Every finding on record at Saint Ann Rehabilitation and Nursing Center

Based on interview and record review, the facility failed to monitor the food's internal temperature to ensure food was safe for consumption on 17 of 30 days reviewed. Findings include: Review on 3/16/26 at approximately 8:30 a.m. of the Main Kitchen with Staff A (Culinary Services Director) revealed that the food temperature logs had missing food temperatures of items served for meals. The following dates and meals did not have food temperatures over the last 30 days:Breakfast: 3/16/26;Lunch: 2/24/26, 2/25/26, 3/5/26;Dinner: 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/23/26, 2/24/26, 2/25/26, 2/26/26, 2/28/26, 3/2/26, 3/3/26, 3/5/26, 3/6/26, 3/9/26, 3/10/26, 3/11/26.Interview on 3/16/26 at approximately 8:35 a.m. with Staff A confirmed the above findings. Interview on 3/17/26 at approximately 10:44 a.m. with Staff B (Administrator) revealed that there is no facility policy regarding taking food temperatures of prepared foods prior to serving.Review on 3/18/26 of the Food Code U.S. Public Health Service 2017 located at https://www.fda.gov/media/110822/download revealed .18. Proper cooking time and temperatures, The cooking temperatures of foods must be measured to determine compliance or noncompliance. the cook temperatures of all of the products should be measured and recorded.Internal Cooking Temperature Specifications for Raw Animal Foods .145 F(Fahrenheit) for 15 seconds Raw eggs cooked for immediate service Fish, except as listed below Intact Meat Commercially raised game animals, rabbits; 155 F for 17 seconds: Ratites (Ostrich, [NAME] and Emu) Injected meats Mechanically tenderized meats Raw eggs not for immediate service Comminuted meat, fish, or commercially raised game animals;165 F for<1 second(instantaneous): Wild game animals Poultry Stuffed fish, meat, pork, pasta, ratites & poultry Stuffing containing fish, meat, ratites & poultry

Based on interview and record review, the facility failed to ensure that PRN (as needed) psychotropic medication orders were limited to 14 days for 1 of 5 residents reviewed for unnecessary medications of a final sample of 13 residents. (Resident identifier is #3.)Finding include:Review on 3/18/26 of Resident #3's physician's orders revealed that he/she had orders for PRN Clonazepam without a specified end date on 2/27/26. Interview on 3/18/26 at approximately 1:00 p.m. with Staff C (Director of Clinical Services) confirmed the above findings.Review on 3/18/26 of the facility's policy title Utilization and Documentation of Psychotropic Medications revealed: . PRN orders for psychotropic drugs are limited to 14 days, at which time the prescribing physician or provider will re-evaluate and if he or she chooses to extend the drug beyond 14 days will document the rationale in the clinical record and indicate the duration of the prn order.

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 resident in a final sample of 12 residents. (Resident identifier is #4)Findings include:Review on 3/18/26 of Resident #4's diagnosis list revealed a diagnosis of Diabetes. Review of Resident #4's Medication Administration Record revealed that the Resident #4 was on insulin for management of his/her diabetes. Review of Resident #4's current care plan revealed that there were no interventions for diabetes. Interview on 3/18/26 at approximately 11:00 a.m. with Staff C (Director of Clinical Services) confirmed the above findings.

Based on record review and interview it was determined that the facility failed to develop a Comprehensive Care Plan for 2 of 5 residents reviewed for unnecessary medications in a final sample of 13 residents (Resident Identifiers #9 and #8). Findings include Resident #9 Review on 3/6/24 of Resident #9's medical record revealed that Resident #9 was receiving Effexor (antidepressant medication) ER (extended release). Further review of the medical record revealed that there was not a care plan developed to address the resident's depression or Effexor ER. Interview on 3/7/24 at 2:20 pm with Staff C (Director of Nursing) confirmed the above findings. Resident #8 Review on 3/6/24 of Resident #8's medical record revealed that Resident #8 has a diagnosis of major depressive disorder and that Resident #8 was receiving Celexa (antidepressant medication). Further review of the medical record revealed that there was not a care plan developed to address the resident's depression or Celexa. Interview on 3/7/24 at 2:20 pm with Staff C confirmed the above findings Review on 03/07/24 of the facility's policy titled Utilization and Documentation of Psychotropic Medications dated 11/1/2017 revealed: .Psychotropic Drugs .Residents receiving any psychotropic medications will have: A care plan that describes awareness by the resident, and or responsible party, of the medication, the purpose, as well as potential side effects.

Based on observation and interview, it was determined that the facility failed to ensure that medications are administered following professional standards for 1 out of 33 medications observed during medication administration (Resident Identifier #23). Findings include: Standards: Review of Clinical Nursing Skills and Techniques, [NAME] A. [NAME] and [NAME], Mosby, 2018, 9th Edition, revealed the following: page 543 Administering Ophthalmic Medications .7a. Apply clean gloves. Observation on 3/7/24 at approximately 7:30 a.m. of Staff B (Licensed Practical Nurse) during medication administration revealed that Staff B administered eye drops into Resident #23's bilateral eyes without wearing gloves. Interview on 3/7/24 at approximately 7:30 a.m. with Staff B confirmed the above findings. Review on 3/7/24 of the facility policy titled Medication Administration Eye Drops dated 1/23 revealed: .Equipment . Gloves, per facility policy . Procedures . 8. With a gloved finger, gently pull down lower eyelid . 13. If administering to both eyes, use a different gloved finger to apply pressure to the inner tear duct .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medication was removed from 1 of 2 medication carts observed and failed to ensure that opened multi-dose vials had the date of opening labeled on them in 1 of 1 medication rooms observed. Findings include: Lilac Unit Medication Cart Observation on [DATE] at approximately 8:00 a.m. of the Lilac Unit Medication Cart revealed a vial of Levemir insulin for Resident #25 with a handwritten date of [DATE]. The date did not specify if it was an open date or an expiration date. Interview on [DATE] at approximately 8:00 a.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed the above finding. Medication Room Observation on [DATE] at approximately 8:20 a.m. of the facility's medication room revealed an opened and undated vial of Tuberculin Purified Protein Derivative (Mantoux) in the medication refrigerator. Interview on [DATE] at approximately 8:20 a.m. with Staff B (LPN) confirmed the above finding. Review on [DATE] of the facility's policy titled Medication Ordering and Receiving From Pharmacy Provider, Medications and Medication Labels dated ,d+[DATE] revealed: .2. Multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications. (Example: Modified expiration dates upon opening the multi-dose vial.). Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label . Review on [DATE] of the manufacturer's instructions for Tuberculin Purified Protein Derivative (Mantoux), undated, revealed: .Storage . A vial of Tubersol which has been entered and in use for 30 days should be discarded . Review on [DATE] of the manufacturers instructions for Levemir insulin, dated ,d+[DATE], revealed: .After vials have been opened: .Throw away all opened Levemir vials after 42 days, even if they still have insulin in them .

Based on interview and medical record review, it was determined that the facility failed to follow physician's orders for laboratory testing and professional standards for documenting medication administration for 1 of 3 residents reviewed on anticoagulation therapy. (Resident identifier is #1.) Findings include: [NAME] A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Page 709: After administering the medication, indicate which medications were given on the client's MAR per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client Review on 6/19/19 of Resident #1's physician orders revealed the following orders: [MEDICATION NAME] 3 mg (milligram) tablet oral, One time daily for six days starting 4/27/19 (dated 4/26/19) and PT/INR ([MEDICATION NAME]/International Normalized Ratio) on 5/3/19. There was no order for [MEDICATION NAME] after 5/2/19. Review on 6/19/19 of Resident #1's laboratory reports revealed no PT/INR testing reports dated 5/3/19. Review on 6/19/19 of Resident #1's Medication Administration Record (MAR) revealed Resident #1 received [MEDICATION NAME] as ordered on between 4/27/19 to 5/2/19. Resident #1 did not receive [MEDICATION NAME] after 5/2/19. Review on 6/19/19 of Resident #1's clinical notes dated 5/8/19 at 11:27 a.m. revealed the resident had been discharged to the hospital. Review also revealed a late clinical note dated 5/8/19 at 7:23 p.m. that the resident received [MEDICATION NAME] 3 mg on 5/7/19 at 7:20 p.m. after a new order was received. Interview on 6/19/19 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview with Staff A further revealed that when the facility receives PT/INR results, they are called in to the physician and new [MEDICATION NAME] orders are obtained. Staff A also revealed that Resident #1's PT/INR specimen was not collected. Staff A confirmed that there no documentation of the medication administration of [MEDICATION NAME] on 5/7/19 on the MAR and that Resident #1 did not receive [MEDICATION NAME] between 5/3/19 and 5/7/19.

Based on observation, interview and record review, it was determined that the facility failed to administer pain medication to a resident in a timely manner for 1 resident in a standard survey sample of 14 residents. (Resident identifier is #243.) Findings include: Professional reference: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 1075 .Administer [MEDICATION NAME] as soon as pain occurs and before it increases in severity . Observation on 4/5/18 at approximately 8:00 a.m. revealed that Resident #243 was grimacing in pain and saying Ouch, Ouch, Ouch when Staff C RN (Registered Nurse) raised the head of Resident #243's bed in order to administer scheduled medications. Observation on 4/5/18 at approximately 8:00 a.m. revealed that Resident #243 told Staff C (Registered Nurse) that they had a pain level of 8 out of 10. When Staff C said that Staff C would give Resident #243 pain medication, Resident #243 said I will take it. Observation on 4/5/18 at approximately 8:05 a.m. revealed that after giving the scheduled medications to Resident #243, Staff C did not get the pain medication for Resident #243, but instead started to hand out breakfast trays to other residents and then stood at the medication cart to monitor three residents who were sitting in the common area, eating breakfast. Interview on 4/5/18 at approximately 8:05 a.m. with Staff C confirmed that Staff C stops the medication pass when trays come out in order to assist with passing out trays and monitoring residents while they are eating. Staff C stated that only in an emergency would Staff C administer medications to residents during this time. Observation on 4/5/18 at approximately 8:29 a.m. revealed Staff C administering pain medication to Resident #243. Review on 4/5/18 of Resident #243's (MONTH) (YEAR) Medications record revealed that Staff C documented administering [MEDICATION NAME] at 8:29 a.m. to Resident #243 for a documented pain level of 9. Interview on 4/5/18 at approximately 8:31 a.m. with Staff C confirmed that approximately 1/2 hour had passed from the time Resident #243 stated they were in pain and would take medication, to when the medication was administered. Interview on 4/5/18 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed that Resident #243 should not have had to wait 1/2 hour for pain medication to be administered in order for trays to be passed and monitoring of residents eating to occur.

Based on observation and interview, it was determined that the facility failed to provide a sanitary environment to prevent the potential transmission of communicable diseases during 1 of 2 medication pass observations. Findings include: Observation on 4/5/18 at approximately 8:30 a.m. revealed that during the medication pass, Staff C (Registered Nurse) reached into the pocket in the front of their shirt and removed a tissue. Staff C then wiped their nose with the tissue and then put the tissue back in their shirt pocket. Staff C then went on to pour the next medication and did not wash their hands or use hand sanitizer before continuing with the medication pass. Interview on 4/5/18 at approximately 8:35 a.m. with Staff C confirmed that Staff C did not clean their hands after wiping their nose and that Staff C should have cleaned their hands before pouring the next medication.

Based on interview and record review, it was determined that the facility failed to develop a comprehensive care plan which includes services to be furnished to achieve the highest level of well being for 2 residents in a standard survey sample of 10 residents. (Resident identifiers are #2 and # 7.) Findings include: Resident #2: Review of Resident #2's Bowel and Bladder assessment dated [DATE], revealed that the conclusion of the bladder assessment and actions needed was for the resident to have a scheduled toileting plan/habit training program. Review of the CHAT Biography (Plan of Care) revealed there was no toileting plan. The Resident Summary (Licensed Nursing Assistant (LNA) instruction sheet) stated the Resident's toileting program is to assist to toilet using walker and gait belt, toilet every 2 hours with assist. Interview with Staff A (Director of Nursing) on 2/8/17 at approximatley 4:20 p.m. confirmed the above findings. Resident #7: Review of Resident #7's Bowel and Bladder assessment dated [DATE] indicated total incontinence. Review of the Resident Summary (LNA instruction sheet) for Resident #7 revealed that Resident #7 was incontinent of urine, incontinent of bowel. Interview on 2/8/17 at 4:30 p.m. with Staff E (LNA) confirmed that there is no documented frequency, on this summary, for toileting or checking this Resident for incontinence. Review of the CHAT Biography (Plan of Care) for Resident #7, stated to monitor for toileting needs and keep clean and dry. There was no frequency specified. Review of Resident #7's Physician orders [REDACTED]. Review of Resident #7's CHAT Biography (Plan of Care) under Quality of Life Emotional Well Being on 2/8/17 revealed that there were no interventions for the use of the Antipsychotic medication, [MEDICATION NAME].

Based on medical record review, Schedule II/III narcotic and Schedule IV Controlled substance dispensing logs, interviews, and the self-reported statement, it was determined that the facility failed to document the need for and the effectiveness of Schedule II/III narcotic medications and Schedule IV Controlled Substances in four residents out of a standard survey sample of 13 Residents. (Resident identifiers are #1, #3, #6, and #11) Findings include: Evaluating the effectiveness's of a pain intervention requires you to evaluate the client after an appropriate period of time. pg 1082, Fundamentals of Nursing 7th ed, Potter Perry. On 12/17/15 the facility reported to the New Hampshire Office of Long Term Care Ombudsman that on 12/16/15 they were presented with a letter in which LPN (Staff H) related drug diversion. In the body of the letter Staff H describes the diversion sequence in which Staff H would offer four specific residents (Resident #1, #3, #6, and #11) if they wanted pain medication and when they declined, Staff H would take the medication. Staff H related this activity occurred since approximately the beginning of November 2015. Record review of narcotics/controlled substances logs, the Medical Administration Records (MAR's) for the months of November and December 2015 of Residents revealed a pattern of schedule II/III narcotics and schedule IV controlled substances signed out for the residents identified. There was no documentation why each medication was needed, that the medications were in fact administered, and the effect each medication dose had on each resident. Documentation is absent in 27 of 33 entries in the narcotics/controlled substances logs that were identified. A records review of the Residents #1, #3, #6, and #11 nurses progress notes found only two entries in which Staff H medicated a resident for pain and recorded the effect of the medication. Interview on 4/1/16 at approximately 2:45p.m. Staff A confirmed findings of the record review of nurses progress notes, MAR's, Schedule II/III narcotic and Schedule IV Controlled substance dispensing logs.

Based on observation and interview it was determined that the facility failed to use proper cleaning procedure after the use of a unit glucometer observed during medication pass. (Resident identifier #15 out of sample) Findings include: References: Obtained on-line 11/20/15 at http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#unsafe, under Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration - Blood Glucose. Also, in the above document under Additional Information on pages 7 and 8 refers to the following resource: FDA Communication: Leter for Manufacturers of Blood Glucose Monitoring Systems Listed with the FDA most current update May 2, 2012 and is found on-line at http://www.fda.gov/MedicalDevices/Productsand MedicalProcedures/InVitroDiagnostics/ucm 5.htm. Page 2 under section 2 Validated cleaning and disinfection procedures states: .Please note that 70% [MEDICATION NAME] solutions are not effective against viral bloodbourne pathogens . During the medication pass for the 100 unit on 3/22/16 at 8:15a.m. with Staff G(RN), performed a repeat blood glucose test on Resident #15. After test was completed, Staff G returned to the medication cart where Staff G wiped glucometer clean with an alcohol wipe. When asked if the glucometer was a common use glucometer for the unit Staff G worked on, Staff G replied that it was. When asked 'What is the accepted protocol for cleaning the glucometer between residents.' Staff G replied 'Alcohol?'.

Based on record review and interview, it was determined that the facility failed to develop a comprehensive care plan that included all pertinent care areas, for 2 resident in a survey sample of 13 residents. (Resident identifiers are #4 and #11.) Findings include: Resident #4 Review of this resident's Annual MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 11/12/15 revealed that the Care Area of [MEDICAL CONDITION] Drug Use triggered, and the facility did a Care Area Assessment (CAA) and determined that they would care plan. Review of the CAA dated 11/19/15 revealed that Resident #4 takes an antidepressant daily . is monitored . for changes in mood and behavior, and any potential side effects Will proceed to care plan as resident is a risk for potential side effects of his medications Review of this resident current care plan reveals, for [MEDICAL CONDITION] Drug Use, the Crosswalk points to the Care Area of Emotional Well Being. Review of the Emotional Well Being section of the care plan reveals that family/staff support is addressed, but there is no mention of any depression, medication use, or monitoring for side effects. Interview with Staff C, RN on 3/24/16 revealed this resident's [MEDICAL CONDITION] medication is used for sleep, not depression. Resident #11 Review of this resident's Significant Change MDS with an ARD of 5/20/15 revealed that the Care Area of [MEDICAL CONDITION] Drug Use triggered, and the facility did a Care Area Assessment and determined that they would care plan for this area. Review of the 5/30/15 CAA for [MEDICAL CONDITION] Drug Use reveals Nursing administers the medications and monitors for changes in mood and behavior is at risk for possible side effects of . medications Review of the hospice document Physician Verbal Order dated 3/22/16 reveals this resident's medications include daily [MEDICATION NAME] ([MEDICATION NAME]) for depression. Review of this resident's current CHAT Biography care plan under Emotional Well Being reveals no mention of the [DIAGNOSES REDACTED].

Based on record review and interview, in was determined the facility failed to ensure MDS assessments were accurate, for 2 residents in a standard survey sample of 13 residents. (Resident identifiers are #5 and #11.) Findings include: Resident #5 Review of this resident's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/22/15 revealed that the resident's Pneumococcal Vaccine was up to date in Section O0300. However, review of a subsequent MDS, the Quarterly with an ARD of 1/19/16 revealed that the resident is coded at O0300 as declined the Pneumococcal vaccine. Resident #11 Review of the Significant Change MDS with an ARD of 5/30/15, and the Quarterly MDS with an ARD of 2/11/16 revealed, on both Assessments, that the resident coded as being on Hospice care While a Resident in Section O0100. However, both assessments coded that the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months in Section J1400. Interview with Staff F, nurse, on 3/23/16 revealed this resident is currently on hospice and has hospice LNA (licensed nursing assistant) three times a week. Review of the hospice Physician Verbal Order document dated 3/22/16 reveals that the resident's hospice care was recertified on 3/15/16, relating the patient's prognosis is six months or less if the disease runs its normal course. Subsequent to survey exit, the facility provided documentation of the Hospice Certification and Plan of Care with a Start of Care Date 5/30/15.

Based on record review and interview, it was determined that the facility failed to provide accurate and/or complete documentation for 3 Residents out of a sample of 16 (Resident identifiers are: #9, #10 and #13 ) The Potter-Perry, 2009, Review of Fundamentals of Nursing, Patricia A. Potter and Anne Griffin Perry, Mosby, St. Louis, Missouri, 2009, 7th Edition, revealed the following, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 699 relates Prescribers must document the diagnosis, condition, or need for use for each medication ordered. and on page 708 The prescriber often gives specific instructions about when to administer a medication. Finding include: Resident #9 Receord review on 6/18/15 at 2:00 p.m. for Resident #9 revealed a Hospice contract and Certificate of Terminal Illness which was signed by the physician on 5/30/2015. Review of a Hospice binder kept at the Nurses station which contained a staff communication log and a list of how many Licensed Nursing Assistants (LNA) and Registered Nurses (RN) would be utilized per week for Resident #9 revealed no schedule of visits by LNA's or RN's visits available. Interview with Staff A (LPN) on 6/18/15 at 2:20 p.m. who stated he/she was not aware of when Hospice came in or would be coming in next as they do not check in upon arrival. Interview with Staff B (ADON) on 6/18/15 at 2:25 p.m. who stated the Plan of Care is for an RN to come in twice a week and an LNA to come in three times a week however it is unknown what the Hospice schedule is or when Hospice staff will be providing services to Resident #9. Resident #10 On 6/18/15 at 8:00 a.m. while observing medication pass with Staff C (LPN), it was noted on Resident #10's MAR indicated [REDACTED] [MEDICATION NAME] 624 mg by mouth (PO) ( by mouth) daily The blister pack instructions were to give [MEDICATION NAME] 324 mg 1 tablet daily. The physician's orders [REDACTED]. Interview with Staff C, who confirmed the order had been transcribed from the doctors order to the MAR indicated [REDACTED] Resident #13 Record review on 6/18/15 at approximately 1:15 pm, revealed that there were PRN (as needed) medication orders that did not have parameters or indications for use. The MAR indicated [REDACTED] Tylenol, 650 mg PO Q 4h PRN pain, and: [MEDICATION NAME] 5mg tab, 5 mg Q 4H PRN pain. The Clinician passing the medication to the resident would not know which medication to use for pain, as it has not been clearly indicated in the physician's orders [REDACTED]. Interview with Staff D, Administrator, and Staff E, Director of Nursing acertained that there was not an attempt to clarify the order, and Staff D and Staff E verbalized understanding that the orders for the above pain medications needed clarification and indications for use.

Based on record review and interview the facility failed to consistently assess a house acquired unstageable pressure ulcer and to have documented evidence that the physician was involved in treatment and decisions for 1 of 16 residents in a standard survey sample. (Resident identifier is Resident #2). Findings include: Resident #2 Review of Resident #2's medical record on 6/19/15 revealed that Resident #2 developed an in-house unstageable pressure ulcer on his/her right heel on 5/7/15. Treatment consisted of skin barrier wipe to heels daily until healed and off-loading of heels. The wound was assessed originally on 5/7/15 and measured 3 cm (length) x 3 cm (width) and the wound bed was documented as -. The wound was not assessed again until 5/18, eleven days later and measured 2 cm (length) x 4 cm (width) and the wound bed was documented as N/A. The next wound assessment was done on 5/27/15, nine days later and measured 2.4 cm (length) x 3.4 cm (width) and the wound bed was documented as Dark Eschar. The wound was next assessed on 6/6, ten days later and measured 3.3 cm (length) x 3.4 cm (width) and the wound bed was documented as Eschar and the last wound assessment was done on 6/16, ten days later and measured 3.0 cm (length) x 3.4 cm (width) and the wound bed was documented as Eschar. This wound was not assessed weekly and there was no documentation beyond the initial notification on 5/7/15 to the doctor that this wound was not improving. Interview with Staff B (ADON) on 6/19/15 who confirmed that the wound was not consistently assessed at least weekly as well as the assessments that were done weekly were not done at least every 7 days and that there was no documentation that the physician had been involved in the review the current ordered treatment to determine effectiveness. Interview with Staff E (DON) on 6/19/15 who confirmed that the wound was not consistently assessed at least weekly as well as the assessments that were done weekly were not done at least every 7 days and that there was no documentation that the physician had been involved in the review the current ordered treatment to determine effectiveness.

Based on record review and interview the facility failed to maintain complete and accurate medical records for 2 of 16 residents in a standard survey sample. (Resident identifiers are resident #10 and #9). Findings include: Resident #9 Record Review on 6/18/15 at 2:00 p.m. for Resident #9 revealed a signed Hospice contract and Certificate of Terminal Illness which was signed by the physician on 5/30/2015. A Hospice binder, kept at the Nurses station, contained a staff communication log and a list of how many Licensed Nursing Assistants (LNA) and Registered Nurses (RN) would be utilized per week for Resident #9. There was no schedule of visits by LNA's or RN's visits available. Interview with Staff A (LPN) at 2:20 p.m. who stated he/she was not aware of when Hospice came in or would be coming in next as they do not check in upon arrival. Interview with Staff B (ADON) at 2:25 p.m. who stated the Plan of Care is for an RN to come in twice a week and an LNA to come in three times a week however it is unknown what the Hospice schedule is or when Hospice staff will be providing services to Resident #9. Resident #10 On 6/18/15 at 8:00 a.m. while observing medication pass with Staff C (LPN), it was noted on Resident #10's MAR indicated [REDACTED] [MEDICATION NAME] 624 mg by mouth (PO) ( by mouth) daily The blister pack instructions were to give [MEDICATION NAME] 324 mg 1 tablet daily. The physician's orders [REDACTED]. Interview with Staff C, on 6/18/15 who confirmed the order had been transcribed from the doctors order to the MAR indicated [REDACTED]

Based on record review and interview with staff it was determined that the facility failed to meet professional standards of care for 1 of 1 resident with a PICC (Peripheral Inserted Central Catheter) in a standard survey sample of 13. (Resident identifier is #5.) Findings include: Resident #5 had a PICC line placed on 4/4/14 at the hospital, and was readmitted to the facility on [DATE]. On review of the facility paper work call "Midline and [MEDICAL CONDITION] (Central Venous Access Device) Documentation Form" it show that a double lumen catheter was placed in the right arm. On the form it asks for (External Catheter Length measure with dressing change and prn) and ( Baseline Mid Upper Arm Circumference). On review of the documentation form it has the upper arm circumference as 38 cm, but the External catheter length space is blank. On review of the facility's Policy Section 4.2 Vascular Access Devices Central Venous Access Device ([MEDICAL CONDITION]) states: 1) Measure upper arm circumference baseline and PRN. 2) Measure external length of catheter baseline and routinely after placement. Interview with Staff A (Assistant Director of Nurses) confirmed that the measurement for the length of the PICC line was not written on the form, and education was provided that day to all staff.

Based on record review and interview, the facility failed to ensure the accuracy of MDS assessments, for 4 residents in a survey sample of 13 residents. (Resident identifiers are #4, #6, #8, and #12.) Findings include: Resident #4 Record review of the Annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/27/14 revealed that Q0500 was coded Yes to indicate the resident (or family or significant other as applicable) wants to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community. However, review of the 1/3/14 and 3/31/14 social service notes did not reveal where this request by the resident was addressed, and the plan was for the resident to remain at an ICF (intermediate care facility) level of care at this facility. Interview on 5/30/14 with Staff C, social services, revealed that the resident had said No, for Q0500, and the MDS was miscoded as Yes. Resident #6 Record review of the Annual MDS assessment with an ARD of 11/21/13 revealed that Q0500 was coded Yes to indicate the resident (or family or significant other as applicable) wants to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community. However, review of the 12/9/13 social service note did not reveal where this request by the resident was addressed, and the plan was for the resident to remain at an ICF level of care at this facility. Interview on 5/30/14 with Staff C revealed that the resident had said No, for Q0500, and the MDS was miscoded as Yes. Resident #12 Record review of the Annual MDS assessment with an ARD of 5/7/13 revealed that Q0500 was coded Yes to indicate the resident (or family or significant other as applicable) wants to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community. Interview on 5/30/14 with Staff C, social services, revealed that the resident's guardian had said No, for Q0500, and the MDS was miscoded as Yes. Record review of the Quarterly MDS with an ARD of 4/10/14 revealed that O0250 was coded to show that the resident received the influenza vaccine, this influenza season, on 11/21/12. Interview with Staff D, RN on 5/30/14 revealed that this is an error, as the flu vaccine was given on 11/12/13. Resident #8. Record review of Resident #8 revealed on the Annual MDS (Minimum Data Set) dated 7/1/13 residents height was 62 inches. Review of the Quarterly MDS dated [DATE] Resident #8's height was listed 72 inches. Interview with Staff B (MDS Coordinator) on 5/28/14, Staff B confirmed that Resident #8's correct height is 72 inches.

Based on record review and interview, the facility failed to notify the physician of a medication not available and not administered as ordered for 1 resident in a standard survey sample of 13 residents. (Resident identifier is #9.) Findings include: Resident #9. Review of medical record for Resident #9 revealed a physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) for the Month of May 2013 revealed that all 7 doses from 5/23/13 through 5/29/13 were circled as omitted on the MAR. The MAR did not have any entries documented of physician notification that the medication was not available. During an interview on 5/29/13 at approximately 2:15 p.m. with Staff A, (RN), Staff A confirmed that the 7 doses of [MEDICATION NAME] 1 mg po that was ordered by the physician for Resident #9 had been documented on the MAR as not administered. Review of the back of the MAR for May 2013 revealed a note dated 5/23/13 which stated the following: "0100 Faxed to (Pharmacy Vendor Name Omitted) that we don't carry [MEDICATION NAME] 1 mg only 3 mg as stock med and to send right away." A second note dated 5/28/13 on the back of the May 2013 MAR stated the following: "[MEDICATION NAME] 1 mg PO (right arrow symbol) Pharmacy notified we/awaiting order delivery at this time." On 5/30/13 at approximately 2:30 p.m. during an interview with Staff B, (ADON), Staff B confirmed that Resident #9 did not receive the [MEDICATION NAME] dose as ordered by the physician for 7 days. Staff B further stated there was no nurses note of physician notification that the medication was not available as ordered.

Based on observation, facility document review, medical record review, review of facilities policies and procedures and staff interview, the facility failed to ensure the professional standards of practice were followed during administration of medications to 1 resident. (Resident identifier is #1.) Findings include: Reference for the professional standard of practice to ensure safe medication administration is the "Fundamentals of Nursing, Potter-Perry", page 841 - 843. This standard refers to the six rights of medication administration and states the following, "All medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1.The right medication 2.The right dose 3.The right client 4.The right route 5.The right time and 6.The right documentation." Review of facility policy on 9/1/11 entitled " Delivery and Receipt of Routine Deliveries " with effective date of 12/01/07 indicates the following: Under " Procedure " 2.4- " Inspect the package(s) for damage or errors and notify Pharmacy as soon as possible but within twenty-four (24) hours of any damage or other discrepancies; " 2.6- " Document any delivery discrepancies (e.g. item received in error, labeling error, ect.) " Review on 9/1/11 of facility " General Dose Preparation and Medication Administration " policy with revision date of 5/01/10, indicates the following: Under " Procedure" 3. "Dose Preparation: ..." 3.7- "Facility staff should verify that the medication name and dose are correct ..." 4.1 "Facility staff should:" 4.1.1 "Verify each medication is administered that it is the correct medication, at the correct dose, at the correct route, ...at the correct time for the correct resident ..." Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 300 mg (milligrams) PO (by mouth) at HS" (hour of sleep). The medication was initialed as being administered on 8/20//11, 8/21/11, 8/22/11, 8/23/11, 8/24/11, and 8/25/11. Review of facility investigation reveals a statement dated 8/26/11 written by Staff D, (RN) that indicates on 8/26/11 at 0315 am, during Staff D ' s review and comparing MARs (Medication Administration Record) for August 2011 and September 2011 for "changeover" Staff D noticed the [MEDICATION NAME] transcription "did not match up exactly" and left a note for clarification on the desk of the unit manager. Resident #1's medication bingo card, revealed the medication label stating "[MEDICATION NAME] SODIUM 300 MG CAPSULE" ([MEDICATION NAME]) with the instructions for "3 CAPS BY MOUTH EVERY BEDTIME" (totals 900mg) the bingo card contains 30 capsules with 19 capsules remaining. Review of the facility investigation reveals a statement made on 8/26/11 by Staff E, (LPN Licensed Practical Nurse) stating, that on 8/23/11 Staff E administered 3 "pills" to Resident #1 "Per pharmacy instruction" indicating that Resident #1 was administered [MEDICATION NAME] 900 mg instead of 300 mg as ordered. Review of a statement dated 8/26/11 by Staff F, RN (Registered Nurse) indicates that on 8/24/11 Staff F administered [MEDICATION NAME] to Resident #1. Staff F stated, "I read the bingo card ...it said to administer 3 caps (capsules). I administered 3 caps ...of [MEDICATION NAME]" Resident #1 was administered [MEDICATION NAME] 900 mg instead of 300 mg as ordered. During an interview on 9/1/11with Staff B, (Director of Nursing), Staff B confirmed the MD order for [MEDICATION NAME] was for 300 mg at HS. Staff B also confirmed that the pharmacy erroneously labeled the dispensed [MEDICATION NAME] Bingo cards containing [MEDICATION NAME] 300 mg capsules with instructions to give 3 capsules at HS (which totals 900mg). Staff B also confirmed that Resident #1 was administered 900mg instead of 300 mg of [MEDICATION NAME] on 8/23/11 and 8/24/11 and unable to confirm a third administration although the remaining capsules in the bingo card reflect that Resident #1 may have received 900 mg of [MEDICATION NAME] on 3 administrations. Cross refer F329 and F333

Based on observation, facility document review, medical record review, review of facilities policies and procedures and staff interviews, the facility failed to ensure that it implements the policy and procedures to prohibit neglect of a resident being administered medications that resulted in 1 resident with a significant medication error resulting in hospitalization . (Resident identifier is #1.) Findings include: Review of facility policy on 9/1/11 entitled " Delivery and Receipt of Routine Deliveries " with effective date of 12/01/07 indicates the following: Under " Procedure " 2.4- " Inspect the package(s) for damage or errors and notify Pharmacy as soon as possible but within twenty-four (24) hours of any damage or other discrepancies; " 2.6- " Document any delivery discrepancies (e.g. item received in error, labeling error, ect.) " Review on 9/1/11 of facility " General Dose Preparation and Medication Administration " policy with revision date of 5/01/10, indicates the following: Under " Procedure " 3. " Dose Preparation: ... " 3.7- " Facility staff should verify that the medication name and dose are correct ... " 4.1 " Facility staff should: " 4.1.1 " Verify each medication is administered that it is the correct medication, at the correct dose, at the correct route, ...at the correct time for the correct resident ... " Review on 9/1/11 of Resident #1's medical record physician's admission orders [REDACTED] Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 300 mg (milligrams) PO (by mouth) at HS " (hour of sleep). The medication was initialed as being administered on 8/20//11, 8/21/11, 8/22/11, 8/23/11, 8/24/11, and 8/25/11. Review of facility investigation reveals a statement dated 8/26/11 written by Staff D, (RN) that indicates on 8/26/11 at 0315 am, during Staff D's review and comparing MAR's (Medication Administration Record) for August 2011 and September 2011 for "changeover" Staff D noticed the [MEDICATION NAME] transcription "did not match up exactly " and left a note for clarification on the desk of the unit manager. Resident #1's medication bingo card, revealed the medication label stating " [MEDICATION NAME] SODIUM 300 MG CAPSULE " ([MEDICATION NAME]) with the instructions for "3 CAPS BY MOUTH EVERY BEDTIME" (totals 900 mg) the bingo card contains 30 capsules with 19 capsules remaining. Review of the facility investigation reveals a statement made on 8/26/11 by Staff E, (LPN Licensed Practical Nurse) stating, that on 8/23/11 Staff E administered 3 "pills" to Resident #1 "Per pharmacy instruction" indicating that Resident #1 was administered [MEDICATION NAME] 900 mg instead of 300 mg as ordered. Review of a statement dated 8/26/11 by Staff F, RN (Registered Nurse) indicates that on 8/24/11 Staff F administered [MEDICATION NAME] to Resident #1. Staff F stated, "I read the bingo card ...it said to administer 3 caps (capsules). I administered 3 caps ...of [MEDICATION NAME]" Resident #1 was administered [MEDICATION NAME] 900 mg instead of 300 mg as ordered. Review of Resident #1's Nurses Notes dated 8/26/11 written by Staff G, (LPN) at 8:00 am indicates Resident #1 was having increased confusion, with difficulty in word finding, nausea and dry heaving. MD (Medical Doctor) was notified and ordered an immediate [MEDICATION NAME] level, the lab was unable to perform the blood draw in a timely manner so the MD ordered Resident #1 to be sent out to hospital for evaluation. Resident #1 left facility at 9:30 a.m. Review of facility documentation by Staff B (DON) dated 8/30/11 indicates that Staff B spoke with the hospital ER physician who indicated that Resident #1 would need to spend a couple of days at the hospital to allow the [MEDICATION NAME] to metabolize throughout the body before restarting any anti-[MEDICAL CONDITION] medication. The 8/30/11 documentation also reveals that the original physician orders [REDACTED]. During an interview on 9/1/11 with Staff B confirmed the MD order for [MEDICATION NAME] was for 300 mg at HS. Staff B also confirmed that the pharmacy erroneously labeled the dispensed [MEDICATION NAME] Bingo cards containing [MEDICATION NAME] 300 mg capsules with instructions to give 3 capsules at HS (which totals 900 mg). Staff B also confirmed that Resident #1 was administered 900 mg instead of 300 mg of [MEDICATION NAME] on 8/23/11 and 8/24/11 and unable to confirm a third administration although the remaining capsules in the bingo card reflect that Resident #1 may have received 900 mg of [MEDICATION NAME] on 3 administrations.

Based on observation, record review, review of facility documents and review of facility policy and procedures the facility failed to ensure that pharmaceutical service procedures assure for accurate acquiring, dispensing and receiving, of medications, that resulted in 1 resident receiving excessive dosage of a medication, adverse effects and hospitalization . (Resident identifier is #1) Findings include: Review of facility policy on 9/1/11 entitled "Delivery and Receipt of Routine Deliveries" with effective date of 12/01/07 indicates the following: Under "Procedure" 2.4- "Inspect the package(s) for damage or errors and notify Pharmacy as son as possible but within twenty-four (24) hours of any damage or other discrepancies;" 2.6- "Document any delivery discrepancies (e.g. item received in error, labeling error, ect.)" Review on 9/1/11 of Resident #1's medical record physician admission orders [REDACTED] Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"dilantin 300 mg (milligrams) PO (by mouth) at HS" (hour of sleep). The medication was initialed as being administered on 8/20//11, 8/21/11, 8/22/11, 8/23/11, 8/24/11, and 8/25/11. Review of facility investigation reveals a statement dated 8/26/11 written by Staff D, (RN) that indicates on 8/26/11 at 0315 am, during Staff D's review and comparing MARs (Medication Administration Record) for August 2011 and September 2011 for "changeover" Staff D noticed the dilantin transcription "did not match up exactly" and left a note for clarification on the desk of the unit manager. Resident #1's medication bingo card, revealed the medication label stating "PHENYTOIN SODIUM 300 MG CAPSULE" (dilantin) with the instructions for "3 CAPS BY MOUTH EVERY BEDTIME" (totals 900 mg) the bingo card contains 30 capsules with 19 capsules remaining. Review of the facility investigation reveals a statement made on 8/26/11 by Staff E, (LPN) stating, that on 8/23/11 Staff E administered 3 " pills " to Resident #1 "Per pharmacy instruction" indicating that Resident #1 was administered dilantin 900 mg instead of 300 mg as ordered. Review of a statement dated 8/26/11 by Staff F, RN (Registered Nurse) indicates that on 8/24/11 Staff F administered dilantin to Resident #1. Staff F stated, "I read the bingo card ...it said to administer 3 caps (capsules). I administered 3 caps ...of dilantin" Resident #1 was administered dilantin 900 mg instead of 300 mg as ordered. Review of Resident #1's Nurses Notes dated 8/26/11 written by Staff G, (LPN) at 8:00 am indicates Resident #1 was having increased confusion, with difficulty in word finding, nausea and dry heaving. MD (Medical Doctor) was notified and ordered an immediate dilantin level, the lab was unable to perform the blood draw in a timely manner so the MD ordered Resident #1 to be sent out to hospital for evaluation. Resident #1 left facility at 9:30 a.m. Review of facility documentation by Staff B dated 8/30/11 indicates that Staff B (DON) spoke with the hospital ER physician who indicated that Resident #1 would need to spend a couple of days at the hospital to allow the dilantin to metabolize throughout the body before restarting any anti-seizure medication. The 8/30/11 documentation also reveals that the original physician orders [REDACTED]. During an interview on 9/1/11 with Staff B, Staff B confirmed the MD order for dilantin was for 300 mg at HS. Staff B also confirmed that the pharmacy erroneously labeled the dispensed dilantin Bingo cards containing dilantin 300 mg capsules with instructions to give 3 capsules at HS (which totals 900 mg). Staff B also confirmed that Resident #1 was administered 900 mg instead of 300 mg of dilantin on 8/23/11 and 8/24/11 and unable to confirm a third administration although the remaining capsules in the bingo card reflect that Resident #1 may have received 900 mg of dilantin on 3 administrations.

Based on, observation, record review, review of facility documentation and interviews the facility failed to ensure that a resident is free of any significant medication errors for 1 resident resulting in a transport and admission to the hospital for evaluation and treatment. (Resident Identifier is #1.) Findings include: Review of Resident #1's medical record on 9/1/11 reveals Resident #1 was admitted to the nursing facility on 8/20/11 with the [DIAGNOSES REDACTED]. Review on 9/1/11 of Resident #1's physician admission orders (hour of sleep) noted by Staff C, RN (Registered Nurse) Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 300 mg (milligrams) PO (by mouth) at HS" (hour of sleep). The medication was initialed as being administered on 8/20//11, 8/21/11, 8/22/11, 8/23/11, 8/24/11, and 8/25/11. Review of Resident #1's Nurses Notes dated 8/26/11 written by Staff G, (LPN) at 8:00 am indicates Resident #1 was having increased confusion, with difficulty in word finding, nausea and dry heaving. MD (Medical Doctor) was notified and ordered an immediate [MEDICATION NAME] level however lab unable to be perform in a timely manner with MD ordering Resident #1 to be sent out to hospital for evaluation. Resident #1 left facility at 9:30 a.m. Review of facility investigation reveals a statement dated 8/26/11 written by Staff D, (RN) indicates on 8/26/11 at 0315 am, during Staff D's review and comparing MARs (Medication Administration Record) for August 2011 and September 2011 for "changeover" Staff D noticed the [MEDICATION NAME] transcription "did not match up exactly" and left a note for clarification on the desk of the unit manager. Resident #1's medication bingo card, revealed the medication label stating "[MEDICATION NAME] SODIUM 300 MG CAPSULE" ([MEDICATION NAME]) with the instructions for "3 CAPS BY MOUTH EVERY BEDTIME" (totals 900 mg) the bingo card contains 30 capsules with 19 capsules remaining. Review of the facility investigation reveals a statement made on 8/26/11 by Staff E, (LPN Licensed Practical Nurse) stating, that on 8/23/11 Staff E administered 3 "pills" to Resident #1 "Per pharmacy instruction" indicating that Resident #1 was administered [MEDICATION NAME] 900 mg instead of 300 mg as ordered. Review of a statement dated 8/26/11 by Staff F, RN (Registered Nurse) indicates that on 8/24/11 Staff F administered [MEDICATION NAME] to Resident #1. Staff F stated, "I read the bingo card ...it said to administer 3 caps (capsules). I administered 3 caps ...of [MEDICATION NAME]" Resident #1 was administered [MEDICATION NAME] 900 mg instead of 300 mg as ordered. During an interview on 9/1/11 with Staff B, Director of Nursing, Staff B confirmed the MD order for [MEDICATION NAME] was for 300 mg at HS. Staff B also confirmed that the pharmacy erroneously labeled the dispensed [MEDICATION NAME] Bingo cards containing [MEDICATION NAME] 300 mg capsules with instructions to give 3 capsules at HS (which totals 900 mg). Staff B also confirmed that Resident #1 was administered 900 mg instead of 300 mg of [MEDICATION NAME] on 8/23/11 and 8/24/11 and unable to confirm a third administration although the remaining capsules in the bingo card reflect that Resident #1 may have received 900 mg of [MEDICATION NAME] on 3 administrations. During an interview with Staff A, (Administrator) on 9/1/11. Staff A confirmed Resident #1 was admitted to the hospital on [DATE].