Every finding on record at Spanish Cove Housing Authority

Based on observation, record review, and interview, the facility failed to provide an environment free of accident hazards involving ingestion of potentially harmful chemicals for 1 (#18) of 2 sampled residents reviewed for accident hazards. The ADON identified two residents at high risk for wandering. Findings: On 08/02/26 at 1:45 p.m., Resident #18 was observed to be in their room with the door closed. There was a 4-foot bookshelf in the resident's which contained the following items:a. a half full spray bottle labeled perineal and skin cleanser was on the top shelf. The number 123 was handwritten on the bottle with a marker,b. an open squeeze bottle of hand sanitizer was observed on the top shelf, andc. a baggie of cookies was on same shelf beside the bottles of chemicals. The warnings observed on each bottle located on the shelf instructed to, Keep out of reach of children. On 08/03/26 at 11:30 a.m., the bottle of perineal and skin cleanser that was previously located on the top shelf of the bookshelf in Resident #18's room was observed on the overbed table beside the resident's bed. On 08/04/26 8:39 a.m., a tour of the facility was conducted. The following observations were made:a. the bottle of perineal and skin cleanser had been returned to room [ROOM NUMBER] was observed to be located on the railing in the bathroom beside the toilet in room [ROOM NUMBER], which was visible from the hall, andb. a large bottle of hand sanitizer with a pump and a small bottle of hand sanitizer was observed on top of the medication cart in the hallway near room [ROOM NUMBER]. A facility policy titled Hand Sanitizer Policy, dated 02/06/25, read in part, No individual hand sanitizer is to be left in common areas within reach of a resident. This will reduce the risk of a dementia resident obtaining the sanitizer and possible ingesting. A quarterly assessment for Resident #18, dated 07/08/26, showed the resident had a brief interview for mental status score of 00 which indicated severe cognitive impairment. A care plan for Resident #18, updated 07/29/26, showed the resident had low safety awareness, required monitoring, and required assistance with most activities of daily living. Physician orders for Resident #18, dated 08/2026, showed the resident had diagnoses which included delusional disorders, Alzheimer's disease, depression, anxiety, dementia, and cognitive communication deficit. On 08/04/26 at 8:39 a.m., LPN #2 verified the hand sanitizer, and perineal wash should not be left in arms reach of Resident #18. LPN #2 stated Resident #18 went into other residents' rooms and took their belongings, and the bottle of perineal cleanser actually belonged in room [ROOM NUMBER]. On 08/04/26 at 8:39 a.m., LPN #2 verified that was the same bottle Resident #18 had taken from the room previously. LPN #2 agreed it should be placed higher out of reach. LPN #2 agreed the hand sanitizer observed on top of the medication carts in the hallway could potentially pose a hazard to Resident #18. On 08/04/26 at 9:10 a.m., certified medication aide #1 stated they had received education to keep all hazardous items out of the residents' reach. On 08/04/26 at 9:22 a.m., the ADON agreed all containers of hand sanitizer should be kept out of reach of all residents. On 08/04/26 at 11:50 a.m., the ADON stated two residents wandered throughout the secure unit which included Resident #18.

Based on record review and interview, the facility failed to accurately code a MDS assessment for one (#37) of five residents sampled for accuracy for MDS assessments. The Administrator identified 44 residents resided in the facility. Findings: A MDS Assessment Coordinator policy, revised November 2019, read in part each individual who completes a portion of the assessment must certify the accuracy of that portion of the assessment Resident #37 was admitted on this date 09/21/24 with diagnosis that included fracture of right femur and depression. A Medication List from admission orders, dated 09/21/24, documented Quetiapine (Seroquel) 25mg one tablet given daily for 5 days. The facility's Comprehensive Assessment, dated 09/28/24, documented in section N that Resident #37 received a Antipsychotic medication upon admission. Section N0450 on assessment was coded a zero for Resident #37 not receiving a Antipsychotic since admission. The facility's Medication Administration Record, dated September 2024, documented Resident #37 received Seroquel 25mg on September 21 through 25th. On 10/22/24 at 10:16 a.m., MDS Coordinator #1 was asked the facility policy for accurately coding MDS. They stated for section N of a MDS the information comes from the MAR(medication administration record). They were then asked to review admission MDS for Resident #37 dated 09/28/24, section N, then asked is the section for Antipsychotic medication was coded correctly. They stated section N0450 is not coded correctly, Resident #37 received Antipsychotic medication since admission. 47453

Based on record review and interview, the facility failed to ensure adequate supervision and assistance with transfers for one (#3) of five sampled residents reviewed for accidents. The ADON identified 42 residents resided in the facility and 31 residents required assistance with transfers. Findings: The facility's Gait Belt policy, dated 2023, read in part, .Gait Belts promote the safe handling and mobility of residents .Spanish Cove requires a gait belt when assisting all residents with ambulation or transfer .Nursing assistants must wear gait belts at all times . The facility's Safe Lifting and Movement of Residents policy, revised 07/2017, read in part, .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents . An undated facility Policy Statement for Agency Staff policy, read in part, .Gait Belt Policy: Gait belt must be used for all transfers unless otherwise contraindicated and in care plan. Gait belt must be used when assisting a resident with ambulation. You are required to arrive at the facility with your gait belt on your person. Your gait belt should always be on your person . Resident #3 had diagnoses which included orthostatic hypotension, difficulty walking, and unsteady on feet. An admission assessment, dated, 09/02/24, documented the resident was dependent on staff for transfers. emergency room /hospital notes, dated 09/12/24 through 09/18/24, documented Resident #3 presented to the emergency department with complaint of syncope which resulted in blunt head trauma, and the development of nausea, vomiting, headache, and lightheadedness. It was documented the resident was found to have had a large right subdural hematoma. It was documented the resident progressively became more somnolent in the ER. It was documented the resident had demonstrable neurologic compression and structural issues which caused significant functional impairment in most activities of daily living for which surgery was appropriate. It was documented the resident underwent subdural hematoma evacuation on 09/18/24. A care plan, updated 09/17/24, documented to encourage use of an assistive device. Staff to use walker and gait belt to/from bathroom/dining room. Second staff member was to follow with a chair. On 09/19/24 at 5:15 p.m., OSDH received a Combined Initial and Final state incident report. It was documented CNA #2 was toileting Resident #3 and they wanted to stand to urinate. It was documented CNA #2 did not put a gait belt on resident. It was documented CNA #2 turned away from the resident and the resident fell backwards into the shower and hit their head. It was documented the resident started having nausea and vomiting shortly after fall and was on plavix. It was documented the resident was sent to the ER and diagnosed with a severe brain bleed. It was documented the resident had emergency surgery on 09/18/24. On 09/25/25 at 2:23 p.m., the ADON stated the policy for transfers was to follow the care plan and to use a gait belt for all transfers except for mechanical lift transfers. On 09/25/24 at 2:26 p.m., the ADON stated their expectation for supervision for all ADLs was to always use a gait belt and ensure they held the gait belt the entire time a resident was standing. On 09/26/24 at 10:18 a.m., the ADON stated agency staff were e-mailed the transfer/gait belt policy. They stated the agency staff were to sign the document before they were allowed to work. On 09/26/24 at 11:24 a.m., the ADON stated they did not have a signed policy statement for CNA#2. On 09/26/24 at 3:23 p.m., the home care director of operations stated they did not have a signed policy document from CNA #2. They stated they received the form a few days prior. On 09/27/24 at 9:27 a.m., CNA #2 stated they had never used a gait belt when assisting Resident #3 with their ADLs.

Based on record review and interview, the facility failed to ensure medications were administered according to physician's orders for one (#1) of three sampled residents whose medication profiles were reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 43 residents resided in the facility. Findings: An Administering Medications policy, revised April 2019, read in part, .Medications are administered in accordance with prescriber orders . Res #1 had diagnoses which included Parkinson's disease and chronic pain. A Physician's Order for Res #1, dated 05/04/23, documented, Lactulose 30mls po once daily. Res #1's MAR, dated May 2023, had no initials for Lactulose on 05/04/23, 05/06/23, 05/08/23, nor 05/09/23. On 05/10/23 at 12:10 p.m., Res #1 stated they had been experiencing constipation and had received an order for a laxative, but had to request it. On 05/10/23 at 3:36 p.m., the DON was asked to review the Lactulose order for Res #1 and the medication administration data on the May 2023 MAR. The DON was asked if the medication had been administered according to the prescriber's order. She stated, No, it doesn't look like it.

Based on observation, review of policy and procedures and staff interviews, it was determined the facility failed to ensure: ~foods in the walk-in refrigerator were labeled with open and/or received dates; ~foods in the walk-in refrigerator were sealed; ~foods in the walk-in were dated; ~foods in the walk-in were sealed; ~utensils were stored in a drawer with items which may pose a threat of cross contamination; ~ the Smilax hood was free of dust, debris and black encrustation; and ~staff with facial hair kept all facial hair covered. This had the potential to affect all 42 residents who received meals in the kitchen. Findings: A facility policy, titled, Handle With Care, documented: Food Storage Food storage is an important of the food service system because - It provides the Food Service Department with the raw materials it needs - Proper food storage helps prevent food spoilage . .Some tips to remember: - always cover food - label and date all food Summary Good food storage is critical to the patient's health and wellbeing Everyone in the Food Service Department must do his job to prevent food spoilage. Food is perishable. remember to handle it with care. A policy, titled, Sanitation - The Whys and Hows, documented: Good sanitation practices apply to all areas of the institutional kitchen. This includes the cleaning and maintenance of large equipment: .Refrigerators - Check for outdated food . A policy, titled, Cleaning Range Hoods, documented: .4. On heavily soiled areas or where grease is baked on, loosen with a brush until the grease and soil are dissolved. Clean out drain trough around the lower inside edge of the hood, as well as the channels which hold the filters . On 02/22/16 at 8:44 a.m., a tour of the dietary department was conducted. The following observations were made: There were chicken breasts in the reach in refrigerator open to air. At 8:45 a.m., the dietary manager stated we should have wrapped it. There was no date or label on a plastic bag filled with a fresh herb. At 8:36 a.m., the dietary manager stated, It was thyme. There was a celery stalk in the walk-in refrigerator. The celery was not completely sealed and open to air. Two 1/2 gallons of butter milk were observed without an open date. Both containers were 2/3 empty. There was a one gallon container of whole milk observed. There was no open date on the container. The container was 3/4 empty. There was a one gallon of skim milk observed. There was no open date on the bottle. The container was approximately 2/3 full. There was a bag of ravioli in the walk-in freezer. There was no open date or label on the ravioli bag. The bag was not the original packaging of the food. At 9:04 a.m., an inspection of the utensil drawers was made. One drawer contained menu signs, a cigarette lighter, money, string. The drawer also contained two pizza cutters, two vegetable peelers, two forks and a bottle with an unknown substance. Observations were made of the tilt skillet doors. The doors were covered with masking tape. The CDM stated, The doors won't stay closed. The range hood was black with dust, grease and encrusted debris on the lower end of the hood. Observations were made of the ice machine. The inside top seal was missing. The right seal had been dislocated from the attachment site. On 02/22/17 at 9:20 a.m., Dietary aide #1 and dietary aide #2 were observed wearing beard guards. Both had mustaches which were not covered. Both had facial hair outside the beard guards. On 02/24/16 at 10:35 p.m., the concerns were discussed with the dietary manager. He stated, I've seen most of the issues. We will get it taken care of.

Based on observation, record review, staff interviews and review of facility policy and procedures, it was determined the facility failed to ensure: a. expired Lantus insulin was not administered and was removed from the east hall medication cart for one (#15) of two sampled residents with physician orders [REDACTED]. b. a vial of Novolog insulin was dated after opening for one (#15) of one sampled resident with physician orders [REDACTED]. This had the potential to affect one resident identified by the facility with physician orders [REDACTED]. c. expired topical Phenergan was discarded and not stored for use on the east hall medication cart for one (#1) of four sampled residents with physician orders [REDACTED].>d. sublingual Lorazepam elixir was stored double locked and in a permanently affixed compartment in the east hall medication room for two (#16 and #17) of six sampled residents with physician orders [REDACTED]. This had the potential to affect eight residents identified by the facility with physician orders [REDACTED]. e. the room temperature for storage of medications was monitored for one (east medication room) of two medication storage rooms observed. This had the potential to affect 24 residents identified by the facility who resided on the east hall and received medications; and f. the medication refrigerator temperature was monitored for one (east medication room refrigerator) of two medication refrigerators observed. This had the potential to affect 24 residents identified by the facility who resided on the east hall and received medications. Findings: A facility policy titled, Labeling of Medication Containers, documented: Policy Statement .All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations . Policy Interpretation and Implementation . 3. Labels for individual drug containers shall include all necessary information, such as . f. The date that the medication was dispensed . h. The expiration date when applicable . A facility policy titled, Storage and Expiration of Medications, Biological's, Syringes and Needles, documented: .Procedure .General Storage Procedures .Facility should ensure that all medications and biologicals, included treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . Facility should ensure that medications and biologicals: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplies guidelines . 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container . 12. Controlled Substances Storage . 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security . A facility policy titled, Administering Medications, documented: Policy Statement .Medications shall be administered in a sage and timely manner, and as prescribed . Policy Interpretation and Implementation . 3. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container . 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A treatment administration record, dated February 2016, documented, .Lantus 100 unit/Ml subcutaneous solution (insulin glargine) 15 units daily at HS . The Lantus insulin was documented as administered for 21 of 22 opportunities during February 2016. On 02/22/16 at 9:00 a.m., the medication cart on the east hall was observed. A vial of Lantus insulin was opened and the box was dated 01/15/16. At 9:05 a.m., LPN #1 was asked how long can Lantus insulin be administered to a resident after the vial is opened. She stated, Says on the bottle this can be used and unrefrigerated for up to 28 days after opening. She was then asked to observe the open date on the vial of Lantus. She was asked if this medication could be administered to the resident. She stated, No. 2. On 02/22/16 at 9:00 a.m., the east hall medication cart, medication storage room and medication refrigerated was observed. The following observations were made: At 9:00 a.m., three syringes of topical Phenergan for resident #1 were observed on the east hall medication cart. The medication was labeled expired 01/07/16. At 9:03 a.m., LPN #1 was asked when does the topical Phenergan expire. She observed the label and stated, January 16th. She was then asked if she would administer the medication to the resident. She stated, Absolutely no. She was asked why the medication was expired and stored with the resident's medications. She stated the medication hasn't been given for awhile. On 02/22/16 at 9:04 a.m., an opened vial of Novolog insulin was found on the east hall medication cart. The vial was not labeled with an open date. At 9:04 a.m., LPN #1 was asked if she could determine when the medication was opened. She stated, No it doesn't show. At 9:10 a.m., the east hall medication refrigerator was observed. The refrigerator was locked. A metal lock box was located inside the refrigerator. The metal box was not permanently affixed and was easily removed from the refrigerator. The lock box was unlocked. Two bottles of liquid Lorazepam elixir for resident #16 and #17 were located inside the unlocked lock box. At 9:10 a.m., LPN #1 was asked how should narcotic medications be stored. She stated, Is that unlocked. Well they should be locked up so people can't get to it. She was asked if the lock box is normally locked. She stated, Yes Ma'am. On 02/22/16 at 9:50 a.m., LPN #1 was asked where staff documented medication room and medication refrigerator temperature monitoring. She stated the charge nurse is responsible for monitoring temperatures. At 9:52 a.m., LPN #2 was asked if medication storage room and medication refrigerator temperatures are monitored. She obtained a binder and stated, I think it's in this book. She located an undated log sheet. A nurse flow sheet, undated, documented, Check temperature in med room q week on Fridays. (Keep between 60*-80*). Check refrigerator temps in med room Nightly .(36*-48*). The flow sheet was reviewed. A staff member documented the medication room temperature was obtained on the 17th, 18th and 19th. There was no month documented. There was no temperature documented. A staff member documented the medication refrigerator temperature was checked on the 1st. There was no month documented. There was no temperature documented. On 02/22/16 at 11:46 a.m., LPN #2 was asked to review the nurse flow sheet. She was asked if she could determine if the medication storage temperatures were monitored and appropriate. She stated, You can't tell when it's done. No one has initiated they have done it. On 02/23/16 at 11:20 a.m., the DON was asked if expired medications should be stored with residents' current medications. She stated, No. She was then notified of the observations. She stated, Ok. She was asked how staff determine when insulin has been opened or when it is expired. She stated, They should date it or it should be replaced in 30 days. She was then notified of the observations. She stated, Ok. She was asked how should narcotic medication which require refrigeration be stored. She stated, Under double lock. She was then notified of the observations. She stated, Ok. She was asked when should medication storage rooms and medication refrigerator temperatures be monitored. She stated the temperature should be monitored each shift. She was then shown the nurse flow sheets from the east hall. She was asked if she could determine if the medication storage temperatures were being monitored. She stated, No. She was notified of the concerns. She stated, Ok.

Based on observation and staff interviews, it was determined the facility failed to ensure: ~ cookware was not stacked wet; ~ open dates and labels were present on open foods in plastic baggies or containers in both refrigerators and freezers; ~ trash was contained; and ~ sanitary food handling was performed during the puree process. This had the potential to affect all 45 residents who resided in the facility. Findings: On 12/15/15 at 9:40 a.m., a general tour of the kitchen was conducted. The following observations were made: Five steam table bins were stacked wet. A plastic container of Chinese noodles was not dated or tabled. The container was 1/3 full. A trash can, with the swinging lid missing, was observed full and overflowing. A bag of flour tortillas open in the walk-in refrigerator with no open date or label. There was a precooked bag of chicken patties with no date or label in the walk-in refrigerator. The patties were open to air. There was one waffle wrapped in plastic with no date or label in the walk-in refrigerator. At 11:27 a.m., D.A. #1 was observed as she removed ladles from the drawer. She picked up the utensils with her bare hands at the scoop end. On 12/15/14 at 11:25 a.m., observations were made of the nutrition supervisor as she prepared pureed food for the noon meal on 12/15/14. She placed two, four ounce scoops of beef stew into the blender. She then proceeded to break a piece of bread with her bare hands and placed the bread into the blender. She was asked at what time a food product can be touched by bare hands. She stated never. She acknowledged the problem On 12/16/14 at 2:20 p.m., the Dietary Manager and Nutrition Supervisor acknowledged the concerns in the dietary department.

Based on observation, review of facility policies and procedures and staff interviews, it was determined the facility failed to ensure expired medications were discarded from two of two medications rooms. This had the potential to affect all 45 residents who resided in the facility. Findings: A facility policy titled, Disposal/Destruction of Expired or Discontinued Medications, documented, "...Applicability: This policy 8.2 sets forth procedures relating to medication disposal and destruction. Procedure: 1. Facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable law, and applicable environmental regulations... 4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction... 8. Facility should dispose of discontinued medication, out-dated medications, or medications left in Facility after a resident has been discharged in a timely fashion, or no more than 90 days of the date the medication was discontinued by Physician/Prescriber, or sooner per applicable law..." On 12/15/14 at 10:25 a.m., observations of the West hall medication room were conducted. The following observations were made of expired medications stored in the medication over flow bins: 1. A card of Loperamide 2 mg contained two capsules, with an expiration date of 11/07/14, for resident #14. 2. A card of Acetaminophen 325 mg contained 94 tablets, with an expiration date of 10/18/14, Two cards of Clonidine 0.1 mg contained a total of 90 tablets, with an expiration date of 09/04/14, A card card of Acetaminophen 325 mg contained 51 tablets, with an expiration date of 08/28/14, for resident #15. 3. A card of Propranolol 10 mg contained three tablets, with an expiration date of 09/09/13, A card of Amlodipine Besylate 2.5 mg contained five tablets, with an expiration date of 09/27/14, for resident #16. 4. A card of Mirtazapine 7.5 mg contained five tablets, with an expiration date of 10/10/13, for resident #10. LPN #1 was shown the medication cards for residents #10 and #13- 16. She was then asked when expired medications were to be taken out of the over flow bins. She looked at the cards and stated they should have been removed. Then stated those are a little excessive with the expiration dates. At 10:45 a.m., observations of the East hall medication room were conducted. The following observations were made of expired medications stored in the medication over flow bins: 1. A card of Warfarin Sodium 2.5 mg, with an expiration date of 12/18/12, A card of Warfarin Sodium 5 mg, with an expiration date of 10/11/14, A card of Warfarin Sodium 1 mg, with an expiration date of 08/28/13, for resident # 17. 2. A card of Diphenhydramine 25 mg, with an expiration date of 12/10/13, for resident #13. LPN #2 was shown the expired medications. She was then asked when the expired medications should be removed from the over flow bins. She stated the removal of expired medications was the night shift responsibility. At 11:15 a.m., the DON was informed of the expiration dates found for medications in the over flow storage bins for each medications room. She then stated the night shift was to remove expired medications every Wednesday. She was then asked if an expiration date of 09/04/14 was an excessive amount of time for a medication to remain in the over flow bins. She stated yes. She was then asked if an expiration date of 10/10/13 or 12/18/12 was an excessive amount of time for medications to remain in the over flow bins. She stated, "Obviously."

Based on clinical record review and staff interview, it was determined the facility failed to ensure hospice records were accessible for two (#8 and #11) of five sampled residents who received hospice services. This had the potential to affect ten residents who received hospice services as identified by the facility. Findings: Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 10/07/14, documented the resident received hospice services. On 12/17/14 at 10:00 a.m., the hospice clinical record was reviewed. A hospice nurse progress note, dated 11/25/14, was found. There were no nurse progress notes found in the hospice record from 11/26/14 to 12/17/14. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/13/14, documented the resident received hospice services. On 12/17/14 at 11:45 a.m., the hospice clinical record was reviewed. A hospice nurse visit note, dated 12/02/14, was found. There were no nurse visit notes found in the hospice record from 12/03/14 to 12/17/14. A hospice aide visit, dated 12/02/14, was found. There were no hospice aide visits found in the hospice record from 12/03/14 to 12/17/14. On 12/17/14 at 1:10 p.m., the DON was asked if hospice notes missing from the hospice chart was an excessive amount of time for records to not be placed in the facility. She stated, "Yeah." She then stated she was not aware the hospice records were required to be in the facility in a timely manner. She then asked what was considered timely. She then stated she did not have direct access to the notes but was able to contact the hospice agencies to obtain the records.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure a care plan was updated to reflect the current status for one (#9) of 11 residents whose care plan was reviewed. This had the potential to affect all 45 residents who resided in the facility. Findings: A facility, policy, titled Using the Care Plan, documented: "..Policy Statement ...The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have a responsibility for providing care or services to the Policy resident. ...Policy Interpretation and Implementation ...3. CNA's are responsible for reporting to the Nurse Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved. ...5. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan may be made. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was severly impaired in his cognitive skills for making daily decisions. The resident required supervision for bed mobility transferring, and ambulation. He required extensive assistance from staff for dressing and bathing. A care plan, dated 10/10/14, documented, "(P) (Resident) has potential for falls related to instability/impulsiveness. (G) Will remain free of injury (A) Floors are free from spills or clutter (A) Provide adequate lighting (A) Personal items within reach (A) Assist to wear non-skid foot ware (A) 1 to 2 person assist with transfers; wheelchair x 1 person assist for mobility/transportation (A) Bed alarm pad to be used in bed at all times; staff to check for placement and function Q and PRN interaction. (A) Chair alarm pad on chair/recliner at all times; staff to check (sic) placement and function every shift and PRN. (A) chair alarm pad on at all times while in wheel chair to alert staff that resident might be getting up or has fallen. This is not a restraint. (A) body alarm as ordered..." On 10/31/13 at 4:40 p.m., a facility incident report report documented, ''...Location of incident: (room # deleted), next to recliner Describe incident: (Please Print) this nurse was walking down the hall and heard residents chair alarm sounding, resident was found laying on the floor to the right side of recliner and side table, feet facing recliner head to wall. res had been sleeping in his recliner. (LPN #1) came into the room and assisted this nurse with residents assessment. an abrasion with a bump is located on the right forehead 2.5 cm x 3 cm. An abrasion 1.5 cm x 2 cm is located on the back side of head... Resident stated he needed to use the bathroom resident was then assisted to the BR, his brief was wet..." On 11/17/14 at 9:15 p.m., a facility incident report documented, ''...Location of incident... Incident Location of incident: In resident's bedroom Describe Incident: (Please print) Alarm sounded and this nurse responded immediately. Resident was observed on his hands and knees on the floor between the recliner and bed..." On 11/19/14 at 10:45 a.m., a facility incident report, documented, "Incident: location of incident: (room number deleted) Describe incident: (Please print) ...CNA stated that resident stood up from his chair, alarm went off, and CNA# 1 went to go get the alarm, resident had fallen. Resident was lying on his side up against the wall opposite side from his bed... Resident was wearing socks and shoes at time of fall. Resident stated, 'I don't know." On 12/16/14 at 2:45 the DON was asked how MDS staff needed to update and revise a resident's care plan. She stated, "When I am notified of them in the alert system." MDS coordinator #1 was asked when the last time the resident's care plan was updated. She stated, "10/25/14 was the last change on it. She further stated most of his interventions haven't changed. He is impulsive. They were asked if they update the care plan with each fall. They stated no. MDS coordinator #2 stated we get alert messages in the box. The QA nurse checks the incident reports and communicates with us. The DON just showed us how to access the 24 hour reports.

Based on observations, review of therapeutic menus and staff interviews, it was determined the facility failed to ensure the approved pureed menu was followed for six (#21 - #26) of six residents whose meal prepartion for pureed diets was observed. This had the potential to affect six residents identified by the facility who had physician ordered pureed diets. Findings: At 11:35 a.m. cook #2 was observed as she pureed the roast beef and gravy. The food was placed in a steam table bin and put on the steam table. No temperatures were taken after the pureed food had been completed. The pureed menu for 10/22/13 consisted of the following: "NDD Level 1: Pureed Pur Pot Roast with 1 #8 scoop Pur Potatoes/Carrots 1 #8sc/#10sc Pur Fried Chicken 1 #8 scoop Rst Chix Skillet Grvy Pur Creamed Potatoes 1 #8 scoop Pur Scand Veg Blend 1 #10 scoop *Pur Dinner Roll/Bread 1 #20 scoop *Pureed Fruit Mix 1 #10 scoop *Denotes main Item" At 11:35 a.m. cook #2 was observed as she pureed the roast beef and gravy. The food was placed in a steam table bin and put on the steam table. She stated, No. Temperatures were taken after the pureed food had been completed. There was no dinner roll slurry or bread prepared for the residents. There was no pureed fruit mix prepared for the residents. At 12:00 noon, a test tray was otained from the East Unit Kitchen Prep area. The cook stated, "I ran out of meat." At 12:12 p.m., the dietary manager was asked about the menus and the pureed food. He stated, "All food was pureed in the prep kitchen. The dietary supervisor was asked when the puree was done, did they reheat it to 165 F. She stated, "No they put them on the steam table and pass them out right away."

Based on observation and staff interviews, it was determined the facility failed to ensure a clean homelike environment as evidenced by resident and facility equipment stored in the hallways. This had the potential to affect all 43 residents who resided in the facility. Findings: An environmental tour was conducted on 10/22/13 at 11:19 a.m.. The following observations were made: ~ a wheelchair was stored in the hallway outside room 141, ~ a wheelchair footrest was stored in the hallway outside room 126, ~ a wheelchair was stored in the hallway outside room 130, ~ two facility resident lifts were stored in the common area of the north side of the east hall, ~ housekeeping cart was stored in the common area of the north side of the east hall, ~ weight scale in the hallway near dining area of the west hall, and ~ surge protection extension cord was plugged into the wall and lying approximately 2 feet into the west hall near dining area. At 1:05 p.m., the following observations were made: ~ facility resident lift was stored in the hallway outside room 101, ~ Geri chair was stored in the hallway outside room 102, ~ an electric wheelchair was stored near the exit of the west hall dining room, ~ a walker was stored in the hallway outside room 104, ~ a walker was stored in the hallway outside room 105, and ~ an electric wheelchair was stored in the hallway outside room 107. At 2:20 p.m., the following observations were made: ~ Geri chair was stored in the hallway outside room 112, ~ wheelchair was stored in the hallway outside room 116, and ~ two wheelchairs and wheelchair foot rests were stored in the hallway outside room 118. An environmental tour was conducted on 10/23/13 at 9:32 a.m. The following observations were made: ~ vacuum cleaner was stored in the common area on the south side of the east hall, ~ facility resident lift was stored in the hallway outside room 101, ~ Geri chair was stored in the hallway outside room 102, ~ an electric wheelchair was stored near the exit of the west hall dining room, ~ an oxygen concentrator not in use was sitting in the west hall dining room, ~ walker was stored in the hallway outside of room 104, ~ walker was stored in the hallway outside of room 105, ~ wheelchair was stored in the hallway outside room 103, ~ wheelchair was stored in the hallway outside room 106, ~ electric wheelchair was stored in the hallway outside room 107, ~ weight scale in the hallway near dining area of the west hall, and ~ surge protection extension cord was plugged into the wall and lying approximately 2 feet into the west hall near dining area, ~ Geri chair was stored in the hallway outside room 112, ~ facility resident lift was stored in the hallway outside room 117, ~ wheelchair was stored in the hallway outside room 116, ~ two wheelchairs and wheelchair foot rests were stored in the hallway outside room 118. On 10/23/13 at 1:00 p.m., the DON was shown the items in the hallway and in the common area of the east hall. She acknowledged the issues. At 1:20 p.m., the administrator was shown the items in the hallway and common area of the west hall. He stated, "We will get this taken care of."

Based on clinical record review and staff interviews, it was determined the facility failed to complete a significant change in condition assessment for one (#6) of 11 sampled residents whose assessments were reviewed. This had the potential to affect all 43 residents who resided in the facility. Findings: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/08/13, documented, the resident was independent with dressing and personal hygiene. She required supervision only with bathing. She was continent of bowels. A quarterly assessment, dated 08/05/13, documented, the resident required extensive assistance with dressing, hygiene and bathing. She was frequently incontinent of bowels. On 10/23/13 at 10:00 a.m., the MDS coordinator was shown the quarterly assessments dated 05/08/13 and 08/05/13. She was then asked if the difference in coding between the two assessments would require a significant change assessment. She stated, "That is the rule, yes."

Based on clinical record review and staff interviews, it was determined the facility failed to fully develop a comprehensive care plan for three (#7, #8 and #10) of 11 sampled residents whose care plans were reviewed. This had the potential to affect 13 residents identified by the facility as receiving hospice services. Findings: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. On 10/23/13 at 4:00 p.m., the resident's care plan was reviewed. The comprehensive care plan failed to address the resident received hospice services. On 10/24/13 at 8:35 a.m., the DON was asked if hospice was addressed in the resident's care plan. She stated, "We usually put it in the advanced directive section." She was then shown the resident's care plan and asked if she could find where hospice was care planned. She stated, "I don't see it." She was then asked if the care plan should address the resident being on hospice. She stated, "Yes." 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 10/24/13 at 9:00 a.m., the resident's care plan was reviewed. Hospice services failed to be fully developed in the comprehensive care plan. Hospice services were addressed under the advanced directives section only. 3. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. On 10/24/13 at 9:15 a.m., the resident's care plan was reviewed. The comprehensive care plan failed to address the resident received hospice services. At 9:20 a.m., the MDS coordinator was asked if the resident's care plan should address hospice services. She stated, "Yes, it should."

Based on clinical record review and staff interviews, it was determined the facility failed to coordinate care with hospice services for three (#7, #8 and #10) of 11 sampled residents who were reviewed for hospice services. This had the potential to affect 13 residents identified by the facility as receiving hospice services. Findings: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. On 10/23/13 at 4:00 p.m., the resident's care plan was reviewed. The comprehensive care plan failed to address the resident received hospice services and failed to coordinate care with hospice services. On 10/24/13 at 8:35 a.m., the DON was asked if hospice was addressed in the resident's care plan. She stated, "We usually put it in the advanced directive section." She was then shown the resident's care plan and asked if she could find where hospice was care planned. She state, "I don't see it." She was then asked if the care plan should address the resident being on hospice. She stated, "Yes." 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 10/24/13 at 9:00 a.m., the resident's care plan was reviewed. Hospice services failed to be fully developed in the comprehensive care plan. Hospice services were addressed under the advanced directives section only. The care plan failed to coordinate care specific to the resident's end stage illness. 3. Resident #10 was admitted the facility with [DIAGNOSES REDACTED]. On 10/24/13 at 9:15 a.m., the resident's care plan was reviewed. The comprehensive care plan failed to address the resident received hospice services and failed to coordinate care with hospice services. At 9:20 a.m., the MDS coordinator was asked if the resident's care plan should address hospice services. She stated, "Yes, it should."

Based on observations and staff interviews, it was determined the facility failed to maintain an environment free of accident hazards for one of two hallways. This had the potential to affect 14 ambulatory residents identified by the facility who resided on the west hall of the facility. Findings: On 10/22/13 at 11:45 a.m., an environmental tour of the facility was conducted. One surge protector extentsion cord was observed plugged into the wall and extending into the hallway approximately two feet between rooms 108 and 109. At 11:52 a.m., the DON was shown the surge protector extension cord in the hallway. She was then asked if she felt it was and accident hazard. She stated, "Yeah, I would say." At 1:05 p.m., one surge protector extentsion core was observed plugged into the wall and extending into the hallway approximately two feet between rooms 108 and 109. On 10/23/13 at 9:32 a.m., one surge protector extentsion core was observed plugged into the wall and extending into the hallway approximately two feet between rooms 108 and 109.

Based on clinical record review and staff interviews, it was determined the facility failed to ensure gradual dose reductions for antipsychotic medications were provided for two (#4 and #6) of two sampled residents who were on antipsychotic medications. This had the potential to affect nine residents identified by the facility who received antipsychotic medications. Findings: 1. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. The care plan, dated 08/05/13, documented for "[MEDICAL CONDITION] Drug Use": "...(Resident name deleted) has potential for drug related complications associated with use of [MEDICAL CONDITION] medications related to anxiety.... (Resident) will remain free of drug related cognitive/behavioral impairment, gait disturbance, [MEDICAL CONDITION] or movement disorder... Observe, document, report to MD prn s/sx of drug related complications... Monitor for target behaviors/symptoms and document per facility protocol." The October 2013 monthly physician's orders [REDACTED]. The orders documented this medication had been at this dose since 07/17/12. Pharmacy consultant medication regimen reviews did not address the need for a gradual dosage reduction of the antipsychotic medication. No gradual dose reductions had been attempted for this resident. 2. Resident #4 was admitted to the facility with generalized anxiety disorder, dementia and [MEDICAL CONDITION]. An annual assessment, dated 08/22/13, documented the resident could rarely make himself understood and could rarely understand others. He had severely impaired cognitive skills for daily decision making. He required limited assistance with toilet use and personal hygiene. The assessment documented the resident had no indicators of [MEDICAL CONDITION] and no behavioral symptoms. A care plan, dated 08/22/13, documented for [MEDICAL CONDITION] drug use: "...(Resident name deleted) has potential for drug related complications associated with use of [MEDICAL CONDITION] medications... (Resident) will remain free of drug related cognitive/behavioral impairment, gait disturbance, [MEDICAL CONDITION] or movement disorder... Adm. medication for dementia/anxiety as ordered by physician. Observe for s/s of adv. reactions... Observe for s/s of effectiveness of [MEDICAL CONDITION] medications weekly." A physician's orders [REDACTED]. Pharmacy consultant medication regimen reviews did not address the need for a gradual dosage reduction of the antipsychotic medication. The resident's clinical record was reviewed. There was no documentation to indicate a gradual dose reduction had been requested or attempted for this medication. On 10/23/12 at 10:00 a.m., the DON was asked if gradual dose reductions had been done routinely on residents who received psychoactive medications. She stated that the pharmacy consultant made recommendations but that gradual dose reductions had not been done on a routine basis. She acknowledged the lack of gradual dose reductions being done was an issue.

Based on clinical record review, staff interview and review of facility policy and procedures, it was determined the facility failed to ensure a gradual dose reduction for an antipsychotic medication was provided for one (#3) of three sampled residents whose antipsychotic medications were reviewed. This had the potential to affect ten residents identified by the facility who received antipsychotic medications. Findings: A facility policy, titled, Policy for Psychopharmacological Drugs, Gradual Dose Reduction, documented: "...Antipsychotics: During the first year of use of these drugs, there must be a gradual dose reduction attempt in two separate quarters, unless clinically contraindicated and documented. The attempts should be at least a month apart. After the first year, the gradual dose reduction should be attempted at least once year... Gradual dose reductions and/or clinically contraindications as determined by the physician will be added to the resident's individualized plan of care..." Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An interdisciplinary note, dated 03/14/12, documented, "...I received a telephone order from (named physician's nurse) at this time to increase Risperadol 0.25 mg to TID... An interdisciplinary note, dated 04/12/12, documented, "...Faxed (named physician) with concerns of res anxiety and possible need to increase resperdal (sic) at this time. Will awakit (sic) response..." A physician communication fax, dated 04/12/12, documented, "...Res is still c/o 'being (illegible) (and) high'. Res is anxious when stating this. She requests something to help her calm down. We adm prn [MEDICATION NAME] but her anxiety is almost daily now. Res currently takes Resperdal (sic) 0.25 TID. Can we increase to 0.5 mg. Do you think it would help..." A interdisciplinary note, dated 05/11/12, documented, "...Received new order r/t faxing (named physician) re: increased anxiety. New order to increase [MEDICATION NAME] to 0.5 mg TID..." An annual assessment, dated 11/05/13, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance from staff with dressing, hygiene and bathing. She was occassionally incontinent of bladder. She was frequently incontinent of bowel. A care plan, dated 12/12/13, documented, "...Problem: (named resident) has potential for drug related complications associated with use of [MEDICAL CONDITION] medications... Goal: (named resident) will remain free of drug related cognitive/behavioral impairment, gait disturbance, [MEDICAL CONDITION] or movement disorder... Approach: Observe, document, report to MD prn s/sx of drug related complications...Monitor for target behaviors/symptoms and document..." A physician's orders [REDACTED]. On 1/27/14 at 2:00 p.m., the residents clinical record was reviewed. There was no documentation of a gradual dose reduction attempt for [MEDICATION NAME]. There was no documentation of a pharmacy recommendation for a gradual dose reduction for [MEDICATION NAME]. On 01/28/14 at 9:10 a.m., the DON was asked to provide pharmacy recommendation for a gradual dose reduction for the resident's antipsychotic medication. She stated, "Pharmacist has not made a recommedation on her. We have only done one GDR with a cognitive resident who requested to decrease her med."

Based on observation, review of temperature logs, and review of policy/procedures, it was determined the facility failed to ensure: a. refrigerator temperatures were consistently monitored; b. food items were dated and labeled in the refrigerator and tightly secured when stored; c. pork chops in a holding bin were kept off the refrigerator floor; d. food from the steam tale bin was not consumed by a staff employee adjacent to the steam table; e. the juice dispenser was free of a sticky substance on the back splash; and f. pureed food temperatures were taken after the food was pureed. This had the potential to affect 37 residents who received meals from the kitchen. Seven residents were identified who received hydration and nutrition solely through a feeding tube. Findings: A policy, titled, "Topic: Food Production", documented, Purpose: To ensure that food is handled in a safe and sanitary manner during all phases of production. Procedure: ...2. There will be no smoking, eating, or chewing gum in the kitchen..." A policy, titled, "Infection Control: Dietary policies", documented, ...3. There is a temperature check list posted on all refrigerators and freezers. These temperatures are recorded daily by the Food Service Department..." A policy, titled, "Cold Storage", documented, Purpose: To provide guidelines for cleaning and sanitizing refrigerators. Procedure: 1. Items stored in the refrigerator must be covered and dated..." On 10/22/13 at 8:55 a.m., an initial tour was conducted of the dietary department. The following observations were made: A document, titled Freezer and Refrigerator Check (Refreshment), documented, 6:00 a.m. Check July: 13 gaps of 31 opportunities August:10 gaps of 31 opportunities September: 8 gaps of 30 opportunities October: 15 gaps of 22 opportunities 6:00 p.m. Check July: 20 gaps of 31 opportunities August: 20 gaps of 31 opportunities September: 26 of 30 opportunities October: 20 of 31 opportunities A document, titled "Freezer and Refrigerator Check (Main)", documented, 6:00 a.m. Check July: 10 gaps of 31 opportunities August: 15 gaps of 31 opportunities September: 15 gaps of 30 opportunities October: 13 gaps of 22 opportunity 6:00 p.m. Check July: 21 gaps of 31 opportunities August: 31 gaps of 31 opportunities September 30 gaps of 30 opportunities October 21 gaps of 22 opportunities A document, titled "Freezer and Refrigerator Check (Bistro)" documented, 6:00 a.m. Check July: 14 gaps of 31 opportunities August: 8 gaps of 31 opportunities September: 23 gaps of 30 opportunities October: 15 gaps of 22 opportunities 6:00 p.m. Check July: 20 of gaps of 30 opportunities August: 7 gaps of 31 opportunities September: 23 Gaps of 30 opportunities October: 20 of 22 opportunities A document, titled, "Upper Lever Reach in" documented, July: 14 gaps of 31 opportunities August: 22 gaps of 31 opportunities September: 30 gaps out of 30 opportunities There was a sticky substance on the back splash of the juice machine. In walk-in refrigerator, there were grapes in a cardboard box. The plastic bag was left open to air. There was no open date or label on the grapes. In the walk-in refrigerator, there was a box of dried cherries. The cherries were open to air and had no open date or label. At 9:05 a.m., the dietary manager stated he should have put them in a container. Slices of cheese were observed, wrapped in cellophane. There was no open date or label on the cheese. There was a bin of pork chops on the floor of the walk-in refrigerator. At 9:21 a.m., Dietary Aide #1 was observed as he ate a drum stick of fried chicken near the steam table. At 11:35 a.m. cook #2 was observed as she pureed the roast beef and gravy. The food was placed in a steam table bin and put on the steam table. No temperatures were taken after the pureed food had been completed. On 10/24/13 at 3:40 p.m., the Clinical Nutrition Supervisor and the dietary manager were made aware of the issues in the dietary department. They acknowledged the concerns.

Based on observation, staff interview and review of facility policy and procedure, it was determined the facility failed to ensure: a. two of two treatment carts containing topical medications were secured; b. one of three vials of insulin were labeled with an open date; c. one of three injectable pens of Forteo, which had an expired open date, were disposed of; d. one of two treatment carts did not have topical and oral medications stored together; and e. two of two medication rooms had double locked, permanently affixed storage for scheduled medications. Findings: A policy and procedure titled, "Security of Medication Cart" documented, "...1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry... 4. Medication carts must be securely locked at all times when out of the nurse's view..." 1. On [DATE], at 11:15 a.m., observations were made of the contents of the medication room refrigerator on the East Hall. One 10 ml vial of Lantus insulin was open and approximately two-thirds full. The vial was not labeled with an open date. LPN #1 was asked what the facility policy was for dating insulin vials. She stated the nurse opening the vial for the first time should date it. She was given the insulin vial and asked if it was dated. She stated, "No, it isn't." The refrigerator contained a black box with a key-lock. LPN #1 was asked to open the box. The box contained schedule IV medication (Lorazepam). The box could be removed from the refrigerator and the refrigerator was not secured with a lock. 2. On [DATE] at 3:15 p.m., observations were made of the contents of the medication room refrigerator on the West Hall. One injectable pen of Forteo had an open date of [DATE]. Manufacturer recommendations printed on the outside of the box documented the medication could be used for 28 days after opening. MDS coordinator/LPN #1 was asked if the medication was expired. She stated, "Yes." 3. On [DATE], at 12:15 p.m., the East Hall treatment cart was not locked. The contents of the cart were observed and a bottle of swish and swallow oral medication was found to be stored with topical medications. LPN #2, who was assigned to the cart, was called to the area. She was asked if the oral medication should be stored with the topical. She removed the oral medication from the treatment cart. She was asked if the cart should be locked. She made no comment and locked the cart. 4. On [DATE] at 3:45 p.m., RN #1 was observed as she prepared to provide wound care to a resident. The treatment cart was parked in front of the resident's doorway at the end of the hall. The RN was unable to locate the topical medication to be used for the treatment. She left the treatment cart, went down the hall to the nurse's desk and was no longer in sight. The treatment cart was not locked. The surveyor remained with the cart. When the nurse returned, the drawers to the treatment cart had been opened by the surveyor. She was asked if she noticed anything wrong. She stated, "I am trying to figure it out." She was asked if she normally locked the treatment cart before leaving it. She stated, "Yes, I would have, but you were standing here." 5. On [DATE] at 1:13 p.m., the west hall treatment cart was observed outside of room [ROOM NUMBER]. Five drawers were unlocked with access to medications. The treatment cart was unattended with no staff members present. At 1:35 p.m., RN #1 came out of room [ROOM NUMBER]. She was asked if there was anything wrong with the treatment cart. She stated, "It's unlocked." She was then asked if treatment carts are normally left in the hallways unlocked and unattended. She stated, "No." She was then asked who was responsible for the treatment cart. She stated, "I am." On [DATE], at 4:00 p.m., the DON was notified of the treatment carts being left unlocked, the undated insulin, the expired Forteo, and the oral medication stored with the topical medications. She acknowledged the problems. She was also notified of the schedule IV Lorazepam not being under double-lock. She stated, "I guess we need a lock on the refrigerator."