Every finding on record at Rockingham County Nursing Home

Based on observation, interview, and policy review, it was determined that the facility failed to store and serve food in accordance with professional standards for food safety to prevent foodborne illness in 2 of 4 kitchenettes observed. Findings include: Review on 8/29/25 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: . On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods . Observation on 8/26/25 at approximately 8:25 a.m. of the [NAME] second floor kitchenette refrigerator revealed six (6) Vital Cuisine Mighty Shakes with no thaw date or use by date. Interview on 8/26/25 at approximately 8:30 a.m. with Staff D (Unit Manager) confirmed that the thickened shakes had thaw date or use by date. Review on 8/26/25 of the manufacturer's instructions for Vital Cuisine Mighty Shakes under storage and handling revealed .Store frozen. Use thawed product within 14 days. Keep Refrigerated . Review on 8/12/25 of the facility's policy titled Unit Pantry Policy, with no date, revealed .Health shakes are required to be labeled with a discard date 12 days following date of thaw.' Observation on 8/26/25 at approximately 11:45 a.m of the [NAME] first floor kitchenette refrigerator with Staff I (Unit manager) revealed 5 Mighty Shakes that had no thaw date or use by date. Interview on 8/26/25 at approximately 11:50 a.m. with Staff I confirmed the above findings. Interview on 8/26/25 at approximately 11:50 a.m. with Staff H (General Dietary Manager) revealed that the Mighty Shakes come in frozen and then are thawed for distribution. Staff H confirmed that the above shakes were not labeled when they had been thawed but should have been labeled.

Based on observation, interview, and record review, it was determined that the facility failed follow currently accepted professional principles for labeling and/or storing drugs and biologicals in 2 of 2 medication rooms, 1 of 3 medication carts observed. (Resident identifiers are #98, #14, #43, #134, #96, and #10.)Findings include: Observation on 8/26/25 at approximately 8:25 a.m. in [NAME] 1 Medication Room of a cabinet of medications revealed:Resident #98's medication card of Furosemide 20 mg (milligrams), expiration date 7/12/25; and Resident #14's medication card of Ariprazole 15 mg, expiration date 7/15/25.Interview on 8/26/25 at approximately 8:25 a.m. with Staff A (Registered Nurse) confirmed the above findings.Observation on 8/26/25 at approximately 8:35 a.m. of the [NAME] 2 Medication Room of a cabinet of medications revealed: Resident #43's medication card of Vitamin D3 50,000 units, expiration date 8/20/25; andResident #134 medication card of Ondansetron 4 mg tablets, expiration date 8/18/25.Interview on 8/26/25 at approximately 8:35 a.m. with Staff B (Licensed Practical Nurse (LPN)) confirmed the above findings.Observation on 8/26/25 of [NAME] Medication Cart revealed:Resident #96's Stiolto Respimat Inhaler was opened and without a date of opening or open expiration date; andResident #10's Trelegy Ellipta Inhaler was opened and without a date of opening or open expiration date.Interview on 8/26/25 at approximately 8:35 a.m. with Staff C (LPN) confirmed the above findings.Review on 8/26/25 of the manufacturer's instructions for Stiolto Respimat Inhaler, Revision Date 1/2025, revealed: . Three months after insertion of cartridge , throw away the Stiolto Respimat even if it has not been used, or when the inhaler locked, or when it expires, whichever comes first.Review on 8/26/25 of the manufacturer's instructions for Trelegy Ellipta, Dated 2023, revealed: . Discard Trelegy Ellipta 6 weeks after opening the foil tray or when counter reads 0 (after all blisters have been used), whichever comes first.Review on 8/26/25 of the facility policy titled, Medication Biological labeling, Revision Date 2025, revealed: . 4. Labels for individual drug containers must include: . h. The expiration date when applicable.Review on 8/27/25 of the facility policy titled, Acquisition & Disposition of Medication, Dated 3/2024, revealed: . 7. Non-Controlled medications awaiting disposal will be removed from the current medication supply within 7 days of discontinuation. Medications awaiting disposal will be stored in a locked secure medication room separate from active medications in that room.Review on 8/28/25 of the facility policy titled, Medication Storage, undated, revealed: . 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments .

Based on interview and record review, it was determined that the facility failed to inform residents or residents' representative of the risk and benefits of psychotropic medication use for 1 out of 5 residents reviewed for unnecessary medications in final sample of 27 residents. (Resident identifier is #4) Findings include:Resident #4Review on 8/28/25 of Resident #4's medical record revealed a physician's order for Escitalopram Oxalate 5 milligrams (MG), give 15MG by mouth one time a day for mood, dated 9/30/2024. Further record review revealed there was no documentation that the risks and benefits of psychotropic medication use were communicated to Resident #4 or their representative.Interview on 8/28/25 at approximately 8:28 a.m. with Staff G (Director of Nursing) confirmed the above findings.Review on 8/28/25 of the facilities policy Use of Psychotropic Medication(s) Revision Date, 2025 revealed .9. Prior to initiating or increasing a psychotropic medication, the resident, the family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that staff wore PPE (Personal Protective Equipment) appropriately for 1 of 1 residents reviewed for Transmission Based Precautions in a final sample of 27 residents. (Resident identifier is #144.)Findings include: Observation on 8/28/25 from approximately 8:05 to 8:10 a.m. outside of Resident #144's room revealed signage to see nurse prior to entering the room. Further observation revealed Staff E (Registered Nurse) at Resident #144's bedside with a gown covering their arms but not covering their shoulders. The top half of their torso was showing and the gown was not tied. Staff E administered medications to Resident #144 and assisted with positioning his/her feet in bed. Interview on 8/28/25 at approximately 8:10 a.m. with Staff E revealed that Resident #144 was on contact precautions and confirmed that Staff E was not wearing their PPE properly. Review on 8/28/25 of the facility Donning and Doffing Personal Protective Equipment (PPE) Competency, Revision Date 8/2025 revealed the following: . Step 1 Donning - Gown: Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in back of neck and waist. Review on 8/28/25 of the facility policy titled, Precautions, Revision Date 3/22/24, revealed the following: . 4. Contact Precautions: In addition to Standard Precautions, use Contact Precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted by direct or indirect contact, . and other highly transmissible infections such as . and herpes (simplex or zoster), or other transmissible conditions . and conditions such as a rash of unknown origin, . 4. Wear a gown (a clean, non-sterile gown is adequate) to protect skin and to prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes of blood, body fluids, secretions or excretions.

Based on observation and interview, it was determined that the facility failed to meet professional standards of quality for the proper positioning of a resident's catheter drainage bag for 1 resident of 1 resident reviewed with a catheter in a final survey sample of 19 residents. (Resident identifier #49) Findings include: Potter, Patricia A., Perry, Anne Griffin, and et al Essentials For Nursing Practice Ninth Ed St. Louis Missouri: Elsevier 2019 copyright. Page 1054. Step 21 .Position drainage bag lower than bladder by attaching to bed frame. Do not attach to side rails of bed or place on the floor. Observation on 6/16/21 at 8:53 a.m. revealed Resident #49's bed was in the lowest position to the floor. The catheter drainage bag was attached to the bed frame. The drainage bag was lying on the floor. The drainage bag was not contained within a privacy bag. Observation on 6/17/21 at 8:55 a.m. of Resident #49 revealed Resident #49's bed was in the lowest position to the floor. Resident #49's drainage bag was attached to the bed frame. The drainage bag was lying on the floor. Interview on 6/17/21 at 9:00 a.m. with Staff A (Registered Nurse) confirmed that Resident #49's catheter drainage bag was on the floor. Staff A also revealed that Resident #49 was a fall risk and Resident #49's bed was at the lowest position for Resident #49's safety. Review on 6/17/21 of the facility's policy titled Suprapubic Urinary Catheter Care, dated 12/28/20, revealed the following: 7. Ensure plastic drainage bags are off the floor. Plastic drainage bags are kept inside a protective, washable cloth bag for dignity and infection control purposes. Change cloth bag when changing drainage bag.

Based on interview and record review, the facility failed to ensure residents were free from neglect when the facility did not investigate allegations or take measure to prevent further potential neglect on two occasions after staff reported the allegations to the Director of Nursing. (Resident identifier is #10.) Findings include: Interview on 10/8/20 at approximately 10:00 a.m. with Staff B (Assistant Director of Nursing) revealed that the facility had an incident on unit B1 on 8/8/20 where Staff M (Medication Nursing Assistant) was suspected to be impaired and was removed from the medication cart and went home. The investigation that followed revealed video footage of Staff M drinking resident's alcohol in the medication room and putting a syringe in their pocket. Staff M told Staff B that they used the syringe to inject [MEDICATION NAME] (benzodiazepine) into their left arm. The police were notified immediately. This was reported to the Board of Nursing on 8/12/20. Record review on 10/8/20 revealed an email from Staff O (Nurse Supervisor) to Staff P (Previous Director of Nursing) notifying Staff P another incident with Staff M on 7/10/2020 where Resident #10 accused Staff M of taking their medications and of being impaired. Interview on 10/8/20 at approximately 12:10 p.m. with Staff O revealed that on 7/10/20 Resident #10 called for Staff O because Resident #10 thought that Staff M was impaired and that Resident #10 did not get their medications because Staff M stole them. Staff O worked with Staff M to take over medication administration for Resident #10. Staff O felt Staff M was impaired and notified Staff P. Staff P did not investigate the incident or remove Staff M from the schedule. Resident #10 called the police who did show up and take a report. Staff O also revealed an incident, a couple days prior to 7/10/20. Staff O stated that Staff M had disappeared from the unit for over an hour and resident's were waiting for medications. Staff M was found in their car and returned to the unit. Staff O said that staff reported to Staff O that Staff M was not okay. It was change of shift so there was a narcotic medication count and Staff M went home. Staff O reported the incident to Staff P but it was not documented. Staff M continued on the schedule.

Based on interview, record review, and policy review, the facility failed to ensure that all alleged violations were reported to the State Survey Agency within 24 hours for 3 out of 3 incidents reveiwed for abuse or neglect allegations. Findings include: Review on 9/29/20 of facility's policy titled, Abuse, Neglect, Mistreatment, Self Neglect, Exploitation, Involuntary Seclusion, or Misappropriation of Property, revision date 1/2017, revealed that Immediately report incident of witnessed abuse to appropriate agencies, i.e. initiate a facility investigation .Sends all appropriate documentation to appropriate state agencies Interview on 9/29/20 at 7:35 a.m. with Staff A (Interim Administrator) revealed that Staff A stated that they had received a phone call on 9/4/20 regarding an allegation of abuse related to Staff J (Licensed Practical Nurse) and Staff K (Licensed Practical Nurse). Staff A also stated that Staff L (Licensed Nursing Assistant) had concerns regarding Staff J. Staff A further stated that Staff L told them that when Staff L reported to Staff J that Resident #1 complained of chest discomfort, Staff J did not follow up with Resident #1. Review on 9/29/20 of an e-mail to Staff B (Assistant Director of Nursing) dated 9/4/20 revealed that a phone call was received on 9/4/20 at the facility switchboard. The caller reported an allegation of abuse. The caller reported to the facility that Staff J and Staff K made inappropriate comments to/about residents on their respective units. Interview on 9/29/20 at 7:40 a.m. with Staff B confirmed the above findings. Staff B stated that Staff B did not report the above allegations of abuse to the State Survey Agency. Interview on 10/8/20 at approximatley 10:00 a.m. with Staff B (Assistant Director of Nursing) revealed that the facility had an incident on unit B1 on 8/8/20 where Staff M (Medication Nursing Assistant) was suspected to be impaired while working on the medication cart. Further interview with Staff B revealed that the facility also had an incident on 9/25/20 where Staff N (Registered Nurse) was suspected to be impaired while on the medication cart on unit D2. These 2 incidents were not reported to the State Survey Agency until 9/30/20. Cross reference F600: Free from Abuse and Neglect.

Based on interview, record review, and policy review it was determined that the facility failed to thoroughly investigate an allegation of misappropriation of property (drug diversion) and neglect for 2 of 2 incidents reviewed. Findings include: Review on 9/29/20 of the facility policy titled Abuse, Neglect, Mistreatment, Self Neglect, Exploitation, Involuntary Seclusion, or Misappropriation of Property in the Section titled Policy States: All alleged incidents of abuse, neglect, mistreatment, self neglect, exploitation, involuntary seclusion, or misappropriation of property will be thoroughly investigated. Record review on 10/8/20 revealed an email from Staff O (Nurse Supervisor) to Staff P (Previous Director of Nursing) notifying Staff P an incident with Staff M on 7/10/2020 where Resident #10 accused Staff M of taking their medications and of being impaired. Interview on 10/8/20 at approximately 12:10 p.m. with Staff O revealed that on 7/10/20 Resident #10 called for Staff O because Resident #10 thought that Staff M was impaired and that Resident #10 did not get their medications because Staff M stole them. Staff O worked with Staff M to take over medication administration for Resident #10. Staff O felt Staff M was impaired and notified Staff P. Staff P did not investigate the incident or remove Staff M from the schedule. Resident #10 called the police who did show up and take a report. Staff O also revealed an incident, a couple days prior to 7/10/20. Staff O stated that Staff M had disappeared from the unit for over an hour and residents were waiting for medications. Staff M was found in their car and returned to the unit. Staff O said that staff reported to Staff O that Staff M was not okay. It was change of shift so there was a narcotic medication count and Staff M went home. Staff O reported the incident to Staff P but it was not documented. Staff M continued on the schedule. Interview with Staff A (Interim Administrator) on 10/8/20 at approximately 10:00 a.m. revealed that Staff P no longer worked at the facility and there was no evidence of an investigation into the above incidents. Interview on 10/8/20 at approximately 10:00 a.m. with Staff B (Assistant Director of Nursing) revealed that there was another incident with staff M on unit B1 on 8/8/20 where Staff M (Medication Nursing Assistant) was suspected to be impaired. At that time Staff M was removed from the medication cart and an investigation followed. The police were notified imediately. This was reported to the Board of Nusing on 8/12/20. Cross reference F600: Free from Abuse and Neglect.

Based on observation and interview, it was determined that the facility failed to provide a sanitary environment in accordance with professional standards for food service safety. Findings include: Standard of Reference: Food Code, U.S. Public Health Service, FDA, 2013, page 174, 6-201.12 Floors, Walls, Ceilings, Utility Lines. (A) Utility service lines and pipes may not be unnecessarily exposed. Accessed from website on 3/7/17: https://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM 0.pdf Observation in the kitchen on 2/22/17 at approximately 9:00 a.m. revealed that there were approximately 300 square feet of ceiling tile missing in the area of the kitchen above the walk in milk cooler and the open space with access to the loading dock, dietician's office, dry storage, and main food preparation/service area. Observation in the kitchen on 2/22/17 at approximately 2:30 p.m. revealed kitchen staff preparing a cart with snacks underneath the exposed ceiling pipes. Interview on 2/22/17 at approximately 2:30 p.m. with Staff G (Maintenance) revealed the ceiling pipes had been exposed since August 2016 when they needed repair. Interview on 2/24/17 at approximately 9:45 a.m. with Staff H (kitchen staff) revealed that carts used for serving snacks and milk are often stored below the exposed ceiling pipes. Interview also revealed that food was transported to storage from the delivery dock and to the kitchen from storage passing underneath the exposed ceiling pipes.

Based on record review, observation and interview, it was determined that the facility failed to maintain complete medical records for seat belt assessments for 4 out of 5 residents using seatbelts in a standard survey sample of 24 residents. (Resident identifiers are #1, # 16, # 17, and # 18.) Findings include: Review on 2/22/17 through 2/24/17 of Residents' Care Plans revealed that Residents #1, #16, #17 and #18 used self releasing seat belts when they were up in wheelchairs. Review of assessments and progress notes revealed that the facility failed to document assessments showing that these residents were able to self release the seat belts. Observation of Residents #16, #17 and #18 on 2/23/17 through 2/24/17 revealed that the residents were able to release their own seat belts when asked. Interview on 2/23/17 at approximately 2:00 p.m. with Staff C (Registered Nurse, Unit Manager) revealed that Resident #1 was able to release her seat belt upon request. Interview on 2/24/17 at approximately 2:45 p.m. with Staff F (Director of Nursing) revealed that seat belt assessments were done at least quarterly. Interview confirmed that there was no documentation for assessments showing that the residents were able to self release their seat belts when asked.

Based on observation and interview, the facility failed to ensure resident care equipment commodes are cleaned sanitized properly to prevent the potential spread of infection by failing to clean multiple resident use commodes in two tub-rooms on 2 of 6 units. Findings include: Observation on 3/3/15 at approximately 11:20 am of Unit B1- Side A Tub room with Staff H, RN revealed 2 commodes that were soiled and had not been cleaned and sanitized after each resident use to disinfect toileting equipment used for multiple residents. Observation on 3/03/15 at approximatley 11:30 am of the B1-side B Tub room with Staff H, revealed 1 commode soiled with dry feces that had not been cleaned and sanitized to disinfect toileting equipment used for multiple residents. Interview with Staff H confirmed the commodes had not been cleaned. Staff H stated it is the responsibility of the LNAs' to clean and sanitize to disinfect multi-resident use equipment following each resident's use to prevent the potential spread of infection.

Based on interview and observation, the facility failed to prevent the potential transmission of infection by failing to appropriately clean multiple resident use glucometer equipment equipment on 2 of 6 units. Findings include: On 3/5/15, interview with Staff D (LPN) and Staff E (RN) regarding how the glucometers are cleaned between resident use, revealed that Staff D and Staff E were cleaning them with alcohol pads. Interview with Staff F (RN, Unit Manager) who stated the glucometers are cleaned with Bleach Wipes between resident use.

Based on observations and interviews the Facility failed to ensure that normal range and high range glucometer testing solutions were properly labeled for 3 of 6 resident care units and failed to ensure that all commodes were clean and sanitary on 1 of 6 units. Findings include: Unit Driscoll 1. On 3/5/15 at approximately 3:35 p.m. observation of the glucometer testing solutions revealed no dates of opening written on either the Assure Dose level 1 (normal) glucometer control testing solution bottle or the Assure Dose level 2 (high) glucometer control testing solution bottle. There was no date observed to be written on the Assure Dose paperboard box. This paperboard box appeared to have the cover torn off leaving a ragged/fuzzy edge on one side of the top of the box. Staff B, LPN, D-1 (Driscoll Unit, 1st floor) Unit Manager reached into the pasteboard box and pulled out a cardboard flap that appeared to have been cut from a box. The severed edge appeared to be cleanly cut. On the underside of this flap was a notation stating the box had been had been opened 1/18/15 and the solutions would expire on 4/18/15. At approximately 3:40 p.m. on 3/5/15, Staff B, D-1 Unit Manager stated she would transfer the dates from the severed box flap onto the bottles and was observed to do this. Observation on 3/5/15 of glucometer testing solutions on the B1 Unit, revealed the bottles of low and high glucometer testing solutions were not dated when they were opened. Interview with Staff F, (RN, Unit Manager B1) on 3/5/15 Staff F verbally confirmed the low and high range glucometer testing solutions had not been dated when they were opened. Observation on 3/5/15, of glucometer testing solutions on the B2 Unit, revealed the bottles of low and high glucometer testing solutions were not dated when they were opened. Interview with Staff G, (RN, Unit Manager B2) on 3/5/15 she verbally confirmed the low and high range glucometer testing solutions had not been dated when they were opened.

Based on observation, record review and interview it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are # 17 and # 18.) Findings include: Resident #18. Observation during a medication pass on 3/4/15 at approximately 9:15 am with Staff A (Licensed Medication Nursing Assistant) revealed the following physician orders [REDACTED]. [MEDICATION NAME] 5 mg. one tablet by mouth every day give 30 minutes before [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) 20 mg one tablet every day. Observation at this time revealed both [MEDICATION NAME] and [MEDICATION NAME] were administered to Resident #18 at the same time on 3/4/15 by Staff A . During interview with Staff A on 3/4/15 after review of the above listed physician orders, Staff A verbally acknowledged that [MEDICATION NAME] and [MEDICATION NAME] were given to Resident #18 at the same time and that [MEDICATION NAME] was not given 30 minutes before [MEDICATION NAME] as ordered by the physician. Resident #17. Observation during medication pass on 3/4/15 at approximately 9 am with Staff C (LPN) revealed the following physician orders [REDACTED]. "Losartan Pot (sic) 100mg tab IC: [MEDICATION NAME] 100mg tab 1 tab PO daily." Interview with Staff C on 3/4/14 at approximately 9:15 after review of the above listed physician orders, Staff C verbally acknowledged that he/she had not administered this medication during the 3/4/15 8:30 am medication administration.

Based on the task review of the resident trust fund and interview it was determined that the facility failed to convey resident funds within 30 days to the estate of the individual or probate jurisdiction administering the resident's estate for 4 out of sample residents. (Resident identifiers are #31, #32, #33 and #34.) Findings include: Review on [DATE] at 11:15 a.m. of deceased residents' accounts revealed that Resident #31, #32, #33 and #34's funds had not been conveyed within 30 days to the estate of the individual or probate jurisdiction administering the resident's estate. Review of the account revealed the following: Resident #31 had expired [DATE] with $2,127.22 remaining in Resident #31's account. Resident #31's funds were submitted to the probate court and signed by the administrator on [DATE]. Resident #32 had expired [DATE] with $113.93 remaining in Resident #32's account. Resident #32's funds were submitted to the probate court and signed by the administrator on [DATE]. Resident #33 had expired [DATE] with $1,059.63 remaining in Resident #33's account. Resident #33's funds were submitted to the probate court and signed by the administrator on [DATE]. Resident #34 had expired [DATE] with $910.62 remaining in Resident #34's account. Resident #34's funds were submitted to the probate court and signed by the administrator on [DATE]. Interview on [DATE] at approximately 11:30 a.m. with Staff A (Business Office Manager) revealed that Resident #31, #32, #33 and #34's funds had not been conveyed within 30 days to the estate of the individual or probate jurisdiction administering the resident's estate. Staff A confirmed that there had been an oversight with these funds.

Based on record review and interview it was determined that the facility failed to notify the physician that medications were not administered to 1 resident as ordered in a survey sample of 30 residents.(Resident identifier is #21,) Findings include: Record review on 4/24/14 of the "MEDICATION ADMINISTRATION RECORD" (MAR) dated "04/01/14 THROUGH 04/30/14" of the physician order's for Resident #21 revealed the following: "[MEDICATION NAME] 10 MG 1 TAB (tablet) BY MOUTH - HTN( hypertension ) [MEDICATION NAME] 5MG 1 TAB BY MOUTH DAILY - [MEDICAL CONDITION] [MEDICATION NAME] 40 MG 1 TAB BY MOUTH DAILY (1200) MICRO-K 10 MEQ 1 TAB BY MOUTH TWICE A DAY ( 1200 AND 2300) ... SENNA 8.6/50 MG PO DAILY..." Review of the front of this MAR for Resident #21 revealed the above listed 5 medications were encircled, indicating that these medications were not given as ordered , on 4/15 through 4/23 for a total of 9 days (one med twice a day). Review of the back of this MAR for Resident #21 revealed documentation that on 4/15 these medications were "declined", on 4/16 declined these medication with "several attempts", 4/19 documentation revealed @ 9 am and 12 pm "unable to take po meds" and 4/23 "held po meds". During interview with Staff G (Registered Nurse) on 4/24/14 after Staff G reviewed the above listed MAR for Resident #21, Staff G verbally confirmed that the physician was not notified that the above listed 5 medications were not administered to Resident #21 as ordered by the physician.

Based on observation it was determined that the facility failed to ensure the resident's dignity and respect while rendering care to two out of sample residents during a medications pass. (Resident identifiers are #35 and #36.) Resident #35. Observation of Staff F (LPN) during a medication pass on 4/24/14 at approximately 11:50 a.m. noon revealed Staff F entering the room of Resident #35. Staff F proceeded to lift Resident #35's blouse to expose the abdomen and feeding tube. This room is a 4 bed room and present at this time was another resident seated in her bedside chair. Staff F did not pull the curtain around Resident #35's bed nor did Staff F close the door to the room while administering medication to Resident #35.. Staff F proceeded to osculate the exposed abdomen and continued with the administration of medication through the abdominal feeding tube and also continued with the multiple water flushes during the administration of the medication. Observation on 4/24/14 at approximately 12 noon during this medication pass showed Staff F entered the main dinning room where multiple resident's were seated for the main lunch meal. Staff F proceeded to the table where Resident #36 was seated with other multiple residents' at this dinning table. Staff F proceeded to lift the upper body shirt of Resident #36 exposing the resident's abdomen and administered an Insulin injection into the abdomen. This injection was visible to not only the resident's seated at the table with Resident #35 but was also visible to other resident's and staff present for the noon time meal in this dinning room. The facility failed to ensure that two resident's were sufficiently covered during administration of their medications to ensure dignity and respect to Resident #35 and Resident #36.

Based on record review, interview and review of the facility and Hospice contract it was determined that the facility failed to collaborate care for hospice services for 1 of 6 resident's receiving Hospice services in a survey sample of 30 residents. (Resident identifier is #21.) Review of the facility Hospice contract revealed the following: "ADDENDUM C: HOSPICE SERVICES AND RESPONSIBILITIES ... B. NURSING SERVICES. A nurse shall be assigned to coordinate and supervise care and services for Patients and families; responsibilities include: 1. Assessment of Patient/Patient's family total care needs; 2. Coordination, implementation of each Patient's POC with facility staff; ... I. Responsibilities of Hospice ... ... Hospice shall assume professional management responsibility for Hospice Services provided to Hospice Patients residing at Facility and their family units, pursuant to the Medicare Conditions of Participation for Hospice Care and state and local laws and regulations. This includes admission and/or discharge of patients, patient and family assessments, reassessments, establishment of the Plan of Care, authorization of all services and management of the care through IDG meetings. Hospice shall make arrangements for and remain responsible for, any necessary continuous care or inpatient care related to a Hospice Patient's terminal illness and related conditions..." Record review on [DATE] of the clinical record for Resident #21 revealed that Hospice services were being provided to Resident #21 with a SOC (Start of Care) date of "[DATE]". Review of the Hospice ""HOME HEALTH CERTIFICATION AND PLAN OF CARE" revealed that Resident #21 was receiving Hospice service of "SN (skilled nursing) 2 x week x 13 weeks" and "MSW (social worker) ,[DATE] x week x 13 weeks". Review of the facility care plan for Resident #21 dated "[DATE]" revealed the following: "Focus: ... had a decline in health over the past year this includes weight loss, loss of mobility, speech and at this time has no awareness of needs secondary to end of life dementia. Guardian and ... has decided to accept Hospice to help with dying process... Interventions: Collaborate with hospice program to coordinate plan of care..." Record review revealed no documented evidence of Hospice notes and/or collaboration to coordinate a plan of care for Resident #21. During interview on [DATE] with Staff G (Register Nurse) after Staff G reviewed the above listed findings, Staff G confirmed that there was no documented evidence of a collaborate care plan with Hospice, no documentation of notes from the Hospice nurse and social worker and that Staff G was not aware of the services that these two Hospice staff were providing to Resident #21. The facility did at the time of survey request faxed documentation from Hospice of the care and services provided to Resident #21 prior to his death on [DATE]. The facility failed to collaborate a plan of care for Resident #21 receiving the Hospice benefit.

Based on record review and interview the facility failed to ensure that a paid feeding assistant feeds only residents who have no complicated feeding problems for 2 of 21 out of sample residents on the feeding assistant program. (Resident identifiers are #37, and #38.) Findings include: Review of the paid feeding assistant program was conducted on 4/22-4/24/14. Review reveled an "Acceptable Feeding List" of 24 residents (3 in sample and 21 out of sample) in total who were being fed and/or assisted by trained feeding assistants. Although the training was compliant the following 2 concerns were revealed. Resident #37. Record review of the current Nutrition assessment dated [DATE] revealed that this resident's diet was recently down graded to a "NDDII (allow soft bread products)" diet and the resident had been referred to Speech therapy because of a swallowing problem. Interview on 4/24/14 at 11:15 a.m. with Staff B (Dietician) revealed that the Resident #37 was downgraded to the above diet because of a choking risk and was a result of Speech therapy's evaluation. Staff B stated that NDD II diet was defined as the National Dysphagia Diet level II meaning ground meat or finely cut up meat with no bread. Review of the "Transitional Evaluation and Plan of Treatment" dated 4/1/14 revealed a [DIAGNOSES REDACTED]." Short-term goals read in part, "...safely consume least restrictive diet and decrease s/s of oral/pharyngeal dysphagia." Review of the Speech Therapy Discharge Summary dated 4/4/14 revealed treatment for [REDACTED]. swallowing abilities the form read, "...with diet downgrade to NDD 2 and caregiver verbal cuing for the use of safe swallowing strategies." In an interview on 4/24/14 at 11:45 a.m. with Staff D (Speech Therapist) Staff D stated that he had treated Resident #37 for swallowing concerns and the resident improved with diet change and needed cuing from staff. Review of Resident #37's current care plan revealed a "Dysphagia : Alteration in swallow function r/t Dx ([DIAGNOSES REDACTED]. Resident #38. Record review of the current Nutrition assessment dated [DATE] revealed that this resident's diet was assessed as an "MOD CHO NDD II with Honey thick liquids" diet and the resident had been referred to Speech therapy because of a swallowing problem. Interview on 4/24/14 at 11:15 a.m. with Staff B revealed that Resident #38 was placed on the above diet because of a Diabetes and a swallowing issue. Staff B stated that this resident was a choking risk and was currently in Speech therapy and on thickened Liquids. Review of the "Speech Therapy SLP Evaluation & Plan of Treatment" dated 4/8/14 revealed a [DIAGNOSES REDACTED]. a severe problem with a [DIAGNOSES REDACTED]." The document also stated that this resident is at risk for aspiration. In an interview on 4/24/14 at 11:45 a.m. with Staff C (Speech Therapist) Staff C stated that she was currently treating Resident #38 for swallowing concerns and dysphagia. In the interviews with Staff C and Staff D both staff stated that they were not aware of the feeding assistant list or the program itself. Review of Resident #38's current care plan dated 4/9/14 revealed a "Dysphagia : Alteration in swallow function r/t Dx (diagnosis) of dementia/[MEDICAL CONDITION] as evidenced by coughing with po (by mouth) intake." In an interview with Staff E (DON) on 4/24/14 in the afternoon Staff E confirmed that these 2 residents should not be on the paid feeding assistant program.

Based on observation and interview it was determined that the facility failed to ensure an environment that is safe and sanitary by not implementing facility wide infection control surveillance. Findings include: Review of the facility documented "Infection Prevention and Control Program" purpose revealed "The purpose of an Infection Prevention and Control Program is to protect residents, healthcare workers, visitors to the facility and the community from infection whenever possible." Review of the facility documented "Infection Control Coordinator" job description revealed "The Infection Control Coordinator, under the direction of the Infection Prevention and Control Committee, is responsible for the quality of resident care as it relates to the investigation, control and prevention of infection. This includes some of the following duties: ... Identify infection control issues (e.g. those identified during environmental rounds) and make recommendations for corrective action..." During interview with Staff E (Registered Nurse, Infection Control Coordinator) on 3/11/13 at approximately 1:00 p.m. Staff E verbalized that no infection control surveillance was done in the facility kitchen area, laundry area, rehabilitation area, medication areas and medication pass and that there is no documented evidence of infection control surveillance in these listed areas. During this interview Staff E verbalized that she had no knowledge that the facility hyrdocollator (a heating element) temperatures and the facility hyrdocollator cleaning was not being performed according to manufacturer's instructions and that the facility was reusing the only single use L'nard boot (a boot used in physical therapy). Cross reference F456.