Every finding on record at Stonehenge of Orem

Based on observation and record review, it was found that the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection and to conduct an annual review of its infection prevention and control program (IPCP) and update their program, as necessary. Specifically, a Certified Nursing Assistant (CNA) and laundry staff handled, transported, and processed soiled linens in a way that did not prevent the spread of infection and the facility did not conduct an annual review of its IPCP policies and procedures.Findings included: 1.On 3/2/26 at 9:28 AM, an observation was made of CNA 1 donning personal protective equipment (PPE) to enter room [ROOM NUMBER], which was an isolation room for influenza. CNA 1 was observed to put on a gown, mask, and gloves. No eye shield was put on before entering the room. There was a sign on the door of room [ROOM NUMBER] that indicated, To prevent the spread of infection, anyone entering this room MUST wear a gown, N95, gloves and shield before entering room. CNA 1 brought linens out from the residents room in a red bag and took them to the soiled linen room. The red bag was not put into a clean bag when it was brought out of the room and taken down the hallway. On 3/4/26 at 8:51 AM, an interview was conducted with Laundry Staff (LS) 1. LS 1 stated that CNA's would bring soiled linens into the soiled linen room in a large trash bin with a lid. LS 1 stated if the linens were from an isolation room, she would place them in a red bag and then into the large trash bin. LS 1 stated that she only wore gloves when she handled the soiled linens, regardless if they were from an isolation room. A concurrent observation was made of LS 1 in the soiled linen room, she was wearing scrubs and a pair of gloves. There were no gowns observed to be available for staff use in the soiled linen room. LS 1 stated she was also responsible for processing linens and resident clothing after they were cleaned. On 3/4/26 at 10:18 AM, an interview was conducted with the Director of Nursing/Infection Preventionist (DON/IP). The DON/IP stated that any laundry that was soiled would be placed in a sugar bag which was intended to prevent and keep infection control. The DON/IP stated that laundry staff did not have to wear gowns because the sugar bag prevented them from handling the soiled linens. On 3/4/26 at 1:23 PM, an interview was conducted with the Administrator (ADM). The ADM stated that soiled laundry from an isolation room was placed into a sugar bag, then that bag would be placed in a red bag, which was then placed into a large laundry bin. The ADM stated the laundry staff would not wear gowns because they used the sugar bags, and that it was best practice to never have any laundry touch staff. On 3/4/26 at 1:56 PM, an interview was conducted with CNA 1. CNA 1 stated if she was in an isolation room handling soiled linens, she would be wearing a gown, gloves, and a mask or face shield. CNA 1 stated she placed the large laundry bin outside of the room, gathered the soiled linens while wearing her PPE, placed them in a sugar bag, tied the sugar bag closed with her soiled gloved hands, placed the sugar bag into a red bag that was found in the resident's room with her same soiled gloves on, and then opened the door, lifted up the lid on the laundry bin outside of the room, placed the red bag into the laundry bin, and then closed the lid. CNA 1 stated she would then remove her soiled gown, gloves, and mask and then immediately take the laundry bin to the soiled linen room. CNA 1 stated she touched the sugar bag with her soiled hands which is why it was also placed into the red bag. CNA 1 stated if any item goes into an isolation room it was considered contaminated. On 3/4/26 at 2:10 PM, an interview was conducted with the Regional Nurse Consultant (RNC) and she stated that CNA staff were gowned and gloved when they put soiled linen from an isolation room into the sugar bags and that there was a potential for contamination on the sugar bags. 2. The 483.80 Infection Control Infection Prevention and Control Program Policy and Procedure was reviewed and it had a revision/review date of 10/22. On 3/4/26 at 10:02 AM, an interview was conducted with the DON/IP and she stated that she was not sure when the IPCP Policies and Procedures were last reviewed or who did that and that the RNC just came and brought her an updated policy. It should be noted that the updated policy had a revision/review date of 10/22. On 3/4/26 at 1:20 PM, an interview was conducted with the ADM and he stated the IPCP policies dated in 2022 were the policies being used. The ADM stated the IP would know when they were last reviewed. On 3/5/26 at 9:26 AM, a follow-up interview was conducted with the ADM and he stated that they had not reviewed the Infection Prevention Program and that they did not have a newer policy in Infection Prevention.

Based on observation, interview and record review it was determined that the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Specifically, the facility did not have a process in place to destroy narcotics when not administered to the residents. Resident identifiers: 129 and 130. Findings included: On 3/13/24 at 8:30 AM, an observation was made of the facility medication cart located on the South hallway with Licensed Practical Nurse (LPN) 1. The following medications were observed inside: a. A multi dose medication card which held Oxycodone 5 mg (milligram) had the back of pocket number 23 was opened with tape now closing it, there was no medications observed in the pocket. The bottom of the narcotic card, under the waste section, had a note written by a staff member that documented, the Oxycodone had been taped closed back into pocket number 23 after the resident refused it. b. A multi dose medication card which held Hydrocodone - APAP (Acetaminophen) 5-325 mg had the back of pocket number 2 was opened with tape now closing it, there was no medication observed in the pocket. No information was documented under the waste section of the form to explain what happened to the narcotic. c. A multi dose medication card which held Oxycodone 10 mg had the back of pocket number 25 was opened with tape now closing it, there was no medication observed in the pocket. No information was documented under the waste section of the form to explain what happened to the narcotic. On 3/13/24 at 8:30 AM, an interview was conducted with LPN 1. LPN 1 stated when a narcotic needed to be discarded it was done by two nursing staff, if available. And the narcotic was put in the sharps container. If two staff were not available LPN 1 stated they had been told that it was okay to tape the narcotic back in the the medication card for future use. LPN 1 stated the staff would circle the number on the narcotic sheet of the pill that was taped back in. LPN 1 stated the medication would then be used when the resident needed that medication again. LPN 1 stated she was unsure how future staff would know if the correct medication had been placed back into the medication card or if the medication was kept clean by the previous nurse. LPN 1 stated she was unsure what the correct process was. On 3/13/24 at 9:00 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated two nurses would dispose of a narcotic and sign it out in the narcotic book. RN 1 stated she did not know what to do if there was only one nurse on duty and a narcotic needed to be wasted. RN 1 stated, you would need to keep it right, and put it back in? RN 1 then stated she just did not know because she had not been faced with that or been told what to do in that situation. On 3/13/24 at 10:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the staff were expected to sign out a narcotic when they get it from the cart. The DON stated when the nurses waste a narcotic they were supposed to waste it with another nurse, if another nurse is not available then the nurse could place the narcotic in a cup and save it to waste when the next nurse came on shift. The DON stated a wasted medication would be one that was dropped, the nurse popped out the wrong medication, or refused by the resident. The DON stated it would be a nursing judgement call whether the medication needed to be discarded. The DON stated she was unsure if the facility had a procedure for disposing of medications. The DON stated the medications could be taped back into the medication card and used again. The DON stated the nurses would have to trust the previous nurse who put the medication in the card that it was the correct medication and that is was kept clean. The DON stated the nurses were not expected to write anything on the narcotic sheet under the waste section if they taped it back into the card, only if they wasted the medication.

Based on observation, interview, and record review it was determined, for 1 of 16 sampled residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, facility staff did not monitor and reassess a resident after the resident experienced a change in condition thus causing the resident to be hospitalized . Resident identifier: 21. HARM Findings include: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 12/17/18. A review of the Progress Notes documented the following entries: a. A physician progress notes [REDACTED]. She doesn't feel well. But is not able to specifically describe why. The patient's nurse reports that the patient is becoming less responsive with a low heart rate. She falls asleep easily. I reviewed her vital chance (sic). Her blood pressure has been stable over the last month, her weights have been stable over the last month, her heart rate has been stable over the last month except for the last 3 days it has trended down. Her heart rate is quite slow at the 40's. Irregular rate. Due to the patient's somnolence not feeling well and [MEDICAL CONDITION] we will send the patient to the acute hospital for further evaluation. There is a suspicion that she may need to reduce her [MEDICATION NAME] and reduce the [MEDICATION NAME]. b. A Nurses Note dated 11/2/18 at 6:36 PM, documented Pt (patient) was unresponsive at 1715 (5:15 PM), did sternal rum (sic) and patient spoke to this nurse, asked her how she was, and she stated that she felt very weak, and continued to go in and out of consciousness, heart rate irregular and faint, resp (respirations) even unlabored, lungs clear, abdomen soft et (and) non-distended, BS (bowel sounds) active, pt has [MEDICAL CONDITION] to BLE (bilateral lower extremities), BUE (bilateral upper extremities 2-3+ ([MEDICAL CONDITION]), Peripheral pulses very faint, hard to palpate. BP (blood pressure)-145/41. HR (heart rate)-41. RR (respiratory rate)-18. O2 (oxygen)-96/4L (liters), T (temperature)-97.0, sent patient with ambulance at 1800 (6:00 PM) to (Local Hospital) ER (emergency room ) for treatment and evaluation, pt husband notified of transfer. A review of the Weights and Vitals Summary documented the following entries: a. 10/31/18 at 10:37 AM, HR 54 beats per minute (bpm) b. 11/1/18 at 9:13 AM, HR 46 bpm c. 11/2/18 at 11:04 AM, HR 42 bpm No documentation was located in the medical record indicating that the staff informed the Medical Doctor (MD) when resident 21's HR was below 60. A review of the physician's orders [REDACTED]. a. On 10/3/18, [MEDICATION NAME] extended release 50 milligrams (mg) at bedtime for hypertension. (Note: According to the Nursing (YEAR) Drug Handbook, the Nursing Considerations for [MEDICATION NAME] revealed Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/(per) minute, withhold drug and call prescriber immediately. (Reference: Nursing (YEAR) drug handbook. (2016). Philadelphia, PA: Wolters Kluwer.) b. On 10/3/18, [MEDICATION NAME] 200 mg twice daily for [MEDICAL CONDITION]. c. On 10/4/18 with a discontinue date of 10/18/18, [MEDICATION NAME] 40 mg daily for [MEDICAL CONDITION]. d. On 10/19/18, [MEDICATION NAME] 60 mg daily for [MEDICAL CONDITION]. A review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. A Basic Metabolic Panel (BMP) obtained from resident 21 on 10/24/18, documented the following laboratory values: a. Potassium High at 5.7. Lab value normal range between 3.5 - 5.0 millimoles per liter (mmol/L). b. Chloride Low at 93. Lab value normal range between 102 - 111 mmol/L. c. CO2 (carbon [MEDICATION NAME]) High at 44. Lab value normal range between 19 - 30 mmol/L d. Glucose High at 153. Lab value normal range between 65 - 99 milligrams per deciliter (mg/dl) e. BUN (blood urea nitrogen) High at 83. Lab value normal range between 8 - 20 mg/dl f. Creatinine High at 1.77. Lab value normal range between 0.60 - 1.10 mg/dl g. Estimated GFR (glomerular filtration rate), Low at 26. Lab value normal range greater than 60 milliliter/minute/ 1.73 squared (ml/min/1.73 sq). (Note: A value less than 60 ml/min/1.73 sq indicates [MEDICAL CONDITION].) A Nurses Note dated 10/24/18, documented (MD name) notified of labs. N.O. (new order) stop any potassium and draw BMP on 10/31/18. A review of the Order Summary Report revealed that resident 21 was not receiving potassium supplements. A physician's orders [REDACTED]. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The BMP lab was unable to be located in resident 21's medical record. On 12/19/18 at 11:00 AM, an interview was conducted with the MD. The MD stated that when he orders to stop any potassium for a resident he does not necessarily know if the resident was receiving potassium. The MD stated that he was not sure if the staff informed him that resident 21 was not receiving potassium. The MD stated that he would not worry about the potassium level until the reading was over 6. The MD stated that the potassium level would not impact a resident's heart rate. The MD stated that the facility staff would usually call him if a resident's heart rate was less than 60. The MD stated that if the resident was stable and on a bp medication then he would not be as worried but the staff were expected to call him if the resident's heart rate was below 60. The MD stated that if a resident's heart rate was to drop into the 40's he would usually call the cardiologist and the cardiologist would have cut back on the [MEDICATION NAME]. The MD stated that he defers heart medications like [MEDICATION NAME] to the cardiologist. The MD stated that if a resident's heart rate dropped down to 42 and the resident was unstable he would have sent the resident out. The MD further stated that he would have decreased resident 21's [MEDICATION NAME] depending on what the lab results were, if resident 21's potassium continued to rise and the kidney function continued to decline it could have made a difference in her condition. The MD stated that he would have liked to see what resident 21's BMP was on 10/31/18. On 12/19/18 at 11:39 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that if the MD was contacted she would document in a nurses note. RN 1 stated that if a resident had a low heart rate she would look at the previous heart rates to identify where the normal was for that resident. RN 1 stated that she would recheck the resident's heart rate to verify the reading and she would do a complete assessment on the resident. RN 1 stated that she could not recall anything out of the normal for resident 21 on 10/31/18. On 12/19/18 at 12:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for obtaining resident labs when a physician's orders [REDACTED]. The DON stated that the lab sheet would be put in the lab book, updated on the calendar, and input into the computer system under the resident orders. The DON stated that when the labs were received from the laboratory the results would be sent to the physician and the results and new orders would be documented in a progress note. The DON stated that when the lab was complete it would be taken out of the lab book and shredded. The DON stated that the outside lab company comes to the facility daily Monday through Friday. The DON stated that if a blood draw was to be completed on the weekend the staff would collect the lab and the transportation driver would deliver the lab to the local hospital laboratory. The DON stated that she was unsure as to why resident 21's BMP was not completed as ordered by the physician on 10/31/18. The DON further stated that she called the local laboratory and they did not have record of the BMP lab being completed for resident 21. The DON stated that nursing staff should call the MD if a resident had a change in condition. The DON stated that the nursing staff should document in a nurses note the change of condition that was occurring, the MD contact, and the MD response. The DON stated that the nursing standard would be to contact the MD and hold medications if the resident's heart rate was below 50. On 12/20/18 at 9:15 AM, an interview was conducted with RN 2. RN 2 stated that when a resident lab was received from the laboratory she would compare the values with the prior lab. RN 2 stated that she would write the prior lab values on the current lab slip so the MD would be able to see what was going on with the resident. RN 2 stated that the lab slip would be sent to the MD by secured email and the new orders were wrote on the lab slip and input into the computer system. RN 2 stated that the next lab draw would be generated in the computer system for the nursing staff to complete. RN 2 stated that she would write the next lab draw on the lab calendar and make a requisition for the nursing staff. RN 2 stated that the requisition would be put in the lab folder and the night nurse would double check the lab folder for lab draws that would need to be completed in the morning. RN 2 stated that when the facility switched to the new computer system the lab draws were messed up. RN 2 stated that she would have been the staff member to receive the resident labs and communicate with the MD. RN 2 stated that when the new order was received from the MD to discontinue resident 21's potassium she would have looked at resident 21's MAR indicated [REDACTED]. RN 2 stated that she would have also discontinued any Medpass because sometimes the medpass will have potassium in it. RN 2 further stated that if a resident was not receiving a potassium supplement she would not have gone back and notified the MD. RN 2 stated that the MD in question was in the facility on Wednesdays and she could not recall if she communicated with the MD regarding resident 21's lab results.

Based on observation and interview it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, items available for use in the walk-in refrigerator were beyond the use by date. Additionally, the dietary manager was observed to change the date on prepared tuna salad and return it to the refrigerator for use. Findings include: On [DATE] at 7:50 AM, the following observations were made during an initial tour of the kitchen. In the walk-in refrigerator: a. A container of tuna salad was dated ,[DATE], use-by ,[DATE]. b. A container labeled blueberries was dated ,[DATE], use-by ,[DATE]. c. A container labeled cream of broccoli soup was dated ,[DATE], use-by ,[DATE]. d. A container of vanilla pudding was dated ,[DATE], use-by ,[DATE]. The Dietary Manager (DM) entered the kitchen and went to the walk-in refrigerator. The DM brought the container of tuna salad out of the walk-in refrigerator and stated that the lid was not fitting right. The DM got a new lid for the container. This surveyor pointed out the date, ,[DATE], to the DM. The DM stated that It's still okay, just needs to be changed. The DM then sniffed the tuna salad and held it out for the surveyor to smell, and stated that it was still good. The DM then placed a new piece of tape on the lid and labeled it ,[DATE] Use-by ,[DATE]. The DM stated that usually Mondays start off by checking for out-dated items. The DM stated that they remind the weekend cooks, but sometimes they miss things. The DM then got the cream of broccoli soup from the walk-in refrigerator and dumped it, stated that it still smelled ok but just to be safe. On [DATE] at 12:48 PM, the Dietary Staff Member (DSM) 1 was interviewed. The DSM 1 stated that anything that gets opened should be labeled with an open date. The DSM 1 stated that anything made in house was kept for three days and then it should be discarded. The DSM 1 stated that everybody in the kitchen should pay attention to the use by dates and discard expired foods. On [DATE] at 9:20 AM, the DM was interviewed. The DM stated that the policy for labeling and dating open refrigerated foods and foods made in house was hanging on the walk-in refrigerator door. The DM stated that foods made in house can be kept for three to seven days. The DM stated that foods would be dated for three days and then checked. The DM stated If the foods did not show signs of spoilage they could be extended for 3 more days. The DM stated that she will check if foods still smell and appear good. The DM stated that she abides by if in doubt throw it out. The DM stated that the cooks should check for expired foods daily and that she will check once a week.

Based on interview and record review it was determined, for 3 of 16 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, a resident did not receive [MEDICATION NAME] as ordered by the physician, as needed (PRN) [MEDICATION NAME] was not administered when a resident's weight was above the parameters ordered by the physician, and blood pressure medications were not held when vital signs were below the parameters ordered by the physician. Resident identifiers: 79, 127, and 128. Findings include: 1. Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 79's medical record was reviewed on 12/18/18. A review of the [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) laboratory result dated 12/11/18, documented an INR result of 1.4. The Registered Nurse documented on the laboratory result form that the Medical Doctor (MD) was notified of the result and the current [MEDICATION NAME] order was 3.75 milligrams (mg) daily. The new order was to increase [MEDICATION NAME] to 4 mg daily and recheck the PT/INR on Friday 12/14/18. A review of the physician's orders [REDACTED]. a. On 12/7/18 with a discontinue date of 12/11/18, [MEDICATION NAME] 3.75 mg in the evening for 1 day. b. On 12/8/18 with a discontinue date of 12/14/18, [MEDICATION NAME] 2.5 mg in the evening every Tuesday, Wednesday, Thursday, Friday, and Saturday. c. On 12/11/18 with a discontinue date of 12/14/18, [MEDICATION NAME] 4 mg in the evening every Monday. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of the Progress Notes documented the following entries: a. On 12/11/18 at 1:28 PM, A physician progress notes [REDACTED]. [MEDICAL CONDITION]. Continue [MEDICATION NAME] bridging to [MEDICATION NAME]. (MD name) following Coumdin levels. Author: Physician Assistant (PA) b. On 12/11/18 at 2:24 PM, Nurses Note (MD name) notified of PT/INR. N.O. (new order) to increase [MEDICATION NAME] to 4 mg QD (daily) and repeat on Friday 12/14. c. On 12/11/18 at 2:29 PM, New Order Note [MEDICATION NAME] Tablet ([MEDICATION NAME] Sodium) Give 4 mg by mouth in the evening every Mon (Monday) related to UNSPECIFIED [MEDICAL CONDITION] FIBRILLATION . per (PA name) PA. (Note: The orders were conflicting between the MD and PA on what dose of [MEDICATION NAME] resident 79 was to receive.) A physician's orders [REDACTED]. Hold for blood presser (sic) lower than 105/60. A review of the (MONTH) (YEAR) MAR indicated [REDACTED] a. On 12/11/18, bp 94/51. b. On 12/12/18, bp 104/51. A physician's orders [REDACTED]. If weight is greater than 207# (pounds) give PRN dose. A review of the Weights and Vitals Summary documented the following entries: (Note: all entries were in pounds.) a. 12/7/18, 215 b. 12/8/18, 214.8 c. 12/9/18, 214 d. 12/10/18, 211.6 e. 12/11/18, no weight entered f. 12/12/18, 213.4 g. 12/13/18, 211.2 h. 12/14/18, 213.6 i. 12/15/18, 207.8 j. 12/16/18, 207.8 k. 12/17/18, 207.2 A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. On 12/18/18 at 9:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there had been a miss communication between providers regarding resident 79's [MEDICATION NAME] dosages. The DON stated that she identified that nursing staff were not following physician ordered parameters for resident medications on Friday, 12/14/18. On 12/18/18 at 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if a resident was admitted from the hospital with physician ordered medication parameters the parameters would be entered into the computer system. LPN 1 stated that if the resident was not admitted with physician ordered medication parameters the house MD parameters would be followed. LPN 1 stated that the resident vital signs must be entered into the computer prior to the medication administration. LPN 1 stated that the computer system does not alert the staff if the parameters were out of range and the medication should not be administered. LPN 1 stated that the computer relies on nursing judgement. LPN 1 stated that resident 79 was alert and oriented and she was aware that the [MEDICATION NAME] PRN order was available at her request. 2. Resident 127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/18, a review of resident 127's medical record was completed. Resident 127's physician's orders [REDACTED]. Resident 127's MAR for (MONTH) (YEAR) was reviewed. Resident 127's [MEDICATION NAME] was administered on the following dates with a systolic blood pressure below 90. a. On 12/9/18, BP was 124/64. b. On 12/10/18, BP was 129/60. c. On 12/11/18, BP was 116/79. d. On 12/12/18, BP was 146/58. e. On 12/13/18, BP was 142/73. f. On 12/14/18, BP was 153/71. g. On 12/15/18, BP was 115/70. h. On 12/16/18, BP was 122/63. i. On 12/17/18, BP was 152/63. On 12/19/18 at 9:10 AM, the DON was interviewed. The DON stated she was not sure why that parameter was used on resident 127's [MEDICATION NAME] order. The DON stated that she was trying to contact the nurse who entered the order. At 12:15 PM, the DON was re-interviewed. The DON stated that she had not been able to get a hold of the nurse who entered the order. The DON stated that she would have expected nursing staff to clarify the parameter. 3. Resident 128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/18/18, a review of resident 128's medical record was completed. Resident 128's physician's orders [REDACTED]. Resident 128's MAR for (MONTH) (YEAR) was reviewed, on the following dates resident 128 was administered [MEDICATION NAME] with a BP below 105/60. a. On 12/7/18 at the 8:00 PM administration, BP was 100/63. b. On 12/19/18 at the 12:00 PM administration, BP was 108/57. c. On 12/10/18 at the 4:00 PM administration, BP was 102/60. d. On 12/10/18 at the 8:00 PM administration, BP was 103/64. e. On 12/12/18 at the 12:00 PM administration, BP was 103/64. f. On 12/12/18 at 8:00 PM administration, BP was 95/63. g. On 12/13/18 at 12:00 PM administration, BP was 103/61. h. On 12/15/18 at the 8:00 AM administration, BP was 98/62. i. On 12/17/18 at the 8:00 AM administration, BP was 104/65. j. On 12/18/18 at the 8:00 AM administration, BP was 103/66. On 12/18/18 at 9:42 AM, LPN 2 was interviewed. LPN 2 stated that per the order she would hold resident 128's [MEDICATION NAME] if either her diastolic or systolic blood pressure were below the parameter. On 12/18/18 at 9:52 AM, the DON was interviewed. The DON stated that they were aware of a problem with nursing staff not following parameters but had just noticed it last week.

Based on observation, interview, and record review it was determined, for 1 of 16 sample residents, the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident who admitted with pressure ulcers did not receive appropriate and timely measures for pressure ulcer prevention and treatment. Resident identifiers: 77. Findings include: Resident 77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/18, a review of resident 77's medical record was completed. Resident 77's Baseline Care Plan dated 12/7/18, included the following problems, goals, and approaches: a. Skilled Services to be provided: Pressure Ulcer Management/Education. Skilled services to be provided per MD (medical doctor) order and as indicated. Educate patient with changes in plan of care. Ensure therapeutic approach at all times. b. Potential for skin breakdown r/t (related to): Decreased mobility, incontinence, decreased sensation of skin. Manifested by history of pressure ulcers. Resident 77's goals were to not have any further skin breakdown. Resident 77's interventions included: encourage to turn/reposition/shift position frequently, air mattress as needed (12/7/18), weekly skin checks, report any skin problems to DON (Director of Nursing), pressure reducing mattress to bed and w/c (wheelchair), provide skin care frequently, clean the patient's skin after each episode of incontinence, apply lotion after shower/peri-care, elevate legs as tolerated, float heels, treatments as ordered per MD, monitor skin breakdown sites for s/s (signs and symptoms) of infection, notify MD PRN (as needed), postpone care when non-compliant and reapproach, [MEDICATION NAME] as ordered, barrier cream as ordered, pup dressing to coccyx as ordered. c. A stage II pressure injury to the sacrum/left buttocks and a stage II pressure injury to the sacrum/right buttocks. With the plan of approach to frequently reposition, air mattress as tolerated, wheelchair cushion, dietitian to monitor nutrition and dressing changes as ordered by the physician, venelex as ordered. A review of resident 77's progress notes documented the following: a. On 12/7/18 at 10:30 PM, .Pt (patient) has R (right) sided weakness r/t stroke Pt is a 2+ extensive transfer as his R side is dead weight . Pt skin assessment completed at this time as well . Pt has scabs to R 1st and 5th finger tips. Pt has scab to L (left) thigh. Pt has scab to R medial ankle. Pt has R sided weakness. Scab to R knee. PT has stage II PU (pressure ulcer) to R and L buttocks. Skin is open and red. Apply venelex to bilat (bilateral) buttocks BID (twice daily) until resolved. b. On 12/8/18 at 4:45 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated Continue with Plan of Care as approved per IDT (interdisciplinary team) and MD. c. On 12/8/18 at 11:53 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated . Continue with Plan of Care as approved per IDT and MD. d. On 12/9/18 at 5:51 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated . Continue with Plan of Care as approved per IDT and MD. e. On 12/9/18 at 10:08 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated . Continue with Plan of Care as approved per IDT and MD. f. On 12/10/18 at 10:25 AM, Physician 1 documented I was asked to see the patient for my advice in managing the patient's functional recovery status [REDACTED]. INTEGUMENTARY: Denies rashes, itching, or skin breakdown REHABILITATION Diagnosis: [REDACTED]. RISK FOR CLINICAL COMPLICATIONS - include but are not limited to the following: falls and their complications, infections, pressure ulcers, skin breakdown, [MEDICAL CONDITION]-embolic events, contractures, pain, medication side effects, etc. g. On 12/10/18 at 1:16 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated . Continue with Plan of Care as approved per IDT and MD. h. On 12/11/18 at 12:39 PM, the Physician Assistant (PA) documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia ASSESSMENT AND PLAN: 1. Hemorrhagic stroke involving the left thalamus with extension into the ventricles resulting in right [MEDICAL CONDITION] and dysphagia . 2. Dysphagia . 3. Hypertension . 4. [MEDICAL CONDITION] . 5. Diabetes . 6.[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease) . 7. Depression . 8. Daytime sleepiness . (Note: The PA did not address resident 77's pressure ulcers identified on admission in the Assessment and Plan.) i. On 12/11/18 at 6:42 PM, Skin/Wound: No new changes to skin integrity noted. Patient has current wounds being treated. coccyx Dressing changes not needed this shift. No noted changes to wounds . Continue with Plan of Care as approved per IDT and MD. j. On 12/12/18 at 5:39 PM, Skin/Wound: No new changes to skin integrity noted. Patient has current wounds being treated. PU on coccyx Dressing changes not needed this shift. No noted changes to wounds . Continue with Plan of Care as approved per IDT and MD. k. On 12/13/18 at 4:02 PM, Skin/Wound: No new changes to skin integrity noted. Patient has current wounds being treated. PU on coccyx Dressing changes as per treatment orders. No noted changes to wounds . Continue with Plan of Care as approved per IDT and MD. l. On 12/14/18 at 2:22 PM, the PA documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia ASSESSMENT AND PLAN: 1. Hemorrhagic stroke . 2. Dysphagia . 3. Hypertension . 4. [MEDICAL CONDITION] . 5. Diabetes . 6.[MEDICAL CONDITION]. 7. Depression . 8. Daytime sleepiness . (Note: The PA did not address resident 77's pressure ulcers identified on admission in the Assessment and Plan.) m. On 12/14/18 at 5:36 PM, Skin/Wound: No new changes to skin integrity noted. Patient has current wounds being treated. PU to coccyx Dressing changes as per treatment orders. No noted changes to wounds . Continue with Plan of Care as approved per IDT and MD. n. On 12/15/18 at 12:17 AM, . pt has significant sore to coccyx. nurse to order air mattress for pt and turn q2h (every 2 hours). pup and venelex to coccyx. pt resting well at this time bed in low position mouth cares done. o. On 12/15/18 at 11:22 AM, Skin/Wound: No new changes to skin integrity noted. Patient has current wounds being treated. stage 2 ulcer on coccyx Dressing changes as per treatment orders. No noted changes to wounds. Stage 2 ulcer . Continue with Plan of Care as approved per IDT and MD. p. On 12/15/18 at 11:34 AM, Pt requested for a cream on scabbed area on R shin, venelex and island dressing applied. PUP dressing applied on R coccyx area for stage 2 ulcer. Slight tint of blood on R coccyx. Pt denied pain and satisfied with tx (treatment). Notified DON. q. On 12/16/18 at 7:04 PM, Pt has stage 2 and three PUs to buttocks and coccyx. Venelex and PUP placed . Area cleaned well by this nurse and CNA (certified nursing assistant) . r. On 12/16/18 at 10:08 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated. N/A (not applicable) . Continue with Plan of Care as approved per IDT and MD. s. On 12/17/18 at 3:17 PM, Physician 1 documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia . I met with the team in a team meeting regarding diagnosis, prognosis, rehabilitation goals, discharge plans, etc . Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated. N/A (Note: Physician 1 did not identify resident 77's pressure ulcers which had been present since admission to the facility.) t. On 12/17/18 at 4:07 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated. N/A . Continue with Plan of Care as approved per IDT and MD. u. On 12/17/18 at 11:14 PM, Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated . Continue with Plan of Care as approved per IDT and MD. v. On 12/18/18 at 2:20 PM, the PA documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia ASSESSMENT AND PLAN: 1. Hemorrhagic stroke . 2. Dysphagia . 3. Hypertension . 4. [MEDICAL CONDITION] . 5. Diabetes . 6.[MEDICAL CONDITION]. 7. Depression . 8. Daytime sleepiness . (Note: Physician 1 did not address resident 77's pressure ulcers identified on admission in the Assessment and Plan.) w. On 12/18/18 at 6:40 PM, Skin/Wound: No new changes to skin integrity noted. Patient has current wounds being treated. PU coccyx, Dressing changes as per treatment orders. No noted changes to wounds . Continue with Plan of Care as approved per IDT and MD. x. On 12/18/18 at 10:06 PM, Skin/Wound: No new changes to skin integrity noted. Patient has current wounds being treated. R buttocks, Coccyx Dressing changes as per treatment orders. Dressing changes not needed this shift. No noted changes to wounds. Stage 2 ulcer . Continue with Plan of Care as approved per IDT and MD. A review of the Admission Nursing Comprehensive assessment dated [DATE], documented that resident 77 had a stage II pressure ulcer on the right buttock which measured 4.35 cm (centimeters) X (by) 2 cm; and a stage II pressure ulcer on the left buttock which measured 4.5 cm X 2.25 cm. A box labeled treatment ordered or required was unchecked and no treatments were indicated. The assessment indicated that resident 77 was totally dependent for bed mobility. A review of the Weekly Skin Check Reports documented the following entries: a. On 12/10/18, resident 77 had an unstageable coccyx pressure injury which measured 8 cm X 5.5 cm and had ensanguine drainage, no odor and treated with venelex and PUP pad. Resident 77 also had an unstageable right buttock pressure ulcer which measured 2.0 cm X 2.5 cm X 0.2 cm and had ensanguine drainage, no door and treated with venelex and PUP pad. b. On 12/15/18, resident 77 had a stage II pressure ulcer on the sacrum measuring 4.5 cm X 2 cm, and a stage II pressure ulcer on the coccyx measuring 4.5 cm X 2.5 cm. c. On 12/17/18, resident 77 had a Suspected Deep Tissue Injury to the coccyx that measured 8 cm X 5.5 cm X 0.2 cm (depth), with ensanguine drainage, no odor and venelex entered for the treatment. Resident 77 also had an unstageable right buttock pressure ulcer which measured 2.0 cm X 2.5 cm X 0.2 cm and had ensanguine drainage, no door and treated with venelex and PUP pad. On 12/19/18, the wound was observed while Licensed Practical Nurse (LPN) 1 completed a dressing change on resident 77. LPN 1 documented the following: a. Blanchable redness which measured 9 cm x 7.5 cm. b. A right buttock deep tissue injury which measured 4.1 cm X 1.9 cm X 0.2 cm. c. A stage II pressure injury which measured 3.9 cm X 0.9 cm X 0.1 cm. Resident 77's physician's orders [REDACTED]. a. Venelex Ointment. Apply to buttocks topically every shift for stage II PU to buttocks. Started on 12/8/18. b. Venelex Ointment. Apply to coccyx topically every day and night shift for PU to coccyx. Started on 12/15/18. c. Turn and Repositioning every 2 hours for PU prevention and treatment. Every day and night shift for non mobile patient. Started on 12/15/18. d. Air mattress to bed at all times every day and night shift for non mobile patient make sure air mattress is functioning. Started on 12/15/18. (Note: This order did not appear on resident 77's Medication Administration Record.) e. large pup to coccyx to protect from pressure every day and night shift for pressure to coccyx. Started on 12/15/18. (Note: This order did not appear on resident 77's Medication Administration Record.) On 12/19/18 at 1:52 PM, LPN 1 and the DON were interviewed. LPN 1 stated that resident 77 had a stage II pressure ulcer and a deep tissue injury to the coccyx. LPN 1 stated that resident 77 was repositioned every 2 hours, had a pup pad in place, and was on an air mattress. The DON stated that she saw that the Physician and PA had documented that resident 77's skin was intact and she did not know why since the injuries were present on admission to the facility. The DON stated that the PUP pad in place was a pressure relieving pad. The DON stated that she had placed a PUP pad on resident 77 on 12/10/18, when she observed the wounds. (Note: There were no orders entered for a PUP pad to be used until 12/15/18.) The DON stated that she had told the nurse on duty to enter in the wound care and air mattress orders for her, she did not know when this had been completed. The DON stated that when she saw the wounds on 12/10/18, she told the MD that resident 77 needed an air mattress and PUP pad, and told the nurse on duty to enter the orders. (Note: Per resident 77's physician's orders [REDACTED].) On 12/19/18 at 2:10 PM, LPN 1 was re-interviewed. LPN 1 stated that she worked 3 days a week and did not recall the PUP pad or air mattress being in place prior to 12/15/18. On 12/19/18 at 2:13 PM, the DON was re-interviewed. The DON stated that she would take measurements weekly on Mondays and then talk to the MD to communicate measurements and orders.

Based on interview and record review it was determined, for 1 of 16 sample residents, that the facility did not ensure that each resident's medical care was supervised by a physician. Specifically, a resident's pressure ulcers (PU) were not addressed by physician(s) who oversaw his care. Resident identifiers: 77. Findings include: Resident 77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/19/18, a review of resident 77's medical record was completed. A review of the Admission Nursing Comprehensive assessment dated [DATE], documented that resident 77 had a stage II pressure ulcer on the right buttock which measured 4.35 cm (centimeters) X (by) 2 cm; and a stage II pressure ulcer on the left buttock which measured 4.5 cm X 2.25 cm. A box labeled treatment ordered or required was unchecked and no treatments were indicated. The assessment indicated that resident 77 was totally dependent for bed mobility. A review of the Weekly Skin Check Reports documented the following entries: a. On 12/10/18, resident 77 had an unstageable coccyx pressure injury which measured 8 cm X 5.5 cm and had ensanguine drainage, no odor and treated with venelex and PUP pad. Resident 77 also had an unstageable right buttock pressure ulcer which measured 2.0 cm X 2.5 cm X 0.2 cm and had ensanguine drainage, no door and treated with venelex and PUP pad. b. On 12/15/18, resident 77 had a stage II pressure ulcer on the sacrum measuring 4.5 cm X 2 cm, and a stage II pressure ulcer on the coccyx measuring 4.5 cm X 2.5 cm. c. On 12/17/18, resident 77 had a Suspected Deep Tissue Injury to the coccyx that measured 8 cm X 5.5 cm X 0.2 cm (depth), with ensanguine drainage, no odor and venelex entered for the treatment. Resident 77 also had an unstageable right buttock pressure ulcer which measured 2.0 cm X 2.5 cm X 0.2 cm and had ensanguine drainage, no door and treated with venelex and PUP pad. On 12/19/18, the wound was observed while Licensed Practical Nurse (LPN) 1 completed a dressing change on resident 77. LPN 1 documented the following: a. Blanchable redness which measured 9 cm x 7.5 cm. b. A right buttock deep tissue injury which measured 4.1 cm X 1.9 cm X 0.2 cm. c. A stage II pressure injury which measured 3.9 cm X 0.9 cm X 0.1 cm. Resident 77's physician's orders [REDACTED]. a. Venelex Ointment. Apply to buttocks topically every shift for stage II PU to buttocks. Started on 12/8/18. b. Venelex Ointment. Apply to coccyx topically every day and night shift for PU to coccyx. Started on 12/15/18. c. Turn and Repositioning every 2 hours for PU prevention and treatment. Every day and night shift for non mobile patient. Started on 12/15/18. d. Air mattress to bed at all times every day and night shift for non mobile patient make sure air mattress is functioning. Started on 12/15/18. (Note: This order did not appear on resident 77's Medication Administration Record.) e. large pup to coccyx to protect from pressure every day and night shift for pressure to coccyx. Started on 12/15/18. (Note: This order did not appear on resident 77's Medication Administration Record.) A review of resident 77's progress notes documented the following: a. On 12/7/18 at 10:30 PM, .Pt (patient) has R (right) sided weakness r/t (related to) stroke Pt is a 2+ extensive transfer as his R side is dead weight . Pt skin assessment completed at this time as well . Pt has scabs to R 1st and 5th finger tips. Pt has scab to L (left) thigh. Pt has scab to R medial ankle. Pt has R sided weakness. Scab to R knee. PT has stage II PU to R and L buttocks. Skin is open and red. Apply venelex to bilat (bilateral) buttocks BID (twice daily) until resolved. b. On 12/10/18 at 10:25 AM, Physician 1 documented I was asked to see the patient for my advice in managing the patient's functional recovery status [REDACTED]. INTEGUMENTARY: Denies rashes, itching, or skin breakdown REHABILITATION Diagnosis: [REDACTED]. RISK FOR CLINICAL COMPLICATIONS - include but are not limited to the following: falls and their complications, infections, pressure ulcers, skin breakdown, [MEDICAL CONDITION]-embolic events, contractures, pain, medication side effects, etc. (Note: Physician 1 did not address or identify resident 77's pressure ulcers which had been present since admission to the facility.) c. On 12/11/18 at 12:39 PM, the Physician Assistant (PA) documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia ASSESSMENT AND PLAN: 1. Hemorrhagic stroke involving the left thalamus with extension into the ventricles resulting in right [MEDICAL CONDITION] and dysphagia . 2. Dysphagia . 3. Hypertension . 4. [MEDICAL CONDITION] . 5. Diabetes . 6.[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease) . 7. Depression . 8. Daytime sleepiness . (Note: The PA did not address resident 77's pressure ulcers identified on admission in the Assessment and Plan.) d. On 12/14/18 at 2:22 PM, the PA documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia ASSESSMENT AND PLAN: 1. Hemorrhagic stroke . 2. Dysphagia . 3. Hypertension . 4. [MEDICAL CONDITION] . 5. Diabetes . 6.[MEDICAL CONDITION]. 7. Depression . 8. Daytime sleepiness . (Note: The PA did not address resident 77's pressure ulcers identified on admission in the Assessment and Plan.) e. On 12/17/18 at 3:17 PM, Physician 1 documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia . I met with the team in a team meeting regarding diagnosis, prognosis, rehabilitation goals, discharge plans, etc . Skin/Wound: No new changes to skin integrity noted. Patient has no wounds presently being treated. N/A (Note: Physician 1 did not address or identify resident 77's pressure ulcers which had been present since admission to the facility.) f. On 12/18/18 at 2:20 PM, the PA documented Impaired mobility and activities of daily living and cognitive function due to a stroke with significant right-sided weakness and severe dysphagia ASSESSMENT AND PLAN: 1. Hemorrhagic stroke . 2. Dysphagia . 3. Hypertension . 4. [MEDICAL CONDITION] . 5. Diabetes . 6.[MEDICAL CONDITION]. 7. Depression . 8. Daytime sleepiness . (Note: PA did not address resident 77's pressure ulcers identified on admission in the Assessment and Plan.) On 12/19/18 at 1:52 PM, the Director of Nursing (DON) was interviewed. The DON stated that she saw that Physician 1 and the PA had documented that resident 77's skin was intact and she did not know why since the injuries were present on admission to the facility. The DON stated that the PUP pad in place was a pressure relieving pad. The DON stated that she had placed a PUP pad on resident 77 on 12/10/18, when she observed the wounds. The DON stated that she would take measurements weekly on Mondays and then communicate with the Medical Director. The DON stated that when she observed resident 77's wounds they had regressed greatly and there was a large area encompassing the open wounds that was purple, smooshy, and boggy. The DON stated that was when she completed the Clinically Unavoidable Pressure Ulcer form due to the drastic change despite interventions; and resident 77's [DIAGNOSES REDACTED]. (It should be noted that at this time resident 77 had not had the PUP pad or air mattress in place.) The DON stated that she was not certain if the Medical Director, Physician 1, or the PA had ever assessed resident 77's pressure injuries. The DON stated that she had communicated with the Medical Director regarding her observations of resident 77's wound and the need for the PUP pad and air mattress on 12/10/18. (It should be noted that these measures were not entered in resident 77's physician's orders [REDACTED].

Based on interview and record review it was determined, for 1 of 16 sample residents, that the facility did not provide or obtain laboratory (lab) services when ordered by the physician. Specifically, a basic metabolic panel (BMP) was not completed as ordered by the physician. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on 12/17/18. A physician's orders [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The BMP lab was unable to be located in resident 21's medical record. On 12/19/18 at 12:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for obtaining resident labs when a physician's orders [REDACTED]. The DON stated that the lab sheet would be put in the lab book, updated on the calendar, and input into the computer system under the resident's orders. The DON stated that when the labs were received from the laboratory the results would be sent to the physician and the results and new orders would be documented in a progress note. The DON stated that when the lab was complete it would be taken out of the lab book and shredded. The DON stated that the outside lab company comes to the facility daily Monday through Friday. The DON stated that if a blood draw was to be completed on the weekend the staff would collect the lab and the transportation driver would deliver the lab to the local hospital laboratory. The DON stated that she was unsure as to why resident 21's BMP was not completed as ordered by the physician on 10/31/18. The DON further stated that she called the local laboratory and they did not have record of the BMP lab being completed for resident 21.

Based on observation, interview, and record review, it was determined that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 16 sample residents. Specifically social services were not provided for a resident who expressed suicidal ideations after receiving the news that he would not be returning to his original home. Resident identifiers: 159. Findings include: Resident 159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/10/17 at 1:26 PM, resident 159 was interviewed. Resident 159 stated that he felt like he was in prison because he was so bored. He stated, If it wasn't so painful, I'd commit suicide. I hate it here. On 10/10/17 at 3:00 PM, resident 159 and his wife were interviewed. The resident raised his fist and stated, I would like to see you sit here for 5 minutes. I hate it. I want to commit suicide. The resident's wife stated that the resident's long term memory was good, but that he had a very poor short term memory. The resident's wife stated that the resident struggled being in a small room because their home is very large and he can wander throughout the home at will. The resident then complained of his wife not being with him at the facility and became agitated. The resident's wife stated that she had been with him at the facility every afternoon until he went to sleep. The resident's wife stated that the resident had not used the word 'suicide' at home, but that he was frustrated by not being at home as he had never been hospitalized before. The resident's wife stated that the resident had a condition that caused vascular dementia. Finally, the resident's wife indicated that the resident's suicidal threats were not credible and that the resident was confused much of the time. On 10/10/17, resident 159's medical record was reviewed. A review of resident 159's nursing Progress Notes revealed the following entries: a. On 10/5/17 at 9:00 PM, Pt expressed to wife suicidal ideation. b. On 10/5/17 at 11:26 PM, Pt had episodes of anxiety and depression this shift. Stated that he was upset with his wife related to having to be here. Also stated that he had broken out of better prison than this one. Mention of wanting to die if he had to continue to stay in facility. Spoke with pt and wife at length about why he was here. He and wife spoke as well after conversion (sic) with this nurse. Seems calmer at this time. No further mention of dying or escaping. Alarm in place for safety. Frequent checks performed as well. Will continue to monitor. c. On 10/6/17 at 10:49 AM, The staff reports that patient expressed self-harm after receiving information that his house will be sold and that his wife, and he will be moving into assisted living. Throughout the night. He is in wash (sic) every hour and the patient has improved significantly. Today the patient states that he feels much better, although he is so upset he has no intention for self-harm. (NOTE: The resident was also noted to have a flat facial expression. This note was authored by the Physician's Assistant (PA).) e. On 10/10/17 at 4:30 PM, DON (Director of Nursing) and Administrator interviewed wife, (name of wife), re: suicidal ideation. (Name of wife) states she told the nurse patient was upset about current situation with being here in this facility and selling of house in (name of state) and suggestion of assisted living. Wife stated patient did not say he wanted to kill himself, but stated, 'If I had to stay here a long time, I would commit suicide,' stating it as a future scenario if he was left in a nursing home. The wife states her husband had no means of committing suicide and no plan, wife also stated patient had no means of elopement from facility on 10/5/17. Wife confirms she spent the night here 10/5/17 until morning of 10/6/17 when PA assessed patients well being and confirmed patient didn't have any active thoughts of suicide but did voice his displeasure with selling the home and being here. f. On 10/10/17 at 6:59 PM, Spoke with pt this evening. Pt states that he is not depressed as long as his wife is with him. He states that the wife is the love of his life but understands that she won't be in the building 24/7. We discussed different activities that he could participate or that the facility could provide for him when wife is not in the building. Pt denies sadness or depression at this time. WTCM (will continue to monitor). A review of the facility's Social Work Progress Notes revealed the following entries: a. On 10/5/17 (no time was provided on the note), IDT (interdisciplinary team meeting) was held today with pt's (patient's) wife and daughter to discuss discharge planning. We discussed assisted living, LTC (long-term care) and going home with private caregivers. We recommended that (resident 159) have full-time help at home. Pt's wife has decided to buy a home in (name of state) that is being built and bring pt home with day-time caregivers. Until the home is completed, pt and spouse will stay with their daughter, (name of daughter). (NOTE: This note was authored by the Social Service Worker (SSW).) b. On 10/10/17 (no time was provided on the note), (Late Note) Pt scored 1-2 on question 1 of the Mood Survey with a total score of 8. He has been making suicidal comments and the nurses have put him on suicide checks. I met with him on 10-6-17 to determine if he is at risk for suicide. He has been depressed and worried that he will not be able to go home with his wife. He sometimes seems confused. We discussed that the discharge plan is for him to go home with his wife to their daughter's home until the new home is built. He seemed content with that plan. Reassurance and emotional support were provided. (NOTE: This note was authored by the SSW.) A review of resident 159's History and Physical showed that the resident did not have a history of mental illness or suicidal ideations. A review of resident 159's Minimum Data Sets (MDS) assessments revealed the following Resident Mood Interviews: a. On 9/24/17, resident 159 was listed as having little interest or pleasure in doing things on half or more of the days and listed as feeling down, depressed, or hopeless on several days. The resident was not listed as being a risk for self-harm. Resident 159's total severity score was 3 out of 27. b. On 10/8/17, resident 159 was listed as having little interest or pleasure in doing things and feeling down, depressed, or hopeless nearly every day. Resident 159 was listed as moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual on several days. Additionally, the resident was listed as having thoughts that you would be better off dead, or of hurting yourself in some way on half or more of the days. Resident 159's total severity score declined to 8 out of 27. Finally, the resident's Brief Interview for Mental Status score was listed as 8, indicating that the resident's cognition was moderately impaired. A review of resident 159's Care Plan dated 9/15/17 revealed that resident 159 had an Adjustment to Placement care plan. The goal for resident 159 included I will understand the benefits of being in the facility. I will feel comfortable and safe at the facility. The interventions included Help me to adjust to a routine I can cope with. Invite me to activities I enjoy. Introduce me to other residents. Invite me to resident council. Help me to understand the benefits of participating in physical therapy, and other reasons why it's good for me to be in short-term rehabilitation. Encourage me to express my feelings and concerns. Provide emotional support and reassurance. A review of resident 159's Care Plan dated 9/15/17 revealed that resident 159 had a Discharge Planning Care Plan. The goal for resident 159 included I will meet with the discharge planner to facilitate a smooth transition to home. The interventions on the care plan included, Refer me for home health care or an out-patient rehabilitation facility before I am discharged . Arrange for any medical equipment that I may need. Inform me of community resources that might be helpful to me. Involve my family in discharge planning if possible. No update to the care plans could be located in resident 159's medical record after resident 159 had a change in condition with the suicidal ideation. On 10/10/17 at 3:05 PM, the SSW was interviewed. The SSW stated that the normal procedure for suicide involved the SSW following up with the patient and the patient's family members. The SSW stated that she would normally update the care plan and should have updated the care plans dated 9/15/17. The SSW stated that her interventions for resident 159 included an IDT meeting on 10/6/17. The SSW stated that she did not have documentation of the IDT meeting yet. The SSW stated that she felt his feelings were situational regarding his future living situation and that her interventions following the mood interview on 10/8/17 included trying to follow up with the resident and his family. The SSW further stated that the resident's wife was not typically in the facility in the mornings. On 10/11/17 at 11:04 AM, resident 159 was interviewed. Resident 159 stated that he sat and stared at the clock and the four walls of his room all day. He stated that he wished he could do something, but that he couldn't get up or walk because he was a fall risk. Resident 159 stated that he couldn't stand sitting in his room day after day. Resident 159 stated that if he had a way out of this life, that he would take it. He stated, I'd kill myself. I can't stand the boredom. If you sat here for two minutes, you would go stark raving mad. Resident 159 stated that he felt that his family and the nurses were too busy to care about him. Resident 159 was noted to have a flat affect during the interview. On 10/12/17 at approximately 9:55 AM, the SSW was interviewed. The SSW stated that emotional support meant that she spoke with the patient and provided supportive listening. The SSW stated that her plan regarding resident 159's suicidal ideations included continuing to watch him and check up on him. The SSW stated that these check-ups were not scheduled and did not provide any additional documentation regarding any visits with the resident. The SSW stated that she would consider setting up talk therapy the next day or during the next week.

Based on observation and interview it was determined that the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, facility staff and resident family members were observed in an isolation room without the proper PPE (personal protective equipment) and clean and folded towels, hand towels and wash cloths were observed to be on top of a laundry barrel. Findings include: 1. On 10/10/17 at 8:00 AM, an observation was made of PPE (personal protective equipment) outside of resident room [ROOM NUMBER]. On 10/10/17 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the resident in room [ROOM NUMBER] had[DIAGNOSES REDACTED] (Clostridium Difficile). On 10/10/17 at 8:21 AM, an observation was made of LPN 1 and CNA (Certified Nursing Assistant) 1 as they provided cares to the resident in room [ROOM NUMBER], without any PPE covering their clothing or their hands. LPN 1 was observed to come out of the room. CNA 1 was observed to come out of the room with what appeared to be a garbage bag. An observation was made of CNA 1 as she placed the garbage bag in a red biohazard bag and placed in the biohazard barrel. On 10/10/17 at 8:30 AM, an interview was conducted with CNA 1. CNA 1 stated that the PPE had been provided by the facility to prevent the spread of infection. CNA 1 stated that everyone who entered the room was to don the PPE. On 10/10/17 at 8:46 AM, an observation was made of the resident's family member as he entered room [ROOM NUMBER] without donning any PPE. An observation was made of LPN 1 standing at the nurse's cart near room [ROOM NUMBER]. An observation was made of CNA 1 standing near room [ROOM NUMBER]. No observation was made of an attempt to inform the resident's family member of the need of donning the PPE. On 10/11/17 at 10:10 AM, an observation was made of two family member's inside of resident room [ROOM NUMBER]. Neither family member were donning the PPE provided. 2. On 10/10/17 at 8:05 AM, an observation was made of a laundry barrel in the hallway near room [ROOM NUMBER]. On top of the laundry barrel were two clean folded bath towels, two clean folded hand towels and two clean folded wash cloths. On 10/10/17 at 8:40 AM, an observation was again made of a laundry barrel in the hallway near room [ROOM NUMBER]. On top of the laundry barrel were two clean folded bath towels, two clean folded hand towels and two clean folded wash cloths. On 10/11/17 at 2:35 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had been receiving a lot of labs recently that stated that[DIAGNOSES REDACTED] had been detected but was indeterminate. The facility DON stated that their facility MD would rather have been overly cautious and placed the resident on isolation precautions just in case. The facility DON stated that they had modified the PPE so that facility staff had to wear the PPE if they were taking the resident to the toilet, providing hygiene cares or when facility staff were handling soiled laundry. The facility DON stated that the PPE should also have been worn while taking out the resident's garbage. The facility DON further stated that the clean folded laundry should have been on a cart that was covered and should not have been on top of the laundry barrel.

Based on observation, interview, and record review, it was determined that, for 1 of 16 sample residents, the facility did not ensure that a resident who displayed psychosocial adjustment difficulties received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically the appropriate treatment and services were not put into place for a resident who expressed [MEDICAL CONDITION] after receiving the news that he would not be returning to his original home. Resident identifiers: 159. Findings include: Resident 159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/10/17 at 1:26 PM, resident 159 was interviewed. Resident 159 stated that he felt like he was in prison because he was so bored. He stated, If it wasn't so painful, I'd commit suicide. I hate it here. On 10/10/17 at 3:00 PM, resident 159 and his wife were interviewed. The resident raised his fist and stated, I would like to see you sit here for 5 minutes. I hate it. I want to commit suicide. The resident's wife stated that the resident's long term memory was good, but that he had a very poor short term memory. The resident's wife stated that the resident struggled being in a small room because their home is very large and he can wander throughout the home at will. The resident then complained of his wife not being with him at the facility and became agitated. The resident's wife stated that she had been with him at the facility every afternoon until he went to sleep. The resident's wife stated that the resident had not used the word 'suicide' at home, but that he was frustrated by not being at home as he had never been hospitalized before. The resident's wife stated that the resident had a condition that caused [MEDICAL CONDITION]. Finally, the resident's wife indicated that the resident's suicidal threats were not credible and that the resident was confused much of the time. On 10/10/17, resident 159's medical record was reviewed. A review of resident 159's nursing progress notes revealed the following entries: a. On 10/5/17 at 9:00 PM, Pt expressed to wife suicidal ideation. Q 1 hr (once every hour) frequent checks initiated. New TO (telephone order): Frequent checks. Q 1 hr for suicidal ideation. b. On 10/5/17 at 11:26 PM, Pt had episodes of anxiety and depression this shift. Stated that he was upset with his wife related to having to be here. Also stated that he had broken out of better prison than this one. Mention of wanting to die if he had to continue to stay in facility. Spoke with pt and wife at length about why he was here. He and wife spoke as well after conversion (sic) with this nurse. Seems calmer at this time. No further mention of dying or escaping. Alarm in place for safety. Frequent checks performed as well. Will continue to monitor. c. On 10/6/17 at 10:49 AM, The staff reports that patient expressed self-harm after receiving information that his house will be sold and that his wife, and he will be moving into assisted living. Throughout the night. He is in wash (sic) every hour and the patient has improved significantly. Today the patient states that he feels much better, although he is so upset he has no intention for self-harm. (NOTE: The resident was also noted to have a flat facial expression. This note was authored by the Physician's Assistant (PA).) d. On 10/9/17, Late entry for 10/06/2017 21:00. N.O. (new order) Discontinue frequent checks, pt stable/family aware feels like he is safe per (name of physician). e. On 10/10/17 at 4:30 PM, DON (Director of Nursing) and Administrator interviewed wife, (name of wife), re: suicidal ideation. (Name of wife) states she told the nurse patient was upset about current situation with being here in this facility and selling of house in (name of state) and suggestion of assisted living. Wife stated patient did not say he wanted to kill himself, but stated, 'If I had to stay here a long time, I would commit suicide,' stating it as a future scenario if he was left in a nursing home. The wife states her husband had no means of committing suicide and no plan, wife also stated patient had no means of elopement from facility on 10/5/17. Wife confirms she spent the night here 10/5/17 until morning of 10/6/17 when PA assessed patients well being and confirmed patient didn't have any active thoughts of suicide but did voice his displeasure with selling the home and being here. f. On 10/10/17 at 6:59 PM, Spoke with pt this evening. Pt states that he is not depressed as long as his wife is with him. He states that the wife is the love of his life but understands that she won't be in the building 24/7. We discussed different activities that he could participate or that the facility could provide for him when wife is not in the building. Pt denies sadness or depression at this time. WTCM (will continue to monitor). A review of the facility's Social Work Progress Notes revealed the following entries: a. On 10/5/17 (no time was provided on the note), IDT (interdisciplinary team meeting) was held today with pt's (patient's) wife and daughter to discuss discharge planning. We discussed assisted living, LTC (long-term care) and going home with private caregivers. We recommended that (resident 159) have full-time help at home. Pt's wife has decided to buy a home in (name of state) that is being built and bring pt home with day-time caregivers. Until the home is completed, pt and spouse will stay with their daughter, (name of daughter). b. On 10/10/17 (no time was provided on the note), (Late Note) Pt scored 1-2 on question 1 of the Mood Survey with a total score of 8. He has been making suicidal comments and the nurses have put him on suicide checks. I met with him on 10-6-17 to determine if he is at risk for suicide. He has been depressed and worried that he will not be able to go home with his wife. He sometimes seems confused. We discussed that the discharge plan is for him to go home with his wife to their daughter's home until the new home is built. He seemed content with that plan. Reassurance and emotional support were provided. A review of resident 159's History and Physical showed that the resident did not have a history of mental illness or [MEDICAL CONDITION]. A review of resident 159's Minimum Data Sets (MDS) assessments revealed the following Resident Mood Interviews: a. On 9/24/17, resident 159 was listed as having little interest or pleasure in doing things on half or more of the days and listed as feeling down, depressed, or hopeless on several days. The resident was not listed as being a risk for self-harm. Resident 159's total severity score was 3 out of 27. b. On 10/8/17, resident 159 was listed as having little interest or pleasure in doing things and feeling down, depressed, or hopeless nearly every day. Resident 159 was listed as moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual on several days. Additionally, the resident was listed as having thoughts that you would be better off dead, or of hurting yourself in some way on half or more of the days. Resident 159's total severity score declined to 8 out of 27. Finally, the resident's Brief Interview for Mental Status score was listed as 8, indicating that the resident's cognition was moderately impaired. A review of resident 159's Care Plan dated 9/15/17 revealed that resident 159 had an Adjustment to Placement care plan. The goal for resident 159 included I will understand the benefits of being in the facility. I will feel comfortable and safe at the facility. The interventions included Help me to adjust to a routine I can cope with. Invite me to activities I enjoy. Introduce me to other residents. Invite me to resident council. Help me to understand the benefits of participating in physical therapy, and other reasons why it's good for me to be in short-term rehabilitation. Encourage me to express my feelings and concerns. Provide emotional support and reassurance. A review of resident 159's Care Plan dated 9/15/17 revealed that resident 159 had a Discharge Planning Care Plan. The goal for resident 159 included I will meet with the discharge planner to facilitate a smooth transition to home. The interventions on the care plan included, Refer me for home health care or an out-patient rehabilitation facility before I am discharged . Arrange for any medical equipment that I may need. Inform me of community resources that might be helpful to me. Involve my family in discharge planning if possible. No update to the care plans could be located in resident 159's medical record after resident 159 had a change in condition with the suicidal ideation. On 10/10/17 at 3:05 PM, the SSW was interviewed. The SSW stated that the normal procedure for suicide involved the SSW following up with the patient and the patient's family members. The SSW stated that she would normally update the care plan and that she should have updated resident 159's care plans. The SSW stated that she entered the information for resident 159's Resident Mood Interviews and that her interventions for resident 159 included an IDT meeting on 10/6/17. The SSW stated that she did not have documentation of the IDT meeting yet. The SSW stated that she felt his feelings were situational regarding his future living situation. The SSW stated that her interventions following the mood interview on 10/8/17 included trying to follow up with the resident and his family. On 10/11/17 at 11:04 AM, resident 159 was interviewed. Resident 159 stated that he sat and stared at the clock and the four walls of his room all day. He stated that he wished he could do something, but that he couldn't get up or walk because he was a fall risk. Resident 159 stated that he couldn't stand sitting in his room day after day. Resident 159 stated that if he had a way out of this life, that he would take it. He stated, I'd kill myself. I can't stand the boredom. If you sat here for two minutes, you would go stark raving mad. Resident 159 stated that he felt that his family and the nurses were too busy to care about him. Resident 159 was noted to have a flat affect during the interview. On 10/12/17 at 10:15 AM, the Activities Director (AD) was interviewed. The AD stated that encouraging resident 159 to come to activities can be tough sometimes. The AD stated that resident 159 used to be excited about Ice Cream Fridays, but that the resident had been showing less excitement recently. The AD further stated that resident 159 had gotten less into things. On 10/12/17 at approximately 9:55 AM, the SSW was interviewed. The SSW stated that emotional support meant that she spoke with the patient and provided supportive listening. The SSW stated that her plan regarding resident 159's [MEDICAL CONDITION] included continuing to watch him and check up on him. The SSW stated that these check-ups were not scheduled and did not provide any additional documentation regarding any visits with the resident. The SSW stated that she would consider setting up talk therapy the next day or during the next week.

Based on interview and record review, it was determined that the facility did not permit each resident to remain in the facility, and not transfer or discharge residents from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs could not be met in the facility. Specifically, 3 of 3 sample residents who were discharged to another long-term care facility. Resident identifiers: 40, 105, and 140. Findings include: 1. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 40's medical record was completed on 6/22/16. The following progress notes were documented within resident 40's medical record: a. 5/2/16; . Pt (patient) discharged with family with meds (medications) and belongings to go to (name of other long term care facility) at 1315 in stable condition. b. 5/2/16; . Patient to be discharged [DATE] with belongings and meds as ordered to (name of other long term care facility) for LTC (long term care) . Resident 40's Discharge Planning Tool was reviewed and documented the following information: . 5/2/16 - . They (resident 40's family) took her to visit (name of other long term care facility) and she was D/C'd (discharged ) to (name of other long term care facility) today for LTC. Medicaid pending . The facility's list of beds by designated certification was reviewed. The list documented that out of the 36 total beds, the 2 beds located within room [ROOM NUMBER] were certified for Medicaid use. The census information was reviewed for 5/2/16. The census documented that both beds were available within room [ROOM NUMBER] on 5/2/16, the day of resident 40's discharge from the facility. 2. Resident 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 105's medical record was completed on 6/22/16. The following progress note dated 1/21/16 was documented within resident 105's medical record: Pt to discharge on 1/22/16 with belongings and meds as ordered to (name of other long term care facility) for long-term care . The census information was reviewed for 1/22/16. The census documented that both beds were available within room [ROOM NUMBER] on 1/22/16, the day of resident 105's discharge from the facility. 3. Resident 140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 140's medical record was completed on 6/22/16. The following progress notes were documented within resident 140's medical record: a. 5/20/16; . pt has discharged today to (name of other long term care facility). pt was accompanied by his son, and his son has signed his discharge papers . (name of other long term care home) nurse has been called and report has been given to them about pt . pt discharged with all belongings. b. 5/19/16; . pt has been working with therapy and tolerating well. he is alert and oriented and has been anxious today about his departure to another facility . c. 5/19/16; . (Name of resident 140) . will be discharged on [DATE] with belongings and meds as ordered and will be admitted to (name of other long term care facility) for LTC . Resident 140's Discharge Planning Tool was reviewed and documented the following information: . 4/4/16 meeting c (with) son and dtr (daughter) today. Pt improving + will continue therapy. Medicaid + LTC discussed. 4/7 Dtr picked up Medicaid appl (application) today. 4/21 T/C (talked with) dtr . they are applying for Medicaid for LTC. Probable D/C in 2-3 wks (weeks). 5/20 PT D/C to (name of other long term care facility) - LTC. Pending Medicaid appl. The census information was reviewed for 5/20/16. The census documented that one of the two beds was available within room [ROOM NUMBER] on 5/20/16, the day of resident 140's discharge from the facility. On 6/21/16 at 1:05 PM, an interview was conducted with the Social Services Worker (SSW). The SSW stated the facility had two beds that were certified for Medicaid use, both of which were located in room [ROOM NUMBER]. The SSW further stated that the facility did not do long term care and residents were referred to other facilities for long term care services. In addition, the SSW stated she was unaware that residents were able to remain at the facility on a long term care basis and had not been offering that option to residents who were seeking long term care services. On 6/21/16 at 1:12 PM, an interview was conducted with the Chief Operations Officer (COO). The COO stated that the facility received Medicaid certification for two beds beginning January 1, 2016. The COO further stated that residents were referred to other facilities for long term care services, and the facility only obtained Medicaid certification due to hospitals' interest in referring Medicaid residents to the facility if they inquire. On 6/22/16 at 9:11 AM, a follow up interview was conducted with the SSW. The SSW confirmed that residents 40, 105, and 140 were transitioning from Medicare to Medicaid coverage, and seeking long term care services upon discharge.

Based on interview and record review, it was determined that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combination of the reasons above. Specifically, 1 of 21 sample residents was receiving [MEDICATION NAME] (an antipsychotic medication) for sleeplessness. Additionally, the resident did not have a history of [MEDICAL CONDITION] or [MEDICAL CONDITION]. Resident identifier: 156. Findings include: Resident 156 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 156's medical record was reviewed on 5/11/15. A review of resident 156's physician's orders [REDACTED]. A review of resident 156's Medication Administration Record [REDACTED]. (Note: Resident 156 was discharged home from the facility on 3/26/15.) A review of the 2014 Lippincott's Nursing Drug Guide revealed the following indications for the use of [MEDICATION NAME]: a. [MEDICAL CONDITION] b. Acute treatment of [REDACTED]. c. Short-term treatment of [REDACTED]. d. Acute treatment of [REDACTED]. e. Maintenance treatment of [REDACTED]. The licensed nursing staff completed a Minimum Data Set (MDS) assessment for resident 156 on 3/13/15. The MDS assessment revealed that resident 156 had a [DIAGNOSES REDACTED]. The MDS assessment revealed that resident 156 did not have a [DIAGNOSES REDACTED]. On 5/12/15 at 10:15 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 156 did not have a [DIAGNOSES REDACTED]. On 5/12/15 at 10:25 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that sleeplessness was not an appropriate [DIAGNOSES REDACTED]. The DON stated that she would have to clarify the order with the physician. On 5/12/15 at 12:10 PM, a second interview was conducted with the DON. The DON stated that resident 156's [DIAGNOSES REDACTED]. The DON stated that the [DIAGNOSES REDACTED]. (Note: The antipsychotic medication [MEDICATION NAME] does not have an indication for use in anxiety disorders.) The DON further stated that resident 156's behaviors had improved after the initiation of [MEDICATION NAME]. The DON provided documentation of the behaviors resident 156 was having prior to the initiation of [MEDICATION NAME]. The DON highlighted the following entries regarding resident 156's behaviors: a. 3/7/15 at 9:55 PM: "Patient is alert to self et. (and) family, disoriented to time et. situation requires frequent reorientation et. 1:1 with family." b. 3/9/15 at 10:30 AM: ". . . frequently confused, safety alarms in place to help prevent pt (patient) from falling as the pt frequently tries to get up on his own." c. 3/9/15 at 9:00 PM: "Pt alert, confused and forgetful. Pt with bed alarm on, sounds occasionally because he tries to get out of bed." d. 3/10/15 at 8:38 PM: "Pt given [MEDICATION NAME] for HS (bedtime) anxiety, tries to get out of bed." e. 3/13/15 at 11:03 AM: "Pt is alert, disoriented to time and season, sometimes to place, confused, pt tries to get up and ambulate by himself, safety alarms in place to prevent pt from falling." f. 3/13/15 at 2:41 PM: "T.O. (telephone order) [MEDICATION NAME] 50 mg 1 tab PO QHS for sleeplessness." A review of the 2014 Lippincott's Nursing Drug Guide revealed that [MEDICATION NAME] had the following black box warning: "Do not use this drug to treat elderly patients with dementia-related [MEDICAL CONDITION]; it causes increased risk of CV (Cardiovascular) mortality, including stroke, MI ([MEDICAL CONDITION] infarction)." A review of Stahl's Essential Psychopharmacology: Prescriber's Guide (Fifth Edition) revealed the following regarding the use of [MEDICATION NAME] in elderly patients: "Elderly patients with dementia-related [MEDICAL CONDITION] treated with atypical antipsychotics are at an increased risk of death compared to placebo, and also have an increased risk of [MEDICAL CONDITION] events."

Based on interview and observation it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, the medication room refrigerator was observed and documented to be below 32 degress Fahrenheit, insulin pens were observed to be unlabeled, and the facility emergency Intravenous medication kit had expired bottles of antibiotic medication. The improperly stored and unlabeled insulin and the expired medications were available for use by facility staff. Findings include: On 4/9/13, the nursing medication carts used by facility staff were examined for properly stored medications. In addition to the medication carts, the facility medication storage room was examined for properly stored medications. 1. On 4/9/13, the following was observed in the medication refrigerator: a. Two Lilly Kwik Humalog insulin pens with no label on the bag or pen to indicate which resident the insulin was prescribed for, or directions on how to use the insulin pen. b. One Novolog insulin pen in a plastic lock box. The Novolog insulin pen had no identifying information on the pen to indicate which resident the insulin was prescribed for nor instructions for usage. 2. On 4/9/13, the refrigerator in the medication storage room was observed to initially have a temperature reading of 20 degrees F (Fahrenheit). The refrigerator contained injectable insulin pens. Review of the "Patient Refrigerator/Freezer Temperature Log" for March and April 2013 revealed that the refrigerator temperatures ranged between 25-32 degrees F. (Note: Review of the "Nursing Drug Handbook, Thirty-first Edition, pg 1076. Lippincott Williams & Wilkins (2011)." Advise patient to store injectable insulin at 36 degrees to 46 degrees F.") 3. On 4/9/13 at 8:45 AM, it was observed that the facility's Intravenous/antibiotic kit was not closed properly. Review of the content within the container revealed that there were 2 vials of Vancomycin powder that had expired on 4/1/13. An interview was conducted with the Director of Nursing (DON) on 4/9/13 at 9:03 AM. The DON was unaware of the Intravenous/antibiotic kit being unsecure and the expired antibiotics inside the kit. The DON stated that she had contacted the pharmacy to request more "zip ties" and replace the antibiotics. The DON further stated that the last time they had received a new kit from the pharmacy was on 3/5/13. When shown the unlabeled insulin pens, the DON confirmed that the insulin pens should have been labeled. The DON was further unaware of the recommended storage temperatures for insulin.

Based on observation and record review, it was determined that the facility did not maintain a medication error rate of 5% or less. Observations of 50 medication opportunities, during medication pass on 04/28/11, revealed three medication errors which resulted in an 6% medication error rate. Resident identifiers: 41, 171, & 196. Findings include: Observations were made on 04/28/11, while facility nurses administered 50 medications to eight residents. A total of three medication errors were observed that included incorrect administration and an incorrect dose of prescribed medication. 1. On 04/28/11 at 8:08 AM, Registered Nurse (RN) 1 was observed to administer [MEDICATION NAME] powder to resident 41. RN 1 was observed to pour 30cc (cubic centimeters) or 2 tablespoons of [MEDICATION NAME] powder into a 30 cc liquid dose cup, instead of the cap provided. The directions on the [MEDICATION NAME] bottle stated to use the lid provided and pour the powder to the line within the cap. The [MEDICATION NAME] bottle stated that if the medication was poured to the line in the cap the dose administered would be 17 grams of [MEDICATION NAME] powder. In addition, the Nursing 2011 Drug handbook, Lippincott, Williams & Wilkins pg. 957 stated that 17 grams of [MEDICATION NAME] is about 1 heaping tablespoon. On 4/28/11, a medical record review for reconciliation of medications was done for resident 41. physician's orders [REDACTED]. On 4/28/11 at 10:15 AM, the DON (Director of Nursing) was observed to pour the [MEDICATION NAME] powder into the cap provided to the indicated line and then pour the powder into the liquid medication cups used by facility staff. Observations of the powder showed the [MEDICATION NAME] powder was measured at the 25 cc line. Facility staff were observed to measure out 30cc of [MEDICATION NAME] powder not the 25cc the powder that should have been administered.. 2. On 04/28/11 at 8:59 AM, LPN 2 (Licensed Practical Nurse) was observed to administer [MEDICATION NAME] powder to resident 174. LPN 2 was observed to pour 30cc (cubic centimeters) or 2 tablespoons of [MEDICATION NAME] powder into a 30 cc liquid dose cup, instead of the cap provided. The directions on the [MEDICATION NAME] bottle stated to use the lid provided and pour the powder to the line within the cap. The [MEDICATION NAME] bottle stated that if the medication was poured to the line in the cap the dose administered would be 17 grams of [MEDICATION NAME] powder. In addition, the Nursing 2011 Drug handbook, Lippincott, Williams & Wilkins pg. 957 stated that 17 grams of [MEDICATION NAME] is about 1 heaping tablespoon. On 4/28/11, a medical record review for reconciliation of medications was done for resident 174. physician's orders [REDACTED]. 3. On 4/28/11 at 8:52 AM, LPN 2 was observed to administer 325 mg (milligrams) of Aspirin to resident 196. On 4/28/11, a medical record review for reconciliation of medications was done for resident 196. physician's orders [REDACTED]. LPN 2 was observed to administer non-[MEDICATION NAME] coated Aspirin to resident 196.

Based on observation and interview it was determined the facility did not label 5 medications with the date they were opened and one medication in the medication cart was expired. Findings include: On [DATE] at 1:53 PM, the medication carts for the north and south halls were inspected. In the north medication cart a vial of Heparin 5,000 Units was observed to be open. The date the vial was opened was not observed to be on the box the vial was contained in nor the vial of Heparin. In the south medication cart four vials of Humalog insulin 100 Units were observed to be open. The dates the vials were opened was not observed to be on the boxes containing the vials nor on the vials of insulin. Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 reported it was facility policy for the vials to be dated when opened. On [DATE], during a medication pass observation, a bottle of Aspirin 81 mg (milligrams) was observed to be on the cart and available for facility staff use. The pharmacy label indicated the bottle of Aspirin expired on [DATE]. The facility nurse was observed to put one of the 81 mg Aspirin tablets into a medication cup to administer to a resident. The facility nurse removed the medication from the dose cup and threw it away after the state surveyor told the nurse the label indicated the medication had expired.