Every finding on record at NHC Healthcare, Sequatchie

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 6 resident's (Resident #6, Resident #9, Resident #10, Resident #47, Resident #48, & Resident #63) of 12 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, PRE-ADMISSSION SCREENING AND RESIDENT REVIEW (PASRR), revised date 11/2016, revealed .For those patients found nursing facility appropriate .center should refer any patient for Level II resident review upon a significant change in status/condition such as newly evident or possible serious mental disorder, intellectual disability or a related condition . 1. A PASARR was not submitted after new mental health diagnoses of Anxiety Disorder, Delusional Disorder, and Psychotic Disorder were added for Resident #6. Review of a Level 1 Pre-admission Screening Resident Review (PASARR) dated 10/31/2025, revealed Resident #6 had 1 mental health diagnosis of Depression (mild or situational). Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Acute Pulmonary Edema, and Anxiety Disorder. Continued review revealed the resident received a new mental health diagnosis of Major Depression on 11/11/2025 and Delusional Disorders on 11/20/2025. Review of a significant Minimum Data Set (MDS) assessment for Resident #6 dated 3/4/2026, revealed Resident #6 had an active diagnosis which included Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. Review of the medical record for Resident #6 revealed a new Level II PASARR had not been submitted to the state designated authority after the mental health diagnoses of Major Depression, Delusional Disorders, and Psychotic Disorder were added. 2. A PASARR was not submitted after a new mental health diagnosis of Delusional Disorder was added for Resident #9. Review of a PASARR Level 1 screen for Resident #9 dated 1/23/2026, revealed the resident had mental health diagnoses including Major Depression, Bipolar Disorder, and Anxiety Disorder. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Chronic Pain, Muscle Spasms, and Dementia. Continued review revealed the resident received a new mental health diagnosis of Delusional Disorder on 1/29/2026. Review of the admission MDS assessment dated [DATE], revealed Resident #9 had diagnoses including Bipolar, Depression, and Anxiety. Review of the medical record for Resident #9 revealed a new Level II PASARR had not been submitted to the state designated authority after new mental health diagnoses were added. 3. A PASARR was not submitted after a new mental health diagnosis of Psychotic/Delusional Disorder was added for Resident #10. Review of a PASARR Level 1 screen for Resident #10 dated 6/10/2025, revealed the resident had a diagnosis of Schizophrenia. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Schizophrenia and Anxiety Disorder. Continued review revealed the resident received a new mental diagnosis of Psychotic/Delusional Disorder on 8/4/2025. Review of a quarterly MDS assessment for Resident #10 dated 3/19/2026, revealed Resident #10 had active diagnoses of Schizophrenia and Anxiety Disorder. Review of the medical record for Resident #10 revealed a new level II PASARR had not been submitted to the state designated authority after the new mental health diagnosis of Psychotic/Delusional Disorder was added on 8/4/2025. 4. A PASARR was not submitted after a new mental health diagnosis of Psychotic/Delusional Disorder was added for Resident #47. Review of a PASARR Level I screen for Resident #47 dated 3/3/2023, revealed a mental health diagnoses of Major Depression. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnosis including Hypothyroidism, Major Depressive Disorder, Hyperlipidemia, and Osteoporosis. Continued review revealed the resident received a new mental health diagnosis of Delusional Disorders on 4/17/2024. Review of a quarterly MDS assessment for Resident #47 dated 3/13/2026, revealed Resident #47 had active diagnoses which included Depression and Psychotic Disorder. Review of the medical record for Resident #47 revealed a new level II PASARR had not been submitted to the state designated authority after the new mental health diagnosis of Delusional Disorder was added on 4/17/2024. 5. A PASARR was not submitted after mental health diagnoses of Major Depressive Disorder, Anxiety Disorder, and Psychotic/Delusional Disorder were added for Resident #48. Review of a PASARR Level 1 screen for Resident #48 dated 7/15/2022, revealed the resident had no mental health diagnosis known or suspected. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Anxiety Disorder. Continued review revealed the resident received a new mental health diagnosis of Psychotic/Delusional Disorder on 3/31/2023. Review of a quarterly MDS assessment for Resident #48 dated 3/6/2026, revealed Resident #48 had active diagnoses of Anxiety, Depression, and Psychotic/Delusional Disorder. Review of the medical record for Resident #48 revealed a new Level II PASARR had not been submitted to the state designated authority after the mental health diagnoses of Major Depressive Disorder, Anxiety Disorder, and Psychotic/Delusional Disorder were added. 6. A PASARR was not submitted after a new mental health diagnosis of Psychotic/Delusional Disorder was added for Resident #63. Review of a PASARR Level 1 screen for Resident #63 dated 8/27/2024, revealed the resident had diagnoses of Major Depression and Bipolar Disorder. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Bipolar Disorder. Continued review revealed the resident received a new mental diagnosis of Psychotic/Delusional Disorder on 10/7/2025. Review of a quarterly MDS assessment for Resident #63 dated 4/7/2026, revealed Resident #63 had active diagnoses including Depression, Bipolar Disorder, and Anxiety Disorder. Review of the medical record for Resident #63 revealed a new Level II PASARR had not been submitted to the state designated authority after the mental health diagnosis of Psychotic/Delusional Disorder was added. During a record review and interview on 4/22/2026 at 10:50 AM, the Assistant Director of Nursing (ADON) stated she was responsible for referring to the state designated agency for PASARRs after new mental health diagnoses were identified and added to the resident's medical record. The ADON confirmed she had failed to refer Resident #6, Resident #9, Resident #10, Resident #47, Resident #48 and Resident #63 to the state designated agency for a Level II PASARRS after the new mental health conditions were added. During an interview on 4/22/2026 at 12:05 PM, the Director of Nursing (DON) confirmed the facility policy for referring to the state agency for PASARRS after identifying new mental health conditions was not followed.

Based on facility policy review and interviews, the facility failed to ensure mail was delivered on Saturdays to 9 residents (Resident #11, Resident #12, Resident #15, Resident #18, Resident #20, Resident #29, Resident #37, Resident #51, and Resident #56) of 9 residents reviewed for mail delivery. The findings include: Review of the facility's policy titled Mail Distribution to Patients, undated, revealed .CMS requires mail to be distributed to the patients within 24 hours of delivery by Postal Service .Be sure your center has a system set up to deliver mail to the patients within 24 hours, including weekends and when Life Enrichment is out of the building . During the Resident Council meeting and interviews on 4/21/2026 at 10:15 AM, Residents #11, Resident #12, Resident #15, Resident #18, Resident #20, Resident #29, Resident #37, Resident #51, and Resident #56 stated they did not receive mail on Saturdays and must wait until Monday when staff were in the front office. During an interview on 4/21/2026 at 10:58 AM, the Administrator confirmed the mail was not being delivered to the residents by the facility staff on Saturdays. The Administrator further confirmed that the Postal Service delivered mail on Saturdays to the facility, and it was his expectation the residents receive their mail on Saturdays as they would on weekdays. Amended F-576 on 5/6/2026.

Based on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment with the potential to affect 90 residents in the facility. The findings include: Review of the facility policy titled, Safety & Sanitization Best Practice Guidelines, dated 11/2017, showed .Equipment must be cleaned and/or sanitized after every use according to the manufacturer's directions .Non-food contact surfaces of foodservice equipment should be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance .Department inspection should be conducted to review sanitation and immediate action should be taken to correct any problems that interfere with meeting sanitary standards . During an observation on 2/6/2023 at 9:56 AM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). During the tour, the following items were observed: 1. The dual burner cook top had spatter of dark- brown/black dried food debris on the back splash panel of the unit. 2. Beside the dual burner cooktop, a small stainless steel table was observed with a large cooking pot on top of it with brown dried food debris on the base of the large cooking pot and the table. 3. The steam cart had dried brown food debris in 6 of 6 wells where the metal serving bins would be placed on top of the steam table. During an interview on 2/6/2023 at 10:35 AM, the CDM confirmed the equipment in the facility's kitchen was not in sanitary condition. The CDM confirmed she was responsible to oversee the cleanliness and sanitary operation of the kitchen in the facility. During an interview on 2/8/2023 at 11:54 AM, the Administrator confirmed the kitchen staff were to follow the equipment cleaning schedule and ensure the kitchen was maintained in a sanitary condition.

Based on Centers for Disease Control and Prevention (CDC) guidance documentation, facility policy review, manufacturer instruction review, medical record review, observation, and interview the facility failed to ensure Personal Protective Equipment (PPE) was donned according to manufacturer's recommendations, failed to follow appropriate infection control practices for PPE for 4 Residents (#17, #22, #2, #16) of 15 residents observed for Transmission Based Precautions, and failed to sanitize hands after glove removal after provided care for 2 residents (#17 and #22) in 1 of 5 hallways. The findings include: Review of the CDC guidance documentation titled, Strategies for Optimizing the Supply of Eye Protection, updated 9/13/2021, showed the following: .When manufacturer instructions for cleaning and disinfection are unavailable, such as for single use disposable face shields or goggles, consider: 1. While wearing a clean pair of gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. 2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA [Environmental Protection Agency]-registered hospital disinfectant solution. 3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue. 4. Fully dry (air dry or use clean absorbent towels). 5. Remove gloves and perform hand hygiene. 6. Cleaned and disinfected eye protection can be stored onsite, in a designated clean area within the facility . Review of the facility's policy titled, Infection Control Policy, dated 1/2023, showed .This Infection Prevention and Control program is designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases .The goal of the Infection Preventive and Control Program is to provide a system of preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for patients, partners, volunteers, visitors, and others who provide contracted services . Review of the facility's policy titled, 905 COVID-19 (SARS-CoV-2), dated 1/2023, showed .COVID-19 is caused by a virus called SARS-CoV-2. It is part of the coronavirus family .coronaviruses spread quickly through droplets that you project out of your mouth or nose when you breathe, cough, sneeze, or speak .HOW COVID-19 Spreads .COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. These droplets and particles can be breathed in by other people or land on their eyes, noses, or mouth. In some circumstances, they may contaminate surfaces they touch. Anyone infected with COVID-19 can spread it, even if they do not have symptoms .CORE PRINCIPLES OF COVID-19 INFECTION PREVENTION .Appropriate staff use of Personal Protective Equipment (PPE) . Review of the facility's policy titled, HAND HYGIENE, updated 1/2023, showed .Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings .'hand hygiene' includes both handwashing with either plain or antiseptic-containing soap and water, and use of alcohol-based products (gels, rinses, foams) that do not require the use of water .PROCEDURE .Provide hand hygiene before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Review of the facility's policy titled, CONTACT PRECAUTIONS, updated 1/2023, showed .In addition to Standard Precautions, use Contact Precautions for patients to prevent transmission of infectious agents .Personal Protective Equipment .Discard PPE before exiting room and perform hand hygiene .Equipment .If equipment must be used among patients, then they must be adequately clean and disinfected before another patient use .Appropriate Contact Precautions sign on door . Review of the facility's policy titled, DROPLET PRECAUTIONS, updated 1/2023, showed .In addition to Standard Precautions, use Droplet Precautions for a patient known or suspected to be infected with microorganisms transmitted by droplets larger than 5 microns in size that can be transmitted through close respiratory or mucous membrane contact with respiratory secretions .PPE .Facemasks should be used upon entry into the patient room .if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield in place of goggles) should be worn .Equipment .If equipment must be used among patients, then they must be adequately cleaned and disinfected before another patient use .Appropriate Droplet Precaution sign on door . Review of the undated N95 manufacturer's instructions, showed .Place respirator under chin with molded nose contour (narrow end) up. Nose cushion must not be creased inside respirator. Raise top strap to top back of head. Pull shorter bottom strap over head, below ears, to around neck. Do not wear with only strap because it may affect fit . Resident #17 was admitted to the facility on [DATE] with diagnoses including Dementia, History of Falling, and Chronic Pain. Review of Resident #17's annual Minimun Data Set (MDS) assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident #17's POC [Point of Care] Test Results dated 1/30/2023, showed the resident tested positive for COVID-19 on 1/30/2023. Review of a Physician's Order dated 1/30/2023, showed .Isolation: Droplet isolation for positive COVID-19; care and services to be provided in pt's [patient's] room . Continued review showed an order for .Contact isolation .due to Covid positive; all care and treatment to be provided in patient's room . Review of Resident #17's Care Plan dated 1/30/2023, showed .Isolation/Infection: COVID-19 Positive .Maintain droplet isolation as ordered .Use gloves and protective clothing as needed. Linen and trash containers in room . Resident #22 was admitted to the facility on [DATE] with diagnoses including Severe Protein-Calorie Malnutrition, Hypertension, and Anxiety. Review of Resident #22's annual MDS assessment dated [DATE], showed the resident had moderately impaired cognitive skills for daily decision making. Review of Resident #22's POC Test Results dated 1/30/2023, showed the resident tested positive for COVID-19 on 1/30/2023. Review of a Physician's Order dated 1/30/2023, showed .Contact isolation .due to Covid positive; all care and treatment to be provided in patient's room . Continued review showed .Droplet isolation for positive COVID-19; care and services to be provided in pt's room . Review of Resident #22's Care Plan dated 1/30/2023, showed .Isolation/Infection: COVID-19 Positive .Maintain droplet isolation as ordered .Use gloves and protective clothing as needed. Linen and trash in containers in room . During an observation on 2/6/2023 at 11:28 AM, outside Residents #17 and #22's room showed an isolation cart outside the door and multiple signs posted on the door. The signage read as follows; .STOP DO NOT ENTER ., .STOP MUST HAVE ON N95 TO ENTER ., .Personal Protective Equipment (PPE) for Healthcare Personnel .Preferred PPE- Use N95 or Higher Respirator .Face shield or goggles .When respirators are not available, use the best available alternative, like a facemask .One pair of clean, non-sterile gloves .Isolation gown ., .STOP .DROPLET PRECAUTIONS .STOP .EVERYONE MUST: Clean their hands, including before entering and when leaving the room .Make sure their eyes, nose and mouth are fully covered before room entry .Remove face protection before room exit ., .STOP CHECK WITH NURSE BEFORE ENTERING .CONTACT PRECAUTIONS (In addition to Standard Precautions) .STAFF and PHYSICIANS .Gloves .Always .Hand hygiene before donning .Gown .Always .Equipment .Dedicate equipment .Disinfect with disinfectant wipes between patients .VISITORS, STAFF and PHYSICIANS .When you enter and each time you leave the room, either: Use waterless foam .OR Wash hands ., .SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT .GOWN .MASK OR RESPIRATOR .GOGGLES OR FACE SHIELD .GLOVES .USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION ., .HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) . Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Remove PPE in the following sequence .GLOVES .GOGGLES OR FACE SHIELD .GOWN .MASK OR RESPIRATOR .Discard in a waste container .WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE .PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE . Further observation showed Temporary Nurse Aide (TNA) #1 and TNA #2 exited the room at 11:32 AM wearing N95 masks and holding their face shields in their hands. The TNAs discarded their N95 masks in a small trash can outside the room. The uncovered trash can was full of discarded N95 masks, surgical masks, and gloves. TNA #1 and TNA #2 cleaned their face shields with bleach wipes and walked down the hallway into another room to store their face shields. During an interview on 2/6/2023 at 11:40 AM, TNA #1 and TNA #2 stated they had discarded their gown and gloves used to provide care for the COVID-19 positive residents in the room and had discarded their N95 mask used during the interaction with the COVID-19 positive residents in the uncovered trash can outside the room. The TNAs stated this was the normal procedure for N95 mask disposal. During an observation on 2/6/2023 at 11:50 AM, TNA #1 donned a gown, gloves, face shield, and N95 mask and entered Residents #17 and #22's room to provide care. TNA #1's straps for the N-95 mask were both located at the base of her neck. During an observation on 2/6/2023 at 11:54 AM, TNA #1 exited Residents #17 and #22's room and wore gloves, N95 mask, and held her face shield in her hands. TNA #1 discarded the N95 mask and gloves in the uncovered trash can outside the room, donned a surgical mask, and sanitized the face shield. TNA #1 did not sanitize the hands after removing the gloves. During an interview on 2/6/2023 at 12:00 PM, TNA #1 confirmed she had discarded the N95 mask in the uncovered trash can outside the room and did not sanitize the hands after she removed her gloves. Further interview confirmed she had not donned the N95 mask appropriately and had worn the 2 straps on the N95 mask at the base of her neck. TNA #1 confirmed one of the straps was to be located at the base of her neck and one should have been on top of her head. During an observation and interview outside Residents #17 and #22's room on 2/6/2023 at 12:06 PM, the Infection Preventionist (IP) stated it staff were to don N95 mask, gown, gloves, and face shield prior to entering COVID positive resident rooms. Gloves and gown were to be discarded in the room. N95 masks were to be discarded in a covered trash can outside the room and face shields sanitized and stored for re-use. The IP confirmed the trash can outside the room used for N95 disposal was not covered and stated .it should have a lid . to prevent contamination . The IP confirmed appropriate infection control practices were not maintained when N95 masks worn in a COVID-19 positive resident room were discarded in an uncovered trashcan. The IP confirmed the trashcan was open and available to anyone who passed the room. The IP further stated hands were to be sanitized after glove removal and confirmed appropriate infection control practices were not maintained when TNA #1 failed to sanitize her hands after glove removal. Continued interview with the IP confirmed N95 straps were to be worn according to manufacturer's instructions with 1 strap at the base of the neck and 1 on the top of the head to ensure appropriate fit. The IP confirmed appropriate infection control practices were not maintained when TNA #1 wore her N95 mask with both straps at the base of her neck. During an interview on 2/7/2023 at 7:13 AM, the DON confirmed N95 mask were to be discarded outside the room in a trash can with a lid. The DON confirmed the trash can was to be covered and contained with a lid to prevent contamination. During an interview on 2/7/2023 at 9:51 AM, the DON confirmed N95 masks were to be worn according to manufacturer's recommendations with .top strap to top back of the head and bottom strap over the head and below the ears . 40606 Resident #2 was admitted to the facility on [DATE] with diagnoses including Malignant Carcinoid Tumor of the Bronchus and Lung, Urinary Retention, Anxiety Disorder, and Chronic Pain. Review of Resident #2's POC [Point of Care] Test Results dated 1/30/2023, showed the resident tested positive for COVID-19 on 1/30/2023. Resident #16 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disorder, Chronic Kidney Disease, Anxiety Disorder, and Major Depressive Disorder. Review of Resident #16's POC [Point of Care] Test Results dated 1/30/2023, showed the resident tested positive for COVID-19 on 1/30/2023. During an observation on 2/6/2023 at 12:24 PM, Certified Nursing Assistant (CNA) #3 donned PPE prior to entering Residents #2 and #16's room. The residents in the room were placed on droplet precautions isolation according to the signage observed on the door. The signage read as follows; .STOP DO NOT ENTER ., .STOP MUST HAVE ON N95 TO ENTER ., .Personal Protective Equipment (PPE) for Healthcare Personnel .Preferred PPE- Use N95 or Higher Respirator .Face shield or goggles .When respirators are not available, use the best available alternative, like a facemask .One pair of clean, non-sterile gloves .Isolation gown ., .STOP .DROPLET PRECAUTIONS .STOP .EVERYONE MUST: Clean their hands, including before entering and when leaving the room .Make sure their eyes, nose and mouth are fully covered before room entry .Remove face protection before room exit ., .STOP CHECK WITH NURSE BEFORE ENTERING .CONTACT PRECAUTIONS (In addition to Standard Precautions) .STAFF and PHYSICIANS .Gloves .Always .Hand hygiene before donning .Gown .Always .Equipment .Dedicate equipment .Disinfect with disinfectant wipes between patients .VISITORS, STAFF and PHYSICIANS .When you enter and each time you leave the room, either: Use waterless foam .OR Wash hands ., .SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT .GOWN .MASK OR RESPIRATOR .GOGGLES OR FACE SHIELD .GLOVES .USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION ., .HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) . Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Remove PPE in the following sequence .GLOVES .GOGGLES OR FACE SHIELD .GOWN .MASK OR RESPIRATOR .Discard in a waste container .WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE .PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND IMMEDIATELY AFTER REMOVING ALL PPE ., Contact Kill Times .Leave Surfaces wet for the times listed below .Bleach Wipes[orange top] 4 Min. [minutes] . CNA #3 exited the room with her face shield on. CNA #3 removed the face shield while she was walking down the hallway and placed it in the storage area without sanitizing the face shield. During an interview on 2/6/2023 at 12:25 PM, CNA #3 confirmed she had not sanitized her face shield prior to storing the face shield in the storage area. CNA #3 confirmed she was aware the face shield should have been sanitized prior to being placed in storage. During an interview on 2/8/2023 at 3:00 PM, the Director Of Nursing (DON) stated the facility was to follow CDC guidelines for the disinfection of eye protection. The DON confirmed facility staff should adhere to the CDC guidance procedures for disinfecting their face shield prior to storage.

Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) after a new mental health diagnosis for 2 residents (#75 and #64) of 10 residents reviewed for PASRR. The findings include: Review of a facility policy titled, Pre-Admission Screening and Resident Review, revised 11/2016, .nursing facility .should refer any patient for Level II resident review upon a significant change .such as newly evident or possible serious mental disorder . Resident #75 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Anxiety. Review of the Level I Form Pre-Admission Screening and Resident Review dated 6/29/2021, showed .mental health conditions .Major Depressive Disorder .Anxiety .MAXIMUS OUTCOME .If the nursing facility (NF) determines any inaccuracies in diagnosis a Status Change review will be required . Review of the medical record showed Resident #75 received a new diagnosis of Dementia and Schizophrenia on 10/1/2022. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #75 had an active diagnosis of .Anxiety .Depression .Schizophrenia . and received antipsychotic, antianxiety, and antidepressant medications on all 7 days of the 7 day look back period. Review of medical record showed no new Level II resident review had been submitted to include a new diagnosis of Dementia and Schizophrenia. Resident #64 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder and Depression. Review of the Level I Form Pre-Admission Screening and Resident Review dated 11/4/2021, showed .mental health conditions .Anxiety Disorder .Depression .MAXIMUS OUTCOME .If the nursing facility (NF) determines any inaccuracies in diagnosis a Status Change review will be required . Review of the medical record showed Resident #64 received a new diagnosis of Schizophrenia was added on 7/13/2022. Review of the quarterly MDS assessment dated [DATE], showed Resident #64 had an active diagnosis of .Anxiety .Depression .Schizophrenia . and received antipsychotic, antianxiety, and antidepressant medications on 4 days of the 7 day look back period. Review of the medical record showed no new Level II resident review had been submitted to include a new diagnosis of Schizophrenia. During an interview on 2/8/2023 at 8:50 AM, the Assistant Director of Nursing (ADON) stated she was responsible for PASARRs. The ADON confirmed Resident #75 had a new diagnosis of Dementia and Schizophrenia added on 10/01/2022, and Resident #64 received a new diagnosis of Schizophrenia on 7/13/2022. The ADON stated the Level I PASARR should have been .resubmitted after the new diagnosis was added .we just overlooked it . During an interview on 2/8/2023 at 12:15 PM, the Director of Nursing stated when a resident in the facility receives a new mental health diagnosis a PASSAR was to be resubmitted.

Based on facility policy review, medical record review, review of the facility's Current Balance Report, Review of Trust Fund Statements, and interview, the facility failed to refund personal funds within 30 days of discharge for 6 residents (Residents #245, #244, #240, #241, #243, and #242) of 56 residents reviewed for resident funds. The findings include: Review of the facility policy titled, Patient Rights, undated, showed .The money you have deposited in your patient trust fund belongs to you and automatically becomes a part of your estate in the event of your death. It will be conveyed promptly, within 30 days, to the individual administering your estate, after a complete and final accounting of your trust fund . Resident #245 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the Current Balance Report dated 12/31/2022, showed Resident #245 had $1051.37 remaining in the trust fund. Review of Resident #245's Trust Fund Statement dated 2/7/2023, showed a refund was issued on 1/9/2023 (3 days overdue). Resident #244 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the Current Balance Report dated 12/31/2022, showed Resident #244 had $934.52 remaining in the trust fund. Review of Resident #244's Trust Fund Statement dated 2/7/2023, showed a refund was issued on 1/9/2023 (64 days overdue). Resident #240 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the Current Balance Report dated 12/31/2022, showed Resident #240 had $50.19 remaining in the trust fund. Review of Resident #240's Trust Fund Statement dated 2/7/2023, showed a refund was issued on 1/9/2023 (75 days overdue). Resident #241 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the Current Balance Report dated 12/31/2022, showed Resident #241 had $20.05 remaining in the trust fund. Review of Resident #241's Trust Fund Statement dated 2/7/2023, showed a refund was issued on 1/9/2023 (22 days overdue). Resident #243 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the Current Balance Report dated 12/31/2022, showed Resident #243 had $18.02 remaining in the trust fund. Review of Resident #243's Trust Fund Statement dated 2/7/2023, showed a refund was issued on 1/9/2023 (71 days overdue). Resident #242 was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the Current Balance Report dated 12/31/2022, showed Resident #242 had $10.03 remaining in the trust fund. Review of Resident #242's Trust Fund Statement dated 2/7/2023, showed a refund was issued on 1/9/2023 (32 days overdue). During an interview on 2/7/2023 at 3:46 pm, the Business Office Manager (BOM) confirmed the facility failed to refund personal funds within 30 days from discharge for Residents #240, #241, #242, #243, #244, and # 245. During an interview on 2/7/2023 at 3:19 PM, the Director of Nursing (DON) stated personal funds were to be refunded as soon as possible but within 30 days of a resident's discharge from the facility.

Based on facility policy review, SAFETY DATA SHEET review, medical record review, observation, and interview the facility failed to ensure an environment was free from accident hazards for 2 residents (#51 and #58) of 22 residents observed on the Memory Care Unit for accident hazards. The findings include: Review of the facility's undated policy titled, Environmental Services Tool Kit, showed .Keep chemicals locked up away from patients when not in use . Review of the SAFETY DATA SHEET for Sani-cloth Bleach Germicidal Disposable Wipe dated 8/12/2016, showed .HAZARD(S) IDENTIFICATION .This product is a clear white liquid with a chlorine odor impregnated on a wipe. There is a small amount of liquid on the wipes and no free liquid in the packages .HANDLING AND STORAGE .Precautions for Safe Handling: Avoid contact with eyes .Keep containers closed when not in use .PRECAUTIONARY STATEMENTS .Hazards to Humans & Domestic Animals .Caution: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling . Resident #51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Anxiety Disorder, Major Depressive Disorder, and Muscle Wasting and Atrophy. Review of Resident #51's Care Plan dated 12/6/2022, showed .At risk for alteration in mood/behaviors r/t [related to] Dementia, Anxiety, Depression .Memory care residency . Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment and rejection of care behaviors were exhibited on 1 to 3 days of the look back period. Resident #51 required supervision for locomotion on the unit. Resident #58 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, Anxiety Disorder, Major Depressive Disorder, and Adult Failure to Thrive. Review of Resident #58's Care Plan dated 3/18/2019, showed .Cognition/Communication .Deficits related to: dementia .Confusion .Long-term memory problem .Short-term memory problem .Elopement risk .Memory care residency to allow more freedom for locomotion in a safe secure environment . Review of Resident #58's annual MDS assessment dated [DATE], showed the resident had a BIMS score of 1, indicating the resident had severe cognitive impairment and behavioral symptoms not directed towards others occurred on 1 to 3 days of the look back period. Resident #58 required supervision for bed mobility, transfers, locomotion on unit, and eating. During an observation in the Memory Care Unit hallway on 2/6/2023 from 11:28 AM - 12:00 PM, showed there was a bedside table with a container of Sani-cloth Bleach Germicidal Disposable Wipes on the table outside next to a isololation cart of a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) positive resident room. Resident #51 was seated in a wheelchair in the hallway. Temporary Nurse Aide (TNA) #1 and TNA #2 exited the COVID-19 positive resident room at 11:32 AM and walked to the bedside table next to the isolation cart, placed a barrier on the table, and sanitized their face shields with the bleach wipes. The TNAs then walked down the hallway into another room to store their face shields. The bleach wipes remained on the bedside table and Resident #51 remained seated in a wheelchair in the hallway outside of the COVID-19 positive residents' room. During the interview with the TNAs at 11:40 AM , Resident #58 propelled herself down the hallway in a wheelchair and stopped outside the COVID-19 positive resident room and interacted with Licensed Practical Nurse (LPN) #1. At 11:50 AM, TNA #1 and TNA #2 entered the COVID-19 positive resident room to provide care and LPN #1 left the area. Resident #51 and #58 remained outside the room and the bleach wipes remained on the bedside table next to the isolation cart in the hallway, unsecured and available for resident use. During an observation and interview in the Memory Care Unit hallway on 2/6/2023 at 12:00 PM, TNA #1 confirmed the bleach wipes were left unsecured with Resident #51 and #58 in the immediate area and stated, .these bleach wipes don't need to be out here .[Resident #58's first name] will grab stuff . TNA #1 then secured the bleach wipes in the a drawer of the isolation cart next to the bedside table. During an interview on 2/7/2023 at 9:51 AM, the DON stated the Memory Care Unit housed residents with poor cognition. The DON confirmed it was the facility's policy that chemicals were locked up and away from residents when not use. The DON confirmed the facility's policy was not followed when bleach wipes were left unsecured on the Memory care unit available for 2 residents with poor cognition.

Based on observation and interview, the facility failed to serve hot food at or above 135 degrees Fahrenheit (F) and failed to serve cold food at or less than 41 degrees F for 1 of 2 resident meal services observed. The findings included: Observation on 6/12/17 beginning at 12:14 PM in the dietary department revealed the resident mid-day meal service was in progress and one resident meal delivery cart had left the dietary department. Further observation revealed the Assistant Dietary Manager obtained 113 degrees F for the grilled chicken. Further observation revealed a pan containing shredded lettuce, chopped tomatoes, and shredded cheese stored in a chilled pan on the counter behind the steam table and was available to be served to the residents. Further observation revealed the Assistant Dietary Manager obtained 56 degrees F for the shredded cheese. Interview with the Assistant Dietary Manager confirmed the facility failed to serve hot food at or above 135 degrees F and failed to serve cold food at or less than 41 degrees F.

Based on observation and interview, the facility failed to maintain 1 of 5 resident medical supply storage areas to ensure expired resident use supplies were disposed of properly. The findings included: Observation with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:45 PM, in the Unit 2 Central Supply Room, revealed 1 suction catheter tray with chimney valve (used to suction sputum) dated ,[DATE] (expired), 11 safety lock vacutainer (used to draw blood) dated ,[DATE] (expired), 42 intravenous (IV) catheters dated ,[DATE] (expired), 7 IV catheters dated ,[DATE] (expired), and 21 IV catheters dated ,[DATE] (expired). Interview with LPN #1, on [DATE] at 2:50 PM, in the Unit 2 Central Supply Room, confirmed all items were expired and available for resident use. Continued interview revealed all of the items should have been discarded.

Based on review of facility policy, review of facility's resident list for dental services, medical record review, observation, and interview, the facility failed to arrange dental services for 2 residents (#141, #156) of 3 residents reviewed for dental of 30 residents sampled. The findings included: Review of facility policy, Dental, revised 2/14 revealed .each resident evaluated on admission, quarterly, and as needed for dental services. Review of the facility's resident list for dental services, dated 4/16/15 revealed the list of names of the facility residents who received dental services on 4/16/15. Further review revealed Resident #141 and #156 was not listed. Medical record review revealed Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed .obvious or likely cavity or broken natural teeth. Medical record review of a Nutritional Assessment Report dated 1/15/15 revealed .Teeth.Gray-brown spots, missing or erupting abnormally. Medical record review of the Consent for Dental Treatment dated 4/3/15 revealed .I consent for dental treatment. Medical record review of a Care Plan dated 4/21/15, .self care deficit.assist with set up for oral/dental hygiene. Observation and interview with Resident #141 on 6/29/15 at 3:49 PM, in the resident's room revealed I have constant teeth pain. The resident had requested to see the dentist, no arrangements had been made, and he had signed a paper. Interview with Licensed Practical Nurse (LPN #1) on 6/30/15 at 4:00 PM, in the Wound Care office revealed LPN #1 faxed the census to the Mobile Dental Services and the Dental Services faxed consents back to the facility. The LPN is unaware of how residents are placed on the list to see the dentist. Continued interview revealed the dentist visited the facility on 4/16/15 and Resident #141 had not received dental services. Interview with the representative from the mobile dentistry, on 6/30/15 at 4:15 PM, by telephone revealed the facility had not returned the consent form back to the dental services in time for the resident to see the dentist on 4/16/15. Interview with the Director of Nursing (DON) on 7/1/15 at 9:15 AM, in the DON Office revealed the consent must be returned to the dentist within 10 days of the scheduled visit. Continued interview confirmed the facility had failed to arrange dental services for Resident #141. Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set, dated dated [DATE] revealed obvious or likely cavity or broken natural teeth. Medical record review of the Consent for Dental Treatment, not dated revealed the Power of Attorney signed the consent for dental services on 4/3/15 for Resident #156. Observation of Resident #156, on 6/29/15 at 12:25 PM, in the resident's room revealed poor dentition with a discolored upper tooth and missing and rotten bottom teeth. Interview with Resident #156 on 6/29/15 at 12:25 PM, in the resident's room confirmed no dental services since admission to the facility .look at my teeth. Interview with LPN #1 on 6/30/15 at 2:00 PM, at the Station 2 nursing station confirmed she was responsible for evaluation of residents for dental care. Continued interview confirmed LPN #1 failed to place the resident on the list for dental services. Interview with the DON on 6/29/15 at 3:00 PM, in the DON office confirmed the facility failed to provide dental services for Resident #156.

Based on review of facility policy, medical record review, and interview, the facility failed failed to arrange vision care for 1 resident (#141) and failed to provide a sufficient discharge for 1 resident (#173) of 30 residents reviewed. The findings included: Review of facility policy, Eye Care, reviewed and revised 7/15 revealed .Nursing Staff assesses the resident's eye care needs.referral to the Social Worker (SW) who arranges the appointment.requests may also be made by the resident. Medical record review revealed Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed .Moderate limited vision. Medical record review of a Care Plan dated 4/21/15, .has had glasses for [AGE] years and does not see well with them. Social Services to arrange for resident to be seen.for an eye exam. Interview with Resident #141 on 6/29/15 at 3:49 PM, in the resident's room revealed the resident had requested to see an eye doctor 8 weeks ago and no arrangements had been made. Interview with the SW on 6/30/15 at 3:22 PM, in the Employee Break Room revealed the resident had requested to see an eye doctor during the Care Plan Meeting on 4/21/15 (70 days ago). Continued interview confirmed the facility failed to make arrangements for an eye appointment. Medical record review revealed Resident #171 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Social Services note dated 6/5/15 revealed .Pt (patient).for 5 day respite stay through.Hospice.will discharge home with daughter.on 6/7/15 (no time). Medical record review of the Discharge Plans dated 6/3/15 revealed .the ambulance service will pick up the patient in the evening of June 7th and transport her home.time of the transport will be approx. (approximately) 7 p.m. per (hospice). Medical record review of a Post Discharge Instructions dated 6/7/15 revealed .Date of Discharge 6/7/15 (no time).total depend (dependent) with all ADL's (activities of daily living) and transfers. Medical record review of a Discharge Summary dated 6/7/15 revealed .unable to voice needs. Interview with Resident #171's daughter on 6/30/15 at 6:49 PM, by telephone revealed the daughter had been returning from Florida on 6/7/15 (day of discharge) and had made arrangements with the facility and hospice for the resident to return home at 7:00 PM. Continued interview revealed the daughter phoned the facility on 6/7/15 at 8:00 AM, and the nurse informed the daughter the resident was discharged at 7:00 AM by ambulance to the daughter's house (1.5 hours from facility). Further interview revealed no caregiver was at the home, the resident was unable to stay alone, and the resident had to stay on the ambulance stretcher until a sitter could arrive. Interview with the SW on 7/1/15 at 9:00 AM, in the Director of Nursing (DON) Office revealed the Post Discharge Instructions were placed at the Nurses Station on 6/5/15 (Friday), the resident was scheduled for discharge on 6/7/15 (Sunday in the PM), and the instructions had not included the time of discharge. Continued interview confirmed the facility failed to notify nursing of the 7:00 PM discharge and the resident was discharged at 7:00 AM by ambulance to the daughter's home with no caregiver present.

Based on review of facility policy, medical record review, and interview, the facility failed to assist 1 resident (#141) to obtain eye care of 30 residents sampled. The findings included: Review of facility policy, Eye Care, reviewed and revised 7/15 revealed .Nursing Staff assesses the resident's eye care needs.referral to the Social Worker (SW) who arranges the appointment.requests may also be made by the resident. Medical record review revealed Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed .Moderate limited vision. Medical record review of a Care Plan dated 4/21/15, .has had glasses for [AGE] years and does not see well with them. Social Services to arrange for resident to be seen.for an eye exam. Interview with Resident #141 on 6/29/15 at 3:49 PM, in the resident's room revealed the resident had requested to see an eye doctor 8 weeks ago and no arrangements had been made. Interview with the Social Worker (SW) on 6/30/15 at 3:22 PM, in the Employee Break Room revealed the resident had requested to see an eye doctor at the Care Plan Meeting 4/21/15 (70 days ago). Continued interview confirmed the facility failed to make an appointment with an eye doctor for the resident.

Based on facility policy, medical record review, and interview, the facility failed to ensure the accuracy of a Physician order [REDACTED].#141) of 30 residents reviewed. The findings included: Review of facility policy, DNR (Do Not Resuscitate), no date revealed .The Physician order [REDACTED]. Medical record review revealed Resident #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed .Special Treatments.Hospice. Medical record review of the Care Plan dated [DATE] revealed .terminal dx (diagnosis).Hospice.assess the residents desires/wishes related to end of life. Medical record review of an Advance Care Plan dated [DATE] revealed .Treatment.By marking no below I have indicated treatment I do not want. Continued review revealed the No box had been marked for CPR (Cardiopulmonary Resuscitation). Medical record Review of the POS [REDACTED]. Box 1, Resuscitate, Box 2, Do Not Resuscitate, both boxes had been checked, and the Resuscitate box was checked and circled. Medical record review of a physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 3:58 PM, in the DON Office confirmed the facility failed to accurately complete the Post Form for Resident #141.

Based on observation and interview, the facility failed to follow standards for the prevention and spread of infections by not disinfecting the hands after the removal of gloves for one observation of one opportunity for intravenous medication administration. The findings included: Observation on February 25, 2014, at 9:55 a.m., during the preparation of intravenous (IV) medication for administration, revealed Registered Nurse (RN) #1 disinfected the hands and donned gloves. Continued observation revealed RN #1 prepared the IV medication with the gloves on, removed the gloves, donned new gloves, cleaned the resident's IV access port, and connected the IV tubing to the access port. Interview with the Director of Nursing on February 26, 2014, at 8:10 a.m., in the director's office, confirmed the facility did not have a policy for disinfecting the hands after glove removal, but the facility's expectation was that the hands would be disinfected when gloves were removed.

Based on medical record review, review of facility fall investigations, observation, and interview, the facility failed to ensure a safety device to prevent falls was in place for one resident (#100) of three residents reviewed for falls, of thirty-one sampled residents. The findings included: Resident #100 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated September 12, 2013, revealed, "...resident was in hallway in Geri-chair. We heard tab alarm sounding. Ran down hallway and (resident) was in the floor...skin tear to elbow..." Medical record review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired and was totally dependent on staff for all Activities of Daily Living (ADLs). Medical record review of a nurse's note dated February 22, 2014, revealed, "...called to day room per CNA (Certified Nurse Assistant). Resident lying in floor on back. Small abrasion noted to chin. No other injuries noted. Tab alarm not sounding because resident removed it before exiting (resident's) chair. Placed back in chair and attached tab alarm..." Continued review of the nurse's note revealed an intervention initiated to prevent future falls "...chair alarm...will check tab alarm periodically to ensure it is properly attached to alarm staff of unsafe behaviors/transfers..." Review of a facility fall investigation dated February 22, 2014, revealed the resident had a tab alarm in place at the time of the resident's fall on February 22, 2014, which the resident had removed. Continued review of the facility fall investigation revealed a new intervention initiated to prevent future falls "...pressure alarm in bed and chair..." Medical record review of the resident's care plan, last updated February 24, 2014, revealed, "...At risk for falls secondary to blindness, no safety awareness, and personal history of falls..." Continued review of the resident's care plan revealed, "...tab alarm while in bed/chair to alert staff of unsafe behaviors..." with a line drawn through with handwritten note "...dc'd (discontinued) 2/24/14..." Further review of the resident's care plan revealed a new intervention to prevent future falls, "...Pressure alarm to bed and chair to alert staff of unsafe behaviors...2/24/14..." Medical record review of a physician's orders [REDACTED]...1. Pressure alarm to bed and chair...2. DC (discontinue) tab alarm to bed/chair..." Observation of the resident on February 25, 2014, at 1:30 p.m., in the resident lounge outside of Station 2 nurse station, revealed the resident laying in a reclined Geri-chair, and appeared to be sleeping. Continued observation of the resident revealed a pull-tab alarm in place on the resident's shirt. Observation of the resident on February 26, 2014, at 7:58 a.m., in the resident lounge outside of Station 2 nurse station, revealed the resident laying in a reclined Geri-chair, and appeared to be sleeping. Continued observation of the resident revealed a pull-tab alarm in place on the resident's shirt. Observation of the resident on February 26, 2014, at 10:33 a.m., in the resident lounge outside of Station 2 nurse station, revealed the resident laying in a reclined Geri-chair, and appeared to be sleeping. Continued observation of the resident revealed a pull-tab alarm in place on the resident's shirt. Interview with Licensed Practical Nurse (LPN) #1 on February 26, 2014, at 10:33 a.m., in the lounge outside of Station 2 nurse station, confirmed a pull-tab alarm was in place on the resident and confirmed a pressure pad alarm was not in place. Interview with the Director of Nursing (DON) on February 26, 2014, at 10:40 a.m., in the Social Services Office, confirmed the resident had a pull-tab alarm in place and the facility had not implemented the pressure pad alarm as indicated.

Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure fingernails were neat and clean for one resident (#3) of thirty-one residents observed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance of two persons for personal hygiene. Review of the resident's care plan dated February 20, 2014, revealed, "...Nail Care: Staff will clean and trim nails as needed..." Observation of the resident's hands on February 24, 2014, at 3:30 p.m., February 25, 2014, at 11:34 a.m., and February 26, 2014, at 8:00 a.m., revealed the resident's fingernails were long and had brown debris under the nails. Review of the facility's policy, Nail Care, revealed, "...All residents will be monitored routinely to assure nails are clean and appropriately trimmed..." Observation and interview with the Assistant Director of Nurses on February 26, 2014, at 8:20 a.m., in the resident's room, confirmed the facility's policy had not been followed and the resident's fingernails needed to be cleaned and trimmed.

Based on review of the CFR Title 42, Volume 3, PART 483 Requirements for States and Long Term Care Facilities (Nurse Aide Training Programs) and interview, the facility failed to ensure no nurse aide was charged for any portion of the program. The findings included: Review of the Requirements for States and Long Term Care (LTC) Nurse Aide Training Requirements revealed, "...Sec.483.152(c) Prohibition of charges. (1) No nurse aide who is employed by, or who has received an offer of employment from, a facility on the date on which the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program..." Interview with the Nurse Aide Training (NAT) Instructor on February 26, 2014, at 9:30 a.m., in the instructor's office, confirmed the facility required each student to pay $80.00 for class materials. Telephone interviews on February 26, 2014, at 9:45 a.m., and 10:40 a.m., with two former NAT students who completed the facility's NAT class offered in January 2014, and currently employed by the facility, confirmed the facility had charged each student $80.00 for class materials. Review of the facility's NAT class records from 2013, and January 2014, revealed the facility currently had fourteen former NAT students employed at the facility, and all fourteen had been charged $80.00 for class materials. Interview with the Administrator on February 26, 2014, at 10:45 a.m., at the Social Worker's office, confirmed the facility had not reimbursed nurse aides for the cost of the class after the nurse aides completed the class and were employed by the facility.

Based on observation, medical record review, review of facility's policy, and interview, the facility failed to ensure proper and safe storage of drugs and biologicals in three of the three medication rooms reviewed, and in two of four medication carts reviewed; and failed to date and time an intravenous medication bag on two days for one (#119) resident of thirty-seven residents reviewed. The findings included: Observation of station one medication room on August 28, 2012, at 2:25 p.m., with Licensed Practical Nurse (LPN) #3, revealed a box of oatmeal containing five individual servings which had expired in July, 2012, mixed with medications on shelf. Interview with LPN #3 on August 28, 2012 at 2:45 p.m., in the station one medication room, confirmed the oatmeal was outdated and mixed with medications. Observation of the station one medication room on August 28, 2012, at 2:30 p.m., revealed the following: four bottles of Normal Saline, opened, undated, and partially empty; one bottle of sterile water, opened and undated; thirty-one blue lab tubes for blood collection, expired July, 2012; thirteen 20g (guage) x 1 inch IV (Intravenous) needles expired in January, 2010; one 20g x 1 inch IV needle expired in April, 2010; three sterile Q-tips expired in July, 2011; and one bottle containing seven glucose test strips opened and undated on the medication cart of the 400 wing. Review of facility policy entitled "Expired Medications" revealed all multiple dose vials of medication and all Insulin were to be dated upon opening. Review of facility policy entitled "Expired Supplies" revealed all supplies should be checked for manufacturer's expiration date, and were to be disposed of as needed. Interview with LPN #3 on August 28, 2012, at 2:45 p.m., in the station one medication room, confirmed the expired medications and supplies had not been disposed of and the facility had failed to ensure proper and safe storage of drugs and biologicals. Observation of the emergency drug kit (ER kit) in station one medication room on August 29, 2012, at 1:15 p.m., with LPN #8, revealed the ER kit had been opened at 5:00 a.m. to remove Augmentin for a patient. Further observation revealed the kit had been left open. Review of the facility policy entitled "Emergency Pharmacy Service and Emergency Kits" revealed the kits were to be resealed upon opening with a color coded lock to indicate need for a replacement kit. Interview with LPN #8 in the station one medication room on August 29, 2012, at 1:30 p.m., confirmed the ER kit had been opened and not resealed, thus failing to ensure proper and safe storage of medications. Observation of station two secure unit medication room on August 28, 2012, at 2:00 p.m., with LPN #2 revealed the following: a bottle containing fifteen opened and undated glucose test strips in the medication cart; a bottle of Lantus Insulin in the medication cart opened and undated; a jar of sauerkraut on the shelf of the medication room which had expired in June, 2012, sitting next to a Fleets enema; and a box of Swiss chocolate rolls which expired on August 17, 2012, on the shelf. Further observation revealed several xerofoam dressings in the treatment cart which had expired on November, 2009. Interview with LPN #2 on August 28, 2012, at 2:15 p.m., in the medication room of the secure unit, confirmed the facility had failed to ensure safe and proper storage of drugs and biologicals. Observation of the station two medication cart (nonsecure unit) on August 28, 2012, at 2:15 p.m., with LPN #1 present, revealed one bottle containing one glucose test strip, opened and undated. Observation of the station two (nonsecure unit) medication room on August 29, 2012, at 1:25 p.m., with LPN #1 present, revealed the ER kit had been opened on August 24, 2012, and was left unlocked and had not been reordered from the pharmacy. Further observation of the medication room revealed a bottle of thickener which had expired July, 2012, on the shelf. Interview with LPN #2 on August 28, 2012, at 2:30 p.m., in the secure unit medication room, confirmed the facility had failed to ensure safe and proper storage of the drugs and biologicals. Observation during medication pass on August 29, 2012, between 4:23 and 5:00 p.m., revealed Registered Nurse (RN) #2 administered medications to three different residents on two separate hallways. Observation revealed RN #2 obtained medications for resident #119, entered the resident's room at 4:32 p.m., without locking the medication cart, and administered medications to the resident. Continued observation revealed RN #2 exited resident #119's room at 4:38 p.m., and moved the medication cart to the end of the 200 hallway, and left the medication cart unattended and unlocked to throw trash in the biohazard room. Continued observation revealed RN #2 moved the medication cart to the 300 hallway, entered resident #72's room, with the medication cart unlocked, and asked the resident a question regarding medications. Continued observation revealed RN #2 exited the resident's room and locked the medication cart at 4:46 p.m., before walking to the station 1 nursing desk. Continued observation revealed RN #2 returned to the 200 hallway, obtained medications for resident #8 at 4:59 p.m., locked the medication cart, and entered the resident's room to administer medications. Continued observation revealed RN #2 exited the room, unlocked the medication cart to obtain supplies to check the resident's blood sugar, and returned to the resident's room, without locking the medication cart at 5:02 p.m. Interview with RN #2 outside resident #8's room on August 29, 2012, at 5:06 p.m., confirmed the medication cart had not been locked every time it was left unattended and medications had not been secured. Resident #119 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders revealed a phone order dated August 24, 2012, for "...3) Clindamycin (Antibiotic) 600mg (milligrams) IVPB (Intravenous Piggyback) q (every) 8hr (hour)..." Review of the facility policy entitled Intravenous Medication Administration with the reviewed and revised date of August 2012 revealed "all IV medications will be labeled with...date, time..." Observation on August 27, 2012, at 11:28 a.m., of the intravenous (IV) therapy hung for resident #119, revealed a bag with the typed label of "Clindamycin 600mg in NS (normal saline) 100ml (milliliters) x (times) 10 days infuse 600mg (milligrams) IV over 30 min (minutes) every 8 hr (hours) 8/24/12." Interview on August 27, 2012, at 11:55 a.m., in the 100 hall medicine room with Registered Nurse (RN) #4 confirmed the 8:00 a.m. intravenous dose of Clindamycin was not labeled with the date and time the dose was given nor the name of the person administering. Continued interview revealed "...we are supposed to label each bag with the date and time of the dose and our initials, I forgot to do that on the 8:00 a.m. dose I hung..." Observation on August 29, 2012, at 8:00 a.m.,in the resident's room, revealed Clindamycin hung with the time of 2400 but no date. Interview on August 29, 2012, at 8:10 a.m., in the resident's room, with Licensed Practical Nurse (LPN) #3 confirmed the Clindamycin was hung at 2400 and was not dated for date when hung.

Based on medical record review, observation, and interview, the facility failed to document and assess a wound for two residents (#118 and #152); failed to provide a physician ordered psychiatric evaluation for one (#130); and failed to document and investigate of the cause of bilateral hand briuses to one (#119) of thirty-seven residents reviewed. The findings included: Resident #118 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated August 7, 2012, revealed, "...At risk for altered skin integrity related to cognitive impairment and physical limitations...Skin assessments q (every) week. Direct care staff to monitor resident during routine care for any redness, open areas..." Medical record review of the Skin Assessment Record completed August, 7, 16, 21, and 28, 2012, revealed no "...alteration in skin integrity..." Observations of the resident on August 28, 2012, at 1:01 p.m., and on August 29, 2012, at 7:33 a.m., in the resident's room, revealed the resident lying in bed, sleeping, with a band-aid on the left forearm. Interview and medical record review with Licensed Practical Nurse (LPN) #1 on August 30, 2012, at 2:30 p.m., at nursing station 2, revealed the LPN was unaware of the band-aid to the left forearm, there were no skin treatments ordered for the left forearm, and was unaware of any skin issues for the resident. Interview with LPN #7 and observation of the resident on August 30, 2012, at 2:45 p.m., in the resident's room, confirmed the resident had a band-aid to the left forearm with no date present on the band-aid, and when the band-aid was removed a "lesion" was present. Further interview with the LPN confirmed the LPN was unaware of the "lesion" and did not know when the lesion developed, when the band-aid was placed, or who placed the band-aid. Interview and medical record review with LPN #7 on August 30, 2012, at 2:55 p.m., at nursing station 2, confirmed no documentation on the skin assessments, nursing notes, treatment orders or care plan regarding the "lesion" or placement of the band-aid over the lesion. Resident #152 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of resident #152 on August 27, 2012, at 8:45 a.m., in the resident's room, revealed a left elbow abrasion with a bandage partially covering it. Further observation revealed the bandage had begun to fall off. Medical record review of the Weekly Skin Assessment Record revealed no skin problems for August 10th, August 11th, August 18th, and August 25, 2012. Medical record review of the care plan completed on August 28, 2012, revealed no documentation of any skin issues. Medical record review of the physician's orders [REDACTED]. Interviews on August 28, 2012, at 10:00 a.m., with Licensed Practical Nurse (LPN) #2 and the treatment nurse outside the 500 unit medication room, revealed both nurses were unaware of the skin abrasion. Medical record review of the nurses note dated August 28, 2012, at 10:40 a.m., by the treatment nurse revealed "Observed an area to the left posterior arm, scabbed area noted with no s/s (signs or symptoms) of infection area washed with soap and water and left open to air. Will report to physician and monitor and treat as ordered. " Medical record review of the nurses notes dated August 28, 2012, to August 30, 2012, at 12:30 p.m., revealed no orders for treatment of [REDACTED]. Observation of the resident on August 30, 2012, at 3:45 p.m., with LPN #5, and LPN #4, in the resident's room, revealed a scabbed area on the left elbow which measured 20mm (milimeters) by 8mm and a reddened area two inches by one inch next to the scab. LPN #5 stated the physician and family would be informed. Further interview with LPN #5 confirmed the facility failed to conduct a comprehensive skin assessment. Resident #130 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED]." Medical record review of the nursing note dated "August 21, 2012 1440" revealed "Order noted for [MEDICATION NAME] to eval (evaluate) and tx. Called spouse and left message. Awaiting call for approval." was signed by Licensed Practical Nurse (LPN) #4. Interview with LPN #4 at 3:10 p.m. on August 30, 2012, in nursing station 2, confirmed LPN #4 had left the message and received no return phone call from the spouse of the resident. Further interview confirmed LPN #4 failed to follow-up with the spouse to get approval for [MEDICATION NAME] to evaluate and treat the resident resulting in a delay of treatment. Resident #119 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on August 28, 2012, at 8:31 a.m., revealed resident #119 with large bright yellow bruising to the top of both hands. Observation on August 29, 2012, at 8:00 a.m., revealed resident #119 with yellow colored bruising to top of hands fading more on the right hand than the left hand. Observation on August 30, 2012, at 9:30 a.m., revealed the resident had darker colored bruising on bilateral top of hands. Medical record review of the physician orders [REDACTED]...1) IV (Intravenous) NS (Normal Saline) at 75cc/hr (cubic centimeters per hour) 2) ...3) [MEDICATION NAME] (antibiotic) 600mg (milligrams) IVPB (Intravenous Piggyback) q 8hr (every 8 hours) 4) [MEDICATION NAME] (antibiotic) 750mg IVPB q 24 hr x (times) 10 days..." Further review revealed a phone order dated August 26, 2012, to "...Decrease [MEDICATION NAME] to 500mg IV q 24hr; decrease rate NS to 50cc/hr..." Medical record review of nursing notes revealed: "...August 24, 2012, 1400 (2:00 p.m.)...#22 (name brand of IV catheter) placed in right hand after multiple sticks...skin condition: warm, dry, intact... 2020 (8:20 p.m.)... IV infusing to right hand. No signs infiltrate noted...August 25, 2012, 0220 (2:20 a.m.)...IV infusing right hand...August 25, 2012, 2140 (9:40 p.m.)...IV infusing right hand...with no signs infiltrate noted...August 26, 2012, 1000 (10:00 a.m.)...skin warm, dry, intact...August 26, 2012, 1140 (11:40 a.m.)...skin warm, dry, intact...reason for alert charting: IV ABT (antibiotic therapy)...observation and assessment findings: IV intact, List care Plan Approaches: monitor IV site, Outcome of Approaches: IV site w/o (without) redness...August 26, 2012, 1800 (6:00 p.m.)... NS infusing...August 27, 2012, 0100 (1:00 a.m.)...IV intact/patent, no s/s (signs/symptoms) of phlebitis or infiltration...continue IV ABT...August 27, 2012, 1400 (2:00 p.m.)...skin condition: warm, dry, intact...August 27, 2012, 1600 (4:00 p.m.)...right hand INT (IV catheter)...with redness. IV infiltrated...INT started in right (FA) forearm... 2245 (10:45 p.m.)...right forearm INT intact with no s/s of infiltration noted...August 28, 2012, 1900 (7:00 p.m.) right forearm INT intact...August 29, 2012, 0150 (1:50 a.m.)...Right forearm INT intact/patent...1000 (10:00 a.m.)...skin condition warm, dry, intact...1700 (5:00 p.m.)...NS infusing to RFA (right forearm)...no s/s infiltration noted...2100 (9:00 p.m.)... IV has infiltrated...2215 (10:15 p.m.)...attempted x 2 to obtain IV access. Unable to obtain..." Review of the Skin/Wound Assessment Record form dated August 6, 13, 20 and 27, 2012, revealed "...no alteration in skin integrity...". Further review revealed no documentation on the back of the form. Interview with Licensed Practical Nurse (LPN) # 3 on August 30, 2012, at 8:24 a.m., in the hall outside room [ROOM NUMBER], revealed the LPN was aware of the bruises and thought they were from multiple IV sticks but failed to document the bruising. Interview with the Assistant Director of Nursing (ADON) in the minimum data set office on August 30, 2012, at 8:41 a.m., confirmed the Certified Nurse Aide and bath aide were to report bruising. Further interview confirmed the nursing notes from August 24 to 30, 2012, lacked documentation regarding the bruising to the tops of both hands. Further interview confirmed the wound nurse was responsible to update the documentation on the back of weekly skin report if notified of skin issue. Further interview confirmed the computerized CNA and nursing documentation from August 24 to 30, 2012, revealed no documentation of skin issues. Interview with the wound care nurse on August 30, 2012, at 9:00 a.m., at nursing station 1, confirmed the wound care nurse had "..noted bruising yesterday when doing tube feeding site treatment..." Further interview confirmed the wound care nurse had not documented the bruising observed on August 29, 2012, during the tube feeding site treatment. Interview with Certified Nurse Aide #6 (bath aide) on August 30, 2012, at 9:40 a.m., outside the resident's room, revealed resident #119 last had a bath on Monday (August 27, 2012), the CNA had noticed bruising on both hands, and did tell a nurse though could not recall which nurse. Further interview with the CNA revealed the nurse had told the CNA the nurse was aware of the bruises and they were due to multiple IV sticks. Interview with the Director of Nursing (DON) on August 30, 2012, at 12:15 p.m., in the social services office, confirmed no investigation of the cause of the bilateral hand bruises or documentation of bruising had been completed for resident #119.

Based on medical record review, observation, and interview, the facility failed to provide activities of interest for three (#130, #121, #152) of seventeen congnitively impaired residents of thirty-nine residents reviewed. The findings included: Resident #130 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set, dated dated dated [DATE], revealed resident #130 had a score of 3 out of 15 (severely impaired) on the Brief Interview for Mental Status (BIMS); no evidence of acute change in mental status; and wandering on a daily basis. Medical record review of the Interview For Preferences dated March 28, 2012, and the Recreational assessment dated [DATE], revealed resident #130 had the following preferences as "Very Important": clothes to wear, choose tub, bath, shower, choose own bedtime, place to lock your things in a safe place, to do things with groups of people, outside for fresh air, and to participate in religious events. Further review revealed the following as "Somewhat Important": have books, magazines, newspapers to read, listen to music-gospel and country, be around animals, and to do favorite activities-watch TV-news and game shows. Review of the Interim care plan dated March 22, 2012, revealed an approach for "...10. Encourage activity attendance..." Review of the care plan dated April 12, 2012, revealed an approach under the Hx (history) of behaviors related to [MEDICAL CONDITION] with Behaviors, Manic [MEDICAL CONDITION] Disorder, & (and) Paranoid [MEDICAL CONDITION] of "...Avoid over stimulation...". Further review revealed: problem addressing: "Resident frequently leaves programs early walking out of activity programs when encouraged to stay...Goal: Resident will attend at least one group activity with out leaving the program for at least five minutes, one time weekly... Approaches: Invite and directly guide Resident to group programs of interest: country and gospel music, dog and cat related activities, outdoor socials, church programs; Provide TV viewing area; Gently attempt to re-direct resident's attention as necessary within the resident's tolerance to remain in the programs or to remain on task; and Provide one-to-one attention during group programs as an attempt to keep on task." Review of the Interim care plan dated June 11, 2012, revealed no activity approaches. Review of the care plan dated July 3, 2012, revealed the identical problems, goals and approaches written in the April 12, 2012, care plan addressing the Behavior problem with the approach to avoid over stimulation and the problem addressing the resident frequently leaving programs. Observations of resident #130 revealed the following: 1. On August 27, 2012, at 9:20 a.m., in the 500 wing Activity room revealed the resident sitting in the activity room watching a DVD of kittens which ran continuously. 2. On August 27, 2012, at 10:45 a.m., the resident was walking on the 500 hallway, and was frequently going up to different staff and talking. 3. On August 28, 2012, at 9:30 a.m., the resident was walking down the 500 hallway. 4. On August 28, 2012, at 10:30 a.m., the resident was standing at the exit door asking someone to let him out. 5. On August 29, 2012, at 9:45 a.m., the resident was wandering in and out of rooms and down the 500 hallway. 6. On August 29, 2012, at 2:30 p.m., the resident was sitting in the activity room with TV on. 7. On August 29, 2012, at 4:15 p.m., the resident was walking up and down the 500 hallway. Resident #121 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident was moderately cognitively impaired and required extensive assistance with transfer and eating. Observation on August 29, 2012, at 7:15 a.m., on the 500 Wing Hallway, revealed the resident wandering in and out of another resident's room. Observation on August 29, 2012, at 9:18 a.m., in the 500 Wing Hallway activity room, revealed the resident in a wheel chair going into the hallway and pushing another resident's wheel chair. Observation on August 29, 2012, at 9:40 a.m., in the 500 Wing Hallway, revealed the resident pushing the wheel chair into the closed door. Observation on August 29, 2012, at 3:20 p.m., in the 500 Wing Hallway, revealed the resident in the wheel chair attempting to pull a picture off the wall, when staff re-directed the resident into the activity room. Observation on August 30, 2012, at 8:00 a.m., revealed the resident in the wheel chair going up and down the 500 Wing hallway. Observation on August 30, 2012, at 10:00 a.m., revealed the activities coordinator placed a video in the DVD player for the residents to watch. Continued observation at 1:00 p.m., revealed the same DVD playing on a continuous loop to "select play". Interview with Licensed Practical Nurse (LPN) #4, on August 29, 2012, at 7:45 a.m. in the 500 Wing Hallway Nurse's Station, revealed "...the first activity is started right after breakfast...weekend activities are scheduled on the weekends but the nurses are responsible to get them started...the CNAs are so busy they do not have time to be in the activity room all the time..." Interview with the Social Services Director, on August 29, 2012, at 10:00 a.m., in the Social Service office, revealed "...on the weekends they have things they can do but the nurses have to get the stuff out there...they can do things when they have time to get them out for the residents ..." Interview with Certified Nurse Assistant (CNA) #5, on August 29, 2012, at 10:30 a.m., in the 500 Wing Hallway, revealed "...activities department assists with activities and sometimes we help to get the resident's to the activity room after the bath...there are limited activities on the weekends...the only thing they may do is watch TV or a church comes in and sings..." Interview with LPN #9, on August 29, 2012, at 3:45 p.m., in the 500 Wing medication room, revealed "...activities are limited on the evenings and weekends...they have books, movies and balloon toss but it does not hold residents attention...it's hard to keep track with them (residents) and do all the other things we have to do..." Interview with CNA #4, on August 29, 2012, at 3:50 p.m., in the 500 Wing Hallway, revealed "...activities are in the activity room...can watch a movie...no other activities in evening...there are only two CNAs on the 500 Wing Hallway... we get them fed and then start getting them ready for bed or they will start going in and out of other rooms wanting to go to bed..." Interview with the Activities Coordinator on August 30, 2012, at 10:06 a.m., in the activity coordinator's office, revealed "...the goals for resident #121 are to stay on task and to be involved directly with the resident...we (activity staff) try to get the residents into the activity room but there are only two of us...we have volunteers sometimes on the weekends such as churches...the nurses assist the residents with activities on the weekends and the evening shift...staffing is an issue...the activity department is spread thin..." Continued interview confirmed the activity coordinator had placed the DVD in the player on August 30, 2012, and "got busy" and "forgot to come back and take the DVD out of the player." Resident #152 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Resident #152 on August 27, 2012, at 1:00 p.m., and 4:00 p.m., on the 500 unit, revealed the resident was not involved in any activities. Observation of the resident on August 28, 2012, at 10:00 a.m., on the 500 unit, revealed the resident was not involved in any activities. Observation of the resident on August 29, 2012, at 9:45 a.m., revealed the resident in the activity room of the secure unit with no activities in progress. The television was on but the resident was not watching it. Observation of the resident on August 29, 2012, at 2:15 p.m., revealed the resident on the patio with eight other residents and the activity staff present. The resident was not engaged with the activity. Observation on August 29, 2012, at 5:00 p.m., revealed the resident sitting in the activity room of the 500 unit with the television on, but not watching it. Further observation on August 29, 2012 at 5:30 p.m. revealed the resident lying on the couch in the secured activity room. Interview with the Activity Director on August 29, 2012, at 8:45 a.m., in the dining room of station two, revealed the resident did not participate much in group activities and no activity personnel were available on the weekends. Activities on weekends were done by nursing staff or volunteers, and there had been less volunteers available lately. Interview with Licensed Practical Nurse (LPN) #4 on August 29, 2012, at 10:30 a.m., at the station two desk, confirmed there were no activity staff available on the weekends, and the LPN would sometimes do activities, but didn't always have the time. Further interview with LPN #4 confirmed the residents were often left with nothing to do, and the facility had failed to meet their activity interests.