Every finding on record at North Park Care Center

Based on observation and staff interview the facility failed to maintain its kitchen area in a manner to prevent food spoilage and prevent food borne illnesses. This had the potential to affect all 30 residents who received food from the facility kitchen. The facility census was 30. Findings include: During the initial kitchen tour conducted on 07/05/22 between 8:15 A.M. and 8:33 A.M. the following was observed and verified with Cook #997 at the time of the observation: · Three cabbage heads were observed to be significantly brown in color. · Two stalks of celery were noted to be extremely wilted and brown in color. · Significant ice buildup was noted on the facility freezer. · An unlabeled and undated bag of approximately 15 to 20 frozen omelets were noted in the freezer. · The outside rubber seal was noted to be dislodged from the refrigerator door, and the temperature of the refrigerator was noted to be 48 degrees Fahrenheit (F) which was reading outside normal on the refrigerator temperature gauge.

Based on observation, interview, record review, and policy review the facility failed to ensure staff ensured a dignified dining experience for Resident #3 during lunch time dining. This affected one (Resident #3) of three (Resident's #2, #3, and #21) who required feeding assistance. The facility census was 30. Findings include: Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and required extensive assistance of one staff for eating. Review of Resident #3's care plan initiated on 05/17/22 for activities of daily living (ADL) revealed self-care performance deficit related to [CONDITION(S)] with an intervention including to provide one staff assistance for eating. Dining observation on 07/05/22 at 12:54 P.M. of the lunch meal revealed State tested Nurse Aide (STNA) #100 was standing next to Resident #3 providing feeding assistance. Interview on 07/05/22 at 1:10 P.M. with STNA #100 confirmed she was standing while feeding Resident #3. STNA #100 stated she would normally sit while feeding a resident. Review of the facility policy titled Assistance with Meals, dated July 2017, revealed residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: Not standing over residents while assisting them with meals.

Based on observation and interview, the facility failed to post up-to-date staffing information in public areas. This had the potential to affect all 30 residents living at the facility at the time of the survey. Findings include: Observation upon entry into the facility on [DATE] at 8:08 A.M. revealed the direct-care staffing information posted by the facility was dated 06/30/22. Interview on 07/05/22 at 8:30 A.M. with Registered Nurse (RN) #101 verified the findings. Interview on 07/05/22 at 4:30 P.M. with the Receptionist #102 revealed the direct care posting for the weekend is created by the receptionist on duty, and it was the receptionist duty to post staffing information in the morning. Receptionist #102 stated she was on vacation, and the receptionist on duty did not post the staffing information for the holiday weekend. Receptionist #102 stated she updated the staffing information and posted the updated version after she arrive to work.

Based on resident funds record review and staff interview, the facility failed to ensure resident's funds were kept separate from facility funds, and that residents received quarterly statements. This affected two residents (Resident #29 and Resident #24) of seven residents whose records were reviewed. The census was 27. Findings include: A request for facility managed resident fund records on 07/08/2021 at 10:40 A.M. for Resident #29 and #24 revealed the facility did not keep nor could produce any type of facility managed resident fund records, including proof that resident funds were kept separate from facility funds and that quarterly statements were provided. During an interview on 07/08/2021 at 11:35 A.M., Accountant #39 verified that neither Resident #29 and #24 funds were kept separate from facility funds and that quarterly statements were provided. Review of an undated personal needs accounting document provided by the facility on 07/11/21 revealed the June 2021 account balance for Resident #29 was 4, 000 dollars. This deficiency substantiates Complaint Number OH 535.

Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one former resident (Resident # 29) of four former residents reviewed for funds conveyance. The facility census was 27. Findings include: Resident #29 was admitted to the facility on [DATE] and expired at the facility on [DATE]. A request for facility managed resident fund records on [DATE] at 10:40 A.M. for Resident #29 revealed the facility did not keep nor could produce any type of facility managed resident fund records including final balances. During an interview on [DATE] at 11:35 A.M., Accountant #39 could not verify the account balance of Resident #29. Accountant #39 revealed the conveyance of remaining funds for Resident #29 had not been released at the time of the survey. Accountant #39 verified Resident #29 expired on [DATE], and the conveyance of all remaining funds was past the 30-day due date. Review of an undated personal needs accounting document provided by the facility on [DATE] revealed the [DATE] account balance for Resident #29 was 4, 000 dollars. This finding substantiates Complaint Number OH 535.

Based on resident funds record review and staff interview, the facility failed to ensure residents had interest bearing accounts with signed witness authorizations. This affected two residents, (Resident #29 and #24) of seven resident records reviewed. The census was 27. Findings include: A request for facility managed resident fund records on 07/08/2021 at 10:40 A.M. for Resident #29 and Resident #24 revealed the facility did not keep nor could produce any type of facility managed resident fund records, including interest bearing accounts and signed witness authorization statements for resident managed funds. During an interview on 07/08/2021 at 11:35 A.M., Accountant #39 verified that neither Resident #29 and #24 had interest bearing accounts or signed witness authorization for facility managed accounts. Accountant #39 could not verify the account balance of Residents #29 or #24. Interview on 07/08/21 at 2:00 P.M. with Social Services # 21 revealed that she thought the Medicaid application for the facility to be the payee was the authorized statement to manage resident funds. She verified there were no signed witness statements for Resident #24 and #29. Review of an undated personal needs accounting document provided by the facility on 07/11/21 revealed the June 2021 account balance for Resident #29 was 4, 000 dollars. This deficiency substantiates Complaint Number OH 535.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately. This affected two of 11 sampled residents (Residents #2 and #23). Findings include: 1. Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and received [MEDICAL TREATMENT]. Review of Resident #2's medical record, physician orders, medication administration records (MARS) and treatment administration records (TARS) for (MONTH) 2019 revealed Resident #2 expired while on hospice in the facility. The discharged MDS was not completed for Resident #2. Interview on [DATE] at 11:06 A.M. with Director of Nursing confirmed Resident #2's discharged assessment dated [DATE] was not complete and the resident expired in the facility on hospice. 2. Record review revealed Resident #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #23's MDS 3.0 assessment dated [DATE] indicated the resident exhibited intact cognitive impairment and received an anticoagulant. Review of Resident #23's medical record, physician orders, medication administration records (MARS) for (MONTH) 2019 revealed Resident #23 received [MEDICATION NAME], an antiplatelet agent, and not an anticoagulant. Interview on [DATE] at 11:06 A.M. with Director of Nursing confirmed Resident #23's MDS 3.0 assessment dated [DATE] was inaccurate and the resident did not receive an anticoagulant.

Based on observation, interview and record review, the facility failed to ensure consistent use of adaptive equipment. This affected one resident (Resident #15) of three residents observed for adaptive equipment. The facility census was 30 residents. Findings include: Review of Resident #15's medical record revealed a readmission date of [DATE] and [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was moderately impaired and had no diet restrictions. Review of Resident #15's meal ticket revealed that Resident #15's food should be cut up prior to serving, all beverages in a two handled cup with a lid and a divided dish for meals. Review of a nutritional care plan updated 07/09/19 revealed Resident #15 was to use sipper cup for fluids and a divided plate. Observation of the lunch meal on 07/08/19 at 12:53 P.M. revealed that Resident #15 was being assisted with eating with a glass of juice at her place setting instead of a sipper cup and entrée was not served on a divided plate. This was verified by Licensed Practical Nurse (LPN) #100 at the time of observation. Observation of the breakfast meal on 07/10/19 at 8:03 A.M. revealed that Resident #15 was feeding herself with a two handled cup with no lid and the entrée was not served on a divided plate. This was verified by State tested Nursing Assistant #102 at the time of the observation. Review of policy entitled, North Park Retirement Community Policy and Procedure- Assistive Devices revealed that assistive devices shall be provided to residents who need them.

Based on observation, record review, staff interview and review of infection control policies and procedures, the facility failed to ensure proper placement of urine collection bag. This affected one resident (Resident #16) of one resident with a urine collection bag. Findings include: Record review revealed Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance with one person for most Activities of Daily Living. Review of physician orders [REDACTED]. Observation of Resident #16 on 07/08/19 at 11:09 A.M. revealed Resident #16's urine collection bag and tubing were on the floor. Interview with State tested Nurse Aide (STNA) #103 on 07/08/19 at 11:09 A.M. verified the catheter bag and tubing were on the floor and stated that it should not have been on the floor and got a nurse to change it. Review of Catheter policy, not dated, revealed that catheter or tubing should not be left on the floor.

Based on observation, policy review and interview, the facility failed to ensure sanitary conditions in the kitchen and servery. This affected 16 residents who received meals from the kitchen and servery (Resident #9 was ordered nothing-by-mouth). Findings include: 1. Observation on 06/11/18 from 9:19 A.M. to 9:43 A.M. during the initial tour of the kitchen revealed the following: two pans were stacked on a shelf with water condensation on the inside and outside of the pans, there was dust on two fans inside a reach-in freezer and the fans were blowing on the food, dinner rolls had a best by date of 06/09/18, a five gallon container of flour and a five gallon container of sugar was not dated and there were small, black spots inside the ice machine near where the ice was ejected. In the servery, a half-gallon carton of milk was dated 06/09/18. Interview on 06/11/18 between 9:19 A.M. to 9:43 A.M. with Dietary Manager #1 verified the findings. 2. Observation on 06/13/18 from 11:02 A.M. to 11:07 A.M. revealed Cook #2 was preparing pureed ravioli and sauce. While the ravioli and sauce was being pureed in the blender, Cook #2 leaned over the opening of the blender and Cook #2's bangs of hair were exposed and not covered by a hair net. Interview on 06/13/18 at 11:07 A.M. with Cook #2 verified the bangs of her hair were not covered by a hair net. 3. Observation on 06/13/18 from 12:50 P.M. to 12:54 P.M. revealed Cook #3 was serving the lunch meal. Cook #3 used her right, gloved hand to grab the handle on the cabinet door to retrieve more soup bowls. Cook #3 then used her right, gloved hand to grab dinner rolls for residents and place the dinner rolls on their plate. State-tested Nurse Aide (STNA) #4 then served the residents their meal plate. Interview on 06/13/18 at 12:59 P.M. with Cook #3 verified she grabbed the cabinet handle with her gloved hand and used the same gloved hand to serve residents their dinner rolls. Review of the undated staff appearance and hygiene policy indicated staff will wash hands during work as often as necessary to keep hands clean.

The facility failed to ensure infection control protocol was followed for Resident #15 when his dressing was changed and his lunch meal was delivered, failed to ensure Resident #10's aerosol nebulizer was clean after medication administration, and failed to adequately track infections in the infection control log book. This had the potential to affect the resident census of 17 residents. Findings Include: 1. Record review revealed Resident #15 was admitted to this facility on 05/08/18 with [DIAGNOSES REDACTED]. His Minimum Data Set 3.0 ((MDS) dated [DATE] showed this resident was cognitively intact. The functional assessment showed he needed extensive assistance for a majority of activities of daily living. Review of this resident's admitting orders did not have an order for [REDACTED].M. revealed the resident was on isolation precautions. At the time of the observation, interview with the Director of Nursing (DON) revealed the resident was on contact isolation due to still having symptoms and a [DIAGNOSES REDACTED]. Observation on 06/11/18 at 12:40 P.M. revealed State tested Nursing Assistant (STNA) # 25 taking Resident #15's lunch tray to him. This aide proceeded to knock on the resident's door and walk in the room. She approached the bedside table and laid the lunch tray on the bedside table. She moved the bedside table with her hand while the side of the table was touching her clothing. The resident refused the meal but wanted the juice. She placed the juice on the bed side table and then lifted the tray off of the bedside table and walked out of the resident's room. This aide then proceeded to walk back to the dining area, placed the tray on the cart in the kitchen area and then obtained another tray and delivered it to another resident. She did not wash her hands before leaving Resident #15's room or don personal protective equipment prior to entering his room. Interview with STNA #25 on 06/11/18 at 1:10 P.M. verified that she did go into Resident #15's room and touch the bedside table with her clothing and her hands and did not put on any personal protective equipment or wash her hands after she came in contact with the resident's furniture. Record review revealed Resident #15 upon admission also had excoriation on the buttocks related to moisture associated contact [MEDICAL CONDITION] and had two pressure ulcers on top of both ears due to his nasal cannula. Review of the physician orders [REDACTED]. The order for the contact [MEDICAL CONDITION] on the buttocks was to apply repair guard 1.5% two times a day and as needed. Observation of Resident #15's dressing change and incontinence care on 06/12/18 at 11:30 A.M. revealed the dressing was changed according to physician's orders [REDACTED]. During the observation of the incontinence care for this resident on 06/12/18 at 11:30 A.M., Licensed Practical Nurse (LPN) #30 proceeded to clean the resident's buttocks of loose stool after he had a small bowel movement, she then proceeded to pat dry this area. After patting the [MEDICAL CONDITION] dry, she proceeded to apply the repair guard to the buttocks. She did not change her gloves or wash her hands after cleaning the resident of incontinent stool and applying the cream. This LPN then proceeded to remove her gloves to apply another clean pair to change his ear dressings. She never washed her hands after removing the soiled gloves and applying fresh gloves. LPN #30 then proceeded to perform the dressing change on the bilateral ears. During the dressing change on the right ear, she proceeded to remove the old dressing, clean the area with normal saline gauze and then applied the sodium impregnated gauze and a cover as ordered. This LPN never changed her gloves and washed her hands after removing the old dressing and cleaning the wound. She kept the same gloves on and applied the clean dressing. This LPN then again changed her gloves and put on a clean pair of gloves to dress the left ear. She again did not wash her hands in between the changing of the gloves. During observation of this LPN dressing the left ear, she again proceeded to remove the old dressing, clean the wound with normal saline soaked gauze and then apply the sodium impregnated gauze and a cover. This LPN did not change her gloves again after removing the old dressing, cleaning the wound and applying the clean dressing. Interview with LPN #30 on 06/13/18 at 12:10 P.M. verified that she did not follow infection control protocol and hand hygiene during these dressing changes. 2. Review of the infection control log book of this facility on 06/14/18 at 10:30 A.M. revealed a spread sheet listing the resident's name, the type of infection, and the antibiotic as well as the hall the infection was on. Further review revealed there was no tracking of infections being done per room and per hall of the facility to monitor for trends in infection. There was no floor plan showing the types of infection or the rooms with the infection. Interview with the Director of Nursing (DON) on 06/14/18 at 11:30 A.M. revealed she took over the infection control tracking and just used the same form the previous DON used. When asked how she was tracking and monitoring for trends, she stated that it was not being done. 3. Review of the record for Resident #10 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physician order [REDACTED]. Observation on 06/13/18 at 8:10 A.M. revealed Licensed Practical Nurse (LPN #200) administered [MEDICATION NAME]-[MEDICATION NAME] per order. On 06/13/18 at 8:20 A.M. LPN #200 checked on Resident #10 after aerosol medication was completed. Resident #10 handed LPN #200 the hand- held nebulizer aerosol. LPN #200 connected the hand-held nebulizer to the aerosol unit without cleaning the hand-held nebulizer. Interview with LPN #200 on 06/13/18 at 9:02 A.M. verified that she did not clean the hand-held nebulizer after Resident #10 received his aerosol medication. LPN #200 stated that she usually cleaned the nebulizer prior to administration of Resident #10's aerosol. Review of undated facility policy titled Aerosol Therapy/ Nebulizer revealed per procedure when the treatment is complete, turn the power off and unplug the unit then clean the medication nebulizer cup. Interview with LPN #200 on 06/13/18 at 12:53 P.M. verified that the facility policy titled Aerosol Therapy/ Nebulizer revealed to clean the medication nebulizer cup after the aerosol treatment. LPN #200 verified that she did not clean the hand -held nebulizer after Resident #10's aerosol treatment per policy. Interview on 06/14/18 at 11:15 AM with Director of Nursing verified that LPN #200 should have cleaned the nebulizer after Resident #10's aerosol treatment per policy.

Based on interview, personnel file review, and policy review, the facility failed to ensure reference checks were completed as required for five of six employees (Registered Nurse (RN) #7, State tested Nurse Aides (STNA)'s #9, #11 and #14, Housekeepers #8 and #10). This had the potential to affect all 17 residents who reside in the facility. Findings include: Review of the personnel files of STNA #9, hired on 02/19/18 and STNA #11 hired on 01/14/18, Registered Nurse RN #7, hired 04/16/18, and Housekeepers #10, hired 01/22/18 and #8, hired on 02/12/18, did not reveal evidence of reference checks. There was no evidence that past employers had been contacted regarding past employment or that any employer had returned a request for reference checks. Review of the facility policy on abuse, updated on (MONTH) (YEAR), revealed all applicants considered for employment should have a completed reference check as part of the hiring and screening practices of the facility. Interview with the Human Resources Director #16 on 06/14/18 at 10:15 A.M. verified the files of the employees did not contain evidence of reference checks.

Based on observation, recipe review, menu review and interview, the facility failed to ensure pureed peas and mushrooms were prepared according to the recipe, failed to ensure the correct serving scoop size was used to serve pureed peas and mushrooms and failed to serve pureed bread as indicated on the menu. This affected two (Resident #2 and Resident #12) residents who were ordered a pureed diet. Findings include: 1. Review of the pureed peas and mushrooms recipe indicated a 0.5 cup of peas and mushrooms and 1.25 teaspoons of thickener were needed to prepare pureed peas and mushrooms. The instructions indicated to blend seasoned vegetables in blender, gradually add thickener and blend until smooth. Observation on 06/13/18 at 11:11 A.M. revealed Cook #2 was preparing pureed peas and mushrooms. Cook #2 poured one cup of peas and mushrooms and one cup of chicken broth into the blender then blended the items together. Cook #2 poured 1.5 ounces of food thickener into the blender then blended the items together. Cook #2 poured 0.5 ounces of food thickener into the blender. A total of two ounces (12 teaspoons) of food thickener was added to the blender. Interview on 06/13/18 at 11:17 A.M. with Cook #2 revealed there wasn't a recipe to follow to prepare pureed peas and mushrooms. Interview on 06/13/18 at 1:28 P.M. with Dietary Manager #1 and Registered Dietitian (RD) #5 verified Cook #2 did not follow the pureed peas and mushrooms recipe when Cook #2 added chicken broth and added too much food thickener. 2. Review of the menu, signed by RD #5, indicated for lunch on 06/13/18, a #10 scoop was to be used to serve the pureed white roll and ½ cup scoop (4 ounces) was to be used to serve the pureed peas. Observation on 06/13/18 at 12:31 P.M. to 12:44 P.M. revealed Cook #3 was serving the lunch meal. Cook #3 used a #10 scoop (3.25 ounces) to serve the pureed peas and mushrooms to Resident #2 and Resident #12. Cook #3 did not serve pureed white roll to Resident #2 or Resident #12. Interview on 06/13/18 at 12:44 PM. with Cook #3 verified the wrong scoop size was used to serve the pureed peas and mushrooms to Resident #2 and Resident #12 and verified pureed bread was not served to Resident #2 and Resident #12.

Based on record review and interview the facility failed to ensure a resident's blood glucose monitoring and insulin coverage where followed per the physician's orders [REDACTED].#11) out of one resident reviewed who received glucose monitoring and insulin coverage per sliding scale. Findings Include: Review of Resident #11's medical record showed that she was admitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. According to her fourteen-day Minimum Data Set 3.0 ((MDS) dated [DATE], this resident needed limited assistance for a majority of activities of daily living. Review of this resident's physician orders' showed that on 05/11/18 she was ordered Humalog insulin 100 unit/ml per sliding scale to be administered subcutaneously before meals and at bedtime. Review of this resident's care plan titled diabetes dated 05/25/18 showed an intervention to monitor fingerstick blood glucose levels according to the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview with the director of nursing on 06/13/18 at 2:30 P.M. verified there was no evidence on the MAR indicated [REDACTED].

Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of an as needed anti-anxiety medication and failed to ensure behavior monitoring was implemented. This affected two (Resident #316 and Resident #2) of five residents reviewed for unnecessary medications. Findings include: 1. Record review of Resident #316 indicated an admission date of [DATE] with [DIAGNOSES REDACTED].#316 was cognitively intact and received seven-days of an antianxiety medication. Review of the May, (YEAR) and June, (YEAR) physician order [REDACTED]. Review of the 05/25/18 baseline care plan revealed there was no evidence Resident #316 was ordered an as needed antianxiety medication. Review of the May, (YEAR) and June, (YEAR) Medication Administration Record [REDACTED]. M, at 12:25 P.M. and at 9:00 P.M., on 05/26/18 at 3:00 P.M. and 9:00 P.M., on 05/27/18 at 9:00 A.M. and 9:00 P.M., on 05/29/18 at 3:35 P.M., on 05/30/18 at 10:30 A.M. and 7:45 P.M., on 05/31/18 at 9:00 P.M., on 06/01/18 at 12:20 P.M., on 06/02/18 at 1:30 P.M. and 10:00 P.M., on 06/03/18 at 2:30 P.M. and 10:00 P.M., at 06/04/18 at 6:30 P.M., on 06/05/18 at 5:50 A.M. and 9:45 P.M., on 06/06/18 at 1:30 P.M. and 9:50 P.M., on 06/07/18 at 2:30 P.M., on 06/08/18 at 7:00 P.M., on 06/09/18 at 6:30 P.M., on 06/10/18 at 4:15 P.M., on 06/11/18 at 12:15 A.M. and 9:00 P.M. Review of the May, (YEAR) and June, (YEAR) behavioral/intervention monthly flow record Resident #316's anxiety and Resident #316's nursing and medication administration progress indicated there was no evidence non-pharmacological interventions were attempted prior to the administration of as needed [MEDICATION NAME] 0.25 mg on the following dates and times: 05/25/18 at 4:20 A.M. and 9:00 P.M., on 05/27/18 at 9:00 P.M., on 05/29/18 at 3:35 P.M., on 05/31/18 at 9:00 P.M., on 06/05/18 at 5:50 A.M., on 06/06/18 at 1:20 P.M., on 06/07/18 at 2:30 P.M., and on 06/10/18 at 4:15 P.M. Interview on 06/11/18 at 12:04 P.M. with Resident #316 revealed he wasn't ordered the as needed [MEDICATION NAME] while he was at home and would take a sip of an alcoholic beverage instead. Interview on 06/12/18 at 5:10 P.M. with the Director of Nursing verified the as needed [MEDICATION NAME] 0.25 mg was administered to Resident #316 during (MONTH) (YEAR) and (MONTH) (YEAR) without prior attempts of non-pharmacological interventions. 2. Record review revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had a care plan dated 02/2018 and revised 07/2018 for psychosocial well-being/ mood for anxiety disorder and major [MEDICAL CONDITION] which included interventions to encourage resident to communicate concerns and feeling, encourage resident to reminisce about past roles and relationships, and offer soothing interventions such as back rub, warm bath, soft music and one on one visits. A physician order [REDACTED]. A physician order [REDACTED]. Review of annual Minimum Data Set ((MDS) dated [DATE] stated Resident #2 did not demonstrate any behaviors during this assessment period. Review of behavioral monthly flow sheets for Resident #2 for September, (YEAR), October, (YEAR) and November, (YEAR) noted no behaviors documented. Review of nursing notes for Resident #2 from September, (YEAR) through November, (YEAR) noted no behaviors documented. Nursing note dated 09/10/17 at 6:00 P.M. stated no change in mentation noted since reduction of Klonopin. On 11/10/17 a physician order [REDACTED]. On 06/12/18 at 3:40 P.M. interview with Director of Nursing verified the monthly behavioral flow sheets, MDS dated [DATE] and nursing notes did not reveal any behaviors documented from September, (YEAR) through November, (YEAR). The Director of Nursing stated the nurse practitioner went by report given to her by staff that Resident #2 had an increase in anxiety when the Klonopin was increased but no behavior monitoring was maintained in relation to Resident #2's anxiety behavior. On 06/13/18 at 3:19 P.M. interview with Resident #2 revealed that she was pleasant but confused and unable to answer questions in relation to her medication. Resident #2 throughout the annual survey revealed no signs of anxiety.

Based on record review and interview the facility failed to ensure a residents' care plan was up to date to include her fall interventions and failed to ensure her urinary diversion site care plan was personalized. This affected two residents (Residents #8, #2) out of 10 residents whose care plans were reviewed. Findings Include: 1. Record review revealed Resident #8 was admitted to this facility on 02/05/18. Her admitting [DIAGNOSES REDACTED]. Her quarterly Minimum Data Set 3.0 (MDS) dated for 05/11/18 revealed this resident had severe cognitive impairment. The functional assessment of this MDS showed that she was totally dependent on staff for transfers, locomotion on and off the unit, dressing and toileting. She needed extensive assistance for bed mobility and for personal hygiene. Review of the fall history for this resident, revealed she had fallen two times in this facility on 03/21/18 and 04/24/18. Her fall risk assessment dated for 03/22/18 showed that she was a high risk for falling. Review of her fall intervention from her first fall on 03/21/18 was to ensure the resident remained in the common area in the evening for dinner, socialization, and activities prior to laying down for the night. Her care plan for risk for injury related to impaired mobility, dependent on staff for transfers and receiving an antidepressant medication, dated 02/18/18 showed interventions including assist with mobility, hoyer lift for all transfers, reposition as needed, keep bed in low position and body pillow next to resident while in bed. Further review of this care plan showed that it did not list the intervention to have the resident in the common area in the evening. At the time of admission Resident #8 had a permanent urinary diversion. A urinary diversion is a surgical procedure that re-routes the flow of urine to a created internal reservoir. This internal reservoir will store urine until it is drained. There is an external opening in the abdomen that is about three inches long and the care giver with a straight urinary tube inserts this tube into the stoma to drain the urine. Review of this resident's physician orders [REDACTED]. On 02/22/18 the order was re-written to include cleanse skin around urinary diversion entry site with soap and water, pat dry and cath urinary diversion site three times a day with a non-latex 16 FR straight urinary catheter. Review of this resident's care plans revealed a care plan titled Urinary Incontinence demonstrated by urinary diversion straight cath dated for 02/18/18. Interventions for this care plan were for staff to provide incontinence care including cleansing, linens/clothing changes and preventative skin care after each incontinent episode and urinary diversion three times daily straight cath. This care plan stated to provide incontinence care for urinary incontinence when this resident was not incontinent of urine. It also did not address the care of the urinary diversion site, the cleansing of the site, the use of a non-latex urinary catheter and to document urine output. Further review of the care plan showed that it did not address this resident's dementia/cognitive impairment and any approaches used to straight cath this resident without causing her any anxiety. Interview on 06/13/18 at 2:30 P.M. with the director of nursing (DON) verified that this resident's care plans were not updated and were not individualized to meet the needs of this resident. 2. Record review of Resident #2 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of Resident #2's care plan which was initiated 02/14/17 and last revised 03/23/18 included a sensor alarm to bed as an intervention. On 09/09/17 Resident #2 observed sitting on the floor. Review of the investigation of the fall revealed Resident #2 stated she fell coming from the bathroom and slipped. The facility post fall intervention was to wear nonskid socks when in bed. On 10/10/17 Resident #2 was observed sitting on the floor in her room. Review of the investigation of the fall revealed Resident #2 stated she was walking to the bathroom. The facility post fall intervention was for bowel and bladder program. The investigation also indicated the resident did not want to be awakened for the bathroom. No other intervention was implemented. On 11/01/17 Resident #2 was found sitting on the floor. Review of the investigation of the fall when questioned Resident #2 stated she was attempting to go to the dining room for lunch. The facility post fall intervention for Resident #2 was to offer bed time snack. On 12/06/17 Resident #2 was found lying on the floor next to her bed. Review of the investigation revealed Resident #2 would crawl in bed on her own and position herself very close to the edge of the bed. The facility post fall intervention for Resident #2 was to ensure a draw sheet to bed to help with re-positioning to ensure safety. On 02/11/18 Resident #2 was found on floor of her room by her bathroom. Review of the investigation revealed she stated she was trying to go to the bathroom. The facility post fall intervention on 02/11/18 for Resident #2 was to encourage and assist Resident #2 to use the bathroom before bed when doing care. On 05/09/18 at 7:30 A.M. Resident #2 was in bed and fell . Review of the investigation revealed the facility post fall intervention for Resident #2 was to add a perimeter mattress to set gentle boundary reminders while in bed. On 05/09/18 at 11:00 A.M. Resident #2 was found on floor in front of her wheelchair. Review of the investigation revealed the facility post fall intervention was to have a face to face visit by the physician nurse practitioner. The nurse practitioner ordered a Vitamin D level, but no other interventions were noted for the fall from the wheelchair. Review of Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 required limited assist with transfer and walking in room. Review of the care plan did not include the post fall interventions of nonskid socks when in bed, offer bedtime snack, ensure draw sheet to bed to help with re-positioning to ensure safety, use bathroom before bed when doing care, and perimeter mattress. Interview on 06/12/18 3:26 P.M. with the Director of Nursing verified that Resident #2 did not have an order to use a sensor alarm to bed and that it should have been discontinued from the care plan. The Director of Nursing also verified the following post fall interventions were not included on the care plan: nonskid socks when in bed, offer bedtime snack, ensure draw sheet to bed to help with re-positioning to ensure safety, use bathroom before bed when doing care, and perimeter mattress. Review of facility policy titled 4.25 Resident Accident and Fall Prevention Program last revised (MONTH) 2010 revealed a fall risk prevention plan will be incorporated into the resident's comprehensive plan of care.

Based on observation, interview and record review, the facility failed to maintain a medication error rate less than five percent. The facility had two errors out of 30 opportunities for a error rate of 6.66 percent. This affected two (Resident #316 and Resident #117) residents of nine residents observed for medication administration. Findings include: 1. Record review of Resident #316 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Observation of medication administration for Resident #316 on 06/13/18 at 8:15 A.M. observed Licensed Practical Nurse (LPN) #200 hand Resident #316 [MEDICATION NAME] suspension 50 mcg/act. Resident #316 administered two sprays to the right nostril, two sprays to the left nostril and went back to the right nostril and administered one more spray to equal a total of three sprays to the right nostril. Interview on 06/13/18 at 12:30 P.M. with Resident #316 stated that he administered two sprays in the right nostril, then administered two sprays in the left nostril and then went back to the right nostril to administer one more spray. Resident #316 stated he sleeps on his right side and felt he had increase sinus blockage in his right nostril and that was why he administered one extra spray. Interview on 06/13/18 at 12:53 P.M. with LPN #200 verified Resident #316 administered two sprays in the right nostril, then two sprays in the left nostril and then went back to the right nostril and administered one more spray. LPN #200 stated that she thought Resident #316 went back to the right nostril to administer one more spray because the first spray Resident #316 administered did not work. LPN #200 verified that she did not ask Resident #316 why he administered the extra spray in his right nostril. LPN #200 verified that Resident #316 received more than the ordered medication. 2. Record review of Resident #117 revealed an initial admission date of [DATE] and a readmission date of [DATE] which included a [DIAGNOSES REDACTED].#117's physician order [REDACTED]. Observation of medication administration for Resident #117 on 06/13/18 at 8:50 A.M. observed Licensed Practical Nurse (LPN) #200 hand Resident #117 [MEDICATION NAME] suspension 50 mcg/act. Resident #117 administered two sprays to the right nostril, and then two sprays to the left nostril. Interview on 06/13/18 at 12:35 P.M. with Resident #117 stated that he administered two sprays in each nostril twice a day. Interview on 06/13/18 at 12:53 P.M. with LPN #200 verified that Resident #117 administered two sprays in each nostril and that she thought that was what his instructions on the physician order [REDACTED].#200 verified after review of [MEDICATION NAME] physician order [REDACTED].

Based on record review and interview, the faciliy failed to ensure baseline care plans were developed. This affected two (Residents #316 and #16) of seven residents reviewed for baseline care plans. Findings include: 1. Record review of Resident #316 indicated an admission date of [DATE] with [DIAGNOSES REDACTED].#316 was cognitively intact and received seven-days of an antianxiety medication. Review of the May, (YEAR) and June, (YEAR) physician order [REDACTED]. Review of the 05/25/18 baseline care plan revealed there was no evidence Resident #316 was ordered an as needed antianxiety medication nor was there non-pharmacological interventions for Resident #316's anxiety. Review of the May, (YEAR) and June, (YEAR) Medication Administration Record [REDACTED].M, at 12:25 P.M. and at 9:00 P.M., on 05/26/18 at 3:00 P.M. and 9:00 P.M., on 05/27/18 at 9:00 A.M. and 9:00 P.M., on 05/29/18 at 3:35 P.M., on 05/30/18 at 10:30 A.M. and 7:45 P.M., on 05/31/18 at 9:00 P.M., on 06/01/18 at 12:20 P.M., on 06/02/18 at 1:30 P.M. and 10:00 P.M., on 06/03/18 at 2:30 P.M. and 10:00 P.M., at 06/04/18 at 6:30 P.M., on 06/05/18 at 5:50 A.M. and 9:45 P.M., on 06/06/18 at 1:30 P.M. and 9:50 P.M., on 06/07/18 at 2:30 P.M., on 06/08/18 at 7:00 P.M., on 06/09/18 at 6:30 P.M., on 06/10/18 at 4:15 P.M., on 06/11/18 at 12:15 A.M. and 9:00 P.M. Review of the May, (YEAR) and June, (YEAR) behavioral/intervention monthly flow record Resident #316's anxiety and Resident #316's nursing and medication administration progress indicated there was no evidence non-pharmacological interventions were attempted prior to the administration of as needed [MEDICATION NAME] 0.25mg on the following dates and times: 05/25/18 at 4:20 A.M. and 9:00 P.M., on 05/27/18 at 9:00 P.M., on 05/29/18 at 3:35 P.M., on 05/31/18 at 9:00 P.M., on 06/05/18 at 5:50 A.M., on 06/06/18 at 1:20 P.M., on 06/07/18 at 2:30 P.M., and on 06/10/18 at 4:15 P.M. Interview on 06/11/18 at 12:04 P.M. with Resident #316 revealed he wasn't ordered the as needed [MEDICATION NAME] while he was at home and would take a sip of an alcoholic beverage instead. Interview on 06/12/18 at 2:50 P.M. with Licensed Practical Nurse (LPN) #17 verified the baseline care plan didn't address Resident #316's as needed [MEDICATION NAME] physician order [REDACTED].#316's anxiety. 2. Closed record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 dated 04/03/18 revealed the resident was cognitively intact and required limited assist with transfer and walking in room. Review of the fall risk assessment dated [DATE] revealed Resident #16 was high risk for falls. Review of the care plan dated 03/27/18 revealed no fall prevention intervention. Review of an incident and accident report summary investigation dated 03/29/18 revealed Resident #16 was found on the floor next to her bed. Resident #16 stated she was trying to plug in her cellphone and put her Easter decorations away. Facility post incident intervention revealed Resident #16 was re-educated on the need to call for assist prior to transferring out of bed. Review of incident and accident report summary investigation dated 04/19/18 revealed Resident #16 lost her balance while walking in her room and fell . Resident #16 reported her walker caught on the floor strip between the room and bathroom and she lost her balance, however, the investigation did not reveal any defect in the floor strip. Resident #16 was sent to hospital and admitted with left [MEDICAL CONDITION]. Interview with Director of Nursing 06/14/18 at 11:15 A.M. verified that Resident #16's baseline care plan dated 03/27/18 did not have fall risk interventions identified. The Director of Nursing verified Resident #16 was high risk per the fall risk scale on admitted [DATE]. Review of facility policy titled 4.25 Resident Accident and Fall Prevention Program last revised (MONTH) 2010 revealed a fall risk prevention plan will be incorporated into the resident's comprehensive plan of care.

Based on record review and interview, the facility failed to ensure an as needed antianxiety medication had a practitioner-documented rationale to extend longer than 14 days for a resident. This affected one (Resident #316) of five residents reviewed for unnecessary medications. Findings include: Record review of Resident #316 indicated an admission date of [DATE] with [DIAGNOSES REDACTED].#316 was cognitively intact and received seven-days of an antianxiety medication. Review of the May, (YEAR) and June, (YEAR) physician orders [REDACTED]. There was no evidence Resident #316 had been assessed by a nurse practitioner or a physician. Review of the May, (YEAR) and June, (YEAR) Medication Administration Record [REDACTED].M, at 12:25 P.M. and at 9:00 P.M., on 05/26/18 at 3:00 P.M. and 9:00 P.M., on 05/27/18 at 9:00 A.M. and 9:00 P.M., on 05/29/18 at 3:35 P.M., on 05/30/18 at 10:30 A.M. and 7:45 P.M., on 05/31/18 at 9:00 P.M., on 06/01/18 at 12:20 P.M., on 06/02/18 at 1:30 P.M. and 10:00 P.M., on 06/03/18 at 2:30 P.M. and 10:00 P.M., at 06/04/18 at 6:30 P.M., on 06/05/18 at 5:50 A.M. and 9:45 P.M., on 06/06/18 at 1:30 P.M. and 9:50 P.M., on 06/07/18 at 2:30 P.M., on 06/08/18 at 7:00 P.M., on 06/09/18 at 6:30 P.M., on 06/10/18 at 4:15 P.M., on 06/11/18 at 12:15 A.M. and 9:00 P.M. Interview on 06/12/18 at 2:21 P.M. with the Director of Nursing verified there was no nurse practitioner or physician documentation of a rationale for why Resident #316's as needed [MEDICATION NAME] 0.25mg was extended beyond 14 days.

Based on record review and interview the facility failed to ensure a comprehensive and thorough investigation was completed for Resident #2 related to an injury of unknown origin. This affected one resident (Resident #2) of 20 sampled residents. Findings Include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #2 required extensive assistance from staff for bed mobility, transfers, dressing, toilet use and personal hygiene. She required limited assistance from staff for walking and locomotion. The assessment revealed the resident was severely cognitively impaired. Record review revealed on 06/25/17 at 4:20 A.M. Resident #2 was observed sitting next to her bed on the floor. The resident was assessed for injuries. No injuries were noted. Vitals were within normal limits. Resident stated she did not hit her head. The fall was unwitnessed. On 06/27/17 Resident #2 complained of shoulder pain. Bruising was noted to posterior right shoulder and armpit area. On 6/27/17 a right shoulder x-ray results revealed a [MEDICAL CONDITION] humeral neck with moderate displacement. Review of the Incident and Accident Report Summary/ Investigation from 06/25/17 revealed Resident #2 had been observed sitting on floor next to bed, sitting up straight, not wearing anything on her feet. She was oriented to person and place. Her vitals were within normal limits. There was no injury noted and the resident was not in pain. The Accident Report Summary revealed the facility determined that the fracture, identified on 06/27/17 was related to the fall on 06/25/17. The incident report included a statement from the licensed practical nurse who had observed the resident after the fall. There were no other statements. There were no further physical assessments. On 09/07/17 at 4:39 P.M. an interview was conducted with the director of nursing (DON) regarding Resident #2's fall on 06/25/17 and shoulder injury identified on 06/27/17. The DON verified she assumed the injury was a result of the fall and did not investigate it as an injury of unknown origin. On 09/07/17 at 5:54 P.M. the DON verified there was no additional information for the fall or injury investigation as noted above.