Every finding on record at Saint Francis Rehabilitation and Nursing Center

Based on observation, interview, and record review it was determined that the facility failed to ensure physician orders were followed for 2 residents in a final sample of 12 residents and 1 of 27 medications observed during medication administration (Resident identifiers are #20, #3, and #13). Findings include: Standards: [NAME], [NAME] A., and [NAME] [NAME]. 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 physician's 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 . Resident #20 Observation on 10/11/23 at approximately 10:30 a.m. of Resident #20 revealed an approximately 2 by (x) 2 inch white dressing, undated adhered to his/her right cheek. Review on 10/11/23 of Resident #20's current physician's order revealed that there was no order for a dressing to Resident #20's right cheek. Observation on 10/12/23 at approximately 11:15 a.m. of Resident #20 revealed an approximately 2 x 2 inch white dressing, undated adhered to his/her right cheek. Interview on 10/12/23 at approximately 11:15 a.m. with Staff B (Licensed Practical Nurse) confirmed that Resident #20 did not have an order for the bandage. Resident #3 Review on 10/11/23 of Resident #3's October 2023 Medication Administration Record (MAR) revealed the following physician's order: Metoprolol Tartrate Tablet 50 mg [milligrams], Give 1 tablet by mouth two times a day for Hypertension/Heart failure, Hold if SBP [Systolic Blood Pressure] is less than 110 or HR [Heart Rate] less than 55, start date 10/3/23. Further review of Resident #3's October 2023 MAR revealed that on 10/9/23 Resident #3's SBP was documented as 113 and HR was documented as 56. The MAR indicated that on 10/9/23 the Metoprolol was not administered for vital signs outside of they parameter of the physician's order. Interview on 10/12/23 at approximately 10:40 a.m. with Staff E (Director of Nursing) confirmed that the vital signs were not outside of the medication parameters and should have been administered as ordered by the physician. Resident #13 Observation on 10/12/23 at approximately 8:10 a.m. of Resident #13's medication administration with Staff C (Medication Nursing Assistant) revealed that Staff C was going to administer Resident #13 Senna 8.6 mg. Review on 10/12/23 at approximately 8:10 a.m. of Resident #13's October 2023 MARs revealed the following order: Sennosides 8.6 mg - docusate sodium 50 mg tablet, 1 oral, start date 1/5/23. Interview on 10/12/23 at approximately 8:10 a.m. with Staff C confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary care to ensure that a resident's ability to hear was maintained with a communication device for 1 of 1 resident reviewed for communication in a final sample of 12 residents (Resident Identifier is #18). Findings include: Resident #18 Interview on 10/11/23 at 10:00 a.m. with Resident #18 revealed that his/her hearing was poor. Resident #18 was having a difficult time hearing the questions asked therefore an interview was not conducted. Observation on 10/11/23 at 10:02 a.m. revealed that Resident #18 did not have a hearing aid in either ear. Interview on 10/11/23 at 10:05 a.m. with Staff C (Medication Nursing Assistant) revealed that Resident #18 wears a hearing aid and that Resident #18's hearing aid was in. Interview on 10/11/23 at 11:30 a.m. with Resident #18's family member revealed that Resident #18's hearing aids were not always in. Resident #18's family member was not aware of who was responsible for helping Resident #18 with putting them in his/her ears or if Resident #18 would be able to put them in himself/herself. Interview on 10/11/23 at 11:32 a.m. with Staff A (Licensed Practical Nurse) confirmed that Resident #18's hearing aid was not in either ear. Observation on 10/11/23 at 11:35 a.m. revealed Resident #18's hearing aid case on his/her bedside table. Resident #18 was not able to put the hearing aids on himself/herself. Observation further revealed Staff A put the hearing aids in Resident #18's ears. Review on 10/12/23 of Resident #18's care plan, Treatment Administration Record and task section in the electronic medical record revealed no documentation of Resident #18's need for a hearing aid. Observation on 10/12/23 at 9:45 a.m. revealed that Resident #18 did not have a hearing aid in either ear while Resident #18 was sitting in his/her chair, dressed, and eating breakfast. Interview on 10/12/23 at 9:47 a.m. with Staff F (Licensed Nursing Assistant) revealed that Staff F was assigned to Resident #18's care for the day. Interview further revealed that Staff F was not aware that Resident #18 wore a hearing aid. Interview further revealed that Staff F follows the tasks section in the electronic medical record to indicate what Resident #18's care needs would be.

Based on observation, interview, and record review it was determined that the facility failed to ensure that medications were labeled and stored appropriately for 1 of 1 medication carts observed. Findings include: Birch Unit Observation on 10/11/23 at 8:36 a.m. of the Birch Unit medication cart revealed a medication cup with 7 white oval pills that were not labeled in the top drawer. Interview on 10/11/23 at 8:36 a.m. with Staff G ( Licensed Practical Nurse) confirmed the above pills were not labeled. Staff G stated medication was acidophilus and that the pill bottle was in the refrigerator. Review on 10/12/23 of a printed paper provided by the facility on 10/12/23 revealed that three residents receive the above medication on the Birch Unit. Review on 10/12/23 of the facilitys policy titled Medication storage/Storage of Medication dated 01/21 revealed, .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations . 1. Medications are to remain in these containers and stored in a controlled environment . 43002

Based on observation, record review, and interview, the facility failed to ensure that physician orders were accurately transferred from the previous Electronic Health Record (EHR) to the current EHR for 2 out of 27 medications reviewed during medication administration (Resident Identifiers are #9 and #7). Findings include: Resident #9 Review on 10/12/23 of Resident #9's October 2023 Medication Administration Record (MAR), found in the previous EHR revealed the following physician's order for medication administration: Esomeprazole magnesium 20 mg [milligram] capsule delayed release, give 1 capsule by mouth one time a day for GERD [Gastroesophageal Reflux Disease], start date 10/3/23. Review on 10/12/23 of Resident #9's physician's orders in the current EHR revealed the following order: Esomeprazole magnesium 40 mg capsule delayed release, give 1 capsule by mouth one time a day for GERD, start date 5/9/23. Interview on 10/12/23 at approximately 7:20 a.m. with Staff D (Licensed Practical Nurse) confirmed that the correct dosage of the medication did not transfer accurately from the previous EHR to the current EHR. Resident #7 Review on 10/12/23 of Resident #7's October 2023's MAR in the previous EHR revealed the following physician's order for medication administration: Citalopram Hydrobromide tablet 10 mg, give 1 tablet by mouth one time a day for depression, start date 10/5/23. Review on 10/12/23 of Resident #7's physician orders in the current EHR revealed the following order: Citalopram Hydrobromide tablet 20 mg., give 1 tablet by mouth one time a day for depression, start date 4/20/22. Interview on 10/12/23 at approximately 7:40 a.m. with Staff D confirmed that the correct dosage of the medication did not transfer accurately from the previous EHR to the current EHR.

Based on observation, interview and policy review, it was determined that the facility failed to store expired medication and label medications in accordance with currently acceptable professional standards for 1 of 1 medication carts (Birch Unit) and 1 of 2 medication storage room (Treatment Supply Room) observed. (Resident identifiers are: #13 and #30) Findings include: Birch Unit medication cart Observation on 11/16/21 at 12:15 p.m. of Birch Unit Medication cart with Staff C (Licensed Practical Nurse (LPN)) revealed an open bag of Resident #30's [MEDICATION(S)] (bronchodilator) 2.5 mg/ml (milligrams/milliliters) with expiration date of 3-2021, an unopened plastic bag of Resident #13's duo-nebs (bronchodilator) total of 90 ml's total with an expiration date of 9/2021. Interview on 11/16/21 at approximately 12:15 p.m. with Staff C confirmed the above expired medications. Staff C stated that expired or discontinued medications should be removed from the medication cart and placed in the medication room. Treatment Supply Room Observation on 11/16/21 at 12:40 p.m. of the Treatment Supply Room with Staff D (LPN) revealed the following: 1. 1 open package of medi-honey with a manufacture expiration date of 9/11/21 and no resident identifier stored with unexpired medications. 2. 1 opened tube of [MEDICATION(S)] ointment (steroid) 1% with no pharmacy label and no resident identifier stored in the treatment cart. 3. 2 opened bottles of ny-stop topical powder (anti-fungal) 100,000 units with no pharmacy label and no resident identifier stored in the treatment cart. 4. 1 tube of opened [MEDICATION(S)] rub (arthritic [MEDICATION(S)] cream) with aloe 3 oz (ounce) with a resident identifier located in the cabinet with the unopened and sealed over the counter medications. Interview on 11/16/21 at approximately 12:45 p.m. with Staff D confirmed the above findings of the treatment supply room. Staff D stated that the expired medi-honey should have been discarded and not left in the treatment cart. Staff D also stated that the [MEDICATION(S)] ointment and ny-stop powder came from the pharmacy and should have had a pharmacy label and resident identifier. Staff D also stated that the open [MEDICATION(S)] should not have been stored in the closet with the unopened over the counter medications. Staff D stated that the [MEDICATION(S)] cream belong to a resident that had expired and Staff D was unable to identify who the ny-stop belong to. Review on 11/17/21 at approximately 11:00 a.m. of the facility policy for Medication Storage dated 01/21 revealed that .14. Outdated, contaminated, discontinued or deteriorated medication and those in containers that are cracked, soiled or without secure closure are immediately removed from stock, disposed of according to procedures for medication disposal Review on 11/17/21 at approximately 11:15 a.m. of the facility policy Disposal of Medications, Syringes and Needles, Discontinued Medications dated 10/07 revealed .2. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy staff Review on 11/17/21 at approximately 11:30 a.m. of the facility policy Medications and Medication Labels dated 05/16 revealed that .5. Non-prescription medications not labeled by the pharmacy are kept in the manufactures's original container. Nursing care center personnel may write the resident's name on the container or label as long as the required information is not covered if applicable by state regulations .6. Medication labels are not altered, modified, or marked in any way by nursing personal. Contents are not transferred from one container to another .10. Floor stock medications kept in the original manufacturer's container must have the expiration date and lot numbers clearly evident Review on 11/17/21 at approximately 11:40 of the facility policy Medication Administration dated 01/21 revealed that .17. The medication cart is kept closed and locked when out of sight of the medication nurse. No medications The cart must be clearly visible to the personnel administering medications when unlocked

Based on observation, interview and record review, it was determined that the facility failed to ensure that food was stored in accordance to professional standards for food safety related to food refrigeration for 1 out of 2 unit kitchenettes observed (Nurse's kitchenette). Findings include: Observation on 11/16/21 at approximately 10:30 a.m. at the nurse's kitchenette located in the activity room revealed that the unit refrigerator had 2 thermometers that registered temperatures of 48 degrees Fahrenheit (°F). Observation also revealed that the refrigerator had food brought in by family that contained meat and vegetables. Observation also revealed milk products such as milk and yogurts, juices and sodas in the refrigerator. Review on 11/16/21 of the facility's refrigerator temperature log for the nurse's kitchenette revealed the following temperatures: 11/2/21 45 °F 11/3/21 45 °F 11/4/21 no temperature documented 11/5/21 no temperature documented 11/6/21 45 °F 11/7/21 44 °F 11/8/21 no temperature documented 11/10/21 45 °F 11/11/21 46 °F, rechecked by staff on 11/11/21 11/12/21 45 °F 11/13/21 42 °F 11/15/21 no temperature documented Further review revealed that refrigerator temperatures should be between 34-39 °F. If the refrigerator temperature is above 42 °F, wait 1 hour and recheck temperature. if still high notify food service director, maintenance director or shift cook. Review also revealed no documented follow up for the above mentioned temperatures. Interview on 11/16/21 at approximately 10:30 a.m. with Staff A (Occupational Therapist, Registered) confirmed the above findings. Review on 11/17/21 of facility's policy on Use and Storage of Food and Beverage Brought in for Residents, with revision date of 1/11/18, revealed .Refrigeration: a. potential cuase of foodborne illness is improper storage of PHF/TCF [Potentially Hazardous Food/Time/Temperature Control for Safety Food] food. Refrigerators must be in good repair and keep foods at or below 41degrees Fahrenheit If temperatures are out of range, notify maintenance and follow facility policy for food disposal Interview on 11/17/21 at approximately 3:30 p.m. with Staff B (Administrator) revealed that Staff B was unable to provide documentation of any follow up for the above mentioned temperatures in the refrigerator temperature log. Interview with Staff B also revealed that refirgerator temperatures should be below 40 °F. Review on 11/17/21 of facility's policy on Use and Storage of Food and Beverage Brought in for Residents, with revision date of 1/11/18, revealed .Refrigeration: a. potential cuase of foodborne illness is improper storage of PHF/TCF [Potentially Hazardous Food/Time/Temperature Control for Safety Food] food. Refrigerators must be in good repair and keep foods at or below 41degrees Fahrenheit If temperatures are out of range, notify maintenance and follow facility policy for food disposal Review on 11/10/21 of the FDA (Food and Drug Administration) Food Code, dated 2017, page 92, revealed that 3-501.12 Time/Temperature Control for Safety Food .(A) Under refrigeration that maintains the FOOD temperature at 5°C (41°F) or less

Based on observation, interview and record review, it was determined that the facility failed to ensure proper storage and labeling in accordance with currently accepted professional principles for 1 out of 2 medication cart observed and 1 out of 1 treatment supply room observed. (Resident identifier is #39.) Findings include: Observation on 10/15/20 at approximately 8:57 a.m. with Staff A (Acting Director of Nursing) in the treatment supply room revealed 2 opened xeroform gauze dressing package with no open date that were stored, in between the unopened gauze packages on top of the treatment cart. Interview on 10/15/20 at approximately 9:00 a.m. with Staff A confirmed the above findings. Staff A stated that they don't have a specific policy on proper storage of dressing supply. Staff A also stated that they would use the manufacturer's instruction. Staff A stated that the supplies in the treatment supply room are ready for use. Interview on 10/15/20 at approximately 9:00 a.m. with Staff B (Unit Manager) revealed that Staff B stated that the xeroform gauze dressing are single use and should have been discarded after use. Staff B also stated that the opened xeroform packages should have been stored in a clean Ziploc bag and labeled with an open date. Review on 10/15/20 of the the xeroform gauze package revealed a label/symbol for single use/do not reuse. Observation on 10/15/20 at approximately 9:45 a.m. with Staff C (Medication Nursing Assistant) in the Birch unit medication cart revealed a OTC (Over the Counter) Acidophilus ([MEDICATION NAME]) 500 million cells per capsule bottle with an open date of 10/3/20 in the medication cart. Review on 10/15/20 of the OTC Acidophilus bottle revealed a storage instruction to refrigerate after opening to maximize potency. Interview on 10/15/20 at approximately 9:45 a.m. revealed that Staff C confirmed the above findings related to the OTC Acidophilus. Review on 10/15/20 of Resident#39's Electronic Medication Administration Record [REDACTED]. Further review of Resident t #39's October 2020 EMAR revealed that Resident #39 received acidophilus on 10/3 to 15/20. Interview on 10/15/20 at approximately 11:00 a.m. with Staff B confirmed above findings on Resident #39's October 2020 EMAR.

Based on interview, medical record review, and policy review it was determined that the facility failed to meet professional standards regarding following physician orders for 1 resident out of a final sample size of 14 residents. (Resident identifier is #2.) Findings include: Patricia 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 699 Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 708 The prescriber often gives specific instructions about when to administer a medication Page 713 .A registered nurse compares the list of medications on the MAR indicated [REDACTED].After administering a medication, record it immediately on the appropriate record form .Recording immediately after administration prevents errors .If a client refuses a medication or is undergoing tests or procedures that result in a missed dose, explain the reason the medication was not given in the nurses' notes. Review on 10/15/20 of Resident #2's physician orders revealed that Resident #2 had an order dated 10/6/20 for Duo Derm every three days starting 10/6/20. Apply Duo Derm dressing to coccyx area every 3 days and PRN (as needed). Review on 10/15/20 of Resident #2's nursing progress note dated 10/10/20 revealed a progress note written by Staff D (Licensed Practical Nurse) that stated Duoderm dressing appears to be causing some irritation due to need to be changed often. [MEDICATION NAME] and melisob dressing applied pending review on wound rounds. Review on 10/15/20 of Resident #2's nursing progress note dated 10/11/20 revealed a progress note written by Staff E (Registered Nurse) that stated [MEDICATION NAME] and Melgisob dressing removed from coccyx, small amount of serous drainage was noted on the dressing. Site was cleansed and [MEDICATION NAME] Touich was applied with [MEDICATION NAME] 4x4 on top of it. Interivew on 10/15/20 at 12:11 p.m. with Staff B (Unit Manager) confirmed that there was no physician order to use [MEDICATION NAME] and Melgisob.

Based on observation, interview and record review, it was determined that the facility failed to maintain resident care equipment, a Coaguchek XS meter (fingerstick device), according to manufacturer's guidelines during medication storage observation. (Resident identifiers are #15 and #31.) Findings include: Review on 10/15/20 of the Coaguchek XS meter manual, page 23, revealed that .8 Clean up if the meter is dirty wipe it with the recommended meter (page 23) .clean/disinfect the exterior (page 34) Review on 10/15/20 of the FDA (Food Drug Administration) website titled, Blood Lancet Labeling - Guidance for Industry and Food and Drug Administration Staff, dated November 2010, revealed that .Blood lancet devices designed for multiple use also should provide manufacturer-validated user instructions for the cleaning and the disinfection of the reusable lancet device base after every use by the individual patient Observation on 10/15/20 at approximately 8:57 a.m. in the treatment supply room with Staff A (Acting Director of Nursing) revealed that the Coaguchek XS meter had a yellow film at the back of the meter and a dry dark reddish brown substance, consistent with blood, at the front and right side of the meter. Interview on 10/15/20 at approximately 9:00 a.m. with Staff A confirmed that there was a yellow film at the back of the meter and a dry dark reddish brown substance on the front and right side of the meter. Interview on 10/15/20 at 9:12 a.m. with Staff B (Unit Manager) revealed that Staff B stated that the Coaguchek XS meter is a meter that is shared among residents when there is a physician order [REDACTED]. Staff B also stated that as a meter shared among residents the meter should be cleaned/disinfect with bleach after each use. Staff B also stated that the last time they use the Coaguchek XS meter was on 10/12/20 for Resident #15 and Resident #31. Observation on 10/15/0 at approximately 9:12 a.m. with Staff B revealed that once the meter was wiped down by an EPA-approved bleached wipe the yellow film and the dry dark reddish brown substance, consistent with blood, was not visible on the meter. Review on 10/15/20 of Resident #15's Electronic Treatment Administration record revealed a physician order [REDACTED]. Review on 10/15/20 of Resident #31's Electronic Treatment Administration record revealed a physician order [REDACTED].

Based on record review and interview, it was determined that the facility failed to implement an appropriate plan of action, education, for an error that occurred with accuracy of and confidentiality of resident medical information for 2 residents in a final survey sample of 11 residents. (Resident identifiers are #1 and #2.) Findings include: Review on 7/3/19 of the facility report, titled .Final Report Wrong Paperwork . dated 5/21/19 revealed that on 5/17/19, Resident #1, .who is a full code, was sent to the emergency room for evaluation. The Advance Directive paperwork sent with (Resident #1) was the DNR (Do Not Resuscitate) form of . roommate (Resident #2) . Review on 7/3/19 of the facility report, titled .Final Report Wrong Paperwork . dated 5/21/19 revealed that the plan was .There will be education for all nurses to remind them to always take the time to check if the paperwork they gather is for the correct resident . Review on 7/3/19 of the packet of information that the facility sent to Resident #1's daughter, on 6/20/19, regarding the error also included the statement that .There will be education for all nurses to remind them to always take the time to check if the paperwork they gather is for the correct resident . Review on 7/3/19 of the copies of the letters written by the facility administrator, dated 7/3/19, to Resident #2 and their DPOA (Durable Power of Attorney) revealed that .In response to the incident, we reviewed our process for protecting your personal information and will provide mandatory education to our staff to prevent this from happening again . Review on 7/3/19 of the facility list of licensed nurse who currently work at the facility revealed that there were 13 nurses. Review on 7/3/19 of the Inservice Sign In Sheet, with the topic of Transfer/D/C (discharge) sheets, double check that legal forms are accurate/correct . dated 5/20/19, revealed that of the 13 nurses listed, only 4 of them had signed the attendance sheet. Interview on 7/3/19 at approximately 1:00 p.m. with Staff A (Administrator) confirmed that only 4 of the 13 nurses had received education after the incident with Resident #1 and Resident #2. Staff A also confirmed that they had planned to send the letters that they had written to Resident #2 and their DPOA out on 7/3/19.

Based on record review, observation, and interview, it was determined that the facility failed to clarify physician orders [REDACTED]. (Resident identifiers are #14 and #44.) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates 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 A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the client suffers Resident #14 Observation during tour of the Birch Lane unit on 2/14/19 at about 10:56 a.m. revealed no oxygen sign on doorway to Resident #14's room, and there is an oxygen concentrator located in Resident #14's portion of the room. Interview on 2/14/19 at about 10:56 a.m. with Resident #14 revealed the Resident #14 uses an oxygen concentrator sometimes when they wash him/her up at night, not every night. Observation on 2/15/19 at about 9:05 a.m. revealed there is now an oxygen in use sign on the doorway to Resident #14's room. Review on 2/15/19 at approximately 9:44 a.m. of the physician orders [REDACTED].#14 has two active orders for oxygen, one for oxygen at 1 L/min (one liter per minute) per nc (nasal cannula), and another for same flow rate except as PRN (as needed) 3x/wk (three times per week), both orders are dated 9/23/18. Interview on 2/15/19 at about 11:50 a.m. with Staff C (Registered Nurse) confirmed that Resident #14 has 2 orders for oxygen; upon her record review, and Staff C related she put both orders in and she could discontinue the continuous oxygen order as Resident #14 uses it only prn and not every day, maybe a couple times a week. Resident #44 Observation on 2/14/19 at about 10:00 a.m. during tour of the Birch Lane unit revealed that there was an oxygen concentrator in Resident #44's room. There was no roommate residing in this room. The oxygen tubing on the concentrator was dated 2/8/19 (indicating a recent tubing change), and there was no oxygen in use signage on the doorway to the room. Interview on 2/14/19 at about 10:18 a.m. with Staff A (Licensed Medication Nursing Assistant) revealed that Resident #44 uses the oxygen (O2) concentrator sometimes, and he should probably have an oxygen sign on the door. Review on 2/14/19 of Resident 44's current CHAT Biography care plan reveals it relates . provide supplemental O2 if .(Resident #44's) O2 sat (saturation) is critically low with symptoms, . Observation on 2/15/19 at about 9:05 am. of Resident #44's room revealed there was now an oxygen in use sign on the doorway to the room. Interview on 2/15/19 at about 11:46 a.m. with Staff B (Licensed Nursing Assistant) revealed the resident has been using prn O2 for a couple months. Review on 2/15/19 of Resident #44's physician orders [REDACTED]. Interview on 2/15/19 at about 12:04 p.m. with Staff D (Licensed Nursing Assistant) revealed Resident #44 used oxygen after he came back from the hospital but he was not now using oxygen on days. Interview with Staff C revealed Resident #44 was in the hospital 1/10-1/14/19 [MEDICAL CONDITION] and URI (upper respiratory infection), and his O2 sats on room air have been good since return from hospital; Staff C related Resident #44 had a discharge order for oxygen from the hospital but Staff C does not see in nurses notes that Resident #44 has used oxygen since returning to the facility on on 1/14/19, and Staff C related she can't find an order in this facility's records for oxygen use in facility after return from hospital. Further interview on 2/15/19 at about 2 p.m. with Staff C revealed Staff C checked (e.g., with Staff B) if Resident #44 used any O2 since return from the hospital and he/she did not, so Staff C related the O2 concentrator and O2 sign were removed from room.

Based on record review and interview, the facility failed to ensure that the MDS (Minimum Data Set) Assessment was accurate for 2 residents in a sample survey of 14 residents. (Resident identifiers are #18 and #25.) Findings include: Resident #25 Review on 12/6/17 of Resident #25's Annual MDS Assessment with ARD (Assessment Reference Date) of 10/19/17, revealed that under Section O0400. (Therapies) that Resident #25 had received 50 minutes of group therapies, as stated in #3 (Group minutes), in the last 7 days; but under O0420 (Distinct Calendar Days of Therapy), the number 0 was listed correctly for the last 7 days (need at least 15 minutes to code as a day). Review on 12/6/17 of Resident #25's Quarterly MDS Assessment with ARD of 5/2/17, revealed that under Section O0400. (Therapies) that Resident #25 had received 50 minutes of group therapies, as stated in #3 (Group minutes), in the last 7 days; but under O0420 (Distinct Calendar Days of Therapy), the number 0 was listed correctly for the last 7 days. Interview on 12/6/17 at 10:16 a.m. with Staff A (MDS Coordinator) confirmed that the information in Section O0400 was incorrect on both the annual and quarterly MDS's and that the information Section O0400 was pulled forward from the previous MDS and Resident #25 did not have any group therapy during these two time periods. Interview on 12/6/17 at 10:16 a.m. with Staff B (Director of Therapy) also confirmed that Resident #25 was not in group therapy during these two time frames. Resident #18 Interview on 12/04/17 at 10:41 a.m. with Resident #18 revealed the following statement: . my teeth are falling out of my head and some of them are broken .sometimes staff help me brush them, but rarely . the dentist comes around about every 6 months to check teeth. A strong pungent odor was perceived on Resident #18's breath at the time of the interview. Review on 12/6/17 at approximately 10:00 a.m., of all available dental notes which ranged from 8/10/15 to 7/18/16, stated that the resident has had some broken teeth. Review of section L Oral/Dental Status on MDS (Minimum Data Set) assessment dated [DATE] has section Z: None of the above were present selected, where section D: Obvious or likely cavity or broken natural teeth should have been selected during the assessment to reflect the correct status of the Resident #18's teeth. Interview on 12/6/17 with Staff A (MDS Coordinator) revealed that item D was the proper assessment status for Resident #18.

Based on observation and interview, it was determined that the facility failed to prepare food under sanitary conditions. Findings include: Observation during the initial tour of the kitchen on 12/19/16 at approximately 9:00 a.m. with Staff A (Director of Food Services) and Staff B (Dietary Aid/Prep Cook) revealed that the food preparation area staff were not wearing either a hair net or other acceptable type of hair covering to prevent the hair from contacting exposed food. Interview at time of observation with Staff A (Food Service Director) confirmed the above finding.

Based on medical record review and interview it was determined that the facility failed to establish a coordinated hospice plan of care which included identifying the care and services the facility and individual hospice would provide in order to be responsive to the unique needs of the resident and failed to ensure that the facility and the individual hospice are aware of the other's responsibilities in implementing the individualized plan of care for 1 hospice resident in a survey sample of 12. (Resident identifier is #6.) Findings include: Review of medical records on 11/23/15 for Resident #6 revealed that the facility and the individual hospice agency failed to establish a coordinated plan of care for Resident #6 that detailed a description of the scope and frequency of physician ordered services provided by the individual hospice agency for frequency of the skilled nurse, licensed nursing aide, social worker, spiritual and volunteer hospice staff providing services to these residents. Review of Resident #6's medical record revealed incomplete documentation of a collaborated plan of care with assessments, measurable goals and interventions for the individual disciplines listed above and the delineation of the palliative and supportive care that is to be provided and a determination of the disciplines at the facility and/or the hospice agency who will provide these services. Interview on 11/24/15 at 8:30 a.m. with Staff A (Administrator) and Staff B (DON) reviewed Resident #6's hospice plan of care and confirmed that although the facility and hospice agency meet regularly to coordinator care, the plan of care needed to be individualized and needed to be integrated between the hospice provider and facility explaining what each provider is responsible for doing for each hospice resident.

Based on record review and interview, it was determined that the facility failed to ensure that the care plan section of the medical record was complete for 1 resident in a survey sample of 12. (Resident identifier is #11.) Findings include: Resident #11 Review of Resident 11's care plan section of the medical record on 11/24/15 revealed that it did not include a complete description or interventions to support a comprehensive approach to managing the pain regime for this resident based on diagnosis. Interview on 11/24/15 with Staff C (ADON) confirmed the above findings.

Based on observation and interview it was determined that the facility failed to ensure that the laundry room, which contained chemicals, door was locked when staff were not present. Findings include: Information regarding the facility's laundry room was received from Resident #1's family member concerning the door to that room being left open on multiple occasions when Resident #1's family member would come visit Resident #1 at the facility. On 5/7/15 at approximately 9:42 a.m. Staff B (RN, Day Charge Nurse) when asked when the laundry room door was locked and replied: "The laundry room door is locked only when staff are out of the room." Observation on 5/7/15 at 9:45 a.m. with Staff B of the laundry room area, off of the foyer, revealed the right door, labeled soiled linen, was locked. The laundry room door, on the left, was unlocked and open. No staff were present as we walked into the laundry room area. An orange 50 ounce plastic bottle of laundry detergent, with approximately 25% to 33% of product remaining, was observed to be sitting on a plastic cabinet to the left of the washing machine in the soiled linen room. It is further noted that the door between the soiled linen room and the laundry room was also unlocked. Interview on 5/7/15 with Staff A (Administrator) reviewed the above information. Staff A confirmed that the laundry room door should be locked when staff are not present and that Staff A would follow up on this to ensure that this was done.

Based on observation and interview it was determined that the facility failed to provide a safe environment that is free of avoidable hazards for 1 of 2 kitchenettes. Findings include: Observation made during tour of the stove burners of the Lakeview kitchenette on 12/10/13 at approximately 9:45 a.m. with Staff A (Director of Food Services) revealed that the surface burner knobs were able to be turned on. During the observation, the door to the dining room was open and there were not any staff present when the surveyor and Staff A entered the room. During interview with Staff A, Staff A stated that the dining room is open to residents and families and Staff A stated Staff A was not aware of a lock out for the stove burners. Observation of the same stove in the Lakeview dining room on 12/11/13 from 8:55 a.m. through 9:50 a.m. revealed the door was open and the same stove surface burner knobs were able to be turned on to a high temperature. There were not any staff in attendance during this period of observation. During this observation period, Resident #5 entered the room unattended. Resident #5's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/15/13 reveals Resident #5's Care Area Section V 02. Cognitive Loss/Dementia is triggered and Resident #5 has a BIMS (Brief Interview for Mental Status) C0500 score of 5 out of 15. During interview with Staff B (Administrator) on 12/11/13 at approximately 10:07 a.m., Staff B confirmed the burners were able to be turned on to the high position. Staff B confirmed the stove surface burner knobs did have a key lock out and the facility did not lock out the stove to prevent unsupervised usage after the last use.

Based on record review and interview the facility failed to notify the physician for clarification of a pain medication for 1 of 13 residents in a standard survey sample and on a change of condition for 2 of 13 residents in a standard survey sample. (Resident identifiers are #1 and #7.) Findings include: Resident #7. Record review on 12/11/13 revealed a Non-pressure ulcer skin condition report sheet with a date of 10/18/13 noting a 6.5 centimeter "superficial break in skin...draining small amount serosanguinous drainage. Tender to touch." Review of the physician's orders [REDACTED]. Interview with Staff C (DON) and Staff D (Unit manager) on 12/12/13 confirmed the above findings. Staff C stated that the finding on 10/18/13 was placed in the Physician's communication book but that there was no documented evidence that the Physician was aware of this open area until 10/31/13. Resident #1 Medical record review for Resident #1 was conducted from 12/10/13 through 12/12/13. This resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MAR for November 1-30, 2013 reveals a q shift (every shift) screening for pain that documents 7 reports by the resident of 7-10 (severe) pain, 11 reports by the resident of 4-6 (moderate) pain and 3 reports by the resident of 1-3 (mild) pain. Further review of this same MAR indicated [REDACTED] - [MEDICATION NAME] 200 mg po BID (milligrams by mouth two times a day) for [DIAGNOSES REDACTED]. - [MEDICATION NAME] 5 mg tablet (for [MEDICATION NAME] 5 mg tablet) - 1 tablet orally at bedtime for a [DIAGNOSES REDACTED]. - [MEDICATION NAME] 25 mcg/hr (micrograms per hour) patch - Apply 1 patch every 72 hours for [DIAGNOSES REDACTED]. - [MEDICATION NAME] HCL 50 mg tablet (for [MEDICATION NAME] 50 mg tablet) - 2 tabs (100 mg) by mouth three times a day for [DIAGNOSES REDACTED]. In addition the following as needed medications were being given to Resident #1 for any additional reports of pain: - [MEDICATION NAME] 2 mg tablet (for [MEDICATION NAME] 2 mg tablet) 1 tablet orally three times a day as needed for severe pain. - Tylenol 325 mg tablet - 2 tabs orally every 4 hours as needed for mild pain (650 mg) maximum 3-4 grams check daily total. - It is noted there is no pain medication ordered for moderate pain of 4 - 6. The physician was not notified for clarification. Resident #1 had a fall during an activity on 11/29/13 as documented in the nursing notes and facility incident report for this fall and was sent to the emergency room for evaluation. She was found to have a minimally displaced [MEDICAL CONDITION] greater trocanter which did not require surgical intervention. Resident #1 returned to the facility on [DATE]. Review of the facility pain assessment dated [DATE] for Resident #1 reveals under "Pain Assessment" that the resident had the following [DIAGNOSES REDACTED]. An acceptable level of pain for Resident #1 is described as a 3-4 and it is the documented plan that "Intervention occurs above this level." But as noted there is no prn medication ordered by the physician for moderate pain of 4 - 6. Review of nursing notes reveals a note dated 12/10/13 at 11:15 pm which reads "... Continues to complain of severe back, leg, neck, shoulder pain 8/10 - medicated with [MEDICATION NAME] 2 mg po at 10:15 pm (Pharmacy late delivery). Effect pending, ... " During an interview on 12/11/13 with Staff G, the nurse who wrote that nursing note on 12/10/13 at 11:15 pm, Staff G stated she noted in the afternoon that this resident was out of one of the pain medications on 12/10/13, so she called the physician to order more from the pharmacy. The physician called the order in to the pharmacy in the afternoon of 12/10/13 but the pharmacy did not deliver the requested medication to the facility until about 9:30 pm on 12/10/13. Staff G did not get an order from the physician of what medications were to be used on a prn basis if Resident #1 had pain prior to the delivery of the medication. Staff G did not write a nursing note on 12/10/13 at the time regarding the residents pain screening/monitoring conducted during the time the pain medication was noted to need refilling but stated to the State surveyor on 12/11/13 during interview that Resident #1 attended activities during the afternoon and was not in pain until later in the evening as documented in the nursing note. Further review of the medical record for Resident #1 reveals there was no documented evidence on the MAR indicated [REDACTED].

Based on record review, staff interview and review of the facility policy and procedure the facility staff did not report an incident of missing pain medication and the facility did not investigate or report the incident for 1 of 13 residents in a standard survey sample. (Resident identifier is #1.) Findings include: Policy and Procedure Review of facility policy and procedure entitled "Abuse Prevention and Reporting" with a revision date of 4/28/11 reveals on page 1 under Requirements - " 3) All alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately after the incident is discovered or observed by the employee to the employee's supervisor on duty. The supervisor on duty has the responsibility to report same immediately to the facility Administrator (or designee). 4) Initial Report - The administrator or designee will report alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property to the Ombudsman's Office immediately. Note: Immediate notification to the Ombudsman means as soon as possible but not to exceed 24 hours after the incident is discovered. 5) All alleged violations will be thoroughly investigated, ... ." Resident #1 Review of the medical record for Resident #1 on 12/10/13 through 12/12/13 revealed a nursing note dated 12/5/13 that indicated this resident's [MEDICATION NAME] was not found on the resident by the nurse. Initial review of the admission nursing assessment form completed on 12/4/13 upon return from the hospital did not reveal the nurse noted the patch on Resident #1 but a late note written on 12/11/13 by Staff E (RN) indicates the patch was observed on the left back of Resident #1 at the time of admission on 12/4/13. During an interview with Staff C (DON) on 12/11/13 regarding Resident #1's [MEDICATION NAME] which went missing on 12/5/13, Staff C stated Resident #1 had a [MEDICATION NAME] on when admitted and it went missing as noted in the nursing note of 12/5/13 but the missing patch was not reported to supervisory staff by the facility nurse who observed the patch missing. Staff C stated because the missing patch was not reported, it was not investigated or reported by the facility to the State per facility policy.

Based on record review and interview the facility failed to ensure that the physician reviewed the resident's total program of care including medications and treatments, and signed and dated all orders at each visit for 1 in sample resident and 1 out of sample resident in a survey sample of 13 residents. (Resident identifiers are #6 and #14.) Findings include: Resident #6. Review on 12/11/13 of the Physicians order sheets from June through December 2013 revealed that the Physician orders, including the recertification for 60 day ICF visits revealed that the Physician reviewed the orders on 6/10/13 and then again on 10/7/13 a period of 119 days. Review of the progress notes, for the above time frame, revealed no documented evidence that the physician reviewed the total program of care including medications and treatments. In an interview with Staff D (Unit Manager) on 12/11/13 in the afternoon Staff D was surprised that her system of notifying the physicians of the need to come in and review the record had failed. Staff D stated that there was no other documentation that indicated the physician had reviewed the orders, confirming the above findings. In an interview with Staff C (DON) on 12/12/13 in the morning Staff C stated that there were no other signed order sheets or documentation that the physician reviewed the record of Resident #6. Resident #14. Review on 12/11/13 of the Physicians order sheets from September through December 2013, while reconciling the medications from the medication pass observation, revealed that the Physician orders, including the recertification for 60 day ICF visits revealed that the Physician reviewed the orders on 9/3/13 and not again including 12/11/13 a period of 99 days. Review of the progress notes, for the above time frame, revealed no documented evidence that the physician reviewed the total program of care including medications and treatments. In an interview with Staff C (DON) on 12/11/13 in the afternoon Staff C stated there were no other signed order sheets or documentation that the physician reviewed the record confirming the above findings.