Every finding on record at Nhc-Maury Regional Transitional Care Center

Based on policy review, medical record review, and interview, the facility failed ensure 2 person assist was used for a resident at risk for falls for 1 of 3 sampled residents (Resident #1) reviewed for falls. The finding include: Review of the facility's undated policy titled, Fall Prevention Program, revealed .Purpose: To reduce patient's risk of falling .Objective: To reduce the number of incidents of patient falls .Procedure: .Apply fall risk interventions as appropriate for the patient. Review of the medical record, revealed Resident #1 was admitted to facility on 12/16/2021 with diagnosis of Cerebral Infarction, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Alzheimer's Disease and Oxygen. Review of the 5 day admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 required extensive assist with 2 or more person physical assist with transfers and toilet use. Review of the Resident Progress Notes revealed, .12/16/2021 .Assist x [times] 2 with transfers .12/17/2021 .Staff assist x 2 with transfers .incontinent care .12/19/2021 .Staff assist X2 with transfers .and incontinence care .12/25/2021 .Extensive assist X2 with ADLs [Activities of Daily Living] and transfers . Review of the FSI-Fall Scene Investigation Report, dated 12/25/2021, revealed .was sitting on toilet and slid off . Review of the Event Report dated 12/25/2021, revealed .Called to room by tech [technician], Observed patient on floor on her right side. Stated she had slid off the toilet. Bump to right side of head, tender to touch. No abrasion or bleeding noted. No C/O [complaints of] pain or discomfort. Patient was assisted to wheelchair and bed. Nuero [neurological] checks initiated and were within normal limits. Vital signs within normal limits .STAFF EDUCATED TO PREPARE MATERIAL BEFORE TOILETING PATIENT IN ORDER TO KEEP PATIENT STABILIZED WHILE TOILETING . During a telephone interview on 2/24/2022 at 12:17 PM, Certified Nursing Assistant (CNA) #1 confirmed he had transferred and placed Resident #1 on the toilet by himself on this date, and had transferred and toileted Resident #1 by himself many times prior to this incident. During an interview on 2/24/2022 at 1:41 PM, the Director of Nursing (DON) was asked if only one CNA should assist a resident that is an extensive assist with 2 or more physical assist for transfers and toilet use. The DON stated, No Ma'am.

Based on hospice contract, medical record review, and interview, the facility failed to ensure medications were administered when a resident's Respite stay was extended for 1 of 3 sampled residents (Resident #1) reviewed for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: Review of the AGREEMENT BETWEEN [Named Hospice] AND [Named Skilled Nursing Facility], dated 12/30/2016, revealed .Nursing Facility is skilled and experienced in the operation of a nursing facility and in the provision of long term services to its residents .Facility Requirements .Facility Protocols. Nursing Facility shall institute, maintain and conduct administrative procedures and patient care protocols .in accordance with recognized professional standards of care for terminally ill patients .Patient Care. Nursing Facility shall provide care to each Residential Hospice Patient in an attempt to keep him or her comfortable . Review of the medical record, revealed Resident # 1 was admitted to the facility on [DATE] and discharged home on 10/23/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was severely cognitive impaired and required supervision and limited assistance for all activities of daily living. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Aspirin Children's chewable 81 milligram (mg), give one tablet by mouth daily. 2. [MEDICATION(S)] delayed release/[MEDICATION(S)] coated 5 mg give one tablet by mouth twice a day. 3. [MEDICATION(S)] 10 mg give one tab by mouth daily. 4. [MEDICATION(S)] 10 mg give one capsule by mouth daily at bedtime (HS). 5. [MEDICATION(S)] powder 100,000 unit/gram topical apply to bilateral groin twice a day. 6. [MEDICATION(S)] 1 mg give one tablet by mouth twice a day. 7. [MEDICATION(S)] 25 mg give one tablet by mouth daily. 8. [MEDICATION(S)] 50 mg give one tablet by mouth at bedtime. 9. [MEDICATION(S)] capsule 10 mg give one capsule by mouth at bedtime. 10. Vitamin D3 25 micrograms (mcg) (1,000 unit) give one capsule by mouth daily. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/23/2021 at 5:13 PM, the Director of Nursing (DON) confirmed the physician was not notified when Resident #1's daughter requested to extend his stay past 10/14/2021 and Resident #1 did not receive his medications after the stop date. The DON stated the order was put in with an automatic 5 day stop, and the physician should have been notified of his extended stay.

Based on review of the facility's Nurse Aide Training (NAT) program, review of work schedules and interview, the facility failed to ensure 2 of 24 (Nurse Aide (NA) #1 and NA #2) NAs were removed from the working schedule and not allowed to perform the duties of a Certified Nursing Assistant CNA after 120 days of taking the NAT program. The findings include: Review of the facility working schedule for the months of February, March, (MONTH) and (MONTH) 2019 revealed NA #1 and NA #2 worked as NA performing the duties of a CNA. Interview with the Director of Nursing (DON) on 6/5/19 at 3:00 PM in the DON's office, the DON was asked if NA #1 and NA #2 had passed the CNA certification exam. The DON stated, No . Interview with the DON on 6/5/19 at 6:03 PM in the conference room, the DON was asked when NA #1 and NA # 2 completed the Nurse Aide Training program. The DON stated .they were in the August/September (2018) class. The DON was asked if NA #1 and NA #2 worked at the facility longer than 4 months without being certified. The DON stated, .yes .they worked up until 2 weeks ago . The DON was asked what duties NA #1 and NA #1 performed. The DON stated, .CNA duties . The DON confirmed the NAs should not have worked longer than 4 months without passing the CNA certification exam.

Based on license review and interview, the facility failed to ensure professional staff were licensed in accordance with applicable State laws for 1 of 41 (Licensed Practical Nurse (LPN) #2) nurses reviewed. The findings include: Review of the facility Personnel Action Form for LPN #2 revealed an employment date of [DATE]. Review of the State of Tennessee Department of Health Division of Health Licensure and Regulation Division of Health Related Boards on [DATE] revealed LPN #2's license number had an expired status with an expiration date of [DATE]. Review of the Department Allocation Worksheet for the pay period for [DATE] revealed LPN #2 worked at he facility through [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 3:00 PM in the DON's office, the DON was asked if LPN #2 worked for the facility. The DON stated, .yes .she worked until the middle of (MONTH) (2019) .at that time we discovered her license was expired . The DON confirmed LPN #2 should not have worked on an expired license. The DON was asked who was responsible for license verification. The DON stated, .we are responsible .

Based on policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 3 of 8 (Certified Nursing Assistant (CNA) #1, Physical Therapist Assistant (PTA) #1, and Licensed Practical Nurse (LPN) #1) staff members failed to perform appropriate hand hygiene during contact isolation for Resident #182 and wound care for Resident #181. The findings include: 1. The facility's HANDWASHING policy with a revision date of 4/23/18 documented, .Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .in the case of spore forming organisms such as[DIAGNOSES REDACTED]icile ([MEDICAL CONDITION]) .require soap and water with friction .PR[NAME]EDURE .Wash hands before and after contact with each patient .and before and after removal of gloves . 2. Medical record review revealed Resident #182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff), [MEDICAL CONDITION] Stage 3, Traumatic Subdural Hemorrhage, Diabetes, [MEDICAL CONDITIONS], and Depression. The physician's orders [REDACTED].Strict Isolation-All services provided in room .for [MEDICAL CONDITION] . Observations in Resident #182's room on 6/3/19 at 12:19 PM revealed CNA #1 delivered ice to the resident, removed the gown and gloves, used hand sanitizer, and exited the room. Observations outside Resident #182's room on 6/4/19 at 8:15 AM revealed PTA #1 donned a gown, mask and gloves, and entered Resident #182's room. PTA #1 remained in the room for 37 minutes and exited the room at 8:52 AM without performing hand hygiene. Interview with PTA #1 on 6/4/19 at 8:52 AM outside Resident #182's room, PTA #1 was asked if she washed her hands before she came out of the room. PTA #1 stated, I don't like to use their bathroom . PTA #1 then used the hand sanitizing gel that was on the isolation kit outside the door, and then walked to the therapy gym. Interview with Registered Nurse (RN) #1 on 6/5/19 at 8:03 AM in the conference room, RN #1 was asked why Resident #182 was in isolation. RN #1 stated, [DIAGNOSES REDACTED]. RN #1 was asked what the staff were supposed to do when they entered and exited Resident #182's room. RN #1 stated, They hand wash .the hand gel stuff don't work with the [MEDICAL CONDITION]. They are supposed to wash hands with soap and water coming out of the room. Interview with the Director of Nursing (DON) on 6/5/19 at 8:42 AM in the conference room, the DON was asked if the staff should perform hand hygiene using hand sanitizing gel after they left Resident #182's room. The DON stated, It's not appropriate for the [MEDICAL CONDITION]. 3. Medical record review revealed Resident #181 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Management notes dated 6/1/19 revealed Resident #181 had extensive [DIAGNOSES REDACTED] (a disease in which calcium accumulates in the small blood vessels of the fat and skin tissue) ulcers, 3 to the left upper arm, 3 to the right upper arm, 1 to the right thumb, 1 to the right hand, and 1 to the right wrist. Observations in Resident #181's room on 6/4/19 at 3:21 PM revealed the following: LPN #1 removed the soiled dressing from Resident #181's right upper arm, cleaned the posterior upper wounds with saline soaked gauze, and then used a cotton swab to apply [MEDICATION NAME] gel, using the same gloves. LPN #1 did not perform hand hygiene between cleaning the wound and applying the clean treatment. LPN #1 placed a saline soaked gauze on the wound to the anterior right upper arm, still wearing the same gloves. LPN #1 did not change gloves or wash her hands between different wounds. LPN #1 removed her gloves, and adjusted the thermostat on the wall. LPN #1 did not perform hand hygiene after removing the soiled gloves. LPN #1 cleaned the [MEDICATION NAME] gel from Resident #181's posterior upper arm wounds with saline soaked gauze, and applied [MEDICATION NAME] One (a dressing used for painful wound management that prevents the outer dressing from sticking to the wound bed) and [MEDICATION NAME] Extra (a moisture retention dressing) using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed her gloves, applied clean gloves, and removed the dressing from Resident #181's right lower arm. LPN #1 did not wash her hands between glove changes and between different wounds. LPN #1 cleaned the wounds to Resident #181's right posterior lower arm using saline soaked gauze and then applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, (abdominal pads (ABD) used for large wounds or wounds needing high absorbency), and conforming gauze dressings using the same gloves. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 removed the dressings from Resident #181's right wrist and hand, cleaned the wounds with saline soaked gauze, and applied [MEDICATION NAME] One dressing. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. LPN #1 changed her gloves without performing hand hygiene, and applied [MEDICATION NAME] Extra, ABD pads, and conforming gauze to Resident #181's right wrist. LPN #1 did not perform hand hygiene between glove changes. LPN #1 removed the dressing from Resident #181's left upper arm and changed her gloves without performing hand hygiene. LPN #1 cleaned the wounds to the left upper arm with saline soaked gauze, applied [MEDICATION NAME] One, [MEDICATION NAME] Extra, and ABD pad dressings, and wrapped the right upper arm with gauze. LPN #1 did not change gloves or perform hand hygiene between cleaning the wound and applying clean dressings. Interview with the DON on 6/5/19 at 8:42 AM in the conference room, the DON was asked when staff should perform hand hygiene during wound care. The DON stated, In between clean and dirty, I want them to be washing their hands and changing their gloves. The DON was asked if they were supposed to wash their hands when they changed gloves. The DON stated, Yes.

Based on policy review, medical record review, and interview the facility failed to administer treatment and services to restore normal bowel function for 2 of 4 (Resident #229, and 230) residents reviewed for bowel incontinence. The findings include: 1. The facility's BM (bowel movement) Protocol policy documented, .Polyethylene [MEDICATION NAME] .17 grams by mouth as needed for constipation if no BM in 2 days .Mix in at least 4oz. (ounces) of water or juice in the morning of the 3rd day .[MEDICATION NAME] 10mg (milligram) suppository rectally as needed for constipation if no results from [MEDICATION NAME] by bedtime of the 3rd day .Fleet Enema rectally as needed for constipation if no results from [MEDICATION NAME] suppository, administer at bedtime on the 4th day .If no BM on the morning of the 5th day notify the physician . 2. Medical record review revealed Resident #229 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #229 on 7/30/18 at 5:26 PM, in her room, Resident #229 stated, .been here since Wednesday .haven't had a BM in a week . Review of the physician's orders [REDACTED].#229 was on the BM Protocol. Review of the Toileting .BM record revealed Resident #229 did not have a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. Review of the Med (medication) PRN (as needed) record dated 7/1/18 to 7/31/18 revealed Resident #229 did not receive Polyethylene [MEDICATION NAME] on 7/28/18 (the 3rd day) and did not receive the [MEDICATION NAME] rectal suppository on 7/29/18 (the 4th day) as ordered per the BM protocol. Interview with Registered Nurse (RN) #1 on 8/1/18 at 2:28 PM in the Minimum Data Set (MDS) office, RN #1 reviewed the Toileting .BM record for Resident #229, and confirmed that Resident #229 had not had a BM on 7/26/18, 7/27/18, 7/28/18, 7/29/18, 7/30/18, and 7/31/18. RN #1 reviewed the Med PRN record dated 7/1/18 to 7/31/18, and stated, She didn't get the medication . 3. Medical record review revealed Resident #230 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#230 was on the BM Protocol. Review of the electronic Toileting .BM record revealed Resident #229 did not have a BM on 7/21/18, 7/22/18, and 7/23/18. Review of the Med PRN record dated 7/1/18 to 7/31/18 revealed Resident #230 did not receive the Polyethylene [MEDICATION NAME] on 7/23/18 (the 3rd day). 4. Interview with the the Nurse Practitioner on 8/1/18 at 11:27 AM in the conference room, the Nurse Practitioner was asked if she had been notified about Resident #229 and 230 not having BMs. the Nurse Practitioner stated, .I was not aware .The expectation is the nurses follow the bowel protocol . Interview with RN #1 on 8/1/18 at 2:38 PM in the MDS office, RN #1 reviewed the Toileting .BM record for Resident #230, and confirmed that Resident #229 had not had a BM on 7/21/18, 7/22/18, and 7/23/18. RN #1 stated, He should have gotten the Polyethylene [MEDICATION NAME] on that third day. Interview with the Director of Nursing (DON) on 8/1/18 at 3:01 PM in the conference room, the DON confirmed that Resident #229 and #230 should have received medication after no BM for 3 days, and stated that it was not appropriate for staff to not follow the bowel protocol.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain respiratory equipment in a sanitary manner for 2 of 2 (Resident #16 and 178) sampled residents reviewed for respiratory care. The findings include: 1. The facility's RESPIRATORY MANUAL .Aerosol Therapy policy last revised 7/14, documented, .Cautions .Nebulizer can become contaminated resulting in an infection . 2. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME] sulfate .1 ampul ([MEDICATION NAME]) nebulization every 2 hours As Needed SHORTNESS OF BREATH NEBULIZATION .Dx (Diagnosis) .[MEDICAL CONDITION] . The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization 3 times per day NEBULIZATION .Dx .[MEDICAL CONDITION] . Observations in Resident #16's room on 7/30/18 at 5:38 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Observations in Resident #16's room on 7/31/18 at 8:30 AM revealed Resident #16 in bed with the nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. The mouthpiece was on the floor. Observations in Resident #16's room on 7/31/18 at 5:09 PM revealed Resident #16 in bed, with a nebulizer on the bedside table. The tubing and mouthpiece were attached and dated 7/26/18. There was no cover or clean barrier for the mouthpiece. Interview with Licensed Practical Nurse (LPN) #1 on 7/31/18 at 5:13 PM on the Grove wing, LPN #1 was asked how the nebulizer tubing, masks, and mouthpieces should be stored. LPN #1 stated, .In a little baggie beside the machine. LPN confirmed the mouthpiece was not on a barrier or covered. 3. Medical record review revealed Resident #178 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .1 ampul nebulization every 6 hours .NEBULIZATION .Dx .shortness of breath . Observations in Resident #178's room on 7/30/18 at 12:51 PM, and on 7/31/18 at 8:44 AM, 11:36 AM, and 4:56 PM, revealed Resident #178 in bed, with a nebulizer on the bedside table. The tubing and mask were attached and dated 7/25/18. The mask and tubing were uncovered without a barrier. Interview with LPN #1 in Resident #178's room on 7/31/18 at 5:14 PM, LPN #1 confirmed the nebulizer tubing and mask were not covered or placed on a clean barrier and stated, It needs to be covered. Interview with the Director of Nursing (DON) on 7/31/18 at 5:31 PM in the conference room, the DON was asked how the nebulizer masks, mouthpieces, and tubing should be stored. The DON stated, There's a bag they are supposed to be using. and further stated it was unacceptable for them to be out on the bedside table without a cover or a clean barrier.

Based on worksheet review, medical record review, and interview, the facility failed to ensure there was communication between the facility and the [MEDICAL TREATMENT] clinic for 1 of 1 (Resident #3) sampled residents reviewed for [MEDICAL TREATMENT]. The findings include: The facility's [MEDICAL TREATMENT] Communication Worksheet documented, .ongoing assessment of the patient's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] clinic .Center nurse complete On [MEDICAL TREATMENT] days Pre-[MEDICAL TREATMENT] section of the form prior to appointment .Send with patient to [MEDICAL TREATMENT] clinic .Request the [MEDICAL TREATMENT] clinic to complete the bottom portion of form .return it to the center with the patient . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICAL TREATMENT] every Tuesday, Thursday, Saturday (medication administration record) each [MEDICAL TREATMENT] 3 times per week (Tuesday, Thursday, Saturday) . The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and the resident received [MEDICAL TREATMENT] services. Review of the Care Plan dated 1/17/18 revealed [MEDICAL CONDITION] with [MEDICAL TREATMENT] three times a week. Review of the [MEDICAL TREATMENT] communication forms revealed documentation was not completed on the forms dated 7/17/18, 7/19/18, 7/21/18 and 7/30/18. Interview with the Director of Nursing (DON) on 8/1/18 at 5:09 PM in the conference room, the DON was asked how she expected the nurses to communicate with the [MEDICAL TREATMENT] center. The DON stated, The nurse fills out the pre [MEDICAL TREATMENT] form .it goes with the patient to [MEDICAL TREATMENT] clinic .the [MEDICAL TREATMENT] clinic completes form .the form comes back with the patient .it's scanned into the system . The DON was asked what she expected the nurses to do if the [MEDICAL TREATMENT] center did not send back the form. The DON stated, .I would think they should call the clinic to see if they can get information .keep me informed so I can know the patient is getting what they need . The facility was unable to provide documentation of communication between the [MEDICAL TREATMENT] center and the facility.

Based on policy review, observation, and interview, 2 of 2 (Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #1) staff failed to ensure infection control practices were maintained to prevent the potential spread of infection during wound care. The findings include: The facility's HANDWASHING policy, dated 10/1/08, documented, Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings, and is an essential element of Standard Precautions .Wash hands before and after contact with each patient, after toileting, smoking or eating, and before and after removal of gloves . Observations in Resident #230's room on 7/31/18 beginning at 11:10 AM, revealed CNA #1 assisting RN #2 with wound care. RN #2 cleaned a marker with a bleach wipe and changed her gloves without performing hand hygiene. CNA #1 touched the bed covers, adjusted the bed, and changed her gloves without performing hand hygiene. RN #1 touched the wound with her gloved left hand and changed her gloves without performing hand hygiene. After applying a foam dressing to the wound, RN #1 changed her gloves without performing hand hygiene. After assisting with positioning Resident #230 during wound care, CNA #1 changed her gloves without performing hand hygiene. Interview with the Director of Nursing (DON) on 8/1/18 at 5:58 PM, in the conference room, the DON was asked what nursing staff should do between removing used gloves and donning clean gloves. The DON stated, Perform hand hygiene.

Based on medical record review and interview the facility failed to notify the Physician of a clinical complication for one resident (#168) of 3 residents reviewed for abuse. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident was rarely/never understood. Medical record review of a nurse note by Registered Nurse (RN) #1 dated 7/18/17 at 8:50 AM revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she noticed the [MEDICATION NAME] was missing around 4 AM. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with LPN #1 on 7/19/17 at 2:55 PM via telephone revealed she worked 7/18/17 from 7 AM to 7 PM and cared for Resident #168. Further interview revealed RN #1 told her at shift change the [MEDICATION NAME] was missing. Continued interview confirmed LPN #1 intended to notify the Physician of the missing [MEDICATION NAME] but failed to do so.

Based on facility policy review, medical record review, and interview, the facility failed to investigate injuries of unknown origin for 1 resident (#379) and failed to initiate an investigation in a timely manner for a missing pain patch for 1 resident (#168) of 35 residents reviewed in Stage II. The findings included: Review of facility policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property, and Exploitation, revised 11/28/16 revealed .abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .An injury should be classified as an injury of unknown source when both of the following conditions are met: (a) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and (b) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property, or exploitation did or did not take place .The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident . Review of facility policy, Miscellaneous Special Situations, Discrepancies, Loss and or Diversion of Medications, dated 6/2016 revealed .All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed .Immediately upon the discovery or suspicion of a discrepancy, suspected loss of diversion, the Administrator, Director of Nursing (DON), Consultant Pharmacist and Director of Pharmacy are notified and an investigation conducted. The Director of Nursing leads the investigation .Appropriate agencies, required by state regulation will be notified . Medical record review revealed Resident #379 was admitted to the facility on [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #379 scored 15/15 on the Brief Interview for Mental Status, indicating she was alert and oriented. Continued review of the MDS revealed Resident #379 required extensive assistance of 2 people for transfers and toileting; extensive assistance of 1 person for dressing and bathing; assistance of 1 person for grooming; supervision for eating; and was frequently incontinent of bowel and bladder. Medical record review of nursing notes dated 10/28/16 revealed Resident #379 had bilateral upper extremity skin tears. Continued review of nursing notes dated 11/4/16 revealed the resident had multiple skin tears to bilateral upper extremities. Review of incident reports revealed none were completed for these injuries and no investigations were completed for multiple injuries of unknown origin Interview with the Director of Nursing (DON) on 7/19/17 at 4:30 PM in the conference room, confirmed there were no incident reports for the skin tears which occurred on 10/28/17 and 11/4/17. Continued interview with the DON confirmed there was no investigation into either injury of unknown origin. Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of a nurse note dated 7/18/17 at 8:50 AM by Registered Nurse (RN) #1 revealed did not find [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) to R (right) chest as documented. will ask on coming nurse to double-check and if none found, to place another patch. Interview with RN #1 on 7/19/17 at 2:25 PM via telephone revealed she worked the 7PM to 7AM shift the night of 7/17/17 and cared for Resident #168. Further interview revealed she checked the placement of the [MEDICATION NAME] around 4 AM and could not find it. Continued interview revealed RN #1 reported the missing [MEDICATION NAME] to Licensed Practical Nurse (LPN) #1 at shift change and asked her to get it replaced if it wasn't found. Interview with RN #3, Unit Manager on 7/19/17 at 2:45 PM in the conference room, when asked her expectation of when staff should notify her of a missing [MEDICATION NAME] on a resident revealed she would expect to be notified immediately. Continued interview revealed she was notified of the missing [MEDICATION NAME] for Resident #168 at approximately 9 AM on this date by LPN #2. Interview with the DON on 7/19/17 at 4:38 PM in the conference room revealed she did not find out about the missing [MEDICATION NAME] until this morning, and an investigation had since been initiated. Continued interview revealed RN #1 did not report the missing [MEDICATION NAME] to the unit supervisor or the DON. Further interview revealed the incident had not been reported to the state agency. Continued interview with the DON confirmed RN #1 did not report the possible misappropriation of narcotic medication in a timely manner and the facility did not report to the State Agency in the required time period.

Based on medical record review and interview the facility failed to accurately document on the Medication Administration Record [REDACTED]. The findings included: Medical record review revealed Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status could not be conducted because the resident is rarely/never understood. Medical record review of the MAR for July 2017 revealed .CHECK - Patch placement every shift . (narcotic pain medication [MEDICATION NAME]). Continued review revealed documentation the patch was not found on the night shift on 7/17/17. Further review revealed documentation for patch placement on 7/18/17 as RT AC (right [MEDICATION NAME]). Interview with Licensed Practical Nurse (LPN) #1 on 7/19/17 at 2:55 PM via telephone when asked did the resident have a [MEDICATION NAME] (narcotic pain medication [MEDICATION NAME]) in place on 7/18/17 stated she could not find it. Continued interview when asked about the documentation of checking the patch placement for the [MEDICATION NAME] on 7/18/17 stated I think I put it was on but I should have put not in place. Further interview revealed LPN #1 stated didn't document it right. Interview with the Director of Nursing on 7/19/17 at 4:38 PM in the conference room when asked about LPN #1's documentation regarding the [MEDICATION NAME] placement on the 7/18/17 day shift revealed it was incorrect. Continued interview with the DON confirmed the facility failed to accurately document the [MEDICATION NAME] placement on 7/18/17 day shift for Resident #168.

Based on review of Notice of Medicare Non-Coverage forms, resident council meeting minutes, medical record review and interview, the facility failed to provide the appropriate liability and appeal notice to 2 of 3 (Residents #26 and 121) sampled residents reviewed for liability and appeal notices, and the facility failed to inform residents of ombudsman information during resident council meetings. The findings included: 1. The Notice of Medicare Non-Coverage form for Resident #26 documented, .The Effective Date Coverage of Your Current Skilled Rehab Therapy Services Will End: 3/9/2016 . The facility was unable to provide any documentation that contact was confirmed by written notice as required. 2. The Notice of Medicare Non-Coverage form for Resident #31 documented, .The Effective Date Coverage of Your Current Skilled Rehab Therapy Services Will End: 05/16/16 . The facility was unable to provide any documentation that contact was confirmed by written notice as required. 3. In an interview with the Social Worker (SW) on 6/9/16 at 11:10 AM, in the conference room, the SW was shown Resident #26 and 121's liability and appeal notices and the SW confirmed they had not been signed. The SW was asked how would she show that the residents had been informed. The SW stated, .I wouldn't . 4. Review of the monthly resident council meeting minutes dated January through May, 2016 did not reflect any discussion of ombudsman information, where the information was posted or who the ombudsman was. 5. Medical record review revealed Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. In an interview with Resident #121 on 6/9/16 at 9:18 AM, in Resident #121's room, she was asked are you familiar with where the ombudsman information is posted. Resident #121 stated, No ma'am. Resident #121 was asked are you familiar with the ombudsman? Resident #121 stated, No ma'am.

Based on policy review, medical record review, observation and interview, the facility failed to provide privacy during medication administration as evidenced by 2 of 5 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) nurses that administered medications while leaving the window blinds open in full view of the parking area. The findings included: 1. The facility's PRIVACY policy documented, .we provide .privacy .maintain a dignified existence .inside and outside the center .In your accommodations you will be provided with at least visual privacy . 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #70's room on 6/7/16 at 9:20 AM, revealed LPN #1 exposed Resident #70's abdominal area and administered medications to Resident #70 via a Percutaneous Endoscopic Gastrostomy (PEG) tube while the window blinds were open to the parking lot area. Resident #70's bed was directly in front of the window. 3. Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #9's room on 6/7/16 at 10:18 AM, revealed RN #1 exposed Resident #9's abdominal area and administered medications to Resident #9 via a PEG tube while the window blinds were open to the parking lot area. Resident #9's bed was directly in front of the window. Interview with the Director of Nursing (DON) on 6/9/16 at 7:55 AM, in the conference room, the DON was asked what she expected staff to do related to privacy when administering PEG medications. The DON stated, Close the door, pull the curtains. The DON was asked if the window blinds should be closed if the parking area is visible from the window. The DON stated, Yes.

Based on review of PATIENT RIGHTS, federal interpretive guidelines, observation and interview, the facility failed to ensure survey results were readily accessible to the residents residing in the facility. The findings included: 1. The facility's PATIENT RIGHTS booklet documented, .8. Survey Results .You will find these reports in one of the public areas of the building. Please ask if you need help . The federal interpretive guidelines documented, The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability .Place readily accessible to residents is a place (such as a lobby or other area frequented by most residents) where individuals wishing to examine survey results do not have to ask to see them . Observations in the conference room on 6/7/16 at 2:45 PM, revealed the current survey results binder was in a far-corner shelf, out of plain view and inaccessible to residents in wheelchairs or other assistive devices, due to furniture in the conference room. Observations in the front lobby area on 6/9/16 at 1:50 PM, revealed the notice regarding the location of the survey results were behind a luggage cart and were above eye level for residents in wheelchairs. Interview with Resident #121 on 6/9/16 at 9:16 AM, in her room, Resident #121 was asked if she knew where the survey results were kept. Resident #121 stated, No ma'am. Resident #121 was asked if she was familiar with the state survey results. Resident #121 stated, No ma'am.

Based on medical record review and interview, the facility failed to ensure the comprehensive assessments were accurate related to hospice services for 1 of 18 (Residents #81) sampled residents reviewed of the 33 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 5/31/16 revealed no documentation that Resident # 81 received hospice services. The physician's orders [REDACTED].Active Orders . 03/03/2015 HOSPICE TO TREAT . In an interview with the Assistant MDS Coordinator on 6/8/16 at 10:00 AM, in the MDS Coordinator's office, the MDS Coordinator if hospice was coded on Resident #81's MDS assessment dated [DATE]. The MDS Coordinator stated, .I missed that . The MDS Coordinator was asked should the MDS be coded for hospice. The MDS Coordinator stated, .yes Ma'am .definitely should be .

Based on medical record review, observation and interview, the facility failed to review and revise the care plan to reflect the current dental status for 1 of 18 (Resident #6) sampled residents with dental problems of the 33 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change Minimum Data Set ((MDS) dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment, and had no natural teeth or teeth fragments, or was edentulous. The comprehensive care plan dated 5/18/16 documented, .Self Care deficit .Denture care as needed (when pt (patient) wants to wear; often does not wear) .Has upper and lower partials . Observations in Resident #6's room on 6/6/16 at 5:09 PM, and on 6/8/16 at 7:39 AM, revealed Resident #6 had multiple missing upper and lower teeth. Resident #6 was not seen wearing any dentures, and no dentures were seen in the room during the survey. In an interview with Resident #6 on 6/8/16 at 7:39 AM, in Resident #6's room, He was asked if he has dentures. Resident #6 stated, No . In an interview with Certified Nursing Assistant (CNA) #1 on 6/8/16 at 9:38 AM, at the 100 hall nurses' desk, CNA #1 was asked if she takes care of Resident #6. CNA #1 confirmed that she did. CNA #1 was asked if Resident #6 has dentures. CNA #1 stated, No, not that I'm aware of. In an interview with Registered Nurse (RN) #2 at the 100 hall nurses' desk on 6/8/16 at 9:39 AM, RN #2 was asked if Resident #6 has dentures. RN #2 stated, I'm not sure if he has any, but he never has them on if he does. RN #2 went to Resident #6's room to check for dentures. RN #2 came out of Resident #6's room on 6/8/16 at 9:43 AM, and stated,I didn't find any (dentures). In an interview with RN #3 on 6/8/16 at 2:03 PM, in the MDS office, RN #3 was asked if the care plan should have been updated to reflect that Resident #6 does not have dentures. RN #3 stated,Yes.

Based on policy review, observation and interview, the facility failed to ensure food was stored and prepared under sanitary conditions as evidenced by opened food stored and not labeled with an opened and use by date. This had the potential to affect 73 of 78 residents residing in the building. Two (2) of 13 Certified Nursing Assistants (CNA #1 and 2) failed to perform hand hygiene during meal service. The findings included: 1. The facility's Safety & (and) Sanitation Best Practice Guidelines documented, .Refrigerated Food Storage Guide Storage Guide. covered securely, date with use by date. Observations in the kitchen on 5/11/15 beginning at 10:40 AM, revealed the following foods with no open date or use by date: a. 3 turkey hot dogs in zip lock bag in the 2 door cooler. b. 1 opened plastic clear bag of french fries in the 2 door freezer. c. 1 opened bag of chuck wagon patties in the walk-in freezer. d. 1 zip lock bag of turkey burgers in the walk-in freezer. e. 1 opened bag of biscuits in the walk-in freezer. f. 1 opened bag of rolls in the walk-in freezer. g. 3 opened zip lock bags of red grapes in the walk-in cooler. Interview with the Dietary Manager (DM) on 5/11/15 at 10:50 AM, in the kitchen, the DM was asked if non-labeled opened food should be labeled in the freezer and cooler. The DM stated, They (the food) should be labeled. 2. Observations in the 100 hall medication room on 5/11/15 at 12:10 PM and on 5/13/15 at 8:50 AM, revealed 1 case of bleach wipes stored on the floor. Interview with the Director of Nursing (DON) on 5/13/15 at 9:27 AM, in the Social Services office, the DON was asked if it was acceptable for items used for patient care to be stored on the floor. The DON stated, No ma'am. Observations in the dining room on 5/11/15 at 12:04 PM, revealed CNA #1 touched her hair when putting her hair behind ears, then set up a resident's lunch without sanitizing her hands. At 12:05 PM, CNA #1 touched her hair again then set up lunch for another resident without sanitizing her hands. Observations in Resident #112's room on 5/11/15 beginning at 12:25 PM, revealed CNA #2 dropped a paper towel on the floor, picked it up, then entered Resident #106's room and set up the resident's tray without hand hygiene. CNA #2 sat to feed Resident #106, touched the chair arms, placed her right hand on her uniform pants leg and then fed the resident without performing hand hygiene. Interview with the Director of Nursing (DON) on 5/12/15 5:58 PM, in the DON's office, the DON was asked if it was acceptable for staff to touch their hair and then serve food without sanitizing their hands. The DON stated, No. Interview with the DON on 5/13/15 at 9:27 AM, in the Social Service's office, the DON was asked what would you expect if a paper towel was dropped on the floor and picked up before serving trays. The DON stated, Wash their hands. The DON was asked if objects were touched while feeding the resident what did she expect. The DON stated, Need to wash their hands.

Based on observation and interview, the facility failed to maintain residents' dignity during 1 of 2 dining observations when 1 of 16 staff members Certified Nursing Assistant (CNA #3) refered to residents as feeders. The findings included: Observations on the 100 hall on 5/12/15 at 5:25 PM, CNA #3 stated, Start with feeders now. Observations in Resident #8 and 46's room on 5/12/15 at 5:27 PM, CNA #3 stated, Made (named resident) a feeder. Interview with the Director of Nursing (DON) on 5/13/15 at 9:27 AM, in the Social Service's office, the DON was asked if it was acceptable for staff to call residents feeders. The DON stated, No, we like to call them dependent diners.

Based on medical record review and interview, the facility failed to ensure the care plan was updated for a suspected deep tissue injury (SDTI) for 1 of 19 (Resident #118) sampled residents of the 38 included in the stage 2 review. The findings included: Medical record review revealed Resident #118 was admitted on [DATE] with [DIAGNOSES REDACTED]. The weekly wound record dated 5/5/15 documented, .R (right) elbow. SDTI. length. 1.0. Width. 1.0. The care plan dated 3/10/15 was not updated to reflect the presence of Resident #118's right elbow SDTI. Interview with Licensed Practical Nurse (LPN) #1 on 5/12/15 at 7:35 AM, in the recreation room, LPN #1 was asked about Resident #118's wound on her right elbow. LPN #1 stated, Has a suspected deep tissue injury on her right elbow, found it last week. Interview with the Director of Nursing (DON) on 5/12/15 at 11:53 AM, in the recreation room, the DON was asked should the care plan reflect residents' current status. The DON stated, Yes, it should. The DON was shown Resident #118's care plan. the DON confirmed there was no care plan for Resident #118's SDTI on her right elbow.