Observations in the kitchen on 7/6/16 at 5:00 PM, revealed the DM and Dietary Staff #4 standing in the kitchen with their hair not completely covered. Observations in the kitchen on 7/7/16 at 1:15 PM, revealed the DM, Dietary Staff #1 and Dietary Staff #2 standing in the kitchen with their hair not completely covered. Interview with the DM on 7/7/16 at 1:45 PM, in the DM's office, the DM was asked should hair be completely covered while in the kitchen. The DM stated,Yes . The DM confirmed that her hair had not been completely covered. The DM was asked should there be expired foods in the kitchen. The DM stated, No .I have work to do . Interview with the Administrator on 7/7/16 at 1:48 PM, in the DM's office, the Administrator was asked if he expected the staff's hair to be completely covered while in the kitchen. The Administrator stated,Yes . The Administrator was asked if it was acceptable for staff's hair not to be completely covered. The Administrator stated, No, Ma'am . The Administrator was asked should there be expired foods in the kitchen. The Administrator stated, No .

Based on policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed by 1 of 3 (Registered Nurse (RN) #1) nurses during medication administration. The findings included: 1. The facility's EYE DROP ADMINISTRATION policy documented, .Do NOT let tip of dropper touch the eye . 2. Medical record review revealed Resident #205 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].ARTIFICIAL TEARS 1.4 % (percent) DROPS .TWO (2) DROPS BOTH EYES FOUR TIMES A DAY . Observations in Resident #205's room on 7/6/16 at 8:14 AM, revealed RN #1 administered 1 drop of Artificial Tears to Resident #205's right eye, touching the tip of the dropper to Resident #205's conjunctiva and lashes. Observations in Resident #205's room on 7/6/16 at 8:22 AM, revealed RN #1 administered 1 drop of Artificial Tears to Resident #205's left eye, touching the tip of the dropper to Resident #205's conjunctiva and lashes. Interview with the Director of Nursing (DON) on 7/7/16 at 1:38 PM, in the Community Room, the DON was asked if it was acceptable for the tip of the dropper to touch the eye during eye drop administration. The DON stated, No Ma'am.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 1 of 2 (Staff Member #1) staff members served food from the steam table in the fine dining room without wearing a hair restraint over his mustache. This could potentially affect 11 residents eating in the dining room. The facility had a census of 44 residents. The findings included: The facility's Safety & (and) Sanitation Best Practice Guidelines policy documented, .Hair Restraints. (a) Dietary partners shall wear hair restraints such as hats, hair covering or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. Observations in the fine dining room on 7/14/15 at 4:35 PM, revealed Staff Member #1 served food from behind the fine dining room steam table without wearing a cover over his mustache. Interview with the Dietary Manager (DM) on 07/14/15 at 5:20 PM, in the kitchen, the DM was asked if Staff Member #1 should have his mustache covered while serving food from the steam table. The DM stated, Yes, that's considered part of the beard and it should be covered too.

Based on policy review, medical record review and interview, the facility failed to ensure neurological (neuro) assessments were completed and documented as ordered for 1 of 17 (Resident #223) sampled residents of the 34 residents reviewed in the stage 2 review. The findings included: The facility's Neurological Checks policy documented, .To do neurological checks-Incidents/accidents with possible head injury(.) Initial assessment followed by, every hour times 3 hours followed by. Review of the medical record revealed Resident #223 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A post fall nursing assessment dated [DATE] documented, .Date and time of incident: 7/13/15 9:45 AM. Pain following the fall? Y (Yes). Pain location: HEAD. Description of injury. (Resident #223) C/O (complained of) HEADACHE. Head Injury - Neurological: Yes (If yes, initiate neuro checks). Review of a neurological flowsheet dated 7/13/15 at 10:00 AM (Immediate assessment), 11:00 AM (1 hour post fall) and 12:00 PM (2 hours post fall), the assessments for the right and left pupil size and the right pupil reaction were blank, indicating the assessment for the pupils was incomplete. There was no neurological assessment documented on 7/13/15 at 1:00 PM (3 hours post fall). Review of a neurological flowsheet dated 7/13/15 at 10:00 PM, 4:00 AM and 7/15/15 at 1:00 AM revealed the neuro assessments for EYES OPEN were documented with a checkmark for 3 responses: (a) spontaneously, (b) to speech, and (c) to pain. Telephone interview with Registered Nurse (RN) #1 on 7/15/15 at 8:31 AM, RN #1 was asked, Did you do neuro checks? RN #1 stated, Yes. RN #1 was then asked, Tell me the policy regarding how often you should do neuro checks after a fall? RN #1 stated, Every hour for 3 hours, then I'm not sure how often they are after that. Interview with RN #2 on 7/15/15 at 9:28 AM, at the 200 hall nurses station, RN #2 was asked, What was the policy for neuro checks. RN #2 stated, Neuro checks are done every hour times 3, then every shift for 72 hours. Interview with the Director of Nursing (DON) on 7/15/15 at 1:45 PM in the community room, the DON was asked if Resident #223's neuro checks were done according to facility policy. The DON stated, On neuro checks, her initial assessment would be from her assessment when she originally fell . She fell at 9:45 (AM). I guess she (RN #1) documented the initial neuro check at 10 (10:00 AM). The DON was asked, How many hourly neuro checks would you expect to be done after the initial neuro check? The DON stated, 3. The DON was asked, Were there 3 neuro checks documented after the initial neuro assessment? The DON shook her head no. The DON was asked Is this neuro check documentation accurate for (Named Resident #223's) eyes to open spontaneously, to speech, and to pain? DON stated, No, they should be rated in only one of those areas. The DON was asked if the right pupil size and the right and left pupil reactions (to light) were documented on the neuro flowsheet. The DON stated, No, but they should be.

Based on policy review, medical record review and interview, the facility failed to ensure documentation was correct and/or complete for a post fall neurological (neuro) assessment for 1 of 17 (Resident #223) sampled residents of the 34 residents reviewed in the stage 2 review. The findings included: The facility's Neurological Checks policy documented, .To do neurological checks-Incidents/accidents with possible head injury(.) Initial assessment followed by, every hour times 3 hours followed by. Review of the medical record revealed Resident #223 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A post fall nursing assessment dated [DATE] documented, .Date and time of incident: 7/13/15 9:45 AM. Pain following the fall? Y (Yes). Pain location: HEAD. Description of injury. (Resident #223) C/O (complained of) HEADACHE. Head Injury - Neurological: Yes (If yes, initiate neuro checks). Review of a neurological flowsheet dated 7/13/15 at 10:00 AM (Immediate assessment), 11:00 AM (1 hour post fall) and 12:00 PM (2 hours post fall), the assessments for the right and left pupil size and the right pupil reaction were blank, indicating the assessment for the pupils was incomplete. There was no neurological assessment documented on 7/13/15 at 1:00 PM (3 hours post fall). Review of a neurological flowsheet dated 7/13/15 at 10:00 PM, 4:00 AM and 7/15/15 at 1:00 AM revealed the neuro assessments for EYES OPEN were documented with a checkmark for 3 responses: (a) spontaneously, (b) to speech, and (c) to pain. Telephone interview with Registered Nurse (RN) #1 on 7/15/15 at 8:31 AM, RN #1 was asked, Did you do neuro checks? RN #1 stated, Yes. RN #1 was then asked, Tell me the policy regarding how often you should do neuro checks after a fall? RN #1 stated, Every hour for 3 hours, then I'm not sure how often they are after that. Interview with RN #2 on 7/15/15 at 9:28 AM, at the 200 hall nurses station, RN #2 was asked, What was the policy for neuro checks. RN #2 stated, Neuro checks are done every hour times 3, then every shift for 72 hours. Interview with the Director of Nursing (DON) on 7/15/15 at 1:45 PM in the community room, the DON was asked if Resident #223's neuro checks were done according to facility policy. The DON stated, On neuro checks, her initial assessment would be from her assessment when she originally fell . She fell at 9:45 (AM). I guess she (RN #1) documented the initial neuro check at 10 (10:00 AM). The DON was asked, How many hourly neuro checks would you expect to be done after the initial neuro check? The DON stated, 3. The DON was asked, Were there 3 neuro checks documented after the initial neuro assessment? The DON shook her head no. The DON was asked Is this neuro check documentation accurate for (Named Resident #223's) eyes to open spontaneously, to speech, and to pain? DON stated, No, they should be rated in only one of those areas. The DON was asked if the right pupil size and the right and left pupil reactions (to light) were documented on the neuro flowsheet. The DON stated, No, but they should be.

Based on policy review, review of resident council meeting minutes and interview, it was determined the facility failed to follow up on the resident council's concerns for 2 of 4 (August 2013 and February 2014) months of resident council meeting minutes reviewed. The findings included: 1. Review of the facility's "RESIDENT COUNCIL SUGGESTIONS" policy documented, "...All concerns voiced by patients are to be written in the minutes, and if action is required it should be reported as well..." 2. Review of the "Patient Council Minutes" dated August 2013 documented, "...patients voiced concerns... about the lack of the hydration cart in the afternoon, and want to have churches visit on Sunday afternoons..." The facility was unable to provide documentation of a follow up documented for these concerns noted. 3. Review of the "Patient Council Minutes" dated February 2014 documented, "...Concerns voiced were... complaints about having too much chicken on the menu..." The facility was unable to provide documentation of a follow up documented for the concern noted. 4. During an interview in the 200 hall on 4/22/14 at 8:45 AM, the Recreation Coordinator (RC) was asked when the meetings are held. The RC stated, "We try to have them right after activity because everybody is gathered and we discuss concerns." The RC was then asked what is the process for resolving concerns by the residents. The RC stated, "I take the concerns to the department head meetings and the issues are resolved." The RC was asked if she followed up in the meetings with the residents or if she documented this follow up. The RC stated, "No, I don't document it..." During an interview in Resident #65's room on 4/22/14 at 4:00 PM, Resident #65 was asked if there is any follow up to resident concerns that are voiced in the resident council meetings. Resident #65 stated, "No."

Based on medical record review and interview, it was determined the facility failed to update the care plan with interventions for aftercare of a shoulder fracture and sling or for a fall for 2 of 16 (Residents #109 and 178) sampled residents of the 28 residents included in the stage 2 review. The findings included: 1. Medical record review for Resident #109 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. a. 4/6/14 - "...WEAR SLING TO RIGHT SHOULDER TILL (until) SEEN BY ORTHO (orthopedic) MD (Medical Doctor)..." b. 4/8/14 - "...ADD DIAGNOSES.. .IMPACTION FRACTURE - GLENOID NECK, RIGHT SHOULDER..." Review of the "Complete Patient's Care Plan" dated 2/27/14 with revisions dated 4/9/14 documented, "...Problem... Fall risk/Safety... Goal... will remain free from significant injury r/t (related to) falls..." The care plan was not revised to reflect the sling or care for the fracture. During an interview in the community room on 4/22/14 at 4:25 PM, the Director of Nursing (DON) was asked if care of the broken shoulder or the sling should be addressed on the care plan. The DON stated, "It's not on here. Yes, it should be." 2. Medical record review for Resident #178 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Post Falls Nursing Assessment" dated 4/19/14 at 8:00 PM, documented "CNA (certified nursing assistant) FOUND PT ON FLOOR BESIDE HER BED..." Review of the care plan dated 4/17/14 documented, "...Safety.. .has several fall risk factors present... history of falls..." The care plan was not revised to reflect an intervention for the fall that occurred on 4/19/14.

Based on review of the "MED-PASS COMMON INSULINS" provided by the American Consultant Pharmacists, policy review, medical record review, observation, and interview, it was determined the facility failed to ensure that 1 of 5 (Nurse #3) nurses administered medications without a significant medication error. Nurse #3 failed to administer insulin within the proper time frame related to meals for Resident #132. The findings included: Review of the "MED-PASS COMMON INSULINS: Pharmocokinetics, Compatibility, and Properties" provided by the American Society of Consultant Pharmacists for typical dosing administration of insulin related to meals documented, "[MEDICATION NAME] R (regular)... ONSET (In Hours, Unless Noted)... 0.5- (to) 1... TYPICAL DOSING / COMMENTS... 30 MINUTES BEFORE MEALS..." Review of the facility's "Insulin Administration" policy documented, "[MEDICATION NAME] R or [MEDICATION NAME] R Sliding Scale Insulin ordered based on before meals (AC) fingerstick will be given within a time range of no greater than 30 minuets before a meal throu (through) no later than 30 minutes post consumption of the meal..." Medical record review for resident #132 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]...11/15/12: FSBS (fingerstick blood sugar) BEFORE MEALS & AT BEDTIME W (with) / [MEDICATION NAME] R SSI (sliding scale insulin)... 161-200= (amount of insulin to administer) 2 UNITS..." Observations in Resident #132's room on 1/23/13 at 11:10 AM, Nurse #3 performed a fingerstick for blood sugar which resulted in a reading of 193. Nurse #3 administered 2 units of [MEDICATION NAME] R subcutaneously to Resident #132 at 11:15 AM. Resident #132 did not receive the lunch tray until 11:55 AM. The administration of the insulin 40 minutes before lunch was served resulted in a significant medication error. During an interview in the Director of Nursing's (DON) office on 1/25/13 at 9:30 AM, the DON was asked when should a meal be served after a resident received Regular insulin. The DON stated, "No greater than 30 minutes before the meal and no later than 30 minutes after the meal."

Based on policy review, observation and interview, it was determined the facility failed to consistently monitor medication storage refrigerator temperatures in 2 of 2 (100 hall and 200 hall) medication storage refrigerators and failed to remove expired medications from 1 of 4 (100 hall medication storage room) medication storage areas. The findings included: 1. Review of the facility's "Medication Storage In the Facility" policy documented, "...Medications requiring "refrigeration" or "temperatures between 2 (symbol for degrees) C (celsius) (36 (symbol for degrees) F (Fahrenheit) ) and 8 (symbol for degrees) C (46 (symbol for degrees) F)" are kept in a refrigerator with a thermometer to allow temperature monitoring..." Review of the 100 hall refrigerator temperature log for January 2013 had no temperature recorded on 1/4/13, 1/7/13, 1/8/13, 1/9/13, 1/10/13, 1/20/13, and 1/22/13. Review of the 200 hall refrigerator temperature log for January 2013 had no temperature on 1/13/13. During an interview at the 100 hall medication cart on 1/24/13 at 9:15 AM, Nurse #1 was asked if the staff was to check the medication refrigerator temperatures and record them daily. Nurse #1 confirmed that the refrigerator temperatures had not been recorded as they should have been. During an interview in the Director of Nursing (DON) office on 1/25/13 at 9:30 AM, the DON was asked who is responsible for checking temperatures of the medication storage refrigerators and should the temperatures be checked and recorded on a daily basis. The DON stated, "The licensed nurses are to check the temperatures daily and they should be recorded." 2. Observations in the 100 hall medication storage room on 1/24/13 at 9:05 AM, revealed 3 bottles of 325 milligram Buffered Aspirin tablets stored past the expiration date of 11/2012. During an interview in the 100 hall medication storage room on 1/24/13 at 9:07 AM, Nurse #2 was asked to confirm the expiration dates on the 3 bottles of aspirin. Nurse #2 stated, "They (3 bottles of aspirin) have not been opened but they are expired." Nurse #1 was asked should you have expired medications in your medication storage area. Nurse #1 stated, "No we should not." During an interview in the Director of Nursing (DON) office on 1/25/13 at 9:30 AM, the DON was asked should the facility store expired medications in the medication storage cabinets. The DON stated, "No it (expired medications) shouldn't (be stored in the medication storage room)..."

Based on medical record review and interview, it was determined the facility failed to accurately assess residents with pressure ulcers for 1 of 15 (Resident #163) sampled residents reviewed of 27 residents included in the Stage 2 review. The findings included: Medical record review for Resident #163 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #163 had "0 ...E. ...Number of unstageable pressure ulcers due to non-removable dressing/device, 0 ...F. ...Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar...0... G...Number of unstageable pressure ulcers with suspected deep tissue injury in evolution..." Review of the "Admission Nursing Assessment Report" dated 10/14/2011 documented an unstageable pressure ulcer to right buttock. During an interview at the 100 hall nurses' station on 10/31/2011 at 2:15 PM, Nurse #1 stated "(Resident #163) had an unstageable wound on her right buttock on admission..." During an interview in the community room on 11/2/11 at 10:00 AM, Nurse #3 stated, "...her (Resident #163's) unstageable wound was actually a purplish spot on her right buttock..." During an interview in the community room on 11/2/11 at 11:00 AM, the Director of Nursing (DON) stated, "Yes, it (the nursing admission assessment) looks like it says an unstageable (pressure ulcer to right buttock)..." During an interview in the community room on 11/2/11 at 1:30 PM, the DON stated, "...the Unstageable (wound) is not coded in the MDS, the MDS is incorrect..." During an interview in the community room on 11/3/11 at 9:20 AM, Nurse #2 was asked if the admission MDS was correctly coded for unstageable pressure ulcers for Resident #163. Nurse #2 stated, "No...it (the MDS) is incorrect and I will have to do a correction..."

Based on medical record review and interview, it was determined the facility failed to ensure 1 of 10 (Resident #161) sampled residents reviewed of 27 residents included in the Stage 2 review were free from unnecessary medication use. The findings included: Medical record review for Resident #161 documented an admission date of [DATE] with diagnoses of [MEDICAL CONDITIONS] with Right [MEDICAL CONDITION], Hypertension, Left Carotid Artery Disease, [MEDICAL CONDITION], History of [MEDICAL CONDITION], Stress Incontinence and [MEDICAL CONDITION] Fibrillation. Review of a physician's orders [REDACTED]. During an interview at the 200 hall nurses' station on 11/2/11 at 10:57 AM, Nurse #4 reviewed the chart and stated, "She (Resident #161) don't have a [DIAGNOSES REDACTED]. During an interview at the 200 hall nurses' station on 11/2/11 at 3:47 PM, the Director of Nursing stated, "...There was no diagnosis (for the use of [MEDICATION NAME]) in the chart..."

Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure there was a justifiable medical reason for the presence of a foley catheter for 1 of 3 (Resident #81) sampled residents reviewed of 3 residents with a foley catheter. The findings included: Review of the facility's "Foley Catheter" policy documented, "...Foley catheter to be inserted as ordered per justification..." Medical record review for Resident #81 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. 11/1/11 documented, "...F/C intact c (with) clear yellow urine draining to BSB (bedside bag)..." Review of the admission 5 day Minimum Data Set (MDS) dated ,[DATE] and the 30 day MDS dated [DATE] documented, "...Section H Indwelling catheter..." Observations in Resident #81's room on 11/1/11 at 3:10 PM, revealed Resident #81 lying in bed with the Foley catheter draining urine to a bedside drainage bag. During an interview in the chart room at the 100 hall nurses' station on 10/31/2011 at 2:59 PM, Nurse #1 stated, Resident #81 had the Foley catheter "per patient request". During an interview in the community room on 11/2/11 at 11:34 AM, the Director of Nursing (DON) was asked what was the medical [DIAGNOSES REDACTED]. The DON stated, "It is per patient request. He (Resident #81) has it because he wants it... he wanted to have the Foley."