Every finding on record at Scotia Village - SNF

Based on observations and staff interviews, facility staff failed to implement infection control policy and procedures when Nurse Aide (NA) #1 and NA #2 did not don Protective Equipment (PPE) to include a gown when providing high-contact resident care activities for Resident #49 who had an indwelling medical device. Resident #49 had a lower back indwelling pleural catheter which was used for draining fluid from the pleural space (fluid filled space that surrounds the lungs) to help with breathing. The deficient practice was identified for 2 of 2 staff members reviewed for infection control practices (NA #1 and NA #2). The findings included: Review of the facility's the facility's Enhanced Barrier Precautions (EBP) signage for long term care facilities (LTCF) dated 07/26/22 read: All residents with any of the following: Wounds (skin opening that requires a dressing) and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of multi-drug-resistant-organism (MDRO) colonization status. All healthcare personnel must: wear gloves and gowns for the following high-contact resident care activities: Handling linen, transferring resident, and changing linen. During an observation on 11/06/24 at 11:25 AM a sign was posted by Resident #49's room door that read in part: Enhanced barrier precautions, and providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, device care or use of a central line, urinary catheters, feeding tubes, and wound care. During an observation from the hall on 11/06/24 at 11:30 AM Nurse Aide (NA #2) and NA #1 were observed in Resident #49's room changing the bed linens. Resident #49 was sitting at the bedside in her recliner. Nurse Aide #2 and Nurse Aide #1 had on gloves when changing the bed linens but were not wearing gowns. A hanging door bin with PPE (personal protective equipment) supplies was on the door, including one time use disposable gowns. An interview was conducted on 11/06/24 at 11:30 AM with Nurse Aide #1 and #2. They stated they did not put on gowns when they transferred Resident #49 to the recliner or when they changed the bed linens. They both knew Resident #49 was on Enhanced Barrier Precautions and acknowledged that they should have worn a gown and gloves when providing direct care, such as the transfer, and should have also worn a gown and gloves when changing bed linens. An interview was conducted on 11/07/24 at 8:55 AM with NA #1. She revealed on 11/06/24 at 11:30 AM when she was helping transfer Resident #49 from bed to Recliner, she went to put on a gown with her gloves, when NA #2 stated she didn't need to don a gown, so she didn't. NA #1 said looking back, she and NA #2 should have worn gowns. An interview was conducted on 11/07/24 at 9:05 AM with NA #2. She revealed she changed Resident #49's bed linens and was aware that the donning gown and gloves were required during high contact resident care activities. She stated they just got in a hurry when transferring Resident #49 and changing her linen. An interview was conducted on 11/07/24 at 9:20 AM with the Director of Nursing (DON). She stated staff should wear the appropriate personal protective equipment PPE when providing direct care to residents on enhanced barrier precautions. She also stated regardless, all the staff knew to abide by the different types of precautions posted on the residents' door and to follow the assigned personal protective equipment (PPE). She stated education would be provided to NA #1 and NA #2.

Based on observations, record review and staff interviews the facility failed to accurately document the completion of a wound treatment in the treatment administration record (TAR) for 1 of 1 residents (Resident #4) observed for pressure ulcers. Findings included: Resident #4 was admitted to the facility on [DATE]. Diagnoses included, in part, pressure ulcer of sacral region. A review of the physician orders revealed an order written on 10/29/24 to cleanse sacral area with normal saline, apply silver collagen matrix (antimicrobial barrier to prevent infections) cut to fit wound, cover with an absorbent silicone (a dressing that absorbs drainage) daily. Review of the Treatment Administration Record (TAR) revealed the wound treatment for Resident #4 was signed off on the TAR as evidenced by a check mark with Nurse #2's initials on 11/05/24. A phone interview was conducted with Nurse #2 on 11/06/24 at 9:45 AM. Nurse #2 revealed she had changed the dressing on 11/04/24 and it was removed around 7:00 PM when Resident #4 got a bath and another dressing was reapplied after her bath on 11/04/24. Nurse #2 stated she did not change it on 11/05/24 since it was changed twice on 11/04/24. Nurse #2 stated she should not have signed off in the treatment administration record that she did the dressing change on 11/05/24 as that was inaccurate documentation. An interview was conducted with the Director of Nursing (DON) on 11/06/24 at 10:30 AM. The DON reported she expected her nursing staff to accurately document in the treatment administration record to reflect the care that was provided. The DON stated Nurse #2 should not have signed off on a treatment that she did not provide.

Based on observations, record review, and staff interviews the facility failed to perform daily wound care treatments on a sacral wound for 1 of 1 resident (Resident #4) observed for pressure ulcers. Findings included: Resident #4 was admitted to the facility on [DATE]. Diagnoses included, in part, pressure ulcer of sacral region and myoneural disorder (spinal compression with paralysis to lower extremities). The quarterly Minimum Data Set assessment dated [DATE] revealed resident was cognitively intact with no behaviors, had impairment on both sides to upper and lower extremities, utilzed a wheelchair for mobility, was always incontinent of bowel and bladder and was coded as having a pressure ulcer stage III. A review of Resident #4's care plan updated on 09/20/24 revealed a plan of care for actual impairment to skin integrity with pressure ulcer to sacrum. The goal was that the skin injury would improve by the next review date with interventions to include, in part, daily treatment to affected area to promote wound healing. A review of the physician orders revealed an order written on 10/29/24 to cleanse sacral area with normal saline, apply silver collagen matrix cut to fit wound, cover with an absorbent silicone dressing daily. Review of the weekly observation tool dated 10/29/24 revealed Resident #4 acquired a stage II pressure ulcer on 09/04/24 which had increased to a stage III pressure ulcer on 10/23/24. The overall impression indicated the wound was improving with epithelial tissue and granulation tissue present (healthy tissue). The assessment noted there was serosanguinous (bloody serum) draining with moderate amounts with no odor. The measurement of the wound was 1.5 centimeters (cm) X 0.7 cm X no depth. An observation of wound care was conducted on 11/06/24 at 9:30 AM with Nurse #1 and the Director of Nursing (DON). Resident #4 was informed that the two nurses were going to change her dressing to her sacrum. Resident #4 was turned to her left side. Nurse #1 proceeded to remove the existing dressing to Resident #4's sacrum which was dated 11/04/24. The wound was noted to be opened with small amount of bloody serum with redness surrounding the wound. Nurse #1 cleansed the pressure ulcer with wound cleanser, patted dry, and applied a small wound size piece of silver collagen to the wound and covered it with an absorbent silicone dressing. An interview with Nurse #1 on 11/06/24 at 9:40 AM was conducted. Nurse #1 was asked about the date on the dressing being 11/04/24. Nurse #1 stated she did not notice the date and proceeded to then remove the dressing from the trash bag. Nurse #1 read the date on the dressing and confirmed the date was 11/04/24. Nurse #1 did not know if the dressing was changed on 11/05/24 as ordered. A phone interview was conducted with Nurse #2 on 11/06/24 at 9:45 AM. Nurse #2 revealed she worked 12 hour shifts from 7:00 AM to 7:00 PM and she had changed the dressing on 11/04/24 and it was removed around 7:00 PM when Resident #4 got a bath and another dressing was reapplied after her bath on 11/04/24. Nurse #2 stated she did not change it on 11/05/24 since it was changed twice on 11/04/24. An interview was conducted with the Director of Nursing on 11/06/24 at 10:30 AM. The DON reported Resident #4's pressure ulcer was a stage II when it was identified on 09/04/24 and had recently increased to a stage III wound. The DON reported Resident #4 requests to get out of bed daily and sit up in her wheelchair for prolonged periods which she believed contributed to the wound worsening. She stated she would have expected Nurse #2 to follow the physician's order and change the dressing daily in order to aide in healing.

Based on observations, record review, staff, Consultant Pharmacist, and Physician interviews the facility failed to protect a residents right to be free from misappropriation of a residents controlled medication (Oxycodone/Acetaminophen ,d+[DATE] milligrams (mg) , Hydrocodone/Acetaminophen ,d+[DATE] mg, Tramadol 50 mg, and Alprazolam 0.5 mg) which was prescribed by the physician for pain and anxiety. This resulted in a total of 42 doses of the medications that were not administered to 8 of 8 residents (Resident #51, #41, #2, #3,#4, #7, #8, #9) reviewed for misappropriation of medications. Findings included. 1a.)Resident #51 was admitted to the facility on [DATE] with diagnoses including fractured vertebra and sacrum, and Arthritis. A physicians order dated [DATE] for Resident #51 revealed Oxycodone/Acetaminophen ,d+[DATE] mgs. Take one tablet every 8 hours as needed for pain. Review of Resident #51's Controlled Drug Record initiated [DATE] revealed Oxycodone/Acetaminophen ,d+[DATE] mgs was signed out of the narcotic count by Nurse #1 on ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Review of Resident #51's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on ,d+[DATE], ,d+[DATE], ,d+[DATE], or ,d+[DATE] that the Oxycodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #51. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #51. During an interview on [DATE] at 11:30 AM Resident #51 was observed sitting in a wheelchair in his room. He was alert and oriented. He stated he did not take any pain medication at this time. He stated he did not have complaints of pain and had never really had much pain. He stated he did not recall getting pain medication regularly or needing pain medication on a regular basis at any time since his admission to the facility. b.) Resident #41 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and depression. A physicians order dated [DATE] for Resident #41 revealed Alprazolam 0.5 mg. take one tablet by mouth as needed for anxiety. Review of Resident #41's Controlled Drug Record initiated [DATE] revealed Alprazolam 0.5 mg was signed out of the narcotic count by Nurse #1 on [DATE] and [DATE]. Review of Resident #41's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on ,d+[DATE] or [DATE] that Alprazolam 0.5 mgs was administered. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Alprazolam 0.5 mgs was administered to Resident #41. During an observation on [DATE] at 11:00 AM Resident #41 was observed sitting in the locked memory unit dining area. She was calm with no signs of increased anxiety. c.) Resident #2 was admitted to the facility on [DATE] with diagnoses including Respiratory failure and chronic pain. A physicians order dated [DATE] for Resident #2 revealed Oxycodone/Acetaminophen ,d+[DATE] mgs. Take one tablet every 6 to 8 hours as needed for pain control. Review of Resident #2's Controlled Drug Record initiated [DATE] revealed Oxycodone/Acetaminophen ,d+[DATE] mgs was signed out of the narcotic count by Nurse #1 on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] at 8:30 AM and 2:00 PM and [DATE]. Review of Resident #2's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #2 on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] at 8:30 AM and 2:00 PM and [DATE]. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #2. During an interview on [DATE] at 1:00 PM the Director of Nursing stated Resident #2 expired on [DATE] due to respiratory disease. d.) Resident #3 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Quadriplegia, and Non-Alzheimer's dementia. A physicians order dated [DATE] for Resident #3 revealed Hydrocodone/Acetaminophen ,d+[DATE] mgs. Take one tablet every 6 hours as needed for pain control. Review of Resident #3's Controlled Drug Record initiated [DATE] revealed Hydrocodone /acetaminophen ,d+[DATE] mgs was signed out of the narcotic count by Nurse #1 on ,d+[DATE], ,d+[DATE] at 7:45 AM and 6:22 PM, ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] at 7:15 AM and 1:15 PM, ,d+[DATE] at 7:15 AM, and 1:30 PM, ,d+[DATE], ,d+[DATE] at 2:00 PM, ,d+[DATE], ,d+[DATE] at 7:15 AM and 5:30 PM, ,d+[DATE], ,d+[DATE] at 8:00 AM, ,d+[DATE] at 8:00 AM and 5:30 PM, ,d+[DATE], ,d+[DATE] at 7:25 AM and 6:26 PM, ,d+[DATE] at 7:30 AM and 6:00 PM, and [DATE]. Review of Resident #3's Medication Administration Record (MAR) dated [DATE] and [DATE] revealed no documentation by Nurse #1 that Hydrocodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #3 on ,d+[DATE], ,d+[DATE] at 7:45 AM and 6:22 PM, ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] at 7:15 AM and 1:15 PM, ,d+[DATE] at 7:15 AM, and 1:30 PM, ,d+[DATE], ,d+[DATE] at 2:00 PM, ,d+[DATE], ,d+[DATE] at 7:15 AM and 5:30 PM, ,d+[DATE], ,d+[DATE] at 8:00 AM, ,d+[DATE] at 8:00 AM and 5:30 PM, ,d+[DATE], ,d+[DATE] at 7:25 AM and 6:26 PM, ,d+[DATE] at 7:30 AM and 6:00 PM, and on [DATE]. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Hydrocodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #3. e.) Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes and left below knee amputation. A physicians order dated [DATE] for Resident #4 revealed Oxycodone/Acetaminophen ,d+[DATE] mgs. Take one tablet every 4 hours as needed for pain. Review of Resident #4's Controlled Drug Record initiated [DATE] revealed Oxycodone/Acetaminophen ,d+[DATE] mgs was signed out of the narcotic count by Nurse #1 on [DATE]. Review of Resident #4's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE] that the Oxycodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #4. Review of the nursing progress notes on [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #4. Resident #4 was discharged from the facility on [DATE]. f.) Resident #7 was admitted to the facility on [DATE] with diagnoses including Congestive heart failure, Non-Alzheimer's dementia, and pain. A physicians order dated [DATE] for Resident #7 revealed Tramadol 50 mgs. Take one tablet by mouth three times a day as needed for pain. Review of Resident #7's Controlled Drug Record initiated [DATE] revealed Tramadol 50 mgs was signed out of the narcotic count by Nurse #1 on [DATE]. Review of Resident #7's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE] that Tramadol 50 mgs was administered to Resident #7. Review of the nursing progress notes on [DATE] revealed no documentation by Nurse #1 that Tramadol 50 mgs was administered to Resident #7. Resident #7 was discharged from the facility on [DATE]. g.) Resident #8 was admitted to the facility on [DATE] with diagnoses including Diabetes, and hip and knee replacement. A physicians order dated [DATE] for Resident #8 revealed Tramadol 50 mgs. Take one tablet by mouth every 6 hours as needed for pain. Review of Resident #8's Controlled Drug Record initiated [DATE] revealed Tramadol 50 mgs was signed out of the narcotic count by Nurse #1 on [DATE]. Review of Resident #8's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE] that Tramadol 50 mgs was administered to Resident #8. Review of the nursing progress notes on [DATE] revealed no documentation by Nurse #1 that Tramadol 50 mgs was administered to Resident #8. Resident #7 was discharged from the facility on [DATE]. h.) Resident #9 was admitted to the facility on [DATE] with diagnoses including right femur fracture, dementia, and chronic pain. A physicians order dated [DATE] for Resident #9 revealed Hydrocodone/Acetaminophen ,d+[DATE] mgs. Take one tablet every 12 hours as needed for pain control. Review of Resident #9's Controlled Drug Record initiated [DATE] revealed Hydrocodone/acetaminophen ,d+[DATE] mgs was signed out of the narcotic count by Nurse #1 on [DATE], [DATE] at 12:31 PM, and [DATE]. Review of Resident #9's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE], [DATE] at 12:31 PM, and [DATE] that Hydrocodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #9. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Hydrocodone/Acetaminophen ,d+[DATE] mgs was administered to Resident #9. Resident #9 was discharged from the facility on [DATE]. Review of the facility investigation initiated on [DATE] revealed: On [DATE] at approximately 11:30 AM Nurse #2 reported that Nurse #3 had suspicions that Nurse #1 was taking resident's medications and not administering the medications to the residents. She stated that one specific resident had an order for a narcotic as needed pain medication, but the resident never complained of pain. She stated that Nurse #1 was the only nurse signing out this narcotic for this specific resident. She stated that over a month ago another resident complained that Nurse #1 crushed her medications although there was no indication or need for the medications to be crushed. Nurse #3 stated that the resident complained and she didn't think the nurse was giving her pain medication. She stated she felt that it was also suspicious that Nurse #1 picked up additional shifts on households that she generally did not work and thought this could be to gain access to medications. Nurse #3 reported that other nurses were suspicious as well and provided a list of nurses and medication aides with concerns. An interview was conducted on [DATE] at 10:00 AM with the Director of Nursing (DON) along with the Administrator. The DON stated she was made aware of the allegation of possible drug diversion regarding Nurse #1 on [DATE] and a full investigation was initiated. She stated she reviewed the narcotic book containing all controlled drug records from the household that Nurse #1 worked on and identified a Resident ( #51) that had an order for Oxycodone/Acetaminophen ,d+[DATE]mg as needed every 8 hours for pain. The order stood out to her because Nurse #1 was the only nurse that signed out this medication for Resident #51 since [DATE]. She stated from [DATE] through [DATE] Nurse #1 signed out the medication 13 times. She stated she reviewed Resident #51's MAR to reconcile with the Controlled Drug Record and found where Nurse #1 failed to document that she administered the medication on the medication administration record on several occasions. She stated Resident #51 rarely complained of pain. She reviewed more resident records and found several other residents that had controlled medication orders and Nurse #1 signed them out on the Controlled Drug Record but didn't sign them out on the MAR as being administered to the residents. She stated she then notified the Administrator, and they interviewed Nurse #1 who denied taking any of the residents medications. The DON stated Nurse #1 stated she always documented on the MAR and didn't understand why the documentation on the MAR didn't show up and she probably just forgot to sign them out on the MAR. The Administrator added that the audits conducted and the interviews with other nurses indicated drug diversion. He stated Nurse #1 had been employed with the facility for [AGE] years and was terminated at that time. The DON added that she informed Nurse #1 that she would be reported to the Board of Nursing. She stated Nurse #1 did not want to review the audits that were done. The DON stated the Board of Nursing submitted their findings to the facility following their investigation. The Board of Nursing findings revealed Nurse #1 admitted that she had been diverting controlled medications from the facility for a period of time. Her nursing license was suspended. During an interview on [DATE] at 11:00 AM Nurse #4 stated she was aware of the allegations of drug diversion and was one of the nurses interviewed during the investigation of Nurse #1. She stated Nurse #1 was suspected of not giving certain residents their pain medications. She stated for example Resident #51 never complained of pain, but Nurse #1 signed out pain medications for him on many occasions. She stated there were other residents identified during the investigation that were affected. She stated she received in-service training during that time regarding drug diversion. During a phone interview on [DATE] at 4:10 PM the Consultant Pharmacist stated she conducted monthly record reviews at the facility. She stated she was made aware of the allegation of diversion in [DATE] regarding Nurse #1. She stated she was not aware until that time of any problems with narcotic medications at the facility. She stated during the monthly record reviews she reviewed prn (as needed) use of medications and did not see on the residents MAR that the medications were being administered or used frequently. She stated she had no concerns since that time with medication administration at the facility. During a phone interview on [DATE] at 4:31 PM the Medical Director stated he was made aware of the medication diversion. He stated he was at the facility on the day the facility was made aware. He stated he made rounds with the nurses weekly at the facility and there was no harm to any of the residents. He stated he had evaluated all of the affected residents during that time and found no negative outcome. He stated he had no concerns with the facility staff. During a follow up interview on [DATE] at 3:00 PM the DON stated a full plan of correction was implemented to include in-service training, audits, and audit results were discussed in the last QA meeting which was held on [DATE]. She stated the audits were completed in [DATE] and the next QA meeting would be held the week of [DATE]. The corrective action for the noncompliance dated [DATE] was as follows: On [DATE] the Director of Nursing and the Administrator were made aware of the allegation and conducted an initial investigation. On [DATE] the State Agency was notified. On [DATE] the DON initiated a 100% audit of the Medication Administration Records (MARs) and Controlled Drug Records of all residents who received Controlled medications and compared to the residents corresponding MAR to identify discrepancies. The audit was to ensure the medication was signed out on the residents Controlled Drug Record and to ensure staff signed the MAR that the narcotic was administered. The outcome of the audit revealed 10 residents identified as being affected. On [DATE] Nurse #1 was terminated. On [DATE] the Medical Director was made aware of the possible drug diversion. On [DATE] the Police Department was notified of the possible drug diversion. On [DATE] affected residents that still remained in the facility were assessed for changes in clinical condition. Interviews were conducted with affected residents or their Responsible Party (RP) to identify any concerns with residents not receiving as needed medications upon request. There were no issues identified. On [DATE] residents with the potential to be affected were assessed to identify any concerns with as needed medications being administered. Interviews were conducted with the residents or their Responsible Party (RP). There were no issues identified. On [DATE], 100% in-service training was initiated with all nurses and medication aides by the Staff Development Coordinator (SDC) regarding signs of narcotic diversion and prevention, reporting requirements of suspected diversion, and medication policy and procedures ensuring that controlled drug records matched the MAR. In-services were to be completed by [DATE]. After [DATE], any staff who had not received the in-service training would not be allowed to work until they completed the in-service training. All newly hired nurses and medication aides would be in-serviced during orientation. Beginning [DATE], the nurse mentors will review all residents with prescribed as needed narcotics to ensure that each narcotic is signed out on the controlled drug record with a corresponding administration record once weekly x 4 weeks, then once every 2 weeks x 1 month, then monthly x 1. The Director of Nursing will forward the results of the audits to the Quality Assurance (QA) Committee Meeting monthly until resolved. The quarterly QA meeting was held [DATE] where the results of the investigation and audits were discussed. Validation of the corrective action was completed on [DATE]. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. Observations were conducted of the medication carts; controlled substance counts were conducted with nursing staff of narcotics stored on the medication carts. Controlled Substance Count Records were reviewed. Audits were verified. A QA meeting was held on [DATE] where audit results were discussed. The facility alleged compliance with the corrective action plan on [DATE].

Based on observations and staff interviews, the facility failed to label/date leftover frozen food items stored available for use and store frozen food items covered in 1 of 1 walk-in freezer and failed to discard expired food in 1 of 1 reach-in cooler in the main kitchen. This had the potential to affect food served to residents. Findings included: The initial tour of the kitchen was conducted on [DATE] at 11:35 AM with the Director of Dining Services (DDS). An observation of the walk-in freezer revealed a leftover bag of sea scallops with no label with date opened, a leftover bag of onions with no label with date opened, and a leftover bag of mixed vegetables with no label with date opened, and a roast with an open plastic wrap cover. Observation of the reach-in cooler revealed a container of cranberry sauce with the expiration date of [DATE]. An interview was conducted on [DATE] at 11:45 AM with the DDS. He stated all leftover food items in the walk-in freezer should be covered and labeled with the expiration date. He further stated that expired food should not be in the reach-in cooler. The DDS indicated the walk-in freezer and the reach-in cooler were checked every day for unlabeled and expired food items.

Based on observation, record review and staff interviews, the facility failed to implement their policies and procedures related to personal protective equipment (PPE) and hand hygiene for 1 of 5 sampled residents (Resident #1) who was on enhanced droplet isolation. These failures occurred during COVID-19 pandemic. The findings included: Record review of facility policy and procedure titled Handwashing/Hand Hygiene revised August 2015 revealed personnel were to use alcohol-based hand rub or soap and water before and after entering isolation precaution settings. Record review of facility policy titled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (Covid-19) revealed staff were to wear full personal protective equipment when working with individuals with known or suspected COVID-19. Residents admitted /readmitted to facility were to be isolated in their rooms for 14 days. Resident #1 was in isolation for COVID-19 observation for 14 days after readmission with an enhanced droplet isolation signage at the door. The signage indicated staff were required to perform hand hygiene, don mask, eye protection, gown and gloves before entering the room. On 12/22/20 at 11:25 AM, Nurse Aide (NA) #1 was observed entering Resident #1's room without a gown or gloves. She did not perform hand hygiene before entering the room as well as when she exited the room. She walked into the room and talked to the resident then exited the room and walked down the hallway and was not observed performing hand hygiene. The enhanced droplet isolation signage was on the door when she entered the room. During an interview on 12/22/20 at 12:05 PM, NA #1 revealed she had been trained regarding infection control practices, hand hygiene and use of PPE when entering isolation rooms. She indicated she was aware that she should have performed hand hygiene and don PPE according to the signage on the door but missed to do it when she entered and exited Resident # 1's room. An interview with Nurse #1 on 12/22/20 at 11:30 AM revealed Resident #1 was on isolation due to readmission from another healthcare facility. Nurse #1 indicated residents placed on isolation had a signage and PPE supplies outside their doors for staff to utilize prior to entering the room. She indicated nursing staff had been trained on hand hygiene and the use of PPE when caring for residents in isolation to prevent infection transmission. She indicated she always donned PPE prior to entering the room and performed hand hygiene when entering and exiting residents' rooms. An interview with Director of Nursing (DON) on 12/22/20 at 11:45 AM revealed she was also the Infection Prevention Nurse (IPN). She indicated all staff had been trained regarding infection control practices, policies and procedures including enhanced droplet precaution requirements. She stated staff were to perform hand hygiene before and after every resident encounter as well as don PPE as per signage on the resident's door. She indicated Resident #1 was on 14 days isolation following readmission on 12/18/20 and had an enhanced droplet isolation signage as well as PPE supply outside her door that staff were required to use prior to entering the room. An interview with the Administrator on 12/22/2020 at 12:25 PM revealed all staff were to perform hand hygiene and don PPE as per signage on the door prior to entering the room of residents on isolation

Based on record review and staff, Family Nurse Practitioner (FNP), and Physician interviews the facility staff failed to raise the footrest on a resident's recliner as directed on the Care Plan and failed to transfer a resident using the required mechanical lift as listed on the Resident Care Guide for 1 of 1 residents (Resident #1) reviewed for accidents. Staff manually transferred Resident #1 to her recliner chair, and she had an unobserved fall from the chair which was not in the elevated position. As a result of the fall, Resident #1 experienced swelling to her right knee and leg pain. An x-ray showed that Resident #1 had a distal femur fracture. The facility staff also failed to report that the resident fell and to have the resident assessed by a nurse prior to moving her. Findings included: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Falls Risk assessment dated [DATE] revealed that Resident #1 was always disoriented. Resident #1's cognitive status had deteriorated, and she had no falls in the past three months. Resident #1 had severely impaired vision, was chair bound, and was unable to ambulate. Resident #1 was at high risk for falls. The Care Plan which was updated on 05/25/20 showed that Resident #1 was at risk for falls. Interventions included the use of a mechanical lift for transfers and that Resident #1 not be left in the recliner unsupervised unless the feet were elevated. The Care Plan also revealed that Resident #1 was a total assist for transfers and that two people were needed for transfers with the mechanical lift. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had short- and long-term memory problems and was severely impaired in skills for daily decision making. Resident #1 was totally dependent on the physical assistance of two people for transfers. The Resident Care Guide that was in effect on 05/31/20 revealed that Resident #1 was at risk for falls. Resident #1 was to be transferred using a mechanical lift with two people. The Clinical Notes Report dated 06/01/20 at 10:21 AM and 1:04 PM revealed no entries mentioning Resident #1's knee swelling. These were the only two notes for 06/01/20. The Clinical Notes Report dated 06/03/20 at 7:31 PM showed a Late entry note for 06/01/20 that was written by Nurse #1. The note specified that on 06/01/20 Nursing Assistant (NA) #1 reported swelling and pain to Resident #1's right knee to Nurse #1 when she put the recliner down to assist Resident #1 with lunch. There was minimal swelling and no bruising. The Clinical Notes Report dated 06/02/20 at 12:11 PM revealed that Resident #1 had right knee swelling and was lying with her legs elevated. Pain was noted when her right leg was moved. The Clinical Notes Report dated 06/03/20 at 7:24 PM showed a Late entry note for 06/02/20 that was written by Nurse Mentor #1. The note specified that Nurse Mentor #1 was notified of Resident #1's right knee swelling by Nurse #1 on 06/02/20 at approximately 9:00 AM. Resident #1 had been scheduled to see the medical provider and Nurse Mentor #1 had spoken to the FNP at 3:43 PM when she ordered an x-ray and labs. At 7:20 PM the results of the x-ray revealed a fracture and the provider was notified. Resident #1 was sent to the Emergency Department (ED). Staff were interviewed and it was discovered that Resident #1 had fallen out of a recliner on 06/01/20 and the fall was not reported by the NAs involved. In a telephone interview on 06/17/20 at 2:15 PM NA #2 confirmed that she was assigned to Resident #1 on the 11:00 PM-7:00 AM shift which began on 05/31/20. NA #2 stated she started working that night on another assignment and had been pulled to work on the Light House hall about 45 minutes into the shift. She indicated that the report she received from NA #3 for her new assignment was that everyone was fine and no information about the resident's care was provided. She stated she did not receive any report from the nurse. NA #2 stated that it was only the second time she had cared for Resident #1. She indicated that when it was time to shower Resident #1, she and NA #3 lifted her out of bed without using the mechanical lift and she took her to the shower room. She indicated after Resident #1 was showered she returned to the room and she and NA #3 lifted her into the recliner without using the mechanical lift. NA #3 left the room. Resident #1 was barefoot and resting in the recliner with the foot of the recliner in the down position. NA #2 stated she turned away and walked about four steps to get an item for Resident #1's arms and when she turned around Resident #1 was sitting on the floor with her back against the recliner and her legs straight out in front of her. NA #2 indicated Resident #1 did not appear to be in pain although there was a small amount of blood on her lip. She stated she ran to get NA #3 to help her with Resident #1. NA #2 indicated that she came back into the resident's room with NA #3 following behind her. She stated that NA #3 closed the door and asked her if she had informed the nurse yet. When NA #2 told her no, NA #3 told her good, don't. NA #2 stated that she and NA #3 lifted Resident #1 off the floor by placing their arms under Resident #1's arms and holding the back of her pants. They did not use the mechanical lift. NA #2 stated that Resident #1's feet were not lifted off the floor and were dragged when they lifted her off the floor, and that once in the recliner Resident #1's legs were raised. NA #2 indicated she stayed until the end of her shift and gave report to the oncoming NA but did not inform her that Resident #1 had fallen from the recliner onto the floor. NA #2 stated that she knew she should have used the mechanical lift to transfer Resident #1 and that she should have reported the fall to the nurse but that she was scared. She indicated she had just been through orientation and received training on the facility no lift policy. She indicated that Resident #1's right knee was a little swollen before the fall but that she had not reported this to the nurse either. She stated that the information on how to care for each resident was on the Kardex in the computer kiosk on the hall. She indicated that she had no time to look at the information prior to taking on her assignment so just cared for the residents the same way she did when she was orienting with another NA on that hall and the mechanical lift had not been used for Resident #1. In a telephone interview on 06/18/20 at 9:27 AM NA #3 confirmed that she worked with NA #2 on the 11:00 PM-7:00 AM shift on 05/31/20 but was not assigned to Resident #1. She stated that she informed NA #2 that Resident #1 needed to be showered and to use a mechanical lift for the transfer. NA #3 stated that NA #2 never came to ask her for assistance in transferring Resident #1 for her shower or to place her in the recliner following the shower and she did not assist with those transfers. She indicated that NA #2 did come to ask for assistance in dressing Resident #1 and that she cared for about three other residents and then took the mechanical lift to Resident #1's room and knocked on the door. When she opened the door, she saw Resident #1 on the floor next to the bed with blood on her lip. NA #3 stated that NA #2 said that Resident #1 had slid down and kept asking if she was going to be in trouble. NA #3 stated that she panicked when she saw the blood and just wanted to get Resident #1 off the floor, so she and NA #2 lifted the resident off the floor and placed her in the recliner. NA #3 admitted that she should have used the mechanical lift to get Resident #1 up off the floor, but she had not. She indicated she told NA #2 to tell the nurse and that NA #2 left the room. NA #3 stated that she left Resident #1 in the recliner and went to finish caring for the residents on her own assignment. She gave report to the oncoming NAs at change of shift, but she did not report Resident #1's fall to anyone. In a telephone interview on 06/17/20 at 5:17 PM Nurse #2, who worked on 05/31/20 on the 7:00 PM-7:00 AM shift and was responsible for caring for Resident #1, stated that neither NA #2 nor NA #3 had informed her that Resident #1 had fallen early that morning. She stated that if she had been informed of the fall, she would have assessed Resident #1 and assisted the NAs with putting her back in the bed or recliner using the mechanical lift. She indicated she would have notified the medical provider of the fall and carried out any orders they gave. She indicated that Resident #1 should have been transferred using a mechanical lift and that she had been available to assist with transfers if needed but had not been asked. Nurse #2 indicated that she had seen NA #2 transport Resident #1 to the shower room and back but had not witnessed the actual transfers. She stated that the NAs knew what each resident needed because it was the responsibility of the nurse to make sure that they knew what care to provide. Nurse #2 stated she had not given any type of report to NA #2 because she had worked on that assignment before and knew what the residents needed. Nurse #2 then stated that she might have mentioned something to NA #2 but was not sure. She stated other than report from the nurse, there would be no other way for the NAs to know what to do for the residents unless maybe there was something when they did their charting. In a telephone interview on 06/18/20 at 10:08 AM NA #1 confirmed that she worked with Resident #1 on the 7:00 AM-3:00 PM shift on 06/01/20. NA #1 stated that she did not receive report from NA #2, but that NA #3 had told her that Resident #1 had been bathed. Neither NA had reported to her that Resident #1 had experienced a fall. She indicated that after she fed Resident #1 lunch and placed the recliner foot up, Resident #1 said oh my leg. NA #1 indicated that she thought the comment was because of the repositioning of Resident #1's legs in the recliner. NA #1 stated that when she went to transfer Resident #1 into the bed from the recliner using the mechanical lift she said oh my leg again. NA #1 undressed Resident #1's lower body at that time and saw the swelling of the right knee. She reported the swelling to Nurse #1. NA #1 stated that prior to that day there had been no swelling in the knee and there had been no complaints of knee pain. In an interview on 06/16/20 at 3:17 PM NA #4 stated she had worked with Resident #1 on 06/01/20 on the 3:00 PM-11:00 PM shift and had been informed by Nurse #1 about Resident #1's knee swelling, but not about a fall as it had not been reported at that time. In a telephone interview on 06/17/20 at 1:38 PM NA #5 confirmed that she had worked with Resident #1 on 06/01/20 on the 11:00 PM-7:00 AM shift. She indicated she saw the swelling to Resident #1's knee and reported it to Nurse #3 who came and assessed the knee. NA #5 stated she repositioned Resident #1 every two hours and did not see any bruising to the knee. NA #5 indicated that Resident #1 did not appear to be in pain. In an interview on 06/16/20 at 2:56 PM Nurse #1 indicated she worked on 06/01/20 on the 7:00 AM-7:00 PM shift. She indicated that NA #1 had informed her around lunch time that Resident #1 had a swollen knee and complained of pain to the knee. Nurse #1 stated she assessed Resident #1 and noted only slight to minimal swelling of the right knee. She indicated she asked NA #1 to remove the support stockings and to elevate Resident #1's legs. Resident #1 was due for scheduled pain medicine, so she provided the medication to the resident with good result. Nurse #1 stated that later in the shift Resident #1's knee looked about the same and that she informed the oncoming nurse (Nurse #3) of the swelling. She stated that when she worked on 06/02/20, the swelling in Resident #1's knee had increased. Nurse #1 stated that she informed Nurse Mentor #1 that Resident #1 needed to be seen by the medical provider. She indicated that at that time there was no bruising to Resident #1's right knee. Nurse #1 indicated that Resident #1 was kept in bed with her leg elevated and was repositioned every two hours. She indicated that during repositioning, Resident #1 complained of pain to the right leg. Nurse #1 stated that the FNP had been in in the afternoon to examine Resident #1 and had ordered an x-ray of the right knee due to the swelling and faint bruising that was now seen on Resident #1's right knee. She indicated that about 7:00 PM she received a call from Nurse Mentor #1 and was told to send Resident #1 to the ED. In an interview on 06/16/20 at 2:06 PM Nurse Mentor #1 stated she spoke with Nurse #1 on 06/02/20. Nurse #1 informed her that Resident #1 had a swollen right knee. Resident #1 was placed on the list to be seen by the provider. There was no bruising or injury that Nurse #1 was aware of at that time. In the afternoon the FNP reported that there was bruising and swelling to Resident #1's right knee and an x-ray and labs were ordered. Nurse Mentor #1 indicated that she initiated an investigation and began to call staff who had worked with Resident #1 over the last few days. She was informed by NA #1 that she had noticed the swelling to Resident #1's right knee on 06/01/20 about midday and had reported the swelling to Nurse #1. Nurse Mentor #1 indicated that Nurse #1 had assessed the knee on 06/01/20 and had informed the second shift NA to leave Resident #1 in bed. She stated that she continued calling staff and spoke with NA #2 who told her that she was unaware of anything happening to Resident #1. Nurse Mentor #1 indicated that NA #2 stated that when she had transferred Resident #1 into a shower chair in the early morning of 06/01/20, Resident #1 had verbalized a yelping sound but that was all. Nurse Mentor #1 stated that when the Radiology Report was received on 06/02/20 and revealed a fracture, she notified the FNP and received an order to send Resident #1 to the ED. Nurse Mentor #1 stated that NA #2 called her back a little while later and related that after showering Resident #1, the resident was transferred into a recliner in the resident's room. Nurse Mentor #1 indicated that NA #2 told her that she turned away from the resident and Resident #1 fell on to the floor. NA #2 went to get NA #3, and they picked Resident #1 up off the floor and placed the resident back in the recliner without informing Nurse #2 of the fall. NA #2 informed Nurse Mentor #1 that she was told by NA #3 not to tell the nurse about Resident #1's fall. Nurse Mentor #1 stated she called the Director of Nursing (DON) and informed her of NA #2's statement. In an interview on 06/16/20 at 2:17 PM the DON indicated that after she became aware of NA #2's statement, she checked the schedule and saw that NA #3 was scheduled to work 11:00 PM-7:00 AM on 06/02/20. She stated she contacted NA #3 via telephone and instructed her not to come to work that night, but to come to the facility in the morning of 06/03/20 for an interview. NA #2 was not scheduled to work on 06/02/20 and was also asked to come to the facility for an interview on 06/03/20. The DON indicated that during her interview NA #2 was upset, tearful, and avoided eye contact. NA #2 verified that she had worked with Resident #1 on the 11:00 PM-7:00 AM shift that began on 05/31/20. NA #2 told the DON that after she showered Resident #1, she placed the resident in a recliner using a mechanical lift. NA #2 told the DON that the foot rest of the recliner was down and that she turned away from Resident #1 and heard a thud. She looked back and saw Resident #1 sitting on the floor with her back against the recliner and both legs straight out in front. NA #2 told the DON that she went to get NA #3 for help and that when NA #3 came into the room she asked NA #2 if she had told Nurse #2. When NA #2 stated that she had not informed the nurse, NA #3 told NA #2 good, don't and they lifted Resident #1 off the floor without using the mechanical lift into the recliner. NA #2 indicated to the DON that Resident #1 was singing and did not appear to be in pain. The DON stated that NA #2 indicated that she knew she should have reported the fall to the nurse. The DON indicated that NA #3 was belligerent, defensive and angry during her interview. She confirmed that she was not assigned to Resident #1 when the fall occurred and that she only assisted with getting Resident #1 off the floor and into the recliner. NA #3 denied that she assisted NA #2 with any mechanical lift transfers for Resident #1 during their shift. She told the DON that she knocked on Resident #1's closed door and when she opened it, she saw Resident #1 sitting on the floor. NA #3 indicated she instructed NA #2 to go and get the nurse and that NA #2 left the room. When NA #2 came back to the room, they lifted Resident #1 off the floor without using a mechanical lift and placed her in the recliner. The DON stated she had the two NAs perform a demonstration of how they lifted Resident #1 into the recliner. The NAs each placed a hand under her arms and lifted her into the chair. NA #3 related to the DON that she knew she should have reported the fall to the nurse but that she did not. NA #3 told the DON that she would never have told NA #2 not to tell the nurse about the fall. The DON stated that both NAs employment was terminated because they failed to properly transfer Resident #1 and failed to report the fall. In an interview on 06/16/20 at 1:46 PM the Staff Development Coordinator (SDC) stated that NA #2 and NA #3 had recently been through orientation. She stated that she had done the orientation herself and knew that they both were aware that the facility was a no lift facility, that residents needed to be transferred according to the information on the Resident Care Guide, and that falls needed to be reported to the nurse right away. She indicated that everyone made mistakes but that they made the wrong choice when they decided not to use the mechanical lift to transfer Resident #1 and to not report the fall to the nurse. The FNP Progress Note dated 06/02/20 revealed she had been requested to examine Resident #1 due to swelling in the right knee. The nurse had denied any recent injury but there was moderate swelling and bruising to the knee. There was pain when passive range of motion (movement) was performed on the knee. Resident #1 was unable to verbalize a possible incident or when the swelling had started. There was no acute distress and no wound was noted. Pulses were present in the right lower extremity. A knee x-ray was ordered. The Radiology Report dated 06/02/20 showed that Resident #1 had a distal femoral supracondylar fracture with medial and posterior displacement (a straight across misaligned break in the thigh bone just above the knee) of indeterminate age (unable to tell by x-ray alone if the fracture was new or old). There was also diffuse osteopenia (a condition that causes the loss of bone mass causing bones to weaken) noted. Multiple attempts to contact the Radiologist were unsuccessful. In a telephone interview on 06/18/20 at 9:49 AM the FNP stated that she performed rounds on Tuesdays at the facility. She indicated she received a list of residents who needed to be seen and Resident #1's name was on the list because of right knee swelling. The FNP stated that when she examined Resident #1's right knee it appeared to be about three times larger than the left knee and had a slight discoloration. Resident #1 was non-ambulatory and could not verbalize what had happened to her knee. The FNP indicated there had been no report of any type of injury so she ordered an x-ray of the knee along with labs. She stated that when the x-ray showed a fracture, she ordered that Resident #1 be sent to the ED. Later she was informed that a NA had come forward and admitted that Resident #1 had fallen on 06/01/20 and the fall had not been reported. The FNP stated that from the severity of the break, she felt the fracture was from the fall and was not pathological (caused by an underlying disease). In a telephone interview on 06/18/20 at 10:40 AM Resident #1's Physician stated that she was severely demented and could not tell anyone what happened. He indicated that he thought the break was traumatic rather than pathological in nature even with a [DIAGNOSES REDACTED].#1 had fallen and that she had not reported it. The Physician stated that the NAs should have used a mechanical lift to transfer Resident #1 from the floor to the recliner after the fall. In a telephone interview on 06/19/20 at 10:43 AM the DON indicated that NA #2 and NA #3 should not have moved Resident #1 prior to reporting the fall to the nurse so an assessment could have been done to rule out injury. Once Resident #1 had been assessed they should have gotten the resident up according to the information in the Resident Care Guide which for this resident was with a mechanical lift with two people assisting. The DON indicated that transfer information was readily available in the care guide in the computer kiosk and both NAs knew how to access that information. The DON confirmed that both NAs had received training in orientation about reporting of incidents and transfers. Both NAs were terminated.

Based on record review and staff and consultant interviews the facility failed to assess resident cognition and resident mood in a quarterly Minimum Data Set (MDS) assessment for 1 of 1 residents (Resident #1) whose MDS was reviewed. Findings included: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed her cognition had not been assessed in section C, and her mood had not been assessed in section D. For C0100 Should a brief interview for metal status be conducted? there was no code documented and the interview was blank. For C0600 Should the staff assessment for metal status be conducted? there was no code documented and the assessment was blank. For D0100 Should resident mood interview be conducted? there was no code documented and the interview was blank. For D0500 Staff assessment of resident mood the assessment was blank. In an interview on 06/16/20 at 4:46 PM the Social Worker (SW) stated that she was responsible for completing sections C and D. She indicated she had planned to go back and complete the quarterly MDS but had forgotten and the sections were missed. The SW stated that the MDS Coordinator had just returned to work, and that a contracted MDS Consultant had been working for the facility for about one month prior to her return. In a telephone interview on 06/16/20 at 5:06 PM the contracted MDS Consultant confirmed that Resident #1's quarterly MDS should have been completed. She stated that she asked the SW several times for the information and was told by the SW she would get it to her, but she never did. The Consultant indicated that the MDS could not be completed without the information from the SW. The contracted MDS Consultant stated that she did not go to the Director of Nursing (DON) or the Administrator to inform them that the MDS could not be completed or to ask for assistance in getting the SW to provide her with the information to complete the quarterly MDS. In a telephone interview on 06/17/20 at 1:21 PM the facility MDS Coordinator stated that the contracted MDS Consultant had sent her a list of what had not been completed while she was out on leave. She confirmed that she read the list and was aware that Resident #1's MDS had not been completed. The MDS Coordinator stated that it was her understanding that the contracted MDS Consultant would complete any outstanding work prior to resident assessment reference dates (ARD) of 06/12/20 even though the MDS Coordinator was back at work. The MDS Coordinator stated that she informed the contracted MDS Consultant she would remind the SW to complete Resident #1's quarterly MDS. The MDS Coordinator stated that a resident's MDS needed to be completed on time so it could be signed off and transmitted to the appropriate agency. In a telephone interview on 06/19/20 at 10:43 AM the Director of Nursing (DON) stated that the contracted MDS Consultant should have notified her or the Administrator when the SW failed to complete her sections of Resident #1's quarterly MDS. She indicated that if they had known, they could have spoken to the SW and the MDS would have been completed on time.

Based on observation and staff interviews the facility failed to keep unattended medication secured in a locked medication cart for 1 of 4 medication carts observed (Lighthouse unit). Findings included: In an observation on 12/03/19 from 4:12 PM to 4:13 PM the medication cart was against the partial wall dividing the dining room from the hallway. The medication cart was not visible from the dining room. The lock of the medication cart did not appear to be engaged. No staff members were seen on the hallway and the nursing station was empty of staff. After approximately 15-20 seconds a staff member walked up to the medication cart from out of the dining room and stood in front of the cart for a few seconds. The lock on the medication cart still appeared to not be engaged as she walked up the hallway approximately 40 feet to a resident room. The staff member returned down the hallway and adjusted the vital sign equipment that was on a cart outside the nursing station. When approached, the staff member confirmed that she was the nurse (Nurse #1) for the hallway. In an interview on 12/03/19 at 4:13 PM Nurse #1 verified that the medication cart was unlocked by pulling open a drawer containing medications without using a key to unlock the cart. She confirmed that she had stopped at the medication cart after leaving the dining room but heard an alarm and responded to it leaving the unlocked medication cart unattended. She indicated that medication carts should always be locked when not attended. Nurse #1 stated if the cart was left unlocked, anyone could come and take whatever drugs they wanted and swallow them. In an interview on 12/05/19 at 10:23 AM the Director of Nursing (DON) stated that medication carts should always be locked if not in the line of sight of the nurse. She indicated that the medication carts should be locked to prevent anyone from getting the medications.

Based on staff interviews, Medical Director interview and record review the facility failed to provide adequate care for one of two sampled residents who did not receive adequate treatment for [REDACTED].#17). Findings included: Resident #17 was re-admitted to the facility on [DATE] after a short hospitalization [MEDICAL CONDITION] related to a urinary tract infection. Pertinent [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set with an assessment reference date of 12/11/17 revealed that Resident #17 had intact long term memory, no behaviors, required extensive assistance with activities of daily living, had an impairment on one side, was frequently incontinent of bowel and bladder, and had received Occupational Therapy for 5 days totaling 232 minutes. Review of the care plan for Resident #17 included: at risk for urinary tract infections with interventions to keep skin clean and dry, observe for confusion and behavior change, and to obtain a urinary analysis if needed. It also included plans for rejection of care, fall risk, [MEDICAL CONDITION] activity risk, pressure ulcer risk, and bowel and urinary continence. Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the urinalysis and urine culture dated 11/14/17 and released 11/16/17 revealed the growth of >100,000 COL/ML Escherichia coli which was resistant to [MEDICATION NAME]. Record review of the hospital history and physical dated 11/27/17 revealed the following impression: UTI-diagnosed 12 days ago, but not appropriately treated until 2 days ago. In an interview conducted with the Medical Director on 12/13/17 at 2:40 PM he revealed that Resident #17 had been given an antibiotic that was not effective. He said there was a complete lack of communication that occurred. He stated that this case had slipped through the cracks and that he was not aware of the situation until after the fact. In an interview conducted on 12/13/17 at 2:45 PM with Nurse #1 he stated that the facility protocol was to call the laboratory for culture results forty-eight hours after a urine sample was sent to determine that antibiotics in use were sensitive and effective. He stated that he had not contacted the laboratory for results of the culture and sensitivity for Resident #17. In an interview conducted on 12/13/17 at 3:30 PM with the Director of Nursing she revealed that Resident #17 had been treated with an antibiotic to which the organism was resistant. She stated that the facility failed to follow up on the laboratory results performed at the hospital emergency room which showed that the antibiotic that was given to the resident was not effective ([MEDICATION NAME]). She said that she expected laboratory results for a urine culture and sensitivity to be followed up on by the facility forty-eight hours after a urine sample was sent to the laboratory which the facility failed to do.

Based on staff interviews, Medical Director interview and record review the facility failed to provide adequate care for one of two sampled residents who experienced urinary tract infections [MEDICAL CONDITION] which resulted in an unnecessary hospitalization for an acute UTI [MEDICAL CONDITION] for Resident #17 . Findings included: Resident #17 was re-admitted to the facility on [DATE] after a short hospitalization [MEDICAL CONDITION] related to a urinary tract infection. Pertinent [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set with an assessment reference date of 12/11/17 revealed that Resident #17 had intact long term memory, no behaviors, required extensive assistance with activities of daily living, had an impairment on one side, was frequently incontinent of bowel and bladder, and had received Occupational Therapy for 5 days totaling 232 minutes. Review of the care plan for Resident #17 included: at risk for urinary tract infections with interventions to keep skin clean and dry, observe for confusion and behavior change, and to obtain a urinary analysis if needed. It also included plans for rejection of care, fall risk, [MEDICAL CONDITION] activity risk, pressure ulcer risk, and bowel and urinary continence. Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the urinalysis and urine culture dated 11/14/17 and released 11/16/17 revealed the growth of >100,000 COL/ML Escherichia coli which was resistant to [MEDICATION NAME]. Record review of the hospital history and physical dated 11/27/17 revealed the following impression: UTI-diagnosed 12 days ago, but not appropriately treated until 2 days ago. In an interview conducted with the Medical Director on 12/13/17 at 2:40 PM he revealed that if Resident #17 had been given the correct antibiotics to treat the UTI the hospitalization would have been avoided. He said there was a complete lack of communication that occurred. He stated that this case had slipped through the cracks and that he was not aware of the situation until after the fact. In an interview conducted on 12/13/17 at 2:45 PM with Nurse #1 he stated that the facility protocol was to call the laboratory for culture results forty-eight hours after a urine sample was sent to determine that antibiotics in use were sensitive and effective. He stated that he had not contacted the laboratory for results of the culture and sensitivity for Resident #17. In an interview conducted on 12/13/17 at 3:30 PM with the Director of Nursing she revealed that the hospitalization of Resident #17 on 11/26/17 for Urosepsis could have been avoided if the correct antibiotic had been administered to the resident. She stated that the facility failed to follow up on the laboratory results performed at the hospital emergency room which showed that the antibiotic that was given to the resident was not effective ([MEDICATION NAME]). She said that she expected laboratory results for a urine culture and sensitivity to be followed up on by the facility forty-eight hours after a urine sample was sent to the laboratory which the facility failed to do.

Based on observation and staff interview the facility failed to clean wall fans blowing into the dish machine and kitchenware storage areas, failed to air dry kitchenware prior to stacking it in storage, and failed to discard/replace kitchenware with abraded/scratched interior preparation/serving surfaces. Findings included: 1. During initial tour of the kitchen, beginning at 11:19 AM on 01/17/17, the blades, front, and back of two wall fans were coated with dust and dirt with the coating as thick as a quarter inch on the back of the fans. One fan was blowing directly into the dish machine area, and the other blew across a storage unit of kitchenware into the dish machine area. During a follow-up inspection of the kitchen, beginning at 9:30 AM on 01/19/17, the blades, front, and back of two wall fans were coated with dust and dirt with the coating as thick as a quarter inch on the back of the fans. One fan was blowing directly into the dish machine area, and the other blew across a storage unit of kitchenware into the dish machine area. At 10:55 AM on 01/20/17 the food service director (FSD) stated the dietary department was responsible for cleaning fans used in the kitchen. He reported currently the fans were not on a cleaning schedule, but were cleaned when the dietary employees noticed dust and dirt were collecting on the fans. According to the FSD, the two fans blowing into the dish machine area should have already been cleaned to avoid contaminating sanitized kitchenware exiting the dish machine and stacked on a storage rack. He commented every three or four weeks the fans should be disassembled with the blades, fronts, and backs of the fans being wiped down with a cloth and degreasing solution. At 11:10 AM on 01/20/17 dietary employee #1 stated the dietary department was supposed to clean wall fans in the kitchen monthly to prevent dust, dirt, and grease build-up on the fan blades and covers from contaminating sanitized kitchenware. He reported the dietary department had been short staffed so some cleaning duties had been overlooked or postponed. The employee commented in order to prevent kitchenware contamination the fans were supposed to be disassembled so dirt and dust from the blades as well as the front and rear grills could be removed using a degreaser. 2. At 9:20 AM on 01/19/17 15 of 21 tray pans were stacked on top of one another with water/moisture trapped between them. The employee operating the three-compartment sink system stated most of these tray pans were washed that morning. At 10:55 AM on 01/20/17 the food service director (FSD) stated within the last month in-servicing was held during which the dietary staff was instructed to air dry kitchenware before stacking it in storage. He reported the employee operating the three-compartment sink on the morning of 01/19/17 had attended this in-service. According to the FSD, the damp, dark, wet environment formed by stacking wet pieces of kitchenware on top of one another created the perfect breeding ground for germs and bacteria. At 11:10 AM on 01/20/17 dietary employee #1 stated during in-services the dietary staff was trained kitchenware should be free of dried food particles and dry before stacking it in storage. He reported the facility had drying racks where tray pans could be air-dried before stacking them on top of one another. The employee commented the geriatric population was very susceptible to the harmful bacteria that grew when moisture was trapped between pieces of wet kitchenware that were stacked on top of one another. 3. At 9:23 AM on 01/19/17 the non-stick coating on 2 of 3 fry/saute pans being utilized by the facility was scratched and flaking. At 11:16 AM on 01/19/17 16 of 18 plastic soup/cereal bowls were abraded inside. At 10:55 AM on 01/20/17 the food service director (FSD) stated when kitchenware became compromised with chips, cracks, and abrasions dietary employees were instructed to pull it out of circulation, take it to a supervisor for evaluation, and almost always it would be counted, replacements would be ordered, and the compromised pieces would be disposed of. According to the FSD, he thought the use of scouring pads had contributed to the breakdown of the non-stick coating and the interior serving surfaces. He reported pieces of the coating and plastic could contaminate the food, and the compromised surfaces made it more difficult to keep the kitchenware free of dried food particles. At 11:10 AM on 01/20/17 dietary employee #1 stated compromised kitchenware was supposed to be taken to a supervisor who could count and reorder it before disposing of it. He reported bits of non-stick coating and abraded plastic could get ingested by residents and make them sick or create a choking hazard.

Based on observation, record review and staff and Registered Pharmacist interviews, the facility failed to store medications inside a locked medication cart for 1 of 4 medication carts, failed to dispose of expired and/or undated medications for 2 of 4 medication storage refrigerators, failed to follow special storage instructions placed by the pharmacy on a medication stored in a medication refrigerator for 1 of 4 medication refrigerators, and failed to store medications at recommended temperatures for 1 of 4 medication refrigerators. Findings included: 1. In an observation on 01/17/17 at 10:58 AM a medication storage card containing 30 capsules of Gabapentin 100mg (milligrams) was seen on top of an unattended medication cart. A continuous observation of the medication and the medication cart was continued until 11:03 AM when Nurse #2 returned to the medication cart. In an interview on 01/17/17 at 11:03 AM Nurse #2 indicated there were two cards of Gabapentin in the drawer of the medication cart so she had removed one and placed it on top of the medication cart with the intention of placing the card in the medication storage room. She indicated she had left her cart unattended with the medication on top to answer a call light. Nurse #2 stated she knew she was not supposed to leave medications unattended on top of the medication cart and should have taken them to the medication storage room. In an interview on 01/20/17 at 11:10 AM the DON stated it was her expectation that nurses not store medications on top of the medication carts and to never leave medications unattended. 2. An observation of the medication storage refrigerator on the Lighthouse nursing unit was conducted on 01/19/17 at 11:10 AM with Nurse #3. The medication storage refrigerator contained one opened and accessed vial of fluvirin vaccine with a handwritten opened date of 11/30/16. The refrigerator also contained an opened and accessed vial of Tuberculin purified protein derivative (PPD) which was in a box with a handwritten opened date of 12/17/16. The instructions on the box read, Once entered, vial should be discarded after 30 days. In an interview on 01/19/17 at 11:15 AM Nurse #3 stated opened vials of medications were to be discarded 30 days after opening. She indicated the medications were no longer effective after 30 days. In an interview on 01/19/17 at 4:00 PM Registered Pharmacist (RPh) #1 stated that after opening, fluvirin was good for 28 days and then should be discarded. She indicated that after 28 days the vaccine may not be effective. She indicated Tuberculin PPD should be discarded 30 days after opening as per the instructions on the box. An observation of the medication storage refrigerator on the Farmhouse nursing unit was conducted on 01/19/17 at 11:22 AM with Nurse #3. The medication storage refrigerator contained one opened and accessed vial of fluvirin vaccine with no opened date. In an interview on 01/19/17 at 11:25 AM Nurse #3 stated it was standard practice for nurses to write the date on the box or vial of a medication when it was opened. She indicated writing the opened date was important because these medications expired 30 days after opening and would not be effective if used after that date. In a telephone interview on 01/19/17 at 4:00 PM RPh #1 stated that after opening, fluvirin was good for 28 days and then should be discarded. She indicated that after 28 days the vaccine may not be effective. RPh #1 stated if there was no opened date on the vial the medication could not be used and should be discarded. She indicated there would be no way to tell if the medication had expired if the dated opened was not on it. In an interview on 01/20/17 at 11:10 AM the DON stated she expected expired medications to be returned to the pharmacy and that the date a medication was opened should be written on the medications. She indicated if the date was not written on the medication the nurse would not know if the medication had expired. 3. An observation of the medication storage refrigerator on the Clubhouse nursing unit was conducted on 01/19/17 at 11:30 AM with Nurse #1. The medication refrigerator contained 1 unopened Humalog (insulin) flex pen, 2 unopened vials of Levemir (insulin), and a storage box containing 2 Levemir (insulin) Flex Touch pens one of which was opened and partially empty. The handwritten opened date on the Levemir flex touch pen read 01/14/17. A yellow label with special instructions placed by the facility pharmacy was noted on the Levemir Flex Touch storage box. The label showed a picture of a refrigerator with an X over it with the instruction, Do not refrigerate this product after opening for use. Store at room temperature. In an interview on 01/19/17 at 11:40 AM Nurse #1 stated special instructions provided by the pharmacy on medications needed to be followed. She indicated the Levemir Flex Touch pen should not have been placed back into the medication refrigerator after it was opened. In a telephone interview on 01/19/17 at 5:30 PM RPh #2 stated once an insulin pen was opened it should be placed in the medication cart and not put back in the refrigerator. In a telephone interview on 01/19/17 at 5:44 PM RPh #3 stated the facility should have followed the special instructions for storage of the Levemir that the pharmacy had placed on the box. In an interview on 01/20/17 at 11:10 AM the DON stated she expected the nurses to follow any special instruction labeling that the pharmacy placed on medications. 4. Review of the December 2016 Clubhouse nursing unit medication refrigerator Temperature Chart revealed: Refrigerators: 36 to 40 degrees. Abnormal temperatures: Please report to Maintenance and Southern Pharmacy immediately. According to the Temperature Chart the medication storage refrigerator in the Clubhouse medication room was installed on 12/14/16. The Temperature Chart revealed 9 out of 18 days where the temperature was below 36 degrees. 17 of the 18 recorded temperatures had staff initials next to them. Review of the January 2017 Clubhouse nursing unit medication refrigerator Temperature Chart revealed: Refrigerators: 36 to 40 degrees. Abnormal temperatures: Please report to Maintenance and Southern Pharmacy immediately. The Temperature Chart revealed 15 out of 19 days where the temperature was below 36 degrees. 19 of the 19 recorded temperatures had staff initials next to them. Review of the United Stated Food and Drug Administration literature revealed, According to the product labels from all three U. S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36 degrees Fahrenheit to 46 degrees Fahrenheit. Avoid freezing the insulin. Do not use insulin that has been frozen. In an observation on 01/19/17 at 11:30 AM the medication refrigerator temperature was 36 degrees. The medication refrigerator contained 1 unopened Humalog (insulin) flex pen, 2 unopened vials of Levemir (insulin), and a storage box containing 2 Levemir (insulin) Flex Touch pens one of which was opened and partially empty. In an interview on 01/19/17 at 11:40 AM Nurse #1 stated that storing medications outside of the parameters set by the manufacturer would impact how the medication worked. She stated if a medication was given that was stored outside the parameters it could hurt someone and the medication would not be effective. She stated medications that had been frozen should not be used and noted that the refrigerator medication storage temperatures had been as low as 28 degrees. In an interview on 01/19/17 at 12:02 PM the Maintenance Manager, who had been employed by the facility for two weeks, stated it was the Maintenance Department's responsibility to respond to nurse requests to check the medication storage refrigerators. He indicated the instructions on the refrigerator temperature charts (to notify maintenance for abnormal temperatures) should have been followed. He indicated he was not aware of any reports from staff that the medication storage refrigerator temperatures were not being maintained at the correct setting but he would check his records. In a telephone interview on 01/19/17 at 4:00 PM RPh #1 indicated medications that had been frozen should not be used. The medication could cause pain if injected. In an interview on 01/19/17 at 4:32 PM the Administrator stated there were no records that staff had notified the Maintenance Department or the Pharmacy that medication storage refrigerator temperatures were out of range. In a telephone interview on 01/19/17 at 4:46 PM Nurse #4, who had initialed 6 out of 9 of the out of parameter temperatures in December 2016 and 12 out of 15 out of parameter temperatures in January 2017, stated she had not notified the Maintenance Department or the Pharmacy when she recorded the out of parameter refrigerator temperatures. She indicated she had adjusted the temperature once but had not recorded that the temperature was okay when she rechecked it. She stated she had not notified the DON or the Administrator that maintaining the medication storage refrigerator temperatures was an issue. In a telephone interview on 01/19/17 at 5:30 PM RPh #2 stated the acceptable practice was to store medications that required refrigeration between 36 degrees Fahrenheit and 46 degrees Fahrenheit. She indicated the nurse who checked the temperature should have called the pharmacy for instructions when the medication storage refrigerator temperature fell below or rose above the acceptable parameters. In a telephone interview on 01/19/17 at 5:44 PM RPh #3 stated medications that were stored in a refrigerator where the temperature had dropped under 32 degrees may have become frozen and should not be used. In an interview on 01/19/17 at 5:50 PM the DON stated she had been made aware of the medication storage refrigerator temperature problem on the Clubhouse nursing unit on 12/26/16. She stated nurses had monitored the temperature for 24 hours and no other follow-up was done. The DON indicated she had not been informed the temperatures continued to be a problem. She indicated she expected the nurses to follow the directions on the Temperature Chart and notify the Maintenance Department and the Pharmacy immediately if the temperatures were not within the parameters on the Temperature Chart. The DON indicated the facility would be replacing the medication storage refrigerator on the Clubhouse nursing unit.

Based on observation and staff interviews the facility failed to post nurse staffing information and also failed to maintain the daily nurse staffing data. Findings included: An initial tour of the facility was begun on 01/17/17 at 10:58 AM. No current or previous nurse staffing information was observed in the facility during the initial tour. In an interview on 01/17/17 at 11:14 AM the staff member responsible for posting the staffing stated she usually placed the nurse staffing on the bulletin boards inside the nursing stations. She indicated she had not posted the staffing for that day. In an observation on 01/17/17 at 12:25 PM nurse staffing had been posted on each unit. In an interview on 01/17/17 at 4:20 PM the Administrator indicated the facility had recently undergone construction and this had caused some issues with the postings. He stated he was unable to discover exactly when the nurse staffing had last been posted as the documentation had been disposed of and not maintained. The Administrator indicated it was his expectation that nurse staffing be posted and updated daily and that the records be maintained. In an interview on 01/20/17 at 11:10 AM the Director of Nursing (DON) stated she expected the nurse staffing information to be posted daily.

Based on observation, record review and staff interviews, the facility failed to provide activities for a resident (resident #49) for 1 of 3 bedridden sampled residents. Findings include: Resident #49 was admitted [DATE] with the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated that resident #49 required total assistance for all of her activities of daily living (ADL) and had severe cognitive impairments. An activity note dated 5/21/12 stated that resident #49 remained on hospice care and unable to attend activities due to her pain. The note stated that she was able to tolerate talking once in awhile but tired easily. The noted stated that her son and daughter in law came everyday to visit. A monthly activity calendar was posted in her room. There was no evidence that AD spoke with resident #49 about her activity preferences. A review of resident #49 ' s annual MDS dated [DATE] in the Care Area Assessment (CAA) indicated that resident #49 triggered for activities, mood and psychosocial well being related to her lack of activity participation. The rationale for the lack of activity participation indicated that resident #49 was a hospice resident and that she remained in her bed where her needs were met by staff and volunteers. Activities was not care planned according the CAA because resident #49 ' s inability to participate due to end of life rather than personal choice for exclusion. A activity note dated 8/22/12 stated that resident #49 continued to stay in bed and that hospice services continued. The family and grandchildren visited resident #49 often. The staff continued to do everything for the resident and no changes made at the time The last evidence that the AD reviewed resident #49 ' s activities preferences was 8/29/12. The AD stated that resident #49 continued to stay in bed and that she was still on hospice The last activity note dated 11/19/12 stated that resident #49 was still under the care of hospice. Resident #49 was in bed daily and visitors stopped in daily. The noted indicated that resident #49 would talk if aware and seem to know who the activity director was. The noted read that resident #49 was " just unable to take part in activities. " On 2/18/13 at 12:40 pm, resident #49 was observed in her room lying in bed with the head of the bed elevated and a nursing assistant #1 (NA). sitting beside resident #49 feeding her lunch. The aide was not engaging in conversation with resident #49 but rather watching television while assisting resident #49. On 2/18/13 at 4:25 pm, resident #49 was observed in her room lying in bed on her back. There was not television or music on in her room. Resident #49 appeared asleep but easily aroused. Resident #49 stated she was not experiencing any pain. She was unable to recall when she had been gotten out of bed. Resident #49 stated she would enjoy getting out of her room if possible. On 2/19/13 at 945 am, the resident was observed in her room lying on left side in bed with eyes closed. She was easily aroused. She stated no pain and expressed no needs. The television was playing in the room. She was not engaged in watching the television. When questioned as to what she was watching, resident #49 stated she was not watching it therefore did not know what was on. On 2/19/13 at 3:30pm, the activity director (AD) stated she did not keep any sort of activity log regarding who attended activities. She stated she wrote a note in the medical record whenever a resident attended an activity. The medical record included 3 activity notes about resident #49 since May 2012. The AD stated resident #49 was on hospice for comfort measures and does not come out of her room. The AD stated that she felt it would benefit resident to leave her room but the nursing staff would not get resident up out of bed when she requested them too. The AD stated the nursing department was aware of the need to get resident #49 up out of bed. She was unable to verify any one on one activities or out of room activities with resident #49. The AD was unable to provide any evidence that any in room activities were done or taken to resident #49. She stated that the family visited resident #49 often. On 2/19/13 at 345 pm, the director of nursing (DON) stated that resident #49 was on hospice and slept in bed all day. The DON stated it was painful for resident #49 to get out of bed. On 2/19/13 at 3:50 pm, nurse #1 stated she was unaware if resident #49 ever got up or was out of her room for any activities .Resident #49 she stated she would like to get out of bed and leave her room. She stated she enjoyed listening to music and church services. On 2/19/13 at 5:00 pm, the DON stated awareness that there were no activity logs or activity notes to verify attendance of any activity attendance or attempt to get resident #49 to attend any out of room activity. On 2/20/13 at 9:00 am, nurse #2 stated that on the weekends she works she has the staff get resident #49 up to a reclining chair if only briefly to sit at the nurses station. Nurse #2 stated, resident did not appear to be in pain and tolerated sitting up for brief periods On 2/20/13 at 10:40 am, resident #49 was observed lying in bed on right side. The television was on and playing low. Resident #49 appeared to be sleeping but was easily aroused. The activity calendar was noted to be posted in her room but resident #49 stated she was unable to see it from where she was lying. Resident #49 voiced interest in music and religious services. On 2/20/13 at 11:50 am, the DON stated her expectation for activities for bedridden residents was for them to be offered to attend but a refusal should be documented and an alternate activity be considered or offered.

Based on observation, staff interview and record reviews the facility failed to apply a wheelchair alarm as indicated per the care plan for 1 of 1 sampled resident (Resident # 73). Resident # 73 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. Review of the fall CAA (Care Area Assessment) dated 12/6/2011 documented the resident" had a fall in his assisted living apartment on 11/21/2011 and finally went to the ER (emergency room ) on 11/23/2011 after which he was admitted to SNF (skilled Nursing Facility) for rehab." The admission Minimum Date Set (MDS) completed on 12/9/2011 indicated Resident # 73 's cognitive status was moderately impaired. The MDS revealed Resident # 73 required extensive assist with bed mobility and transfer. A review of the care plan dated 12/14/2011 revealed Resident # 73 was identified to have a potential for injury due to recent fall and history of falls. The care plan indicated "we have added a safety precaution bed/ chair alarm." On 12/21/2011 at 12:06 PM, Resident # 73 was observed sitting in the wheelchair in his room. There was no alarm attached to the wheelchair. The staff was not within view of the resident. In an interview on 12/21/2011 at 12:30 PM, Nurse # 2 stated the resident had a fall in his apartment before being admitted to the facility on [DATE]. Unit Nurse added she had not checked the resident since coming on her shift to ensure the wheelchair alarm was intact. She added she expected the Nursing Assistant (NA) to have put the alarm to the wheelchair after placing the resident in the wheelchair. In an interview on 12/21/2011 at 12:35 PM, NA # 1 indicated she was aware Resident # 73 was to have a wheelchair alarm in place when in the wheelchair. NA # 1added she did not recall putting the alarm to the wheelchair after getting the resident up in the morning. In an interview on 12/21/2011 at 12:40 PM, the Director of Nursing (DON) indicated she expected all staff to ensure the resident wheelchair alarm was intact. The DON concluded she expected the alarm to be intact on the wheelchair as indicated per the care plan.

Based on observation, record review, and staff interviews the facility failed to prevent a significant medication error for 1 of 10 sampled residents (Resident #57), that resulted in the wrong dosage of [MEDICATION NAME] administered. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. The quarterly Minimum Data Set completed on 12/23/11 indicated Resident #57 was cognitively intact. A review of a physician telephone order dated 12/20/11 during drug reconciliation revealed [MEDICATION NAME] 7.5 milligram (mg) was to be administered on Monday, Wednesday, Friday and Sunday; and [MEDICATION NAME] 5mg was to be administered on Tuesday, Thursday and Saturday. A review of the MAR (Medication Administration Record) dated 12/20/11 revealed [MEDICATION NAME] 7.5 mg was administered in error on 12/20/11 (Tuesday) by Nurse #1. On 12/20/11 at 4:05 PM, during a medication observation Nurse #1 administered [MEDICATION NAME] 7.5 mg one tablet to Resident #57 by mouth. In an Interview on 12/20/11 at 4:45 PM, Nurse #1 stated she administered [MEDICATION NAME] 7.5 mg as indicated on the MAR. She added, the MAR indicated [REDACTED]. In an Interview on 12/21/11 at 10:32 AM, the Director of Nursing (DON) indicated she expected the correct dosage of [MEDICATION NAME] to be administered ([MEDICATION NAME] 5 mg). The DON concluded the facility did not have a system in place to date, to verify if medications had been transcribed correctly onto the MAR by the nurses. In an interview on 12/21/11 at 11:00 AM, Nurse #2 stated she incorrectly transcribed the dates onto the MAR.

Based on observations and staff interviews, the facility failed to properly store plastic utensils to prevent contamination and failed to ensure food items were completely covered during transport from the kitchen to the dining room. Findings include: 1. During kitchen observations on 1/19/11 at 12:05 PM, plastic utensils were noted in a storage area in two plastic bags within two cardboard boxes. The plastic bags were open, exposing the plastic utensils to dust, spillage, and contamination. The storage area also contained bottles of cleansers and sanitizers which had not been opened. Observations on 1/20/11 at 11:40 AM revealed the two plastic bags of utensils had been placed in plastic bins instead of cardboard boxes. The plastic bags remained open and there were no lids on the bins. The cleansers and sanitizers had been removed to another area. During an interview on 1/20/11 at 11:40 AM, the Certified Dietary Manager (CDM) stated, "They (plastic utensils) should be covered." The Dietary Manager placed metal pans on top of the plastic bins which covered the utensils. The Dietary Manager stated, "We'll get lids for these bins." 2. During an observation on 1/20/11 at 12:20 PM, Dietary Staff #1 was observed pushing the meal tray cart by the nursing station from Tartan 1 down the halls to the dining room by Tartan 2 nursing station. It was a metal cart without doors. There were slices of chocolate pie on individual plates on the resident's meal trays that were not covered. There was a very small piece of clear wrap that covered a part of the top of the pies, leaving the desserts exposed during transport through the facility from the kitchen to the dining room. Dietary Staff #1 was questioned about the education he had received regarding transporting food on the carts. He stated he washed dishes only, but transported the carts to the halls every day. He indicated he had not received any education about making sure the food was covered during transportation. Dietary Staff #1 stated he did not prep the food or place it on the carts, just delivered the cart only. On 1/20/11 at 12:25 PM, the meal trays were observed being delivered to residents at their tables in the dining room. During an interview on 1/20/11 at 2:15 PM, the Certified Dietary Manager (CDM) stated, "The desserts should have been completely covered by the plastic wrap. That was an oversight on our part."

Based on observation and staff interviews, the facility failed to ensure proper labeling of one medication on one of three medication carts and failed to ensure the medication cart was maintained in a locked position when out of sight of the medication nurse for two observations of one of three medication carts. Findings included: 1. During a medication cart check on 1/18/2011, it was observed that a medication called Fluticasone Propionate (Flonase) had a label stating the medication was Nasonex. The plastic bag containing the medication also was labeled Nasonex. The Geriatric Dosage Handbook (12th Edition) indicated Fluticasone Propionate is a corticosteroid inhalant used in the treatment of [REDACTED]. Brand names included: Cultivate, Flonase and Flovent HFA. Nasonex is also a corticosteroid inhalant used for the maintenance treatment of [REDACTED]. Brand names included: Asmanex, Twisthaler, Elocon and Nasonex. On 1/18/2011 at 1:00 PM., the Director of Nursing observed the medication and stated that the label on the medication and the bag containing the medication indicated the medication was Nasonex when, in fact, it was Flonase. She indicated she expected the pharmacy to label medications properly. 2. During medication pass observation on 1/18/2011 at 3:45 PM., Nurse #2 obtained medications for a resident, closed the drawer of the medication cart and entered the resident's room to administer the medication. The medication cart was out of view of the medication nurse. The lock on the medication cart was protruding out indicating the cart was unlocked. On 1/18/2011 at 3:50 PM., Nurse #2 stated he should have locked the cart when he left it. He indicated he did not lock it because the cart was so close to the room and he knew he would be in and out of the room quickly. On 1/18/2011 at 4:40 PM., the Director of Nursing indicated she expected the medication cart to be locked when the cart was out of view of the nurse. On 1/20/2011 at 6:45 PM., Nurse #2 obtained medications for a resident, closed the drawer of the medication cart and entered the resident's room to administer the medication. The medication cart was out of view of the medication nurse. The lock of the medication cart was protruding out indicating the cart was unlocked. On 1/20/2011 at 6:50 PM., Nurse #2 indicated he should have locked the cart when he left it. He indicated he just forgot.

Based on observation, staff interview and record review, the facility failed to evaluate and attempt a restraint reduction for 1 of 2 residents with restraints (#7). Findings: A review of the facility's Restraint Policy and Procedure, dated 3/02, indicated "3. Evaluation A. Evaluate need for continued use of restraint at each care conference or sooner if indicated. B. Evaluate trials without restraint in order to reduce its use." Resident #7 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had moderately impaired cognitive skills and long and short term memory problems. She required extensive assistance with bed mobility, dressing, hygiene and bathing. She required extensive assistance with locomotion off unit. She did not ambulate during the assessment period. The MDS further indicated the resident had a trunk restraint that was used daily. A review of the resident's care plans, last updated on 12/22/10, indicated there were no care plans to address the use of the restraint. A review of the nurse's note indicated the following: 4/22/10 at 11:48 a.m. - resident tried to get up out of the wheelchair by herself. 4/27/10 at 1:47 p.m. - Nurse called the resident's physician to obtain an order for [REDACTED]. 4/27/10 at 3:21 p.m. - Nurse went to the dining room earlier that morning and the resident was attempting to get up from the dining room chair. "Resident had already gotten up from her wheelchair and gotten into the dining room chair. Has made many other attempts to get up on her own today. Order obtained for use of a lap buddy to prevent falls." A lap buddy was placed on the resident's wheelchair. A review of a Pre-Restraining Assessment, dated 4/27/10, included a section that indicated "Alternatives to restraints (include length of time to be tried." It was blank. A review of the nurse's note indicated the following: 4/28/10 at 9:13 p.m., 4/30/10 at 2:19 p.m., and 5/4/10 at 11:55 a.m. - resident had attempted to get up out of the wheelchair even with the lap buddy in place. 5/14/10 at 4:50 p.m. - indicated the facility would try a waist restraint rather than the cushion enabler because it was bothering the resident to have the cushion sitting on her legs. A review of a Pre-Restraining Assessment, dated 5/14/10, indicated the lap buddy was changed to a waist restraint to allow more leg movement. "Alternatives to restraints (include length of time to be tried" was blank. A review of the nurse's note, dated 7/4/10 at 11:08 a.m., indicated the resident attempted to get up unassisted. A review of a Pre-Restraining Assessment, dated 8/10/10, indicated under the section "Interdisciplinary Team Evaluation" "Recommendation", "Continue with use of waist restraint." "Alternatives to restraints (include length of time to be tried" was blank. A review of the nurse's note indicated the following: 9/14/10 at 3:58 p.m. - "In S.O.C. (standards of care meeting) we discussed the use of the waist restraint and we think we should continue the use of it when she's out of bed because it allows her to wander without falling. Without the waist belt she would try to stand and walk which she cannot do independently." A review of a social work note, dated 9/28/10 at 8:31 p.m., indicated, "A restraint is used to prevent her from getting up, as she does not understand the risk of falling." A review of a Pre-Restraining Assessment, dated 1/11/11, indicated to continue with the use of the soft waist restraint. "Alternatives to restraints (include length of time to be tried" was blank. A nurse's note, dated 1/15/11 at 12:46 p.m., indicated the resident had been observed trying to stand up from the wheelchair. The waist belt was in place. During an observation on 1/19/11 at 10:15 a.m. and 1/20/11 at 10:20 a.m., Resident #7 was observed with a soft waist restraint that tied to the back of her wheelchair. It was not self releasing. During an interview on 1/20/11 at 10:10 a.m. and 11:56 a.m., Nurse #1 stated Resident #7 had a soft waist restraint to prevent falls. She stated the resident does not ambulate. She indicated she had attempted to walk the resident a few weeks ago and "she could not last long." She stated if the resident did not have the seat waist restraint on, she would probably find a way to get out of the wheelchair. She indicated the resident did not have the strength to stand up from the wheelchair. She was questioned if they had attempted to reduce or discontinue the use of the restraint and she indicated they had not. During an interview on 1/19/11 at 12:15 p.m., Nursing Assistant (NA) #1 stated the resident did not attempt to get up out of her chair as often now. She stated it took 2 people to walk her to the bathroom. She stated the resident walked with a "bent over" posture. During an interview on 1/19/11 at 11:45 a.m., the Assistant Director of Nursing (ADON) stated they had a standards of care meeting once monthly to discuss restraints. She indicated initially they had used a lap buddy with Resident #7, but they felt it was too restrictive. She stated they would have documented on the Pre-Restraining Assessment if a restraint reduction was attempted. She reviewed the Pre-Restraining Assessments and indicated there had been no attempted restraint reduction. The ADON indicated the justification of the restraint was that the resident couldn't remember due to dementia and she needed assistance with her activities of daily living. During an interview on 1/20/11 at 9:30 a.m. and 3:10 p.m., the Rehab Manager indicated the rehabilitation department was usually involved with restraint reduction. He stated he had spoken with the facility's physical therapist and she indicated she had not been involved with a restraint reduction for Resident #7. During an interview on 1/19/11 at 4:15 p.m., the Director of Nursing stated they should be assessing for a restraint reduction on a quarterly basis. She stated during the reduction attempt, they would ask the nurses to leave it off for a few hours and see if the resident tried to get up. They would then review the findings during the monthly or quarterly meeting. She indicated they had not attempted a restraint reduction for Resident #7.