Every finding on record at NHC Place Sumner

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to provide the required level of assistance with eating for 1 (Resident #70) of 3 residents reviewed for activities of daily living care. Findings included: An undated facility policy titled, Activities of Daily Living (ADL), Supporting, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy further indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with, which included, d. dining (meals and snacks). An undated facility document titled, Meal Assist Levels, indicated, Use the following guidelines to ensure that each patient receives the appropriate level of assistance. The policy further revealed, YELLOW-Patient requires intermittent supervision with meals with verbal cues for initiation, attention to task, encouragement to increase intake and/or safe swallowing strategies. RED-Patient will need physical assistance with meals from minimal to total assist. Patient does not receive meal until staff is able to assist. Patient is not to be unattended until meal is completed. The policy revealed, The assist level will be indicated on the meal ticket above the patient's name listed on the bottom of the form. A Resident Face Sheet revealed the facility admitted Resident #70 on 12/12/2022. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of adult failure to thrive, dysphagia (difficulty swallowing); gastro-esophageal reflux disease (a stomach disorder that allows stomach acid and contents to back up into the esophagus); and unspecified, protein-calorie malnutrition. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/04/2026, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident required partial to moderate assistance with eating. Resident #70's Care Plan included a problem area revised 02/09/2026, that indicated the resident had a limited ability to perform self-care related to weakness, difficulty walking, cognitive impairment, and hospice care. Interventions directed staff to set up meals and assist as needed (initiated 12/12/2022). Resident #70's occupational therapy progress note, dated 05/08/2025, indicated the resident required increased assistance at that time for meals by mouth and that the resident was changed to RED level assist at that time. Resident #70's View Dietary Order record included an order, with a start date of 05/08/2025 and a stop date of 06/16/2025, that indicated a Heart Healthy diet. The record revealed the Consistency specified mechanical chopped meat. Per the record, Special Instructions indicated, RED Level Assist. Resident #70's View Dietary Order record included a current order, with a start date of 06/16/2025, that indicated a Heart Healthy diet. The record revealed the Consistency specified mechanical ground meat. Per the record, Special Instructions indicated, RED level assist. During an observation on 03/16/2026 at 11:40 AM, Resident #70 was in bed, feeding themself lunch, without assistance. No staff were present in the resident's room. Resident #70's lunch meal card, dated 03/18/2026, revealed the resident was a Yellow Assist level for meals. During an observation on 03/18/2026 at 11:28 AM, Certified Nursing Assistant (CNA) #2 entered Resident #70's room with a lunch tray, positioned the resident, provided meal set-up, asked the resident if the resident needed anything else, then exited the room. During an interview on 03/18/2026 at 11:30 AM, CNA #2 stated she believed Resident #70 was considered a yellow assist level for eating. She stated that yellow assist indicated the CNA opened everything for the resident and then needed to come back later to check on the resident. During an observation on 03/18/2026 at 11:32 AM, Resident #70 was in bed, eating lunch, with no staff present in the resident's room. During an interview on 03/18/2026 at 11:53 AM, CNA #2 stated she followed the meal tray card to know the level of assistance a resident required. During an interview on 03/18/2026 at 11:47 AM, Registered Nurse (RN) #3 stated yellow assist level indicated the resident required meal set-up assistance and could feed themself. She stated red assist level for dining indicated the resident needed help to eat. RN #3 referred to Resident #70's orders and stated the resident was considered a red assist level. She stated that the nursing staff followed the tray cards. She confirmed Resident #70's tray card indicated the resident was a yellow assist level and not red as it should have been. During an interview on 03/18/2026 at 12:44 PM, the Registered Dietician (RD) stated Resident #70's meal tray card did not indicate the resident was red level assist. She stated that the resident changed from yellow level to red level assist on 05/08/2025. She stated the resident had been changed to red level assist for nutrition purposes to maximize meal intake. During an interview on 03/19/2026 at 9:19 AM, Occupational Therapist (OT) #4 stated Resident #70 was having a low appetite and needed physical assistance to eat. She stated the resident could use their left hand to hold a fork but needed intermittent stand-by assistance. She stated that based on the order, the resident should have had assistance with eating since 05/08/2025. During an interview on 03/19/2026 at 10:41 AM, the Director of Nursing (DON) stated that the CNAs used the meal tray cards to identify the level of assistance a resident needed for eating. She stated Resident #70's diet order revealed the resident was considered a red assist level, and the meal tray card should have matched the order. She stated she expected the meal tray card to match the order. She stated her expectation for red assist was that the tray was taken into a resident's room when the staff was ready to assist the resident with the meal, and she expected the staff to stay with and assist the resident with their meal. During an interview on 03/19/2026 at 11:01 AM, the Administrator stated red assist level was when a CNA took a tray to a resident's room and assisted with the entirety of the dining process. He stated that the level of assistance for a resident was communicated to the CNAs on the meal tray ticket. He stated his expectation was that the tray card matched the diet order for the level of assistance a resident required.

Based on facility policy review, record review, and interview, the facility failed to ensure physician orders were obtained, as well as entered in the medical record for 1 (Resident #101) of 2 residents reviewed for the use of assistive devices. Specifically, the facility failed to obtain an order for a hip brace when the facility readmitted the resident with a hip brace and failed to transcribe an order to wear the hip brace over the resident's clothes. Findings included: A facility policy titled, Section VIII: Nursing Services Documentation Guidelines, revised 05/2025, revealed, General policies for orders: All orders should be directly entered into the EHR [electronic health record] upon receipt, or if handwritten by a provider, should be entered into the EHR from the written orders. All written orders will be scanned into the EHR. A Resident Face Sheet indicated the facility admitted Resident #101 on 05/16/2023 and re-admitted the resident on 05/27/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of left hip hemiarthroplasty (a partial hip replacement) and left hip arthroplasty dislocation (dislocation of the hip after a hip replacement). Per the Resident Face Sheet, the facility discharged the resident on 07/12/2023. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2023, revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Resident #101's Hospitalist Discharge Summary, dated 05/29/2023, indicated that the resident had a left hip dislocation due and had recently had a partial hip replacement. Per the record, the orthopedic provider included instructions to Mobilize in brace. Resident #101's Resident Orders revealed no physician order for the use of a brace on the resident's left hip. A handwritten physician order form from Resident #101's orthopedic surgeon, dated 06/15/2023, included orders to put their hip brace on over the resident's clothes. Resident #101's Resident Orders revealed no evidence of the orthopedic surgeon's order being transcribed as an order. Resident #101's June 2023 Medication Administration Record [MAR] revealed no evidence the orthopedic surgeon's order dated 06/15/2023 was transcribed on the MAR. During an interview on 03/18/2026 at 2:12 PM, the Assistant Director of Nursing (ADON) reviewed Resident #101's medical record and stated that she did not see an order for the hip brace. The ADON stated that the physician order from 06/15/2023 for the brace to be placed over the resident's clothes should have been entered into the EHR as an order. The ADON stated she did not know why the order was not put in the EHR, but it was important for the nurses to know to put the brace on over the resident's clothes. During an interview on 03/19/2026 at approximately 11:55 AM, the Director of Rehabilitation stated if an assistive device was present at the time of admission, the nurse notified therapy staff. She stated that if there was a clear order for the device, the nurse entered the order into the EMR, but if there was not, the therapist called the physician to get clarification. During an interview on 03/19/2026 at 12:39 PM, the Director of Nursing (DON) stated there was not an initial order for the hip brace for Resident #101. The DON stated that ideally, staff should have called the physician and clarified an order for the hip brace and transcribed the order. She stated that the physician order for the brace to go over the clothes should have been entered into the electronic health record after the doctor's appointment on 06/15/2023. During an interview on 03/19/2026 at 12:07 PM, the Administrator stated that when an outside provider sent an order, he expected nursing staff to receive the order and place it in the facility's provider's box. He stated that the facility's provider then approved the order, then the nurse entered the order into the electronic health record. The Administrator stated that he did not remember Resident #101.

Based on facility policy review, medical record review, and interview the facility failed to document medication administration for 1(Resident #5) of 3 residents reviewed. Review of the facility's policy Administering Medications, revised 12/2012, showed .The individual administering the medication must initial the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones . Record review showed Resident #2 was admitted to the facility on [DATE], with diagnoses which included Secondary Neoplasm of Brain and Type 2 Diabetes Mellitus with [CONDITION(S)]. Review of the admission Mininmum Data Set (MDS) dated [DATE], showed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of the care plan dated 4/30/2021, showed Resident #2 was care planned for at risk for complications related to diabetes. The interventions were to monitor blood glucose levels as ordered and administer medications and insulin as directed. Review of the physician orders dated 4/1/2021 through 4/30/2021, showed Resident #2 had these medications ordered during the day shift on 4/29/2021, [MEDICATION(S)] 50 mcg (micrograms) 1 tablet daily, [MEDICATION(S)] 500 mcg 1 tablet daily, [MEDICATION(S)] 4 mg 1 tablet every 6 hours at 9:00 AM and 3:00 PM, [MEDICATION(S)] 50 mcg 1 spray each nostril twice daily, Blood sugar check every 6 hours (9:00 AM and 3:00 PM), [MEDICATION(S)] NPH 20 units every 6 hours (9:00 AM and 3:00 PM), Lactocabcillus acidophilus 0.5 mg daily, [MEDICATION(S)] 500 mg twice daily, [MEDICATION(S)] 1000 mg 1 tablet twice daily, [MEDICATION(S)] 100 mg 1 tablet every 12 hours, [MEDICATION(S)] 0.25mg subcutaneous once a day on Thursdays, [MEDICATION(S)] 10 mEq (milliequivalent) 1 tablet daily, and [MEDICATION(S)] nanocrystallized 145 mg 1 tablet daily. Review of the medication administration record (MAR) dated 4/1/2021 through 4/30/2021, showed Resident #2 did not receive his scheduled day shift medications on 4/29/2021. During an interview on 5/26/2021 at 11:42 AM, LPN #2 confirmed she did not mark on the MAR; she had administered the medication on 4/29/2021 and did not know why she did not sign off on them. During an interview on 5/26/2021 at 2:06 PM, the DON confirmed she did not see any initials indicating LPN #2 signed off on medication administration on 4/29/2021.

Based on review of facility policy, medical record review, and interview the facility failed to report an alleged violation involving abuse to the State Survey and Certification Agency within two hours of the allegation being made. This affected one resident (Resident #3) of three residents reviewed for abuse. This had the potential to affect all 85 residents residing in the facility. The findings include: Review of facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation and Exploitation, dated 12/11/17, showed that any partner having direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately, but no later than two hours after forming suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in abuse or serious bodily injury. Review of the medical record, showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 scored 12 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the Care Plan dated 10/20/20, showed the resident had limited ability to perform self-care due to left sided paralysis and weakness requiring assistance with activities of daily living. During an interview conducted on 3/30/21 at 8:58 AM, the Administrator stated that he was notified by the Director of Nursing (DON) that Resident #3 stated that Licensed Practical Nurse (LPN) #1 was rough with her during catheter care. The resident stated that it was painful when LPN #1 repositioned her legs. The resident further stated that she was uncomfortable and felt that LPN #1 was looking at her private parts. The Administrator stated that after interviewing the resident, he concluded there was no abuse because Resident #3 confirmed that she always experiences pain during catheter care due to contractures of her lower extremities and that two staff members are always present during catheter care. The Administrator stated that he interviewed LPN #1 who confirmed he is never alone with the resident while performing catheter care, as she requires two staff to perform this task. The Administrator interviewed Certified Nurse Assistant (CNA) #1 who confirmed that LPN #1 always asks her to assist him with catheter care and that Resident #3 always experiences pain during catheter care or personal care due to her contractures. The Administrator confirmed a police investigator from the local police department was in the facility on 3/26/21, investigating another allegation of abuse, at which time, he interviewed Resident #3. The Administrator stated the police investigator did not find any evidence and closed the case. Review of the facility investigation, dated 3/26/21, showed the Administrator and the DON were notified by the Assistant Director of Nursing (ADON) that Resident #3 reported that LPN #1 was rough with her while adjusting her in bed. The resident stated that LPN #1 caused pain when he opened her legs to perform catheter care. The resident further stated that she believed LPN #1 was looking too closely at her private area. Resident #3 confirmed that she experiences pain with all catheter care, regardless of who is providing the care. Resident #1 further confirmed that two staff are always present when catheter care is performed. The DON interviewed all staff working on the hallway and all residents with BIMS scores 8 or higher. During an interview conducted on 3/30/21 at 9:05 AM, the DON stated that immediately following the allegation, she interviewed all staff working on the hallway and all residents with BIMS scores 8 or higher. A skin assessment was performed on Resident #3, which showed no bruising or concerns of abuse. On 3/26/21, LPN #1 was placed on suspension pending the investigation and in-serviced on abuse and the facility's Better Way Promises program. During an interview conducted on 3/30/21 at 12:02 PM, Resident #3 stated that during the incident, she believed that LPN #1 was rough when he was turning her and moving her legs for catheter care. She stated that he made her feel uncomfortable when he looked at her private parts. Resident #3 stated that another staff member was in the room when her catheter care was performed. During an interview conducted on 03/31/21 at 10:40 AM, the Administrator stated that he did not report Resident #3's allegation of potential abuse to the state agency because his own investigation concluded that there was no abuse. The Administrator confirmed that he should have reported the allegation to the state agency within two hours.

Based on review of facility policy, interview, and medical record review, the facility failed to correctly administer medication and failed to obtain weights as ordered by the physician. This affected one resident (Resident #1) of three residents reviewed for medications. The findings include: Review of facility policy titled, Administering Medications, dated 12/2012, showed that medications shall be administered in a safe and timely manner, and as prescribed. Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 9/14/20, showed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The resident required supervision for bed mobility, transfers, and toileting. Review of the Care Plan, dated 9/16/20, showed the intervention to weigh the resident weekly, times four, after admission and then monthly if stable. Review of Resident #1's Physician Order, dated 9/9/20, showed the order for [MEDICATION(S)] 120 milligrams (mg), one tablet, twice daily, by mouth with the instructions to hold the medication if the apical pulse is less than 60 beats per minute (bpm) and/or the systolic blood pressure (SBP) is less than 100. Review of Resident #1's Physician Order, dated 9/9/21, showed the order for daily weights, for three days, on admission. Review of a Physician Order, dated 9/12/20, showed the order for strict daily weights, to be obtained twice daily. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Her blood pressure was 92/56 millimeters of mercury (mm HG). On 9/11/20, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Her blood pressure was 95/55 mm HG. Per the physician order, the medication should have been held if the SBP was less than 100. Review of the Treatment Administration Record (TAR), dated 9/2020, showed no weights recorded. During an interview conducted on 3/30/21 at 2:10 PM, Licensed Practical Nurse (LPN) #4 confirmed Resident #1 was administered [MEDICATION(S)] 120 mg on 9/10/20 and 9/11/20 and both doses should have been held per the physician order. LPN #4 further confirmed the medical record shows that no weights were obtained for Resident #1, as ordered by the physician. During an interview conducted on 3/30/21 at 2:45 PM, the Director of Nursing (DON) confirmed Resident #1 was administered [MEDICATION(S)] 120 mg on 9/10/20 and 9/11/20 and both doses should have been held per the physician order. The DON further confirmed the medical record shows that no weights were obtained for Resident #1, as ordered by the physician.

Based on observation, medical record review, review of facility documentation and interview, the facility failed to accurately assess restraints for 1 (#64); failed to accurately assess hospice for 1 (#48); and failed to accurately assess the discharge status for 1 (#84) of 28 resident assessments reviewed. The findings include: Medical record review revealed Resident #64 was admitted to the facilty on 9/13/2019 with [DIAGNOSES REDACTED]. Medical record review revealed no restraint assessment or consent form was completed for Resident #64. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 used a limb restraint less than daily. Observations of Resident #64 on 1/21/2020 at 10:05 AM and on 1/22/2020 at 9:30 AM in her room revealed no restraints were in use for Resident #64. Interview with the Director of Nursing (DON) on 1/23/2020 at 11:45 AM in the conference room confirmed there was an MDS discrepancy regarding restraints on the Quarterly MDS dated [DATE] for resident #64. Interview with the MDS Coordinator on 1/23/2020 at 12:00 PM in the conference room confirmed she made an error when entering the Quarterly MDS data dated for 12/21/2019 regarding restraints for Resident #64. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #48's physician order [REDACTED]. Medical record review of Resident #48's Quarterly ((MDS) dated [DATE] revealed the resident received no hospice services. Interview with MDS Coordinator on 1/23/2020 at 11:59 AM in the conference room confirmed hospice service were not coded on the Quarterly MDS dated [DATE] for Resident #48. Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #84's discharge MDS dated [DATE] revealed resident #84's discharge status was Acute Hospital. Medical record review of Resident #84's Transition of Care/Discharge Summary dated 12/21/2019 revealed discharge destination: home. Interview with the MDS Coordinator on 1/23/2020 at 5:00 PM in the conference room confirmed the discharge MDS dated [DATE] was inaccurately coded as discharged to acute hospital instead of home on 12/21/2019.

Based on facility policy review, medical record review, observation and interview, the facility failed to store nebulizer tubing in a safe and sanitary manner and date a humidifier for 4 (#4, #36, #134 and #140) of 20 residents reviewed receiving respiratory treatments. The findings include: Facility policy review, Respiratory Manual, revised 7/2014, revealed .Be sure nebulizer and tubing are labeled with the date and initials . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 required oxygen therapy. Medical record review of the physician orders [REDACTED].Oxygen at 1 L (liter)/min (minute) via nasal cannula (device for inhalation of oxygen into the lungs) . Observation on 1/21/2020 at 10:18 AM in Resident #4's room revealed the humidifier was undated. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 7/9/19 revealed .Respiratory Conditions: At risk for complications due to [MEDICAL CONDITIONS], supplemental O2 (oxygen), and recent [DIAGNOSES REDACTED]. Medical record review of the physician orders [REDACTED].Oxygen at 2 L via nasal cannula (device for inhalation of oxygen into the lungs) continuous . Observation on 1/21/2020 at 10:04 AM, 1:45 PM, and 3:54 PM in the day area revealed Resident #36's humidifier was undated. Medical record review revealed Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #134's Physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) solution for nebulization (administer medication in the form of a mist inhaled into the lungs) 0.5 mg (milligram)-3 mg/3 mL (milliliter) give (3 ml) every 6 hours . Medical record review or Resident #134's Physician order [REDACTED].Change nebulizer tubing. Change and date nebulizer tubing, place in new respiratory equipment bag . Observation on 1/21/2020 at 8:57 AM and 2:02 PM in Resident #134's room revealed the resident's nebulizer tubing was not dated. Continued observation revealed the nebulizer tubing and mouthpiece was placed on the nebulizer machine not stored in a bag. Observation and Interview on 1/21/2020 at 4:05 PM in Resident #134's room with Registered Nurse (RN) #1 confirmed the nebulizer tubing and mouthpiece not dated or stored in a bag. Medical record review revealed Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #140's Physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] solution for nebulization; 0.5 mg-3 mg 3 mL; Special Instructions: One (1) via (by) inhalation x 1 dose as needed for wheezing/dyspnea . Medical record review of Resident #140's Medication Administration Record [REDACTED]. Observation on 1/21/2020 at 2:07 PM and 3:45 PM in Resident #140's room revealed the resident's nebulizer tubing was not dated and the nebulizer mask was placed on top of the nebulizer machine not stored in a bag. Observation and Interview on 1/21/2020 at 3:55 PM in Resident #140's room with RN #1 confirmed the resident's nebulizer tubing and mask was not dated or bagged. Interview with the Director of Nursing (DON) on 1/22/2020 at 5:22 PM in the 1000 Hallway confirmed her expectations were for the oxygen and nebulizer tubing and mask to be dated and stored in a bag when not in use. Interview with the DON on 1/23/2020 at 1:34 PM in the conference room stated all the oxygen equipment should be changed Sundays with removing the old and throwing it away and dating the equipment.

Based on review of the facility policy, review of the medical record, and interview, the facility failed to administer an intravenous (IV) antibiotic (ABT) medication per professional standard and per policy for 1 resident (#1) of 3 residents reviewing IV ABT. Findings included: Review of the facility policy, Reconstitution of Medication for [MEDICATION NAME] Administration, effective 6/2016 revealed .Policy .To provide for the safe and accurate reconstitution of [MEDICATION NAME] medications prior to administration, manufacturer information is reviewed .Procedures .Read medication package literature, medication label, or other appropriate reference to determine the correct [MEDICATION NAME] and quality to be used .Administer medication or add to intravenous (IV) solution as directed . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Medications form dated 5/8/19 revealed .[MEDICATION NAME] (Trade Name: [MEDICATION NAME]) (IV ABT) 2000 mg (milligrams) Intraven.(Intravenous) every 12 hours .until 6/10/19 . Further review revealed .[MEDICATION NAME] (IV ABT) 1 gram Intraven. every 24 hours .until 6/10/19 . Medical record review of the facility admission Physician Order Report dated 5/8/19-5/28/19 revealed .[MEDICATION NAME] ([MEDICATION NAME]) (IV ABT) recon soln (reconstituted solution); 2 gram .intravenous Special Instructions: 2000 mg every 12 hours IV for left foot osteo[DIAGNOSES REDACTED] . was ordered on [DATE] and to be ended on 6/11/19. Further review revealed .[MEDICATION NAME] recon soln; 1,000 mg .intravenous Special Instruction: one gram IV every 24 hours .for Left foot osteo[DIAGNOSES REDACTED] . was ordered on [DATE] and discontinued (DC) on 5/17/19. Further review revealed an order dated 5/17/19 for .[MEDICATION NAME] recon soln; 1000 mg; intravenous Special Instructions: one gram IV every 24 hours .for Left foot osteo[DIAGNOSES REDACTED] (dosed per (named physician)) . was DC on 6/11/19. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #1 had adequate hearing and vision, clear speech, and made self understood and understood others. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. The resident was administered insulin and ABT for the past 7 days of the review period. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED].Drug/Item Unavailable . The [MEDICATION NAME] was administered daily as ordered except for 5/21/19 when .Drug/Item Unavailable . Medical record review of the Event Report dated 5/28/19 at 4:22 PM revealed Resident #1 had a .Medication Error .Date Error Began/Ended .5/28/19 .Date Error Found .5/28/19 .Error Found By .(Licensed Practical Nurse (LPN) #1) .What is Correct Order? .[MEDICATION NAME] 1 gram to be infused in 250 mL (milliliter) .Type of Error .Incorrect Dose .Describe .Supposed to be in 250 mL bag, but gave it in a 150 mL bag .Observation .Are any of the following adverse drug reactions present? .None of the above . Interview with the Consulting Pharmacist Coordinator on 7/17/19 beginning at 5:10 PM in the admission room or the medication room revealed the First Dose Box contents included the [MEDICATION NAME] powder. Further interview revealed a separate storage container held a variety of fluids, including normal saline IV solution in 100 mL, 250 mL, 500 mL, and 1000 mL. Further interview revealed the fluid storage container contents included the .IV .Reconstitution Guideline . which specified what amount of fluid to use based on the [MEDICATION NAME] dose order . Further interview confirmed Resident #1's [MEDICATION NAME] order of 1000 mg required a 250 mL normal saline solution for reconstitution. When asked what reaction a resident would have if the [MEDICATION NAME] 1000 mg were reconstituted in 100 mL solution, the Pharmacist revealed .would have reaction to [MEDICATION NAME], like [MEDICAL CONDITION] .and would be at the time of administration . Interview with the Director of Nursing on 7/18/19 at 9:00 AM in the admission office when asked what her expectations were when nurses were administrating medications, revealed she .expected nurses to administer medications by the physicians orders . as per policy. Telephone interview with LPN #1 on 7/18/19 beginning at 9:20 AM confirmed LPN #1 had administered .went to the First pick box to get the [MEDICATION NAME] and then got fluid stored in a separate box. Only 1 normal saline in the box, was 100 mL or 150 mL, can't remember now. I got the medication set up and got the MDS nurse to help. I verified set up was right but later knew infused wrong bag. The MDS nurse realized it was the wrong (normal saline) bag, stopped the infusion and removed the bag. The bag may have been half gone .

Based on medical record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) for 1 (#10) of 32 residents reviewed. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #10 had a Quarterly MDS dated [DATE] and a Significant Change MDS dated [DATE]. Further medical record review revealed no Quarterly MDS was completed in (MONTH) (YEAR). Interview with Registered Nurse (RN) #1 on 1/23/19 at 4:20 PM in her office revealed Resident #10 did not have a Quarterly MDS completed in (MONTH) (YEAR). RN #1 stated, The Quarterly MDS was due in (MONTH) (YEAR) and I feel like I just missed it.

Based on medical record review, review of facility investigation, and interview, the facility failed to accurately assess 2 (#21 and #68) of 32 residents reviewed. The findings include: Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had been discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 had no falls. Review of the facility investigation dated 12/20/18 revealed Resident #21's legs gave out and the staff present assisted the resident to the floor. Further review revealed the resident had no injury resulting from the fall. Medical record review of the Discharge MDS dated [DATE] revealed Resident #21 had no fall since admission/entry or reentry or prior assessment. Medical record review of the Admission 5 day MDS dated [DATE] revealed Resident #21 had 1 fall with injury since admission/entry or reentry or prior assessment. Interview with Registered Nurse (RN) #1, responsible for the MDS, on 1/24/19 at 9:35 AM in the conference room, after reviewing the facility investigations, when asked if the 12/29/18 MDS failed to accurately assess Resident #21's fall on 12/20/18, the RN stated Yes. When the RN was asked if the 1/11/19 MDS was to identify the 12/20/18 fall the RN stated .No, the 12/20/18 fall would be on the 12/29/18 MDS . Further interview with the RN at 11:35 AM in the conference room confirmed the 12/29/18 and the 1/11/19 MDS's .were not correctly coded for falls . Medical record review revealed Resident #68 was admitted to the facility on [DATE] and discharged to the community with home health services on 12/11/18. Medical record review of the physician order [REDACTED].DC (discharge) home on 12/11/18 with home health, PT (Physical Therapy) , OT (Occupational Therapy) and nursing . Medical record review of the Discharge and Transfer Discharge Plan of Care and Recapitulation revealed Resident #68 was discharged to the community with home health on 12/11/18. Medical record review of the Discharge MDS dated [DATE] revealed Resident #68 was discharged to an acute hospital. Interview with the Director of Nursing on 1/24/19 at 5:55 PM in the conference room confirmed the 12/11/18 discharge MDS was not accurate for the discharge status to an acute hospital. Interview with RN #1, responsible for the MDS, on 1/24/19 at 6:10 PM in the conference room confirmed the discharge MDS dated [DATE] failed to accurately identify the discharge status as a community discharge.

Based on facility policy review, medical record review and interview, the facility failed to have a baseline care plan adressing falls for 1 (#50) of 32 residents reviewed. The findings include: Review of the facility policy, Care Plan Development dated 7/3/08 revealed .Interim plan of care within 48 hours of admission addressing the immediate needs of the patient . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the care plan dated 12/6/18 revealed the baseline care plan was updated on 12/9/18 for falls risks. Interview with the Director of Nursing (DON) on 1/24/19 at 5:51 PM in the conference room confirmed .the baseline care plan is part of the admission process and should be completed in 48 hours . Further interview with the DON confirmed .looks like on the day she was entering the care plans he had a fall .

Based on facility policy review, observation, and interview, the facility failed to provide a sanitary environment for 3 of 86 rooms reviewed. The findings included: Review of facility policy Equipment Cleaning Guidelines dated 10/16/16 revealed .Equipment will be sprayed with appropriate chemical solution and allowed to air dry .equipment is then wiped down to remove particles and ensure equipment is ready for use .This equipment includes: IV poles, pumps, walkers, oxygen concentrators, nebulizers, bi-pap machines, and any extra furniture . Observation on 1/08/18 at 11:50 AM in room [ROOM NUMBER] revealed the feeding pump, pole, cord, and the wall behind the pole was splattered with tan dried debris. Interview with the Licensed Practical Nurse # 3 on 1/08/18 at 12:03 PM in room [ROOM NUMBER] confirmed The equipment and the wall should not be dirty. Observation on 1/10/18 at 8:39 AM in room [ROOM NUMBER], observation on 1/10/18 at 8:45 AM in room [ROOM NUMBER], and observation on 1/10/18 at 8:50 AM in room [ROOM NUMBER] with the Director of Nursing (DON) present revealed feeding pumps, poles, cords, and the wall had tan dried debris splattered on them. Interview with the DON on 1/10/18 at 9:00 AM in the chart room behind the nurses' station #2 confirmed tan dried splattered debris should not be present on the feeding pumps, poles, cords, or the wall. Further interview confirmed the facility failed to provide a sanitary environment for 3 of 86 rooms.

Based on facility policy review, medical record review and interview, the facility failed to follow the Care Plan, resulting in a fall for 1 Resident (#38). The findings included: Medical record review of facility policy,Incident and Accident Process dated 3/1/01, revised 8/13/13 revealed, .review the Care Plan for any possible updates that might be required related to a change/update . Review dated 11/10/17 revealed Resident #38 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Medical record review of the Safety Interventions Document dated 12/10/17 revealed, additional intervention: out of room when up to wheelchair . Medical record review of Care Plan dated 12/13/17 revealed .no more falls, pull patient out of room when in wheelchair . Medical record review of .Post Falls Nursing Assessment . dated 1/5/18 revealed .Patient was heard yelling for help, found patient on the floor on his left side with arms extended and legs drawn up, fell from wheelchair . Interview with Nursing Assistant #5 on 1/10/18 at 9:18 AM at the Nurses Station revealed .we try to keep him in the hallway when he is up in his wheelchair . Interview with Licensed Practical Nurse (LPN) #1 on 1/10/18 at 9:30 AM at the Nurses Station #2 revealed, .He is confused and a fall risk. Yesterday he did have a fall he got up to the restroom and fell this makes his fourth fall he has had in the last two weeks . Further interview confirmed .I was working when he fell on [DATE], and he was in his room in the wheelchair and we do not know who left him in his room . LPN #1 confirmed the facility failed to follow the Care Plan for Resident #38 on 1/5/18.

Based on facility policy review, medical record review and interview, the facility failed to update the Care Plan of 1 resident (#325). The findings included: Review of Facility policy Updating and Revising Care Plans . dated 7/3/08 revealed .Routine Reviews and Updates: Care plans updated as needed . Medical record review revealed Resident #325 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Care Plan dated 1/7/18 revealed .UTI (Urinary Tract Infection)[MEDICATION NAME]([MEDICATION NAME]) (antibiotic) . Medical record review of a Physician order [REDACTED]. Interview with Licensed Practical Nurse #4 on 1/10/18 at 11:33 PM at the common area .She came to the facility without a foley catheter, and the doctor ordered an in and out catheter, and then the doctor ordered the foley Catheter. On the Foley catheter her output was no less than 350 ml (milliliter) for the whole shift . Interview with the Physician Assistance on 1/10/18 at 11:53 AM at Nurse Station #1 revealed that Resident #325 had [MEDICAL CONDITION] and an indwelling catheter was ordered. Interview with the Director of Nursing on 1/10/18 at 3:47 PM in the common area, after review of the care plan the DON confirmed the facility failed to update Resident #325 care plan to reflect the use of a indwelling foley catheter for [MEDICAL CONDITION].

Based on medical record review and interview, the facility failed to ensure [MEDICAL CONDITION] medication behavior monitoring was completed for 1 resident (#12) of 17 residents reviewed. The findings included: Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] and the Discharge MDS dated [DATE] revealed Resident #12 received antipsychotic medication during the assessment look-back period. Medical record review of a Physician order [REDACTED]. Continued review revealed this order was discontinued on 11/7/17. Further review of a Physician order [REDACTED]. Medical record review of the November 2017 Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. Medical record review of a Physician order [REDACTED]. Medical record review of the December 2017 and January 2018 MAR indicated [REDACTED]. Continued review revealed no behavior monitoring for the antipsychotic medication for the month of December 2017. Further review of the January 2018 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 1/10/18 at 2:40 PM in the conference room revealed she expected behavior monitoring to be completed when a resident received a antipsychotic medication. The DON confirmed the facility failed to complete antipsychotic medication behavior monitoring for Resident #12 as required.

Based on medical record review and interview, the facility failed to update the care plan for behaviors for 1 of 17 (Resident #154) sampled residents of the 20 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #154 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #154 was moderately cognitively impaired, and exhibited no behaviors. Review of the quarterly MDS assessment dated [DATE] revealed Resident #154 was moderately cognitively impaired, and exhibited verbal/physical aggression toward others 1 to 3 days of the review period and rejected care 4-6 days during the review period. Review of the Medication Administration Records (MAR) revealed Resident #154 refused the morning House Supplement on 9/16/16, the evening packet of Juven on 9/10/16, 9/14/16, 9/20/16, and 9/21/16, the Promod Liquid on 9/10/16, 9/16/16, 9/28/16, and 9/29/16, and the Vitamin D3 on 9/12/16. Review of the Certified Nursing Assistant (CNA) Flow Sheet Report for 9/16/16 to 9/22/16 revealed Resident #154 exhibited physically abusive behaviors on 9/19/16 and resisted care on 9/18/16, 9/19/16, 9/20/16, and 9/22/16. Review of the comprehensive care plan revealed it had not been updated to include Resident #154's behaviors of rejection of care or physical behaviors. Interview with the MDS Coordinator on 10/19/16 at 5:50 PM, in the MDS office, the MDS Coordinator was asked where she obtained the information regarding resident behaviors. The MDS Coordinator stated, The chart .based on what they are charting, staff interviews, MDS meeting in the morning, we go over it there .the CNA charting . The MDS Coordinator was asked if a resident rejected care or exhibited verbal or physical aggression, should those behaviors be addressed on the care plan. The MDS Coordinator stated, I would think so . The MDS Coordinator was asked if Resident #154's care plan included interventions to address her behaviors. The MDS Coordinator stated, No, I guess it is not on there .