Every finding on record at Pleasantview Home

Based on observation, interviews, and policy review the facility failed to discard expired food and beverage items, maintain sanitary work stations, and ensure staff complete hand hygiene during meal preparation during 3 of 3 kitchen observations. The facility reported a census of 58 residents. Findings include:1. During the initial observation on 03/30/2026 from 10:12 AM through 10:52 AM the following items were noted to be expired:a. A box of black tea with a use by date of 11/13/2025 was located on a top shelf in view of the food preparation areab. Four boxes of shredded wheat cereal with use by dates of 01/17/2026 were located on the top shelf in the dry storage roomc. Six bottles of almond milk with use by dates of 01/04/2026 were located on a top shelf in view of the food preparation aread. A powdered cherry thirst quencher with a use by date of 03/06/2026 was located near the almond milk; and a powdered orange thirst quencher with a use by date of 03/14/2026 was located next to the cherry drinkOn 03/30/2026 at 10:55 AM Staff R, Dining Services Coordinator stated she audited for expired items and if an item was found to be expired or not covered, she expected the person who found it to remove it.During a follow up observation on 03/31/2026 at 11:03 AM observed all expired items were still present in the kitchen.2. During a continues observation on 03/31/2026 from 11:09 AM through 12:36 PM, Staff B, Cook, shirt or arm touched food, during food preparation, and meal service at:a. At 11:30 AM, Staff B elbows on top of the metal service counter next to divided plates and a ladle with holes;b. At 11:36 AM, Staff B leaned over the steam table's white preparation and cutting surface with her shirt covering about 3 inches, then walked to silver food preparation service counter and leaned back against it;c. At 11:43 AM, Staff B shirt touched full plate that contained fried chicken, green beans, mashed potatoes, and gravy;d. At 11:51 AM, Staff B shirt touched a plate and the white prep surface, Staff B then cut chicken on the white prep service and placed it on the plate.Throughout the meal service, Staff B put on gloves, removed then and piled them on the silver food preparation surface next to the box of clean gloves, and then put on clean gloves without completing hand hygiene. At 12:36 Staff B began her puree process. She moved the box of clean gloves to the side, threw away the pile of soiled gloves, and pureed both chicken and green beans without changing gloves or sanitizing the surface.During an interview with Staff B on 03/31/2026 at 12:41 PM she stated the counters required a 3-step sanitizing process when they were soiled. She reported staff were trained on kitchen expectations with a 2-hour video. Staff were expected to wash hands any time they went in and out of the kitchen, touched the trash, went from one project to another, before and after glove use, and before and after touching raw food.3. During an observation on 4/1/26 at 11:05 AM, Staff B took the temperature of all items on the steam table with the exception of the sweet potatoes. Staff B explained they didn't temp sweet potatoes, they went by softness because they usually came out of the oven at 186 degrees.During an interview on 04/01/2026 at 12:47 PM, Staff A, Dietary Services Director stated she expected staff to wash their hands every time they changed a task or changed gloves. She stated staff should not lean on serving or preparation surfaces at all and needed additional education. She stated she saw the chicken bones piled on the steam table's white preparation surface and did not understand why Staff B did not put them in the lidded trash can by the handwashing sink. She said gloves should immediately be put in the garbage, not piled on the counter. Staff A stated it was not okay that Staff B did not temp the sweet potatoes, and said that was why there was a spot on the temperature sheet for vegetables and starches and all the other things they serve.An undated policy titled Storage documented older stock items would be rotated forward. It did not address expired food disposal.An undated policy titled Hand Washing indicated hand washing was the most important component for preventing the spread of infection. Hand washing should occur after contact with soiled or contaminated articles, before and after food was eaten or handled, and after removal of gloves.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to assist a resident to use the bathroom in a timely manner causing them to have been incontinent for 3 of 4 resident (Resident #6, Resident #21and Resident #64) reviewed for dignity. The facility reported a census of 58 residents.Findings included:1. Review of Resident #21 Minimum Data Set (MDS) assessment, dated 3/17/26, revealed the resident had intact cognition based on a a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS indicated Resident #20 required substantial assistance with toileting and dependent for transfers. The MDS assessed Resident #21 frequently incontinent of urine and always incontinent of bowel. On 3/30/26 at 11:51 AM, during an interview, Resident #21 reported staff used a non-powered mechanical standing lift (a lift known as a Sara Steady) to transfer from her wheelchair to the toilet. The resident reported having to wait 30 minutes to get into the bathroom on a daily basis due to staff waiting on the Sara Steady to be available. Resident #21 reported she had been incontinent as a result of waiting on staff to get her into the bathroom. The resident reported she did wear an incontinent brief at night and a pad during the day. During an observation on 4/1/26 at 10:54 AM, Staff J, Certified Nurse's Assistant (CNA), pushed the Sara Steady lift into Resident #21's room doorway and said she needed to go get help. Resident #21 was sitting in her wheelchair in the middle of her room. Resident #21 reported she needed to go to the bathroom and she had already been waiting 20 minutes and she had been watching the clock in her room. The resident's call light not activated during the observation. Resident #21 explained a staff person came in and shut her light off. At 10:56 AM, Staff J, CNA, returned to the resident's room with Staff K, CNA. The staff then assisted the resident to transfer from her wheelchair to the toilet by using Sara Steady lift. The resident had a bowel movement and urinated in the toilet. During an interview on 4/1/26 at 11:01 AM, Staff J, CNA, reported there were two Sara Steady lifts in the building, one located on the memory care unit and one for Halls 1 and 2. Staff J reported she did turn Resident #21's call light off prior to assisting the resident and left to find the Sara Steady. Staff J stated the Sara Steady was being used so she had to wait. Staff J reported she went to the Memory Care Unit to get another Sara Steady lift. Staff J denied the resident had waited 20 minutes for assistance. Staff J reported there were times that more than one resident had to wait for at least 20 minutes to transfer, because they were waiting on the Sara Steady lift. Staff J explained there were several newer residents that came to the facility and starting using the Sara Steady lift. On 4/1/26 at 11:03 AM, during an interview, Staff K, CNA, reported that residents typically did not have to wait, but they had to wait more over the last month. Staff K explained at one point, there were only two residents using the Sara Steady lift, and both residents resided in the same area. Staff K reported now they used one Sara Steady on the memory unit and had only one Sara Steady for residents on Halls 1 and 2. Staff K stated they needed another lift for Hall 1 and 2, and she thought at least 5 residents were using the Sara Steady lift for transfers.On 4/2/26 at 8:43 AM, during an interview, Resident #21 reported she continued to have to wait for longer than 15 minutes for staff to bring the lift in order for her to use the bathroom. Resident #21 denied that she would be incontinent of bowel and bladder if staff were able to get her into the bathroom within 15 minutes. Resident #21 said that it made her feel like a baby, because she had to go to the bathroom in her pants. 2. The MDS assessment for Resident #6, dated 3/10/26, revealed a BIMS score of 15 out of 15, which indicated an intact cognition. The assessment identified the resident was frequently incontinent of bowel and bladder and depending for transfers and toileting. On 3/30/26 at 12:36 PM, during an interview, Resident #6 reported she had to wait a long time, sometimes 20 to 30 minutes to go to the bathroom. Resident #6 reported staff told her that the lift (Sara Steady) was not available.During an observation on 4/1/26 at 11:38 AM, Resident #6's sat in her wheelchair in her room, with the call light activated. Resident #6 stated she had turned her call light on 10 minutes ago, and she had to go to the bathroom. The resident reported she had been incontinent in the past due to waiting on staff to help her to the bathroom. At 11:41 AM, Staff K, CNA, entered the resident's room. Resident #6 stated she needed to go to the bathroom. When Staff K attempted to get the residents walker to assist her, the resident requested the use of the Sara Steady. Staff K left the room and returned at 11:43 AM with the Sara Steady lift and Staff D, CNA. Staff K and Staff D assisted the resident with standing to the lift and transferring from the lift to the resident's toilet. On 4/2/26 at 9:29 AM, during an interview, Resident #6 reported watched the clock after she activated her call light. She reported not been incontinent in while, and it bothered her more that she had to wait when she needed to have a bowel movement. 3. Review of the Nursing admission Screening assessment for Resident #64, dated 3/25/26, revealed the resident had a right femur fracture with surgical repair, had intact cognition, urge incontinence of the bladder, and dependent for transfers and toilet use. Review of a progress note, titled Skilled Assessment, dated 3/28/26, revealed Resident #64 used three to four staff to assist with a mechanical lift and used the commode in her room. On 3/30/26 at 2:02 PM, during an interview, Resident #64 reported she was at the facility to recover from a right leg fracture. Resident #64 reported a problem with having to wait for staff to respond to the call light. She reported 3 times on this date she needed to use the bathroom, and she had to go in her incontinent brief due to staff slow response. She explained if staff answered the call light, they would tell her they had to wait for a second staff. The resident reported using the standing lift (Sara Steady) and three staff due to being non-weight bearing on the right leg. On 4/2/26 at 9:50 AM, during an interview, the Director of Nursing (DON) confirmed seven total residents utilized the Sara Steady lift, one resident on the memory care unit, and six residents on Halls 1 and 2. The DON stated she was not sure that staff or residents complained about wait times associated with the lift, but they did do an audit about two weeks ago. The audit was a study on who used the Sara Steady lift and the timeframes the lift was in use. The DON explained she also talked with the Therapy Department as part of the audit, as they occasionally used the Sara Steady. The DON reported, as a result of the audit, Therapy needed to leave the Sara Steady out on the floor, and not in the Therapy Department. She reported 6 residents were utilizing the lift at the time of the audit. The DON reported they had also considering purchasing another machine. Review of the facility's policy, titled Activities of Daily Living (ADL), dated 1/2026, revealed, in part, The purpose of this policy is to ensure that residents in (facility) receive appropriate assistance and support with their activities of daily living (ADLs) to maintain their independence and quality of life . Supportive Care: Assistance provided by nursing staff to residents with ADLs to meet their physical, emotional, and psychosocial needs.

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to ensure nursing staff administered medications without a significant medication error for 1of 10 residents (Resident #47) reviewed for medication administration. The facility reported a census of 58 residents. Findings included:Review of the Minimum Data Set assessment, dated 1/20/26, revealed that Resident #47 had a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. The list of diagnoses included major depressive disorder (MDD) and anxiety disorder. The MDS indicated that Resident #47 received antipsychotic, antianxiety, and antidepressant medications. Review of the Care Plan, initiated 8/11/25, directed staff to administer psychotropic medications as ordered by physician, document and report as needed to the physician, and observe for any side effects. Review of the electronic health record (EHR) revealed a Health Status Note, dated 3/29/26 at 11:06 PM, entered by Staff S, Registered Nurse (RN): Nurse administered medications to the resident then after administering the medications, realized that the medications were for a different resident. Charge nurse notified and nurse on call for facility notified. Nurse instructed to observe resident for signs and symptoms of adverse reaction to medications given. No adverse reactions to medications noted remainder of shift. Message left for family member to contact facility. Review of the EHR revealed a lack documentation of assessment of Resident #47 following the identified medication error. Review of the facility incident report titled Medication Error Report, dated 3/29/26, revealed that on 3/29/26 at 8:30 PM, Resident #47 received another resident's medications, which included: a. Pravastatin 20 milligrams (mg) by mouth (medication used to help lower cholesterol). b. Quetiapine 25 mg by mouth (antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder). c. Lorazepam 0.25 mg by mouth (antianxiety medication used for short-term management of severe anxiety, insomnia, acute seizures, and pre-anesthesia sedation). The incident report revealed that the medication error occurred due to nurse preparing the medications having been called away for an emergency and upon returning to the medication cart, resumed passing medications, and took medications to the wrong resident. The incident report documented that the nurse administering medications realized the error right away and notified the on-call nurse of medications given in error, the on-call nurse determined it was not necessary to contact physician, and the provider would be informed on rounds the next morning. The incident report identified precautions to take to prevent a similar error were to follow the rights of medication administration and avoid distractions while administering medications. The physician signed the incident report on 3/30/26. Review of Resident #47's Medication Administration Record (MAR), dated March 2026, revealed that the following scheduled bedtime medications were also given on 3/29/26: a. Aripiprazole 5 mg, with directions to take 1 and 1/2 tablets (7.5 mg) by mouth at bedtime for diagnosis of major depressive disorder (antipsychotic used to treat schizophrenia, bipolar one disorder, depression, and irritability in autism). b. Atorvastatin 40 mg, take 1 tablet by mouth at bedtime for diagnosis of hyperlipidemia (medication used to lower cholesterol). c. Mirtazapine 30 mg, take 1 tablet by mouth at bedtime for diagnosis of depression (antidepressant used to treat major depressive disorder). d. Ropinirole 4 mg, take 1 tablet by mouth at bedtime for diagnosis of restless legs syndrome (medication used to treat Parkinson's disease and moderate-to-severe Restless Legs Syndrome (RLS) by stimulating dopamine receptors in the brain). e. Terazosin 2 mg, take 1 capsule by mouth at bedtime for diagnosis of essential hypertension (used to treat high blood pressure). f. Eliquis 5 mg, take 1 tablet by mouth twice per day (AM and bedtime) for diagnosis of atrial fibrillation (anticoagulant (blood thinner) that lowers the risk of stroke, blood clots, deep vein thrombosis (DVT), and pulmonary embolism (PE)). g. Gabapentin 100 mg, take 1 capsule by mouth every AM and bedtime for pain (medication used primarily to treat neuropathic pain (nerve pain from shingles) and manage partial seizures). h. Acetaminophen (Tylenol) 500 mg, take 2 tablets (1000 mg) by mouth three times a day for pain. Additionally, Resident #47 received scheduled Lorazepam 0.5 mg, with directions to give 1/2 tablet (0.25 mg) by mouth twice per day (AM and PM), administered on 3/29/26. During an interview on 3/31/26 at 2:25 PM, Resident #47 reported that on 3/29/26 at approximately 9:00 PM, she received bedtime medications, then the nurse returned with more medications and said she did not get all her meds. Resident #47 stated the staff was from an agency and Resident #47 had not seen her before. Resident #47 stated that during the same night, she had experienced visual hallucinations of a man in her room that stood about 6 feet tall and said she knew this was not real because there was no one she knew that looked like that. Resident #47 denied any staff checking her vital signs or asking her questions about medication side effects since the incident. During an interview on 4/02/26 at 8:30 AM, Staff S, RN confirmed working 3/29/26 evening with Resident #47. Staff S stated this was the first shift she had worked at the facility and mistakenly gave Resident #47 another resident's bedtime medications. Staff S confirmed that Quetiapine, Lorazepam, and Pravastatin were given in error to Resident #47. Staff S stated she notified the on-call nurse, Assistant Director of Nursing (ADON), of incident and was instructed to complete medication error report and monitor Resident #47. Staff S stated she completed the medication error report and gave to the on-coming nurse at the end of her shift. Staff S denied checking any vital signs on Resident #47, was instructed to just watch for any reactions. During an interview on 4/02/26 at 10:36 AM, ADON confirmed receiving a call from Staff S, RN on 3/29/26, regarding Resident #47 receiving another resident's bedtime medications, and instructed to assess, check vital signs, and monitor Resident #47 for any adverse reactions. The ADON reported that the physician should be called if there were any changes in Resident #47's condition and document in Health Status notes. The ADON stated that if Resident #47 had experienced hallucinations after receiving additional antipsychotic and antianxiety medications, this should have been documented and reported to the physician. During an interview on 4/02/26 at 1:15 PM, the Director of Nursing (DON) reported that Staff S, RN was instructed to monitor Resident #47 for adverse reactions and check vitals signs, but had not followed this instruction. The DON revealed expectation of nurses to monitor, assess, and document a resident's condition following an incident. Review of the facility policy titled, Medication Administration, revised 3/12/26, revealed the Purpose Statement of policy was to provide a medication regime safely and effectively. The Section, Procedures, instructed the following, in part: #5. Compare medication label to the MAR to verify the correct resident, medication, dosage, time, route, and indication of use. #14. Observe the resident for medication side effects and inform the licensed nursing personnel whom should inform the provider. Review of the facility policy titled, Medication Errors and Drug Diversions, dated December 2025, revealed the Policy Statement was to ensure timely reporting, documentation, investigation, and corrective action when a medication error or suspected drug diversion occurs in order to protect resident safety and maintain regulatory compliance. The Section titled, Procedure: Medication Errors, revealed the following: 1. Immediate Resident Assessment: a. Assess resident immediately for adverse effects or potential harm. b. Intervene as clinically indicated (vital signs, provider contact, monitoring). 2. Notification: a. Notify the Power of Attorney (POA), include this in your risk management documentation. b. Notify the provider immediately. c. If there is no imminent danger to the resident, notification may be placed in providers folder for review on routine rounds. Include this in your risk management documentation. 3. Documentation: a. Complete Medication Error Report form and start a risk management assessment. b. Document assessment and vital signs. c. Correct the MAR appropriately, do no delete entries. 4. Internal review: a. DON/ADON reviews medication error report form. b. Conduct root cause analysis. c. Assign corrective actions. d. Review in Quality Assurance and Performance Improvement (QAPI) monthly.

Based on clinical record review, observation, facility policy review and staff interview, the facility failed to ensure staff performed hand hygiene with a change in gloves after completing catheter care for 1 of 1 sampled residents (Resident #10.) The facility reported a census of 58 residents. Findings included: Review of the Minimum Data Set (MDS) assessment for Resident #10, dated 3/10/26, revealed the resident had an indwelling urinary catheter and required partial to moderate assistance with toileting and personal hygiene, set up assistance with oral hygiene, substantial assistance with lower body dressing, and partial to moderate assistance for upper body dressing. On 4/1/26 at 7:21 AM, Staff D, Certified Nurses Aide (CNA), performed hand hygiene, put on a gown and gloves prior to entering Resident #10's room. Resident #10 was lying in bed. Staff D unhooked the urinary catheter bag from the side of the bed and hooked it to the resident's walker. Staff D helped the resident to sit up in bed, and then applied a gait belt around the resident's waist. Staff D cleaned off the resident's glasses, put them on the resident, removed the resident's gripper socks, put new socks and shoes on the resident and helped him to ambulate to the bathroom toilet with his walker. Staff D pulled the resident's pants and incontinent brief down, and helped the resident to sit on the toilet. Staff D hung the catheter bag on the safety grab bar by the toilet. Staff D then ripped open the unsoiled incontinent brief, took off the resident's shoes, pulled his pants off, pulled the catheter bag out of the resident's pajama pants leg, disconnected the catheter tubing from the leg strap and removed the leg strap. Staff D opened up the port of the resident's catheter bag and emptied the urine in the bag into a graduated cylinder. Staff D set the cylinder in the corner of the bathroom on the floor. Staff D cleaned the port of the catheter bag, tubing, and catheter port with a sanitizing wipe. Staff D then connected a catheter leg bag to the catheter port. Staff D used another sanitizing wipe to clean the tubing and connector site off. Staff D placed the used catheter bag in a small basin and set the basin off to the side. Staff D changed her gloves without performing hand hygiene. Staff D applied a leg strap to the resident and put the catheter tubing in the leg strap holder. Staff D started a new incontinent brief and pants on the resident, and then put shoes on the resident. Staff D picked up the graduated cylinder with the resident's urine and placed it back on the floor closer to the sink. Without changing gloves and performing hand hygiene with a glove change, Staff D removed the resident's pajama top, and then helped the resident to don a shirt. Staff D helped the resident to stand and used a wet washcloth and cleansing agent to clean the resident's urinary meatus and perineal area. Staff D dried the area, pulled the resident's incontinent brief and pants up the rest of the way. Without changing gloves and performing hand hygiene with a glove change, Staff D helped the resident to stand to the sink and put warm water in a container for the resident to do his own oral cares. On 4/2/26 at 7:08 AM, during an interview, Staff V, CNA reported she had changed Resident #10's catheter bag to a leg bag that morning (4/2/26). She reported she removed her gloves and washed her hands after changing the resident's catheter bag. Staff V reported the need to perform hand hygiene (hand wash or use an alcohol-based hand sanitizer) after cares and between glove changes. On 4/2/26 at 9:00 AM, during an interview, the Director of Nursing (DON) reported staff should perform hand hygiene after the removal of gloves and between glove changes. Review of the facility's policy, titled Handwashing, dated 1/2026, revealed, in part, Hands should be thoroughly washed before and after providing resident care. Including after removal of gloves and/or personal protective equipment .Hand sanitizer may be used as an alternative to handwashing when hands are not visibly soiled. Review of the facility's policy, titled Catheter Care and Empty Drainage Bag, dated 10/19/23, revealed, in part, staff needed to perform hand hygiene, put on gloves, place plastic barrier under the graduate, open drain and let urine run into the graduate, wipe drain with antiseptic and close, measure and calculate amount, empty, rinse and return equipment to storage, remove gloves and complete hand hygiene. For catheter cares, staff needed to perform hand hygiene, glove, cleanse area around the meatus and then wash the catheter tubing 4 inches down from meatus, clean and put away equipment, remove gloves and complete hand hygiene.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to administer oral medications following standard infection control practices for 2 of 6 residents observed for medication administration (Resident #6 and Resident #9). The facility reported a census of 59 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of the March 2025 Medication Administration Record (MAR) revealed Resident #9 scheduled the following medication in the morning: a. Omeprazole 40 mg (milligram) 1 cap (capsule) PO (by mouth) early every morning. b. Cetirizine 10 mg 1 tab (tablet) PO early every morning. c. Tamsulosin 0.4 mg 1 cap PO early every morning. d. Vitamin B-12 500 mcg (microgram) 1 tab PO every morning. e. Vitamin C 500 mg 1 cap every morning. f. Acetaminophen 325 mg 2 tabs PO TID (three times a day). During an observation on 3/25/25 at 7:56 AM, Staff A, RN (Registered Nurse) popped out the morning tablets/capsules out of the bubble pack into his bare hands. Between each pill he picked up another card. Staff A stuck his fingers into the stock acetaminophen bottle and took 2 pills out of the bottle. Staff A popped the Vitamin B-12 tablet into his hand and as he went to put it into the medication cup, it fell on to the clipboard on the medication cart. Staff A picked it up and placed it in the cup. Staff A then proceeded to administer the medications to Resident #9. 2. The MDS assessment dated [DATE] revealed Resident #6 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. Review of the March 2025 MAR revealed Resident #6 scheduled the following medications in the morning: a. Levothyroxine 75 mcg 1 tab early every morning. b. Acetaminophen 500 mg 2 tabs PO TID c. Celecoxib 200 mg 1 tab PO every morning. d. Clopidogrel 75 mg 1 tab PO every morning. e. Cranberry con cap- 500 mg 1 cap PO every morning. f. Finasteride 5 mg 1 tab PO every morning. g Digoxin 0.125 mg 1 tab PO every morning h. I-Vite tab 1 tab PO every morning. i. Metoprolol Suc 50 mg ER (extended release) 1 tab PO every morning. j. Docusate 100 mg 1 cap PO BID (twice daily). k. Senna 8.6 mg 1 tab PO every morning. During an observation on 3/25/25 at 8:05 AM, Staff A, RN popped Resident #6's medication out of a bubble pack into his bare hands. Between each tablet/capsule Staff A picked up another medication card. Staff A stuck his fingers in the stock acetaminophen bottle and pulled out 2 tablets, then popped the cranberry concentrated capsule out of the bubble cap into his hand, tipped his hand towards the medication cup, and the capsule rolled onto the clipboard, Staff A proceeded to pick up the capsule and put it in the medication cup. Staff A also stuck his fingers into the stock docusate bottle and pulled out a capsule and stuck his fingers in the senna stock bottle and took out a tablet. During an interview on 3/25/25 at 1:41 PM, Staff A stated he did touch the tablets/capsules when he administered the medications for Resident #9 and Resident #6. Staff A stated he should not have touched the medications with his bare hands, and he usually tried to pop the medications in a cup. Staff A stated he washed his hands between residents and that was why he felt more confident in doing it that way. During an interview on 3/27/25 at 9:59 AM, Staff B, LPN (Licensed Practical Nurse) stated tablets and/or capsules should not be touched when they are taken out of the bubble pack or stock bottle during medication administration. During an interview on 3/27/25 at 10:45 AM, the DON (Director of Nursing) stated she expected staff to not touch tablets/capsules with their bare hands during medication administration. Review of the policy titled, Medication Administration , dated 4/28/23 directed staff, if hands are contaminated or soiled at any time during the medication pass wash your hands.

Based on observations, clinical record review and staff interviews, the facility failed to provide adequate supervision to ensure resident safety and to mitigate risk for elopement for 1 of 2 residents reviewed. (Resident #2) The facility reported census was 49. Findings include: According to a Minimum Data Set (MDS) with a reference date of 12/26/23, Resident #2 had a Brief Mental Status (BIMS) score of 5 indicating a severely impaired cognitive status. Resident #2 required limited assistance with transfers, mobility and extensive assistance with dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included Alzheimer's and an aortic aneurysm. According to Resident #2's plan of care dated 1/3/23, Resident #2 is an elopement risk related to wandering behavior with interventions which included monitoring location frequently across all shifts, document wandering behavior if observed, the use of a wander guard, and staff to ensure it is in place and functioning properly each shift and to replace it as needed. In an interview on 2/20/24 at 10:04 a.m. Staff B, Registered Nurse, stated she heard the door alarm on the north hall sound (10/16/23 at 2:25 p.m.) and responded immediately. Staff B stated she looked out doors through the window and did not see anyone, so she returned to the nurse's station without verifying the cause for the alarm or initiating elopement protocols which included doing a head count to ensure all residents were accounted for. Staff B stated shortly after returning to the nurse's station, someone said that someone (Resident #2) was outside and was being escorted back into the facility. Staff B stated Resident #2 was an elopement risk and was wearing a wander guard at the time of the event. In an interview on 2/20/24 at 10:45 a.m. the Director of Nursing (DON) stated on 10/16/23, Resident #2 exited the building through the North door setting off the alarm. The DON stated Resident #2 was wearing a wander guard bracelet at the time and was discovered on the East side of the building by their maintenance guy 5-10 minutes later and escorted back into the building. The DON stated her expectations upon a door alarm sounding would be that staff immediately respond to determine the cause for the alarm which may include stepping outside to check for residents. If a resident is not seen and the cause of the alarm cannot be determined, staff are to complete a resident headcount to ensure all residents are accounted for. If a resident is missing, elopement protocols are to be initiated. Observations on 2/20/24 at 10:45 a.m. found the North hall exit alarmed and functioning properly. The door sits on the other side of double doors (not alarmed) leading off of the long term care unit. The North door alarm does not have a wander guard monitor. According to a Disciplinary Notice dated 10/25/23, Staff B given a verbal warning for failing to go outside and check for residents when responding to a door alarm and failing to alert staff and account for residents.

Based on observations, clinical record review, staff interview and facility document review the facility failed to supervise 2 out of 3 random observations of medication administration. The facility reported a census of 52 residents. Findings included: 1. The Annual Minimum Data Set (MDS) Assessment for Resident # 6 dated 12/30/22, reflected diagnoses of heart failure, hypertension and osteoporosis. The MDS indicated a Brief Interview for Mental Status score of 15 (intact cognition). The Care Plan for Resident # 6 dated 9/15/21, identified she wanted to remain as independent as possible and wanted to continue to do things for herself, even if it tires her out. The Care Plan failed to identify Resident #6 as independent in administering her own medication. Resident #11's Significant Change MDS dated [DATE], reported diagnoses of Alzheimer's disease and hypertension. The MDS listed Resident # 11's BIMS as 6 (severe cognitive impairment). On 03/22/23 at 8:18 AM, Staff A, Certified Medication Aid (CMA), sat a cup of medication in front of Resident # 6 with a second medication cup that held apple sauce and a spoon at the table. Resident # 6 sat across from Resident #11 The Staff B walked away from the table and failed to come back. She stood at her medication cart in the hall with her back to the residents in the dining room. On 03/22/23 at 8:21 AM, Staff B CMA, administered medication to Resident # 11. Staff A left the dining room area. On 03/22/23 at 8:29 AM, Resident # 6 moved the medication cup in front of her. Resident #6 added 1 pill at a tip to spoon with apple sauce and put the medication in her mouth. Resident #6 repeated this 4-5 times. The CMA's failed to observe Resident # 6 take the medication. 2. On 03/22/23 at 12:11 PM, Staff B, carried 2 medication cups to Resident # 6 and set them on the table to the left of her. Staff B stood and talked with a family across the table. On 03/22/23 at 12:12 PM, Staff B, walked to her med cart with her back to R #6. On 03/22/23 at 12:17 PM, Staff B, walked back over at the table and administered Resident # 11 medications and went back to the medication cart. On 03/22/23 at 12:22 PM, Staff B, left the dining room and took the medication cart back the the nurses station at the center of the building. On 03/22/23 at 12:39 PM, Resident #6 moved the medication cup in front of her as she pushed her plate away. Resident # 6 took the medications from the medication cup and placed them in her mouth. Staff B failed to provide supervision as Resident # 6 took medications. On 03/23/23 at 9:02 AM, Staff C, Registered Nurse (RN) stated none of the resident's on Hall two took medications independently. She confirmed, she supervised residents as they took medications. On 03/23/23 at 9:06 AM, the MDS Coordinator, stated all the resident's at the facility required supervision while they took medication. On 03/23/23 at 9:09 AM, the Acting Director of Nursing (DON), reported all of the current residents take medication with supervision. The Acting DON revealed she expected is the staff stay with the residents until all the medications are administered. The Acting DON stated it is the standard of practice, she stated the facility failed to have a policy on Medication Administration. The facility provided an audit tool titled Medication Pass undated, directed at point # 9 Administered medication and certified consumption.

Based on clinical record review and staff interview, the facility failed to ensure resubmission of the PASARR following change in medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 54 residents. Findings include: The annual Minimum Data Set (MDS) assessment for Resident #52 dated 11/5/21 recorded the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was moderately cognitively impaired. The Face Sheet for Resident #52 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan dated 12/10/19 documented she had a psychosocial well-being problem related to anxiety and depression. The Level 1 Form Pre-Admission Screening and Resident Review, review date of 8/9/18, documented the following question: 1. Does the individual have any of the following Major Mental Illnesses? >> No. The form documented options for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 12/02/21 at 9:52 AM, the Social Worker stated a resident's Level 1 PASSAR assessment would be resubmitted if the nurses communicated a significant change or medication change. The Social Worker reviewed Resident #52's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/2/21 at 10:59 AM, the Social Worker stated the resident had no other PASARR forms in her record. On 12/2/21 at 9:49 AM, the facility's Administrator explained the facility followed regulation and did not have a specific PASARR policy.

Based on observation, record review, and interview, the facility failed to ensure staff wore the proper Personal Protective Equipment (PPE) to help prevent the spread of communicable disease and infection for 2 of 4 sampled in 14 day quarantine. Concerns identified for Resident #1 and #2. The facility reported a census of 54. Findings include: 1. During an observation on 6/17/20 at 9:00 a.m., Staff A (Nurse Aide) entered Resident #1's room and placed a mask on him. Staff A was in close proximity to the resident as she assisted him to walk to the bathroom with a gait belt and a walker. Staff A then assisted the resident in the bathroom. Staff A did not put on a gown before she entered the room, assisted him to walk, and assisted him to the bathroom. In an interview immediately after cares, Staff A stated the resident had been incontinent of both bowel and bladder and she assisted him with perineal cleansing. An untitled facility document, provided to the survey team on 6/17/20, stated Resident #1 was quarantined to his room for 14 days through 6/19/20 due to a hospitalization . 2. During an observation on 6/17/20 at 9:45 a.m., Staff B (Nurse Aide) entered Resident #2's room and placed a mask on him. Staff A was in close proximity to the resident as she walked with him to the bathroom and assisted him with perineal cleansing. Staff B did not put on a gown before she entered the room and assisted the resident. An untitled facility document, provided to the survey team on 6/17/20, stated that Resident #2 was quarantined to his room for 14 days through 6/24/20 due to an eye doctor visit. The facility policy Considerations for New Admissions or Readmissions to the Facility, dated 4/30/20, directed staff to wear eye protection, masks, gloves, and gowns with residents readmitted to the facility in the last 14 days. The facility policy Outpatient Appointment and Potential Exposures, dated 6/8/20, directed staff to place residents into quarantine for 14 days after an outpatient appointment. A facility census document, dated 6/11/20, stated Resident #1 and #2 had a quarantine status. During an interview on 6/17/20 at 11:00 a.m., the Director of Nursing (DON) stated staff should have worn full PPE(gown, gloves, mask) when caring for Resident #1. She stated the facility erred and grouped him with other residents such as Resident #2 who had brief medical visits. She stated it was her understanding if residents left the facility for a brief medical visit, they were to stay in their rooms but staff did not have to wear full PPE. The CMS QSO-20-29-NH Memorandum Summary dated May 6, 2020 directed staff to wear gloves, gown, eye protection and an N95 or higher-level respirator if able for residents with known or suspected COVID-19.

Based on clinical record review and staff interview, the facility failed to submit a Level II evaluation and determination to the state designated authority for 1 of 3 sampled (Resident #59) who had a newly evident or possible serious mental disorder, intellectual disability, or other related condition. The facility reported a census of 64. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #59 had [DIAGNOSES REDACTED]. The MDS identified Resident #59 NOT considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition. The Care Plan revised on 5/8/18 revealed Resident #59 received antipsychotic and antidepressant medication. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 8/26/16. The Level I screen documented no under question 1, does the individual have any of the following Major Mental Illnesses, which included [MEDICAL CONDITION]. The [DIAGNOSES REDACTED].#59 had a [DIAGNOSES REDACTED]. The clinical record lacked documentation Resident #59 received a Level II evaluation and determination. During an interview on 8/14/19 at 12:25 p.m., the Provisional Administrator stated she filled out the PASARR paperwork prior to Resident #59's admission to the facility. She stated she obtained the information from the family in order to complete the paperwork. The DON acknowledged she should have checked Resident #59's clinical record to ensure she completed the paperwork accurately.

Based on observation, record review and staff interview, the facility failed to activate the alarms to the front entrance doors during periods without staff supervision and failed to ensure resident safety with the placement of a sewing machine in a wood cabinet at the top of stairs leading to the first floor, and failed to provide safe resident transfer with the assist of 2 staff. The facility reported a census of 75 residents. Findings include: 1. Random observations of the front entrance doors revealed no staff supervision and no alarms sounded when doors were opened at the following dates and times: 2/27/17 at 5:15 p.m., on 2/28/17 at 6:15 a.m. and on 3/1/17 at 6:15 a.m. 2. Daily observations between 2/27/17 and 3/2/17 revealed a SINGER sewing machine in a wood cabinet placed at the top of stairs from the main lobby to the first floor of the facility causing a trip hazard. The main lobby was located immediately outside the resident rooms on the West Unit resident rooms. During an interview on 3/1/17 at 9:47 a.m., Staff A, RN reported the receptionist usually leaves around 4 or 5 p.m. at night then the alarm should be turned on, that the front door is not alarmed, unsure as to who is responsible for locking the front door on second shift and when he arrives to work at 5:20 a.m., the door is already unlocked. In an interview on 3/1/17 at 1:12 p.m., Staff F, RN reported the receptionist usually leaves the facility at 5:00 p.m. and the CNAs usually turn on the alarms to the front doors between 10:00 and 11:00 p.m. During an interview on 3/1/17 at 4:00 p.m., Staff H, CNA reported she was unsure of when the receptionist at the front desk leaves for the day and thought the alarms to the front entrance doors turned on automatically. In an interview on 3/1/17 at 2:55 p.m., the director of nursing reported the alarms to the front entrance doors are usually activated by the night shift nurses at 10:00 p.m., that the receptionist usually leaves between 4:30 and 5:00 p.m. and there is a wanderguard alarm system to the front entrance which is activated 24 hours a day, seven days a week. She also reported the sewing machine is placed at the top of the stairs as a deterrent to keep residents from going down the stairs. She has been employed at the facility for three and a half years and it has been there since then and before then. 3. An observation on 2/28/17 at 6:10 a.m. revealed the front door not alarmed with the exception of the armed wanderguard system. There were no staff members at the reception desk or in sight of the front door. An observation on 2/28/17 at 6:27 a.m. revealed the front door not alarmed with the exception of the armed wanderguard system. There were no staff members at the reception desk. A nurse passed medications in the west hall but entered resident rooms and was not within sight of the front door at all times. An observation on 3/2/17 at 6:40 a.m. revealed a sign on the front door alerting visitors to enter the facility through the chapel door before 8:00 a.m. and after 5:00 p.m. A board was present in front of the lobby stairway blocking the steps. Facility documentation revealed 6 residents listed as cognitively impaired and independently mobile not utilizing a wanderguard system. During an interview on 3/2/17 at 6:40 a.m., the Director of Nursing stated the facility would lock the front doors before 8:00 a.m. and after 5:00 p.m. and would construct a gate to block the stairway.

Based on observation, staff interview, and facility policy, the facility failed to use the correct scoop sizes for 7 pureed diets and to utilize all the pureed mixture for portion sizes to insure the same nutritional equivalents as for regular diets was maintained. The pureed lettuce mixture failed to include any dressing for those residents on the pureed diets. The facility reported a census of 75 residents. Findings include: During an observation of the pureed process on 02/28/2017 at 10:56 A.M., Staff D (dietary cook) placed (7) 8 ounce servings of lettuce into the food blender with approximately 1 cup of tomato juice and placed the mixture into a measuring cup. The 4 and 1/2 cup mixture called for a #6 scoop (5 and 1/3 ounces) for each portion according to the Pureed Diet Portion chart from the Food Distribution service. Staff D utilized a # 10 scoop (3 and 1/4 ounces) for each portion. Staff D also only filled the # 10 scoop to 7/8 full instead of to the top which left another 1/4 cup in the measuring cup. Staff D failed to use all the pureed lettuce mixture for the portions and failed to use the correct size scoop. Staff failed to included any salad dressing with the lettuce mixture. Observation on 02/28/2017 at 10:22 A.M., Staff E (dietary cook) placed 7 bread sticks and meat balls (4 ounces each serving) with milk into the robo coup. The mixture measured 6 and 1/2 cups. Staff E consulted the Pureed Diet Portion chart and verbalized a # 8 (4 ounces) and a # 16 (2 ounces) scoop should be used for each portion. The Surveyor checked the same Pureed Diet Portion chart and realized the scoops required to meet the correct portions sizes should be a #16 (2 ounces) slightly heaped and a # 6 (5 and 1/3 ounces) for each serving. During the noon meal service on 02/28/2017 at 11:28 A.M., Staff E mixed pureed spaghetti and milk in a nose cup (has a portion of the top of the cup cut out for the nose in order to allow the resident to tip the cup closer when drinking. Staff E stirred the mixture while standing over the steam table. The mixture splashed out of the cup into the regular spaghetti sauce and into other areas of the steam table. During an interview on 03/01/2017 at 1:20 P.M., the Assistant Dietary Supervisor (ADS), verbalized witnessing Staff D failing to use the entire pureed lettuce mixture for the 7 portions and confirmed Staff E should not mix food in nose cups over the steam table. The ADS also confirmed witnessing the spillage of the mixture into food on the steam table. During an interview on 02/28/2017 at 2:30 P.M., The Dietary Supervisor agreed Staff D needed to use all the pureed lettuce mixture for the pureed portions instead of throwing it away. The Pleasantview Home Nutrition Services policy for pureed diets dated 03/04/2016 directed staff to use the volume chart to identify the correct scoop size to use for each portion of the total volume of the pureed mixture measured.

Based on observation, record review and staff interview, the facility failed to follow a Resident's plan of care for transfer (R#4). The facility reported a census of 75 residents. Findings include: The MDS(Minimum Data Set) assessment tool, dated 2/8/17, listed [DIAGNOSES REDACTED]. The MDS stated the resident required supervision and setup assistance for eating, extensive assistance of 1 staff for dressing and personal hygiene, and extensive assistance of 2 staff for bed mobility, transfers, walking, toilet use, and bathing. The MDS stated the resident was not steady and only able to stabilize with staff assistance while moving from seated to standing, walking, turning around, moving on and off the toilet, and transferring between the bed and chair or wheelchair. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. During an observation on 2/28/17 at 6:40 a.m., Staff C CNA placed a gait belt on the resident and assisted him/her to transfer from the recliner to the wheelchair and then from the wheelchair to the toilet. After assisting the resident with personal cares, Staff C then placed a gait belt on the resident and assisted him/her to transfer from the toilet to the wheelchair. The resident appeared weak during the transfers. No additional staff members were present to assist with the transfers. A care plan entry, revised 11/8/16, stated the resident was at risk for falls due to [MEDICAL CONDITION] medication use and weakness. A 2/10/17 entry stated the resident required the assistance of 2 staff and a gait belt for transfers. During initial tour on 2/27/17 at 9:00 a.m., Staff G LPN(Licensed Practical Nurse) stated the resident required the assistance of 2 staff or a mechanical lift for transfers. During an interview on 3/2/17 at 8:00 a.m., the Director of Nursing confirmed the resident required the assistance of 2 staff for transfers.

Based on observation, record review, and interview, the facility failed to carry out adequate infection control measures for 1 of 1 residents with a catheter (Resident #4) and 1 of 3 residents with a skin treatment (Resident#13). The facility reported a census of 75 residents. Findings include: 1. The MDS(Minimum Data Set) assessment tool, dated 2/8/17, listed [DIAGNOSES REDACTED]. The MDS stated the resident required supervision and setup assistance for eating, extensive assistance of 1 staff for dressing and personal hygiene, and extensive assistance of 2 staff for bed mobility, transfers, walking, toilet use, and bathing. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. During an observation on 2/28/17 at 6:40 a.m., Staff C CNA(Certified Nursing Assistant) strung the resident's catheter bag though his/her pants while he/she sat on the toilet. Staff C then placed the catheter bag directly on the floor while she put the resident's shoes on. Staff C then assisted the resident to stand up and the end of the catheter's tubing slipped out of the protective sheath and came in contact with the toilet. Staff C replaced the tubing into the protective sheath without cleansing the end with alcohol. A care plan entry, dated 2/10/17, directed staff to ensure contamination of the catheter drain did not occur. The October 2013 facility policy entitled Catheter Care and Empty Drainage Bag directed staff to ensure contamination of the catheter drain did not occur. During an interview on 3/1/17 at 10:00 a.m., Staff B RN(Registered Nurse) stated catheters should not touch the floor and staff should cleanse the end of the tubing drain with alcohol should it become contaminated. During an interview on 3/1/17 at 2:48 p.m., the Director of Nursing stated catheter bags should not touch the floor. 2. Resident #13's MDS quarterly assessment completed 12/29/16 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident to be cognitively impaired with a brief interview for mental status score of 5 out of 15 and required extensive staff assistance with most activities of daily living. The care plan with the target date of 4/6/17 did not address the problem of skin lesions. The physician orders dated 1/11/17 and February 2017 had documentation of an order for [REDACTED]. During an observation on 2/28/17 at 6:50 a.m., Staff A, RN used one cotton tipped applicator to apply [MEDICATION NAME] and [MEDICATION NAME] cream to 3 different skin lesions on the resident's chest then stated I guess I should have used a different Q tip for each site. During an interview on 3/1/17 at 9:19 a.m., Staff B, RN reported if she had to apply topical medication to more than one site, she would use a different cotton tipped applicator or glove for each site. In an interview on 3/1/17 at 9:47 a.m., Staff A, RN reported if he had to apply topical medication to more than one site, he would use a different cotton tipped applicator for each site and admitted he failed to do that during the observation on 2/28/17 as he did not have extra applicators. During an interview on 3/1/17 at 1:12 p.m., Staff F, RN reported if she had to apply topical medication to more than one site, she would use a different cotton tipped applicator or glove for each site. In an interview on 3/1/17 at 2:55 p.m., the director of nursing reported when applying topical medication to different sites, she would expect staff to use a different cotton tipped applicator for each site. A review of the facility policy dated as last reviewed March 2017 revealed the following: Purpose: to administer topical medications in a safe, accurate and effective manner. Procedure: wash hands, put on examination gloves, if a resident has multiple treatment sites, the cleanest site is treated first and each site is treated as a separate dressing.

Based on interviews and call light logs, the facility failed to ensure staff responded to residents call lights promptly (no longer than 15 minutes) for 1 of 5 residents interviewed during the group interview; and for 3 of 4 residents listed on the call light log. The facility reported a census of 75 residents. Findings include: During the group interview a resident reported staff needed to answer call lights more quickly. The resident stated he/she had to wait up to an hour for someone to answer the call light when he/she needed pain medicine and stated this made him/her feel a little disgusted. Review of call light logs for the period of 1/27/16-2/3/16 revealed Resident #6 with call light response times greater than 20 minutes. The log also identified 3 out of 4 other residents sampled with call light responses greater than 20 minutes. Review of the facility Resident Council minutes for 1/13/16 revealed several residents were concerned about the length of time their call lights were being answered. During an interview on 2/3/16 at 3:30 p.m., the Director of Nursing stated call lights should be answered in 15 minutes or less.

Based on record review, interviews and facility policy, the facility failed to investigate and timely report an allegation of abuse by a visitor for 1 of 1 resident review (Resident #4). The facility reported a census of 75 Residents. Findings include: The quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #4 documents [DIAGNOSES REDACTED]. The nursing notes dated 11/1/15 at 9:00 p.m., documented staff found Resident #4's visitor kneeling beside the resident's bed, rubbing the resident ' s back and perineal area. Investigation notes dated 11/19/15 documents the DON's conversation with Staff E, Licensed Practical Nurse, (LPN), regarding observations of inappropriate touching between Resident #4 and the visitor. The Care Plan entry dated 11/19/15 indicated the resident ' s visits with a particular individual visitor require staff to supervise the visit(s) or be held in public area (dining room). Review of a progress note dated 11/24/15 documented a conversation between the Social Worker, DON and the resident ' s Power of Attorney (POA), regarding a visitor on 11/1/15 who was witnessed inappropriately touching the resident. In a telephone interview on 2/3/16 at 8:25 a.m., Staff H (CNA) recalled working on 11/1/15 and stated she observed a visitor of Resident #4 walk into the resident's room and close the door behind them. Staff H went to the nurse's station and asked the nurse (Staff E) if the visitor could be in the resident's room with the door closed, the nurse (Staff E) replied no, the door must remain open. Upon entry to the resident's room she observed the resident in bed with the visitor kneeling beside the bed with both hands touching the resident. One hand was on the front lower abdomen/pubis area, under the covers and other hand was on the resident's back. The visitor immediately removed his/her hands, and stated he/she was giving the resident a back rub. Staff H suggested the visitor leave since it was already (after) 8 p.m. Staff H exited the resident's room and stood outside the open door, and heard the visitor tell the resident you can't tell anyone about this, the big man is coming. After the visitor left, she reported the incident to the nurse (Staff E). During an interview on 2/2/16 at 12:50 p.m., Staff E, Licensed Practical Nurse, (LPN), stated a CNA called her to Resident # 4's room around 8:15 p.m. on 11/1/15. The CNA reported when she entered the resident's room, the visitor had been kneeling beside the bed touching the resident's back and perineal area. Resident #4 had been in bed. After the visitor left the room, we gathered at the nurse's station and discussed the incident and protocol. Staff E stated she documented the event in the nurse's note and notified the nurse manager. In an interview on 2/3/16 at 9:45 a.m., the DON stated the incident on 11/1/15 was not reported to her until 11/19/16. The Staff C, RN, Nurse Manager, was absent during this time frame and was unaware of the accusation, so the follow up was disrupted. The DON admits the facility failed to do a complete investigation, interviewed staff, and failed to report this incident to the Department of Inspections and Appeals (DIA) in a timely manner. The DON can't recall who reported the incident to him/her. In an interview on 2/3/16 at 2:00 p.m., the Administrator stated that the facility reported the incident concerning Resident # 4, when they were made aware of it on 11/23/15. The Administrator stated this resident had never made any accusations concerning this visitor. A document titled Abuse Prevention Polices and Procedures provided by the facility, documents staff will assure that no resident is subjected to abuse through the words or deeds of anyone, including but not limited to family members. Also documents that upon completion of the investigation, the Administrator or Director of Nursing will report allegations to the appropriate authorities immediately within 24 hours.

Based on observation, record review, and interview, the facility staff failed to treat one (1) of ten (10) residents with respect and maintain their dignity during personal cares (Resident #3). The facility reported a census of 75 residents. Findings include: 1. The admission care plan for Resident #3 listed an admission date of [DATE] with an admission [DIAGNOSES REDACTED]. The interventions included in the resident's care plan directed staff to: a. listen carefully and be non-judgmental b. keep topics of conversation light and cheerful c. be reassuring and listen to concerns d. explain what you intend to do while providing care. The current Physicians Order Sheet for Resident #3 listed a [DIAGNOSES REDACTED]. During an observation on 2/3/16 at 10:01 a.m., Staff B, Registered Nurse (RN) prepared to change the frostbite wound dressings on Resident #3's feet. When Staff B removed the dressings from Resident #3's foot and stated, it looked like rats had been chewing on the resident's foot. Throughout the dressing change, Staff B did not explain to the resident what he was doing and talked about another individual's wound/dressing treatment he had taken care of in the past. During the dressing change, Staff B stated to the resident, he(Staff B) wished the resident had taken his/her pain medicine but the resident knew (what was) best, except when it came to walking around outside in the cold barefoot During an interview on 2/1/16, during the initial tour at 9:30 a.m., the Nurse Manager stated Resident #3 came to the facility due to frostbite. She stated the resident had dementia and had gotten frostbite from leaving his/her home and going outside barefoot in the cold. During an interview on 2/4/16 at 8:40 a.m., the Director of Nursing stated she expected staff to treat residents with kindness and courtesy; and was not sure how the resident was treated during the observation. She stated staff should not be condescending or rude.

Based on observation, record review, and staff interview, the facility failed to follow manufacturer's recommendations for 1 of 1 resident receiving [MEDICATION NAME] insulin(Resident # 17). The facility reported a census of 75 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 1/21/16, listed [DIAGNOSES REDACTED]. During an observation on 2/4/16 at 7:39 a.m., Staff A LPN(Licensed Practical Nurse) injected 7 units of insulin into Resident #17's abdomen using a [MEDICATION NAME]. Staff A did not prime the pen prior to dialing up and injecting the insulin. The current physician's orders [REDACTED]. The [MEDICATION NAME] instructions, provided by the Director of Nursing, directed staff to prime the needle as described in the following steps prior to injecting insulin: 1. Dial 2 units 2. Hold the syringe with the needle pointing up and tap reservoir gently to move air bubbles to top of needle. 3. Press the push button on your syringe as far as it will go until a drop of insulin appears. During an interview on 2/4/16 at 8:40 a.m., the Director of Nursing stated the [MEDICATION NAME] pens should be primed with 2 units prior to use.

Based on observation, record review, and staff interview, the facility failed to ensure staff sanitized glucometer for 1 of 1 resident (Resident #17) in accordance with in accordance with facility policy. The facility reported a census of 75 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment tool, dated 1/21/16, listed [DIAGNOSES REDACTED]. During a medication pass observation on 2/4/16 at 7:36 a.m., Staff A LPN (Licensed Practical Nurse) obtained Resident #17's blood sugar. When finished, Staff A briefly wiped off the glucometer with an alcohol pad. Staff A did not allow the alcohol pad to sit on the glucometer for any length of time. During an interview on 2/4/16 at 7:40 a.m., Staff A stated the facility used the glucometer for multiple residents. The facility policy for blood glucose monitoring, with a review date of July 2015, directed staff to disinfect the meter using bleach wipes by following the label instructions. During an interview on 2/4/16 at 8:40 a.m. the Director of Nursing stated she would expect staff to use a bleach wipe to cleanse the glucometers. She stated staff could use an alcohol wipe but agreed that a bleach wipe would be preferable.

Based on observation, record review, and resident and staff interviews, the facility failed to administer medications as ordered for 1 of 30 medication administration opportunities observed, Resident #16, did not access the Emergency Medication Box for 48 hours to replace a routine medication ordered as needed for Resident #10 when the medication was available in the Emergency Medication Box failed to follow professional standards for medication administration and storage for 2 residents, Resident #12 and #17, and failed to administer medications at appropriate intervals and as ordered by the physician, Resident #1. The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had [DIAGNOSES REDACTED]. Medication ordered by the physician included: Dorzol/Timol (medication used to decrease internal eye pressure) 2 percent-0.5 percent, 1 drop instilled to each eye 2 times per day, apply light finger pressure to the lacrimal sac for 1 minute following administration. The February, 2015 Medication Administration Record [REDACTED].M. (morning) and EVE (evening), with the statement: Apply light finger pressure to lacrimal sac for 1 minute following administration recorded by the medication entry. Observation on [DATE] at 3:26 p.m. revealed Staff A, Certified Medication Aide (CMA) administered 1 drop of the Dorzol/Timol eye drop medication to each eye, and did not apply pressure to the lacrimal ducts after the medication was administered. The medication bottle had a label applied by the pharmacy that stated: "Instill 1 drop into each eye 2 times per day. Apply light finger pressure to lacrimal sac for 1 minute following administration". During an interview on [DATE] at 2:58 p.m., the Director of Nursing (DON) stated that he/she expected staff to follow physician orders [REDACTED]. 2. The Minimum Data Set (MDS) Assessment tool dated [DATE], revealed Resident #12 had [DIAGNOSES REDACTED]. Medications ordered by the physician included: [MEDICATION NAME]-R insulin: 13 units administered subcutaneous daily before the evening meal. Resident #12's [DATE], and February 2015, Medication Administration Records (MAR's) revealed the ordered [MEDICATION NAME]-R insulin was documented as administered daily between [DATE] and [DATE]. Observation on [DATE] at 5:35 p.m. revealed Staff B, Registered Nurse (RN) removed Resident #12's bottle of [MEDICATION NAME]-R insulin from the medication cart. The bottle had a pharmacy prescription label attached to it that stated the bottle was dispensed on [DATE], and directed staff to discard the bottle 28 days after the date opened. Another pre-printed "date opened" label affixed to the bottle had a hand-written [DATE] date on it. The bottle was approximately ,[DATE] full, had 10 milliliters (ml) when originally dispensed, with 100 units of [MEDICATION NAME]-R insulin per ml concentration. During an interview at the observation time, Staff B asked what he/she should do, then obtained a new bottle of [MEDICATION NAME]-R insulin from the facility's Emergency Medication Box and used it to administer the resident's insulin. Staff B stated replacement insulin was always available in the Emergency Medication Box and discarded the insulin bottle dated as opened [DATE]. During an interview on [DATE] at 8:45 a.m., the facility pharmacist stated pharmacy labels the insulin with the most restrictive date of expiration for discard, that another insulin type expired 28 days after opened and the shelf-life of [MEDICATION NAME]-R insulin was 30 days after the date opened, the medication would lose effectiveness after 30 days and should have been replaced at that time. During an interview on [DATE] at 2:58 p.m., the Director of Nursing (DON) stated that he/she expected staff to follow professional standards of practice, if the insulin bottle was labeled to discard 28 days after the date opened that staff should have discarded the bottle 28 days after it was opened. 3. The Minimum Data Set (MDS) Assessment tool dated [DATE] revealed Resident #17 had [DIAGNOSES REDACTED]. from bed and chair, bathing and eating, and weight of 143 pounds without weight gain or weight loss. Physician orders [REDACTED]. Aspirin 81 milligrams (mg) administered oral daily scheduled at 8:00 a.m. [MEDICATION NAME] (a blood pressure medication) 12.5 mg administered oral daily scheduled at 8:00 .m. [MEDICATION NAME] (a [MEDICAL CONDITION] hormone replacement) 75 micrograms (mcg)administered oral daily scheduled at 8:00 a.m. Posture-D (a calcium and vitamin D supplement) administered oral daily scheduled at 8:00 a.m. Ensure Clear (a nutritional supplement) 200 ml (approximately 7 ounces) administered oral daily. A notation in the resident's record revealed that the dietary department provided the ordered supplement. Resident #17's February 2015 Medication Administration Record [REDACTED]. Observation on [DATE] at 9:17 a.m. revealed Staff I, Certified Medication Aide (CMA) poured approximately 4 ounces of "Med-Pass" (a different nutritional supplement) into a 4 ounce-sized cup and handed to the resident with his/her medications scheduled at 8:00 a.m. The resident looked at the cup of Med Pass and stated "what's this?". Staff I stated "that's Med Pass, it's good for you" and directed the resident to drink it. The resident drank the supplement as he/she swallowed the medications. During an interview on [DATE] at 8:56 a.m., Staff M, Registered Nurse (RN) stated he/she would not administer the Med Pass supplement to a resident unless it was ordered by a physician. During an interview on [DATE] at 8:35 a.m., when asked if staff should have a physician order [REDACTED]. During an interview on [DATE] at 1:30 p.m., the facility's Registered Dietician stated that sometimes nursing staff will offer different nutritional supplements to residents to determine the resident's preference before the physician order [REDACTED]. 4. Resident #1's Minimum Data Set (MDS) dated [DATE] identified the resident's [DIAGNOSES REDACTED]. The MDS revealed the resident had short and long term memory problems and has severe impairment with daily decision making skills. The MDS further indicated Resident #1 required extensive assistance of one staff with eating. The Care Plan dated [DATE], revised [DATE], identified a problem of: Tired from constant walking and my pyshotropic drug use. An approach for the problem was for staff to give medications as ordered to help with agitation and observe for desired and or untoward effects. The Medication Administration Record [REDACTED] [MEDICATION NAME] 1000 milligrams (mg) by mouth 3 times a day a.m., midday and evening. Aspirin 81 mg by mouth every morning, in a.m. [MEDICATION NAME] 20 mg by mouth every day, in a.m. Donepezil 5 mg at bed time. [MEDICATION NAME] 0.5 mg ,[DATE] tab(0.25 mg) by mouth 3 times a day, in a.m., midday and evening. Levetiraceta 500 mg by mouth 2 times a day, in a.m. and evening. [MEDICATION NAME] 100 micrograms (mcg) by mouth every morning before meal, in a.m. [MEDICATION NAME] 20 mg by mouth every morning, in a.m. Oyster Shell 500 mg by mouth daily, in a.m. [MEDICATION NAME] 17 grams mixed with 8 ounces of water by mouth daily, in a.m. Vitamin B-12 1000 mcg by mouth every morning, in a.m. Vitamin D3 1000 units by mouth every morning, in a.m. During an observation of the meal on [DATE] at 12:42 P.M., showed Staff G present to assist Resident #1 with the meal pureed cake, meat, mashed potatoes, with juice and water. Staff H, Registered Nurse (RN), administered bites from a medication cup full of crushed pills to Resident # 1. At [DATE] at 1:15 p.m., observation revealed Staff I, Certified Medication Aide (CMA), attempting to give Resident #1 a large spoon full of chunky brown pudding-like substance from a medication cup. Resident #1 stood in the Merry Walker while Staff I CMA stood next to the medication cart. During an interview on [DATE] at 1:15 P.M., Staff I reported attempting to administer Resident #1's midday medication [MEDICATION NAME] 1000 mg and [MEDICATION NAME] 0.25 mg. The surveyor requested Staff I check with Staff H before administering medications. During an interview with Staff H at 1:17 p.m., Staff H reported administering Resident #1's morning medications at the lunch table at 12:42 p.m. because Resident # 1 got out of bed late today. During an interview/observation on [DATE] at 1:20 P.M., Staff H reported to Staff I she was just telling the on-coming ,[DATE] nurse in report Resident #1's mid-day medications would need to be administered between ,[DATE] p.m. Staff H stated the facility allows Resident #1 to set the schedule. Staff I was directed by Staff H to waste the mid-day medication because Resident #1 just had the a.m. medication. Staff H directed Staff I to reorder the medications from the pharmacy and use the spare dose at ,[DATE] p.m. On [DATE] at 1:32 p.m., Staff J, Licensed Practical Nurse, stated the expectation was AM medications are administered by ,[DATE]:30 a.m. Staff J continued to state if Resident #1 got up and was restless, give the med and hold the noon dose. Staff J provided a guide titled RxCareAssurance undated from the front of the MAR indicated [REDACTED]. Staff J produced a new physician's orders [REDACTED].#1's [MEDICATION NAME] 1,000 milligrams (mg) give by mouth when awakens in the am, 2 p.m. and hour of sleep. The [MEDICATION NAME] 0.25 mg decreased to 2 times a day, when awakens and hour of sleep. During an interview on [DATE] at 10:14 a.m. the Director of Nursing reported the nurse and medication aide need to work on communication when doing medication pass. The facility provided a policy titled Medication Administration dated [DATE], the policy directed the staff to follow the 5 rights of medication administration. 1. Right Resident 2. Right Medication. 3. Right Time. 4. Right Dose. 5. Right Route. 5. Resident #10's Minimum Data Set assessment ((MDS) dated [DATE], documented the resident had [DIAGNOSES REDACTED]. Resident #10's MDS dated [DATE] identified the resident to score 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident to be cognitively intact. The Care Plan last updated on [DATE] directed Nursing Staff to administer the [MEDICAL CONDITION] medications as ordered, monitor the resident for a change in behavior/mood and for adverse reactions to the medications and report to the physician if any noted. Nursing Staff to also encourage the resident to discuss feelings/concerns as needed. The physician's orders [REDACTED].#10, dated [DATE] documented an order for [REDACTED]. During an interview on [DATE] at 3:00 p.m., Staff E, RN/Charge Nurse indicated generally when an order is received for a resident the Nurse will call the Pharmacy and it is usually delivered that day later around 6:00 p.m.- 6:30 p.m. Staff E reported the facility had an Emergency Kit (E Kit) if it is a Stat (give immediately) order. The staff can get the medication out of the E kit. During an interview on [DATE] at 3:05 p.m., Staff B, RN/Charge Nurse reported the pharmacy delivered medications each day Monday - Friday around 6:00 p.m. - 6:30 p.m., and have delivered as needed over the weekend. Staff B did state the facility has an E Kit for emergency orders or Stat orders if they need the medication more immediately than the pharmacy cna provide. During an interview on [DATE] at 3:30 p.m., Resident #10 reported taking [MEDICATION NAME] (anti-anxiety medication) on a as needed basis and asks for it for leg tremors and cannot sleep without it. Resident #10 indicated he/she always asked for the PRN [MEDICATION NAME] and when asked for the medication on Friday, [DATE]th was told the medication was out and needed to be re-ordered. Resident #10 reported being told by the 2nd Shift Nurse/ Registered Nurse (RN) Staff O, that the pills would not be available till Monday, February 2nd. Resident #10 stated he/she had mentioned to Staff O, the 2nd Shift Nurse on Saturday night, [DATE]st there were no pills and Staff O said yes. On Sunday, February 1st Resident #10 reported Staff O told the resident there were pills in the Emergency Medication Kit and got a pill from the kit and gave to the resident. Resident #10 reported his/her legs did tremor without the PRN [MEDICATION NAME], but did sleep Friday and Saturday night. It bothered the resident some, but did sleep and the resident didn't say anything to anybody. During an interview on [DATE] at 3:55 p.m., Staff B, RN/Charge Nurse reported did not talk to Resident #10 on [DATE]th about the PRN [MEDICATION NAME] being out. Staff B reported had not been working the hall Resident #10 resided on. Staff B reviewed the PRN Medication Administration Record [REDACTED]. During an interview on [DATE] at 4:05 p.m., Staff L, RN/Nurse Manager reported when preparing to walk out of the facility on Friday, [DATE]th, was approached by the Certified Medication Aide (CMA) working the hall where Resident #10 resided. The CMA reported to Staff L had noticed after supper that Resident #10 was out of the PRN [MEDICATION NAME]. Staff L reported had looked along with the CMA for any cassettes in the medication room of the PRN [MEDICATION NAME] for Resident #10, but none were found. Staff L stated had directed the Agency Staff Nurse working that night, Staff N, RN to look for the Pharmacy slips to see if the PRN [MEDICATION NAME] had been reordered or had come in. Staff L then directed Staff N if had not come in to check the E Kit for a dosage of [MEDICATION NAME] if available in the dosage prescribed for Resident #10. Next Staff L directed Staff N that if no [MEDICATION NAME] available then to call the doctor for an alternative medication to replace the [MEDICATION NAME] that was available in the E Kit, and do not borrow from any resident. Staff L reported talked to Staff N about what to do, but didn't think that Staff N was getting it. Staff L indicated had just worked a nearly 20 hour day and went home after directing Staff N on what to do. Staff L reviewed the [DATE] PRN MAR indicated [REDACTED]. During an interview on [DATE] at 8:35 p.m., Staff N, RN/Agency Nurse reported did work the night of Friday, [DATE], but did not pass medications. Staff N reported the CMA passing medications that night found Resident #10 out of the PRN [MEDICATION NAME] and brought that to Staff N and Staff L's attention. Both Staff N and Staff L looked looked to see if the medication was reordered, but none was found. Staff L directed Staff N to let Resident #10 know would have to wait till the pills were delivered from the Pharmacy and not sure if would be over the weekend or till Monday. Staff N reported was aware of the E Kit and there was a [MEDICATION NAME] 0.5 mg tablet in the kit, but did not take the pill out as would have to split the pill to get the proper dosage. Staff N indicated did not recall Staff L directing to call the doctor for a possible order for an alternative pill that could have been used from the E Kit. During an interview on [DATE] at 8:45 p.m., Staff O, RN reported did work the weekend of ,[DATE]-[DATE] and worked the hall that Resident #10 resided on. Staff O stated yes, the resident was out of the PRN [MEDICATION NAME] pills. Staff O reported the resident did want to request a PRN [MEDICATION NAME] on [DATE] , but told Staff O knew there were no pills and had to wait till Monday till the pharmacy delivered them. Staff O indicated never thought to look into the E Kit to see if any [MEDICATION NAME] was in the kit on [DATE]. Staff O reported did look into the E Kit on Sunday, [DATE] when Resident #10 was not happy having to wait for the [MEDICATION NAME]. Staff O reported found a 0.5 mg [MEDICATION NAME] tablet in the E Kit and took one and split the pill in ,[DATE] to get the desired dosage prescribed of 0.25 mg for Resident #10 as the doctor ordered and gave that to the resident. Staff O then stated had wasted the ,[DATE] [MEDICATION NAME] pill with another Nurse and disposed of the pill in the sharps container. Review of the PRN Medication Administration Record [REDACTED]. Review of the PRN MAR for February 2015 indicated the [MEDICATION NAME] documented as given on [DATE]. Review of the Pharmacy Communication sheet dated [DATE] noted Resident #10's name documented for a re-order of [MEDICATION NAME] PRN entered by Staff N. A second Pharmacy Communication sheet dated for [DATE] indicated the order sheet fax send result report dated [DATE] sent to the Pharmacy at 4:54 a.m. Review of the Emergency Drug Box Usage slip noted an entry dated for [DATE] documented for Resident #10 for an [MEDICATION NAME] 0.5 mg and ,[DATE] tablet given. The entry was signed by Staff O on the slip. Review of a Packing Slip from the Pharmacy dated [DATE] indicated that the [MEDICATION NAME] pills were delivered for Resident #10 that day. During an interview on [DATE] at 9:40 p.m., The Director of Nursing (DON) indicated the date and time stamp on the Fax machine was correct when asked about the time when the Pharmacy Communication slip to reorder Resident #10's [MEDICATION NAME] was sent. Review of the Medication Administration policy last reviewed on [DATE] indicated the standard of the policy was that all medications are administered safely and appropriately.

Based on record review and staff interviews, the health service supervisor failed to ensure the personnel responsible for administering medications, administered medication as ordered by the physician for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 76 residents. Findings include: 1. The Admission Record sheet dated 6/7/13 for Resident #1 identified [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, with a reference date of 4/16/2013 revealed Resident #1 had no cognitive impairments. Resident #1 required extensive assistance of two staff with bed mobility, transfers, toilet use and bathing. The Care Plan dated 4/24/13 identified a problem with the resident needing assistance with activities of daily living due to myotonic [DIAGNOSES REDACTED] which caused pain at times. The approaches directed staff to allow ample time for self-care and praise efforts. The Care Plan directed staff to provide assistance with transfers by using a gait belt and provide assistance with daily personal hygiene. The hospital Discharge Summary dated 3/31/13 to 4/9/13 revealed a list of discharge medications that included [MEDICATION NAME] ([MEDICATION NAME]) 5 milligrams (mg) by mouth every day. The facility generated a physician's orders [REDACTED]. The History and Physical sheet dated 5/30/13 revealed Resident #1's had a chief complaint of shortness of breath. The sheet revealed Resident #1 had increasing [MEDICAL CONDITION] over the past 1 to 2 weeks and increased shortness of breath over the past 5 days. Current medications listed with [MEDICATION NAME], reportedly 50 mg a day. The sheet revealed Resident #1 had quite clearly received 10 times the intended dose of [MEDICATION NAME] for the last 6 1/2 weeks. The [MEDICATION NAME] was discontinued. The April 2013 Medication Record revealed the order for [MEDICATION NAME] SR 50 mcg tablet by mouth every day. The May 2013 Routine Medications sheet revealed the order for [MEDICATION NAME] 10 mg ER tablet take 5 tablets (50 mg) by mouth once a day. The Physician's Telephone Orders sheet dated 6/3/13 revealed an order for [REDACTED]. The Medication Error Report sheet dated 6/3/13 revealed [MEDICATION NAME] 50 mg given instead of 5 mg due to a transcription error. The staff discovered the error during an audit. The Nurse's Notes dated 5/26/13 at 3:00 p.m. revealed Resident #1 had 2 plus [MEDICAL CONDITION] to both ankles. The Nurse's Notes dated 5/27/13 at 10:20 p.m. for 3:55 p.m. revealed Resident #1 had mid chest pain and rated it an "8-9" out of "10" and complained of shortness of breath. Resident #1's oxygen saturation on room air recorded at 90 percent. The staff administered a nebulizer treatment. The staff contacted the physician and received an order to give Nitro stat 0.4 milligrams sublingual as needed and repeat every 5 minutes times two for chest pain, oxygen per nasal cannula as needed to keep oxygen saturation greater than 90 percent, [MEDICATION NAME] 40 milligrams by mouth every day for four days then report and may transport to the emergency room as resident and family wishes. The staff administered Nitro 3 times and then Resident #1 reported feeling better. The Nurse's Notes dated 5/28/13 at 1:40 p.m., Resident #1 reported feeling awful but felt better wearing the oxygen. Resident #1 complained of right shoulder pain. The Nurse's Notes dated 5/28/13 at 10:35 p.m. revealed Resident #1 stated, "I just wanted to die". The staff provided emotional support. The physician gave an order to taper the [MEDICATION NAME]. Resident #1 had non[MEDICAL CONDITION] to the back of the right hand. The Nurse's Notes dated 5/29/13 at 1:00 p.m. Resident #1 complained of hurting from head to toe and difficulty swallowing. The staff administered [MEDICATION NAME] without any relief. The staff noted slight crackles to both lung bases and two plus [MEDICAL CONDITION] to both lower extremities. Resident #1 asked to go to the hospital. The staff called the physician. At 5:15 p.m., the physician called back and gave orders to decrease the [MEDICATION NAME] and may send to the hospital if continues to voice the need or desire to go to the hospital. At 5:30 p.m., Resident #1's family at bedside and no longer voicing desire to go to the hospital. The Nurse's Notes dated 5/30/13 at 1:30 p.m. revealed Resident #1 complained of inability to get air. Resident #1 had oxygen on at 2 liters per minute. The staff checked Resident #1's oxygen saturation and obtained a reading of 90 percent. The staff turned the oxygen up to 3 liters per minute and gave [MEDICATION NAME] for complaints of hurting all over. At 2:00 a.m., continued to complain of discomfort. The staff repositioned Resident #1 in bed, gave a back rub and placed a fan at the bedside. Resident #1 reported feeling better. The Nurse's Notes dated 5/30/13 at 12:00 p.m. revealed Resident #1 complained of not feeling well. The staff heard crackles in both lung bases. Resident #1 had 2 plus [MEDICAL CONDITION] to the right hand and forearm. The staff elevated Resident #1's right arm. Staff gave Resident #1 [MEDICATION NAME] for complaints of hurting all over. The staff notified the physician of the new [MEDICAL CONDITION] and no new orders received. At 3:15 p.m., Resident #1 requested to go to the hospital and complained of not being able to breathe. The staff had Resident #1 transported to the hospital. The Discharge Summary dated 6/5/13 revealed the following discharge [DIAGNOSES REDACTED]. The Consultant Pharmacist Progress Note sheet revealed the Consultant Pharmacist reviewed Resident #1's medications on 4/10/13 and 5/14/13. The Drug Information sheet received 6/26/13 from the pharmacy revealed the adult dosing of 2.5 5 and 10 mg for [MEDICATION NAME]. The sheet recommended to start at 5 mg by mouth every day or 2.5 mg by mouth if elderly or hepatic impairment increase every two weeks; maximum dose 10 mg a day. The adverse reactions included sever [MEDICAL CONDITION] and [MEDICAL CONDITION]. The common reactions included [MEDICAL CONDITION], headache, flushing, dizziness, palpitation, [MEDICAL CONDITION], reflex [MEDICAL CONDITION] gingival [MEDICAL CONDITION]. The Pharmacy facsimile dated 4/9/13 at 3:36 p.m. revealed the April 2013 Medication Record contained a note beside the [MEDICATION NAME] SR 50 mcg by mouth every day order. The pharmacy note revealed several orders not on the discharge orders and the pharmacy called the facility nurse. The note revealed the pharmacy verified the [MEDICATION NAME] dose to be 50 mg. The pharmacy explained 5 - 10 mg tablets would be sent to make the dose. The Pharmacy facsimile dated 4/11/13 at 4:56 p.m. revealed the Physician's Rounds with Resident #1's medications listed. The pharmacy made a note that they called the facility to verify the [MEDICATION NAME] dose to be 50 mg not mcg. The Overview on Medication Protocol Re-education June 2013 sheet revealed staff were educated to repeat verbal orders back to the physician in order (medication, dosage, how given and when given), make notation in chart whenever medication conversation with physician or pharmacist, do not give medications you do not know without referring to medication book, verify dosage if you feel it is too high and if the pharmacy questions a medication call the physician to verify. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By July 15, 2013, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The facility provided medication administration education which addressed the following: . 5 resident rights of medication administration . Check Medication Administration Record (MAR) . Read each order entirely . Remove medication from the drawer. Read label 3 times . If any discrepancy between the MAR and the label, check the physician's orders [REDACTED]. . Call physician for clarification order . Document detailed information from the conversation in the nurse's notes . If the label is wrong, send medication back to the pharmacy for relabeling. If the MAR is wrong, yellow-out medication, write discontinue (DC), initial, date, and rewrite correct information in a new block. The nurses received re-education regarding physician telephone orders, notation of calls, and medication resource books were located on all medication carts and in the medication room. As of the exit conference on 7/17/2013, the facility needed to: .Continue to provide medication administration inservices to employees responsible for administering medications .Monitor nursing staff to assure compliance with the facilty policy and procedures for medication administration.

Based on clinical record review and interviews the pharmacist failed to report irregularities to the attending physician and the director of nursing. (Concerns identified for Resident #10). The facility reported a census of 76. Findings include: 1. The Admission Record sheet dated 6/7/13 for Resident #1 identified [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairments. Resident #1 required extensive assistance of two staff with bed mobility, transfers, toilet use and bathing. The Care Plan dated 4/24/13 directed the staff to allow ample time for self care, praise efforts, provide assistance with transfers using a gait belt and provide assistance with daily personal hygiene. The Discharge Summary dated 3/31/13 to 4/9/13 revealed a list of discharge medications that included Plendil (Felodipine) 5 milligrams (mg) by mouth every day. The facility generated physician's orders [REDACTED]. The History and Physical sheet dated 5/30/13 indicated Resident #1's had a chief complaint of shortness of breath. The sheet revealed Resident #1 had increasing edema over the past 1 to 2 weeks and increased shortness of breath over the past 5 days. Current medications listed with Felodipine, reportedly 50 mg a day. The sheet revealed Resident #1 had quite clearly received 10 times the intended dose of Plendil for the last 6 1/2 weeks. The Plendil was discontinued. The April 2013 Medication Record revealed the order for Felodipine SR (sustained release) 50 mcg tablet by mouth every day. The May 2013 Routine Medications sheet reflected the order for Felodipine 10 mg ER (extended release) tablet take 5 tablets (50 mg) by mouth once a day. The Physician's Telephone Orders sheet dated 6/3/13 revealed an order for [REDACTED]. The Medication Error Report sheet dated 6/3/13 revealed Felodipine 50 mg was given instead of 5 mg due to a transcription error. The staff discovered the error during an audit. The Nurse's Notes dated 5/30/13 at 12:00 p.m. revealed Resident #1 complained of not feeling well. The staff heard crackles in both lung bases. Resident #1 had 2 plus edema to the right hand and forearm. The staff elevated Resident #1's right arm. Staff gave Resident #1 Hydrocodone for complaints of hurting all over. The staff notified the physician of the new edema and no new orders received. At 3:15 p.m., Resident #1 requested to go to the hospital and complained of not being able to breathe. The staff had Resident #1 transported to the hospital. The Discharge Summary dated 6/5/13 revealed the following discharge [DIAGNOSES REDACTED]. The Consultant Pharmacist Progress Note sheet revealed the Consultant Pharmacist reviewed Resident #1's medications on 4/10/13 and 5/14/13. The Drug Information sheet received 6/26/13 from the pharmacy revealed the adult dosing of 2.5 and 10 mg for Felodipine. The sheet recommended to start at 5 mg by mouth every day or 2.5 mg by mouth if elderly or hepatic impairment increase every two weeks; maximum dose 10 mg a day. The adverse reactions included sever hypotension and syncope. The common reactions included peripheral edema, headache, flushing, dizziness, palpitation, hypotension, reflex tachycardia and gingival hyperplasia. The Pharmacy facsimile dated 4/9/13 at 3:36 p.m. revealed the April 2013 Medication Record contained a note beside the Felodipine SR 50 mcg by mouth every day order. The pharmacy note revealed several orders not on the discharge orders and the pharmacy telephoned the facility nurse. The note revealed the pharmacy verified the Felodipine dose to be 50 mg. The pharmacy explained 5 - 10 mg tablets would be sent to make the dose. The Pharmacy facsimile dated 4/11/13 at 4:56 p.m. revealed the Physician's Rounds with Resident #1's medications listed. The pharmacy made a note that they called the facility to verify the Felodipine dose to be 50 mg not mcg. The facility interview notes received 7/10/13 revealed the facility met with the Pharmacist. The Pharmacist reported he/she had other clients who resided in long term care facilities that received high daily doses of Felodipine. One received 25 mg and another received 40 mg. Because of that and the verification of physician's orders [REDACTED]. The Overview on Medication Protocol Re-education June 2013 sheet revealed staff were educated to make a notation in chart whenever they had a medication conversation with physician or pharmacist, and to verify the medication dosage if you feel it is too high and if the pharmacy questions a medication call the physician to verify the order. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By July 15, 2013, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The facility provided the following instruction/education which addressed the following: . If any discrepancy between the MAR and the label, check the physician's orders [REDACTED]. . If the pharmacist questions an order, the faciltiy staff will contact the physician and clarify. . Call physician for any clarification of an order . Document detailed information from the conversation in the nurse's notes . If the label is wrong, send medication back to the pharmacy for relabeling. If the MAR is wrong, yellow-out medication, write discontinue (DC), initial, date, and rewrite correct information in a new block. The nurses received re-education regarding physician telephone orders, notation of calls, and medication resource books were located on all medication carts and in the medication room. As of the exit conference on 7/17/2013, the facility needed to: . Monitor that irregularities are reported by the pharmacist to the Director of Nursing and the Physician. . Continue to ensure the irregularities are evaluated and acted upon.

Based on observation, record review, and resident and staff interviews, the facility failed to assess weight loss and provide timely interventions for a resident who had adverse symptoms which represent a change in a physical condition (Resident #6). The sample consisted of 15 residents and the facility reported a census of 76 residents. Findings include: 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of 7/31/2012 which identified a [DIAGNOSES REDACTED]. The MDS indicated the resident required staff set up help at mealtime and the resident could eat independently. Resident #6 had an admission weight of 144 pounds (lbs.). A review of the physician orders [REDACTED]. from the admission weight. A review of the resident's admission plan of care revised on 10/24/12 directed staff to: a. provide tray and setup for all meals and snacks every day as needed. b. provide a general diet in the west dining room (10/24/12). c. provide supplement as ordered-4 ounces of 2 CAL (nutritional supplement) at bedtime (10/24/12). d. offer bedtime snack (10/24/12). A review of the resident's Care Card (quick view reference information for staff identifying the resident's needs in an abbreviated form) posted in the resident's room and at the nurse's station revealed staff was instructed to weigh the resident daily on the 6 a.m.-2 p.m. shift. The resident's weight record revealed the resident did not have daily weights recorded consistently from admission to 11/15/12 (date of survey). From 7/20/12 through 11/15/12 the resident's weight was documented 56 days out of a possible 118 days. The resident's weight remained stable (according to the weights recorded) through 10/17/12 with readings between 140-148 lbs. On 10/23/12 the resident's weight was recorded 138 ? lbs. A review of the Registered Dietician's (RD) quarterly assessment dated [DATE] revealed the RD noted the resident experienced a gradual weight loss and documented an [MEDICATION NAME] blood test level of 2.7 grams per deciliter (normal level is 3.4 - 5.4 grams per deciliter). The RD indicated the resident had a moderate depletion of body protein stores due to the [MEDICATION NAME] results and the associated weight loss. The Registered Dietician recommended the resident be placed on an oral nutritional supplement of 4 oz. 2 CAL at bedtime. The dietician noted the resident was to be weighed daily. A review of a Dietary Care plan created on 10/23/12 revealed the resident had [MEDICATION NAME] (low internal protein stores) and required additional protein in the diet to increase the resident ' s protein stores in the body as recommended by the facility RD. A review of the physician order [REDACTED]. a. DC (discontinue) low salt diet and start general diet with salt substitute at the table. b. 4 Ounces (oz.) 2 CAL (nutritional supplement) at HS (bedtime). The order was noted by Staff D, LPN (Licensed Practical nurse), on 10/24/12 at 1:50 p.m. and a Change of Diet form was sent by Staff D to the dietary department. The form directed kitchen staff to provide the resident with a general diet with salt substitute at table. The form did not include the order to place the resident on a nutritional supplement. The Nurse's Notes documentation on 10/24/12 revealed Staff D noted she received the order from the physician to change the resident's diet to general with a salt substitute at the table and to administer 4 oz. 2 CAL every night. Further review of the resident's weights were as follows (in lbs.): 10/14/12- 142 10/24/12- 136 ? 10/25/12- 137 ? 10/30/12- 140 10/31/12- 136 11/7/12- 137 11/8/12- 133 ? 11/11/12- 133 ? 11/14/12- 127 ? (RD stated this was a possible miss-weigh) 11/15/12- 133 The resident was calculated as having a significant weight loss of 6.3% for 30 days from 10/14/12 through 11/15/12. A significant weight loss occurs when the resident's loss is greater than 5% in one month, 7.5 % in three months, and 10% in 6 months. Weight loss above these parameters is considered significant (severe) loss. A review of the Resident #6's October and November 2012 Medication/Treatments Administration Records (MAR/TAR) and intake record from the kitchen revealed the resident was not receiving 4 oz. 2 CAL nutritional supplement daily as ordered. During an observation of Resident #6 on 11/14/12 at 12:50 p.m. he/she ate lunch in the west dining room with spouse (a resident of the facility and roommate). The resident appeared to have no difficulty feeding self and ate approximately half of the meal consisting of chicken, squash, and baked potato. The resident refused the tossed lettuce salad. On 11/15/12 at 10:00 a.m. Resident #6 was interviewed and stated he/she was worried because he/she kept losing weight. The resident stated he/she was not receiving a liquid drink before bedtime at night. The resident's spouse (BIMS score 11 as documented on MDS dated [DATE]) confirmed the resident was not receiving a nutritional supplement in addition to meals and snacks. On 11/15/2012 at 8:50 a.m. the Food Service Supervisor (FSS) was interviewed and stated the dietary department currently delivers supplements to four residents in the facility. Resident #6 was not on this list. The FSS stated he did receive a diet change communication for Resident #6 from the nursing department but no additional instructions to provide a daily 4 oz. 2 CAL supplement. On 11/15/12 at 1:30 p.m. Staff D, LPN, was interviewed and stated she received and noted the order from the physician on 10/24/12 to change the resident's diet and to initiate the 4 oz. 2 CAL nutritional supplement. She stated she sent a Change of Diet notice to the kitchen to change the resident's diet to a general diet. She stated she forgot to document the physician order [REDACTED]. Staff D stated she took responsibility for the error. On 11/15/12 at 11:00 a.m. the facility Registered Dietician (RD) was interviewed and stated when she makes a recommendation for a resident concerning dietary needs she discusses the recommendation with the resident and/or family and informs the nursing staff. The nursing staff are responsible for notifying the physician for orders and for initiating the recommendation. The RD was unaware Resident #6 was not receiving the supplement daily. She stated the resident ' s weight loss at the time of her latest evaluation (10/23/12) was not a significant weight loss. She stated she was monitoring the resident for an insidious (gradual and subtle) weight loss. She stated the lack of nutritional supplement for the past month may have contributed to the resident ' s recent significant weight loss. The RD stated she expected nursing staff to document the administration of the nutritional supplements on the resident MARs and nursing was to give bedtime supplements with the evening medication pass. She stated she would re-educate the facility staff on the various types of supplements and which department was responsible for administering the supplements. On 11/15/12 at 9:15 a.m. the Director of Nursing was interviewed and stated there was a breakdown in communication between the nursing department and the dietary department as to which Department administers the supplement.

Based on observation, record review, interviews with resident, physician and staff, the facility failed to plan for and direct nursing care and services to ensure a resident received adequate supervision with application of hot packs. Resident #12 sustained a burn/injury to their skin when a staff member placed a hot pack on his/her back. The director of nursing and or the facility failed to plan for and direct hot pack treatment(s) to ensure staff monitored the treatment. The facility had no written policy/protocol or guidance in place to ensure resident(s) were protected from hazards in their environment. The sample consisted of 15 residents with a census of seventy five (75) residents. Findings Include: 1. Resident #12's quarterly Minimum Data Set (MDS) assessment, dated 11/01/11 revealed his/her pertinent [DIAGNOSES REDACTED]. The cognitive assessment, Brief Interview of Mental Status (BIMS) determined no impairments with recall ability, repetition, orientation and the resident scored 15 out of 15 on the BIMS test. The assessment determined Resident #12 required extensive physical assistance of at least 2 facility staff for bed mobility, transfers, personal hygiene, toilet needs; and one staff physical assistance when dressing. The assessment revealed Resident #12 had limited range of motion on both sides of his/her upper extremities (shoulder, elbow, wrist, and or hand) that interfered with his/her daily function or placed the resident at risk for injury. The resident also had limited range of motion of his/her lower extremity (hip, knee, ankle, and or foot). The resident utilized a walker when assisted by facility staff in the bedroom and a wheelchair outside of his/her room. The assessment documented no current or unhealed skin conditions. (The facility's documentation identified the terms "hot pack" and "warm pack". The investigation determined both terms are interchangeable and equivalent when discussed in this investigation.) The nurses notes dated 10/19/11 at 10:30 a.m., documented the resident requested a hot pack for his/her back discomfort. On the same date at 10:00 p.m., the notes documented Resident #12 received a warm pack again. Additional nurse's notes documented the following: On 10/20/11, the resident received a warm pack and pain medication after his/her meal. The resident reported both of these helped with his/her pain. On 10/22/11 at 5:45 p.m., the resident complained of mid-thoracic pain and requested a hot pack. On 10/25/11 at 10:50 a.m., staff applied a warm pack to the resident's right lower back for pain. The notes documented when the resident had been toileted next, a pink area (measuring) 6 centimeter (cm) by 5 centimeter had been noticed. The notes dated 10/25/11 at 11: 00 a.m., identified a nurse's order had been written to monitor right mid to lower back pink area. The notes dated 10/31/11 at 10 p.m., documented staff applied treatment to the resident's right lower back burn area and covered the area with Telfa dressing. A Skin Injury Report on 10/25/2011 indicated the injury to the right mid to lower back was possibly caused by a hot spot in the warm pack applied to the resident's back. The facility staff treated the injured area with 3 different cool moist cloths to the area. Resident # 12's Treatment Administration Record for October 2011 revealed an order received on 10/25/2011 for Silvadene cream 0.1%. The order called for staff to apply the cream to the resident's right side mid back pink area twice a day and covered with a Telfa pad and tape until resolved. A Skin Condition Report measured dated 10/25/11 measured a wound of 6 centimeters by 5 centimeters on the right mid to lower back of the resident. The skin sheet documented the wound area as pink in color. The Skin Condition Report dated 11/01/11, the area measured 1.3 centimeter by 2.5 centimeter, pink in color, and without drainage. On 11/07/2011 the area measured 1 centimeter by 0.5 centimeter with sloughing and pink in color. During an observation on 11/10/2011 at 1:05 P.M., Staff B entered Resident # 12's room and prepared to administer a treatment to the resident's right mid to lower back burn. Staff measured the dark red center as 0.5 centimeters by 0.5 centimeters, the sloughed areas as 1 centimeter by 0.5 centimeter, and the outer pink areas as 2 centimeters by 2 centimeters. Additional red skin sections surrounding the right lower to mid back area failed to receive any measurements, treatments, or documentation. The resident's clinical record lacked a physician's orders [REDACTED]. The order specified only a licensed nurse should prepare and apply the warm pack to the resident. The plan of care with a problem onset date of 11/11/2010 directed facility staff to provide assistance with bed mobility and for staff to assist with his/her activities of daily living. The resident's care plan dated 11/11/2010 did not provide any direction(s) or guidance for placing a warm pack on the resident. During an interview on 11/10/11 at 12:05 p.m., the resident's physician verbalized only receiving a phone call when the incident occurred and giving an order for [REDACTED]. The surveyor asked the physician if he recommended the facility staff use of towels warmed up in the microwave for heat packs and stated, "No, not a good practice." The physician verbalized warming towels in a microwave could leave potential hot spots and an uneven distribution of the heat. The physician stated he could not identify the degree of burn Resident#12 sustained as he had never seen the resident's back at that time or any time since the burn occurred. The physician stated he did not have any written notes or dictation of the burn area. During an interview on 11/14/11 at 10:55 a.m., Resident # 12 identified Staff Z as the person who applied the warm pack on 10/25/2011. The surveyor asked the resident if it hurt, and the resident responded with a strong "yes". The resident verbalized the warm pack placement as directly on his/her right mid to lower back. Resident#12 estimated approximately 2 minutes passed before the warm pack started to burn and hurt. Resident # 12 reported he/she was not able to move off the right side and unable to reach and remove the warm pack. Resident #12 stated he/she used the call light to alert staff and even though it felt like a long time for staff to answer the call light, they answered it at least 15 minutes later. During an interview on 11/14/2011 at 9:25 A.M., Staff Z verbalized preparing the warm pack which caused the burn. Staff Z stated she wet a hand towel, folded the wet hand towel in a plastic trash bag, and then in a pillow case. At that point, she placed the entire pack into the microwave for 45 seconds on full power. Staff Z reported the (warm/hot) pack did not seem warm enough, so she heated the (warm/hot) pack for 15 seconds more on full power. Staff Z took the warm pack into the resident's room and placed it on Resident #12's right mid to lower back area over the resident's house clothing and left the room. Staff Z stated Resident #12 would alert her if the warm pack was too hot by putting on the call light and then she went down another hall to make beds. Staff Z reported using the microwave located in the assisted dining room. In a later interview on 11/14/2011 at 11:45 A.M., Staff B revealed when she made up a warm pack to place on the resident's back, she only slightly wet a hand towel and placed it in the microwave for 50 seconds. After being warmed, she placed the towel in a plastic trash bag, then in a pillow case and placed a dry hand towel on the resident's back before applying the warm pack to the area. On 11/15/2011 at 2:00 P.M., Staff CC reported she assessed the burn when found and placed 3 moist cool cloths on the burn area to diffuse the irritation from the burn. Staff CC stated she prepared warm packs for the resident prior to this incident by dampening a hand towel, placing it in the microwave for approximately a minute; then placed a towel in a plastic trash bag with a pillow case to cover the (hot/warm) pack. Staff CC reported she would then place the warm pack on the resident's right mid to lower back area with a pillow against it. Staff CC reported using the microwave located in the assisted dining room. On 11/14/2011 at 11:30 A.M., the Director of Nursing (DON) and the nurse consultant assisted with a demonstration of warming of a warm pack in the assisted dining microwave. The DON wet a hand towel, folded it one time and placed it in a plastic bag, and then in a pillow case. The DON set the microwave on full power for 45 seconds and then for 15 seconds. Utilizing 2 of the facility's digital thermometers, the nurse consultant and the surveyor placed the thermometer probes in a fold of the pillowcase. The thermometers read 159 degrees Fahrenheit (F) and the other 120 degrees (F). The prior technique was replicated a second time with another wet towel, trash bag, and pillowcase. This time the digital probes were placed on the surface of the pillowcase and another piece of pillowcase placed over the probe. The thermometers read 119.6 degrees (F) and 122 degrees (F). The warm packs test demonstrated degrees of variability which could occur with being warmed in the microwave and which could result in a burn for a resident. During an interview on 11/15/2011 at 9:20 A.M., the DON revealed the facility did not have a policy/procedure for staff to follow on the correct preparation of a warm pack. Staff interviews revealed different techniques being used between Staff Z, Staff B and Staff CC when preparing the hot/warm packs. The DON and or the facility did not plan for and direct nursing care and services to ensure staff received guidance on how to safely utilize, prepare or monitor hot/warm packs on residents. Based on observation, clinical record review, facility policy review and staff interviews, the facility failed to ensure residents received adequate supervision an assistive devices in order to prevent accident/hazards for three of fifteen residents reviewed. (Residents #2, #9 & #18) The facility census was 75 residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed to have a Brief Interview of Mental Status score of 12 indicating a mildly impaired cognitive status. The MDS identified the resident's mood and behavior symptoms as having trouble falling asleep and verbal behavior towards others. The MDS identified the resident as being independent with ambulation in his/her room and needing set-up help and supervision by staff while ambulating in the hallways with a wheeled walker. The MDS balance assessment noted the resident was unsteady upon walking but could stabilize him/herself without assistance. The current care plan dated 9/27/11 recorded a safety goal for the resident was that the resident would not leave the building without supervision. Interventions noted on the care plan included the use of a Wanderguard alarm bracelet on the resident at all times. Additional interventions for safety and supervision of the resident included the staff was instructed to check the functioning of the resident's Sondergaard each shift and to redirect the resident if he/she was moving toward an exit door. The admission elopement assessment score for the resident dated 7/14 11 was "2" which indicated the resident was a moderate elopement risk and needed to be monitored by staff. On 7/28/11 the resident's family requested the use of a Wanderguard alarm for the resident and an additional elopement risk assessment was completed with the resident again scoring a "2". The treatment flowsheet dated October 2011 revealed the Wanderguard was placed on the resident's wheeled walker instead of his/her wrist due to the resident's fragile skin status. A facility wide re-assessment of all the residents for elopement risk revealed Resident #2 was scored as a "3" indicating the resident was now a high risk of elopement and precautions would be initiated. Assessment for skin status revealed the resident was a low risk for skin issues such as pressure ulcers as indicated by a score of 23 (a score of 12 or below indicates high risk for skin issues). The resident's fall risk was assessed at 10 (a score of 10 or above indicates a high risk for falls). An elopement Incident Report Form dated 10-22-11 revealed a resident saw Resident #2 leave the building. The report states the last time the resident was seen by staff was at 8:55 a.m. At 9:00 a.m., Staff D located the resident outside the door by a bush approximately 10 feet from the door. The resident was found to be in good condition after an assessment by Staff C at 9:10 a.m. The resident's family was notified at 9:20 a.m. and the physician was notified at 9:45 a.m. The weather was described on the form as "sunny" and the outdoor temperature was 60 degrees. Nurse notes recorded by Staff C, RN, at 9:00 a.m. state "power surge. door alarms all sounding. Resident went outside not using walker. Spotted by another Resident and immediately redirected into the building. Resident instructed not to go outside and to use walker at all times. During interview on 11/9/11 at 7:00 a.m. and at 9:30 a.m., Staff C, (RN) stated they worked Hall 1 West Unit on 10/22/11. At around 9:00 a.m., they passed medications in the dining room. The power went out briefly (approximately 10 seconds) and they heard the emergency generator start. Power was restored and all of the resident call light alarms, lights over the bedroom doors and bed alarms sounded. Staff C stated they sent the certified nurse aides (CNA) to check on the residents and to turn off the alarms. Staff C stated the exit door alarms were not sounding. Staff C left the dining room and headed towards Hall 1 (north end) and an unidentified aide told them a resident had walked out of the north exit door on Hall 1. Staff C stated they went to down the hall to see what was happening. Staff D and Staff E brought Resident #2 into the building and they all went into the resident's room. Staff C assessed the resident, notified the resident's family and physician and continued passing medicines. Staff C stated they did not check the alarm panel at the nurse's station or call maintenance to check the door alarms as they thought the other nurse (Staff B) working Hall 2 West Unit had done these things. Staff C stated they worked as an agency nurse for "many years" and was frequently assigned to work at the facility. During interview on 11/9/11 at 10:00 a.m., Staff B, RN, revealed they were in charge of Hall 2 West Unit on 10/22/11. Staff B stated they were in the dining room passing medications when the power went out. Staff B stated when the power came back on, within 30 seconds, all of the hall 1 bed and door alarms were sounding. Staff B stated they were not sure if an exit door alarm went off because of the other call light and bed alarms sounding. Staff B saw Staff C leave the dining room and thought Staff C was going to check the alarm panel at the nurse's station. Staff B stated they remained in the dining room passing medications. Ten minutes later Staff B went to the nurse's station and learned of the resident's elopement. During interview on 11/8/11 at 4:00 p.m., Staff D, CNA stated they were taking a resident down Hall I (towards the north end) when the power went off briefly. A resident called out to them and stated Resident #2 had gone out of the north exit door. Staff D stated they called to Staff E who had come up behind them to assist. Staff D stated the exit door alarm was not sounding however the residents call light alarms were sounding. Staff D and Staff E opened the closed north exit door and saw the resident standing outside without his/her walker. Staff D and Staff E assisted the resident back into the building and to his/her room. During interview on 11/9/11 at 4:40 p.m., the Director of Nursing (DON) stated the power outage was a community wide event and the emergency generator started up and supplied power to the facility within approximately 10 seconds. The DON stated when the power goes off the call light alarms sound, the bed alarms sound, the call lights above the resident room doors light up and the firedoors located half way down the hallways close. The DON stated at the time the power returns the exit door alarms re-arm automatically. The DON stated there was an alarm panel at the nurse's station on the West unit that will flash a light indicating the location if an exit door was opened. The DON stated they were told that maintenance was paged after the incident to come into the building to check the alarms. Observation during the re-enactment revealed the DON opened the Hall 1 north exit door and the exit alarm (a very loud, shrill, continuous noise that is audible throughout the West unit) did not sound. The DON kept the door open approximately 15-20 seconds. Upon checking the alarm panel at the nurse's station simultaneously it was discovered the north door alarm button did not light up. The maintenance supervisor, Staff F, was notified and he came up to the north hall exit door. He opened the door and the alarm went off. A second surveyor was standing at the alarm panel at the nurse's station and observed the north exit alarm button flashed continuously until re-set by staff. Staff F was unable to find a cause for the door not alarming initially when the DON first opened the door. It was determined the door alarm was not reliable. During interview at the time Staff F stated the exit door alarms were checked every morning and the Wanderguard doors were also checked for correct functioning. He physically opens each door and takes a transmitter to check Wanderguard function. Some of the facility doors are alarmed, some are wanderguarded alarmed, and some have both alarms. The north exit door in Hall 1 is alarmed but does not have a Wanderguard alarm. Staff F stated Staff BB (on-call maintenance for 10/22/11) told him that he did not receive a page from the facility on 10/22/11. Investigation did not reveal who paged maintenance on 10/22/11 after the power outage event. The maintenance supervisor provided flowsheets which indicated the north door alarm was checked on 10/23/11 through 11/9/11 without any problems noted with functioning. Staff F stated the alarm on the north door was slightly older then alarms on other exit doors. He stated he evaluated the north exit door alarm after the 10/22/11 elopement incident and ordered a new magnetic alarm from a parts company but the alarm had not been received yet. 2. Resident #9 had an admission MDS with an assessment reference date of 8/26/11, which indicated the resident required extensive assistance of 2 persons for transfers and did not ambulate in room or hallway. The functional limitation in range of motion indicated the resident had impairment on both sides of lower extremities. The mobility device was a wheelchair. The care plan dated 9/1/11 indicated for ADLs (activities of daily living) the approaches were provide 2 staff to assist for transfers using the stand Hoyer, and provide 1 assist for mobility in the wheelchair. Observation on 11/9/11 at 11:45 a.m., revealed Staff O, dietary manager push the resident from the dietary door to the main dining without foot pedals in place to prevent the residents feet from dropping to the floor. The resident's wheel chair pedals were flipped up and out to the side on the wheel chair. 3. Resident #18 had an annual MDS with an assessment reference date of 9/20/11, which indicated the resident required the extensive assistance of 2 persons to transfer and functional limitation in range of motion indicated the resident had no impairment. The resident used a walker or wheelchair for mobility. The care plan dated 9/22/11 indicated for ADLs the approaches were: - provide assistance for locomotion on and off the unit. - assist with transfers using 2 assist and gait belt and when resident not compliant or too tired to stand, use 2 staff and use stand Hoyer. Observation on 11/09/11 at 8:25 a.m., revealed Staff S, restorative aide propel Resident #18 from the hallway to a table in the assisted dining room without foot pedals on the wheelchair. Facility policy regarding Wheelchair use (undated) indicated to lower foot rests and place resident's feet on foot rests if used. On 11/10/11 at 9:00 a.m., the director of nursing indicated resident's have a bag on the back of the wheelchairs to hold the foot rests. When staff push the resident, staff should put the foot rests on the wheelchair.

The following deficiency relates to incident -I: Based on clinical record review and staff interviews, the facility staff failed to provide adequate supervision and implement or update care plan interventions for one of three residents reviewed. Resident #1 sustained a fall and left hip fracture when a staff transferred the resident without the use of a gait belt. For approximately two weeks prior to the fall, the majority of staff had been transferring the resident with the assistance of two staff however the care plan did not reflect this update. The facility reported a census of 63 residents. Findings include: According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 7/5/11, identified Resident #1 with short and long term memory deficits with severely impaired cognitive skills for daily decision making. Resident #1 required extensive assistance with physical assist of one to two staff with bed mobility, transferring, locomotion, dressing, personal hygiene, toilet use and bathing. Resident #1's [DIAGNOSES REDACTED]. Resident #1's plan of care dated 7/7/11 identified a problem with impaired activities of daily living (ADL) abilities and risk for fall/injury due to dizzy spells with approaches which included: a. Assist with locomotion and transfers using a gait belt if walking and wheelchair for longer distances. b. Use a gait belt when walking with me as he/she used a wheeled walker. The aides communication notes dated 6/29/11, revealed Resident #1 had trouble standing and required the assistance of two staff. The same communication notes identified the following: On 6/30/11 assist of two (staff). On 7/3/11 not standing or walking well- wheelchair all day. On 7/4/11 not standing or walking well- wheelchair all day. On 7/5/11 two (staff) assist with transfers, leaning forward. On 7/7/11 leaning forward, not stand straight or for long, 1-2 assist wheelchair all day. On 7/8/11 not standing or walking all day. On 7/9/11 resident would not help at all, needed two assist (staff) all shift. On 7/10/11 two assist in morning; 2-10 shift, 2 assist all shift. On 7/11/11 1 assist with wheelchair, not walking or standing to well. 2-10 shift, resident seemed weaker, tired before and after supper; fell asleep in wheelchair. On 7/12/11, two (staff) assist got resident to shower- he/she did not fell so good. On 7/13/11 - two assist getting resident out of bed, trouble walking. On 7/14/11- got out of bed but fell transferring from commode to wheelchair. Sent to hospital for x-rays on left hip. Nurse ' s notes dated 7/8/11 documented it was harder to transfer the resident and often needed 2 (staff) assistance for transfers. Nurse ' s notes dated 7/12/11 documented the resident continued to need two staff assistance with transfers. Nurse ' s notes dated 7/13/11 documented a monthly update which identified Resident #1 transferred with assistance of two to wheelchair. The history and physical dated 7/14/11 from the hospital documented Resident #1 had been sent to the ER with a concern of possible left hip fracture. The report documented the resident had left leg external rotation and shortening. During the physical examination, the resident displayed obvious left hip pain and showed severe pain with any attempts of motion or touching his/her left hip. The assessment revealed a left hip intertrochanteric fracture displaced. In an interview on 7/28/11 at 12:52 p.m. Staff A indicated she had been on vacation and had reviewed the aides communication notes. Staff A stated they had been using 2 people to transfer as needed, but not all the time. Staff A stated she decided to see if the resident needed two staff people or just one. Resident #1 was determined as an assist of one with gait belt and walker support during transfers. Staff A stated on 7/14/11 at around 7:30 a.m. Resident #1 was first transferred from his/her bed onto a commode using the gait belt and walker as care planned. Resident #1 stood with good strength and balance and the transfer was uneventful. Staff A finished dressing and providing cares for Resident #1 and then attempted to transfer him/her from the commode into the wheel chair, this time forgetting to re-apply the gait belt. Staff A was positioned to the left and back side of Resident #1 with her right arm around the resident's waist. Resident #1 stood with the support of the walker. As Staff A reached to remove the commode and pull the wheel chair into position behind Resident #1, the resident began to lean to his/her left. Staff A continued to attempt to position the wheel chair behind Resident #1 so he/she could be seated and never removed her right hand from Resident #1's waist. Resident #1 continued to lean and as he/she was going down, partially sat onto the edge of the wheelchair and then slid onto the floor. Staff A indicated she had one arm around the resident's waist and the other hand on the wheelchair, but was unable to stop Resident #1 from falling. Staff A indicated she slowed the progression of the fall and didn't believe Resident #1 impacted the floor hard. During another interview with Staff A on 8/11/11 at 12:24 p.m. she indicated she was working by herself with a few residents on the morning of 7/14/11. Staff A stated if she would have needed help, she would have asked another staff. In an interview on 7/28/11 at 1:44 p.m. Staff B indicated he was called to Resident #1's room at around 7:20 a.m. on 7/14/11. Resident #1 was lying on his/her bedroom floor. Staff B assessed Resident #1 and eventually assisted Resident #1 up and into his/her recliner. Staff B indicated Resident #1 was care planned as an assist of one using a gait belt for transfers, but noted Resident #1 had become weaker and staff had been utilizing two staff with transfers the last 5-6 days. Staff B stated the resident was still taking steps with a front wheel walker but increasingly becoming more difficult for 1 staff to manage. Staff B stated Staff A had been on vacation and was not aware of these changes being made. In an interview on 7/28/11 at 12:35 p.m. Staff C indicated Resident #1 was determined as an assist of one with gait belt for transfers prior to his/her fall, but occasionally needed two staff to safely transfer. Staff C indicated all residents needing assist with transfers or ambulation are to wear a gait belt. In an interview on 7/28/11 at 12:35 p.m. Staff D indicated Resident #1 was determined as an assist of one with gait belt for transfers prior to his/her fall. Staff D indicated all residents needing assist with transfers or ambulation are to wear a gait belt. Facilities Policy and Procedures 1. Transfer Bed to Chair (1 person) Procedure: #9 Secure gait belt around resident waist. #13 Grip gait belt with palms up. 2. Gait Belts for Transfers Standard: Gait belts are provided to assist staff to safely transfer or ambulate residents. Procedure: #2 Apply belt around resident waist. #4a Transfer: Assist resident to a standing position by grasping belt at the waist from underneath.