Every finding on record at The Health Center at Concordia

Based on observation and interview, the facility failed to ensure food was being prepared in accordance with professional standards of practice for food safety. The DON identified 27 residents resided in the facility. Findings: On 11/13/24 at 9:57 a.m., Dietary Aide #1 was observed preparing and rinsing fresh food items in the left compartment of the sink. In the right compartment of the sink raw fish was being defrosted with running water. On 11/13/24 at 9:58 a.m. the dietary manager reported the dietary aide #1 was not to rinse and prepare fresh food items in the sink compartment next to the raw fish defrosting.

Based on record review and interview, the facility failed to ensure an advance directive was available for one (#2) of two sampled residents reviewed for advance directives. The DON identified 27 residents resided in the facility. Findings: An Advance Directive policy, dated 11/01/07, read in part, 9. If the resident has prepared such documents, obtain a copy and place in the resident's clinical record. Res #2's clinical record was reviewed. There was no advance directive available. On 11/14/24 at 2:58 p.m., the social services director reported there was no documentation of Res #2's advance directive.

Based on observation, interview, and record review, the facility staff failed to implement infection control measures when using the blood pressure cuffs from resident to resident. The DON identified 24 residents depended on staff to obtain their blood pressure before administering medication. Findings: The infection control policy, dated 09/23/23, documented the purpose was to provide and ensure an ongoing program to establish and maintain an infection prevention and control program to provide safety, sanitary, and comfortable environment and prevent the development and transmission of communicable disease and infections. It documented the process would be reviewed annually or as needed to update the program through the QAPI process. During medication administration on 11/14/24, LPN #1 and LPN #2 were observed using the blood pressure cuff from their medication carts to obtain blood pressure readings for residents. On 11/14/24 at 7:38 a.m., LPN #1 stated they should have used hand sanitizer on the blood pressure cuff between residents. On 11/14/24 at 8:40 a.m., LPN #2 stated the blood pressure cuff should have been wiped down with Lysol disinfectant wipes between residents. 11/15/24 at 10:39 a.m., the DON stated staff should use sanitizer wipes before and after blood pressure cuff use.

Based on record review and interview, the facility failed to ensure: a. infection control tracking and trending was conducted for three (June, July, and August) of six months reviewed for infection control, and b. a water management system was in place to detect/prevent Legionella. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 28 residents resided in the facility. Findings: 1. Infection control logs were reviewed for the past six months. There was no documentation infection control tracking and trending had been conducted in June, July, or August 2023. On 09/12/23 at 11:28 a.m., the Administrator was asked what the policy was for infection control tracking and trending 2023 tracking and trending. She stated they could not locate it. On 09/12/23 at 11:36 a.m., the AL director was asked what the policy was for conduction infection control tracking and trending. They stated staff were to fill out an infection surveillance sheet and give it to the DON. They stated the DON would look at the sheets and track antibiotics. They stated they utilized a facility map and color coded infections to see if they had trends of infections or could identify a common denominator. The AL director stated, if a trend was identified, they would conduct an in-service related to the issue. They stated the information would be incorporated into the facility's QA. The AL director was asked if they could locate infection control tracking and trending for June, July, and August 2023. They stated, There's nothing. They were asked how the facility ensures trends are identified and actions taken if needed. The AL director stated by completing the infection control tracking and trending monthly and providing education on trends that were identified. 2. On 09/13/23 at 1:04 p.m., the DOO was asked if they had a water management system in place for monitoring/preventing Legionella. He stated they monitored the water for ph and stuff like that, but had no monitoring or prevention for Legionella.

Based on record review and interview, the facility failed to develop a comprehensive care plan to include a pressure ulcer for one (#1) of 12 sampled residents reviewed for care plans. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 28 residents resided in the facility and one had a pressure ulcer. Findings: Resident #1 had diagnoses which included pressure ulcers. An Admission Assessment, dated 08/20/23, documented Resident #1 had one stage two pressure ulcer and one stage three pressure ulcer on admission. A Wound Care note, dated 08/29/23, documented Resident #1 had a pressure ulcer to the left heel. res has wounds to left heel. A Care Plan, dated 08/30/23, failed to document pressure ulcers. On 09/13/23 at 2:55 p.m., the AL director was asked how staff determined what areas were included in a residents' care plan. They stated care plans were generated based on MDS assessments. The AL director was asked if an MDS documented pressure ulcers, would that be on the care plan. They stated, I would think it should be.

Based on record review and interview, the facility failed to ensure a discharge summary was completed after a discharge for one (#24) of one sampled resident reviewed for discharge. The Resident Census and Conditions of Residents report, dated 09/12/23, documented 28 residents resided in the facility. Findings: Resident #24 had diagnoses which included COVID-19. A Census Line report, dated 07/07/23, documented Resident #24 had been discharged . On 09/13/23 at 4:24 p.m., the SSD was asked when a discharge summary would be completed. They stated when a resident discharges. The SSD was made aware a discharge summary was not conducted.

Based on observation, record review, and interview, the facility failed to ensure a physician's order for a urinary catheter was obtained and I/O's were obtained routinely for one (#13) of one sampled resident reviewed for catheters. The Resident Census and Conditions of Residents report, dated 09/12/23, documented three residents had a catheter. Findings: Resident #13 admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of bladder. Physician's Orders, dated 08/16/23, documented to change catheter monthly and perform catheter care every shift. There was no order for the catheter. An Intake and Output task, dated 08/18/23 though 09/10/23, failed to document output 19 out of 28 opportunities. On 09/12/23 at 1:45 p.m., Resident #13 was observed in bed. A catheter and drain bag were observed secured to the bed frame. On 09/13/23 at 3:31 p.m., the AL director was asked what the policy and procedure was for monitoring I/O's for a resident with a catheter. They stated there was no policy to monitor I/O's. The AL director was asked if there should be an order for a resident with catheter. They stated there should be an order for the catheter.

Based on record review and interview, the facility failed to ensure tracking and trending of infections had been conducted for four months (December '21, April '22, May '22, and June '22) of the last twelve months reviewed for infection control. The Resident Census and Conditions of Residents report, dated 08/25/22, documented 27 residents resided in the facility. Findings: An Infection Control Surveillance policy, dated 2007, read in part, .PURPOSE .To conduct surveillance of resident and employee infections to guide prevention activities . Infection control tracking and trending was reviewed from September 2021 through July 2022. There was no documentation tracking and trending had been conducted for December '21, April '22, May '22, or June '22. On 08/25/22 at 12:35 p.m., the DON was asked to provide infection control tracking and trending for December '21, April '22, May '22, or June '22. She stated there were lists of who had infections each month in the QAPI book. On 08/25/22 at 2:39 p.m., the DON was asked if the QAPI book contained any tracking and trending documentation for December '21. They stated, I don't see any. The DON was asked what the purpose of tracking and trending infections. They stated, To see where they are and what's causing it and how can we stop it. They were asked if the QAPI book contained any documentation for April, May, or June tracking and trending and education provided. They stated, No.

Based on record review and interview, the facility failed to complete a discharge summary for one (#26) of one closed records reviewed. The facility identified 10 residents who had discharged from the facility since 06/01/22. Findings: Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's progress note, dated 06/10/22, for Resident #26 documented the resident went home from the facility. A review of the clinical record for Resident #26 contained no documentation of a discharge summary. On 08/25/22 at 10:44 a.m., the DON was asked where the discharge summary for Resident #26 would be located. The DON stated it was located in the electronic record under progress notes title discharge summary. The DON looked into the electronic record and stated one was not located in the record, however the DON would check to see if anything had been completed on paper. On 08/25/22 at 11:01 a.m., the DON stated no discharge summary had been completed for the resident and the summary should have been completed by the end of the shift, by the nurse completing the discharge.

Based on record review, observation, and interview it was determined the facility failed to ensure residents were free of significant medication errors for one (#77) of one new admission records reviewed. The facility identified six residents who had been admitted in the past 30 days on CMS form 802 (Resident Matrix). Findings Resident #77 was admitted to the facility on [DATE] at 4:33 a.m., with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A a review of Resident #77 hospital discharge orders, dated 08/23/22, read in part, .meropnem (Merreem) 500 mg for home infusion .inject one dose intravenous injection every 12 hours for nine days There was no documentation on the discharge orders as to when the last dose of the meropnem was provided to Resident #77 at the hospital. A review of the facility medication manifest, dated 08/23/22, documented Resident #77 antibiotic was received at the facility at 11:18 p.m. A review of the facility order Summary for Resident #77, dated 08/24/22, documented the resident was to receive the meropnem at 9:00 a.m. and 6;00 p.m. and the order was to start on 08/24/22. There was no documentation the facility consulted with the hospital and or the physician to start Resident #77 antibiotic the day after admission. A review of the treatment administration record for Resident #77 documented the first dose was provided at 10:33 a.m., 18 hours after the resident had been admitted to the facility. On 08/24/22 at 11:45 a.m., LPN #1 was observed in the residents rooms disconnecting an intravenous bag. Present at the time was Resident #77 family who indicated the resident was admitted on the previous day and had not received his intravenous antibiotic medication until now. On 08/24/22 at 1:59 p.m., LPN #1 one stated the resident was to receive the IV antibiotic every 12 hours and was not sure why it had started on 08/24/22. LPN #1 confirmed she provided the first dose to Resident #77 at approximately 11:00 a.m. On 08/24/22 at 2:09 p.m., the DON stated Resident #77 arrived to the facility at 4:33 p.m. with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON then stated she would look and see what the medication had not been administered prior to the first dose at 10:33 a.m. On 08/25/22 at 7:51 a.m., the DON stated she did not see any documentation the antibiotic should have been started on 08/24/22 or documentation when the hospital last provided the medication. The DON stated they had called the hospital and found out the last dose was provided to Resident #77 at 2:00 p.m. on 08/23/22 with the next dose to be provided at 2:00 a.m. on 08/24/22. The DON added the facility did not provide the antibiotic as they should have and acknowledged the medication error.

Based on record review and interview, it was determined the facility failed to ensure five (#4, 10, 11, 15 and #16) of 13 sampled residents were provided with written information regarding advance directives. The facility identified 23 residents who resided in the facility. Findings: On 06/04/19 at 9:42 a.m., the record of resident #15 was reviewed. There was no documentation of the resident having an advance directive. There was no documentation that information regarding an advance directive had been discussed with the resident or of their acceptance and/or refusal of an advance directive. On 06/04/19 at 12:28 p.m., the Administrator stated, residents admitted as a continuum of care resident would have not received an admission packet which included information on the advance directives. Only residents who would have been admitted directly into the long term care level at the facility would receive the advance directive information. The records were reviewed of the 13 continuum of care residents who resided in long term care. Five of the resident's had no advance directive information documented in their records. On 06/05/19 at 8:55 a.m., the DON was asked what the procedure was for determining if a resident had an advance directive. She stated, I will look in computer to see if it's scanned in. If not scanned in, I go to social services to see if they have one. They get the information on admission. She was asked if there was information on advance directives included in the admission packet. She stated, There is information on advance directives in the contract. The DON was asked who was responsible for ensuring the advance directive information had been provided/updated. She stated, Normally social services handles that. The DON was asked if resident # 15 had an advance directive or had been provided with information regarding advance directives. She stated, She does not have one in her documents. I can't show that she was given any information on it. The DON was asked if residents #4, 10, 11 and #16 had advance directives or had been provided with information regarding advance directives. She stated, In my system I don't see anything. I will check with social services. On 06/05/19 at 9:18 a.m., the ISSD was asked what was the procedure for determining if a resident had an advance directive. She stated, On admission, I go through the contract with the resident. I ask if they have an advance directive or living will. Most say yes. If not, I provide information about advance directives and ask if they want to have one. Sometimes they will, sometimes they won't. She was asked if she documented the discussion. She stated, I don't. She was asked if she was aware the information should be documented. She stated, No, I'm kind of new at this. The ISSD was asked who was responsible for ensuring the advance directive information had been provided/updated. She stated, I get them to sign it and get it into the chart. I give it to medical records to file it also. She stated the Social Services Director audited them every few months around care plan time. The ISSD was asked if resident #15 had an advance directive or had been provided with information regarding advance directives. She reviewed the resident's record, then stated, No, I don't see anything in her chart. The ISSD was asked if residents #4, 10, 11 and #16 had advance directives or had been provided with information regarding advance directives. She stated, I'll have to check. At 12:59 p.m., the ISSD was asked if she had reviewed the identified resident's records. She stated, Yes. She was asked if the identified residents had an advance directives or had been provided information regarding advance directives. She stated, No, they have not.

Based on observation, record review and interview, it was determined the facility failed to provide adequate supervision, implement new interventions and effectively monitor for the prevention of falls for one (#14) of one sampled resident reviewed for falls. The facility identified 23 residents who resided in the facility and were at risk for falls. Findings: Resident #14 had [DIAGNOSES REDACTED]. The resident had four falls from 04/13/19 to 05/13/19. Adequate supervision and new interventions were not implemented to prevent further falls. A significant change assessment, dated 04/24/19, documented the resident was moderately impaired in cognition and was totally dependent on staff for assistance with transfers and ambulation. On 06/06/19 at 11:12 a.m., the DON was asked where new interventions would have been documented following the resident's falls. She stated the nurse was to document it on the incident report and it would also have been on the care plan. At 11:20, the MDS coordinator was asked if the care plan had been updated to include the resident's falls and new interventions which had been implemented. She stated, the incident's which occurred in (MONTH) should have been included she just had not gotten to them yet. At 11:24 a.m., the DON was asked to review the incident reports of the resident's falls. She was then asked if they had included new interventions to prevent further falls. She stated no, she did not see any new interventions implemented on the incident reports.

Based on observation, record review and interview, it was determined the facility failed to ensure one (#5) of three sampled residents reviewed for respiratory conditions had an order for [REDACTED]. The facility identified seven residents who were receiving oxygen therapy. Findings: Resident #5 had a history of [REDACTED]. On 06/03/19 at 2:25 p.m., the resident was observed to be on oxygen by nasal cannula at 2.5 L/min. There was no date label observed on the oxygen tubing or humidifier. On 06/05/19 at 9:37 a.m., the resident was observed to be on oxygen by nasal cannula at 2L/min. There was no date label observed on the oxygen tubing or humidifier. A review of the resident's record revealed there was no order for oxygen documented in the physician's orders [REDACTED]. On 06/05/19 at 10:19 a.m., LPN #1 was asked when residents were placed on oxygen. She stated when the resident had signs and symptoms of [MEDICAL CONDITION]. She stated they would call the resident's physician to get an order. She was asked if a physician's orders [REDACTED]. She stated, Yes. LPN #1 was asked how often oxygen tubing was changed. She stated, I think you can keep tubing for 2 weeks to 30 days or if tubing is damaged or discolored. She was asked how she would know when to change the tubing. She stated, If there were an order to change it or if tubing is damaged or discolored. She was asked where oxygen tubing changes were documented. She stated, In the tasks or in the TAR. She stated she had only been working in the facility for about five weeks and had not had to change one yet. She was asked if she would label the tubing when she changed it. She stated, I would, yes. LPN #1 was asked to review the resident's record. She was then asked if the resident had an order for [REDACTED]. She stated, Honestly, I don't know. I would have to look at her record. LPN#1 was asked to observe the resident's oxygen tubing and was asked if the tubing was dated. She stated, No. On 06/05/19 at 10:30 a.m., LPN #2 was asked when residents were placed on oxygen. She stated, We check O2 sats. If they're below 92 or 93 we would contact their doctor to make determination if O2 was needed. She was asked if a physician's orders [REDACTED]. She stated, Yes. LPN #2 was asked how often oxygen tubing was changed. She stated, Every Wednesday evening. She was asked how she would know when to change the tubing. She stated, It's policy to change O2 on 3-11 shift every Wednesday. She was asked if the tubing was labeled when it was changed. She stated, Yes, yes they're supposed to. She was asked where oxygen tubing changes were documented. She stated, It's kind of like a standing order. Some resident's have a click Yes (in the electronic medical record) that tubing has been changed, some don't. LPN #2 was asked to review the resident's record. She was then asked if the resident had an order for [REDACTED]. She was asked why the resident was on oxygen when there was no order for it. She stated, For low O2 and shortness of breath on 6/3 at 6:56 (a.m.). The doctor was notified and gave orders for chest X-ray and all that. She was asked if the order for O2 had been overlooked. She stated, I assume we did get a verbal order and it was possibly not placed in the computer. LPN#2 was asked to observe the resident's oxygen tubing and was asked if the tubing was dated. She stated, It's not. She was asked if it should have been labeled. She stated, Yes. On 06/05/19 at 11:05 a.m., the DON was asked when residents were placed on oxygen. She stated they checked the resident's oxygen level and if it was low they would call their physician to determine if they wanted the resident placed on oxygen. She was asked if there needed to be a physician's orders [REDACTED]. She stated, Yes. The DON was asked how often oxygen tubing was changed. She stated, That is to be changed every Wednesday. She was asked if the oxygen tubing was labeled when had been change. She stated, Yes, it is to be labeled. She was asked where oxygen tubing changes were documented. She stated, It should be documented in the chart. Some resident's have it as a task (in the electronic medical record), some don't. The DON was asked to review the resident's record. She was then asked if the resident had an order for [REDACTED]. She was asked when the oxygen had been discontinued. She stated, 2/3/19. She was asked why the resident was on oxygen when there was no order for it. She stated, I can't answer that. The DON was informed of the observations that the oxygen tubing had not labeled. She was asked if the tubing should have been labeled. She stated, Yes.

Based on interviews and record review, it was determined the facility failed to ensure accuracy of assessments for one (#17) of nine sampled residents whose assessments were reviewed for accuracy. The facility identified 25 residents who resided in the facility. Findings: Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED].) every eight hours as needed for pain. The treatment administration record, dated 03/2018, documented the resident had not received [MEDICATION NAME]for the entire month. It documented he had received [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg. on 03/30/18 and 03/31/18. The treatment administration record, dated 04/2018, documented the resident had not received [MEDICATION NAME]from 04/01/18 through 04/26/18. It documented he had received [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg. on 04/01/18, 04/03/18, 04/04/18, and 04/05/18. The care plan, dated 04/03/18, documented the resident had a [DIAGNOSES REDACTED]. It documented an intervention to administer diabetes medication as ordered by the doctor. An annual assessment, dated 04/05/18, documented he was independent in cognitive skills for daily decision making. It was documented he had not received a prn (as needed) pain medication in the last five days. It was documented No for the question Should pain assessment interview be conducted? It was documented he had received insulin for the seven days prior to the assessment. It documented he had not received an opioid medication in the last seven days. The care plan, dated 04/10/18, documented the resident was on pain medication therapy related to [MEDICAL CONDITION] and chronic pain. It documented a goal to be free of any discomfort through the review date. It documented interventions that included to administer [MEDICATION NAME] medications as ordered and to monitor for side effects and effectiveness every shift. On 04/30/18 at 10:44 a.m., licensed practical nurse (LPN #2) was asked when the resident had received the [MEDICATION NAME] insulin. He stated the resident had not received the [MEDICATION NAME]since 04/11/17. On 04/30/18 at 12:24 p.m., the director of nursing (DON) was asked who was responsible to ensure the accuracy of assessments. She stated she was. She was asked how often she had monitored the assessments for accuracy. She stated before the new nurse started doing the assessments two weeks ago, she had reviewed every assessment before she had signed them. She stated the administrator had completed the assessments prior to the new nurse being hired. She was asked when the last time was she had reviewed the assessments. She stated it had been about one month ago. The DON was asked if resident #17 had pain. She stated, Yes. She was asked if the resident took pain medication. She stated, Yes. The DON was asked to review the annual assessment dated [DATE]. She was asked what the assessment documented related to the resident receiving pain medication. She stated it documented he had not received pain medication. She was asked if it was accurate. She stated, No. She was asked what was documented related to a pain assessment being performed. She stated it indicated there was no need for a pain assessment. She was asked why a pain assessment was not performed on the assessment. She stated it was an error. She was asked what medication the resident received for pain. She stated [MEDICATION NAME] 7.5 as needed every eight hours. She was asked if the medication was an opioid. She stated, Yes. She was asked if the resident had taken insulin in the seven days prior to the assessment. She stated, No. She was asked why the assessment documented he had received insulin the seven days prior to the assessment. She stated that would have to be an error.

Based on interview and record review, it was determined the facility failed to provide a copy of the baseline care plan for one (#21) of one resident who was reviewed for the baseline care plan. The facility identified 25 residents who resided in the facility. Findings: Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 04/11/18, documented the resident was severely impaired in cognitive skills for daily decision making. Review of the clinical record revealed the resident/family had not received a copy of the baseline care plan. On 04/30/18 at 2:30 p.m., the DON was asked what their process was for completing the baseline care plans. She stated the charge nurse completed the care plan within 48 hours of admission. She was asked how they provided the resident and/or the family member with a copy of the care plan. She stated they provided a copy within one week. She stated they provided the copy to the skilled residents during their weekly meetings with the resident/family. She was asked how often they had a care plan meeting with the non-skilled residents. She stated every three months. She was asked what her interpretation of the new regulation was regarding baseline care plans. She stated she would have to read the regulation. She was asked if she was aware the regulation included to provide a copy to the resident and/or family within 48 hours. She stated, No.

Based on interview and record review, it was determined the facility failed to ensure a response was received from the physician for a gradual dose reduction recommendation for one (#17) of five sampled residents who were reviewed for unnecessary medications. The facility identified 25 residents who received medications. Findings: Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].) one time a day for depression. The care plan, dated 03/30/17, documented the resident was on an antidepressant medication for depression. It documented a goal to be free from a depressed mood and discomfort of adverse reactions related to antidepressant therapy through the review date. It documented an intervention to administer antidepressant medications as ordered by the physician. A medication regimen review (MMR), dated 07/31/17, documented the resident was taking [MEDICATION NAME] 60 mg. daily. It documented the resident did not appear to be a candidate for a dose reduction at that time. It documented to please consider providing a written rationale describing why a dose reduction for this medication was clinically contraindicated. It documented a note was written to the physician. The clinical record did not reveal a response was received from the physician. A MMR, dated 08/30/17, documented the resident was taking [MEDICATION NAME] 60 mg. daily. It documented the resident did not appear to be a candidate for a dose reduction at that time. It documented to please consider providing a written rationale describing why a dose reduction for this medication was clinically contraindicated. It documented no response had been received from the physician. The clinical record did not reveal a response was received from the physician. A MMR, dated 09/28/17, documented the resident was taking [MEDICATION NAME] 60 mg. daily. It documented the resident did not appear to be a candidate for a dose reduction at that time. It documented to please consider providing a written rationale describing why a dose reduction for this medication was clinically contraindicated. It documented a note was written to the physician. The clinical record did not reveal a response was received from the physician. An annual assessment, dated 04/05/18, documented he was independent in cognitive skills for daily decision making. It was documented he had received an antidepressant for the seven days prior to the assessment. On 04/30/18 at 12:39 p.m., the director of nursing (DON) was asked how they completed the gradual dose reduction (GDR) after the pharmacist made a recommendation. She stated the recommendations had to be approved by the physician and then they implemented the orders. She was asked how they monitored to ensure they received a response from the physician in a timely manner. She stated the physician for resident #17 was outside of their medical director, so they had to fax or mail the GDR to his physician. She stated the medical record staff brought the GDR to the DON when they were received back from the physician. She was asked who tracked the GDR. She stated she did not have a tracking system to make sure they received them back. She stated it was probably not picked up on until the following month, when the pharmacist performed the next monthly medication review. The DON was asked what she expected in a response from the physician on a GDR. She stated the physician did not always give a response. She stated if the response was left blank they usually approved the recommendation. She was asked if they assumed the physician was okay with the recommendation if the physician did not give a response. She stated, Yes.

Based on observation and interview, it was determined the facility failed to ensure ~ expired medications were discarded from the facility's medication room, and ~ medications were appropriately labeled and dated. The facility identified 25 residents who received medications. Findings: On 04/25/18 at 2:24 p.m., the medication storage room was observed with licensed practical nurse (LPN) #1. The following expired medications were observed in the medication storage room cabinets: ~Atorvastatin - label documented discard after 09/09/17, ~ [MEDICATION NAME] 325 mg.- label documented expiration date as 12/17, ~[MEDICATION NAME] tablets 4 milligrams (mg.)- label documented expiration date as 12/13/17, ~ [MEDICATION NAME] capsules 2 mg.- label documented expiration date as 12/23/17, ~ [MEDICATION NAME] 325 mg. tablet - label documented expiration date as 02/18, ~ [MEDICATION NAME] Sodium 4 mg.- label documented use before 02/15/18, ~ Odansetron 4 mg. - label documented expiration date as 03/18, and ~ Duloxetine 60 mg. capsules - label documented discard after 03/09/18. The observation of the medication room also revealed a plastic bin with eleven small containers of mixed medications (pills and capsules) which were unlabeled and undated. LPN#1 was asked who the medications in the plastic bin were for. She stated they had been for a resident who had recently been in the facility for respite care. She stated they had brought the medications with them and they came that way. She stated they should not have been left that way, they should have been removed and discarded. On 04/25/18 at 2:59 p.m., LPN#1 was asked what the facility did with expired medications. She stated the director of nursing (DON) took the medications and placed then in a locked cabinet. She stated someone came and destroyed them. On 04/30/18 at 3:42 p.m., the DON was asked why the expired and unlabeled medications found in the medication room had still been on the active stock shelves. She stated, They had not been discarded appropriately.

Based on observation, record review and interview, it was determined the facility failed to ensure the care plan was updated with new interventions to prevent further falls for two (#28 and #42) of three sampled residents who were reviewed for falls. The facility identified 15 residents who were at high risk for falls. Findings: 1. Resident #28 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 10/10/16, documented the resident was a high risk for falls. The interventions were for staff to ensure the call light was within reach, encourage use of the call light for assistance and ensure the resident was wearing appropriate footwear. Staff were also to encourage the resident to notify staff at the time of a fall. An incident report, dated 03/22/17 at 11:00 p.m., documented the resident was found sitting on the floor in her room near the bed. The resident stated she stumbled and fell . Contributing factors to the fall were documented as the resident having hurried ambulation. Corrective actions were to ensure the floor was clear of obstacles and encourage the resident to walk slower. A quarterly assessment, dated 04/05/17, documented the resident was moderately impaired in cognitive skills for daily decision making and required limited assistance with bed mobility, transfers, ambulation and toilet use. The resident required extensive assistance with bathing. An incident report, dated 05/08/17 at 6:00 p.m., documented the resident was observed getting up from her wheelchair, lost her balance and fell to the floor. The report documented the fall resulted in skin tears to the forehead and the upper lip. Contributing factors to the fall were documented as the resident having an unstable gait and unaware of limitations. Corrective actions were to remind the resident to request for assistance with transfers and mobility. An incident report, dated 05/24/17 at 1:20 p.m., documented the resident was found on the floor by the chair in her room. She was unable to describe what happened. Mobile x-rays were ordered. Contributing factors to the fall were the resident having dementia and not aware of own safety limits. Corrective actions were to monitor the resident more frequently and anticipate her needs. An incident report, dated 05/28/17 at 1:40 p.m., documented the resident was found sitting on the floor with her back to the bed. She was unable to describe what happened coherently. Old bruising due to previous fall were noted. Occurrence was documented to have been a possible result of resident being non-compliant with education to call for staff assistance with transfers and toileting and wait for staff to come and assist her. Resident was sent to the emergency room for an evaluation and treatment. No corrective actions were documented following the fall. An incident report, dated 05/29/17 at 2:35 p.m., documented the resident was found on the floor beside her bed. She was unable to describe what happened. Contributing factor to the fall was documented as the resident not knowing own safety limits. Corrective actions included floor mats, personal alarm in place, routine monitoring, anticipate the resident's needs and routine toileting to be provided. The care plan had not been updated to include the falls. There was no documentation to indicate revisions to the care plan had been made to include new interventions to prevent further falls. On 06/01/17 at 3:50 p.m., the director of nursing (DON) was asked to review the resident's falls. She was then asked if the care plan had been updated to include new interventions to prevent further falls. The DON stated there probably had been interventions put in place but they were not documented. She was asked if the care plan should have been updated to include new interventions. She stated yes. 2. Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 02/07/17, documented the resident was a high risk for falls. The interventions were for staff to anticipate and meet the resident's needs, keep the call light in reach and encourage the resident to use it for assistance, respond promptly to all requests for assistance, ensure use of the bed, chair and personal alarms, and footrests to be on with wheelchair reclined to reduce the risk of leaning forward and falling. Staff were to also implement frequent visual checks around the clock and visual monitoring by the nurses station, never leave the resident alone on the the toilet, transfer the resident with two staff members and provide toileting assistance before and after meals. A quarterly assessment, dated 05/01/17, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. An incident report, dated 04/19/17 at 2:10 a.m., documented the resident was found standing in the door to the bathroom and was lowered to the floor by staff. He stated he wanted to walk. Contributing factors to the fall documented the resident was resistant to care. Corrective actions were two hour bed checks throughout the night. An incident report, dated 05/15/17 at 4:00 p.m., documented the resident was found on the floor in his room beside the recliner. Contributing factors to the fall documented the resident was unaware of own safety limits and not willing to call for assistance with standing. Corrective actions were to encourage the resident to call for assistance, regular monitoring, assure personal alarm was in place and anticipate the resident's needs. An incident report, dated 05/17/17 at 5:10 a.m., documented the resident was found lying on the floor. The resident was unable to state how he got on the floor. The report documented the resident had removed his body alarm. Contributing factors to the fall documented the resident was not compliant with the instructions to call for help when necessary. Corrective actions were for staff to ensure the personal alarm was on and frequently check on the resident. An incident report, dated 05/28/17 at 10:50 p.m., documented the resident was found lying on the floor. The resident was unable to tell how he got on the floor. Contributing factors to the fall documented the resident was not compliant with the instructions to call for help when needed. Corrective actions were frequent visual checks and assess the resident's needs. The care plan had not been updated to include the falls. There was no documentation to indicate new interventions had been implemented to prevent further falls. On 06/01/17 at 3:58 p.m., the director of nursing (DON) was asked to review the resident's falls. She was then asked if the care plan had been updated to include new interventions to prevent further falls. The DON stated no. She was asked if the care plan should have been updated to include new interventions. She stated yes.

Based on observations, record review and interviews, it was determined the facility failed to ensure a physician's order was obtained for hospice services for one (# 5) of one sampled resident whose record was reviewed for hospice services. The facility identified nine residents who received hospice services and resided in the facility. Findings: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The physician's admitting order, dated 05/13/16, documented the resident was to receive hospice services. The physician's order, dated November 2016, documented the resident continued to receive hospice services. No order was documented for the resident to have received hospice services from December 2016 through May 2017. A quarterly assessment, dated 05/17/17, documented the resident was severely impaired in cognitive skills for daily decision making. She required extensive assistance of one staff member for toileting, hygiene and bathing. The assessment further documented the resident received hospice care. On 05/31/17 at 3:30 p.m., the director of nursing (DON) was asked if the resident received hospice services. She stated, yes. She was asked if a physician's order was required in order for the resident to have received hospice services. She stated, yes. The DON was asked if the resident had an order for [REDACTED]. At 4:22 p.m., the DON stated, it appeared hospice services would have been added to the physician orders every 99 days with the recertification of services. The last order appeared on the November 2016 orders and was never put back on again.

Based on observations, record review and interviews, it was determined the facility failed to provide supervision to prevent falls, identify the root cause of falls and to consistently identify and implement appropriate interventions to aid in the prevention of falls for two (#28 and #42) of three sampled residents who were reviewed for falls. The facility identified 15 residents as being at high risk for falls. Findings: 1. Resident #28 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 10/10/16, documented the resident was a high risk for falls. The interventions were for staff to ensure the call light was within reach, encourage use of the call light for assistance and ensure the resident was wearing appropriate footwear. Staff were also to encourage the resident to notify staff at the time of a fall. An incident report, dated 03/22/17 at 11:00 p.m., documented the resident was found sitting on the floor in her room near the bed. The resident stated she stumbled and fell . Contributing factors to the fall were documented as the resident having hurried ambulation. Corrective actions were to ensure the floor was clear of obstacles and encourage the resident to walk slower. A nurse note, dated 03/23/17 at 7:20 a.m., documented focused charting related to non-injury fall. The resident complained of back pain and routine pain medication was administered. A nurse note, dated 03/23/17 at 1:10 p.m., documented focused charting related to non-injury fall. The charting documented the resident complained of being sore all over this morning, routine pain medication was administered and resident voiced relief this afternoon. A nurse note, dated 03/24/17 at 6:09 a.m., documented focused charting related to non-injury fall. The charting documented the resident complained of left arm pain and was administered pain medication. A nurse note, dated 03/24/17 at 2:36 p.m., documented focused charting related to non-injury fall. The charting documented the resident complained of aching all over and was administered pain medication. A quarterly assessment, dated 04/05/17, documented the resident was moderately impaired in cognitive skills for daily decision making and required limited assistance with bed mobility, transfers, ambulation and toilet use. The resident required extensive assistance with bathing. A nurse note, dated 05/03/17 at 4:26 p.m., documented earlier in the morning, the resident had been seen by a staff member from therapy sitting on a bench by the nurse's station. The resident was asked if she had ambulated alone. She stated yes, I forgot I was not supposed to. An incident report, dated 05/08/17 at 6:00 p.m., documented the resident was observed getting up from her wheelchair, lost her balance and fell to the floor. The report documented the fall resulted in skin tears to the forehead and the upper lip. Contributing factors to the fall were documented as the resident having an unstable gait and being unaware of limitations. Corrective actions were to remind the resident to request for assistance with transfers and mobility. An incident report, dated 05/24/17 at 1:20 p.m., documented the resident was found on the floor by the chair in her room. She was unable to describe what happened. Mobile x-rays were ordered. Contributing factors to the fall were the resident having dementia and not being aware of her own safety limits. Corrective actions were to monitor the resident more frequently and anticipate her needs. A nurse note, dated 05/24/17 at 11:49 p.m., documented the resident denied pain after the fall but was crying at the time. The physician ordered x-rays. The x-rays were negative for fractures. A nurse note, dated 05/25/17 at 4:37 p.m., documented focused charting related to non-injury fall. The charting documented the resident was instructed to always use call light for help. A nurse note, dated 05/26/17 at 4:08 p.m., documented focused charting related to non-injury fall. The charting documented the resident was instructed to always use call light for help. An incident report, dated 05/28/17 at 1:40 p.m., documented the resident was found sitting on the floor with her back to the bed. She was unable to describe what happened coherently. Old bruising due to previous fall was noted. Occurrence was documented to have been a possible result of resident being non-compliant with education to call for staff assistance with transfers and toileting and wait for staff to come and assist her. Resident was sent to the emergency room for an evaluation and treatment. No corrective actions were documented following the fall. A nurse note, dated 05/28/17 at 11:05 p.m., documented the resident returned from the hospital with negative results to tests. Resident in bed crying and yelling help me, would then deny any needs when staff went in her room to check on her. Bed was in lowest position, call light within easy reach, staff to monitor and anticipate needs. An incident report, dated 05/29/17 at 2:35 p.m., documented the resident was found on the floor beside her bed. She was unable to describe what happened. Contributing factor to the fall was documented as the resident not knowing own safety limits. Corrective actions included floor mats, personal alarm in place, routine monitoring, anticipate the resident's needs and routine toileting to be provided. A nurse note, dated 05/31/17 at 7:58 a.m., documented the resident found slipping off the bed and sitting on the floor mat. Bed alarm went off and bed in low position. No injury or bruising noted at this time. On 06/01/17 at 2:42 p.m., licensed practical nurse (LPN) #1 was asked how she knew which residents were at high risk for falls. She stated residents who had a history of [REDACTED]. She was asked interventions which were put in place for residents at high risk for falls. She stated personal alarms, bed alarms and floor mats were used. The bed would be placed in low position, bolsters put on the side of the bed, frequent checks made and anticipating the resident's needs. The LPN was asked the process if she had a resident who had fallen. She stated she would complete a full assessment, notify the director of nursing (DON) and family, follow any orders received from the physician and continue to monitor the resident for 72 hours. She was asked who was responsible for determining the cause of the fall and implementing new interventions. She stated the DON. At 3:50 p.m., the DON was asked to review the resident's clinical record regarding her falls. She was then asked if the root cause had been determined with new and appropriate interventions implemented to prevent further falls. The DON stated there probably had been interventions put in place but they were not documented. The resident had a lower bed, body alarm and fall mats. She further stated the physician and staff were looking at behaviors and other cause factors. She was asked if the root cause had been determined. She stated no. 2. Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, dated 02/07/17, documented the resident was a high risk for falls. The interventions were for staff to anticipate and meet the resident's needs, keep the call light in reach and encourage the resident to use it for assistance, respond promptly to all requests for assistance, ensure use of the bed, chair and personal alarms, and footrests to be on with wheelchair reclined to reduce the risk of leaning forward and falling. Staff were to also implement frequent visual checks around the clock and visual monitoring by the nurses station, never leave the resident alone on the the toilet, transfer the resident with two staff members and provide toileting assistance before and after meals. A quarterly assessment, dated 05/01/17, documented the resident was severely impaired in cognitive skills for daily decision making and required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. An incident report, dated 04/19/17 at 2:10 a.m., documented the resident was found standing in the door to the bathroom and was lowered to the floor by staff. He stated he wanted to walk. Contributing factors to the fall documented the resident was resistant to care. Corrective actions were two hour bed checks throughout the night. An incident report, dated 05/15/17 at 4:00 p.m., documented the resident was found on the floor in his room beside the recliner. Contributing factors to the fall documented the resident was unaware of own safety limits and not willing to call for assistance with standing. Corrective actions were to encourage the resident to call for assistance, regular monitoring, assure personal alarm was in place and anticipate the resident's needs. An incident report, dated 05/17/17 at 5:10 a.m., documented the resident was found lying on the floor. The resident was unable to state how he got on the floor. The report documented the resident had removed his body alarm. Contributing factors to the fall documented the resident was not compliant with the instructions to call for help when necessary. Corrective actions were for staff to ensure the personal alarm was on and frequently check on the resident. An incident report, dated 05/28/17 at 10:50 p.m., documented the resident was found lying on the floor. The resident was unable to tell how he got on the floor. Contributing factors to the fall documented the resident was not compliant with the instructions to call for help when needed. Corrective actions were frequent visual checks and assess the resident's needs. On 06/01/17 at 2:36 p.m., certified nursing assistant (CNA) #2 was asked how he knew which residents were at high risk for falls. He stated the staff would be notified from report if residents needed to be watched closely. He was asked what interventions had been put in place to prevent residents from falls. He stated they used bed and chair alarms, lowered the beds and distracted them with activities when needed. The CNA was asked the process he would follow if he found a resident who fell . He stated he would ask if they were ok and notify the nurse so the resident would be assessed. The CNA also stated a book was placed at the nurse's station for direct care staff to review updated interventions and changes with the residents. At 3:58 p.m., the DON was asked to review the resident's clinical record regarding his falls. She was then asked if the root cause had been determined with regarding the resident's falls. She stated no, she knew he had several falls recently. The DON was asked if new and appropriate interventions were implemented after each fall. She stated no and call lights were not appropriate for him.