Every finding on record at NHC Healthcare, Somerville

Based on American Nurses Association article review, policy review, Director of Nursing (DON) job description review, Licensed Practical Nurse (LPN) job description review, medical record review, Emergency Medical Services (EMS) record review, hospital record review, observation, and interview, the facility failed to provide pain management consistent with professional standards of practice for 1 of 2 (Resident #2) residents reviewed for pain management. Resident #2, a moderately cognitively impaired resident who required assistance of staff with activities of daily living (ADLs), sustained an unwitnessed fall that resulted in bilateral (right and left) femur (the thigh bone between the hip and knee) fractures on 11/1/2025 between 6:30 PM and 6:59 PM. Resident #2's pain level was assessed at a level of 10 (on a pain scale of 1 to 10 with 10 being the highest level of pain) after the fall (post fall). The facility staff failed to administer pain medication and failed to notify the physician of Resident #2's pain level of 10, prior to transfer to the hospital, approximately 5 hours later. The failure of the facility to appropriately assess, monitor, and treat Resident #2's pain resulted in Actual Harm to Resident #2. The findings include: 1. Review of the American Nurses Association article titled, The Ethical Responsibility to Manage Pain and the Suffering It Causes, dated 2018, revealed .The purpose of this position is to provide ethical guidance and support to nurses as they fulfill their responsibility to provide optimal care to persons experiencing pain.Nurses have an ethical responsibility to relieve pain and the suffering it causes.The nursing profession agrees pain is whatever the experiencing person says it is, existing whenever he says it does.Nurses and other healthcare professionals have a moral obligation to respond to this patient need.Effective pain control strategies emphasize.informed and thorough pain assessment.barriers to effective pain management, nurses, other healthcare professions should engage in.strategies to.prevent, assess, and treat pain. 2. Review of the undated facility policy titled, Pain Assessment and Management, revealed, .Nursing will monitor use of medication for pain and relief of pain and will contact the physician as needed. Patients will be assessed as needed for pain at least quarterly.All patients will have access to the best level of pain relief that may safely be provided.The administration of PRN [as needed] medications for pain will include documentation on the MAR [Medication Administration Record].Patients who are non-verbal may be observed for the presence of pain using indicators of grimacing flinching, crying out, elevated blood pressure, and/or elevated pulse. Any patient who reports unrelieved pain.will be re-evaluated as needed, and appropriate interventions will be instituted. If analgesic medication is being used, the physician will be notified of unrelieved pain. 3. Review of the DON's job description dated 3/1/2018, revealed .To provide an administrative and overall managerial authority for all functions (including care delivery activities and training) of the Nursing Department.Monitors to see that treatments and medications are administered as ordered.Monitors to see that there is accurate and adequate documentation in the medical records. Review of the undated LPN job description, revealed .Monitor unit/units to ensure that appropriate nursing care (according to policies and procedures) is being provided and that doctors and families are being notified of changes in patient's condition.Assist patients to attain the highest level of self-care possible. 4. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Heart Failure, Dementia, Disorders of Bone Density, Adult Failure to Thrive, and Anxiety. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #2 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Resident #2 required moderate assistance of staff to perform ADLs. Review of the facility's Incident Report dated 11/1/2025 at 6:59 PM, revealed Resident #2 was found on the floor in her bedroom.Patient [Resident #2] exhibit (showed) or complain of pain .10 - Excruciating Pain - worst Possible -Interferes with ability to carry on with daily routines, socialization or sleep .Injury: Yes, Bone Fracture, Bilateral femur fractures, Range of Motion Painful/limited lower extremity .Interventions Pain Management. ER [Emergency Room] . Review of the Medication Administration Record dated 11/2025, revealed no documentation that pain medication was administered on 11/1/2025 for Resident #2's complaints of pain at a 10. There was no documentation any pain relief interventions were implemented. Review of the Nurse's Note dated 11/1/2025 at 8:18 PM, revealed Nurse reported that pt [patient-Resident #2] has been discovered in bedroom at bedside on the floor. Upon getting to room pt observed lying on back at the foot of her bed. Staff already in bedroom assisting to get pt off the floor.Vitals obtained and assessed client [Resident #2] and noted that client was complaining of left knee pain and grabbing left leg stating it really hurts. Pt confused and [at] this time and anxiety very increased. Once assessment completed staff assisted this nurse in putting client in w/c [wheelchair] to decrease risk of future falls and rolled client to nurses [nurses'] station for closer monitoring. Called [Call] placed to son.to notify him of fall and possible need for xray [radiology] son.stated im [I'm] fine with that and call placed to on call to report fall and possible injury to leg knee. Order given for xray of pelvis, left hip, left femur, and left knee r/t [related to] noted swelling and c/o [complaints of] pain when attempting to reposition no other c/o pain at this time. Order then placed in [Named facility's electronic computer system] and called placed to mobile xray. Awaiting for xray at this time. Event completed nurse will continue to observe. Review of the Nurse's Note dated 11/1/2025 at 10:38 PM, revealed [Recorded as Late Entry on 11/02/2025 09:58 AM] Report [regarding Resident #2] given to oncoming nurse of fall and possible left knee injury. Event completed Mobile xray arrived and staff assisted pt to bed with noted swelling to left knee only at this time by nurse pt observed holding lower left thigh near knee. This nurse assisted x-ray technician with repositioning pt and tech [xray technician] stated there appears to be something wrong with the right knee as well related to withdrawal during repositioning. Lab Tech [xray technician] stated he would x-ray both knees at this time. Report later received by nurse of bilateral lower femur fracture. Review of the (Named Mobile) Radiology Report dated 11/1/2025, revealed .Left Knee X-ray.Findings.Acute distal femur fracture [break in the lower part of the thigh bone].Right Knee X-ray.Findings.Acute distal femur fracture. Resident #2 sustained bilateral femur fractures. Review of the Nurse's Note dated 11/2/2025 at 12:17 AM, revealed .Mobile x-ray findings of Bilateral displaced distal femur fracture. Patient's [Resident #2] appearance and pertinent findings: Both knees visibly swollen, some bruising to left arm noted. BACKGROUND: Primary/Pertinent diagnoses: Dementia, Fall risk. Blood Pressure: 150/64 Pulse: 94 Respirations: 18 Temperature: 98.0 [degrees Fahrenheit] O2 [Oxygen] Sats [Saturation]: 95 Level of Care: Continuing Care, ASSESSMENT: Bilateral knees visibly swollen, verbalized pain. PROVIDER RECOMMENDATIONS AND ORDERS: Send to ER, Patient Representative/Family Notified.(son).MD [Medial Director]/NP [Nurse Practitioner] Notification. Review of the Nurse's Note dated 11/2/2025 at 12:31 AM, revealed Mobile XRAY findings of Bilateral displaced distal femur fracture [injury that commonly causes severe knee pain just above the knee joint where bone fragments are out of alignment] r/t [related to] fall. Bilateral knees visibly swollen. On-call NP.notified, order to send to ER. Notified.(son) he asked she be sent to [named hospital] and that he would meet them there. EMS [Emergency Medical Services] arrived around 11:45 PM, assisted EMS to transfer to stretcher. Report called to ER . There was no documentation that Resident #2 received any pain medication or pain reducing interventions after she complained of pain on 11/1/2025 at 6:59 PM to 11/2/2025 at 12:17 AM when Resident #2 was taken by EMS to the hospital. 5. Review of the EMS Record for Resident #2 dated 11/1/2025, revealed the primary clinical impression of paramedics was injury of the upper thigh and the secondary clinical impression was extremity pain. Continued review revealed Resident #2 reported a pain level of 10 and was administered Lorazepam (a medication to treat anxiety) 1.0 milligram (mg) intramuscularly (an injection in the muscle), Zofran (a medication to treat nausea and vomiting) 4 mg intravenously (IV-medication administered in the vein for rapid and direct effect), and Ketamine (a rapid-acting medication used as a pain reliever and for general anesthesia) 50 mg IV. Continued review revealed, .Narrative .The patient's condition was noted to be improved upon arrival at the hospital . 6. Review of Hospital #1's Emergency Department (ED) Physician's Note dated 11/2/2025 at 1:29 AM, revealed .[Resident #2] presented from [Named Facility] with bilateral femur fx [fracture] after a fall .previous left hip fracture and IM nail [surgical procedure for repairing hip fractures by inserting a metal rod into the thigh bone and a screw into the femoral head] .EMS placed the patient on a ketamine drip due to pain .Unable to get any history from the patient due to dementia and sedation. History provided by EMS and the patient's son .X-rays of the patient's femur shows bilateral distal femur fractures .spoke with .orthopedics and sent him copies of the images [xrays] .He recommended sending the patient to trauma center .DISPOSITION: transfer to [Named trauma center Hospital #2] . 7. Review of Hospital #2's History and Physical Note dated 11/2/2025, for Resident #2 revealed .[Resident #2] was transferred from outside hospital for further management of bilateral femur fractures .family opting for non-operative management .Plan .NWB [Non-Weight Bearing] BLE [Bilateral Lower Extremity] .Bedrest .Plan for nonsurgical management of bilateral distal femur fractures with soft dressings/knee immobilizers [a rigid, straight brace to prevent knee movement following surgery or serious injuries] . 8. During a telephone interview on 2/18/2026 at 11:24 AM, LPN D was asked about Resident #2's incident on 11/1/2025. LPN D stated staff had already gotten the Resident up out of the floor by the time she got to the Resident's room. LPN D stated, I'm not sure exactly who got her up, but it was between 6:30-6:45 PM before shift change. LPN D was asked if she administered any pain medication during her shift to treat the resident's pain. LPN D stated, She declined any pain medication. LPN D was asked if she documented the Resident's refusal. LPN D stated, I'm not sure. LPN D was asked if she notified the provider of the Resident's pain and the refusal. LPN D stated, No, because she usually refuses her meds if she has increased anxiety. LPN D was asked if she treated the Resident's increased anxiety. LPN D stated, No, she refused that too. There was no documentation Resident #2 was offered and refused pain medications. During a telephone interview on 2/18/2026 at 2:19 PM, Certified Nursing Assistant (CNA) C was asked if she recalled if Resident #2 was in pain on 11/1/2025 during her shift from 7:00 PM-7:00 AM. CNA C stated, Yes, she was hollering in pain that she was hurting more on her right leg than her left. CNA C was asked if she recalled if Resident #2 was sitting in a wheelchair or in bed. CNA C stated, She was up in a wheelchair at the nurse's station, but they had to lay her down for the mobile x-ray until she left to go to the hospital. During a telephone Interview on 2/18/2026 at 2:49 PM, CNA E was asked if she recalled Resident #2 being in any pain on 11/1/2025 after she fell. CNA E stated, I recall her knees being swollen with her right [knee] worse.She was in pain. CNA E was asked how she knew the resident was in pain. CNA E stated, She was moaning and groaning when she was in her w/c at the nurse's station. During a telephone interview on 2/18/2026 at 3:08 PM, LPN F was asked if she recalled the evening Resident #2 fell on [DATE]. LPN F stated, Yes, I assumed her care when I came on my shift at 7:00 PM. LPN F was asked did you asses the Resident for pain or administer pain medications during your shift. LPN F stated, She complained of pain and her left knee was noticeable [noticeably] swollen. LPN F was asked if Resident #2 rated her pain. LPN F stated, She verbalized her pain. LPN F was asked what was given for her pain. LPN F stated, I think [LPN D] was going to give her pain medication since I assumed her care at 7:00 PM.The Resident was very fidgety and her baseline is confused.She was trying to crawl out of bed again, me and a CNA got her out of bed, put her in [her] wheelchair.she was so fidgety. LPN F was asked do you think that her being so fidgety could be related to her pain. LPN F stated, That was not my first thought. LPN F was asked if Resident #2 could rate her pain. LPN F stated, No, she was not able to rate her pain, but she was sent out pretty quickly. LPN F was asked if Resident #2 fell at 6:45 PM. LPN F stated, That sounds about right. LPN F was asked if at 8:53 PM, the CNA assisted the Resident back to bed for mobile x-ray. LPN F stated, Yes, that sounds right. LPN F was asked did Resident #2 have any pain during the xray. LPN F stated, Yes, the tech [the mobile xray technician] reported Resident had pain during the repositioning for the xray. LPN F was asked if she recalled assessing the Resident's pain. LPN F stated, Yes, I asked her several times throughout the night if she was in pain, and she said her knee hurt but she didn't appear to be in pain, so I didn't report it or give her anything. During an interview on 2/18/2026 at 3:59 PM, the DON was asked when the xray was ordered for Resident #2. The DON replied on 11/1/2025 at 8:18 PM by the NP. The DON was asked when the mobile xray was performed. The DON stated, At 10:38 PM and resulted [results of the xray called to the facility] at 12:17 AM. The DON was asked when staff should treat a Resident's pain. The DON stated, If the Resident is having symptoms of pain. The DON was asked what staff should do when a Resident's pain is a 10. The DON stated, They should report it and administer pain medication if available. The DON was asked should staff document the Resident's pain and intervention for pain in the medical record. The DON stated, Yes. The DON was asked if Resident #2's pain was assessed post fall on 11/1/2025. The DON stated, Yes, at 8:18 PM, she was grabbing her knee. The DON was asked if the pain was rated on a pain scale. The DON stated, Yes, a 10. The DON was asked what do you expect staff to do for a Resident with a pain of 10. The DON stated, Offer pain medications and contact the provider. The DON was asked was anything given to Resident #2 for pain. The DON stated, I would have to look at her MARS. I do not see anything given for pain. The DON was asked do you expect staff to treat a Resident with pain of 10 or exhibiting symptoms of pain. The DON stated, Yes I would expect them to treat that Resident with a pain of 10. During a telephone interview on 2/19/2026 at 9:11 AM, the NP was asked regarding Resident #2's fall with injury on 11/1/2025. The NP stated, I don't recall this resident specifically, I only take call for the facility after hours .I do not have access to their charting system, and I am not familiar with the residents. The NP was asked if she documents calls received by the facility or reports staff concerns to the Medical Director. The NP stated, No, I do not. The NP was asked should staff report the pain to the provider if the resident is exhibiting symptoms of pain after a fall. The NP stated, Yes, I would assume so. The NP was asked should staff administer pain medications if a resident reports having pain. The NP stated, Yes, I would assume. During a telephone interview on 2/19/2026 at 10:41 AM, the Attending Physician was asked when he was made aware of Resident #2's fall with injury on 11/1/2025. The Attending Physician stated, After the fact, she had been sent to the hospital. The Attending Physician was asked what are your expectations of staff if a Resident has a pain of 10 post fall. The Attending Physician stated, I expect them to call me or the NP. The Attending Physician was asked do you expect staff to treat a Resident's pain if the medication is available. The Attending Physician stated, Yes, but if the Resident has a pain of 10, they need to be sent out to the ER. The Attending Physician was asked if the Resident refuses treatment due to increased confusion and anxiety, should staff report to the Physician and document it. The Attending Physician stated, Yes, I would expect the staff to report it and document it.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when expired and undated food items were observed in the kitchen. The facility had a census of 71 and 69 of the residents were served from the kitchen. The findings include: 1. Review of the facility's policy titled, .Safety & Sanitation Best Practice Guidelines., dated 6/2025, revealed . Refrigerated and frozen foods will be stored properly for optimal Product Safety.Foods should be clearly labeled with the contents with the use by date.Expiration dates, Best by Dates, used by dates will be used.to ensure food safety. 2. Observation in the kitchen in the walk-in refrigerator on 2/18/2026 beginning at 11:37 AM, revealed the following: a. A clear, round, plastic storage container that contained cottage cheese dated 2/6/2026, with no expiration or use by date. b. A clear, opened, plastic storage bag that contained ham, dated 2/17/2026, with no expiration or use by date. c. An unopened package of salami dated 2/6/2026, with no expiration or use by date. d. An unopened package of bologna dated 2/6/2026, with no expiration or use by date. e. A clear, opened, plastic storage bag that contained unwrapped, individual slices of cheese dated 2/17/2026, with no expiration or use by date. 3. During an interview in the kitchen at the walk-in refrigerator on 2/18/2026 at 11:53 AM, the Dietary Manager (DM) was asked how food should be stored. The DM stated, They should have a prep [preparation] date which is the day they get it [food item] out of the box [container the items were shipped in] and an expiration date and a use by date.use by 7 days [after prep date]. The DM looked at the date on the food items and confirmed the dates were the prep dates. 4. Observation and interview in the kitchen at the walk-in freezer on 2/19/2026 at 10:12 AM, revealed a clear, plastic bag with meatballs dated 2/18/2026, with no expiration date or use by date. The DM confirmed the meatballs did not have an expiration date on the package and the date on the meatballs was the prep date.

Based on Lippincott Manual of Nursing Practice, 10th Edition, policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by undated, unlabeled, and unsealed food items, expired food items, carbon build up on a pan, improper cleaning of a food thermometer, dented cans, and improper thawing of frozen food, and when 2 of 19 (Certified Nursing Assistant (CNA) #1 and #2) staff members failed to perform hand hygiene during dining. The facility had a census of 70 residents with 68 of those residents receiving a tray from the kitchen. The findings include: 1. The Lippincott Manual of Nursing Practice,10th EDITION documented, Hand hygiene is the single most recommended measure to reduce the risks of transmitting microorganisms .Hand hygiene should be performed between patient contacts .after contact with .contaminated equipment or articles . 2. The facility's Safety & (and) Sanitation Best Practice Guidelines policy revised ,[DATE] documented, .Thawing .Store raw foods on pans on the lowest shelves to prevent them from dripping or splashing on other foods .Herbs and spices .A best practice is to use herbs and spices within 2 years of purchase date .Foods will be stored in their original packages .If opened, packages should be closed securely to protect the product .A designated area in or near the storeroom should be labeled for dented cans and damaged product temporary storage .dented cans should be placed in the designated area . 3. Observations in the kitchen on [DATE] beginning at 8:50 AM, revealed the following: a. An undated bag of salmon in the walk-in freezer b. An undated bag of meatballs in the walk-in freezer c. An undated bag of bar-b-que in the walk-in freezer d. An undated bag of beef steaks in the walk-in freezer e. 9 undated rolls of ground beef in the walk-in freezer f. An undated bag of lima beans in the walk-in freezer g. An undated bag of tortilla shells in the walk-in freezer h. An undated, unlabeled, and unsealed package of tater tots in the walk-in freezer i. 2 undated packages of waffles in the walk-in freezer j. An undated package of pancakes in the walk-in freezer k. An undated, unlabeled piece of cake in aluminum foil in the walk-in freezer l. 6 undated containers of strawberries in the walk-in freezer m. 1 loaf of bread with a green colored substance on the bread with a best by date of [DATE] n. 1 loaf of bread with a best buy date of [DATE] o. 2 loafs of bread with a best buy date of [DATE] p. 4 loafs of bread with a best buy date of [DATE] n. 1 loaf of wheat bread with a best buy date [DATE] o. 4 bags of hoagie sandwich buns with a green colored substance on the buns p. 2 undated packages of hot dog buns q. 1 undated plastic container of cocoa in the dry storage room r. 3 undated jars of cherries in the dry storage room s. 1 pan with carbon build up on the bottom of the pan t. 1 undated plastic container of corn flakes on the prep table Observations in the kitchen on [DATE] beginning at 11:10 AM, revealed the following: a. 2 jars of cherries not dated in the dry storage room b. 1 dented can of cream of coconut on the shelf with other canned foods in the dry storage room c. 1 dented can of green beans on the shelf with other canned foods in the dry storage room d. 1 dented can of potatoes on the shelf with other canned foods in the dry storage room e. 1 dented can of tomatoes on the shelf with other canned foods in the dry storage room f. 3 rolls of ground beef thawing on a tray above cartons of milk in the walk-in refrigerator g. 1 container of nutmeg with a delivery date of [DATE] in the dry storage room Observations in the kitchen on [DATE] beginning at 11:55 AM, revealed the following: The Dietary Manager was performing tray line temperatures and placed the thermometer on the shelf with the tip of the thermometer touching a black bag lying next to the thermometer, then placed the thermometer in a tray of pork chops to obtain a temperature without cleaning the thermometer. Interview with the Dietary Manager on [DATE] at 10:45 AM, in the Dietary Manager Office, the Dietary Manager was asked if a thermometer should be used to obtain the temperature of a pork chop after it has touched the thermometer bag, without cleaning the thermometer probe. The Dietary Manager stated, No, ma'am. The Dietary Manager was asked if dented cans should be on the shelf with the other canned items. The Dietary Manager stated, No, ma'am. The Dietary Manager was asked if food should be dated and labeled. The Dietary Manager stated, Yes, ma'am. The Dietary Manager was asked should food be sealed. The Dietary Manager stated, Yes, ma'am. The Dietary Manager was asked should frozen ground beef that was thawing be on a tray above crates of milk. The Dietary Manager stated, No, ma,am. The Dietary Manager was asked if bread should have mold on it. The Dietary Manager stated, No, ma,am. The Dietary Manager was asked if bread should be used by the best by date. The Dietary Manager stated, If not used by the best by date it won't have the quality. Interview with the Dietary Manager [DATE] at 3:50 PM, in the Kitchen, the Dietary Manager was asked if carbon should be on pans. The Dietary Manager stated, No, ma'am. 4. Observations in the Dining Room on [DATE] beginning at 12:50 PM, revealed the following: CNA #1 moved a chair, prepared the meal tray for Resident #54, and fed Resident #54 without performing hand hygiene. CNA #2 moved a chair, prepared the meal tray, and fed Resident #1 without performing hand hygiene. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM, in the DON Office, the DON was asked should staff move a chair and then feed a resident without performing hand hygiene. The DON stated, No .

Based on the Lippincott Manual of Nursing Practice, 10th Edition, policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #3 and #4) nurses followed practices to prevent the potential spread of infection when nebulizing equipment was not properly stored and overfill of a liquid medication was poured back into the dispensing bottle during medication administration. The findings include: 1. The Lippincott Manual of Nursing Practice, 10th Edition, documented, .Disassemble and clean nebulizer after each use .a thorough proper cleaning, sterilization, and storage of equipment, organisms can be prevented from entering the lungs . 2. The facility's Specific Administration Procedures policy dated (MONTH) (YEAR) documented, .When treatment is complete, turn off nebulizer and disconnect T-piece, mouth piece and medication cup . 3. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME]; 0.5 mg (milligram) - 3 mg .3 ml (milliliter) .inhalation four times a day . Observations in Resident #67's room on 5/13/19 at 3:58 PM, revealed LPN #3 removed Resident #67's nebulizer mask with the reservoir after a breathing treatment had been administered. LPN #3 placed the nebulizer mask and the reservoir into a plastic bag without disconnecting the T-piece, mouth piece and reservoir. There was moisture in the mask and medicine cup when she placed the equipment into the plastic bag. 4. Medical record review revealed Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] acid liquid .250 mg / 5 ml .3.5 ml - 125 mg; gastric tube every 8 hours . Observations at the North Hall Medication Cart 1 on 5/14/19 at 10:10 AM, revealed LPN #4 overfilled the medication cup with [MEDICATION NAME] Acid. LPN #4 poured the overfill of [MEDICATION NAME] Acid back into the Resident #172's medication bottle. Interview with the LPN #4 on 5/14/19 at 10:20 AM, at the North Hall Medication Cart 1, LPN #4 was asked if it was appropriate to pour the overfill of medication back into the original dispensing bottle. LPN #4 stated, .probably not . Interview with the Director of Nursing (DON) on 5/14/19 at 1:25 PM, in the DON office, the DON was asked what she expected her nursing staff to do when too much liquid medication was poured in the medicine cup. The DON stated, .dispose of the overfill medication in a sharps container . The DON was asked if it was appropriate to pour the overfill of medication back into the dispensing bottle of medication. The DON stated, .No, not appropriate .

Based on policy review, Manufacturer Guidelines, medical record review, observation, and interview, 2 of 4 (Licensed Practical Nurse (LPN) #1 and #2) nurses failed to follow the facility policy for the destruction of a medication and failed to follow facility policy for the application of a [MEDICATION NAME] during medication administration. The findings include: 1. The facility's Controlled Substance Disposal policy dated (MONTH) (YEAR) documented, .It (Controlled Substance) is destroyed in the presence of two licensed nurses, and the disposal is documented on the accountability record/book on the line representing that dose . The (Named Manufacturer's) instructions for the [MEDICATION NAME] Patch, with a revision date of 12/2018 documented, .Do not apply to a skin area where cream, lotion, or powder has recently been applied . The facility's Specific Medication Administration Procedures IIB13: [MEDICATION NAME] Drug Delivery System (Patch) Application policy dated (MONTH) (YEAR) documented, .Identify the clean, hairless location on the body for patch placement . 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] - Schedule V (5) capsule; 400 mg (milligram) .po (by mouth) three times a day . Observations at the North Hall Medication Cart 2 on 5/14/19 beginning at 9:52 AM, revealed LPN #1 dropped Resident #61's [MEDICATION NAME] on top of the medication cart. LPN #1 discarded the pill into the sharps container, on her medication cart, without obtaining a witness to waste the narcotic. Interview with LPN #1 on 5/14/19 at 10:27 AM, at the North Hall Medication Cart 2, LPN #1 was asked what was the facility policy regarding medication destruction. LPN #1 stated, .I should have had another nurse witness that I had destroyed the [MEDICATION NAME]. Interview with the Director of Nursing (DON) on 5/14/19 at 1:25 PM, in the DON office, the DON was asked how she expected her nursing staff to destruct [MEDICATION NAME]. The DON stated, .it ([MEDICATION NAME]) is considered a narcotic and it should be witnessed by 2 nurses when destructing . 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].rivastigmine patch 24 hour; 13.3 mg / 24 hour .[MEDICATION NAME] .Once a day . Observations in Resident #21's room on 5/14/19 at 9:56 AM, revealed LPN #2 removed Resident #21's old [MEDICATION NAME] from her left arm and placed a new [MEDICATION NAME] on her right back. The right back was not cleaned prior to the new [MEDICATION NAME] application. Interview with LPN #2 on 5/14/19 at 9:56 AM, at the North Hall Medication Cart 2, LPN #2 was asked if she should have cleaned the right back area prior to administering the patch. LPN #2 stated, .No, you don't do that . Interview with the DON on 5/14/19 at 1:25 PM, in the DON office, the DON was asked what the procedure was for applying a [MEDICATION NAME]. The DON stated, .clean the site it's ([MEDICATION NAME]) going on . Interview with Certified Nursing Assistant (CNA) #3 on 5/15/19 at 1:29 PM, at the North Hall Nurses Station, CNA #3 was asked what activities she did with Resident #21. CNA #3 stated, .I provide personal care . lotion her up . CNA #3 was asked if she applied lotion to her back after a shower or bath. CNA #3 stated, .sometimes I do put lotion on her back .and massage too .

Based on record review, observation and staff interview the facility failed to ensure a resident with a contracture had a comprehensive care plan addressing the contracture for 1 of 16 (Resident #25) residents reviewed. The findings included: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE] revealed the resident was severely cognitively impaired for daily decision making. Review of the Range of Motion section revealed, Resident #25 was limited in her upper and lower extremity on one side, required extensive assistance of two for bed mobility and was totally dependent of two persons for all other activities of daily living (ADL). Review of the care plan dated 6/15/17 revealed, Self-care deficit; requires total staff assist for all ADL needs. One of the approaches was Resident #25 would receive passive range of motion (PROM) and active assist range of motion (AAROM) exercises daily. There was no care plan found regarding her one sided upper and lower limitation. Observations on 6/27/17 at 10:38 AM Resident #25 was observed in her bed sleeping. Her right and left hand were in a fist like position. Observations on n 6/28/17 at 9:00 AM, 10:00 AM, 11:45 AM and 1:21 PM the resident was observed to be lying in bed with both of her hands to be held in a fist like position her legs were bent at the knees. Observations on 6/28/17 at 10:54 AM Resident #25 was observed in bed, pillow between legs, bilateral heel protector boots and she facing towards the door. Both of her hands remained in a fist like position and her legs were bent at the knee. During an interview on 6/26/17 at 1:51 PM, Registered Nurse (RN) 2 stated that Resident #25 had bilateral upper and lower extremity contractures. During an interview on 6/28/17 at 10:04 AM Certified Nursing Assistance (CNA) #4 stated Resident #25' s lower extremities were contracted as well as her left hand contracted. During an interview on 6/28/17 at 10:45 AM Licensed Practical Nurse (LPN) #4 stated she has worked with Resident #25 on and off for the past five years and Resident #25 has been contracted of her left hand and bilateral lower extremities since this time. During an interview on 6/28/17 at 4:25 PM with the MDS coordinator, The MDS coordinator stated she must have made an error in coding the MDS as Resident #25 has limited ROM in the bilateral upper and lower extremities. During an interview on 6/28/17 at 4:30 PM with the Assistant Director of Nursing (ADON), the ADON confirmed when a resident has contractures a care plan should be in place. There was no care plan found regarding the resident's contractures.

Based on policy review, observation, and interview the facility failed to ensure food was served under sanitary conditions when 4 of 21 (Certified Nursing Assistant (CNA) #5, 6, and 7 and Licensed Practical Nurse (LPN) #1) staff members observed during dining failed to perform proper hand hygiene. The findings included: 1. The facility's Blood-Borne Pathogen Exposure Control Plan policy documented, .HANDWASHING PROCEDURES .When to wash hands .Before passing out trays or handling food . 2. Observations in Resident #24's room on 6/26/17 at 11:55 AM, revealed CNA #5 raised the head of the bed, opened the salad dressing and placed it on the salad without performing hand hygiene. Observations in Resident #59's room on 6/26/17 at 11:57 AM, revealed CNA #5 raised the head of the bed, opened the silverware, placed the clothing protector around the resident's neck, opened the straw and placed it in the tea, then opened the salad and the cake without performing hand hygiene. Observations in Resident #10's room on 6/26/17 at 12:00 PM, revealed CNA #5 touched the lettuce in the bowl with her bare hand, set up Resident #10's meal tray, and then served the meal to Resident #10 without performing hand hygiene. Observations in Resident #48's room on 6/28/17 at 12:05 PM, revealed CNA #6 pulled the bed linens over Resident #48 and then opened the silverware, took the lid off the glass of milk,and opened a container of ice cream without performing hand hygiene. Observations in Resident #66's room on 6/26/17 at 12:07 PM, revealed CNA #6 raised the head of the bed, then opened the silverware, placed a clothing protector around the resident's neck, opened the straw and placed in the drink, opened the ice cream, took the lid off the salad and then placed salad dressing on the lettuce without performing hand hygiene. Observations in Resident #66's room on 6/26/17 at 12:22 PM, revealed LPN #1 raised the head of the bed, then opened the containers of liquids and fed Resident #66 without performing hand hygiene. Observations in Resident #24's room on 6/28/17 at 8:10 AM, revealed CNA #7 turned her name badge over to the back of her uniform with her hand, then placed butter and jelly on a biscuit, opened a sugar package and placed the sugar over the cereal, and poured the milk over the cereal without performing hand hygiene. Observations in Resident #59's room on 6/28/17 at 8:13 AM, CNA #7 raised the head of the bed, then took the lids off the drinks, took the cover off the plate, then cut up a biscuit and opened the orange juice without performing proper hand hygiene. Observations in Resident #66's room on 6/28/17 at 8:35 AM, LPN #1 raised the head of the bed, moved a chair close to the bed, then began to assist Resident #66 with the meal, then lowered the bed and fed the resident more food without performing hand hygiene. Interview with the Director of Nursing (DON) on 6/28/17 at 9:45 AM, in the DON office, the DON was asked if it is acceptable to touch objects in the environment and then assist the resident or feed the resident without performing hand hygiene. The DON stated, No, not without washing their hands

Based on observation, and interview the facility failed to provide care in a manner that ensured the residents' dignity, respect, and quality of life was maintained when 1 of 21 (Licensed Practical Nurse (LPN) #1) staff members observed during dining stood over a resident while assisting them to eat. The findings included: Observations in Resident #66's room on 6/26/17 at 12:22 PM, revealed LPN #1 stood over Resident #66 while assisting him to eat. Interview with the Director of Nursing (DON) on 6/28/17 at 9:45 AM, in the DON office, the DON was asked if it was acceptable to stand over a resident while assisting them to eat. The DON stated, No, ma'am.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 5 dietary staff members (Cook #1) performed hand hygiene during meal preparation. This had the potential to effect 66 of 67 residents receiving a meal tray. The findings included: Review of the facility's Handwashing policy revealed, .Hands should be washed . after touching hair, face, or body . before putting on gloves . touching clothing or apron; or after touching anything that might contaminate hands, such as dirty equipment, work surfaces, or towels . Observations in the kitchen on 4/19/16 at 11:20 AM, revealed Cook #1 prepared the corn bread and removed gloves. Cook #1 then picked up a electrical cord for the warmer from the floor barehanded and wrapped the cord around the handle of the warmer. Cook #1 then threw the gloves away and scratched her nose. Cook #1 uncovered the foil over the food on the steam table and picked up a dirty, wet rag off of the steam table and place on her shoulder. Then Cook #1 began to obtain the temperatures of the food on the steam table and recorded temperatures on a paper log. Cook #1 touched a bowl of salad while getting the temperature of the salad and recorded the temperature on a paper log and opened a carton of milk and took the temperature of the milk and logged it. Cook #1 picked up the dirty alcohol wipes that she was using to clean the thermometer and documented the temperature of the milk while holding the wipes. Cook #1 then stacked the plate covers on the shelf above the steam table, positioned the plate cart next to the steam table, donned gloves and began to put food on the plates. Cook #1 did not perform hand hygiene. Interview with the Kitchen Manager (KM) on 4/19/16 at 11:50 PM, in the kitchen, the KM was asked what she expected her staff to do between glove changes. The KM stated, I expect them to wash their hands in between tasks and when they change gloves.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 5 dietary staff members (Cook #1) performed hand hygiene during meal preparation. This had the potential to effect 66 of 67 residents receiving a meal tray. The findings included: Review of the facility's Handwashing policy revealed, .Hands should be washed . after touching hair, face, or body . before putting on gloves . touching clothing or apron; or after touching anything that might contaminate hands, such as dirty equipment, work surfaces, or towels . Observations in the kitchen on 4/19/16 at 11:20 AM, revealed Cook #1 prepared the corn bread and removed gloves. Cook #1 then picked up a electrical cord for the warmer from the floor barehanded and wrapped the cord around the handle of the warmer. Cook #1 then threw the gloves away and scratched her nose. Cook #1 uncovered the foil over the food on the steam table and picked up a dirty, wet rag off of the steam table and place on her shoulder. Then Cook #1 began to obtain the temperatures of the food on the steam table and recorded temperatures on a paper log. Cook #1 touched a bowl of salad while getting the temperature of the salad and recorded the temperature on a paper log and opened a carton of milk and took the temperature of the milk and logged it. Cook #1 picked up the dirty alcohol wipes that she was using to clean the thermometer and documented the temperature of the milk while holding the wipes. Cook #1 then stacked the plate covers on the shelf above the steam table, positioned the plate cart next to the steam table, donned gloves and began to put food on the plates. Cook #1 did not perform hand hygiene. Interview with the Kitchen Manager (KM) on 4/19/16 at 11:50 PM, in the kitchen, the KM was asked what she expected her staff to do between glove changes. The KM stated, I expect them to wash their hands in between tasks and when they change gloves.

Based on policy review, observation, and interview, the facility failed to maintain a resident's dignity and respect during dining and activities for 1 of 12 (Resident #103) sampled residents of the 24 residents included in the stage 2 review. The findings included: Review of the facility's Patient's Rights policy revealed, .Your comfort, safety, health and happiness are our concern . Observations in the dining room on 4/18/16 at 12:22 PM, revealed Resident #103 sitting in her wheelchair at a dining table. Resident #103 was eye level with the top of the dining table. Observations in the dining room on 4/19/16 at 3:05 PM, revealed Resident #103 was sitting at a table coloring a picture. Resident #103 had to raise her arm up and over the table top to reach the picture she was coloring. Interview with Resident #103 on 4/19/16 at 8:10 AM, in Resident #103's room, Resident #103 was asked if the height of the dining tables during her meals and activities ever bothered her. Resident #103 stated, Sure, I don't like it. I've been little all my life. I almost bit the table during a meal by accident and just hoped no one saw. Sometimes I will put a blanket in my chair to lift me up some. Interview with the Director of Nursing (DON) and the Administrator on 4/20/16 at 10:25 AM, in the Administrator's office, the DON and Administrator were asked what was the first thing you would notice about Resident #103. The DON stated, She's a short and petite lady. The DON and Administrator were asked if anyone had spoken to Resident #103 about her positioning during dining and activities. Both the Administrator and DON shook their head, indicating no. The Administrator stated, I don't think anybody has asked her how she feels about being eye level to the table top.

Based on medical record review and interview, the facility failed to ensure a resident's assessment was updated on a quarterly basis for 1 of 12 (Resident #11) sampled residents reviewed of the 24 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) had an assessment reference date of 11/3/15. The facility was unable to provide documentation of a quarterly MDS being completed after the admission MDS of 11/3/15. Interview with the MDS Coordinator on 4/19/16 at 3:05 PM, in the MDS office, the MDS Coordinator was asked about the quarterly MDS for Resident #11. The MDS Coordinator stated, I missed it. The MDS coordinator was asked if it was due in February 2016. The MDS Coordinator stated, I believe so, we are working on it now.

Based on medical record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) for diagnosis, medication, and height for 1 of 12 (Resident #103) sampled residents of the 24 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] did not document a [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] did not document the use of an antidepressant or the height of 56 inches. The History and Physical dated 1/5/16 documented Resident #103 had a [DIAGNOSES REDACTED]. The Physician orders [REDACTED]. [MEDICATION NAME] (antianxiety) 7.5 mg (milligrams) . by mouth twice daily . [MEDICATION NAME] (antidepressant) 10 mg . 1 by mouth daily . Interview with the MDS Coordinator on 4/20/16 at 9:25 AM, in the conference room was asked if the admission MDS [DIAGNOSES REDACTED].#103 was taking the medication [MEDICATION NAME]. The MDS Coordinator stated, No, it's not accurate. The MDS Coordinator was asked if the MDS dated [DATE] was accurately as Resident #103 was taking the medication [MEDICATION NAME]. The MDS Coordinator stated, No, it's not accurate. Interview with the MDS Coordinator on 4/20/16 at 3:15 PM, in the Director of Nursing's office, was asked if the admission MDS and the quarterly MDS was accurate for Resident #103's height. The MDS Coordinator stated, No, the admission MDS is not accurate. The resident is 56 inches.

Based on review of a Survey and Certification Letter, record review and interview, the facility failed to provide the appropriate liability and appeal notice to 3 of 3 (Residents #15, 59 and 87) sampled residents reviewed for liability and appeal notices. The findings included: 1. The Survey and Certification Letter Ref (reference): S&C (Survey and Certification) - 09-20 dated 1/9/09 documented, .Notice Delivery to Representatives . Providers are required to develop procedures to use when the beneficiary is incapable . and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact . provider should telephone the representative . Confirm telephone contact by written notice mailed on that same date . 2. The Notice of Medicare Non-Coverage form for Resident #15 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & (and) Therapy) Services Will End: 1/19/16 . Telephone contact was made with the resident's responsible party on 1/14/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 3. The Notice of Medicare Non-Coverage form for Resident #59 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 11/6/2015 . Telephone contact was made with the resident's responsible party on 11/2/15. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 4. The Notice of Medicare Non-Coverage form for Resident #87 documented, .The Effective Date Coverage of Your Current (Skilled Nursing & Therapy) Services Will End: 3/09/2016 . Telephone contact was made with the resident's responsible party on 3/4/16. The facility was unable to provide any documentation that the telephone contact was confirmed by written notice as required. 5. Interview with the Social Worker (SW) on 4/20/16 at 11:00 AM, in the Social Worker's office, the SW was asked if the date on the top of the page was the date she notified the legal representative of the end of their services for Resident #15, 59 and 87. The SW stated, Yes, I called them. The SW was then asked did she have any documentation that the Notice of Medicare Non-Coverage letters were mailed on the date of notice. The SW stated, No, I thought as long as I documented I talked to them then that was all I had to do.

Based on policy review, observation and interview, the facility failed to ensure formula was not store past the expiration date, failed to date food products when opened and failed to store opened cleaning solutions away from food preparation areas on 2 of 4 days of the survey (3/29/15 and 3/30/15). The findings included: 1. Review of the facility's Safety & (and) Sanitation Best Practice Guidelines policy documented, .Cleaning and sanitizing chemicals must be stored separate from food and storage areas in designated areas such as janitor's closet or mop room. Foods will be stored in their original container. Clearly labeled with the contents and the use by date. Once food is cooked, such perishable items must be labeled with the discard date before placing in the refrigerator. 2. Observations in the walk in freezer at 3/29/15 at 9:00 AM, revealed an open bag of frozen hamburger patties and frozen meatballs. There was no open date or use by date noted on the bags. Interview with the Dietary Manager (DM) on 3/29/15 at 9:35 AM, in the kitchen the DM was asked if the open bags of food should be dated. The DM stated, Yep, they did not put the date opened. 3. Observations in the walk in refrigerator on 3/29/15 at 9:20 AM, revealed 2 cases of 8 ounce cans of formula stored past the expiration date of January 2015. Interview with the DM on 3/29/15 at 9:20 AM, in the walk in refrigerator, the DM confirmed the formula supplement was expired. 4. Observations in the kitchen on 3/29/15 at 9:30 AM, revealed water running over 2 beef pot roasts in the manufacture packaging, and a zip lock baggie of hamburger patties thawing in the two compartment sink. There was a bucket of cleaning solution and a bucket of sanitizer sitting on the ledge of the sink. Observations in the kitchen on 3/30/15 at 4:45 PM, revealed a bucket of cleaning solution and a bucket of sanitizer sitting on the ledge of the two compartment sink. Interview with the DM on 3/29/15 at 9:33 AM, in the kitchen, the DM was asked if it was acceptable for the cleaning solutions to be sitting on the ledge next to the thawing food. The DM stated, It (cleaning solution) is what we clean and wipe down with. One is the sanitizer. The DM never answered if it was acceptable for the cleaning solutions to be sitting on the ledge next to the thawing food. 5. Observations in the kitchen on 3/29/15 at 9:35 AM, revealed a half gallon of burgundy sauce, one gallon of marsala sauce, olive oil, bag of chips and a 12 pound tub of chocolate icing were opened and undated. The top of the 12 pound tub of chocolate icing was not snapped shut. Interview with the DM on 3/29/15 at 9:38 AM, in the kitchen, the DM was asked about the opened containers that were not dated. The DM stated, Usually has a discard date. I don't see it.

Based on policy review, observation and interview, the facility failed to ensure medications were securely stored in 1 of 8 (North short hall medication cart) medication storage areas. The findings included: Review of the facility's medication administration policy documented, .Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observations on the north short hall on 3/31/15 at 9:01 AM, revealed the north short hall medication cart was left unlocked, unattended and out of the nurse's view. Interview with the Director of Nursing (DON) on 3/31/15 at 9:03 AM, in the north short hall, the DON was asked if she noticed anything about the medication (med)cart. The DON stated, The cart is unlocked The DON was asked what she expected of her staff. The DON stated, I expect the nurses to lock the cart when they are out of the line of site of the med cart. Interview with Licensed Practical Nurse (LPN) #2 on 4/11/15 at 1:48 PM, in the charting room, LPN #2 was asked about leaving her medication cart unlocked. LPN #2 stated, I'm sorry. We have too many wandering patients. That is not kosher. I'm so sorry.

Based on medical record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for urinary continence for 1 of 3 (Resident #32) sampled residents reviewed of the 31 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #32 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital transfer form dated 10/7/14 documented Resident #32 was incontinent of bowel and bladder. Review of the interim care plan dated 10/7/14 documented, .Incontinence care as needed per protocol. Review of the admission MDS dated [DATE] documented the resident was assessed to always be continent. Review of a care plan dated 10/30/14 documented, .Cleanse and dry thoroughly after each incontinent episode. Patient at risk for complications related to functional incontinence. Review of the 30 day MDS dated [DATE] documented the resident was assessed to frequently be incontinent. Interview with Registered Nurse (RN) #1 on 3/31/15 at 4:30 PM, in the MDS office, RN #1 was asked where the information was obtained for the MDS assessment. RN #1 stated, I go around and talk to the CNTs (certified nursing technicians). RN #1 was asked if the CNT documentation shows continent versus incontinent. RN #1 stated, Their documentation shows amount of assistance the patient needs but not if they are continent or incontinent. Interview with RN #1 on 4/1/15 at 7:47 AM in conference room, RN #1 was asked if she followed up staff interviews with chart reviews for information concerning residents. RN #1 stated, Yes. Interview with CNT #1 on 4/1/15 at 1:37 PM, on the south hall next to room [ROOM NUMBER], CNT #1 was asked if Resident #32 was continent or incontinent when he arrived at the facility. CNT #1 stated, He would try to hold his urine but sometimes he couldn't. Sometimes I would have to change his clothes. CNT #1 was asked how she would document if a resident had 1 episode of incontinence. CNT #1 stated, Document it incontinent times one, would be incontinent. Interview with RN #1 on 4/1/15 at 1:38 PM in conference room, RN #1 was shown the admission MDS along with the nurses' admission documentation. RN #1 was asked if she would consider the admission MDS to be inaccurate. RN #1 stated, Yes, it is inaccurate.

Based on policy review, medical record review, observation and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN) #1) nurses administered the correct amount of water flush before and after administering medications through Resident #55's gastrostomy tube. The findings included: Review of the facility's specific medication administration policy documented, .10) Put 30ml (milliliters) (ml is same as cubic centimeters (cc)) of water in syringe and flush tubing using gravity flow. 11) Pour dissolved / diluted medication in syringe. allowing medication to flow by gravity. 12) After all medications have been administered, flush tubing with 30ml water. Medical record review revealed Resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/17/15 documented, .Provide TF (Tube Feeding) flushes 450cc minimal q (every) shift TID (three times per day). Observations in Resident #55's room on 3/31/15 at 9:24 AM, revealed LPN #1 flushed the PEG tube with 15 ml of water, administered the medications via the gastrostomy tube, and then flushed the tube with 15 ml of water. Interview with the Director of Nursing (DON) on 3/31/15 at 10:20 AM, in the conference room, the DON confirmed the tube should be flushed with 30 ml of water as stated in the facility policy. Interview with LPN #1 on 3/31/15 at 11:08 AM, in the conference room, LPN #1 was asked how much water she used to flush the tube at the beginning and the end of administering medications to Resident #55. LPN #1 stated, I used 15 (ml) to flush the tube then, I used 15 (ml) at the end again.

Based on observation and interview, it was determined the facility failed to ensure facility partners and/or visitors did not enter the kitchen without wearing a hair covering on 2 of 3 (9/16/13 and 9/18/13) days of kitchen observations and failed to ensure an opened bag of chicken strips was dated when opened on 2 of 3 (9/16/13 and 9/17/13) days of kitchen observations. The findings included: 1. Observations in the facility's kitchen on 9/16/13 at 9:05 AM, revealed an adult male dressed in street clothes without a hair covering on standing in the kitchen. Observations in the facility's kitchen on 9/18/13 at 11:31 AM, revealed 2 staff members getting drinks in the kitchen without hair coverings on. At 11:35 another staff member entered without a hair covering on, and at 11:40 AM a fourth staff member entered the kitchen without a hair covering on. 2. Observations in the facility's kitchen refrigerator on 9/16/13 at 9:15 AM and 9/17/13 at 1:46 PM, revealed a half of a bag of chicken strips closed with a twist tie. The bag was not dated when opened. During an interview in the kitchen on 9/18/13 at 12:00 PM, the Certified Dietary Manager (CDM) confirmed the opened bag of chicken strips had not been dated when opened. The CDM stated the facility's corporate policy, to this date, has been to allow staff in the kitchen in the self-serve drink area to get their own drinks.

Based on review of the facility's patient rights booklet, medical record review, observation and interview, it was determined the facility failed to promote care that maintained the residents' dignity, respect and quality of life by allowing a resident to remain suspended in the air in a sling of a lift with the hallway door open and the privacy curtain not pulled for 1 of 25 (Resident #57) sampled residents included in the stage 2 review. The findings included: Review of the facility's patient's rights booklet documented, "...PRIVACY... we provide you with privacy so that you may maintain a dignified existence..." Medical record review for Resident #57 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #57's quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #57's cognitive level was severely impaired and was dependent on 2 staff members for transfer that required a lift. Observations in Resident #57's room on 9/16/13 10:59 AM, revealed Resident #57 suspended in the air in a sling while Certified Nursing Technician (CNT) #2 moved the wheelchair under the resident. The privacy curtain was not pulled and the door was open to the hall. During an interview in the Director of Nursing's (DON) office on 9/17/13 at 4:30 PM, the DON was asked if it is acceptable for a staff member to use the lift to get a resident up in the wheelchair with the door open and the curtain not pulled around the bed while the resident is up in the sling and she is trying to get the wheelchair under the resident. The DON stated, "No, absolutely not."