Every finding on record at Scott Health & Rehabilitation

Based on observations, interviews, and record review, the facility failed to maintain sanitary conditions in the kitchen related to unclean refrigerator and failed to properly use the dish machine and the 3-compartment sink correctly to prevent food borne illness. This deficient practice had the potential to effect 44 residents receiving an oral diet. Findings include: On 8/26/22 at 7:44 a.m. an initial tour of the kitchen was conducted. The following was observed: * White stand-up refrigerator/freezer on the back porch was observed with seven dead flies in the bottom of the refrigerator; under the vegetable bins, multiple dead flies observed; and vegetable bins unclean, sticky with food crumbs. * Dish machine was observed being used by the Assistant Dietary Manager. She was observed to cycle three loads of dishes and put them away. First load wash cycle temperature reached 80 degrees Fahrenheit (F) and the rinse cycle reached 90 degrees F; The second load wash cycle reached 86 degrees F and the rinse cycle reached 104 degrees F. On the third load, the Assistant Dietary Manager was asked to confirm the temperatures. She confirmed that the temperature for the wash cycle reached 95 degrees F and the rinse cycle reached 110 degrees. She stated that about a month ago, they had concerns with the water temperatures not reaching the required 120 degrees F in the dish washer and the facility purchased a new water heater. She stated they had to go to paper products temporarily until the water temps were corrected. She confirmed that the temperatures were not reaching the 120 degrees F today and that she would call maintenance and rewash all the dishes once the temperature was corrected. She stated that they are to check the temperature multiple times when washing dishes, but she had not checked the temperature today because she just started washing dishes. At that time, the Assistant Dietary Manager was asked to check the sanitizer in the three-compartment sink. She checked with multiple strips which revealed there was no sanitizer agent in the water. Assistant Dietary Manager was observed to let the water out and stated she was going to call maintenance. * Above the air-conditioning unit on the wall in the kitchen, a build-up on black dust was observed on the ceiling. This was directly over the dish machine where clean dishes were coming out and were stored. * Dirt and dust build-up was observed on the box of one fire extinguisher and on top of a second fire extinguisher. Both were directly over open, exposed napkins. On 8/27/22 at 9:10 a.m. Certified Dietary Manager (CDM) was observed using the dishwasher. Observation with the CDM and the Maintenance Director revealed the temp was 102 degrees F for the wash cycle and 120 degrees F for the rinse cycle. The CDM stated that if the dishwasher wasn't in use for a while, they had to run it twice to get the temperature back up. She was observed to wash the same dishes in a second cycle. That second cycle temps were 122 degrees F for the wash and 134 degrees F for the rinse. She stated that the kitchen staff are supposed to know the process of running the dish machine multiple times until the temperature is over 120 degrees F. At that time, the Maintenance Director stated that the dust build-up on the ceiling was last cleaned last summer. He stated that he hadn't even seen the build-up and that he would have to come during the night shift to clean it. During this observation with the CDM, she confirmed an observation of flies in the double door reach-in refrigerator and in the white stand-up refrigerator on the back porch. The CDM stated that they clean the refrigerator once a week and stated they had not been having any issue with flies. On 8/27/22 at 9:40 a.m. the Maintenance Director stated that he will suggest to the CDM that they run a cycle first before doing any dishes so that the temp can get up to the correct temperature. During a comprehensive tour of the Kitchen on 8/27/22 at 2:07 p.m. the CDM confirmed dirt/dust build up on ceiling and on two fire extinguishers. She stated that she had cleaned the flies out of the refrigerators; however she confirmed during this observation, there was another fly on the bottom of the white stand-up refrigerator and there was still debris/crumbs under and in the vegetable bins. On 8/27/22 at 2:26 p.m. during an interview with the Administrator, she stated that she was not sure about the processes of kitchen cleaning and who was responsible for the dust build-up on the ceiling in the kitchen. She was asked to provide any process or policy related to cleaning in the kitchen. She stated that she was not aware of a concern related to flies in the refrigerators on the back porch but that she would address it.

Based on observations, record review, and interviews, the facility failed to implement the care plan for two of 23 sampled residents (R) (R#13, R#39) related to ensuring that the over the bed table (with personal items) was pulled within reach for R#13 and ensuring the call light was accessible for R#13 and R#39. Further, the facility failed to develop a care plan for one of 23 sampled residents (R#11) related to contractures. Findings include: 1. A review of R#13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. A review of R#13's Care Plan last updated 8/17/22 revealed resident is at risk for falls and to keep personal items within reach. Observation on 8/27/22 at 9:30 a.m. R#13 was observed in bed. There was a cup of water and snacks on his bedside table, but the table was near the window and the resident could not reach it if he wanted it. Observation on 8/27/22 at 11:10 a.m. R#13 was observed in bed. The call light was clipped to the upper right side of bed. Resident stated he could not reach it and asked for assistance with placing it within his reach. He confirmed at this time that he could not reach items on his bedside table because it was placed near the window and not next to his bed. Observation and interview on 8/27/22 at 11:13 a.m. Certified Nursing Assistant (CNA) HH stated that the call light was supposed to be attached near R#13's hands so that he could use it when needed. She confirmed that he could not reach up to get it where it was located at this time. She was observed to place the call light cord near the resident's hand. When asked about the bedside table, she stated that he could get to his personal items himself if the table was pulled over to him. She was observed to place the bedside table within his reach. 2. A review of R#39's Annual MDS dated [DATE] revealed a BIMS score of 14, indicating intact cognition and one-person extensive assist with toileting. A review of the Care Plan last updated 8/16/22 noted that R#39 is at risk for falls with intervention to keep call light in reach. Observation and interview on 8/27/22 at 1:57 p.m. revealed R#39 sitting in a Broda Chair. The call light was on the bed, not within her reach. She stated that she needed to go to the bathroom and was trying to get someone to come into her room to help her, but she couldn't find her call light button. 3. Review of R#11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#11's quarterly MDS dated [DATE] revealed Section C-Cognition: BIMS score of five (5) indicating poor cognition; Section G-Functional Status: resident was totally dependent for all activities of daily living (ADL's). The MDS did not indicate the resident was receiving therapy or restorative nursing. Review of R#11's Care Plan revealed a plan in place for self-care deficit and needs assistance using utensils and bringing food/liquids to mouth. Further review of the care plan revealed no care plan in place for the use of bilateral palm protectors or for the bilateral hand contractures. Review of R#11's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] One time per day wipe both hands to ensure they are clean and apply bilateral palm protectors for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 8/26/22 at 11:47 a.m. revealed R#11 had bilateral contractures of hands and wrists. There were no splints noted on/in hands, wrists, or arms. Observation on 8/27/22 at 12:18 p.m. revealed R#11 in her bed, feet elevated on heel block, and no splints noted on hands. R#11 was able to open her hands and she was able to open them halfway. She indicated she doesn't wear hand splints. No palm protectors noted in either hand. Observation and interview on 8/28/22 at 8:39 a.m. revealed R#11 sitting up in bed being fed by CNA CC. There were no splits noted on hands. CNA CC revealed she cleans R#11's hands during ADL care and sometimes she puts wash cloths in her hands. An interview held on 8/28/22 at 8:46 a.m. with Licensed Practical Nurse (LPN) AA revealed when she works at night, she cleans the R#11's hands and puts a rolled-up wash cloth in the residents' hands. An observation and interview held on 8/28/22 at 9:00 a.m. the Director of Nursing (DON) revealed that both of R#11's hands were clean with no redness or odor noted from palms of hands. She indicated the splints are put on her hands at night and removed in the morning. A phone interview held on 8/28/22 at 9:33 a.m. with the MDS Coordinator BB, who is also the Restorative Nurse, revealed the resident is not on restorative services at this time. She indicated residents are reevaluated for the need for restorative during the period around completing a comprehensive assessment. If the DON indicates a decline in function or a new concern, she will reevaluate the need for restorative services. She indicated the resident has a current order for splints, and she would expect her to have a care plan for it.

Based on observations, interviews and record review, the facility failed to accommodate the needs of two of 23 sampled residents (R) (R#13, R#39) by not ensuring the over the bed table (with personal items) was pulled within reach for R#13, and not ensuring the call light was accessible for R#13 and R#39. Findings include: 1. A review of R#13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition. A review of R#13's Care Plan last updated 8/17/22 revealed resident is at risk for falls and to keep personal items within reach. On 8/27/22 at 9:30 a.m. R#13 was observed in bed. There was a cup of water and snacks on his bedside table, but the table was near the window and the resident could not reach it if he wanted it. On 8/27/22 at 11:10 a.m. R#13 was observed in bed. The call light was clipped to the upper right side of bed. Resident stated he could not reach it and asked if I could get it for him. He confirmed that he could not reach items on his bedside table because it was still placed near the window and not next to the bed. On 8/27/22 at 11:13 a.m. an interview was conducted with Certified Nursing Assistant (CNA) HH. She stated that the call light was supposed to be attached near R#13's hands so that he could use it. She confirmed that he could not reach up to get it where it was located at this time. She was observed to place the call light cord near the resident's hand. When asked about the bedside table, she stated that he could get to his personal items himself if the table was pulled over to him. She was observed to place it within his reach. 2. A review of R#39's Annual MDS dated [DATE] revealed a BIMS score of 14, indicating intact cognition and one-person extensive assist with toileting. A review of the Care Plan last updated 8/16/22 noted that R#39 is at risk for falls with intervention to keep call light in reach. Observation and interview on 8/27/22 at 1:57 p.m. revealed R#39 sitting in a Broda Chair. The call light was on the bed, not within her reach. She stated that she needed to go to the bathroom and was trying to get someone to come into her room to help her, but she couldn't find her call light button. Observation and interview on 8/27/22 at 1:59 p.m., Licensed Practical Nurse (LPN) DD walked in the room and stated that she would assist the resident to the bathroom. She confirmed that the call light was not within reach. She stated that the staff are supposed to put it on the chair when R#39 is up in the chair so that she can call for assistance as needed.

Based on observations, clinical record review and staff interview the facility failed to ensure behavior monitoring was reviewed and utilized regarding an attempt at gradual dose reductions for an antipsychotic medication for Residents (R#7 and R#52). This affected 2 residents of 5 reviewed regarding unnecessary medications. Findings include: 1. R#7 had [DIAGNOSES REDACTED]. The medical record current Physician order [REDACTED]. The medication had no attempted gradual dose reductions since the order date. The medical record Minimum Data Set (MDS) quarterly assessment dated [DATE] (Section C) regarding cognitive status, revealed the resident's Brief Interview for Mental Status (BIMS) score was five out of a possible 15, which indicated the resident was severely cognitively impaired. The MDS also revealed the resident received antipsychotic medication. The MDS quarterly assessment dated [DATE] revealed the BIMS was a score of seven out of 15, which indicated the resident was severely cognitively impaired. The medical record Care Plan dated 7/5/17 revealed [MEDICAL CONDITION] drug use due to [MEDICAL CONDITION]. The Care Plan dated 7/5/17 revealed the resident had a cognitive deficit with decision making. The medical record Behavior Monitoring forms dated 7/1/17 through present revealed the resident had 19 episodes of delusions, impulsive aggression, purposeful vomiting. The monitoring forms revealed 14 of the episodes had a positive response to non-pharmacological interventions. R#7 was observed in the wheelchair in the dining room on 9/18/17 at 12:40 p.m., eating lunch independently and was further observed in the wheelchair in her room on 9/19/17 at 9:20 a.m., She was not observed exhibiting any behaviors according to the Behavior Monitoring forms documentation. An interview with the Regional Registered Nurse (RRN) on 9/20/17 at 3:30 p.m. verified there were no gradual dose reductions attempted for the [MEDICATION NAME] (an antipsychotic) since the order on 11/19/10. The facility policy regarding Monitoring of Antipsychotics, updated January 2016 indicated .the continued use of an antipsychotic medication is reassessed monthly by the responsible physician.The gradual dose reduction is attempted with all patients who receive antipsychotic medications. 2. Review of the medical record for R#52 revealed [DIAGNOSES REDACTED]. The medical record current Physician order [REDACTED]. There were no attempted gradual dose reductions since the medication had been ordered. The medical record quarterly MDS assessments date 5/9/17 and 8/4/17 revealed the BIMS (Section C) was unable to be performed due to the resident was unable to respond. In (Sections D and E) which reflect mood and behavior, indicated the resident had hallucinations and delusions, however exhibited no mood or behaviors and was rarely or never understood. The medical record Care Plan dated 8/16/17 revealed .the resident should be monitored for side effects related to [MEDICAL CONDITION] side effects. The care plan dated 8/16/17 indicated .the resident had a cognitive deficit associated with dementia evidenced by the inability to communicate. The care plan dated 8/16/17 revealed .the resident had a self-care deficit that required total care by the staff for activities of daily living. Observations of R#52 were made on 9/18/17 at 12:30 p.m., in the dining room. The resident was in a cushioned high back chair being fed a pureed lunch by the staff. The resident was eating without difficulty. The resident was in the high back cushioned chair in her room on 9/19/17 at 9:15 a.m. Very little verbalization then she shut her eyes. On 9/20/17 at 10:30 a.m., an interview with the RRN verified the Behavior Monitoring forms for June 2017 through present revealed the resident had nine episodes of reaching for things in front of her that were not there. The Behavior Monitoring forms indicated there were non-pharmacological interventions which had a positive effect on the resident. She verified there had been no gradual dose reductions since the order on 4/29/15. R#52 was observed on 9/20/17 at 11:30 a.m., in the high back cushioned chair in her room with her eyes closed. The Licensed Practical Nurse (LPN) AA spoke to the resident about glucose testing and insulin administration. The resident spoke a few words that were not comprehensible. The resident closed her eyes after receiving the insulin. An interview with LPN AA at 11:40 a.m., revealed the resident had a pleasant demeanor and preferred to sleep. The resident was observed on 9/20/17 at 12:20 p.m., in a chair in the dining room at the table. An aide was sitting next to the resident feeding her the pureed lunch. The resident was observed to be cooperative and did not speak. The facility policy regarding Monitoring of Antipsychotics, updated January 2016 indicated .the continued use of an antipsychotic medication is reassessed monthly by the responsible physician.The gradual dose reduction is attempted with all patients who receive antipsychotic medications.

Based on clinical record review and staff interview the facility failed to ensure one Resident (R#7), who was severely cognitively impaired, had a responsible party to assist with making decisions. The sample size was 20 residents. Findings include: Medical record review revealed R#7 had [DIAGNOSES REDACTED]. The current medical record Physician order [REDACTED]. The medication had no attempted gradual dose reductions since the order date. The medical record Minimum Data Set (MDS) quarterly assessment dated [DATE], (Section C) regarding cognitive status, revealed the resident's Brief Interview for Mental Status (BIMS) was a five out of a possible score of 15, which indicated the resident was severely cognitively impaired. The MDS also revealed the resident received antipsychotic medication. The MDS quarterly assessment dated [DATE] revealed the BIMS was seven out of 15, which indicated the resident was severely cognitively impaired. The medical record Care Plan dated 7/5/17 revealed the resident had a cognitive deficit with decision making. R#7 was observed in the hall on 9/20/17 at 2:15 p.m., She asked the surveyor to help her find out about a paper. She stated it had to do with taking care of her. The surveyor informed the resident she would have a staff person assist her with her question. An interview with the Administrator on 9/20/17 at 2:30 p.m., revealed R#7 did not have a responsible party. She stated the resident was not cognitively able to make her own decisions. The Administrator further stated the physician and the ethics committee made the decision the resident was to be a Do Not Resuscitate (DNR). The Administrator indicated she signed the resident's documents when she needed to go to the hospital and there had never been an effort made to get a guardian/responsible party to make decisions for the resident. An interview with the Social Worker (SW) on 9/20/17 at 2:50 p.m., verified R#7 had no responsible party. She stated the resident was unable to make her own decisions. She further stated, It has been like that since I got here a year ago. An interview on 9/20/17 at 3:45 p.m., with the Administrator revealed there was no facility policy and procedure regarding residents who were unable to make informed decisions yet had no responsible party.

Based on medication administration observation, record review and staff interviews, the facility failed to ensure that their medication error rate was less than five percent (5%). There was a total of two (2) medication errors in twenty-five opportunities observed made by two (2) of two (2) nurses, for a medication error rate of eight percent (8%). A total of three (3) residents were observed during the med pass. Findings include: 1. Observation of medication administration on 7/19/16 at 8:30 a.m., Licensed Practical Nurse (LPN) AA applied [MEDICATION NAME] one percent (1%) topical gel two (2) grams to resident #56's left hand. Review of resident #56's physician's orders [REDACTED]. Use supply on hand. Review of the Medication Administration Record [REDACTED]. Use supply on hand. Continue order for as needed (prn) as previously written. [DIAGNOSES REDACTED]. During an interview with LPN AA on 7/19/16 at 9:30 a.m. he/she confirmed he/she applied the [MEDICATION NAME] 1% gel to resident #56's left hand. LPN AA further revealed the treatment nurse told him/her to apply the [MEDICATION NAME] to the resident's left hand. Further interview with LPN ''AA on 7/19/16 at 10:25 a.m. revealed LPN AA stated he/she should have applied the [MEDICATION NAME] gel to the resident's back because the [DIAGNOSES REDACTED]. LPN AA further revealed that the MAR indicated [REDACTED]. Review of the physician's orders [REDACTED]. Interview on 07/19/16 at 10:40 a.m. with the Director of Nurses (DON) confirmed the order for the [MEDICATION NAME] was not clear because it did not say where to apply the [MEDICATION NAME] but she further stated that because the MAR indicated [REDACTED]. The DON stated the Physician order [REDACTED]. Interview on 07/19/16 at 11:00 a.m., with the DON revealed that she expected for the nurse to put the [MEDICATION NAME] 1% gel on the resident's back since the [DIAGNOSES REDACTED]. The DON further revealed she expects the physician's orders [REDACTED]. 2. During observation of medication administration on 7/19/16 at 8:45 a.m. with Licensed Practical Nurse (LPN) BB, LPN BB was observed administering Vitamin D3 one thousand (1,000) units per tablet one (1) tablet by mouth (po) to resident #41. Review of resident # 41's physician's orders [REDACTED]. Interview on 07/19/16 at 10:42 a.m. with Licensed Practical Nurse (LPN) BB confirmed that he/she administered only one (1) of the two (2) Vitamin D3 one thousand(1,000) unit tablets to resident # 41. LPN BB confirmed that he/she should have administered two Vitamin D3 tablets as ordered on the physician's orders [REDACTED].>Interview on 07/19/16 at 11:00 a.m., with the DON regarding medication administration observed for resident # 41, the DON revealed that she expects the physician's orders [REDACTED].#41 should have been administered two (2) Vitamin D3 one thousand (1,000) unit tablets as ordered by the Physician. DONE

Observation on 3/10/15 at 7:25 a.m. revealed that CNA " DD " had to move a table to allow a random resident in a wheelchair room to exit the dining room. Based on observation and staff interview, the facility failed to provide adequate space and accommodation for meals during the first seating arrangement for twenty eight (28) of thirty five (35) residents. Findings Include: The initial dining room observation on 3/9/2015 at 12:35 p.m. revealed a crowded seating arrangement of the residents. A resident sitting in a geri chair was position at a rear center table and was blocking the aisle walkway in the dining room. A random wheel chair bound resident tried to leave the dining room but lacked the space to maneuver his/her wheel chair. Certified Nurse Aide (CNA) "AA" was observed to stop feeding a resident to move chairs and a table to allow this wheel chair bound resident to exit the dining room. Dining observation on 3/9/2015 at 12:50 p.m. revealed a random ambulatory resident attempting to exit the dining room, but the resident's pathway was blocked by a staff member feeding a resident at another table. The ambulatory resident had attempted to move a table in order to leave the dining room. At this time, CNA " BB " stopped feeding a resident and got up to move the table that was blocking this ambulatory resident's pathway. Observation on 3/10/15 at 7:20 a.m. revealed that CNA " BB " stopped feeding a resident to move the CNA's chair and to allow CNA " CC " to pass with a chair which was placed at another table where a resident was waiting to be assisted with feeding. Observation on 3/10/15 at 12:42 p.m. revealed a random ambulatory resident attempting to exit the dining room, however other residents chairs and staff assisting with feeding was blocking the resident's exit. The resident stood by the table and looked around for a space to exit. During an interview on 3/11/15 at 8:00 a.m. revealed that CNA " DD " verified that he/she had to move a table to help a random wheel chair resident exit the dining room. During an interview on 3/11/15 at 8:20 a.m. revealed that CNA " BB " verified he/she had to stop feeding a resident to move his/her chair to allow CNA " CC " to pass with a chair requiring CNA "BB" to stop feeding a resident during the move. During an interview on 3/11/15 at 8:13 a.m. revealed that the Director of Nursing (DON) verified that there was a crowding problem during the first seating arrangement in the dining room.

Based on record review, staff interview and review of the facility "Medication Administration-General Guidelines" the facility failed to maintain accurate clinical record regarding the administration of anticoagulant medication for one (1) of eighteen (18) sampled residents. Findings include: Review of resident #60's clinical record revealed a 1/19/15 physician's orders [REDACTED]. However, review of the Medication Administration Record [REDACTED]. An interview with Registered Nurse (RN) "FF" on 3/12 /2015 at 8:47 a.m. revealed that while he/she had administered the [MEDICATION NAME] as ordered he/she had failed to initial the medication as administered on 1/31/15. Review of the facility "Medication Administration-General Guidelines" revealed under Procedural Guidelines, #10. The resident's Medication Administration Record [REDACTED]. Initials on each MAR indicated [REDACTED]. An interview with the Director of Nurses (DON) on 3/12/2015 at 8:16 a.m., revealed that the nurses responsible for medication administration on the above dates had failed to document the [MEDICATION NAME] as administered. The DON further stated that it was his/her expectation that the nurse initial the Medication Administration Record [REDACTED].

Based on staff interviews and record review the facility failed to assess one (1) resident's (#66) nutritional needs in a timely manner of twenty (20) sampled residents. Findings include: Review of the clinical record for resident # 66 revealed a hospital stay from 6/26/13 thru 7/23/13 with a [DIAGNOSES REDACTED]. Upon readmission to the nursing home on 7/23/13 the resident's weight was 219. Review of the resident's 7/23/13 Treatment Administration Record (TAR) revealed the resident had a stage 4 pressure ulcer on his/her coccyx, a deep tissue injury to the right and left heels, and a stage 2 pressure ulcer to the ischial. Review of the resident's medical record of 7/29/13 revealed the resident's weight was recorded as having been two hundred and four (204) pounds, a fifteen (15) pound loss since readmission. Review of the medical record revealed the facility addressed the resident as having a significant weight loss on 8/1/13 in a Patient at Risk ( PAR) review form however, there were no interventions or recommendations to address the weight loss. An interview on 9/26/13 at 9:30 a.m. with the Dietary supervisor revealed that the nutritional assessment for new admissions and readmissions should be completed within fourteen (14) days of admission, Further interview revealed that the facility had a Registered Dietitian (RD) who visited the facility once a month to assess residents. She further stated that the RD would not be called for a resident with pressure sores or weight loss but would be seen on the RD's next facility visit. An interview on 9/26/13 at 11:00 a.m. with the Director of Nurses (DON) revealed that the facility should have contacted the RD concerning the resident's weight loss and should have implemented the facility's wound care nutrition algorithm which included the use of vitamins and oral supplements. Record review of the RD's 8/8/13 assessment revealed that the resident had inadequate energy intake related to acute illness (ileus requiring nothing by mouth or clear diet for extended period of time) as evidenced by an eighteen (18)% weight loss for one (1) month. She recommended that the resident receive:1) one (1) multivitamin with minerals a day; 2) 500 milligrams of Vitamin C twice a day; 3) 30 milliliters of liquid protein supplement three (3) times a day until wounds were healed; and Ensure Clear every day between meals.

Based on record review and staff interview, it was determined that the facility failed to follow the care plan intervention related to monitoring and documenting behaviors for one (1) resident (#54), of twenty (20)sampled residents. Findings include: Review of the clinical record for resident #54 revealed the resident had multiple [DIAGNOSES REDACTED]. Review of the resident's care plan dated 5/30/13 to address the resident's need for [MEDICAL CONDITION] medication related to [DIAGNOSES REDACTED]. Review of the resident's Medication Administatrion Record (MAR) for July, August and September 2013 revealed there was not any documentation regarding monitoring and behaviors each shift. Review of the nursing notes for the same time frame revealed no documentation of monitoring or behaviors by the facility staff. An interview with the Director of Nursing (DON) on 9/26/13 10:15 a.m. revealed that monitoring for behaviors and/or side effects of residents receiving an antipsychotic medication are to be done by the Nurses each shift and documented on the residents MAR. The DON confirmed that licensed nurses had failed to monitor for side effects/effectiveness or to document any behaviors. Please Cross refer to F329

Based on record review and staff interview the facility failed to monitor for behaviors and/or side effects for one (1) resident #54 who was receiving an antipsychotic medication of twenty (20) sampled residents. Findings include: Review of the clinical record for resident #54 revealed the resident had a current physicians order for an antipsychotic medication, [MEDICATION NAME] 100 milligrams, every day as well as a care plan dated 5/30/13 to address the resident's need for [MEDICAL CONDITION] medication related to [DIAGNOSES REDACTED]. Review of the resident's care plan revealed an intervention for nursing staff to monitor and document frequency and behaviors resident exhibits. Review of the July, August and September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview with the Director of Nursing (DON) on 9/26/13 10:15 a.m. revealed that monitoring for behaviors and/or side effects of residents receiving an antipsychotic medication are to be done by the nurses each shift and documented on the residents MARS. The DON confirmed that licensed nurses had failed to monitor/document any behaviors and/or side effects for the resident.

Based on observation and staff interview the facility failed to ensure that planned menus were followed to provide accurate portion sizes for eight ( 8) residents receiving regular diets and ten (10) residents receiving a pureed diet from a total of twenty (20) residents being served in the main dining room from a total census of (fifty) 57 residents. Findings include: Observation of the lunch meal conducted 9/25/13 at 12:30 p.m. revealed the meal consisted of a pork and cheddar bake, California vegetable blend, a dinner roll and bake apples. Continued observation of the lunch meal being served to 18 of the 20 residents seated in the main dining room for the lunch meal revealed residents in the dining room who were on a regular diet received one (1) white handled scoop portion of the pork/cheddar bake and the residents on a pureed diet received one (1) green handled ladle portion of the pork/cheddar bake. Review of the therapeutic menu listed that a resident on a regular diet should receive nine (9) ounces of the pork and cheddar bake and residents on the pureed diet should receive two (2) # eight (8) scoops. Review of the weekly menu revealed that a number eight (8) scoop to equal 4- 5 ounces. While all other served items were adequately measured and served, the pork and cheddar bake was not measured correctly before being served which was confirmed by the Dietary Supervisor, during an interview on 9/25/13 at 3:30 p.m., revealing that the white handled scoop and the green handled ladle each measured a four (4) ounce serving and that the residents did not receive the required portions listed in the menus. .

Based on observations conducted during medication pass, it was determined that the facility failed to ensure that it was free of a medication error rate of five (5) percent or greater. Findings include: Observations conducted on 3/14/12 beginning at 11:01 a.m. revealed one (1) of three (3) nurses on two (2) of two (2) halls administering medications. Three (3) medication errors were observed from sixty (60) opportunities. This resulted in a medication error rate of 5%. Resident #63 had an order for [REDACTED]. During medication observation with Licensed Practical Nurse (LPN) "AA" on 3/14/12 at 11:01 a.m., she gave resident #63 one (1) capsule of [MEDICATION NAME] one hundred (100) milligrams (mg), and at 11:02 a.m., she gave resident ten (10) mg of [MEDICATION NAME] XL and Liquid Tears one (1) drop in each eye. The LPN "AA" agreed that this was the correct amount of medication prior to administration.. Interview with LPN "AA" on 3/14/12 at 1:15 p.m., she concurred that the resident was only given one (1) [MEDICATION NAME] capsule during medication pass. Continued interview revealed that the [MEDICATION NAME] should have been given at breakfast time, and that the liquid tears, given at 11:02 a.m., was the 8:00 a.m. dose.

Based on record review and staff interview the facility failed to follow the care plan related to a chair alarm for one (1) resident (#39) from a sample of twenty-three (23) residents. Findings include: Review of the medical record for resident #39 revealed that the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed that the resident was assessed for falls. Review of the Care Area Assessment (CAA) summary revealed that the resident would be care planned for falls. Review of the resident care plan revealed that the resident was at risk for falls related to history of falls with the resident attempting to stand up and transfer unassisted. Interventions were Pressure sensitive bed alarm, Tab alarm on Broda chair. Electric bed in low position, Broda chair as tolerated, Replace regular socks with no-slip socks and fall mat on one side of the bed. Review of a nursing note dated for 02-07-12 at 4:00 p.m. revealed that the resident was found on his knees in the dining room. The resident was assessed and placed back in the Broda chair without injury. Continued review revealed that that the Chair alarm was present but was not attached to the resident's shirt. Interview on 03-14-12 at 1:25 p.m. with the Director of Nursing (DON) revealed that the resident is unable to remove the Tab alarm from his clothing or the chair. Interview on 03-15-12 at 10:20 a.m. with the Resident Care Coordinator revealed that the resident's chair alarm was was not attached properly to the resident clothing on the day of his fall.

Based on observation and staff interviews, the facility failed to maintain appropriate infection control measures to prevent the likelihood of the spread of infection during dining for one (1) randomly observed resident. The census was fifty-two (52) resdients. Findings include: Observation on 03/13/12 at 7:45 a.m. during breakfast in the main dining room revealed Certified Nursing Assistant (CNA) "BB" feeding a resident. The Cna was standing feedng the resident but after four found a chair and sat down to continue feeding the resident. The CNA did not wash or sanitize her hands after touching the chair. Continued observation revealed the CNA breaking the bacon from the residents tray, into two (2) pieces and feeding the resident with her bare hands. Interview with the Administrator and Regional Nurse on 03/14/12 at 4:30 p.m. revealed that she expected all of her staff to feed residents with the proper utensils and to use hand sanitizer or wash their hands between residents. Both the Administrator and the Regional Nurse agreed that it would never be appropriate for the staff to use their bare hands to feed residents.

Based on record review, observation and staff interview, the facility failed to serve a therapeutic diet as ordered by the physician for one (1) resident (#4) of the sampled twelve (12) residents. Findings include: Review of the clinical record for resident #4, revealed a current physician's orders [REDACTED]. Continued review of the clinical record revealed that the resident had a weight loss of eleven-point-nine percent (11.9%) within the last six (6) months, defined as a significant weight loss. Further review of the clinical record revealed that on 05/11/10 the Registered Dietician assessed the resident and included the double portion meal size in the assessment. Observation on 06/22/10 at 12:55 p.m., 06/23/10 at 8:05 a.m. and 1:03 p.m. of the meals served to resident #4 revealed regular food portions were served, not double portions. Interview on 06/23/10 at 3:40 p.m. the Director of Nursing confirmed that the physician ordered double portions of food for the months of the April, May and June 2010.

Based on record review and staff interview the facility failed to issue Medicare beneficiary liability notices which included the resident's right to an expedited appeal, rationale for discharge from Medicare services and the potential liability to the resident for a non-covered stay for two (2) of the four (4) random residents records reviewed. Findings include: Review of the facility's Liability Notices and Appeal Rights records for four (4) residents revealed no evidence that the facility had issued a liability notice in accordance with CMS S&C-09-20, for one (1) resident discharged from Medicare services. Continued review revealed that one (1) resident and/or responsible party had received the denial notice, but the notice was issued two (2) days after services had been discontinued. During interview on 06/23/10 at 2:30 p.m. the Financial Controller acknowledged these findings.