Every finding on record at Pruitthealth - Ashburn

Based on observation, interview, and review of the facility's policy titled, Patients/Resident's Personal Food, the facility failed to label and date food items stored in the nourishment refrigerator. This deficient practice had to the potential to affect all residents who currently resided in the facility.Findings include:Review of the facility's policy titled, Patients/Resident's Personal Food revised 08/12/2024, revealed, It is the policy of [facility name] to allow the patients/resident's family to provide food items for patient/resident consumption. The patient/resident's personal food will be maintained in a clean environment to ensure sanitary storage, appropriate food handling and safe consumption of foods brought into the facility by resident's family and visitors. The policy specified, 6. Foods requiring refrigeration must be stored in the nursing units' nourishment refrigerators or in existing individual in-room refrigerators. Those items stored in the nursing units' nourishment refrigerators must be kept to a minimum due to limited space. The main facility kitchen food storage refrigerators will not be used. All food items requiring refrigeration must be labeled and dated. Any opened (non -condiment) foods will be discarded after 48 hours. Per the policy,8. Nursing/housekeeping partners will be responsible for the disposal of outdated foods maintained in the patient/resident's room and those stored in the nursing units' nourishment refrigerators/freezers.During a tour of the residents' nourishment refrigerator on 9/3/2025 at 7:17 am, there was sign posted on the door of the refrigerator that indicated the refrigerator was the residents' refrigerator only and not to place food or drinks in the refrigerator without a name or date. The following items were found in the refrigerator:-an unlabeled and undated half-full bottle of water-an unlabeled and undated can of nacho cheese-an unlabeled and undated half bottle of soda-an unlabeled and undated tray of deviled eggs-six unlabeled and undated snack size cups of yogurt-an unlabeled and undated half-full plastic cup of juice-an unlabeled and undated Styrofoam container of grits-an unlabeled lunch bag-an unlabeled and undated, half-full, opened bottle of Gatorade-an unlabeled and undated half-full jar of picklesIn the freezer, there were an unlabeled and undated single size cup of vanilla caramel covered sundae, four unlabeled and undated frozen television dinners, and an unlabeled and undated opened package of frozen chocolate candiesDuring an interview on 9/3/2025 at 7:24 am, the Dietary Manager (DM) revealed that staff knew not to use the refrigerator as it was only supposed to be used for the residents. Per the DM, everything in the refrigerator should be dated and labeled. The DM stated she would throw all the food items out.During an interview on 9/5/2025 at 9:28 am, Certified Nursing Assistant (CNA) #12 revealed that staff were not supposed to store food in the residents' nourishment refrigerator. CNA#12 stated the housekeeping staff was responsible for maintaining the resident refrigerator.During an interview on 9/5/2025 at 9:47 am, CNA #13 revealed that all foods stored in the resident refrigerator required a name, date, and room number. CNA #13 revealed that the housekeeping department was responsible for maintaining the resident refrigerator. During an interview on 9/5/2025 at 10:05 am, Licensed Practical Nurse (LPN) #14 revealed that all food items stored in the residents' refrigerator were to be labeled with the resident's name and dated. LPN #14 revealed that the housekeeping staff were responsible for removing all non-labeled or dated food items.During an interview on 9/5/2025 at 10:24 am, the Housekeeping/Floor Technician Supervisor revealed that she did not believe it was the responsibility of the housekeeping department to maintain the residents' refrigerator.During a follow-up interview on 9/5/2025 at 10:34 am, the DM confirmed that all food items stored in the resident refrigerator was to be labeled and dated by CNAs. The DM stated the housekeeping staff was responsible for making sure all food items were labeled and dated and for the removal of all unlabeled, undated food items.During an interview on 9/6/2025 at 11:37 am, the Administrator confirmed that all food stored in the resident's refrigerator should be labeled and dated and that he expected all staff to follow the facility's policy.

Based on observation, interview, record review, and review of the facility's policy titled, Enhanced Barrier Precaution (EBP), the facility failed to ensure staff wore personal protective equipment (PPE) during the provision of care for one of six sampled Residents (R) (R13) observed for medication administration.Findings include:Review of the facility's policy titled, Enhanced Barrier Precaution (EBP) revised 5/27/2025, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy specified, Enhanced barrier precautions refer to an infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high-contact resident care activities. Per the policy, 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing.Review of the Resident Face Sheet for R13 revealed the facility admitted R13 with diagnoses that included but not limited to, diagnoses of dysphagia and gastrostomy status.Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/31/2025, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for eating, had a feeding tube, and received greater than 51% of their calories and 501 cubic centimeters or more of fluids per day through a tube feeding. Review of R13's Care Plan included a problem statement dated 3/8/2024, that indicated the resident had a tube feeding risk for aspiration, dehydration, and weight loss. Interventions directed staff to observe enhanced barrier precautions with care (initiated 8/20/2025).Review of R13's Physician Order Report for the timeframe 9/1/2025 - 9/5/2025, revealed an order dated 4/1/2025, that directed staff to administer one Jevity 1.5 bolus by way of a percutaneous endoscopic tube with 100 milliliter flush five times per day.During medication observation on 9/3/2025 at 9:18 am, Licensed Practical Nurse (LPN) #10 did not put on a gown when she entered the room of R13 to administer the resident's medications, to include their bolus tube feeding.During an interview on 9/3/2025 at 9:45 am, LPN #10 stated she observed the signage posted to the door of R13's room that indicated the resident was on EBP for their gastrostomy tube and that staff were to wash their hands before and after and wear the proper PPE to include a mask, gloves, and a gown when they cared for the resident. LPN #10 stated she was only required to wear a gown when she cared for a resident who had a wound or if the resident had an infection in their gastrostomy tube site.During an interview on 9/4/2025 at 3:36 pm, the Infection Preventionist (IP) stated residents with gastrostomy tubes, catheters, ostomies, or multidrug-resistant organisms were to be on EBP. The IP stated staff were to recognize the need for EBP by signage posted to a resident's door. The IP stated staff were to wear a gown and gloves when they provided direct care to residents on EBP. According to the IP, the nurse who provided gastrostomy tube care to include medication administration should have worn a gown during the provision of care.During an interview on 9/5/2025 at 3:32 pm, the Administrator stated he was not clinical but expected staff to wear a gown and gloves for residents on EBP. Per the Administrator, LPN #10 should have worn a gown during the provision of care for R13.

Based on record review and staff interview, and review of the facility policy titled, Care Plans, the facility failed to develop a care plan to address an anti-platelet medication prescribed for a stroke for one of five Residents (R)19 and failed to implement care plan interventions for one of four residents R55 related to abuse. The sample size was 31 residents. Findings include: Review of the facilities policy titled, Care Plans, dated 7/27/2023 revealed: Baseline Care Plan- Must include the minimum health care information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavior interventions, and assistance with activities of daily living, as necessary. 1. Record review revealed R19 was admitted on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment. A primary admitting diagnosis, other cerebral infarction and other diagnoses included but not limited to, stroke, vascular dementia, unspecified severity, with anxiety, and depression, unspecified. Further review of the clinical records revealed the resident was readmitted to the facility under hospice after a brief hospital stay. A Minimum Data Set (MDS) Significant change assessment dated [DATE] revealed section A - reentry from acute care hospital on 3/18/2024, section C - cognitive patterns documented BIMS score 00, section I- stroke. A review of the physician orders dated 4/1/2024 through 4/30/2024 revealed that R19 was ordered to receive clopidogrel tablet 75 mg, an anti-platelet: one tablet by mount once daily with a start date of 3/18/2024 for her diagnosis of cerebral infarction. Review of R19's care plan revealed there was no care plan for a stroke or for the medication, clopidogrel, an anti-platelet. Interview on 5/2/2024 at 9:59 am with Registered Nurse (RN), Case Mix Director (CMD) revealed care plans were done when a new medication was prescribed that could cause complications or if the medicine was something the resident had never been prescribed. CMD revealed that it was her expectations that medications were care planned. 36377 2. R55 was admitted to facility on 2/21/2023 with the following diagnoses of but not limited to moderate intellectual disabilities, dysphagia, and seizures, and delusional disorders. The Minimum Data Set (MDS) assessed a Brief Interview Mental Status Score (BIMS) of seven indicating severe cognitive impairment. Record review of R55's Electronic Medical Record (EMR) documented two incidents of R55 being a victim of sexual abuse by two residents. The Police Report dated 3/27/2024 and 3/20/2024 reported incidents of abuse involving residents in which the facility contacted law enforcement. Record review of R55's care plan revealed no plan of care created to address the sexual abuse incidents involving resident. Interview on 5/2/2024 at 9:45 am, the RN Case Mix Director reported being aware of R55 's incident of exposure to abuse by two male residents in the facility. She confirmed that a care plan was not created for R55 related to abuse to ensure prevention of future abuse. She stated that any nurse/clinical staff could update/create a care plan whether it is a fall or abuse. Interview on 5/2/2024 at 10:15 am, Director of Health Services (DHS) reported that her expectations for her staff to create care plans in a timely manner for abuse victims. Care plans are individualized reported being unaware that R55 was not done in a timely manner. The MDS Manager and Social Service are responsible for ensuring the care plan is completed. The Unit Manager would be responsible for creating the care plan at the time the incident occurred.

Based on staff interview, record review, and review of the facility policy titled, Physician Narratives, Orders, and Services for Hospice, the facility failed to obtain a physician's order for one of nine residents, resident (R) R19 receiving hospice services. Findings included: Review of facility policy titled, Physician Narratives, Orders, and Services for Hospice dated 11/22/2021 revealed under physician orders: 2. The hospice receives a verbal or written order from a physician to admit the patient to hospice. 5. Documentation of receipt of verbal orders and written orders sent to physician for signature is maintained in the patient's clinical record. Stamped signatures are not accepted. Electronic signatures may be accepted if they meet the criteria established by the MAC. 6. When the signed order is returned it is filed in the patient's clinical record and the unsigned order is removed. 8. Documentation is maintained of all efforts to obtain signed orders from physicians in a timely manner. Record review revealed R19 was admitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. A primary admitting diagnosis, other cerebral infarction and other diagnoses included but not limited to, vascular dementia, unspecified severity, with anxiety, and depression, unspecified. A further review of the clinical records revealed R19 was readmitted to the facility under hospice after a brief hospital stay. A Significant change assessment dated [DATE] revealed section A - reentry from acute care hospital on 3/18/2024, section C - cognitive patterns documented BIMS score 00, and section O - special treatment and programs listed hospice care. Review of the comprehensive care plan for R19 revealed plan of care for hospice services that included, problem set-has elected terminal care dated 3/19/2024, goal-death with dignity thru next review 7/11/2024, and interventions- call hospice first about any changes in condition, emergency, questions about care, medication changes or transport and prior to any procedures, monitor signs and symptoms of pain, notify hospice as appropriate and as family agrees, for evaluation for hospice services, meds as ordered, notify MD of any changes, provide comfort measures. Record review revealed the authorization form for hospice services, Medicaid Hospice Election Form dated and signed on 3/18/2024 by R19's family contact, a hospice representative, and the nursing home's Clinical Competency Coordinator (CCC). Hospital discharge orders did not include hospice. The CCC's signature was located on the discharge orders indicating she reviewed the orders. Interview on 5/2/2024 at 11:25 am with Director of Health Services (DHS) revealed that if a resident were in house and required hospice services, the medical director of the facility would write an order. If the hospital were referring the resident the hospice doctor would write the order. When asked where R19's hospice order was located the DON stated that R19 came back from the hospital with hospice therefore they would not have an order but would review the hospital discharge orders and get back to us. A follow up interview on 5/2/2024 at 12:53 pm DHS revealed that when a resident was sent to the hospital, all standing orders from the facility were discontinued and new orders were completed upon re-entry into the facility. The DON revealed that an order for hospice occurred while R19 was in the hospital and confirmed there would not be an order for hospice written by the facility. The DHS revealed her expectations were that there would be an order written for hospice services, and orders be entered promptly and accurately.

Based on interviews, record review, and review of facility policy titled Care Plans the facility failed to ensure the family representative for one resident ((R) R#21) of five residents reviewed participated in scheduled care plan meetings. The sample size was 24. Findings include: Review of facility policy titled Care Plans, revised date 7/21/2021, Admission Comprehensive Plan of Care number 7. (fourth bullet point) revealed Care plan meetings should be documented in AHT/LTC using the Multidisciplinary Care Conference User Defined Assessment (UDA) as evidence that the care conference has taken place and occurred with the multidisciplinary team, the patient/resident, and the patient/resident representative. Record review for R#21 revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS Quarterly assessment dated [DATE] Section C (Cognitive Pattern) C0500 indicated BIMS score of 00 indicating resident had cognitive impairment. Section G (Functional Status) revealed resident is total dependent on staff for dressing, bathing, eating, transfers, repositioning, and personal hygiene. Review of R#21 care conference attendance forms for the last four care conferences dated 9/7/21, 12/2/21, 3/1/22, and 5/24/22, revealed there was no documentation that R#21's responsible party attended the conference. MDS Coordinator confirmed that the person listed on R#21 care conference form was not the responsible party, nor any other family member of R#21. Interview on 7/29/22 at 11:54 a.m. with R # 21 family member revealed they have never attended any care plan meetings for residents in person due to living in another state, nor over the phone. Continued interview also revealed that there had not been any invitations to attend care plan meetings since resident has been admitted to facility. Interview on 7/30/22 at 10:59 a.m. with Social Worker revealed that residents and family members are notified of care plan meetings prior to meeting date. It was reported that there is a book with all notifications that are given to the residents and family members in the Social Worker's office. Interview on 7/30/22 at 2:19 p.m. with Minimum Data Set (MDS) Coordinator revealed that the care plan schedule is completed monthly from the residents quarterly or annual assessment due date. The disciplines that attend the care plan meeting are the Social Worker, MDS, therapy, the resident, and the residents' responsible party. Continued interview also revealed that the care conference information which includes who attended the conference and what areas were discussed is documented on the care conference sheet in the residents' chart. The Social worker is reported as being responsible for notifying the resident and the resident's responsible party for the date and time of the care plan meetings.

Based on record review, resident interview, and staff interviews the facility failed to offer one resident (R#12) of 24 sampled residents the opportunity to participate in activities of choice. Findings include: Review of the medical record for R#12 revealed that he was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] for Section C: Cognitive Patterns revealed that R#12 has a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact and able to make his own decisions. Further review of the medical record did not reveal any documentation of activities offered or provided to R#12. During an interview with R#12 on 7/30/22 at 10:09 a.m., he stated that he does not receive any activities, and he does not receive one-on-one room activities. R#12 stated he does not want to get up out of the bed every day, but he does want to get up sometimes. He stated the Activities Director does not come to his room and does not offer or provide him with any type of activities. R#12 stated he can hear other residents participating in activities. Interview with Activities Director (AD) on 7/31/22 at 10:19 a.m. revealed the activity assistant provides one-on-one room activities to residents who does not get out of bed. She stated it should be documented in the electronic health record Matrix Care. AD could not provide documentation to prove that one-on-one room visits was provided to R#12. AD stated the activities assistant is out of town attending a family reunion and she is unavailable for interview. AD further stated that the activities assistant should be documenting one on one visits, but she does not see any documentation of the weekly one-on-one visits in R#12 's chart. AD further stated she does not have any written documentation of one-on-one room visits.

Based on observation, staff interview, and review of the facility policies titled, Pot/Pan Washing and Sanitation and Food Temperature, the facility failed to ensure clean pans washed in the three-compartment sink were sanitized and failed to maintain a food temperature below 41 degrees Fahrenheit (F) for cold foods. This deficient practice had the potential to effect 53 of 56 residents receiving an oral diet. Findings include: 1. A record review of the policy titled Pot/Pan Washing and Sanitation dated 2014 revealed the following Procedure: Pots, pans, and utensils must be sanitized in the sanitizer sink according to one of the following methods: Heat Sanitizer: 170-degree F water for 30 seconds immersion, or Chemical Sanitizers: i. Chlorine concentration is 50 - 100 ppm and has a 75-degree F - 110-degree F water temperature with a one-minute immersion. (Chlorine becomes corrosive if water temperature is over 120-degree F; even on stainless steel). ii. Quaternary concentration is to be 200 - 300 ppm's with a water temperature of above 75 degrees or as specified by manufacture. Items need to be immersed for 60 seconds in the Quaternary. iii. Test strips for chlorine and quaternary are different. Test strips should be available to check the sanitizer level before each use. Test with appropriate test strip and record water temperature and sanitizing level during each set-up using the Three Compartment Sink Temperature/Sanitizer Log. An observation on 5/28/19 at 1:29 p.m. of the three compartment sinks, which were full of water in all three compartments, although the compartments weren't labeled the interim Dietary Manager (DM) stated that the sink the right was the sanitizer rinse sink. A Quat litmus test was done by the Cook/Aide AA, and it was revealed that it did not register that any chemical sanitizer was present. Cook/Aide AA who was washing the dishes added a pink chemical by pressing a button on the wall after she was told to do so by the interim DM, the test strip then read 500 ppm. On the right side of the three-compartment sink were four square metal pans, two spoodles, a pair of tongs, and a metal sheet pan. During an interview at this time with Cook/Aide AA, who was washing the dishes she revealed, yes, the dishes had been washed and rinsed in the sinks without any chemicals. During an interview on 5/30/19 at 11:27 a.m. with the Administrator revealed his expectations are, if there is an issue it is brought to him to be fixed. He further stated the chemical testing company came to the facility on [DATE] and replaced the broken chemical pump. 2. Record review of the policy for food temperatures titled Food Temperature revealed the following Procedure: all potentially hazardous cold foods must be held at 41 degrees or less. Potentially hazardous cold food should be held on the line in an ice bath at 41 degrees or below. An observation on 5/30/19 at 12:27 p.m. revealed that the coleslaw was sitting on a tray, not in an ice bath, and there were three servings of coleslaw 51-degree F, 54 - degree F, and a third serving tested registered 55 - degrees F. This was out of eight servings prepared on the food trays to be served on the South hall. During an interview on 5/30/19 at 12:30 p.m. with the Registered Dietician (RD) revealed that her expectations are for the staff to check the temperatures first before serving and that the food (that were not within safe temperatures) would not be served to the residents.

Based on resident interview, record review, and staff interview, the facility failed to provide the resident/family with a written explanation of reason for a transfer to an acute care hospital for one of three residents (R#26) reviewed for hospitalization . Findings include: Review of a Minimum Data Sets (MDS) revealed a Discharge Minimum Data Set ((MDS) dated [DATE] that documented a discharge from the facility to an acute hospital. Record review revealed that R#26 was readmitted to the facility on [DATE]. Resident interview on 5/29/19 at 9:02 a.m. with R#26, who had a Brief Interview for Mental Status score of 15 dated 4/12/19, indicating that he was cognitiely intact, revealed that the resident had to go to the hospital a little over a month ago for the flu. He stated that he was in the hospital from Monday through Friday. Review of two Situation, Background, Assessment Recommendation (SBAR) forms dated for 4/2/19 revealed that the first SBAR at 10:00 a.m. documented that the Physician was notified and ordered [MEDICATION NAME] 1 gram for 10 days, a chest x-ray was ordered and an order for [REDACTED]. Review of a Physician order [REDACTED]. Review of the medical record revealed that there was not any evidence of any documentation that the resident or family were notified in writing of the reason for the transfer to the hospital. Interview on 5/31/19 at 8:55 p.m. with the Administrator revealed that they do not give out written notices to the residents and/or family members when residents are transferred to the hospital.

Based on observation and staff interview, the facility failed to provide a dignified dining experience for one resident (#23) from a total sample of 21 residents. Findings include: During a random observation on 5/30/17 at 1:10 p.m., Certified Nursing Assistant (CNA) AA was assisting Resident (R) #23 to eat lunch in his room. While assisting the resident to eat, CNA AA was speaking loudly to a visitor in the room and complaining about work related issues. During an interview on 6/1/17 at 4:40 p.m., the Administrator stated that she would have expected the CNA to act in a professional manner while assisting the resident, and not to be complaining about work related issues.

Based on interview and record review, it was determined that the facility failed to follow up on recommendation for eye glasses for one resident (A) from a total sample of 21 residents. Findings include: Resident A was admitted to the facility on [DATE]. A 1/27/17 Admission Minimum Data Set (MDS) documented that the resident had highly impaired vision. During an interview on 5/31/17 at 11:36 a.m., Resident (R) A stated that her vision had declined in the last three months and that she could not see well. The resident also stated that had received eye medication in the past. A review of the clinical record revealed that the resident had an eye exam on 2/6/17. The eye exam consultation report documented that the resident had a central corneal ulcer to the right eye. The physician ordered for licensed nursing staff to administer one drop of [MEDICATION NAME] eye drops to the right eye four times daily, for 30 days to treat the ulcer. The consultation report referenced a prescription for pseudophakic spectacles for the left eye. A follow up visit on or about 4/6/17 was also ordered. A further review of the clinical record revealed that the resident received the [MEDICATION NAME] eye drops as ordered. However, there was no evidence that the presciption for eye glasses was addressed by facility staff. The resident had a follow up eye exam on 4/4/17. However, there was no evidence that staff had obtained and reviewed a copy of the consultation report until after surveyor inquiry on 6/1/17 at 3:45 p.m. The prescription for eye glasses was again referenced on the 4/4/17 eye exam consultation report. There was no evidence that facility staff had reviewed the eye consultation reports and notified the resident of the prescription for eye glasses. During an interview on 6/1/17 at 5:20 p.m., the Social Service Director confirmed that she was not aware of the physician's note about the glasses.

Based on observation, staff interview, and policy review, the facility failed to ensure nursing staff washed or sanitized their hands before assisting two randomly observed residents with meal trays from a total sample of 21 residents. Findings include: The facility's Hand Hygiene policy documented that hand hygiene must be performed routinely and thoroughly. During a random observation on 5/30/17 at 12:41 p.m., CNA AA reached down and scratched her left pants leg, then removed a lunch tray from the food cart in the hallway and entered room [ROOM NUMBER] to serve a resident. After serving the lunch tray to a resident and exiting the room, she touched her hair and face, then removed another lunch tray from the food cart and entered room [ROOM NUMBER] again to serve another resident. She did not wash her hands or utilize hand sanitizer after touching her leg, hair and face and prior to serving the lunch trays. During an interview on 6/1/17 at 4:40 p.m., the Administrator stated that she would have expected the CNA to use the sanitizer that is located in the hallway to clean her hands after touching her body.

Based on medical record review, staff interview and review of the medication administration records, (MARs), the facility failed to notify physician per his/her orders for blood sugar greater that 400 dL for one (1) resident #40, from a sample of thirty one (31) residents. Findings include: Medical Record review for resident #40 revealed a physicians order dated 07 - 28 - 15 for [MEDICATION NAME] Injectable Flex Pen. Instructions were to check finger stick blood sugar (FSBS) before meals and at bedtime, record results and administer sliding scale insulin subcutaneous. According to the orders, if FSBS is below 60 dL or over 400 dL the physician is to be contacted. There was no order for insulin coverage for a FSBS over 400 dL. On 8-02-15 at 11:30 AM the FSBS was 445. Review of medical record reveals no contact made with physician. Review of MAR indicated [REDACTED]. Review of Skilled Daily Nurses Notes dated 08-02-15 reveals that at 4:30 PM nurse documented that resident #40 was worried about blood sugar. States that writer told resident that she would call the physician tomorrow and discuss increase in blood sugar. No follow-up noted. Interview with Director of Nursing (DON) on 8-06-15 at 1:30 PM confirmed that the nurse on 8-02-15 at 11:30 AM did not contact the physician with the FSBS results over 400 dL and that the MAR indicated [REDACTED].

Catherine Segelman, RN Based on medical record review, staff interview and review of the medication administration records, (MARs), the facility failed to follow physician orders [REDACTED].#40, from a sample of thirty one (31) residents. Findings include: Medical Record review for resident #40 revealed a physicians order dated 07 - 28 - 15 for [MEDICATION NAME] Injectable Flex Pen. Instructions were to check finger stick blood sugar (FSBS) before meals and at bedtime, record results and administer sliding scale insulin subcutaneous. According to the orders, if FSBS is below 60 dL or over 400 dL the physician is to be contacted. There was no order for insulin coverage for a FSBS over 400 dL. On 8-02-15 at 11:30 AM the FSBS was 445. Review of medical record reveals no contact made with physician. Review of MAR indicated [REDACTED]. Review of Skilled Daily Nurses Notes dated 08-02-15 reveals that at 4:30 PM nurse documented that resident #40 was worried about blood sugar. States that writer told resident that she would call the physician tomorrow and discuss increase in blood sugar. No follow-up noted. Interview with Director of Nursing (DON) on 8-06-15 at 1:30 PM confirmed that the nurse on 8-02-15 at 11:30 AM did not contact the physician with the FSBS results over 400 dL and that the MAR indicated [REDACTED].

Catherine Segelman, RN Based on observation, medical record review and staff interview the facility failed to ensure that the head of the bed was elevated to the ordered elevation to prevent aspiration of tube feeding on one resident (#74) out of ten (10) tube feeding resident sample of 31. Findings include: Observation on 8-05-15 at 8:40 AM revealed that resident #74 was lying on his back in bed with a continuous tube feeding infusing. He appeared to be lying almost flat. Bed did not have a degree scale to determine height of bed. Medical record review revealed that head of bed is ordered to be elevated between thirty five (35) and forty (40) degrees to prevent aspiration of tube feeding. Interview with DD on 08-05-15 at 9:00 AM revealed that head of bed is elevated to prevent aspiration. When asked how was the degree of the head of bed determined, she held up her hand at a slight angle and stated about this much. Assessed bed in resident #74 room and DD confirmed that there was no degree scale on bed or any way to accurately determine the elevation of the head of the bed. Based on observation, medical record review and staff interview the facility failed to ensure that the head of the bed was elevated to the ordered elevation to prevent aspiration of tube feeding on one resident (#24) out of ten (10) tube feeding resident sample of 31. Findings include: During Medication Administration on 08/05/15 at 08:28 AM it was discovered that resident (#24) was lying on her back in bed with a continuous tube feeding infusing. Resident appeared to be lying almost flat. Bed did not have a degree scale to determine elevation of the head of the bed. Interview with GG on 08/05/15 AT 8:36 AM regarding resident (#24) revealed that Resident (#24) head of the bed should be elevated 30 degrees to prevent aspiration. When asked at what degree resident's head of the bed is currently at? GG Licensed Practical Nurse looked at the bed and said maybe about fifteen or twenty degrees. Assessed bed in resident (#24) room revealed there was no degree scale on bed or any way to accurately determine the elevation of the head of the bed. Interview with FF on 08/05/15 at 8:57 AM FF Certified Nurses Assistant, revealed that when she went into provide patient care to resident (#24) earlier that morning that resident (#24) was like that , pretty flat. I had to come in and clean her up and when I finished I left her like that. I know with a feeding tube the resident could aspirate I just forgot. Interview with Facilities Nurse Consultant on 08/05/15 at 9:10 AM revealed that none of the beds in the facility have a degree scale to measure the elevation of the head of the bed. 08/06/15 at 4:40 PM Review of Medical Records revealed: No aspiration or complications noted. Per Physician order [REDACTED].

Based on observation and review of the temperature log and a manufacturer's recommendation for storage, it was determined that the facility failed to properly store lemon juice after opening and to hold hot foods above the danger zone (135 degrees Fahrenheit). Findings include: 1. According the the manufacturer's label on the bottles of lemon juice, the lemon juice was supposed to be refrigerated after opening. However, it was observed on 12/03/12 at 12:45 p.m., that staff had opened four seven bottles of unsweetened lemon juice but the staff had not refrigerated those bottles. The four opened bottles were being stored on a shelf in the dry storage room. Staff had not dated the bottles to indicate when they had been opened. Staff had written a date on each bottle cap (11/16/12) but, there was not an indication of what the date represented. . 2. Although the temperature log included staff documentation that food temperatures were acceptable (above the danger zone) at the beginning of food service for lunch on 12/3/12, it was observed that the staff failed to maintain consistent food temperature control. It was observed on 12/03/12 at 12:50 p.m. that potentially hazardous hot foods were being held in the danger zone at less than 135 degrees Fahrenheit (F.). The sweet potatoes were being held at 120 degrees F. The pureed sweet potatoes were being held at 124 degrees F. The squash was held at 100 degrees F. The pureed squash was being held at 92 degrees F. Chopped pork was being held at 110 degrees F. The pureed pork was being held at 100 degrees F. .

Based on record review and staff interview, the facility failed to consult the physician in a timely manner for a significant change in condition for one (1) resident (#1) from a survey sample of (7) residents. Findings include: Record review for Resident #1 revealed a Daily Skilled Nurses Notes entry of 11/26/2011 at 3:00 p.m. which documented the resident had complained of loose stools. A Physician's Interim Orders sheet of 11/26/2011 specified a physician's orders [REDACTED]. A Physician's Interim Orders sheet of 12/01/2011 again ordered [MEDICATION NAME], two (2) tablets after each episode of diarrhea, then one (2) tablet after each subsequent episode (up to 8 tablets in 24 hours) for 48 hours, as needed. According to the December 2011 Medication Record (MR), Resident #1 was medicated with two (2) [MEDICATION NAME] tablets at 10:00 a.m. on 12/01/2011. A Daily Skilled Nurses Notes entry of 12/02/2011 at 2:00 p.m. documented that the resident's [MEDICATION NAME] 100 milligram capsule was held with a complaint of loose stools, with the resident having had two (2) bowel movements and with a [MEDICATION NAME] tablet given by mouth. This Notes entry also documented that the resident had a poor intake of less than 50 percent of the meal eaten, while a previous Daily Skilled nurses Notes entry of 11/29/2011 at 6:30 p.m. had documented that the resident's oral intake had been 50 to 60 percent of meals eaten that day. A Daily Skilled Nurses Notes entry of 12/03/2011 at 1:30 p.m. documented that Resident #1 had been medicated twice on that date with [MEDICATION NAME] 2 milligrams related to diarrhea. This Notes entry also documented that the resident had a poor oral intake, with only 3 to 4 spoonfuls of food eaten, which was less than 5 percent of the meal. A Daily Skilled Nurses Notes entry of 12/04/2011 at 8:25 a.m. documented that the breakfast food was refused, with the resident drinking only a few sips of coffee and one-half of a 4 ounce glass of juice and stating that she could not eat and did not want anything to eat. A Daily Skilled Nurses Notes entry of 12/04/2011 at 2:00 p.m. documented that Resident #1 was assisted by staff with spoon feeding at lunch and consumed only approximately 20 percent of food and drink. This Notes entry also documented that the resident's anti-diarrhea medication continued after loose stools. A Change of Condition Nurses Notes entry of 12/05/2011 at 8:30 a.m. documented that the treatment nurse had found the resident confused, disoriented, and having watery diarrhea. This Notes entry documented that the physician was then notified of the change in condition and ordered for the resident to be sent to the hospital for evaluation and treatment. Based on the above, after obtaining a second physician's orders [REDACTED]. However, despite the resident's continued diarrhea and increasingly poor oral intake, facility staff failed to consult with the physician until 12/05/2011, when the resident was found to be confused, disoriented, and having watery diarrhea. During an interview with the Director of Nursing (DON) on 01/25/2012 at 5:15 p.m., the DON acknowledged that there was no evidence to indicate that the physician had been notified of this resident's significant change in status until 12/05/2011 at 8:25 a.m..

Based on record review and staff interview, the facility failed to provide care, in accordance with the Care Plan, for two (2) residents (#1 and #2) who had pressure sores, of three (3) residents reviewed for pressure sores, from a total survey sample of seven (7) residents. Findings include: 1. Please cross refer to F314, example 1, for more information regarding Resident #2. Record review for Resident #2 revealed a Care Plan entry, originally dating from 03/14/2011, which identified the resident to be at increased risk for pressure sores, with an Approach to do weekly skin assessments. However, record review revealed, and interview with Nurse "AA" on 03/15/2012 at 4:45 p.m. acknowledged, that there was no evidence of weekly body audits, per the Care Plan, from 01/31/2012 until 03/05/2012, and on the scheduled date that it was to be done on 3/12/12 on the 7 p.m. to 7 a.m. shift. 2. Please cross refer to F314, example 2, for more information regarding Resident#1. Closed record review for Resident #1 revealed a 07/26/2011 Care Plan which identified a problem of the resident being at risk for impaired skin integrity, with an Approach to address this risk specifying weekly skin assessments. However, further review of the resident's closed record revealed that the most recent weekly skin assessment, the Body Audit Form, had been done on 11/22/2011. A Change Of Condition Nurses Notes entry of 12/05/2011 at 8:30 a.m. documented that an order had been obtained to transfer the resident to the hospital. Thus, even though the resident's Care Plan specified weekly skin assessments, a period of thirteen (13) days had elapsed since the resident's 11/22/2011 skin assessment. During an interview with the Administrator conducted on 03/14/2012 at 5:00 p.m., the Administrator acknowledged that no weekly skin assessment had been done for this resident from 11/22/2011 until the resident's 12/05/2011 transfer and admission to the hospital.

Based on record review, observation, and staff interview, the facility failed to provide the appropriate monitoring, per the Care Plan, for two (2) residents (#1 and #2) who had pressure sores, of three (3) residents reviewed for pressure sores, from a total survey sample of seven (7) residents. Findings include: 1. Record review for Resident #2 revealed an Admission/Nursing Evaluation Form of 01/26/2012 which documented a Stage II, one (1) centimeter (cm.) by one (1) cm. pressure ulcer on the resident's left buttock. The Wound Assessment Documentation Form of 02/02/2012 documented a Stage II pressure ulcer on the left inner buttock measuring 0.4 cm. by 0.4 cm. by 0.2 cm.. Resident #2 had Care Plan entry, originally dating from 03/14/2011, which identified the resident to be at increased risk for pressure sores, with an Approach to do weekly skin assessments. However, record review revealed, and interview with Nurse "AA" on 03/15/2012 at 4:45 p.m. acknowledged, that there was no evidence of weekly body audits, per the Care Plan, from 01/31/2012 until 03/05/2012, and on the scheduled date that it was to be done, on 3/12/12 on the 7 p.m. to 7 a.m. shift.. Further record review revealed the Resident #2 had been going to a wound specialist every two weeks in February 2012 for wounds on the left buttocks and right outer ankle. During an observation of the resident's buttocks with the treatment nurse on 03/14/2012 at 11:10 a.m., the resident was turned over on his left side, and two Stage II pressure areas were observed on the left buttock, One on the left outer buttock measuring 3 cms. by 1.4 cm, and one on the left inner buttock measuring 3.2 cms. by 1.2 cm.. 2. Closed record review for Resident #1 revealed a 07/26/2011 Care Plan which identified a problem of the resident being at risk for impaired skin integrity related to a history of pressure sore development. An Approach to address this risk specified weekly skin assessments. Further review of the resident's closed record revealed that the most recent weekly skin assessment, the Body Audit Form, had been done on 11/22/2011 and documented a normal sacrum, hip and buttocks. A Change Of Condition Nurses Notes entry of 12/05/2011 at 8:30 a.m. documented that an order had been obtained to transfer the resident to the hospital for evaluation and treatment. During an interview with the Administrator conducted on 03/14/2012 at 5:00 p.m., the Administrator acknowledged that no weekly skin assessment had been done for this resident from 11/22/2011 until the resident's 12/05/2011 transfer and admission to the hospital.

Based on observation, staff interview and record review, it was determined that the facility failed to implement planned interventions for one resident (#2) in a total sample of 28 residents. Findings include: Resident # 2 had a history of [REDACTED]. There was an intervention since 5/19/11 for the use of a clip chair alarm. During observations on 10/13/11 at 11:30 a.m., 1:00 p.m., and 2:45 p.m., the resident was seated alone in his/her room in a geri-chair. However, staff had not applied the clip chair alarm on the resident. See F323 for additional information regarding resident # 2.

Based on observations, staff interview and record review, it was determined that the facility failed to provide care necessary to reduce the risk of falling for one resident (#2 ) in a stage 2 sample of three residents who had accidents in a total sample of 28 residents. Findings include: Resident #2 had [DIAGNOSES REDACTED]. Licensed staff coded him/her on his/her 2/21/11 and 7/27/11 Minimum Data Set (MDS) assessments as needing total assistance with activities-of-daily living and as having been non-ambulatory . The resident's plan of care since 2/22/11 had addressed his/her risk of falling because of his/her amputation, weakness and impaired vision. After the resident fell on [DATE], nursing staff revised the care plan on 5/19/11 to include an intervention for nursing staff to use a clip chair alarm and a wedge gel form cushion to his/her geri-chair to reduce the risk of the resident falling. Nursing staff documented that the resident had fallen on 2/26/11, 3/28/11, 3/31/11, 4/02/11, 4/09/11, 4/17/11, 4/26/11, 5/19/11 and 9/25/11 but, he/she was not injured in those falls. Nursing staff noted on 4/17/11 that they were to ensure the use of the fall alarm. However, during observations on 10/13/11 at 10:05 a.m., 11:30 p.m., and 2:45 p.m., the resident was sitting alone in his/her room in a geri-chair but, staff had not applied the chair alarm. During an interview on 10/13/11 at 2:30 p.m., licensed practical nurse (LPN) "AA" stated that resident # 2 was supposed to have a clip alarm on his/her geri-chair. She said that the resident had a bed alarm that nursing staff was supposed to move to the geri-chair when he/she was seated in it. In a subsequent interview at 2:45 p.m. that day, LPN "AA" and the nurse consultant "DD" said that the resident was on an "Occurrence Intervention Program" because of his/her fall on 9/26/11. They said that information (interventions) that the certified nursing assistants were supposed to implement were listed on the "ADL sheet." Review of the resident's ADL sheet revealed that the intervention that certified nursing staff were supposed to implement, apply a chair alarm to the resident, was printed on it. However, it was observed that they had not applied the clip alarm. During an observation of care while the resident was seated in the geri-chair, the restorative certified nursing assistant confirmed on 10/13/11 at 1:00 p.m., that there was not an alarm attached to the resident's geri-chair. In an interview on 10/13/11 at 2:15 p.m., certified nursing assistant (CNA) "CC", who was assigned to provide care for the resident, stated that she had not seen an alarm to put on the resident's chair. However during an observation on 10/13/11 at 2:45 p.m. with licensed nurse AA, there was not an alarm on the chair in which the resident was sitting but, one was still attached to the resident's bed.