Every finding on record at The Cedars of Chapel Hill

Based on records review, and staff interviews, the facility failed to include code status in the resident's record for 1 of 1 resident reviewed for Advance Directives (Resident #15). Findings included: Resident #15 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired. Care Plan dated 4/8/24 indicated the resident had no care plan for Advanced Directives. The quarterly MDS dated [DATE] revealed the assessment was still in progress. Assessment indicated Resident #15 was severely cognitively impaired. Review of physician's orders on 6/2/24, revealed there was no active order for code status in Resident #15's Electronic Health Record (EHR). Review of the paper chart used in the facility on 6/3/24, the chart did not have physician orders related to the code status. The chart review revealed the orange-colored sheet for Do not Resuscitate (DNR) was from the discharging hospital. Review of the hospital discharge paperwork in the chart dated 1/30/24 revealed in discharge orders that the resident was a DNR and Do not intubate (DNI). An interview was conducted with Nurse #1 on 6/3/24 at 2:15 PM. Nurse #1 stated the code status was displayed on the paper chart of the resident. A red round sticker was placed on the outside of the charts for residents who had DNR as their code status and there was no sticker placed on the outside of the charts for residents on were on Full Code status. She indicated based on the resident's chart the resident was a DNR. She further indicated that the resident had an orange sheet (golden rod) in the chart which indicated the resident was a DNR. Nurse #1 stated the admission nurse reviewed the medication and the code status with the physician and new orders received were entered in the chart by the admission nurse. During an interview on 6/3/24 at 2:30 PM, Nurse #2 stated she was the admitting nurse for Resident #15, and she typically only reviewed the discharge medication with the physician over the telephone. The code status was not discussed with the physician. She indicated the advance directive paper for DNR in the chart was from the hospital. During an interview on 6/4/24 at 10:32 AM, the Social Worker stated the advance directives were discussed with the resident and / or resident's representative during admission. The Social Worker indicated that she placed the Advance Directive Form in the resident's chart that indicated the resident's code status preference. The form contained the resident's preference and the signature of the resident or resident representative. The admitting nurse was responsible for conveying this information to the resident's physician. The Social Worker did not recall any specifics about Resident #15 code status but recollects talking to the resident. During a telephone interview on 6/4/24 at 1:37 PM, the Physician stated that the admitting nurse would reviewed with the physician the discharge medication and code status at the time of the admission / readmission from the discharge summary for any resident admitted to the facility. Sometimes the physician reviewed discharge papers. The Physician stated during the initial physician assessment the code status was discussed with the resident or representative to confirm their preferences. The Physician stated the code status order was signed, and/or verbal approval given. The admission staff would then enter the information in the resident's medical chart. During an interview on 6/4/24 at 2:00 PM, the Director of Nursing (DON) stated the admitting nurse was responsible to discuss the discharged medication and the code status of the resident with the physician. If the physician agreed and the verbal order was given, then this order was verified by 2 nurses and entered in the residents' medical records (electronic and paper chart). The physician during the initial assessment discussed the code status and confirmed with the resident. If the resident elected to be a DNR then the form was completed by the nurse and signed by the physician. This form was then placed in the resident's paper chart. The DON indicated the resident was care planned based on his code status. The DON stated the order was not verified by the admitting nurse and new orders were not entered. The DON further stated the physician had mentioned in her admission assessment that the resident was a DNR, however no order was given.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe (14 days of the Assessment Reference Date (ARD), the last day of the look-back period) as specified in the Resident Assessment Instrument (RAI) manual for 1 of 1 residents reviewed for resident assessment (Resident #2) and 1 of 1 resident reviewed for completion of quarterly assessment (Resident # 15). Finding included. 1. Resident #2 was admitted to the facility on [DATE] Review of Resident #2's quarterly MDS assessments revealed the assessment had an Assessment Reference Date (ARD, the last day of the look-back period) of 4/3/24. The quarterly MDS dated [DATE] was in process and was incomplete. It was not signed by the Registered Nurse (RN) Assessment Coordinator, 60 days after the ARD date. During an interview on 6/03/24 at 11:46 AM, the MDS Nurse indicated she was hired on 4/1/24 and the facility had a remote MDS staff prior to her employment. She indicated some of the assessments were missed or incomplete. She stated the resident's quarterly assessment was partially completed and not yet signed by the RN. She indicated that assessments should be completed within 7 to 14 days from the ARD. 2. Resident # 15 was admitted to the facility on [DATE]. Review of the resident's #15's quarterly MDS assessments revealed the assessment had an Assessment Reference Date (ARD, the last day of the look-back period) of 5/7/24. The quarterly MDS dated [DATE] was in process and was incomplete. It was not signed by the Registered Nurse (RN) Assessment Coordinator, 27 days after the assessment reference date. During an interview on 6/3/24 at 11:46 AM, the MDS Nurse stated indicated that assessments should be completed within 7 to 14 days from the ARD. She further stated that she ran weekly report to ensure all the assessments were completed within the required time frame. She indicated she must have overlooked and was an oversite of her. During an interview on 6/04/24 at 8:11 AM, the Director of Nursing (DON) stated that the previous MDS staff was let go in January 2024 as the MDS assessments were not completed in a timely manner. Until the facility could hire a new MDS staff, the MDS assessments were completed by a consulting company remotely. The consultant staff member was not completing the assessments in a timely manner. The DON indicated after multiple efforts to hire a MDS staff, the facility was able to hire a new staff on April 1st, 2024. The DON indicated that the facility had identified the issue with MDS assessments in January 2024 and had a plan of correction drafted. This plan of corrections has only been able to be implemented after the new staff member was hired in April 2024. The plan of correction was discussed in the Quality Assurance (QA) meeting in May and the MDS Nurse was given 90 days from the date of hire to complete the assessments. The MDS staff was trying to complete all incomplete MDS assessments from oldest to the newest. The DON indicated she reviewed the MDS at risk for noncompliance tool on the Electronic Medical Record (EMR) system weekly to ensure the assessments were completed. This was her monitoring tool. She indicated the completion date was June 30th. The quarterly assessments were also monitored in the same way. The plan of correction included all types of MDS assessments. Once the MDS staff completed the assessment the DON was made aware, and she would sign off on them as RN. The new staff had to be educated on how to transmit these completed MDS and it was still a work in progress. During an interview on 6/4/24 at 9:06 AM, the Administrator stated the plan of correction was discussed in the QA meeting held on 5/16/24. This was a review of the April 2024 QA meeting. This was the first QA meeting after the MDS Nurse was hired. The completion date was discussed as 6/30/24 in the meeting. The facility was aware of the backlogs in MDS assessment and working to complete it in a timely manner.

Based on record reviews and staff interviews, the facility failed to complete and transmit Discharge Minimum Data Set (MDS) assessments within the required time frame for 4 of 4 residents (Resident #14, Resident #1, Resident #5, and Resident #13) selected for Resident Assessments. Findings included: 1. Resident #14 was admitted on [DATE] The last MDS assessment completed and transmitted was an admission MDS assessment dated [DATE]. Review of the progress note by the Social Worker dated 5/19/24 revealed Resident #14 was moved to a non-certified bed in the facility on 5/15/24. Review of the discharge return not anticipated MDS assessment revealed an Assessment Reference Date (ARD) of 5/15/24 indicated the resident had a planned discharge and was moved to a non-certified bed in the nursing home. The assessment indicated it was incomplete and the assessment was still in process. During an interview on 6/3/24 at 11:46 AM, the MDS Nurse indicated the resident was discharged to a non-certified bed in the facility on 5/15/24 and the discharge MDS assessment was not completed. The MDS Nurse stated the assessment was incomplete and must have been overlooked. 2. Resident #1 was admitted on [DATE]. The last MDS assessment completed and transmitted was an admission MDS assessment dated [DATE]. Review of the progress note by the Social Worker dated 4/30/24 revealed Resident #1 was discharged home with her family. Review of the discharge return not anticipated MDS assessment revealed an Assessment Reference Date (ARD) of 4/30/24 indicated the resident had a planned discharge and was discharged to the community. The assessment indicated it was incomplete and the assessment was still in process. During an interview on 06/03/24 11:46 AM, the MDS Nurse indicated the resident's assessment must have been missed as the resident was initially discharged home and later was admitted to a non-certified bed in the facility. The assessment must have been missed and was still incomplete. 3. Resident #5 was admitted on [DATE]. The last MDS assessment completed and transmitted was an admission MDS assessment dated [DATE]. Review of the discharge return not anticipated MDS assessment revealed an Assessment Reference Date (ARD) of 1/31/24 indicated the resident had a planned discharge and was discharged to the community. The assessment indicated it was completed and signed by the RN nurse on 2/20/24. The assessment was not transmitted. During an interview on 6/3/24 at 11:46 AM, the MDS Nurse indicated this assessment was completed by the previous remote MDS staff. She further indicated she was unsure why the assessment was not transmitted. MDS Nurse stated a completed and signed MDS assessment should be transmitted within 7- 14 days of completion. 4. Resident #13 was admitted on [DATE]. The last MDS assessment completed and transmitted was an admission comprehensive MDS assessment dated [DATE]. Review of the progress note by the Social Worker dated 12/29/23 revealed the resident was discharged to a non-certified bed at the facility. Review of the discharge return not anticipated MDS assessment revealed an Assessment Reference Date (ARD) of 12/29/23 indicated the resident had a planned discharge and the resident was discharged to a non-certified bed. The assessment indicated it was completed and signed by the RN nurse on 2/20/24. The assessment was not transmitted. During an interview on 6/3/24 at 11:46 AM, the MDS Nurse indicated the assessment was completed by the previous remote MDS staff and unsure why this was not transmitted. A completed and signed MDS assessment should be transmitted within 7- 14 days from completion. The MDS Nurse indicated she was hired in April 2024 and was in the process of identifying assessments that were incomplete and/ or not transmitted. During an interview on 6/04/24 at 8:11 AM, the Director of Nursing (DON) stated that the previous MDS staff was let go in January 2024 as the MDS assessments were not completed in a timely manner. Until the facility could hire a new MDS staff, the MDS assessments were completed by a consulting company remotely. The consultant staff member was not completing the assessments in a timely manner. The DON indicated after multiple efforts to hire a MDS staff, the facility was able to hire a new staff on April 1st, 2024. The DON indicated that the facility had identified the issue with MDS assessments in January 2024 and had a plan of correction drafted. This plan of corrections has only been able to be implemented after the new staff member was hired in April 2024. The plan of correction was discussed in the Quality Assurance (QA) meeting in May and the MDS Nurse was given 90 days from the date of hire to complete the assessments. The MDS staff was trying to complete all incomplete MDS assessments from oldest to the newest. The DON indicated she reviews the MDS at risk for noncompliance tool on the Electronic Medical Record (EMR) system weekly to ensure the assessments were completed. This was her monitoring tool. She indicated the completion date was June 30th. The quarterly assessments were also monitored in the same way. The plan of correction included all types of MDS assessments. Once the MDS staff completed the assessment the DON was made aware, and she would sign off on them as RN. The new staff had to be educated on how to transmit these completed MDS and it was still a work in progress. During an interview on 6/4/24 at 9:06 AM, the Administrator stated the plan of correction was discussed in the QA meeting held on 5/16/24. This was a review of the April 2024 QA meeting. This was the first QA meeting after the MDS Nurse was hired. The completion date was discussed as 6/30/24 in the meeting. The facility was aware of the backlogs in MDS assessment and working to complete it in a timely manner.

Based on record reviews and staff interviews, the facility failed to ensure that 4 of 5 sampled residents or residents' legal representatives were provided education regarding the benefits and potential side effects of the pneumococcal immunization. (Residents #2, 11, 24, 27). Findings included: Review of the facility's immunization records revealed 4 of 5 sampled residents did not receive and/or were not educated on the pneumococcal vaccine. There was no documentation of the provision of education related to the vaccine. During an interview on 3/2/15 at 2:36pm, the DON (Director of Nursing) revealed that approximately three weeks ago, the facility's Nurse Consultant brought it to her attention that the immunization records for the pneumoccocal vaccination were incomplete. At that time, she (DON) began the process of auditing the immunization records of all residents to check which residents had not received the pneumococcal vaccine as well as the education piece and had not signed a consent/declination form. The DON acknowledged there were no consent/declination forms or the educat provision in any of the residents' medical records. The DON revealed that she recently developed a pneumococcal education and consent form; and was updating the facility's Immunization Policy and Procedures. The DON indicated that she presented the first draft to the Medical Director for approval 2/24/15.

Based on observations and interviews the facility failed to remove from service expired medications and sterile supplies comingled with non-expired medications and supplies in 2 of 3 medication storage areas (medication room and wound care treatment cart). The findings include: On 03/18/2014 at 3:40 p.m., an observation was made of the facility's medication room and wound care treatment cart with nurse #1. The following items were found to be expired and comingled and ready for use with non-expired medications, wound care dressings, and treatment supplies: Medication room - In the wall cabinets the following were observed to be expired: Sterile ABD pads 8x10 (2 boxes - 24 ea) lot # CAC06-12, expiration date 06/14/2013 Sterile ABD pads 8x10 (3 ea) lot # CAC05-01, expiration date 05/07/2013 Sterile ABD pads 5x9 (1 box - 18 ea) lot # CAC05-07, expiration date 05/06/2013 Adaptic impregnated wound dressing 3x16 (1 box - 32 ea/packages) lot # 0843/5/1/2 expiration date 10/2013 Collagen Dressing 1 package Lot # A 54 Expiration date 09/02/2011 Sodium Chloride 0.45% IV solution (1000 ml bag) Lot # C 7 Expiration date 08/2014 (Note - The Rx label on the IV bag was dated 03/06/2013 and was observed to be half torn off so resident's name was missing and the mixed with other medication information was not visible. Nurse #1 could not state who the IV was for or what other medications was possibly mixed with the IV medication solution, or why the IV solution was being kept. Zeroflo Sterile Guaze Dressing (1 box - 12 ea) Lot # 6, expiration date 11/2010 Zeroflo Sterile Guaze Dressing (6 ea/packages) Lot # 0, expiration date 01/2011 DuoDerm 4x4 wound dressing 3.7 x 3.8 (1 box - 2 ea/packages) Lot #8L , expiration date 11/2013 (other non-expired packages in same box) Solosite Conformable wound gel dressing (1 box - 9 ea/packages) lot # , expiration date 10/2012 Allevyn AG Silicone gel (Silver Alginate) wound dressing (1 box - 10 ea/packages) lot # 1123, expiration date 06/2013 Also in the Medication Room - In a blue plastic container on a wire shelf next to room door (used for resident #15): Hydrogen Peroxide, 1 opened 8 fl/oz bottle 3/4 full, lot # 9EP0604, with an expiration date of 05/2011 Extra Strength Benadryl cream, 1 opened and ? used tube, Lot # 1161LZ, expiration date 03/2013 Aquacel Hydrofiber impregnated antimicrobial wound dressing 2 x 2 (1 open box - 10 ea/packages) lot # 2A , expired 01/2014 Aquacel Hydrofiber impregnated antimicrobial wound dressing 2 x 2 (1 open package) lot # 2A , expired 01/2014 In the Wound Care treatment cart located in the medication room: Isopropal 70% alcohol 16 fl/oz bottle - opened/1/4 used, Lot # expiration date 02/2014 Lubricating jelly packs (1 opened box - 14 ea/packs) lot # 1, expiration date 02/2013 Aquacel Hydrofiber 2 x 2 impregnated antimicrobial wound dressing (1 box - 10 ea/packages) lot # 2A , expired 01/2014 On 03/18/2014 at 4:15 p.m., an interview was conducted with nurse #1. The nurse indicated all of the above medications were expired. The nurse indicated all nurses were responsible for ensuring expired medications, wound care dressings, and sterile supplies were removed from service as to not be used on any resident. Nurse #1 indicated resident #15 was being administered all of the expired medications, wound care dressings, and sterile supplies on a daily basis per the request of the resident as to what she wanted on a given day. Nurse #1 indicated the wound care treatment cart and all items within were used on a daily basis to treat the resident ' s wound care needs. On 03/18/2014 at 5:05 p.m., an interview was conducted with the facility's ADON. The ADON indicated all of the above medications were expired and should have been removed from the medication room and wound care treatment cart. On 03/18/2014 and interview was conducted with the facility's DON. The DON indicated the night shift nurse was responsible for doing audits of the medication room, supplies, medications, as well as the wound care treatment cart. The DON indicated the night shift nurse was supposed to ensure expired medications, wound care dressings, and other supplies were removed from service as to not be used on any resident. The DON indicated it was her and the facility's expectation that all expired medications, creams, dressings, IVs, and/or other supplies be removed from service and not comingled - ready use, by the nursing staff.

Based on observations, interviews, and record reviews, the facility failed to ensure staff followed infection control procedures when providing care for 1 of 1 (#7) residents on contact isolation. The findings included: A review of the facility's policies and procedures entitled - Methicillin and [MEDICATION NAME] Resistant Staph MRSA/ORSA dated 01/24/2014 read in part on page 47 in items 1 - 4: 1a. wash your hands thoroughly with soap and water before the procedure. 1f. wash your hands thoroughly with soap and water upon completion of your task or procedure. 2. Wear appropriate personal protective equipment/PPE (e.g., gloves, gown, mask, eyewear, etc. as necessary) to prevent exposure. Don gloves prior to entering the room and gown if risk of clothes coming into contact with objects in the room. 4. Remove PPE and leave in appropriate containers just before exiting the room. Resident # 7 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's Medication Administration Record (MAR) for the months of January - March 2014 and Physician's Monthly Order Sheet (POS) for the months of January - March 2014 indicated the resident was receiving two types of antibiotics daily for the [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE] indicated the resident was moderately impaired and needed extensive assistance of 1 staff member for all Activities of Daily Living (ADLs) except eating. The physician's progress notes dated 01/14/2014 indicated the resident was treated for [REDACTED]. On 03/18/2014 at 5:55 p.m., an observation of a medication pass was conducted. Nurse #1 was observed to pull up resident # 7's medication, put on gloves at the nurse's station then go to the resident's room. The nurse then entered the resident's posted "Contact Isolation" room to administer the medication. The nurse was observed to enter the room without gowning (nurse only had gloves on). Per the signage on the resident's door the resident was on contact isolation and gloves, gown and/or mask were required. The nurse was observed to move the resident's bedside table with her body/left side of her leg, to get in front of the resident to administer the medication. After administering the resident's medication the nurse was then observed to exit the room without removing her gloves or washing her hands. There was no special container observed in the room to dispose of the Personal Protective Equipment (PPE) The nurse walked back to the nurse's station then removed her gloves and put them into the garbage can next to the medication cart and then washed her hands. On 03/19/2014 at 8:15 a.m., an observation was made of the Dietary Aide carrying a breakfast tray into the contact isolation room of resident # 7. The Dietary Aide was not wearing gloves or gown (duty uniform and hair net only). The Dietary Aide moved the resident's bedside table with her bare hands and set up the resident's breakfast tray while touching against the resident's bed. The Dietary Aide was then observed to exit the resident's room without washing her hands and push an open air 3 shelf meal tray service cart down the hall towards the facility's kitchen. On 03/19/2014 at 8:22 a.m. an interview was conducted with the Dietary Aide. The Dietary Aide indicated she knew the resident was on isolation precautions per the sign on the resident's door and she should have been wearing gloves and a gown prior to entering the resident's room. The Dietary Aide indicated she had training during her orientation and annual training concerning infection control and isolation precautions. A review of each staff member's education files was conducted. The review revealed Nurse # 1 took the Infection Control (edition 3) online course (facility required) on 07/15/2013. The review revealed the Dietary Aide took the Infection Control (edition 3) online course (facility required) on 07/09/2013. On 03/19/2014 at 3:10 p.m., an interview with the facility's DON was conducted concerning the facility's isolation precautions and procedures while providing care. The DON indicated all facility staff were required per the facility's policies and procedures to gown and glove when entering a room where a contact isolation resident lives. The DON indicated that if there is possible contact with any object in the room including the resident the staff were to gown as well as glove. The DON indicated the staff were supposed to remove the gown and gloves and wash their hands prior to exiting the contact isolated resident's room. The DON indicated resident # 7 was treated for [REDACTED]. The DON indicated it was her expectation that all staff followed the facility's isolation precaution procedures and gown and glove when entering a contact isolation resident's room. On 03/19/2014 at 3:32 p.m., an interview with Nurse # 1 was conducted concerning the facility's isolation precautions and procedures while administering medications to resident #7. The nurse indicated she did not wear a gown when going into resident #7's room on 03/18/2014 to administer the resident's medication (only wearing gloves). The nurse indicated she did not think she touched the resident's bedside table while administering the resident's medication. The nurse indicated she was unaware of the need to remove her gloves and wash her hands prior to exiting the resident's room.

Based on observations, record reviews, staff and resident interviews, the facility failed to ensure a self administration of medications assessment was conducted/completed for 1 of 11 residents (#5), observed during tour to have medications kept at the bedside and was self administering medications. The findings include: A review of the facility's undated policies and procedures entitled - Self Administration of Medications read in part on page 33: Item 1 - A resident may not be permitted to administer or retain any medications in his/her room unless so ordered, in writing by the attending physician, after the resident successfully demonstrates that he/she is capable for self administration. Item 2 - The Inter-Disciplinary Team (IDT) will review the "Assessment for Self Administration of Medications" form; then determine ability of resident to administer own medications. Item 4f - The licensed nurse will observe ability and/or train the resident in self administration of medications. Resident #5 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's medications included continuous oxygen at 2 liters/minute via a nasal cannula. The resident's quarterly MDS dated [DATE] indicated the resident to be cognitively intact and needing extensive assistance of 1 staff for activities of daily living. The resident's care plan dated 11/12/2013 with updates indicated the resident was to receive continuous oxygen for the [DIAGNOSES REDACTED]. On 03/17/2014 a tour of the facility was conducted. During the tour resident # 5's room was observed. During the observation it was noted that there were 2 medications (AYR nasal gel and ARY nasal spray) on the bedside table. An interview with the resident revealed the resident was using the medications for her nose which hurt due to the nasal cannula she was wearing. Resident #5 indicated the nurse talked to the doctor and told her she could use the medications and keep them in her room. Resident #5 could not state when she started self administering the medications or how long she had been keeping the medications in her room but did indicate she felt it was possibly several weeks. On 03/19/2014 at 9:20 a.m. a medication pass observation was observed. During the medication pass to resident #5 the same 2 medications (AYR nasal jelly and AYR nasal spray) were observed still on the resident's bedside table. On 03/19/2014 at 9:25 a.m., an interview with the nurse #2 was conducted. The nurse was asked how long resident #5 had been self administering and keeping the medications observed on the bedside table. Nurse #2 indicated the resident had been self keeping and administering the medications for a while (no specific time frame). On 03/19/2014 a review of the resident's medical record was conducted. The physician's orders [REDACTED]. A clarification telephone order dated 03/12/2014 indicated - Clarification: AYR saline nasal gel, Apply to nostrils three times daily (TID) as needed (PRN) complaint of (c/o) nasal dryness. May keep at bedside and self administer. an order for [REDACTED]. During the review of the resident's chart there was no documentation or other evidence to indicate resident #5 had been assessed for self administration of medications. Further review of the chart also revealed there was no documentation or evidence to indicate the facility's Inter-Disciplinary Team had reviewed an Assessment for Self Administration of Medications for resident #5 at any time. On 03/19/2014 at 10:16 a.m., an interview was conducted with the ADON. The ADON indicated the facility was supposed to conduct and complete an assessment for self administration of medications and fill out the associated form before letting any resident self administer and keep medications in their rooms. The DON indicated she had talked to resident #5 on 03/17/2014 about the physician's orders [REDACTED]. The DON indicated she did not document anything in the resident's chart or any other records except the physician's orders [REDACTED]. On 03/19/2014 at 11:10 a.m. an interview was conducted with the facility's DON concerning self administration of medications. The DON indicated it was her expectation that an assessment for self administration of medications be conducted and the assessment be reviewed by the IDT team prior to letting any resident keep medications in their room and/or self administer medications.

Based on record reviews and staff interviews the facility failed to act on the consultant pharmacist's monthly Medication Regimen Review recommendations for 2 of 5 residents (# 6 and # 12) reviewed for unnecessary medications. The findings included: 1) Resident # 6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's medications included an order dated 01/15/2014 for Zofran ODT (Ondansetron ODT) 4 milligram tablet 1 PO (by mouth) TID (3 times daily) as needed for nausea and vomiting. The resident's Minimum Data Set ((MDS) dated [DATE] indicated the resident to be severely cognitively impaired. The MDS also indicated resident #6 needed extensive to total assistance for all Activities of Daily Living (ADLs) except eating and had an active [DIAGNOSES REDACTED]. The physician's progress notes dated 02/20/2014 indicated resident # 6 having two episodes of Hernial Incarceration in the past three months along with constipation, Acid reflux (GERD), and microscopic colitis. A review of the facility's contracted pharmacist's monthly Medication Regimen Reviews (MRRs) indicated there was a MRR conducted for each month since the resident's admission. The consultant pharmacist's monthly MRR dated 02/16/2014 indicated the consultant pharmacist documented a recommendation to the Physician/Director of Nursing to discontinue the resident's Zofran or change it to an alternate therapy. The consultant pharmacist also indicated that if the medication (Zofran) was to continue, further testing (via an EKG) was needed to be done on the next convenient lab day and every 6 months there after as there was a risk of resident # 6 getting "Torsade de Pointes," a prolonged electrical QTc wave interval as seen on an EKG. A second entry by the consultant pharmacist was made on the 03/12/2014 during resident # 6's monthly MRR. The note indicated there had been 0 (zero) action on 02/16/2014 recommendation to discontinue resident #6's Zofran medication or change it to another medication. Further review of resident #6's medical record revealed there was no documentation to indicate the consultant pharmacist's recommendation had been reviewed or acted on by the physician or the DON during the 4+ weeks since the consultant pharmacist's initial recommendation. On 03/19/2014 at 2:45 p.m. an interview was conducted with the DON. The DON indicated the facility had changed the way it was receiving the facility's consultant pharmacist's consultation reports (pharmacist's recommendations). The DON indicated the reports were no longer being sent with the medications being delivered to the facility but now being transmitted on line and had to be downloaded and printed off. The DON indicated she was unaware if there were any pharmacist ' s recommendations for the past two months but would access the site and see if there were any. On 03/19/2014 at 3:20 p.m. the DON indicated she had found several consultation reports documenting recommendations for facility residents dated 02/16/2014 and printed them off for the survey team's review. An interview was conducted withj the DON on 03/19/2014 at 3:30 p.m. The DON was asked if the recommendations had been acted on by the physician or herself. The DON indicated the physician had not yet seen the recommendations as she had only just now accessed the web site and printed off the recommendations. The DON indicated since printing the reports/recommendations she knew the recommendations were over a month old and there had been no action taken by her (DON) or the physician. The DON could not explain why the reports were not accessed in a timely manor and presented to the physician for review/action. The DON indicated she was unaware the consultant pharmacist had recommended further testing (doing an EKG) if the drug (Zofran) was to be continued. The DON indicated it was her fault that the reports/recommendations had not been acted on by the physician as she had not accessed/printed the consultant pharmacist's recommendations from the computer in a while. 2) Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #12 ' s Physician order [REDACTED]. Resident #12 ' s Medication Administration Record [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #12 was cognitively impaired and required limited to extensive assist for her Activities of Daily Living. She was assessed for the use of antidepressants daily. A review of the Care Plan revealed Resident #12 received antidepressant medications Celexa and Trazadone on a regular basis. The interventions included to plan for a trial period of dose reduction with Resident #12 and the Physician. A review of Resident #12 ' s medical chart revealed a Psychoactive Medication Informed Consent dated 2/10/2014 for Celexa and Trazadone that included drug classifications, benefits and adverse reactions signed by Resident #12 ' s responsible party. Pharmacy Progress Notes dated 2/16/2014 revealed a notation for Trazadone plus Celexa. On 03/19/2014 at 2:45 p.m. an interview was conducted with the DON. The DON indicated the facility had changed the way it was receiving the facility ' s consultant pharmacist ' s consultation reports (pharmacist ' s recommendations). The DON indicated the reports were no longer being sent with the medications being delivered to the facility but now being transmitted online and had to be downloaded and printed off. The DON indicated she was unaware if there were any pharmacist ' s recommendations for the past two months but would access the site and see if there were any. On 03/19/2014 at 3:20 p.m. the DON indicated she had found several consultation reports documenting recommendations for facility residents dated 02/16/2014 and printed them off for the survey team ' s review. On 3/19/2014 at 3:30 PM an interview with the Director of Nursing revealed she had not presented the Consultant Reports dated 2/16/14 for Resident #12 to the Physician nor had she acted upon the recommendations. A review of the contracted consultant pharmacist ' s Consultation Reports (two) dated 2/16/2014 with an electronic signature from the Consultant Pharmacist was conducted. The first report revealed Resident #12 was taking two antidepressant medications (Trazadone and Celexa) concomitantly. The consulting pharmacist ' s recommendation was to re-evaluate the continued use of this combination with the rationale; the combined use of two or more antidepressant medications not only increase cost, but also complicate the drug regimen and may increase the potential for adverse events. The second report also dated 02/16/2014, indicated the medications Trazadone, Celexa, and Tramadol when taken together increased the risk for serotoni[DIAGNOSES REDACTED]. The consulting pharmacist ' s recommendation was to re-evaluate the continued use of these medications concurrently, to discontinue the use of Tramadol and/or Trazadone with the rationale; drug interactions exist between these medications with the potential for serotoni[DIAGNOSES REDACTED]. Serotoni[DIAGNOSES REDACTED] presents with mental, autonomic and neuromuscular changes, included but not limited to, confusion, [DIAGNOSES REDACTED] (twitching of a muscle), tremor, agitation, ataxia (lack of voluntary coordination of muscle movements), restlessness, diarrhea, nausea, diaphoresis (profuse perspiration) and tachycardia (a faster than normal heart rate). There was no documentation in resident ' s chart or that the facility could provide to indicate the Director of Nursing (DON) or Physician had acted on the consultant pharmacist ' s recommendations.

Based on observations and staff interviews, the facility failed to clean dinnerware, utensils and pots and pans, in a manner to allow air drying. The facility also failed to properly label, store and date perishable items. Findings include: During the initial tour of the Kitchen conducted on 8/19/10 at 7:00 AM, the following, utensils, pots and pans and water containers (for the residents) were observed stored wet/soiled in a manner that prevented air drying. Findings included: 4 - 1/2 pans wet Dry rack above the sink - (2) 20 quart size pan were wet . (1) 18 quart size pan were wet 27 resident water pitcher and tops were wet. The Kitchen personnel were about to fill them when they were told the containers were still wet. 1 large can opener had a black substance on the cutting point 4 ladles (size 4) were wet (water lying in the bowl part of the ladle) and 1 with a dried white substance on the bowl (part of scoop) 8 of 9 carving knives had a brown substance on the blades 2 bags of frozen hash browns in the freezer were open and un-dated 1 plastic bag of breakfast sausage in the freezer was unlabeled and undated 1 container of seafood base on a counter top was unlabeled and undated 23- to go containers with leftovers (various foods) were in the refrigerator unlabeled and undated 1 large bag of spinach in the refrigerator was unlabeled and undated 3 large bundles of celery in the refrigerator were uncovered and unlabeled 1 large bag of broccoli in the refrigerator was unlabeled, undated 1 (3lb.) bag of scallops in the freezer was unlabeled and undated 2 bags of bread sticks on the counter top were opened and undated and unlabeled 1/2 bottle Marsala wine (brown color) on the shelf was undated. The odor was pungent. 8 loaves of bread unlabeled and undated (5 loaves opened) on a shelf under a utility table 2 dozen hamburger rolls undated and unlabeled were on a shelf under a utility table 1 bag of hoagie rolls -were unlabeled and undated, opened, on a shelf under a utility table 1 18 liter (1/2 full) burgundy wine sitting on the floor, dated 3/11/10 (see interview with the Administrator). The kitchen staff did not know what the date meant. 1 bag of grapes in the refrigerator was opened, undated and unlabeled 2 packages of strawberries, with a slimy substance on the bottom of one of the containers were in the refrigerator unlabeled and undated 1 plastic container of thickener with a plastic cup inside, sitting on the counter was unlabeled and undated. On 8/19/10 at 7:30 am an interview with the Cook revealed it is the responsibility of the kitchen staff to label all food and make sure the dishes, pots and pans, and utensils etc. are dry before using. 8/19/10 @ 9:00 am an interview with the Director of Dining/Food and Beverage revealed; " My expectations are there should not be any wet dishes, utensils etc. All food should be labeled and thrown out if not properly labeled. I am extremely upset with this as I have never had deficiencies in the past. I have many other buildings to look after but this is no excuse." The interview continued and he further stated, "The training we provide is constant. I wish the RD (registered dietician) was here but she is on vacation. I am overall in charge and she is the RD." On 8/19/10 at 9:15 am an interview with the chef revealed, " I can only tell you we have staff turn over but my expectations are everything needs to be air dried. I take full responsibility. Everything needs to be labeled and dated. I am so upset with this." The Chef further stated that the dietary staff is responsible for air drying of all the kitchen equipment and labeling the food where necessary. "The policy and procedures were not followed. " On 8/19/10 at 10:00 am the Chef asked the surveyor to come to the kitchen where he was observed putting all the unlabeled and undated food into garbage bags and were disposed of. The chef indicated the Policies and Procedures were not followed. A copy of the Policy and Procedures was provided and indicated in part, the following: 1. All foods will be properly covered, labeled and dated. 2. Expired products will be monitored and discarded on a daily basis. On 8/19/10 at 11:00 am an interview with the Administrator revealed that all food should be labeled and if they are not labeled then the items need to be thrown out. She indicated an expiration date and open date need to be on the label as well. She further indicated that the date on the wine (3/11/10) is probably the expiration date and needs to be thrown out. Her expectations were that the kitchen staff is responsible for washing and air drying of all utensils/dishware/cooking items, etc. On 8.19/10 at 2:30 pm the Administrator indicated that a call was made to the distributor of the Paul Mason Wine that was stored in the kitchen. She was told that there is no expiration date and a discontinue of use would be due to a change in color or smell. The date on the box 3/11/10 indicated it was the manufacturer's date when the wine was packaged. The Administrator indicated that the wine would be discarded as she did not know how long it had been opened and no one drinks it. It is used specifically for cooking. No one knew if the color or smell had changed.