Every finding on record at Pine View Transitional Rehab

Based on interview and record review the facility failed to report an allegation abuse or neglect to the State Survey Agency immediately, for 1 of 15 sampled residents. Specifically, an allegation was not reported when a resident reported a nurse yelled at him. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic wounds, osteomyelitis, and wedge compression fracture of second lumbar vertebra. On 4/14/25 at 9:32 AM, an interview was conducted with resident 13. Resident 13 stated he had to wait for an hour for assistance one night and he was yelling out as loud as he could to get staff attention to assist him in changing his brief. Resident 13 stated a nurse came into his room and yelled Why are you yelling? Resident 13 stated he talked to management about the nurse yelling at him. Resident 13 stated he felt like they were non-caring and then he felt screw it all, I don't care. Resident 13 stated the manager sat with him and listened to his story. On 4/16/25 at 2:21 PM, a follow up interview was conducted with resident 13. Resident 13 stated he pushed his call light and it was going off for almost an hour and then he started yelling. Resident 13 stated a nurse finally came in and yelled What are you yelling for? in a gruff mean tone. Resident 13 stated the nurse told him there was an emergency but he did not know that. Resident 13 stated the nurse was really loud and she should not do that to him. Resident 13 stated he did not know what else to do. Resident 13 stated he talked to the person in charge of everything and he had not worked with that nurse since. Resident 14 stated sometimes he has trouble breathing so he was worried about the call light not being answered. Resident 13's medical record was reviewed 4/14/25 through 4/16/25. There was no information located in resident 13's medical record about the incident. On 4/15/25 at 7:30 AM, an interview was conducted with the Administrator in Training (AIT) and the Director of Nursing (DON) stated there were no abuse or neglect reports. On 4/15/25 at 1:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she was notified that resident 13 complained of a night shift nurse. The DON stated resident 13 stated the nurse yelled at him when she entered his room. The DON stated when she investigated what happened the night of 4/10/25 into the morning of 4/11/25, she found there were was an emergency that night so it took longer for resident 13's call light to be answered. The DON stated she talked to the nurse who stated resident 13 waited about 30 minutes for cares because of the emergency with another resident. The DON stated resident 13 was yelling because he was unable to find his call light and was anxious for waiting to long. The DON stated she called the nurse who stated they did not yell at resident 13 but resident 13 was yelling. The DON stated resident 13 originally stated the nurse yelled at him and there was a Certified Nursing Assistant (CNA) there also. The DON stated resident 13 reported he told the nurse thank you but he did not want to be treated that way because he was important. The DON stated with the original report she would have considered it possibly abuse but after talking to the nurse it was determined not to be. The DON stated she had not followed up with resident 13 since the initial interview. On 4/15/25 at 1:45 PM, an interview was conducted with the AIT. The AIT stated he talked to resident 13 on 4/11/25 and resident 13 was explaining that the call light was going a little to long. The AIT stated he provided education on not rushing through cares with residents to the CNA's. The AIT stated he was not aware resident 13 stated a nurse yelled at him. The AIT stated the incident was not reported to the State Survey Agency because he did not think to report it and write down an investigation. The AIT stated he was the staff member responsible for reporting allegations of abuse to the State Survey Agency. On 4/15/25 at 1:50 PM, an interview was conducted with the Regional Director of Operations (RDO). The RDO stated this event needed to be verified and it was maybe a misunderstanding and needed to be investigated. The RDO stated he would need to interview the resident and determine the allegations because yelling meant different things. The RDO stated if he felt there was verbal abuse then it would be reported to the State Survey Agency. The RDO stated there was a fine line of what verbal abuse was. The RDO stated verbal abuse needed to be derogatory to the resident and the nurse did not attack the patient about anything. The facility provided a grievance regarding resident 13 dated 4/15/25 which revealed the compliment/concern report to: Long call light time with complaint of raised voice by nurse. The concern using factual terms revealed Patient states that on the evening of 4/10-4/11 he waited an hour for the nurse to respond to his call light and started yelling, he states nurse came in with an aide and yelled 'What are you yelling about.' Patient expressed frustration with negative response by staff. The resolution of concern revealed patient was told of conversation with staff, he expressed gratitude and stated he 'just didn't want to be treated that way'. The form was signed. Additional information provided via email on 4/17/25 revealed the definitions of abuse with examples of abuse which included yelling or hovering over a resident, with the intent to intimidate. The facility policy revealed verbal abuse as oral, written, or gestured language that included disparaging and derogatory terms to patients and their families. The Administrator and DON completed an investigation of the incident including a written summary of the finding no later than five working day of the report. It should be noted the grievance was not started until after the Surveyor inquired about the incident.

Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse or neglect, for 1 of 15 sampled residents. Specifically, an allegation of a nurse yelling at a resident was not investigated. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, chronic wounds, osteomyelitis, and wedge compression fracture of second lumbar vertebra. On 4/14/25 at 9:32 AM, an interview was conducted with resident 13. Resident 13 stated he had to wait for an hour for assistance one night and he was yelling out as loud as he could to get staff attention to assist him in changing his brief. Resident 13 stated a nurse came into his room and yelled Why are you yelling? Resident 13 stated he talked to management about the nurse yelling at him. Resident 13 stated he felt like they were non-caring and then he felt screw it all, I don't care. Resident 13 stated the manager sat with him and listened to his story. On 4/16/25 at 2:21 PM, a follow up interview was conducted with resident 13. Resident 13 stated he pushed his call light and it was going off for almost an hour and then he started yelling. Resident 13 stated a nurse finally came in and yelled What are you yelling for? in a gruff mean tone. Resident 13 stated the nurse told him there was an emergency but he did not know that. Resident 13 stated the nurse was really loud and she should not do that to him. Resident 13 stated he did not know what else to do. Resident 13 stated he talked to the person in charge of everything and he had not worked with that nurse since. Resident 14 stated sometimes he has trouble breathing so he was worried about the call light not being answered. Resident 13's medical record was reviewed 4/14/25 through 4/16/25. There was no information located in resident 13's medical record about the incident. On 4/15/25 at 7:30 AM, an interview was conducted with the Administrator in Training (AIT) and the Director of Nursing (DON) stated there were no abuse or neglect reports and no investigations. On 4/15/25 at 1:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she was notified that resident 13 complained of a night shift nurse. The DON stated resident 13 stated the nurse yelled at him when she entered his room. The DON stated when she investigated what happened the night of 4/10/25 into the morning of 4/11/25, she found there were was an emergency that night so it took longer for resident 13's call light to be answered. The DON stated she talked to the nurse who stated resident 13 waited about 30 minutes for cares because of the emergency with another resident. The DON stated resident 13 was yelling because he was unable to find his call light and was anxious for waiting too long. The DON stated the nurse stated they did not yell at resident 13 but resident 13 was yelling. The DON then stated that resident 13 originally stated the nurse yelled at him and there was a Certified Nursing Assistant (CNA) there also. The DON stated resident 13 reported he told the nurse thank you but he did not want to be treated that way because he was important. The DON stated with the original report she would have considered it possibly abuse but after talking to the nurse it was determined not to be. The DON stated she had not followed up with resident 13 since the initial interview. On 4/15/25 at 1:45 PM, an interview was conducted with the AIT. The AIT stated he talked to resident 13 on 4/11/25 and resident 13 was explaining that the call light was going a little to long. The AIT stated he provided education to CNA's about not rushing through cares with residents. The AIT stated he was not aware resident 13 stated a nurse yelled at him. The AIT stated the incident was not reported to the State Survey Agency because he did not think to report it and write down an investigation. The AIT stated he was the staff member responsible investigating allegations of abuse and he did not have an investigation. On 4/15/25 at 1:50 PM, an interview was conducted with the Regional Director of Operations (RDO). The RDO stated this event needed to be verified and it was maybe a misunderstanding and needed to be investigated. The RDO stated he would need to interview the resident and determine the allegations because yelling meant different things. The RDO stated if he felt there was verbal abuse then it would be investigated and reported to the State Survey Agency. The RDO stated there was a fine line of what verbal abuse was. The RDO stated verbal abuse needed to be derogatory to the resident and the nurse did not verbally attack the patient. The facility provided a grievance regarding resident 13 dated 4/15/25 which revealed the compliment/concern report to: Long call light time with complaint of raised voice by nurse. The concern using factual terms revealed Patient states that on the evening of 4/10-4/11 he waited an hour for the nurse to respond to his call light and started yelling, he states nurse came in with an aide and yelled 'What are you yelling about.' Patient expressed frustration with negative response by staff. The resolution of concern revealed patient was told of conversation with staff, he expressed gratitude and stated he 'just didn't want to be treated that way'. The form was signed. It should be noted the grievance was not started until after the Surveyor inquired about the incident. Additional information provided via email on 4/17/25 revealed the definitions of abuse with examples of abuse which included yelling or hovering over a resident, with the intent to intimidate. The facility policy revealed verbal abuse as oral, written, or gestured language that included disparaging and derogatory terms to patients and their families. The Administrator and DON completed an investigation of the incident including a written summary of the finding no later than five working day of the report.

Based on observation, interview and record review the facility failed to provide reasonable accommodations of needs and preferences except when to do so would endanger the health or safety of resident or other residents for 1 of 15 sampled residents. Specifically, a resident was not provided assistive devices for bed mobility. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on ,d+[DATE]//25 with diagnoses which included type 2 diabetes mellitus, chronic wounds and wedge compression fracture of second lumbar vertebra. On 4/14/25 at 9:32 AM, an interview was conducted with resident 13. Resident 13 stated he used a rail at another facility that helped him with repositioning in bed. Resident 13 stated he had asked CNAs, nurses, and therapy staff about a rail but was told the state did not allow them. Resident 13 stated it would be helpful with repositioning in bed and sitting on the side of the bed. Resident 13 stated there were not always 2 staff member when changing his brief and he felt nervous without a positioning bar. An admission Minimum Data Set, dated dated dated [DATE] revealed resident 13 had limited range of motion to to both sides of his upper extremity. Resident 13 required partial/moderate assistance with the helper providing less than half the effort for roll left to right, sit to lying position, lying to sitting on the side of the bed and sit to stand. Resident 13 had Brief Interview for Mental Status score of 14 out of 15 indicating cognition was intact. A care plan dated 12/20/24 during the prior admission revealed resident 13 required and received staff assistance with activities of daily living (ADL) related to limited mobility, generalized weakness wounds and neuropathy. The goal was resident 13 would increase strength and endurance. Approaches included functional mobility would improve throughout the patient's stay, Staff to allow for and encourage patient choices and preferences and Staff to encourage independence / participation with ADLs as able. On 4/16/25 at 2:18 PM, a follow up interview was conducted with resident 13. Resident 13 stated when he turned onto his side, it would help for him to have a positioning bar. Resident 13 stated he had asked Certified Nursing Assistants (CNA), nurses and therapy for something to help him with bed mobility but was told side rails and bed canes were illegal. Resident 13 stated when he was rolled to his side he was afraid he would fall off of the bed. Resident 13 stated he felt it was harder for staff when he was unable to help with an assistive device. Resident 13 stated CNAs opened the top drawer to the night stand next to his bed and he held onto that when he was on his side. Resident 13 stated he tried to use the overbed table but it rolled away and was dangerous. Resident 13 stated when he rolled to his other side he used his walker against the bed to hold onto to reposition. Resident 13 stated the walked moved so it was not stable. An observation was made of resident 13 positioning the walker while lying in bed against the bed to hold the handle to reposition. The walker was observed to move. Resident 13 stated CNAs tried their best to help me feel secure but it would be nice if he could reposition himself with an assistive devices while in bed. On 4/15/25 at 2:39 PM, an interview was conducted with the Director of Rehab (DOR). The DOR stated resident 13 had some bed mobility with minimal assistance. The DOR stated resident 13 did not get out of bed very often for therapy and refused therapy 2-3 times per week. The DOR stated resident 13 had not asked for anything to help him reposition in bed. The DOR stated he did not think of a bed cane because the facility did not allow them. The DOR stated as we were talking the facility had trapeze's that could be used for bed mobility and that might help him with lift up in bed but not side to side. On 4/16/25 at 1:44 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the admitting nurse reviewed discharge instructions to determine how much assistance residents needed with ADL's. RN 1 stated therapy completed an evaluation the next day and provided staff with information on what ADL assistance a resident needed. RN 1 stated there had not been any reports of resident 13 requesting an assistive device for bed mobility. RN 1 stated resident 13 was unable to readjust himself while in bed. RN 1 stated resident 13 was alert and oriented and able to use his call light for staff assistance. RN 1 stated a bed cane or repositioning bar would be considered a restraint, so they were not allowed in the building. On 4/16/25 at 1:52 PM, an interview was conducted with CNA 1. CNA 1 stated resident 13 required 1 to 2 person extensive assistance with bed mobility. CNA 1 stated he can shimmy himself up in bed a little bit and required assistance of a CNA to roll in bed. CNA 1 stated resident 13 having a positioning device maybe helpful because she had resident 13 hold onto an open drawer of the night stand to stabilize himself when he was rolled onto his side. CNA 1 stated a bed cane or positioning device might be helpful to pull himself upward in bed. CNA 1 stated during a previous admission resident 13 put his hands over his head and pulled himself up in bed by the head board. CNA 1 stated resident 13 did not have strength for that anymore. CNA 1 stated they had not notified therapy or nursing that they were having resident 13 use the night stand drawer. On 4/16/25 at 2:28 PM, an interview was conducted with CNA 2. CNA 2 stated when resident 13 was being rolled he held onto the towel around his neck to support his neck. CNA 2 stated resident 13 held onto the night stand drawer or the walker depending on the side. CNA 2 stated those supported and made him feel more comfortable. CNA 2 stated resident 13 liked to have another staff member on the side to hold onto. CNA 2 stated if resident 13 had an assistive device, they felt like it would help with with adjusting form side to side when in bed. CNA 2 stated they felt like it would be hard not have something to hold onto when repositioning in bed. On 4/16/25 at 1:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated repositioning devices for the facility included a trapeze, wedge pillows, a draw sheet to reposition and pillows. The DON stated they were a Restraint free facility because it was corporate policy. The DON stated therapy determined if a resident needed a trapeze. The DON stated resident 13 required 2 staff member to reposition him in bed. The DON stated resident 13 sometimes asked to hold onto the drawer to for comfort when he was on his side. On 4/16/25 at 2:05 PM, a follow up interview was conducted with the Director of Rehab (DOR). The DOR stated resident 13 had improved with bed mobility from moderate assistance to minimum assistance with bed mobility since admission. The DOR stated the trapeze might help scooting up in bed but not moving side to side. The DOR stated there should be a staff member for resident 13 to hold onto when he was rolled onto his side. The DOR stated resident 13 had not requested an assistive device. On 4/16/25 at 2:12 PM, an interview was conducted with the [NAME] President of Clinical Operations (VPCO). The VPCO stated a bed cane and side rails were a restraint according to corporate policy. The VPCO stated anything that had a risk for entrapment was not used because they were a restraint free company. The VPCO stated there was an assessment that could be done for the bed cane if a resident was insistent on that. The VPCO stated CNAs repositioned resident 13 using a draw sheet and he had declined a trapeze.

Based on observation, interview and record review the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical and nursing needs that are identified in the comprehensive assessment. Specifically, a resident's care plan did not include objectives and interventions related to the resident's urinary tract infection that was treated in the facility. This occurred for 1 of 18 sampled residents. Resident identifier: 36. Findings include: Resident 36 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 at 10:46 AM, resident 36 was observed sitting in a recliner in her room. Resident 36 stated that she thought she may have had a urinary tract infection ([CONDITION(S)]). On 12/14/21 resident 36's medical record was reviewed. Resident 36's admitting Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed that resident 36 was frequently incontinent, was on a toileting program, and had been diagnosed with a [CONDITION(S)] in the last 30 days. On 11/22/21 at 5:00 AM, resident 36 complained of stroke-like symptoms. At 5:40 AM resident 36 was sent to the hospital. On 11/22/21 at 1:09 PM, resident returned to the facility from the hospital's emergency room following evaluation with a new order for [MEDICATION(S)] 500 mg (milligram) daily by mouth for 7 days for a [CONDITION(S)]. The [MEDICATION(S)] antibiotic was started 11/22/21 and was stopped on 11/29/21. Daily progress notes revealed resident 36 received the oral [MEDICATION(S)] antibiotic without any adverse symptoms or reactions. On 12/3/21, resident 36 had increased lethargy and confusion. Resident 36 was evaluated by the house NP (Nurse Practitioner), who was in the facility. Labs were ordered and [MEDICATION(S)] (double strength) ([MEDICATION(S)]-[MEDICATION(S)]) 800-160 mg twice a day by mouth for 7 days was ordered for resident 36's [CONDITION(S)]. The [MEDICATION(S)] antibiotic was started 12/3/21 and was stopped 12/10/21. On 12/4/21, resident 36's UA (urinalysis) revealed WBC (whole blood cells) greater than 100,000 CFU/mL (colony forming units per milliliter) Lactobacillus species. [Note: A UA with WBCs greater than 100,000 colonies/ml represents a [CONDITION(S)].] Daily progress notes revealed resident 36 received the oral [MEDICATION(S)] antibiotic without any adverse symptoms or reactions. On 12/14/21, a review of resident 36's care plan revealed no problems related to resident 36's [CONDITION(S)]. On 12/14/21 at 12:34 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that new or updated care plan interventions are communicated daily during their morning meetings. RN 1 was not sure how resident care plans were initiated or updated. On 12/15/21 at 12:43 PM an interview was conducted with the facility's Director of Nursing (DON). The DON stated he reviews daily messages regarding resident cares from the facility's electronic medical record (EMR). The DON stated some of the EMR messages are antibiotic orders, which he reviews to determine if the resident has an appropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that new orders are sent to the facility's MDS Coordinator, who then initiates and updates residents' care plans. The DON stated that if a resident had a [CONDITION(S)], which was treated with an antibiotic, that it should have been added to the resident's care plan. On 12/15/21 at 12:49 PM an interview was conducted with the facility's MDS Coordinator. The MDS Coordinator stated that if a resident was treated with antibiotics for a [CONDITION(S)] that she would have added that to the resident's care plan. Resident 36's care plan was reviewed with the MDS Coordinator and the MDS Coordinator acknowledged that resident 36's [CONDITION(S)] cares were not part of her care plan. The MDS Coordinator stated it was missed.

Based on interview and record review it was determined, for 1 of 13 sampled resident, that the facility did not test residents and facility staff based on the identification of any individual identified as diagnosed with COVID-19 in the facility. Specifically, a resident was identified as COVID-19 positive after admission and outbreak testing of all staff and residents was not conducted. Resident identifier 1. Findings include: Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/7/21 resident 1's medical records were reviewed. Resident 1's immunization record documented that resident 1 had received the Pfizer vaccine, first dose on 2/4/21 and the second dose on 3/1/21. Review of resident 1's progress notes revealed that on 4/6/21 at 10:52 AM, the note documented, Lab called this AM reporting positive COVID result from hospital. Patient placed on Droplet precautions immediately. Rapid test negative at facility. Patient denies any symptoms r/t (related to) COVID. Family notified. Anticipated discharge to COVID unit. Review of the facility policy and procedure for COVID-19 Emergency Plan documented under Testing Trigger # 3: Outbreak that staff and residents in a facility with an outbreak of [CONDITION(S)]-CoV-2 (regardless of vaccination status) should have a [CONDITION(S)] test every 7 days until no new cases were identified for 14 days. On 7/7/21 at 2:35 PM, an interview was conducted with the Director of Nursing. The DON stated that resident 1 had tested positive in the hospital, was fully vaccinated and had previously had COVID-19. The DON stated that the positive results were received after the resident had arrived at the facility. The DON stated that the resident was not placed on quarantine when she arrived d/t having received both COVID-19 vaccines. The DON stated that they had made arrangements for the resident to be transferred to a COVID facility. The DON stated that after resident 1's admission they did not initiate outbreak testing because she was positive in the hospital and she was placed on droplet precautions. Once they received the positive result she was placed on droplet precautions. The DON stated that resident 1 was in the facility for 24 hours without transmission based precautions prior to receiving the positive test results. The DON stated that she conducted rapid tests for the staff on 4/5/21, 4/6/21, and 4/7/21. The DON stated she conducted it on all three days to capture all staff. The DON stated that she tested the staff again on 4/12/21 and 4/13/21. The DON stated that all test results were negative. The DON stated that it was not all staff members that were tested , but only those staff that she had identified were in the building while the resident was there. The DON stated that they did not test the residents.

Based on observation, interview and record review it was determined that the facility did not maintain an infection control program designed to provide a safe, sanitary environment to prevent the development and transmission of communicable diseases and infections. Specifically, personal protective equipment (PPE) was used by multiple staff members without the proper disinfection between staff use. Findings include: On 7/7/21 at 1:15 PM, an observation was made of resident rooms throughout the facility. Multiple face shields were observed to be hanging outside each door throughout the facility. The face shields were observed to have a foam headpiece. None of the face shields were observed to be labeled with staff names. On 7/7/21 at 1:17 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that there were community face shields that were hanging outside the residents' rooms. RN 2 stated that staff did not have designated face shields specific to specific staff members. RN 2 stated that staff would don a face shield prior to entering a room on isolation precautions, and then doff and sanitize the face shields upon exiting the resident room. When asked about the sanitation process for the face shields, RN 2 stated that each face shield was sprayed with a disinfectant after staff members used the face shields. On 7/7/21 at 2:35 PM, an interview was conducted with the Director of Nursing. The DON stated that the face shields were used by multiple staff members and sanitized between each use. The DON stated that the face shield foam area was sanitized with spray and then hung to dry. The DON stated that the spray used was a Windex brand disinfectant. The DON stated that the porous foam was sprayed down thoroughly and that was how they determined it was cleaned effectively. On 7/7/21 at approximately 3:00 PM, an observation was made of the east hallway. Located outside each resident room was a bottle of Windex multi surface disinfectant sanitizer cleaner, EPA no. 4822-593- . Review of the United States Environmental Protection Agency (EPA) List N Tool: COVID-19 Disinfectants documented that the Windex Disinfectant Cleaner, EPA no. 4822-593, was effective for the disinfection of [CONDITION(S)]-CoV-2 with a contact time of 10 minutes. The site documented that the disinfectant could be used on hard nonporous surfaces such as doorknobs, faucets, light switches and sealed wood. The disinfectant was not indicated for the use on porous surfaces. https://cfpub.epa.gov/wizards/disinfectants/ Review of the United States Food and Drug Administration Questions About Personal Protective Equipment (PPE) documented, In general, most PPE cleared by the FDA is intended to be used only one time and by one person. Sharing PPE is not advised. The protective capabilities of single use PPE cannot be assured when it is reused by the same person or used by more than one person. Sharing PPE that is intended for single use may expose another person to infectious materials. PPE should be removed promptly after use and disposed of properly. The guidance was last updated on 3/11/2020. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/questions-about-personal-protective-equipment-ppe

Based on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, multiple items were found to be expired or labeled inadequately. Findings include: On 8/1/17 at approximately 8:30 AM an initial kitchen tour was conducted. The following items were observed in the facility's refrigerator: a. A jar of peanut butter with a manufacturer's best by date of 5/4/17 and a use by date of 7/4/17. b. A carton of half and half with a manufacturer's best by date of 7/29/17. c. A carton of buttermilk with a manufacturer's best by date of 7/27/17. d. A container labeled cooked chix (chicken) with the date of 7/29 written on it. It was not noted if that was the pull date from the freezer, the preparation date, or the use by date. e. A bottle of Dijon mustard with a manufacturer's best by date of 6/29/17. f. A bottle of Italian salad dressing with a manufacturer's best by date of 3/17/17. g. A container of sauerkraut with a manufacturer's best by date of 6/6/17. h. A bottle of raspberry vinaigrette salad dressing with a manufacturer's best by date of 6/8/17. i. A covered bowl containing an unknown pink liquid without a label or date. j. A roast beef with a date of 7/29 written on it. It was not noted if that was the date that it was pulled from the freezer or the use by date. On 8/2/17 at approximately 3:30 PM the Food Service Director (FSD) was interviewed. The FSD stated We once had a dietitian say that when something is opened, no matter what it is, to discard it within 7 days. At approximately 3:35 PM, the FSD was re-interviewed. The FSD stated that salad dressings must be used within 3 months of opening. The FSD confirmed that the other food items were expired.

Based on observation and interview it was determined that the facility did not ensure the environment remained as free from accident hazards as was possible. Specifically, hot water temperatures exceeded 120 degrees Fahrenheit in resident rooms and bathrooms. Findings include: 1. On 8/1/17 at 10:03 AM, an observation was made of the bathroom sink in room 123. The water temperature reached 127 degrees Fahrenheit within 50 seconds. 2. On 8/1/17 at 10:22 AM, an observation was made of the bathroom sink in room 125. The water temperature reached 120.2 degrees Fahrenheit within 50 seconds. 3. On 8/1/17 at 10:15 AM, an observation was made of the bathroom sink in room 130. The water temperature reached 129.8 degrees Fahrenheit within 45 seconds. 4. On 8/1/17 at 10:22 AM, an observation was made of the bathroom sink in room 129. The water temperature was 122 degrees Fahrenheit. 5. On 8/2/17 at 2:15 PM, an observation was made in the sink in room 128. The water temperature was 121.4 degrees Fahrenheit in 90 seconds. 6. On 8/2/17 at 2:35 PM, an observation was made of the facility mixing valve temperatures. The temperatures for the 3 mixing valves were 120 degrees Fahrenheit. 7. On 8/2/17 at 2:40 PM, the following water temperature measurements were completed with the House Keeping Supervisor (HKS): (Note: All temperatures were in degrees Fahrenheit.) a. In room 123 the surveyor's thermometer read 130.0. The HKS's thermometer read 129.0. b. In room 126 the surveyor's thermometer read 119.2. The HKS's thermometer read 118.0 c. In room 119 the surveyor's thermometer read 119.9. The HKS's thermometer read 119.3. d. In room 101 the surveyor's thermometer read 123.1. The HKS's thermometer read 124.0 e. In room 106 the surveyor's thermometer read 127.1. The HKS's thermometer read 126.8. (Note: The thermometers calibration was checked and the surveyor's thermometer was .2 degrees above and the HKS's thermometer was exact. In addition, the HKS checked the water temperature lower in the water stream than the surveyor.) On 8/2/17 at 2:30 PM, an interview was conducted with the HKS. The HKS stated that water temperatures were taken using a bucket. The HKS stated that she was trained to fill the bucket and then test the temperatures. The HKS stated she did not know why the temperatures were not obtained directly from the stream of water. The HKS stated that the water temperatures were higher when residents were using the showers. The HKS stated that if there were water temperatures over 120 degrees Fahrenheit, she reported the temperatures to the maintenance director. On 8/2/17 at 3:45 PM, an interview was conducted with the facility Administrator. The Administrator stated that the temperatures should not be higher than 120 degrees since the mixing valve was set at that temperature. The Administrator stated she did not know why the high temperatures were not observed by the house keeping staff. The Administrator stated she did not know why the temperatures were obtained using a bucket.

Based on interview and record review it was determined that for 1 of 23 sample residents, the facility did not give proper notification of financial liability when the facility and/or Medicare provider had determined that the Medicare benefit was no longer necessary. Resident identifier: 6. Findings include: On 8/2/17, resident 6's medical record was reviewed and revealed that facility staff had issued a form to resident 6. (Note: This form is issued to beneficiaries when the provider and/or health plan feels the beneficiary no longer requires skilled services. The form is issued to beneficiaries 48 hours in advance of the beneficiary no longer receiving the skilled services.) Resident 6's form revealed that the last day of skilled nursing services would be on 7/8/17. The resident 6's representative signed the form on 7/7/17. The facility did not give the notice 48 hours in advance. In addition, there was no documentation that resident 6 initiated an early discharge. On 8/2/17 at 4:24 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 6 decided to discharge prior to two days. LPN 1 stated that resident 6 was waiting for her urine analysis results to be cleared. LPN 1 provided the urine analysis results which were on 7/6/17 at 12:00 PM. LPN 1 stated she was not at the facility on 7/6/17 when the urine analysis results were obtained so the next day resident 6 was issued the form.

Based on interview and record review, it was determined that for 1 of 23 sample residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons stated above. Specifically, a blood pressure drug was given when a resident's BP (blood pressure) was outside of the physician's orders [REDACTED]. Findings include: Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/2/17, resident 3's medical record was reviewed and revealed a physician's orders [REDACTED]. The special instructions stated, Give if SBP (systolic blood pressure) is greater than 150. Resident 3's Medication Administration Record [REDACTED] a. 7/7/17 BP: 150/80 b. 7/16/17 BP: 136/68 c. 7/19/17 BP: 146/82 d. 7/30/17 BP: 148/90 (Note: [MEDICATION NAME] was administered four times when resident 3's BP was less than the physician ordered parameters.) On 8/2/17 at approximately 4:30 PM, the Director of Nursing (DON) was interviewed. The DON stated confirmed that the [MEDICATION NAME] was given when resident 3's BP was outside the ordered parameters.

Based on interview and medical record review it was determined, for 1 of 20 sample residents, that the facility did not provide biologicals to meet the needs of each resident. Specifically, a resident missed two doses of a prescribed medication because the medication was not available from the pharmacy. Resident identifiers: 15. Findings include: Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15's medical record was reviewed on 5/24/16. On 4/22/16, a physician's orders [REDACTED]. A review of resident 15's Medication Administration Record [REDACTED] a. 4/22/16 at 7:34 AM, Not Administered: Drug/Item unavailable. Comment: Pharmacy won't bring it until next dose is due. Resident 15's blood sugar was documented as 101 milligrams (mg) per (/) deciliter (dl). b. 4/22/16 at 11:43 AM, Not Administered: Drug/Item unavailable. Comment: Pharmacy notified. Still waiting on medication. Resident 15's blood sugar was documented as 198 mg/dl. c. 4/22/16 at 5:00 PM, resident 15's blood sugar was documented as 438 mg/dl. (Note: resident 15 received the 5:00 PM dose of insulin.) On 5/24/16 at 11:36 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the error in administration had occurred and there was no additional documentation.

Based on interview and medical record review it was determined, for 1 of 20 sample residents, that the facility did not ensure that residents were free of significant medication errors. Specifically, a resident did not receive [MEDICATION NAME] and potassium for three days after a change in the dose and the resident did not receive insulin as ordered by the physician. Resident identifier: 15. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15's medical record was reviewed on 5/24/16. On 5/13/16, a physician's orders [REDACTED]. A review of resident 15's Medication Administration Record [REDACTED]. A review of resident 15's vitals for May 2016 documented the following weights in pounds: a. 5/12/16 - 191 b. 5/13/16 - 190.5 c. 5/14/16 - 192.5 d. 5/15/16 - 194 e. 5/16/16 - 195.5 f. 5/17/16 - 193.5 2. On 4/22/16, a physician's orders [REDACTED]. A review of resident 15's Medication Administration Record [REDACTED] a. 4/22/16 at 7:34 AM, Not Administered: Drug/Item unavailable. Comment: Pharmacy won't bring it until next dose is due. Resident 15's blood sugar was documented as 101 mg per (/) deciliter (dl). b. 4/22/16 at 11:43 AM, Not Administered: Drug/Item unavailable. Comment: Pharmacy notified. Still waiting on medication. Resident 15's blood sugar was documented as 198 mg/dl. c. 4/22/16 at 5:00 PM, resident 15's blood sugar was documented as 438 mg/dl. (Note: resident 15 received the 5:00 PM dose of insulin.) On 5/24/16 at 11:36 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the error in administration had occurred and there was no additional documentation.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was monitored adequately. Specifically, facility staff did not monitor residents' pain medication effectiveness for 3 of 23 sample residents. Resident identifiers: 36, 90, and 186. Findings include: 1. Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 36's medical record was reviewed on 6/9/15. Resident 36's May 2015 Medication Administration Record [REDACTED]. Resident 36's May 2015 MAR indicated [REDACTED]. There were three post pain scores documented out of the twenty-two doses given. For the other nineteen doses, effective or asleep was documented. Resident 36's June 2015 MAR indicated [REDACTED]. There were two post pain scores documented out of the twelve doses given. For the other ten doses, effective or asleep was documented. 2. Resident 186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 186's medical record was reviewed on 6/9/15. Review of resident 186's June 2015 physician orders [REDACTED]. On 6/6/15 the physician changed the order from as needed to scheduled every four hours. Resident 186's June 2015 MAR indicated [REDACTED]. There were five post pain scores documented out of the eleven doses given. For the other six doses, effective or asleep was documented. 3. Resident 90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 90's medical record was reviewed on 5/9/15. Resident 90's May 2015 MAR indicated [REDACTED]. Resident 90's May 2015 MAR indicated [REDACTED]. There were four post pain scores documented out of the eleven doses given. For the other seven doses, Effective was documented six times, and Somewhat effective was documented once. Resident 90's June 2015 MAR indicated [REDACTED]. Resident 90's June 2015 MAR indicated [REDACTED]. There were no post pain scores for any of the four doses of [MEDICATION NAME]-[MEDICATION NAME] given to resident 90. Effective was documented three times, and, Effective Pt. Sleeping was documented once. On 6/10/15, the facility's Pain Management Policy and Procedure was reviewed. The policy revealed that patients were to be assessed for intensity of pain utilizing a standard pain scale of 0-10. The purpose of this was to ensure that persistent pain not relieved with the current regimen could be re-evaluated and the physician notified for further orders/interventions. The policy also indicated that administration of PRN (as needed) medications shall be evaluated for effectiveness within 30-60 minutes following administration and that results should identify the intensity of current pain as per the 0-10 scale. On 6/10/15 at 9:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected nursing staff to document effectiveness of the pain medications within 30 to 60 minutes after administration using a numerical scale. The DON confirmed that facility staff had not appropriately entered the numerical scale indicating medication effectiveness for residents 36, 90, and 186.

Based on interview and record review it was determined the facility did not provide adequate monitoring for 10 of 21 sample residents receiving pain medication and/or psychoactive medications. Resident identifiers: 60, 61, 68, 72, 84, 178, 192, 193, 195 and 197. Findings include: 1. Resident 195 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], hyperplastic [MEDICAL CONDITIONS] ulcer,hypertension, end stage [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]. On 4/16/13 at 8:59 AM, resident 195 stated her pain level was a 10/10 and that her pain was "murder this morning." Resident 195 then stated, "just shoot me." On 4/17/13 at 8:55 AM, resident 195 was asked about her pain. Resident 195 reported her pain was a 10/10. Resident 195 stated, "I can't eat, I hurt too much." Resident 195's medical record was reviewed on 4/17/13. The Medication Administration Record (MAR) for April 2013 was reviewed. Resident 195 was receiving [MEDICATION NAME] as needed (PRN). The MAR included the pain level when the medication was given, however it included the response assessment as "P" or "E", meaning pending or effective. The assessment did not include a numeric value to assess resident 195's pain level or a FLACC (face, legs, activity, crying, consolability) score. 2. Resident 68 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 68's medical record was reviewed on 4/17/13. The MAR for April 2013 was reviewed. Resident 68 was receiving [MEDICATION NAME] as needed. The MAR included the pain level when the medication was given, however it included the response assessment as "E", meaning effective. The assessment for the effectiveness of the pain medication did not include a numeric value to assess resident 68's pain level. 3. Resident 193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 193's medical record was reviewed on 4/17/13. The MAR for April 2013 was reviewed. Resident 193 was receiving [MEDICATION NAME] scheduled and as needed. The MAR included the pain level when the medication was given as an as needed medication, however it included the response assessment as "E", meaning effective. The assessment did not include a numeric value to resident 193's pain level or a FLACC score. The scheduled [MEDICATION NAME] was not assessed before or after receiving the medication. Resident 193 was also receiving the psychoactive medication [MEDICATION NAME] once a day. Tracking for resident 193's depression was not located in the medical record. 4. Resident 197 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 197's medical record was reviewed on 4/17/13. Resident 197's admission physician orders [REDACTED]. a) [MEDICATION NAME] 20 mg (milligrams) daily for a [DIAGNOSES REDACTED]. b) [MEDICATION NAME] 0.5 mg at bedtime as needed for anxiety; and c) [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 7.5 mg/325 mg 1-2 tablets by mouth every 4 hours as needed for pain. On 4/10/13, a facility licensed nurse completed a "Psychopharmacological Medication Review" for the use of the [MEDICATION NAME] and [MEDICATION NAME]. The licensed nurse documented that the [MEDICATION NAME] was prescribed for a [DIAGNOSES REDACTED]." The licensed nurse also documented that the [MEDICATION NAME] was prescribed for a [DIAGNOSES REDACTED]." Review of the medical record revealed the facility staff did not document behavior monitoring to ensure the resident received only those medications, in appropriate doses and for the duration that was clinically indicated to treat the resident's assessed conditions. Additionally, the licensed nursing staff did not document non-pharmacological interventions (such as behavioral interventions (individualized non-pharmacological approaches (including direct care and activities) that were provided as part of a supportive physical and psychosocial environment, that were directed toward preventing, relieving, and/or accommodating a resident's distressed behavior) which were considered and used when indicated, instead of, or in addition to, medication administration. Review of the April 2013 MAR revealed that resident 197 received: a) 11 doses of [MEDICATION NAME] 7.5 mg/325 mg 2 tablets from 4/7/13 through 4/10/13. The facility staff documented "E" (effective), but did not document a method for determining how the [MEDICATION NAME] was effective. b) 46 doses of [MEDICATION NAME] 7.5 mg/325 mg 2 tablets every 4 hours from 4/9/13 to 4/17/13. There was no documentation available for review which indicated the facility staff documented where resident 197's pain was, how resident 197 rated her pain, or a method of evaluation of the effectiveness of the pain medication. c) 8 doses of [MEDICATION NAME] 0.5 from 4/8/13 through 4/16/13. There was no documentation as to why the [MEDICATION NAME] was administered. The facility staff documented that the [MEDICATION NAME] was "E" (effective), but did not document how it was determined the [MEDICATION NAME] was effective. On 4/17/13 at 10:45 AM, Registered Nurse (RN) 1 was interviewed related to pain effectiveness and behavior monitoring. RN 1 stated that behaviors would be documented in a "Nurse's Note" if there was any. RN 1 further stated that she documented "effective" after administering pain medications if the resident told her that that their pain was "better" or "decreased". RN 1 was unable to state what method of evaluating the effectiveness of pain relief was implemented. On 4/17/13 at 11:17 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that the facility did not track behaviors when a resident was taking an antidepressant or antianxiety. The DON was unable to provide documentation that a "behavioral monitor" was implemented for resident 197. 5. Resident 72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 72's medical record was reviewed on 4/17/13. Resident 72''s admission orders [REDACTED]. On 3/19/13, a facility licensed nurse completed a "Psychopharmacological Medication Review" for the use of the [MEDICATION NAME]. The licensed nurse documented that the [MEDICATION NAME] was prescribed for a [DIAGNOSES REDACTED]." Review of the medical record revealed the facility staff did not document behavior monitoring to ensure the resident received only those medications, in appropriate doses and for the duration that was clinically indicated to treat the resident's assessed conditions. Additionally, the licensed nursing staff did not document non-pharmacological interventions (such as behavioral interventions (individualized non-pharmacological approaches (including direct care (and) activities) that were provided as part of a supportive physical and psychosocial environment, that were directed toward preventing, relieving, and/or accommodating a resident's distressed behavior) which were considered and used when indicated, instead of, or in addition to, medication administration. 6. Resident 60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 60's medical record was reviewed on 4/17/13. Resident 60's April 2013 physician orders [REDACTED]. Resident 60's April 2013 MAR revealed that resident 60 had received [MEDICATION NAME] 22 times as of 4/17/13. Before administering the pain medication, nursing staff documented resident 60's pain on a scale of 1 to 10. After adminstering the pain medication, nursing staff did not document the effectiveness of the medication. Instead, staff documented "E". Resident 60's April 2013 MAR also revealed that resident 60 had received [MEDICATION NAME] one time as of 4/17/13. After administering the pain medication, nursing staff did not document the effectiveness of the medication. 7. Resident 61 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 61's medical record was reviewed on 4/17/13. a) Resident 61's April 2013 physician orders [REDACTED]. Resident 61's April 2013 Medication Administration Record (MAR) revealed that resident 61 had received [MEDICATION NAME] 19 times as of 4/17/13. After adminstering the pain medication, nursing staff did not document the effectiveness of the medication. Instead, staff documented "E". Resident 61's April 2013 MAR also revealed that resident 61 had received Tylenol 16 times as of 4/17/13. After administering the pain medication, nursing staff did not document the effectiveness of the medication. b) Resident 61's April 2013 physician orders [REDACTED]. No documentation could be found to indicate that resident 61's depression behaviors were being tracked. 8. Resident 192 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 192's medical record and MAR for April 2013 were reviewed on 4/17/13. Resident 192 was receiving [MEDICATION NAME] 5-325 mg every four hours as needed. The MAR included the number of pills given, pain level when the medication was given, however it included the response assessment as "E", meaning effective or "P" meaning pending. The assessment for the effectiveness of the pain medication did not include a numeric value to assess resident 192's pain level. Resident 192's medical record revealed no follow up nurse's notes for the "pending" effectiveness that had been charted on the MAR. An Interview was conducted with the Director of Nursing on 4/17/13 at approximately 10:30 AM. She stated that alot of the pain medications were scheduled at shift change and the nurse that gave it would not be present to follow up on the effectiveness, so it had then been charted as a "P" for pending. The DON further stated that the oncoming nurse was doing a follow up on the pain and should have been charting something about the effectiveness in the nurses notes. 9. Resident 84 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 84's medical record was reviewed on 4/17/13. Resident 84's admission orders [REDACTED] a) [MEDICATION NAME] 10 mg daily for a [DIAGNOSES REDACTED]. b) [MEDICATION NAME] 1-3 mg at bedtime as needed for anxiety; c) [MEDICATION NAME] 10 mg daily at bedtime for pain; and d) [MEDICATION NAME] 5-325 mg 1-2 tablets every four hours as needed for pain. Review of the medical record revealed the facility staff did not document behavior monitoring to ensure the resident received only those medications, in appropriate doses and for the duration that was clinically indicated to treat the resident's assessed conditions. Additionally, the licensed nursing staff did not document non-pharmacological interventions (such as behavioral interventions), individualized non-pharmacological approaches (including direct care and activities) that were provided as part of a supportive physical and psychosocial environment, that were directed toward preventing, relieving, and/or accommodating a resident's distressed behavior) which were considered and used when indicated, instead of, or in addition to, medication administration. Review of the April 2013 Medication Administration Record (MAR) revealed that resident 84 received: a) 52 doses of [MEDICATION NAME] 5-325 mg 1-2 tablets every four hours as needed from 4/1/13 through 4/16/13. The facility staff documented "E" (effective), but did not document a method for determining the [MEDICATION NAME] was effective. b) 16 doses of [MEDICATION NAME] 10 mg daily at bedtime for pain from 4/1/13 to 4/16/13. There was no documentation available for review which indicated the facility staff documented where resident 84's pain was, how resident 84 rated her pain, or a method of evaluation of the effectiveness of the pain medication. c) 15 doses of [MEDICATION NAME] 1mg 1-3 tablets from 4/1/13 through 4/16/13. There was no documentation as to why the [MEDICATION NAME] had been administered. The facility staff documented that the [MEDICATION NAME] was "E" (effective), but did not document how it was determined the [MEDICATION NAME] was effective. The facility staff had no documentation in the nurse's notes or in MAR tracking behaviors for this medication. d) 16 doses of [MEDICATION NAME] 10 mg tablet from 4/1/13 through 4/16/13. The facility staff had no documentation in the nurse's notes or in MAR tracking behaviors for this medication. Resident 84 was receiving [MEDICATION NAME] 5-325 mg every four hours as needed. The MAR included the number of pills given, pain level when the medication was given, however it included the response assessment as "E", meaning effective or "P" meaning pending. The assessment for the effectiveness of the pain medication did not include a numeric value to assess resident 84's pain level. Resident 84's medical record was reviewed on 4/17/13, revealed no follow up nurse's notes for the "pending" effectiveness that had been charted prior on the MAR. 10. Resident 178 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 178's medical record was reviewed on 4/17/13. Resident 178's admission orders [REDACTED] a) [MEDICATION NAME] 300 mg daily for depression; b) [MEDICATION NAME] 20 mg daily for depression; c) [MEDICATION NAME] 1 mg daily at bedtime for anxiety. d) [MEDICATION NAME] 5-325 mg 1-2 tablets every four hours as needed for pain. Review of the medical record revealed the facility staff did not document behavior monitoring to ensure the resident received only those medications, in appropriate doses and for the duration that was clinically indicated to treat the resident's assessed conditions. Additionally, the licensed nursing staff did not document non-pharmacological interventions (such as behavioral interventions),(individualized non-pharmacological approaches (including direct care and activities) that were provided as part of a supportive physical and psychosocial environment, that were directed toward preventing, relieving, and/or accommodating a resident's distressed behavior) which were considered and used when indicated, instead of, or in addition to, medication administration. Review of the April 2013 MAR revealed that resident 178 received a) 96 doses of [MEDICATION NAME] 5-325 mg 1-2 tablets from 4/1/13 through 4/16/13. The facility staff documented "e" (effective), but did not document a method for determining the [MEDICATION NAME] was effective. b) 16 doses of [MEDICATION NAME] XL 300 mg from 4/1/13 through 4/16/13. The facility staff had no documentation in the nurse's notes or in MAR tracking behaviors for this medication. c) 16 doses of [MEDICATION NAME] 20 mg tablet from 4/1/13 through 4/16/13. The facility staff had no documentation in the nurse's notes or in MAR tracking behaviors for this medication. Resident 178 was receiving [MEDICATION NAME] 5-325 mg every four hours as needed. The MAR included the number of pills given, pain level when the medication was given, however it included the response assessment as "E", meaning effective or "P" meaning pending. The assessment for the effectiveness of the pain medication did not include a numeric value to assess resident 178's pain level. Resident 178's medical record was reviewed on 4/17/13, revealed no follow up nurse's notes for the "pending" effectiveness that had been charted prior on the MAR. 11. On 4/17/13 the facility policy and procedure for Pain Management was reviewed. The following was included in the policy and procedure: " . . . Documentation of PRN medication administration shall include the administering nurse's initials on the front of the patient MAR on the appropriate day. Additionally, the administrating nurse shall complete the back of the MAR to include the date and time of administration, the medication given, route of administration . . . and intensity of pain as per the 0-10 scale or FLACC scale numerical score and the administering nurse initials.. . .Administration of PRN medications shall be evaluated for effectiveness within 30-60 minutes following administration and the results documented on the corresponding line of the back of the MAR and initialed appropriately. Results should identify the intensity of current pain as per the 0-10 scale or FLACC numerical score. . . " The facility "Psychopharmacological Medication Management" policy and procedure was reviewed. The policy documented: "PURPOSE: To provide comprehensive management of [MEDICAL CONDITION] medications for all patients in compliance with F329. POLICY: Patients admitted to facility receiving [MEDICAL CONDITION] medications will receive a comprehensive and ongoing evaluation of their current medication regimen. Evaluation will examine appropriateness of medication, dosage, duration and [DIAGNOSES REDACTED]. Each patient's drug regimen will be free from unnecessary drugs as outlined in F329. ...PROCEDURE: ...8. Patients receiving [MEDICAL CONDITION] medications for management of behavioral symptoms will have a behavior monitor in place identifying non-pharmaceutical interventions and their outcomes with quantitative and objective evaluation to be completed by the D.O.N. (Director of Nursing) or designee..."

Based on observation the facility did not store, prepare, distribute or serve food under sanitary conditions. Specifically, cross-contamination was noted during dining, and food was stored improperly. Findings include: 1. On 4/16/13 at 8:00 AM, an initial tour was conducted of the facility kitchen. The following items were observed: a) A box of tilapia filets was in the freezer. The filets were not completely covered, and were open to the air. b) Several beverage-filled glasses were in the refrigerator. They were not covered, and were open to the air. c) Twenty-five bowls of yogurt were in the refrigerator. They were not covered, and were open to the air. d) Several stalks of broccoli were in the refrigerator. The broccoli was stored in a pan of water and was observed to be moldy. 2. On 4/16/13 at 7:57 AM, Dietary Staff Member (DSM) 1 was observed to exit the kitchen when a resident called for her through the tray window. DSM 1 was observed to go to the resident, stand by the resident's side, and rub the resident's upper left back while she spoke to the resident. DSM 1 then proceeded back intoto the kitchen without washing and/or santizing her hands. DSM 1 was then observed to again come out of the kitchen, speak with a different resident, touch the resident's shoulder, and then return to the kitchen without washing and/or sanitizing her hands. 3. On 4/17/13 at 9:41 AM, DSM 2 was observed while carrying a large stack of clean bowls out to the counter area in the dining room. The stack of bowls was resting on her chest, and were stacked up to her chin, with her chin resting on the top bowl. DSM 2 then proceeded to stack the clean bowls on the counter with ungloved hands.

Based on observation and interview, it was determined the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted processional principles, and included the expiration date when applicable. Specifically, (1) There were two vials of insulin that were opened but not labeled with a puncture date and (2) one one vial of insulin, that was available for use, had surpassed the 30 day puncture date. Resident identifiers: 50, 60, and 192. Findings include: 1. On 4/16/13 at 8:45 AM, an audit of the medication cart used to store medications for rooms 101-115 was conducted. There was a vial of Humulin R for resident 192 that was punctured. The licensed nursing staff did not document when the vial of insulin was punctured. 2. On 4/16/13 at 8:50 AM, an audit of the medication cart used to store medications for rooms 116-130 was conducted. The following was observed: a. There was a vial of Humulin R insulin for resident 50. The facility licensed nursing staff documented a puncture date of 3/12/13. The puncture date of the insulin had surpassed the 30 day expiration date and was available for use. b. There was a vial of Humulin R insulin for resident 60 that was punctured. The licensed nursing staff did not document when the vial of insulin was punctured. On 4/16/13 at 8:55 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that the vials of insulin should have been labeled with a date which indicated when the vial was punctured. LPN 1 further stated that the vial of insulin should have been disposed of 30 days after the vial was punctured. On 4/17/13 at 1:10 PM, the facility Director of Nursing (DON) was interviewed. The DON stated that all vials of insulin should have been labeled with a puncture date and should have been disposed of 30 days after the puncture date.

Based on interview, observation, and medical record review it was determined for two sample residents that the facility did not ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, two residents developed pressure sores within the facility after being admitted to the facility with no pressure sores. Resident Identifiers: 26 & 92. Findings include: 1. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/21/11 resident 26's medical record was reviewed. Review of the Nursing Admission assessment dated [DATE] revealed that facility nursing staff assessed resident 26 as having blanchable redness on her coccyx on admission. No areas of skin breakdown were documented on the Nursing Admission Assessment. Review of resident 26's care plan revealed a "Pressure Ulcer Risk Protocol and care plan" dated 5/3/11. Facility staff documented that resident 26 was a "moderate risk" for developing a pressure ulcer due to decreased mobility. Facility staff documented the goal that resident 26 would have decreased risk of developing pressure ulcers with appropriate inteventions in place while maintaining the patient's independence and rights including the right to refuse interventions with appropriate informed decision making. Interventions documented by facility staff were for a routine turning schedule, barrier ointment, and heel protectors. Review of the facility care plan for resident 26 revealed a care plan for "Risk for Impaired Skin Integrity related to decreased mobility" dated 5/16/11. The goal listed on the care plan was for resident 26 to not develop pressure ulcers during her stay. Facility staff were to accomplish the goal by completing the following approaches: "pressure reducing mattress, cushion to wheelchair, encourage and or assist to reposition at least every 2 hours, foam heel protectors/bridging while in bed, monitor skin daily during cares and report changes to LN/MD (Licensed Nurse/Medical Doctor), keep skin clean and dry. and barrier ointment QS (every shift) PRN (as needed)". No documentation could be found in the medical record to show that facility staff completed the interventions of a routine turning schedule, barrier ointment or heel protectors. Review of resident 26's care plan revealed a care plan for self-care deficit dated 5/16/11. The care plan indicated that resident 26 required extensive assistance with Activities of Daily Living (ADLs) including bathing, grooming and hygiene, dressing, toileting, and dining. Review of the Interim Care Plan dated 5/3/11 revealed that facility staff assessed resident 26, on admit, as being incontinent with bladder and bowel. Staff assessed resident 26 as needing incontinent products "full time" and that resident 26 required total assistance with toileting. Review of the care plan for resident 26 revealed an Incontinence care plan dated 5/16/11. Facility staff assessed resident 26 as being incontinent of urine 2 to 6 times weekly related to decreased mobility and bladder spasms. Facility staff documented the following interventions to achieve the goal of resident 26 being clean, dry, odor free, and free of skin breakdown related to incontinence: Incontinent pads or briefs, check every 2 hours; change incontinent products and provide peri-care if soiled, and assist to utilize toilet, commode, bedpan or urinal as needed. On 5/9/11 it was documented on the Incontinence Care Plan that resident 26 had declined a toileting program. No documentation could be found in resident 26's medical record to show that resident 26 was educated regarding the risks and possible outcomes of the decision to refuse the toileting program. No "Refusal of Treatment" form, signed by the patient, could be located in resident 26's medical record for refusal of barrier cream, turning and repositioning, or a toileting program. On 6/23/11 at 9:45 AM, resident 26 was interviewed regarding her stay at the facility. Resident 26 stated that facility staff never did put any cream on her bottom prior to the pressure sore developing. Resident 26 stated that staff never did help her turn or reposition while she was in bed. Resident 26 stated that staff did not place a cushion in her wheelchair during her stay because she used a walker most of the time. Review of Nurse's Notes revealed an entry dated 5/24/11. It was documented in the nurse's notes by a facility staff member,"Stage II pressure ulcer found on pt.s (patients) coccyx. Open area measures 1cm (centimeter) wide by 1 cm tall, very superficial. Wound bed presents with slough, Surrounding tissue very red, nonblanchable. Air mattress placed." Review of facility nurse's notes revealed no entries regarding resident 26's skin condition prior to the pressure sore identified on 5/24/11. On 6/22/11 the facility's policy and procudure for Pressure Ulcer Prevention was reviewed. It was documented in the policy that the purpose of the policy was, "To identify at risk patients and provide a standard of care to implement protective and preventive measures." It was stated in the procedure portion of the policy that the facility would: "1. Upon admit, the patient will be completely examined to identify current issues and appropriate treatment orders obtained if not already addressed on the Admit Orders. 2. The initial skin examination will be documented on the Admit Nursing Assessment. 3. The Admitting Nurse will evaluate the patient utilizing the Pressure Ulcer Risk Assessment determining a numerical score of risk. 4. Based upon the numerical score identiified on the Pressure Ulcer Risk Assessement, the Admitting Nurse will complete the Pressure Ulcer Risk Protocol and Care Plan and initiate the appropriate interventions as suggested on the form. 5. The Admitting Nurse is responsible for ensuring the selected interventions are initiated and appropriate equipment is placed. 6. The Admitting Nurse will communicate interventions to direct care staff via the completed PURA (Pressure Ulcer Risk Assessment) and CP (care plan), Interim and Temporary Care Plans, Treatment Record, Alert Charting and /or verbal report. 7. The completed assessment and care plan will be placed in the care plan section of the chart. 8. If a patient declines a specific intervention or treatment, he/she will be educated on the risks and possible outcomes of their decision. This will be documented on a Refusal of Treatment form which will be signed by the patient and placed in the medical record under the Admission Records tab. 9. ... 10. If an ulcer develops after admission, the Treatment Nurse and/or Nurse Manager will immediately notify the physician for appropriate treatment orders to be placed on the Treatment Record. 11. ...." Review of the Certified Nursing Assistant (CNA) flow sheets or documentation sheets revealed that Barrier Cream every shift and turn every two hours was not written on the flow sheet nor signed by facility staff as being completed until 5/25/11. On 6/22/11 at 10:00 AM, the Director of Nursing (DON) was interviewed. The DON stated that the Interim Care plan was what the CNAs used to determine what interventions should be implemented. The DON stated that all residents should have barrier cream applied to their coccyx area. The DON stated that the interventions are placed on the flow sheet when a resident develops a pressure ulcer so the CNAs can be held accountable for putting the barrier cream on. The DON further stated that facility staff have no way of tracking if the barrier cream was applied by the CNAs unless it is specifically writtin on the flow sheets or the nurses treatment sheets. On 6/23/11, the DON stated that decreased mobility is the only reason she could give to explain why resident 26 developed a stage II pressure ulcer while at the facility. On 6/23/11 the Wound Nurse was interviewed. The Wound nurse stated that resident 26's pressure ulcer was not documented in her weekly skin report. The wound nurse was unable to find any documentation regarding weekly skin reports or checks. On 6/23/11, the Minimum Data Set (MDS) Nurse stated that resident 26 had refused the toileting program. The MDS Nurse stated that resident 26 was incontinent. The MDS Nurse further stated that the facility staff tried their best to keep resident 26 clean and dry. 2. Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 92's medical record was reviewed on 6/22/11. An admission skin assessment completed on 5/6/11, did not document the presence of a sore on resident 92's left heel. A document entitled "Pressure Ulcer Risk Protocol and Care Plan" dated 5/6/11, documented that resident 92 was at "moderate risk" of developing pressure ulcers due to decreased mobility. Interventions included a routine turning schedule, barrier ointment, and heel protectors. Reivew of the CNA flow sheets revealed that facility CNAs did not document assisting resident 92 with repositioning until 5/20/11. Resident 92's nurses notes included the following entries: a) 5/6/11 Nurse at facility spoke with nurse at acute care hospital who stated "that brace is to remain on LLE (left lower extremity) at all times. Also stated to keep LLE dressing in place until 5/7 then okay to remove old drsg (dressing). . ." b) 5/7/11 " . . Wrap and drsg taken off on LLE. 4 x4 [MEDICATION NAME] (non-stick dressing) placed to 4 sites (incision (with) staples) and ace wrap left off . . 2+ [MEDICAL CONDITION] to (left) foot and (left) knee." c) 5/9/11 "Dressing to LLE removed. 4.3 cm (centimeter) tall by 5.8 cm wide purple/black nonstageable pressure ulcer to (left) heel. (No) open areas are present. see NO (new order) for [MEDICATION NAME] heel and multipodus boot." On 6/23/11 at 8:30 AM, an interview was conducted by telephone with Registered Nurse (RN) 2. When asked about resident 92's dressing change on 5/7/11, RN 2 confirmed that she had removed resident 92's LLE dressing, and that it had covered his toes up to his mid-thigh. RN 2 stated that resident 92's LLE was swollen and that his incision "looked good." RN 2 also stated that she was not aware that the LLE had not been fully assessed upon admission due to the dressing. RN 2 stated that she did not assess the skin on resident 92's LLE, and did not alert anyone else to assess the LLE. In addition, RN 2 stated that she did not notice the presence of a sore on resident 92's left heel and that "no one told me I was supposed to assess his heel." On 6/23/11 at 8:50 AM, an interview was conducted with the Wound Nurse. The Wound Nurse stated that Physical Therapist (PT) 1 had resident 92's leg propped up on a chair during therapy on 5/9/11 and noticed the discoloration on resident 92's heel. The Wound Nurse stated that PT 1 then informed her of resident 92's heel condition. In addition, the Wound Nurse stated that if a resident had a physician's orders [REDACTED]. The Wound Nurse stated that facility staff "just write if someone's heels are floated on the flow sheet for the residents we are concerned about. We are afraid if we put it on everyone's flow sheet, it would get looked over." When asked to define floating heels, the Wound Nurse stated that facility staff were to use a pillow under a resident's calf, with the heel not touching the mattress, but that facility staff were currently using a rolled up towel for resident 92 because "it doesn't squish down like a pillow." (Note: review of resident 92's Interim Care plan and CNA flow sheets did not include instructions for resident 92 to have his heels floated.) On 6/23/11 at 9:15 AM, an interview was conducted with PT 1. PT 1 stated that either a CNA or a nurse found the sore on resident 92's left heel and informed PT 1. PT 1 stated that when he initially looked at resident 92's heel, the blackness of the heel "was more like a bruise, not eschar" and that the "skin was intact." PT 1 stated that he then intiated several interventions such as debridement and scoring of the wound. PT 1 stated that in addition, staff were ensuring that resident 92's left heel was floated. When asked to define floating heels, PT 1 stated that facility staff were to place a pillow the long way under resident 92's calf to ensure that resident 92's left heel was not touching the bed. On 6/22/11 at 3:05 PM, an observation was made of resident 92 while he was lying in bed. Resident 92 had a rolled towel under his ankle instead of his calf, and his heel was resting directly on the raised end of an air mattress. On 6/22/11 at 1:40 PM, an observation was made of resident 92's left heel. The heel was noted to have a granulated wound area measuring 3.3 centimeters (cm) by 3.5 cm. In addition, resident 92's heel was observed to have a black eschar area measuring 1 cm by 2 cm. On 6/23/11 an interview was conducted with the DON. The DON stated that the facility "had to claim it as in-house pressure sore because it was not found for three days."

Based on observation and interview the facility did not store, prepare, or serve food under sanitary conditions. Findings include: 1. On 6/20/11 at 10:15 AM, an initial tour was conducted of the facility kitchen. The following observations were made: a) A container of uncovered whipped cream in the facility refrigerator. b) One open container of instant wheat cereal in the food preparation area. c) One open container of instant rice cereal in the food preparation area. d) The drain hose from the handwashing sink did not have a sufficient air gap between the hose and the floor drain. 2. On 6/23/11 at 8:20 AM, the dishwashing machine was observed. The machine did not have a sufficient air gap between the hose and the floor drain. In addition, the drain hose from the handwashing sink continued to have an inadequate air gap between the hose and the floor drain. On 6/23/11 at 4:00 PM, an interview was conducted with a Dietary Service Manager (DSM). The DSM stated that she was aware that the air gap was insufficient in the dishmachine area, but that when the hose was elevated, the floor would flood with water. 3. On 6/20/11 at 10:30 AM, an initial tour was conducted of the facility medication room. The resident food refrigerator in the medication room was noted to be soiled with dried brown spots on the bottom shelf.

Based on observation and staff interview, it was determined that the facility did not ensure proper storage of medications. Findings include: On 6/20/11 at 10:40 AM an intial tour of the facility medication storage room was conducted. During the tour, the following were observed: a) Two bottles of Hydrogen Peroxide that expired in 12/08. b) One bottle of enteric coated Aspirin that expired on 3/28/10. c) One bottle of Acetaminophen that expired in 12/09. d) Three packages of thickened water that expired on 5/1/11. e) One box of Ipratropium Bromide that expired on 11/3/08. On 6/20/11 an interview was conducted with the facility Nurse Manager (NM). The NM stated she was not aware of the expired medications in the medication storage room.

Based on interview and medical record review it was determined for one sample resident that the facility did not provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. Specifically, the facility only offered Religious Services of one faith, thus not meeting the needs of a resident who wanted a different Religious Service offered. Resident Identifier: 186 Findings Include: Resident 186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/23/11 resident 186's medical record was reveiwed. Review of resident 186's medical record revealed no activities assessment or psychosocial assessment. Review of the Minimum Data Set (MDS) completed by facility staff on 6/16/11 revealed that resident 186 responded that participation in religious services or practices while in the facility was very important to her. Review of the medical record revealed no care plan for attending activities or religious activities. On 6/23/11 at 8:30 AM, the Admissions Coordinator was interviewed. The AC stated that she would be the one to ask residents about religious preference and help initiate those services if the resident wanted. The AC stated that the facility only offered LDS church services but residents could leave and go to church if they wanted. The AC stated that since the new MDS, she had stopped doing a psychosocial assessment. The AC stated that the psychosocial assessment addressed the question of religious preference but since she did not complete it anymore she did not ask that question anymore. The AC stated she would only arrange religious services for residents if the resident told her they had a preference to attend a different religious service other than LDS services. On 6/20/11 resident 186 was interviewed about religious activities. Resident 186 stated that the facility offered LDS services on Sunday but no other religious services. Resident 186 stated that she would like other religious services offered within the facility. Resident 186 stated that no staff had discussed with her her religious preference or what services she would like to attend.