Every finding on record at The Lodge at Mills River

Based on record review, observation and staff interviews, the facility failed to ensure accurate and updated information was provided on the daily nursing staff postings for 24 of 154 days: 11/6/24, 11/11/24, 11/14/24, 12/9/24, 11/21/24, 12/18/24, 12/19/24, 12/23/24, 12/26/24, 1/1/25, 1/6/25, 1/13/25, 2/7/25, 2/17/25, 3/3/25, 3/25/25, 3/26/25, 3/31/25, 4/3/25, 5/1/25, 5/15/25, 5/20/25, 5/31/25, and 6/1/25 reviewed for staffing. Findings included: a. A review of the daily nursing staff postings revealed on: 11/6/24, 11/11/24, 11/14/24,12/9/24, 12/19/24, 12/26/24, 1/6/25, 3/25/25, 3/26/25, 3/31/25, 4/3/25, 5/1/25, 5/15/25, 5/16/25, 5/20/25, and 5/31/25 no RN hours were included. A review of the Director of Nursing (DON) and Assistant Director of Nursing (ADON) employee time clock records revealed at least 8 consecutive Registered Nurse (RN) hours were recorded on: 11/6/24, 11/11/24, 11/14/24,12/9/24, 12/19/24, 12/26/24, 1/6/25, 3/25/25, 3/26/25, 3/31/25, 4/3/25, 5/1/25, 5/15/25, 5/16/25, 5/20/25, and 5/31/25. A joint interview with the Regional Clinical Manager and Administrator was conducted on 06/03/25 at 4:00 PM. The Regional Clinical Manager revealed it was a 50 bed facility, and she had filled out the daily nursing staff postings. She revealed either her as the interim DON or the ADON had worked at least 8 consecutive hours, but their RN hours were not included on the daily nursing staff posting unless they worked directly with residents administering medications. The Administrator confirmed the DON and ADON RN hours were not included on the daily nursing staff posting unless they administered medications. Both the Administrator and Regional Clinical Manager revealed they were not aware the DON, ADON or Unit Supervisor RN hours could be included on daily nursing staff posting when no other RN was scheduled. b. A review of the daily nursing staff posting revealed on: - 11/21/24, 6 RN hours were recorded. The employee time sheet records revealed the ADON, RN had worked eleven hours on 11/21/24. - 12/18/24, 6 RN hours were recorded. The employee time clock records revealed the ADON, RN had worked 12 hours on 12/18/24. - 12/23/24, 4 RN hours were recorded. The employee time sheet records revealed the ADON,RN had worked 8 hours on 12/23/24. - 1/13/25 the 11:00 PM through 7:00 AM shift recorded one Certified Nursing Assistant (CNA) worked 8 hours. The employee time sheet records revealed two CNAs had worked 8 hours from 11:00 PM through 7:00 AM on 1/13/25. - 2/7/25 the 11:00 PM through 7:00 AM shift recorded two CNAs worked 16 hours. The employee time sheet records revealed a third CNA had worked from 11:00 PM through 2:23 AM on 2/7/25. - 3/3/25, 4 RN hours were recorded. The employee time sheet records revealed the ADON, RN worked 11 hours on 3/3/25. During an interview on 06/03/25 at 4:00 PM, the Administrator confirmed the RN and CNA hours on the daily nursing staff posting were incorrect based on the employee time clock records. The Administrator revealed daily nursing staff posting should be completed daily and include accurate information for each shift. c. A review of the daily nursing staff posting revealed the resident census was not included on 12/9/24, 12/19/24, 1/1/25, 2/7/25, 2/17/25. A joint interview with the Regional Clinical Manager and Administrator was conducted 06/03/25 at 4:00 PM. The Regional Clinical Manager revealed she filled out the daily nursing data postings and the resident census was required and if not included it was human error on her part. The Administrator revealed the resident census information should be included on daily nursing data postings. d. An observation on 06/01/25 at 10:01 AM revealed the daily nursing staff posting was dated 5/30/25 and not the current date 6/1/25. During an interview on 06/01/25 at 9:25 AM Nurse #1 revealed she was the nurse in charge on 6/1/25 and the current staff included herself, Nurse #2 and two CNAs and a third CNA was coming in at 12:00 PM. During a phone interview on 06/03/25 at 2:06 PM, Nurse #1 revealed she was not responsible for updating the daily nursing staff postings. During a phone interview on 06/03/25 at 3:00 PM, Nurse #2 revealed she had worked on 5/31/25 and 6/1/25. Nurse #2 stated she was not responsible for updating the daily nursing staff posting. A joint interview with the Regional Clinical Manager and Administrator was conducted on 06/03/25 at 4:00 PM. The Regional Clinical Manager revealed she filled out the daily nursing staff postings and when she was not available the nurses on duty were responsible for completing the postings and should be updated every day. The Regional Clinical Manager revealed neither Nurse #1 or Nurse #2 knew how to update the daily nursing staff posting or that they were supposed to complete one for 6/1/25. The Administrator revealed daily nursing staff posting should be completed daily and include accurate information for each shift.

Based on observations, record review, review of manufacturer's instructions, Nurse Practitioner, family and staff interviews, the facility failed to ensure securement was according to manufacturer recommendations for providing a safe facility van transport when a resident fell out of the wheelchair onto his side on the floor of the van resulting in minor abrasions and bruising to his face, arm and side for 1 of 2 residents reviewed for accidents (Resident #22). The findings included: Review of the manufacturer's instructions for the QRT-1 Series, which is the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport, specified in part: B. Secure Passenger: 1. Attach lap belts by using integrated stiffeners to feed belts through opening between seat backs and bottoms and/or armrests to ensure proper belt fit around occupant. 2) Attach shoulder belt by extending the belt over the passenger's shoulder, across upper torso and fasten pin connector onto the lap belt. Note: Combination lap/shoulder belts serve as both window-side lap belt and shoulder belt. 3) Ensure belts are adjusted as firmly as possible but consistent with user comfort. Warning: Lap and shoulder belt should not be held away from the passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels, or frame. Ensure belt webbing is not twisted while being worn by passenger. Belts should always bear upon the bony structure of passenger's body and be worn low across the front of the pelvis, with the junction between lap and should belts located near the passenger's hip. Resident #22 was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or loss of strength on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #22 with modified independence for daily decision making. His speech was unclear but was usually understood and usually able to understand others. He required extensive to total staff assistance with all activities of daily living and had no impairment of the upper and lower extremities. The MDS indicated Resident #22's height was 70 inches and he weighed 182 pounds. A staff progress note dated 09/14/22 at 3:45 PM written by the Director of Nursing (DON) read in part, Nursing staff notified Resident #22 fell out of wheelchair. Resident #22 observed lying on floor on left side and left posterior upper arm. Assessment by Registered Nurse reveals Resident #22 noted to have cut on left side of face and complaining of back pain. NEURO (relating to the nerves or nervous system) checks within normal limits. Nurse Practitioner (NP) assessed resident. Orders received to transport to Emergency Department (ED) for evaluation. Resident #22's spouse aware of incident. Emergency Medical Services (EMS) notified and transported Resident #22 to the hospital. An interview was attempted with Resident #22 on 11/28/22 at 11:56 AM with his spouse at bedside. Resident #22 remained non-verbal and did not answer questions. Resident #22's spouse reported in September 2022, Resident #22 was being transported back to the facility from a dental appointment and when they arrived at the facility, the Director of Nursing (DON), Assistant Director of Nursing (ADON) and other staff were all waiting out in front of the building. She recalled as she was walking toward the van, she noticed through the window that Resident #22's wheelchair was upright but she did not see him and was thinking he had a heart attack. When she got to the door of the transportation van, the ADON and DON were already in the van and Resident #22 was on the floor. Resident #22's spouse recalled his wheelchair was still in an upward position and anchored to the floor at the back of the van and Resident #22 was lying on his side with his head next to the seat toward the front of the van. She recalled Resident #22 was examined in the transportation van by the NP who told staff not to move him and have him transported to the hospital by EMS for evaluation. Resident #22's spouse stated when they had left the dental appointment, she did not watch Nurse Aide (NA) #1 (the facility's transportation driver) secure him into the van. She was not sure how he was able to fall out of his wheelchair as he was very contracted and couldn't straighten his legs or at what point during transport he actually fell . She stated due to the fall, Resident #22 sustained a cut on the left side of the face/cheek that turned into a black eye and cut on his upper left arm. Since the incident, she spoke with the Administrator who stated it was an accident and after several conversations, neither he or the facility's Insurance Adjuster had been able to explain how or when Resident #22 fell during transport. She added the Administrator did tell her they had a plan of correction and NA #1 was reassigned back to the floor as a Nurse Aide. Also, she stated the facility had the Occupational Therapist (OT) assess Resident #22's wheelchair and they wanted to purchase Resident #22 a restraint vest to wear during transport as an extra safety measure. During a telephone interview on 11/29/22 at 12:17 PM, NA #1 stated she was the facility's transportation driver from March 2022 to September 2022 until she left the facility for other employment. NA #1 confirmed she was driving the transportation van on 9/14/22 when Resident #22 fell out of his wheelchair during transport. NA #1 explained she had transported Resident #22 to a dental office not far from the facility and after his appointment, she loaded him into the transportation van, attached the floor retractor hooks to the frame of his wheelchair and then secured the shoulder/lap belt across his chest and lap, pulled on the straps twice to make sure they were secure, and then proceeded to transport him back to the facility. She recalled when they were about 1 1/2 minutes from the facility as she was slowing down to stop at the stop sign before making a turn, she heard a thud sound and when she turned around to look, Resident #22 was on the floor. She explained he had fell forward out of his wheelchair, landing on his side with his head next to the seat toward the front of the van. NA #1 stated she immediately called the facility to inform them what happened and asked staff to meet her out front of the building. NA #1 stated she was not sure how Resident #22 fell from the wheelchair and restated she had made sure he was secured in his wheelchair before starting transport, the shoulder/lap belt did not budge when the straps were pulled and the only thing that she could think might have happened was that the shoulder/lap belt must not have locked properly. NA #1 added Resident #22 was not on the floor long before she got him back to the facility, only a matter of minutes and when she arrived at the facility, the DON and other staff were waiting outside. NA #1 stated later that day, the Administrator and DON asked her to explain what had happened but did not have her do a reenactment of how she loaded and secured Resident #22 into the transportation van. NA #1 stated the following day (09/15/22), she received reeducation from the Maintenance Director regarding proper securement when transporting residents in the facility van. The NP progress note dated 09/14/22 revealed in part, asked to come outside to transport van to assess Resident #22. Resident #22 observed lying on his left side on the floor of the van. Resident #22 verbalizes 'mmhmm which equals 'yes' to back and head pain. Left cheek area with small abrasion and bleeding. Unable to obtain vitals due to positioning .normocephalic (referring to a head of normal shape and size) appearing and to palpation (touch) .bilateral contractures of the extremities .no neurological appearing acute deficits, responds to spouse and answers questions in his own usual way .Assessment/Plan: fall from wheelchair during transport returning from dental appointment. Instructed nursing staff to stabilize Resident #22's head and not to move given complaints of back and head pain. Send to Emergency Department (ED) for further evaluation. During an interview on 12/01/22 at 10:28 AM, the NP recalled on 09/14/22, staff came into the facility to get her and ask her to come out to the transportation van to assess Resident #22. She stated when she got outside, the side door of the van was open and she had a clear visual of Resident #22 who was lying on his left side on the floor with his head up toward the front of the van. The NP stated she was not sure how Resident #22 fell out of his wheelchair and thought maybe his wheelchair was positioned in the middle of the van but couldn't really state for sure where it was located as her main focus at the time was to ensure Resident #22 was ok. She recalled Resident #22 was alert and able to say mmhmm to questioning, had a small abrasion on his cheek that was bleeding and he complained of pain so she told staff not to move him and call EMS to transport him to the hospital for evaluation. The EMS report dated 09/14/22 noted upon arrival at the skilled nursing facility, Resident #22 was lying on his left side in the transportation van. The EMS report read in part, Per staff on scene, it is unknown how long the patient has been laying in the back of the van and when the van arrived at their facility, the patient was on the floor. Patient noted to be conscious, alert and oriented to his normal per family on scene. Patient noted to be non-verbal. Patient noted to be complaining of pain in his lower back. Unable to place the patient in a C-collar (medical device used to support the neck) due to the patient having a short neck. Stabilized the patient's neck via manual c-spine and rolled patient onto his back. Patient noted to have a laceration to the upper posterior area of his left arm from where he laid on a latch in the back of the van and an abrasion below his left eye. Placed the patient on a backboard and carried him to the stretcher. Wrapped the patient's laceration to his arm, placed towels around the patient's head for stabilization and transported to the hospital. The ED physician progress note dated 09/14/22 read in part, History: Patient arrives via EMS due to injury. Patient with a history of intracerebral hemorrhage (type of stroke caused by bleeding within the brain tissue) three and a half years ago which has left patient completely bedridden and contracted. Spouse at bedside states that he left his dentist appointment and was placed in the transportation van but when they arrived at the facility everybody came rushing out of the facility to the van. When she got to the van, she found Resident #22 on the floor of the van on his left side. Wheelchair was still strapped in the back of the van. Patient arrives with an abrasion to the left cheek and to the left upper arm. There are abrasions and bruising noted to the left lateral side and left hip area. Patient is able to answer yes and no questions. Complains of pain to the lumbar spine with palpation as well as to the left hip with palpation. Patient is contracted with legs bent towards the torso, unable to fully extend. Assessment/Plan: skin tears cleaned and bandages applied. Skin tear to left inner arm consistent with sliding on floor. It was further noted x-rays conducted on 09/14/22 of Resident #22's lumbar spine and left hip were negative for acute fractures. Resident #22 was discharged from the hospital on 09/14/22 back to the skilled nursing facility in stable condition. A staff progress note dated 09/15/22 at 8:00 AM written by the Assistant Director of Nursing (ADON) read in part, Resident #22 awake and alert per baseline this AM with spouse at bedside. Skin assessment reveals skin tear to left upper posterior arm approximately 2 centimeters (cm) x 1 cm x 0.1 cm with scant serous drainage (thin, watery and clear substance exiting the wound), no redness, no odors. Left uppermost posterior arm presents with superficial abrasion approximately 5 cm x 1 cm x 0 cm without drainage, no redness or signs of infection. Left elbow with superficial abrasion approximately 1 cm x 1 cm x 0 cm, no redness or drainage. Light purple/red bruising to left forearm approximately 2.5 cm x 2 cm x 0 cm, skin intact. Left facial cheek presents with superficial abrasion approximately 0.25 cm x 1 cm x 0 cm, no drainage or redness. Chin presents with superficial abrasion approximately 0.2 cm x 0.3 cm x 0 cm, no drainage, no redness. Resident #22 status post fall from yesterday 9/14/22 without any latent injuries observed, moves all extremities within baseline, neuro checks in place and ongoing, within normal limits per baseline. Resident #22 complains of general mild discomfort with new order for Tylenol 500 milligrams (mg) 2 tablets every 6 hours as needed for pain/discomfort administered. Vital signs stable, no signs/symptoms of distress. During an interview on 11/30/22 at 9:17 AM, the Assistant Director of Nursing (ADON) stated on 09/14/22, when he went outside to the front of the building with the DON, he saw the transportation van coming up the road with Resident #22's spouse following the van in her car. As soon as the van parked, he and the DON opened the side door and saw Resident #22 lying on the floor on his left side. The ADON stated Resident #22 was alert and appeared calm and upon assessment he didn't have any significant bleeding, however, they decided not to move him as they weren't sure if he had any injuries that were not visible and wait for EMS to arrive to get him on the backboard to take him to the hospital for further evaluation. The ADON stated when he opened the door of the van, Resident #22 was lying on the floor in front of his wheelchair that was still secured to the floor van with his head next to the seat toward the front. He stated the wheelchair was still in an upright position and the shoulder/lap belt was pulled from the side with the strap caught around the armrest on the left side of the wheelchair and was not sure what happened or how it came loose. The ADON stated Resident #22 did not have any purposeful movement, was contracted and would not have been able to use his hands to unbuckle the shoulder/lap belt. During an interview on 12/01/22 at 2:26 PM, the Maintenance Director recalled on 09/14/22, he was in the maintenance building behind the facility when he got a call and was told to come to the front of the facility with tools to remove the front seats of the transportation van. He stated when he arrived, staff were outside by the van, the side door was open and he saw Resident #22 on the floor of the van lying on his left side with his head up toward the driver's seat. The Maintenance Director recalled he had to remove Resident #22's wheelchair from the transport van for EMS to get into the van to assist Resident #22. He recalled Resident 22's wheelchair was in an upright position, the shoulder/lap belt was not engaged and the floor securement retractor straps were intact and connected to the frame of the wheelchair. The Maintenance Director stated the van was placed out of service pending a safety inspection from an outside company; however, he also checked the securement system thoroughly and found nothing out of the ordinary. The Maintenance Director confirmed he provided NA #1 with reeducation on wheelchair securement after the van accident involving Resident #22 which included NA #1 providing a return demonstration. In addition, he had since trained the new facility transportation driver that also included a return demonstration for proper securement. An observation of the facility transportation van and follow-up interview was conducted with the Maintenance Director on 12/01/2 at 2:40 PM. The facility transportation van was a mid-size van with a lift located at the back of van. When the side door on the right side of the van was opened there were 2 shoulder/lap belts (approximately a wheelchair apart) attached to the roof of the van on the left side of the van, 2 buckle straps on the right side for the shoulder/lap belt to connect to when pulled across the resident seated in the wheelchair and on the floor were retractor with straps that had hooks to connect to the bottom of the wheelchair frame. The Maintenance Director stated on 09/14/22, Resident #22's wheelchair was positioned in the middle of the van toward the back closest to the lift. From the wheelchair to the seat (pushed up flush to the back of the driver's seat) was approximately 2 feet of space which was where he stated Resident #22 landed when he came out of the wheelchair onto his left side. He explained Resident #22's head was close to the seat located directly behind the driver's seat, up next to the left wall of the van and there was a floor retractor that Resident #22's left arm landed on. The Maintenance Director stated when he first observed Resident #22's wheelchair and removed it from the transportation van, the shoulder/lap belt was not engaged. He explained the buckle strap to the right of the wheelchair was lying on the floor, the shoulder/lap belt was positioned to the left at home base which he described as not pulled from its original position and the shoulder/lap strap was not caught on the arm rest of the wheelchair. A joint interview was conducted with the Administrator and DON on 11/29/22 2:00 PM. The DON stated she was informed by facility staff that NA #1 was on her way back to the facility and had called to report Resident #22 had fallen out of his wheelchair during transport. The DON stated she called the Administrator to notify him of the situation as she walked outside to meet NA #1 upon their arrival and less than 5 minutes passed before the transportation van pulled up to the facility. The DON recalled when she and the ADON opened the side door of the van, Resident #22 was lying on his left side on the floor. Upon assessment, she stated Resident #22 was alert and responding per his baseline. The DON explained the way Resident #22 was lying on the floor it appeared as if he somehow leaned forward toward the front of the van and came out of the wheelchair. She added Resident #22 was not able to move his upper extremities on command but would move around at times, although very limited. The DON recalled NA #1 was very distraught and trying to explain what happened but the DON could not recall what NA #1 said as her main concern at the time was ensuring Resident #22 was ok. The DON stated when she assessed Resident #22 she noticed a small laceration on his left cheek that was bleeding and a skin tear on his upper arm. She added the NP also assessed Resident #22 the best she was able given his positioning on the floor of the van. She stated Resident #22 was not moved or repositioned until EMS arrived to transport him to the hospital and as EMS got him on the backboard she observed other abrasions to his arm where he had laid on the floor. The DON restated her focus was on Resident #22 and did not observe the securement of his wheelchair but did state the shoulder/lap belt was not on Resident #22 when he was on the floor of the transportation van. A joint interview continued with the Administrator and DON on 11/29/22 2:00 PM. The Administrator stated he was not at the facility when notified by the DON that NA #1 had called the facility to report Resident #22 had fallen out of his wheelchair during transport. By the time he arrived back to the facility, the transportation van was already parked at the front of the building and staff were outside assessing the situation. The Administrator recalled Resident #22's wheelchair was positioned upright and the floor securement retractors were attached to the frame of the wheelchair. The Administrator stated immediately after Resident #22 was transported to the hospital, he and the DON sat down with NA #1 to ask her what happened and she had described the steps she had done to ensure Resident #22 was secured in his wheelchair prior to transport. The Administrator stated they did not have NA #1 conduct a reenactment of how she secured Resident #22 into his wheelchair and explained she had been in the position since February 2022 and transported a lot of residents to outside appointments without incident. The Administrator stated they were unable to determine the root cause of Resident #22's fall and explained maybe the movement of the transportation van caused the shoulder/lap belt to come loose or the buckle malfunctioned. He added it was hard to determine what actually happened as Resident #22 could not tell them and they only had NA #1's account of the incident. During a follow-up interview on 11/29/22 at 3:50 PM, the Administrator explained after the incident on 09/14/22, they implemented a plan of correction which included placing the facility transportation van out of service until thoroughly checked by an outside company, utilizing an outside transportation company for resident appointments until the facility van was placed back into service on 09/21/22 and monitoring systems for ensuring a safe transport. He added NA #1 did not do any further transport and the new Transportation Driver was educated on proper securement by the Maintenance Director, who was also the backup transportation driver. On 11/29/22 at 4:44 PM, the Administrator and Director of Nursing were notified of Immediate Jeopardy. The facility provided the following Allegation of Compliance with the correction date of 09/15/22: Based on incident dated 09/14/22, Resident #1 was being transported back to the facility from a dentist appointment when Resident #1 slid out from his wheelchair to the floor of the van. 1. For the Resident affected: Driver notified facility immediately. Resident #1 was not moved from his position until Emergency Medical Services (EMS) arrived. Nurse Practitioner was notified and assessed Resident #1. Orders received to transport Resident #1 to the Emergency Department for evaluation. Resident #1 was transported to the hospital by EMS. 2. For the Residents with the potential to be affected: Services were immediately suspended with facility transportation by the Administrator on 09/14/22 pending investigation of the incident. The transportation van was taken to an outside company first thing on the morning of 09/15/22 for a full safety inspection. The driver was re-educated on 09/15/22 upon returning to work on Van Safety and Van lift check off. Additionally, transportation drivers were educated on defense driving on 09/15/22. Resident #1's wheelchair was screened for positioning by the building's Occupational Therapist. 3. Systematic Change: Education was provided to all in-house transport drivers by the Administrator on the proper securement of residents while riding in a wheelchair accessible van on 09/15/22. Education included pre-securement steps, securement steps, and final check sections. Safety inspection sheets will be used and monitored by facility designee. 4. Monitoring: Facility designee will observe loading and unloading of resident to ensure proper securement of residents in the vehicle. Also, safety inspection sheets will be monitored by facility designee. Audit will be done 3 days a week times 2 weeks, then 2 days a week times 2 weeks, then two times a week times 2 months. Additionally, Resident #1 will be assigned a designee to ride with them on their next 5 transportations to ensure Resident #1's positioning is secure. Starting on 09/15/22, data obtained during the auditing process will be analyzed for patterns and trends and reported to the Quality Assurance and Performance Improvement (QAPI) by the Administrator monthly for two months. At that time, the QAPI committee will evaluate the effectiveness of the interventions to determine if continued auditing is necessary to maintain compliance. Alleged date of compliance: 09/15/22. The facility's Allegation of Compliance was validated from 11/29/22 to 12/01/22 and concluded the facility implemented an acceptable corrective action plan effective 09/15/22. It was confirmed all authorized drivers were trained on wheelchair securement and a transport driver skills assessment was completed with NA #1 by the Maintenance Director on 09/15/22. The facility provided documentation that included monthly safety inspections of the facility transportation van, Transport Drivers training and facility audits. The transportation audit sheets that were started on 09/21/22 when the facility transportation van was placed back into service were reviewed with no concerns identified and remained ongoing. Residents who were transported to outside appointments were interviewed and reported no concerns. Facility staff were interviewed and confirmed they received training on transportation safety that included how to properly secure a resident in the wheelchair and perform return demonstrations. The corrective action plan was reviewed by QAPI on 10/21/22 and 11/17/22.

Based on observations and staff interviews, the facility failed to discard dry food items that were past the use by date, opened, and ready for use in 1 of 1 pantry, failed to discard fresh vegetables with visible signs of spoilage in 1 of 1 walk-in refrigerator and failed to discard frozen food items with visible signs of freezer burn and ice accumulation stored in 1 of 1 walk-in freezer. This had the potential to affect food served to residents who resided in the facility. Findings included: An initial observation of the kitchen and concurrent interview was conducted with the Dietary Manager (DM) on [DATE] at 9:32 AM that revealed the following: Stored in the pantry and available for use was a clear plastic bag containing instant chocolate pudding mix labeled with a use by date of [DATE]. The DM removed the bag of chocolate pudding from the pantry shelf and stated it should have been discarded 90 days after it had been opened. Stored in the walk-in refrigerator were approximately 12 fresh green peppers stored together in a cardboard box, open to air, with 3 green peppers that had visible signs of spoilage (mold, soft mushy spots and one with the bottom completely rotted). The DM removed the green peppers that were spoiled and explained she had looked through the box of green peppers yesterday, discarded several and had just missed the ones at the bottom of the box. Stored in the walk-in freezer was a clear plastic bag containing approximately 5 frozen chicken tenders with visible ice crystallization inside the bag and on the chicken. The bag was unlabeled with no opened date. The DM removed and discarded the bag of frozen chicken tenders. The DM stated the bag of chicken tenders should have been dated when opened and discarded when observed with ice crystallization. A second observation of the kitchen and concurrent interview was conducted with the DM on [DATE] at 4:30 PM that revealed the following: Stored in the walk-in refrigerator were approximately 9 green bell peppers stored together in a carboard box, open to air, with 2 green peppers that had visible signs of spoilage (soft mushy spots and rotted areas). Also, a separate cardboard box on the same shelving unit contained 3 bags of celery. One of the bags of celery had visible brown, mushy spots on the bottom of the stalks. The DM removed the green peppers and celery that were spoiled and discarded them in the trash. Stored in the walk-in freezer was an unopened bag of frozen chicken portions that had noticeable freezer burn with ice crystallization on the inside of the bag. The DM removed the bag of chicken, stating it was unusable, and discarded the bag into the trash. During the same interview, the DM explained dietary staff were instructed to label food items with the date it was prepared and/or opened and the use-by-date as indicated on the Use-By-Date procedure posted in the kitchen. The DM added dietary staff were usually very good at following the posted procedure for labeling, dating and discarding expired food items and explained they just hadn't noticed the items that were identified during the observations conducted on [DATE] and [DATE]. The DM stated it was the responsibility of all dietary staff to check the pantry, refrigerators and freezers daily to make sure food items were properly labeled and dated and discard any items that were spoiled or expired. During an interview on [DATE] at 4:50 PM, the Administrator stated he would expect for food items to be labeled and dated when opened or prepared and discarded if they had visible signs of spoilage or were past the expiration and/or use-by-date.

Based on record review, observations, interviews with residents and staff the facility failed to assess the capability of residents to self-administer medications for 2 of 2 residents reviewed for self-administration (Resident #9 and #17). The findings included: 1. Resident #9 was admitted to the facility on [DATE]. Review of the admission MDS dated [DATE] revealed Resident #9 was assessed as being cognitively intact. Review of the physician orders revealed none were in place for lubricating eye drops. Review of the medical records for Resident #9 revealed there was no documentation or assessment to show the resident was safe to self-administer medications. An observation and interview were conducted on 11/28/22 at 11:09 AM with Resident #9. In the room on the bedside table was a box labeled lubricating tear eye drops. Resident #9 stated she self-administered 1 drop in each eye twice a day and explained the drops weren't prescription and just used for moisturizing. A second observation and interview were conducted on 11/29/22 at 12:08 PM. Resident #9 revealed she hadn't requested to self-administer the eye drops and was told by someone yesterday, she didn't recall, not to leave the eye drops out in the open and showed the item was stored in the top drawer of the nightstand. Resident #9 revealed no one at the facility had asked her about self-administering or checked to ensure she was able to do so. Resident #9 revealed she used the eye drops at home and indicated she was able to self-administer. An interview was conducted on 11/29/22 at 12:19 PM with Nurse #1. Nurse #1 confirmed she was assigned to administer medications for Resident #9 but hadn't worked this assignment for the past couple of weeks. Nurse #1 revealed she didn't notice the eye drops in Resident #9's room and stated anytime a resident wanted to keep those in their room a physician's order would need to be in place to self-administer. Nurse #1 revealed she wasn't sure if an assessment was needed before a resident could self-administer medications and sometimes a resident or Family Member brought those items in, and staff weren't aware of it. During an interview on 12/01/22 at 10:54 AM the Nurse Practitioner (NP) revealed if medications were kept at the resident's bedside, she would expect a physician's order would be in place to self-administer. The NP revealed staff usually told her when a resident wanted to use eye drops, they did at home, and she would assess their ability to self-administer. An interview was conducted on 12/01/22 at 4:44 PM with the Director of Nursing (DON). The DON revealed a physician's order should be in place for a resident to self-administer eye drops and their ability to self-administer would be assessed before left in the room. An interview was conducted on 12/01/22 at 5:01 PM with the Administrator. The Administrator stated he expected over-the-counter medications were not stored in a resident's room. The Administrator revealed room checks were done regularly and if those items were missed the residents didn't have it very long. 2. Resident #17 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #17's cognition was assessed as being moderately impaired. Review of the physician orders for Resident #17 revealed none were in place for eye supplements or lubricating eye drops. Review of the medical records for Resident #17 revealed there was no documentation or assessment to show the resident was safe to self-administer medications. During an observation and interview on 11/28/22 at 11:51 AM a clear zip lock plastic bag was placed on the top of a small refrigerator in the room of Resident #17. The bag contained a bottle of over-the-counter vitamin and mineral eye supplement capsules and a 10-milliliter bottle of over-the-counter lubricating eye drops. Resident #17 revealed a Family Member brought the supplements and eye drops to him and he was supposed to take those each day and would self-administered both the supplements and eye drops. A second observation and interview were conducted on 11/29/22 at 12:27 PM. The supplements and eye drops remained in a clear plastic bag on top of the refrigerator in Resident #17's room. Resident #17 confirmed no one from the facility had assessed his ability to self-administer and no one from facility was involved with him taking the over-the-counter supplements or eye drops. An observation and interview were conducted on 11/29/22 at 3:25 PM with Nurse #1 and Resident #17. Nurse #1 observed the bottle of supplements and eye drops in same location. Nurse #1 asked Resident #17 if he had taken those and the resident responded yes but not every day. Resident #17 explained a Family Member brought the items into the facility and gave to him to take. Nurse #1 explained to Resident #17 a physician's order was needed to self-administer and he couldn't take those without one. Resident #17 agreed to let Nurse #1 remove the supplements and eye drops from the room and store in locked area. Nurse #1 confirmed there was no physician's order for the supplements or eye drops and no order for Resident #17 to self-administer. During an interview on 12/01/22 at 10:54 AM the Nurse Practitioner (NP) revealed if medications were kept at the resident's bedside, she would expect a physician's order would be in place to self-administer. The NP revealed staff usually told her when a resident wanted to take a supplement or use eye drops, they took at home, and she would assess their ability to self-administer. During an interview on 12/01/22 at 4:44 PM the DON revealed it was the facility's policy when a resident wanted to self-administer medications including supplements or eye drops a physician's order should be in place. The DON revealed before a resident could self-administer an assessment of their ability was done before those items were left in the room. An interview was conducted on 12/01/22 at 5:01 PM with the Administrator. The Administrator stated he expected over-the-counter medications were not stored in a resident's room. The Administrator revealed room checks were done regularly and if those items were missed the residents didn't have it very long.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the area of functional status for 1 of 12 sampled residents reviewed for MDS accuracy (Resident #22). Findings included: Resident #22 was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or loss of strength on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. The Hospice plan of care, revised 04/11/22, for Resident #22 revealed a care plan in place to address a problem of area of pain due in part to contractures in bilateral legs and arms. Interventions included: pillow to support limbs and rolled washcloth in hand due to contracture. The quarterly MDS assessment dated [DATE] revealed Resident #22 required extensive to total staff assistance with all activities of daily living and had no impairment in the upper or lower extremities. The quarterly MDS assessment dated [DATE] revealed Resident #22 required extensive to total staff assistance with all activities of daily living and had no impairment in the upper or lower extremities. During an interview on 12/01/22 at 09:15 AM, the MDS Coordinator explained Resident #22 was receiving restorative therapy and had some movement in his upper and lower extremities which was why she marked no impairment when completing the MDS assessments dated 08/09/22 and 11/08/22. The MDS Coordinator confirmed Resident #22 did have contractures of both the upper and lower extremities with limited range of motion. She stated based on the Resident Assessment Instrument manual (instructional guidelines), the MDS assessments should have been coded to reflect Resident #22 had impairment in both the upper and lower extremities and modifications would be submitted. During an interview on 12/01/22 at 4:50 PM, the Administrator confirmed Resident #22 had contractures in both the upper and lower extremities and stated he would expect for the MDS assessments to be completed accurately.

Based on observations, record review, staff and Nurse Practitioner (NP) interviews the facility failed to follow the Physician order for the use of supplemental oxygen for 1 of 2 residents reviewed for respiratory care (Resident #191). Findings included: Resident #191 was admitted to the facility 11/22/22 with diagnoses including chronic obstructive pulmonary disease (abbreviated as COPD and meaning a condition involving constriction of the airways and difficulty breathing) and respiratory failure (a condition in which the lungs have difficulty loading the blood with oxygen or removing carbon dioxide). Resident #191 had a Physician order dated 11/22/22 for oxygen at 2 liters per minute via nasal cannula (a tube in the nose) to maintain saturations (the amount of oxygen in the blood) above 90%. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #191 was cognitively intact and used oxygen. Review of a respiratory care plan initiated 11/29/22 revealed Resident #191 was at risk for impaired gas exchange related to the use of oxygen. Interventions included administering medications as ordered, administering oxygen as ordered, and monitoring oxygen as ordered and prn (as needed). Review of Resident #191's November 2022 Medication Administration Record (MAR) revealed her oxygen saturations ranged from 90-97%. An observation of Resident #191 on 11/28/22 at 10:40 AM revealed she was receiving oxygen via nasal cannula. An observation of Resident #191's oxygen concentrator at the same date and time revealed it was set to provide oxygen at 4 liters per minute. An observation of Resident #191 on 11/29/22 at 10:40 AM revealed she was receiving oxygen via nasal cannula. An observation of Resident #191's oxygen concentrator at the same date and time revealed it was set to provide oxygen at 3 liters per minute. An observation of Resident #191 on 11/30/22 at 09:37 AM revealed she was receiving oxygen via nasal cannula. An observation of Resident #191's oxygen concentrator at the same date and time revealed it was set to provide oxygen between 3 and 4 liters per minute. During an interview with Nurse #1 on 11/30/22 at 10:58 AM she confirmed Resident #191's oxygen was set between 3 and 4 liters per minute. She stated she usually checked to make sure the oxygen concentrator settings matched the oxygen orders each shift and she had not yet checked the oxygen setting for Resident #191 on 11/30/22. An interview with the Nurse Practitioner (NP) on 12/02/22 at 10:57 AM revealed she expected nursing staff to follow Physician orders for oxygen use. She stated if a resident required more oxygen than ordered she would expect to be notified so a new oxygen order could be obtained. An interview with the Director of Nursing (DON) on 12/01/22 at 04:41 PM revealed she expected staff to follow Physician's orders for oxygen use. She stated nurses should verify the oxygen concentrator was set correctly when they were in the resident's room checking vital signs. An interview with the Administrator on 12/01/22 at 05:07 PM revealed he expected staff to follow Physician orders for oxygen use.

Based on record review, staff and family interviews, the facility failed to allow a resident to remain in the facility and failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 3 residents reviewed for transfer and discharge (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plans dated 11/13/17 for Resident #1 included a plan for discharge with the goal of a smooth transition to home or assisted living facility. The approach listed was to initiate discharge planning. There was no care plan initiated for behaviors. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had moderate impairment in cognition and displayed no wandering or other types of behaviors. The MDS indicated Resident #1 required extensive assistance of 1 staff member for toileting, dressing, transfers and bed mobility. The MDS noted an active discharge plan to the community was in process. Resident #1 was transferred to another skilled nursing facility on 11/20/17. Review of Resident #1's medical record revealed no documentation related to discharge planning, a discharge summary which described the services Resident #1 received while at the facility, a transfer and discharge notice, or statement describing the specific needs and behaviors of Resident #1 that could not be managed or met at the facility. An interview on 2/23/18 at 3:08 PM with the Director of Resident Services (DRS) revealed all beds within the facility were dually certified for Medicare and Medicaid and discharge planning was started within 72 hours of a resident's admission to discuss discharge needs. The DRS stated she was informed by the Administrator Resident #1 would need alternate placement due to wandering behaviors. She indicated Resident #1's Family Member (FM) was provided a list of secured facilities and placement was obtained at the facility of their choice. The DRS was unable to recall the date she discussed alternate placement with the FM and added the FM had not questioned why Resident #1 could not stay at the facility until after she was transferred to another facility. The DRS confirmed she did not document any of the discharge planning for Resident #1 and did not provide Resident #1 or the FM with written notification of the reason for the transfer and discharge. A phone interview on 02/23/18 at 4:35 PM with the FM for Resident #1 revealed they had requested this facility as it was close to their home. The FM indicated the facility was informed during the admission process Resident #1 would not be able to return home and would need long-term care. The FM stated they received a phone call from the facility 2 days prior to Resident #1's discharge informing them she would be transferred to another skilled nursing facility. The FM stated they questioned why Resident #1 could not remain at the facility but never got a good answer why she couldn't stay. The FM added they were not provided choices of optional facilities or written notification for the transfer. An interview on 2/24/18 at 2:05 PM with the Administrator revealed he met with the FM the day Resident #1 was admitted to the facility and they did not indicate she would need long-term care. He recalled during the process of completing the admission paperwork, the FM mentioned Resident #1 had wandered outside when she was at home prior to her recent hospitalization . The Administrator stated he explained to the FM the facility was unable to manage wandering behavior and he would have the DRS find placement for Resident #1 at a more secured facility. He indicated the FM had been agreeable to alternate placement for Resident #1. He stated he felt the DRS didn't document discharge planning efforts because they were trying to find quick placement to ensure Resident #1's safety. He was unable to recall any episodes of wandering or exit seeking behavior Resident #1 displayed while at the facility. The Administrator confirmed there was no written notification of the transfer and discharge. He added he didn't think of it as a discharge since Resident #1 was being transferred to another skilled nursing facility.

Based on record review, staff and family interviews, the facility failed to provide the resident or Family Member (FM) a written notification for the reason for transfer to another skilled nursing facility and failed to send a copy of the notice to the Ombudsman for 1 of 3 residents reviewed for transfer and discharge (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had moderate impairment in cognition. Resident #1 was transferred to another skilled nursing facility on 11/20/17. Review of Resident #1's medical record revealed no documentation of a transfer and discharge notice or statement describing the specific needs and behaviors of Resident #1 that could not be managed or met at the facility. During an interview on 2/23/18 at 3:08 PM the Director of Resident Services (DRS) revealed she completed notices when residents discharged from the facility and provided a copy of the notice to the Ombudsman. The DRS confirmed a notice of transfer and discharge was not completed for Resident #1. She also confirmed Resident #1, her FM or the Ombudsman was not provided with written notification of the reason for her transfer to another skilled nursing facility. During a phone interview on 02/23/18 at 4:35 PM Resident #1's FM revealed they received a phone call from the facility 2 days prior to Resident #1's discharge informing them she would be transferred to another skilled nursing facility. The FM added they were not provided choices of optional facilities or written notification of the reason for the transfer. During an interview on 2/24/18 at 2:05 PM the Administrator stated he was not aware written notification which indicated the reason for the transfer should have been provided to Resident #1 or her FM since verbal notification was given and the FM was agreeable to alternate placement. He confirmed there was no written notification of the transfer and discharge for Resident #1 and stated he felt the DRS didn't document discharge planning efforts because they were trying to find quick placement to ensure Resident #1's safety.

Based on observation and staff interview the facility failed to keep the cold salad filling in sandwiches at or below 41 degrees Fahrenheit during operation of the trayline, failed to cover the facial hair of an employee handling sanitized kitchenware, and failed to wash fresh fruit before cutting it up. The facility also failed to air dry tray pans prior to stacking them on top of one another on storage shelving, and failed to remove dried food particles from the interior top of the microwave. Findings included: 1. At 5:30 PM on 09/05/17 the kitchen trayline was in operation. A large baking pan containing chicken salad sandwiches was laying across empty wells of the steam table next to a well which contained hot soup. At 5:32 PM on 09/05/17 a calibrated thermometer was used to check the temperature of the chicken salad filling in the sandwiches. The thermometer registered 64.6 degrees Fahrenheit. At this time a dietary employee stated there were still six residents in the dining room yet to be served. She stated the trayline had begun operation at 4:50 PM on 09/05/17. At 5:35 PM on 09/05/17 the Dietary Manager (DM) provided the trayline temperature log, and no food temperatures were recorded at any meal on 09/05/17. However, the DM reported she did take the temperature of the chicken salad filling as the trayline began operation, and the calibrated thermometer registered 40 degrees Fahrenheit. At 9:24 AM on 09/07/17 the ingredient label on a container of the commercially prepared chicken salad, served to residents at lunch on 09/05/17, documented the chicken salad contained chicken, salad dressing, egg yolks, vinegar, mustard, onion, and sweet pickle relish. At 3:04 PM on 09/08/17 the DM stated it was a challenge to keep the chilled filling of sandwiches at 41 degrees Fahrenheit or below without making the bread tough. She reported when the facility was serving cold salad plates the salads made with mayonnaise, eggs, and/or salad dressing were kept cold by placing them above steam table wells which had been turned off and filled with ice. At 3:12 PM on 09/08/17 Dietary Employee #1 stated she was trained to make up the sandwiches as they were needed by placing chilled salad filling stored over or in ice between slices of bread at the trayline. She reported if salads made with mayonnaise remained over 41 degrees Fahrenheit for long periods of time it increased the chance that bacteria could grow in them. 2. During observation of the dish machine process on 09/07/17 between 9:03 AM and 9:16 AM one dietary employee was loading and unloading kitchenware as it entered and exited the dish machine. This male was handling sanitized kitchenware as he unloaded it from racks and placed it in storage. He had side burns, a moustache, and a beard which were not covered during the observation. The facial hair in the sideburns and moustache was 1/2 inch to 3/4 inch maximum in length, and the facial hair in the beard was 3/4 inch to one inch maximum in length. At 3:04 PM on 09/08/17 the Dietary Manager (DM) stated facial hair could contaminate kitchenware which was sanitized by the heat of the dish machine as an employee with uncovered facial hair was placing it in storage. At 3:12 PM on 09/08/17 Dietary Employee #1 stated hair found on kitchenware or in food could cause cross contamination by spreading germs and bacteria. She commented the elderly population was especially susceptible to sickness since they often had compromised immune systems. 3. At 10:55 AM on 09/07/17 the cook retrieved a whole watermelon from the walk-in refrigerator. She placed the melon on a cutting board and used a knife to slice it open without washing it first. At 3:04 PM on 09/08/17 the Dietary Manager (DM) stated whole fresh fruit should be washed before cut open because it had been transported and stored in places where the outside peel or rind could have become contaminated by dirt and bacteria. She reported if the fruit was not washed first, a knife could carry this dirt and bacteria from the rind into the flesh of the fruit as the knife passed through it. At 3:12 PM on 09/08/17 Dietary Employee #1 stated she was trained to always wash fresh fruit before cutting it up so that dirt and bacteria on the outside of the fruit did not contaminate the inside of the fruit which was eaten by residents. 4. At 9:12 AM on 09/07/17 3 of 10 tray pans stacked on top of one another on a storage shelf had moisture trapped inside of them. At this time the cook stated the tray pans were stacked wet the night before because today she had not yet run any tray pans through the three-compartment sink system. At 3:04 PM on 09/08/17 the Dietary Manager (DM) stated bacteria could grow in the moisture trapped inside of kitchenware which was stacked in storage overnight. She reported this practice had the potential of making residents sick. At 3:12 PM on 09/08/17 Dietary Employee #1 stated she was trained that all kitchenware was supposed to be air dried and clean before stacking items on top of one another in storage. 5. During initial tour of the kitchen, beginning at 2:32 PM on 09/05/17, the interior top of the microwave was covered in dried food particles. At 9:06 AM on 09/07/17, during a follow-up tour of the kitchen, the interior top of the microwave was covered in dried food particles. At 3:04 PM on 09/08/17 the Dietary Manager (DM) stated the microwave was on the cleaning schedule to be cleaned daily, and the assignment was rotated between the three cooks. However, she reported it looked like the cooks were wiping down the bottom and sides of the microwave, but forgetting to clean the interior top. She explained the dietary staff heated a lot of soup for the residents, and she thought that was where a lot of the dried food was coming from. According to the DM, these dried food particles could fall into fresh food which was being heated, causing contamination of the fresh food. At 3:12 PM on 09/08/17 Dietary Employee #1 stated she was trained that the microwave was supposed to be wiped out after each breakfast, lunch, and supper meal. She reported she was taught to clean the interior top, bottom, and sides of the microwave so dried food particles did not contaminate foods currently being heated in the microwave.

Based on record review and staff and physician interviews the facility failed to administer a medication ordered by the physician for 1 of 5 residents (Resident #33) whose medications were reviewed. Findings included: Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #33 was moderately cognitively impaired. Review of the Consultant Pharmacist Communication to Physician form dated 07/14/17 revealed a recommendation to increase Resident #33's dose of donepezil ([MEDICATION NAME]) to 10 milligrams (mg) every evening to optimize the potential benefits of the medication. There was a handwritten response from the physician dated 07/22/17 to increase [MEDICATION NAME] (donepezil) to 10mg by mouth every evening. There were no initials or notations from a nurse that the order had been noted. Review of the July, August, and September 2017 Medication Administration Records (MAR) revealed the physician order, dated 07/22/17, of increasing the daily dose of [MEDICATION NAME] was never transcribed on the MAR. As a result, Resident #33 received a daily dose of 5 mg of donepezil ([MEDICATION NAME]) for dementia instead of 10 mg for 49 days. In an interview on 09/07/17 at 4:05 PM Resident #33's Physician stated the rationale for increasing the dose of the [MEDICATION NAME] was to stabilize Resident #33's dementia. He stated he was not aware that his order was not being followed and that he expected the facility to follow his orders. In an interview on 09/07/17 at 4:24 PM Unit Manager (UM) #1 stated the Consultant Pharmacist Communication to Physician form would be considered an order once filled out and signed by the Physician. He indicated the process would be to note the order and transcribe it to the MAR. UM #1 indicated the order should then be initiated. In an interview on 09/07/17 at 4:38 PM the Director of Nursing (DON) stated the Consultant Pharmacist Communication form would be considered an order once signed by the Physician. She indicated the process was for the Physician to give her the signed recommendations and that she would then give the recommendation to a Unit Manager or a nurse. She indicated the order would then be placed on the MAR and carried out. In an interview on 09/08/17 at 9:40 AM UM #2 indicated she had received the signed Consultant Pharmacist Communication form. She stated she spoke to Resident #33's family on 07/24/17 but they were unsure if they wanted Resident #33 to receive an increased dose of [MEDICATION NAME]. She indicated she had not updated the MAR for the increased dosage as she was waiting for a response from Resident #33's family. She stated she had not done any other follow-up until the morning of 09/08/17 when she spoke with a member of Resident #33's family.

Based on record review and staff and physician interviews the facility failed to follow-up on a urine culture which resulted in the administration of unnecessary antibiotics for 1 of 5 residents (Resident #33) whose medications were reviewed. Findings included: Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #33 was moderately cognitively impaired and occasionally incontinent of bladder. Review of the Physician Telephone Orders dated 07/30/17 revealed an order to obtain a urine sample for culture and sensitivity. A second Telephone Order dated 07/30/17 revealed an order for [REDACTED]. Review of the Laboratory urine Culture and Sensitivity results reported 08/02/17 revealed no growth in 48 hours (signifying no infection). Review of the August 2017 Medication Administration Record [REDACTED]. In a telephone interview on 09/08/17 at 10:30 AM Resident #33's Physician indicated someone at the facility should have reviewed the laboratory urine culture results and contacted him. He stated if the facility had notified him he would have discontinued the antibiotic since the results were negative. In an interview on 09/08/17 at 11:00 AM the Director of Nursing (DON) stated she did not review urine culture and sensitivity results. She indicated she expected the resident's nurse to review any laboratory results for the resident. She also expected the nurse to notify the physician of any results needing follow-up. She stated the physician should have been notified of the negative culture result so the medication could have been discontinued. In a telephone interview on 09/08/17 at 11:40 AM Nurse #1, who was Resident #33's nurse during a 12 hour shift on 08/02/17, stated she did not remember seeing the laboratory results for the urine culture and sensitivity. She indicated the results were faxed to the facility and anyone could have picked up the results. Nurse #1 stated that since she never saw the results she did not notify the physician and did not follow-up on the culture results.

Based on record review and staff, Consultant Pharmacist, and Physician interviews the Consultant Pharmacist failed to advise the facility that a medication dosage increase ordered by the Physician was not being administered. Findings included: Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #33 was moderately cognitively impaired. Review of the Consultant Pharmacist Communication to Physician form dated 07/14/17 revealed a recommendation to increase Resident #33's dose of donepezil (Aricept) to 10 milligrams (mg) every evening to optimize the potential benefits of the medication. There was a handwritten response from the physician dated 07/22/17 to increase Aricept (donepezil) to 10 mg by mouth every evening. Review of the July, August, and September 2017 Medication Administration Records (MAR) revealed the physician order, dated 07/22/17, of increasing the daily dose of Aricept was never transcribed on the MAR. As a result, Resident #33 received a daily dose of 5 mg of donepezil (Aricept) for dementia instead of 10 mg for 49 days. In an interview on 09/07/17 at 4:05 PM Resident #33's Physician stated the rationale for increasing the dose of the Aricept was to stabilize Resident #33's dementia. He stated that when the Consultant Pharmacist reviewed the MAR's he should have seen the order for the Aricept was not increased and informed the facility. In a telephone interview on 09/08/17 at 9:00 AM the Consultant Pharmacist stated the process for the monthly medication review included reviewing the resident's MAR and monitoring any recommendations he made to the Physician. The Consultant Pharmacist stated it was unfortunate that Resident #33 had not received the Aricept as ordered and acknowledged that he should have informed the facility that the increase in Aricept had not been implemented.

Based on record review and staff and physician interviews the facility failed to notify the physician of urine culture and sensitivity results which resulted in the administration of unnecessary antibiotics for 1 of 5 residents (Resident #33) whose medications were reviewed. Findings included: Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #33 was moderately cognitively impaired and occasionally incontinent of bladder. Review of the Physician Telephone Orders dated 07/30/17 revealed an order to obtain a urine sample for culture and sensitivity. A second Telephone Order dated 07/30/17 revealed an order for [REDACTED]. Review of the Laboratory urine Culture and Sensitivity results reported 08/02/17 revealed no growth in 48 hours (signifying no infection). Review of the August 2017 Medication Administration Record [REDACTED]. In a telephone interview on 09/08/17 at 10:30 AM Resident #33's Physician indicated someone at the facility should have reviewed the laboratory urine culture results and contacted him. He stated if the facility had notified him he would have discontinued the antibiotic since the results were negative. In an interview on 09/08/17 at 11:00 AM the Director of Nursing (DON) stated she did not review urine culture and sensitivity results. She indicated the laboratory faxed the results to the facility. She indicated there was no one assigned to retrieve the results and provide them to the resident's nurse but that she expected the resident's nurse to review them. She stated she expected the nurses to notify the physician if any follow-up was needed including if the resident was on the wrong antibiotic. She stated the physician should have been notified of the negative culture result so the medication could have been discontinued. In a telephone interview on 09/08/17 at 11:40 AM Nurse #1, who was Resident #33's nurse during a 12 hour shift on 08/02/17, stated she did not remember seeing the laboratory results for the urine culture and sensitivity. She indicated laboratory results were faxed to the facility and anyone could have picked up the results. Nurse #1 stated that since she never saw the results she did not notify the physician and did not follow-up on the culture results. She indicated that whoever picked up the results from the fax machine should have provided the results to a nurse for review.

Based on record review and staff interview the facility failed to accurately code discharge destinations for 2 of 3 sampled residents (Resident #54 and #135) who had discharge minimum data set (MDS) assessments completed. Findings included: 1. Record review revealed Resident #135 was admitted to the facility on [DATE] and discharged from the facility on 05/11/17. The resident's documented [DIAGNOSES REDACTED]. The resident's 05/11/17 discharge minimum data set (MDS) documented he was discharged to an acute care hospital. A 05/12/17 progress note (late entry for 05/11/17 3:00 PM) documented Resident #13 attended ortho appt (orthopedic appointment) with orders for OK to d/c (discharge) home, amb (ambulating) via r/w (rolling walker) steady gait, (family member designation) at side and involved with d/c, reviewed med (medications) and d/c orders, stated had all meds at home . At 11:38 AM on 09/08/17 the MDS Nurse stated she coded the discharge destination in the MDS system based on her review of resident progress notes. After reviewing Resident #135's progress notes, she reported her coding of the resident's discharge destination was inaccurate. She explained the resident went home, and not to the hospital as she documented in the resident's 05/11/17 discharge MDS. According to the MDS Nurse, when she saw the progress note about Resident #135 going out of the facility to an orthopedic appointment, she must have gotten this resident mixed up with another resident who went from a doctor's appointment to the hospital. At 4:25 PM on 09/08/17 the Director of Nursing (DON) stated it was her expectation that the information on the MDS assessments be coded correctly. 2. Record review revealed Resident #54 was readmitted to the facility on [DATE] and discharged from the facility on 04/06/17. The resident's documented [DIAGNOSES REDACTED]. A 04/05/17 5:55 PM Therapy Note documented, Occupational Therapy (OT) discharge performed during today's session with evaluation and assessment of patient's functional progress toward short and long term goals and carryover of therapeutic gains. Recommendations for discharge include caregiver assist/supervision for all self-care with home health therapy to evaluate and treat as indicated to facilitate safe return to PLOF (previous level of function) with ADLs (activities of daily living) within the home. A 04/05/17 12:17 PM Therapy Note documented, Physical Therapy (PT) plan of care and PT goals/safety training for falls prevention reviewed with patient with PT discharge summary completed and written. The resident's 04/06/17 discharge minimum data set (MDS) documented he was discharged to an acute care hospital. At 11:38 AM on 09/08/17 the MDS Nurse stated she coded the discharge destination in the MDS system based on her review of resident progress notes. After reviewing Resident #54's progress notes, she reported her coding of the resident's discharge destination was inaccurate. She explained the resident went home with home health services, and not to the hospital as she documented in the resident's 04/06/17 discharge MDS. According to the MDS nurse, she could not explain why she coded Resident #54's discharge destination as an acute care hospital when the therapy notes clearly indicated the resident was going home. At 4:25 PM on 09/08/17 the Director of Nursing (DON) stated it was her expectation that the information on the MDS assessments be coded correctly.

Based on record review and staff interview the facility failed to clarify a physician order [REDACTED]. (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 14 day assessment dated [DATE] revealed Resident #1 had been identified as cognitively intact and receiving an anticoagulant. Review of a [MEDICATION NAME] recommendation signed by the physician on 08/31/15 revealed a recommendation to restart [MEDICATION NAME] on 09/01/15. Review of a Medication Administration Record [REDACTED]. An interview with the Director of Nursing (DON) on 01/21/16 at 11:49 AM revealed Resident #1 did not have a [MEDICATION NAME] order upon admission. Resident #1 had gone out for a procedure on 08/31/15 and returned with instructions to restart [MEDICATION NAME] on 09/01/15. She stated Resident #1 was not on [MEDICATION NAME] at that time. She stated the family questioned the resident not being on [MEDICATION NAME] after the procedure, and requested they get it restarted. A call was placed to the physician, and an order for [REDACTED]. An Interview with the DON on 01/21/16 at 3:52 PM revealed her expectation of the nurse receiving the order would have been to clarify that order with Resident #1's physician to see if he wanted the [MEDICATION NAME] restarted.

Based on medical record review and staff interviews the facility failed to administer significant medication as ordered by the physician for 2 of 3 sampled residents. (Residents #2 and #8 ) The findings included: 1. Resident #8 was admitted to the facility 02/15/12 with cumulative [DIAGNOSES REDACTED]. The current care plan for Resident #8 dated 01/02/16 included the following problem areas: -Potential for dehydration related to diuretic medication due to [MEDICAL CONDITION]/hypertension. Approaches to this problem area included, Medications as ordered. -Potential for respiratory infections, shortness of breath and increased confusion related to [DIAGNOSES REDACTED]. Approaches to this problem area included, Administer medication as ordered. -Potential for signs/symptoms or injury related to the use of antianxiety meds for anxiety and depression. Approaches to this problem area included, Administer medications as ordered. Resident #8 was admitted to the hospital 12/23/15 and readmitted to the facility 12/26/15. Hospital discharge records dated 12/26/15 indicated discharge [DIAGNOSES REDACTED]. A nurses note in the medical record of Resident #8 dated 12/26/15 at 4:34 PM and written by Nurse #1 noted, Physician (physician's name) in house and verified orders and faxed to pharmacy, awaiting medication arrival. A list of 12/26/15 admission medications for Resident #8 that were signed by the resident's physician on 12/26/15 included the following medications: [REDACTED] [MEDICATION NAME] Diskus ([MEDICATION NAME][MEDICATION NAME]) 1 puff inhalation two times a day [MEDICATION NAME] (diuretic) 40 milligrams (mg) every day [MEDICATION NAME] (anti-anxiety medication) 10 mg twice a day Review of the December 2015 Medication Administration Record (MAR) and January 2016 MAR for Resident #8 noted the [MEDICATION NAME] and [MEDICATION NAME] were not included and had not been administered from the time of readmission 12/26/15 through the time of the investigation on 01/21/16. The [MEDICATION NAME] was listed on the December 2015 MAR and January 2016 MAR after readmission on 12/26/15 and read, [MEDICATION NAME] 10 mg give one tablet by mouth twice daily at 9:00 AM and 4:00 PM for anxiety. The only time listed for administration was 9:00 AM. The 4:00 PM dose of [MEDICATION NAME] was not included on the MARs and had not been administered from the time of readmission through the time of the investigation on 01/21/16. On 01/21/16 at 3:00 PM The Director of Nursing (DON) stated medications should be administered to residents as ordered by the residents' physician. The DON stated admission orders [REDACTED]. The DON stated a separate nurse was supposed to check the medications entered into the facility electronic system against the hospital discharge orders to ensure accuracy. The DON stated the nurse that did the second check did not sign or document the second check had been completed so it was impossible to track if a second check had been completed. The DON stated there was no monthly reconcilliation of orders once entered into the MAR in the facility electronic system. The DON reviewed the hospital discharge orders from 12/26/15 for Resident #8 with the December 2015 and January 2016 MARs for Resident #8 and could not explain why the [MEDICATION NAME] and [MEDICATION NAME] were not administered as ordered by the physician. On 01/21/16 at 4:20 PM Nurse #1 (who admitted Resident #8 on 12/26/15) reviewed the 12/26/15 hospital discharge orders with the December 2015 and January 2016 MARs for Resident #8 and verified he had entered the medications into the facility electronic record. Nurse #1 could not explain why the [MEDICATION NAME] and [MEDICATION NAME] were not included on the 2015 December and 2016 January MARs for Resident #8. Nurse #1 could not explain why the 4:00 PM dose of [MEDICATION NAME] was not included on the 2015 December and 2016 January MARs for administration to Resident #8. Nurse #1 stated usually another nurse checked orders entered into the facility electronic MAR to ensure accuracy but stated there was nothing to document if this had been done or who did the second check. On 01/21/15 at 4:30 PM attempts were made to contact the physician/nurse practitioner of Resident #8 but were unsuccessful. 2. Resident #2 was admitted to the facility 10/21/15 after hospitalization with [DIAGNOSES REDACTED]. Hospital discharge orders for Resident #2 noted medications which included [MEDICATION NAME], 12.5 milligrams (mg), two times daily. A nurses note in the medical record of Resident #2 included, Medications taken from FL2 (an admission form which included a listing of medications from the receiving facility) provided by family. The FL2 for Resident #2 listed medications which included [MEDICATION NAME], 12.5 milligrams, two times daily. A progress note by the physician of Resident #2 dated 10/23/15 noted a [DIAGNOSES REDACTED].#2 to treat hypertension included [MEDICATION NAME] 12.5 mg, twice a day. Review of the Medication Administration Records (MAR) from October and November 2015 for Resident #2 included an order for [REDACTED]. The only time listed for administration on the MAR during the time of admission at the facility for Resident #2 was 9:00 AM. On 01/21/16 at 3:00 PM The Director of Nursing (DON) stated medications should be administered to residents as ordered by the residents' physician. The DON stated admission orders [REDACTED]. The DON stated a separate nurse was supposed to check the medications entered into the facility electronic system against the hospital discharge orders to ensure accuracey. The DON stated the nurse that did the second check did not sign or document the second check had been completed so it was impossible to track if a second check had been completed. The DON stated there was no monthly reconcilliation of orders once entered into the MAR in the facility electronic system. The DON reviewed the hospital discharge orders from 10/21/15 for Resident #2 with the October 2015 and November 2015 MARs for Resident #2 and could not explain why the [MEDICATION NAME] was not administered as ordered by the physician. The DON stated the nurse that admitted Resident #2 on 10/21/15 no longer worked at the facility and contact information was not available. The blood pressures of Resident #2 were reviewed through time of admission at the facility with systolic pressures ranging from 118-164 and diastolic pressures ranging from 60-88. On 01/21/15 at 4:30 PM attempts were made to contact the physician/nurse practitioner of Resident #2 but were unsuccessful.

Based on observations and staff interviews the facility failed to clean shelving used to store food items in the walk in refrigerator, maintain an environment in the kitchen to prevent pests from accessing the kitchen and remove a dented can stored ready for use in dry storage. The findings are: 1. During the initial tour of the facility kitchen on 04/29/13 at approximately 10:10 AM three, four tiered open shelving units in the walk in refrigerator were noted to have a significant accumulation of dust and sticky debris covering the surface area. The dirty matter was easily removed when wiped with a paper towel. Food was stored on all the shelving units. On 05/02/13 at 3:20 PM the shelving was noted in the same condition. The Food Service Director (FSD) was present at the time of the observation and noted the accumulation of dust and debris on the surface area of the shelving. The FSD stated the shelving is usually cleaned by aides on a weekly basis. The FSD had no explanation why the shelving had a significant accumulation of dust and debris. 2. During the initial tour of the facility kitchen on 04/29/13 at 10:10 AM a 1" X 1" hole was noted on the interior bottom seam section in the walk in refrigerator and an approximate 1/4" X 1/4" hole was noted on the interior top seam. From inside the walk in refrigerator outside daylight was visible through these holes. On 05/02/13 at 3:20 PM these holes remained in the walk in refrigerator. The Food Service Director (FSD) was present at the time of the observation and reported she was not aware of the holes in the walls in the walk in refrigerator. The FSD stated it was a concern and should have been reported to the maintenance director for repair. On 05/02/13 at 4:00 PM the maintenance director reported he was not aware of the holes in the stainless steel in the walk in refrigerator. The maintenance director stated the holes should have been repaired to prevent unwanted pests from entering into the walk in refrigerator through the holes. 3. On 05/01/13 from 10:20 AM-12:20 PM observations were made of the exit door located in the kitchen. The interior door was open leaving the wooden screen door to provide a barrier between the outside area and the interior kitchen. The wooden screen door did not fully close; exposing an approximate 1" gap at the bottom of the door. On 05/02/13 at 12:00 PM the wooden screen door was observed with the same 1" gap. On 05/02/13 at 3:30 PM the wooden screen door was noted in the same position, with an approximate 1" gap at the bottom of the door. The Food Service Director (FSD) was present at the time of the observation and reported she did not realize the wooden screen door did not fully close shut. The FSD stated the concern should have been reported to the maintenance director for repair. On 05/02/13 at 4:00 PM the maintenance director reported he was not aware the wooden screen door in the kitchen did not fully close. The maintenance director stated the door could be repaired to prevent unwanted pests from entering the kitchen area. 4. On 05/02 at 3:20 PM a 50 ounce can of cream of potato soup was observed stored ready for use on shelving in dry storage. The top lid of the can of soup had a large 1 1/2" X 2" dent involving the rim. The Food Service Director (FSD) stated dented cans were supposed to be removed from storage and placed in an area designated for can return. The FSD could not explain why the can of cream of potato soup had not been removed when the large rim dent had been noted.

Based on medical record review, facility bowel records and staff interviews the facility failed to monitor for and administer medication for constipation for 1 of 10 residents reviewed for constipation. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #36's most recent Quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was cognitively intact. The MDS indicted Resident #36 was always incontinent of bowel and bladder. Review of bowel records revealed Resident #36 did not had a bowel movement from 04/03/13 through 04/09/13. Review of physician orders [REDACTED]. Review of the Medication Administration Records for the month of April 2012 revealed Resident #36 had not recieved the suppository during the month of April 2012. An interview was conducted on 05/02/13 at 12:16 PM with Nurse #1 who worked with Resident #36. Nurse #1 stated if Resident #36 had something ordered she should have recieved it if she had not had a bowel movement in three days. She stated every morning nurses are given a list with residents names who had not had bowel movements in three days. She did not give an explanation as to why Resident #36 did not recieve the suppository that had been ordered if she had no bowel movement in three days. On 05/02/13 at 1:56 PM the Director of Nursing (DON) was interviewed. The DON stated Resident #36 was given prune juice on 04/10/13 and she had a bowel movement. She further stated Resident #36 should have been given the [MEDICATION NAME] suppository on 04/05/13 when she had not had a bowel movement for three days.

Based on observations, family interviews, staff interviews, and medical record review, the facility failed to provide oral care for 1 of 1 residents (Resident #33) requiring extensive or total assistance for activities of daily living. The findings are: Resident #33 was admitted to the facility on [DATE]. The comprehensive Minimum Data Set ((MDS) dated [DATE], indicated the resident was severely cognitively impaired and required extensive assistance for personal hygiene. The MDS did not indicate the resident resisted care. During an interview on 04/29/13 at 1:00 PM, family member of Resident #33 indicated that Resident #33's dentures were frequently dirty and Resident #33 always kept her dentures very clean when she was able to take care of them herself or when family assisted her to take care of them. According to Dental Record from Periodic Oral Exam conducted on 03/19/13, the dentist recommended the following: "Remove Denture at night and Clean" ("Clean" is underlined several times). Under the recommendations was handwritten "Clean dentures!" During an interview on 05/01/13 at 11:15 AM, the MDS Coordinator revealed that care cards called "Nurse Aide's Information Sheets" had been developed for each resident for nursing assistants to use as a guide to indicate what care was needed for each resident for each ADL area. The MDS Coordinator also reported that the data system used by nursing assistants had grooming grouped together, so if grooming was checked on a given day, that meant all the grooming skills had been completed that day, including oral care, hair care and nail care. The MDS Coordinator said nursing assistants could document when a resident refused care. During an interview on 05/01/13 at 11:45 AM, Nursing Assistant (NA) #1 stated that at least since January of 2013, she had taken Resident #33's denture out, cleaned it, and put it back into her mouth in the morning, evening, after each meal, and as needed, each time she was assigned to work with Resident #33. NA #1 stated Resident #33 was totally dependent on caregivers for oral care and did not resist care at all. During an interview on 05/02/13 at 3:10 PM, Nursing Assistant (NA) #2 stated Resident #33 did not have dentures. NA#2 said she worked with Resident #33 about three days each week and when she worked with Resident #33, she brushed her teeth, gave her mouth wash and performed basic dental care after she ate and after she received a shower. When asked how she knew what type of oral care Resident #33 needed, NA #2 reported she reviewed the care plan and didn't use the care cards. During an observation of NA #2 providing oral care for Resident #33 on 5/02/13 at 3:20 PM, NA#2 was observed approaching Resident #33 with a toothbrush and toothpaste. When Resident #33 opened her mouth, NA #2 told Resident #33 to wait while she got equipment to clean her dentures. When asked why NA #2 had said earlier that Resident #33 had not had dentures, NA #2 stated that she had been confused because most of the time Resident #33 would not let you take out her dentures. NA #2 was observed getting Resident #33's denture cup from her bedside. NA #2 reported the denture cup appeared to be filled with lotion and she went to the nurse's station to get a clean denture cup. When NA #2 returned with a clean denture cup, she washed her hands, put on gloves, and removed Resident #33's upper denture and examined it. The upper denture was coated with food particles and brown solid debris on the top and the bottom. NA #2 reported that the denture should have been cleaned after lunch that day by the nursing assistant assigned to her during first shift. During an interview on 05/02/13 at 3:35 PM, Nurse #1 revealed her expectation of oral care for Resident #33 was that NAs would clean her denture and mouth in the morning, evening, and after meals. When asked what Nurse #1 would expect Resident #33's denture to look like currently, Nurse #1 reported they should be clean with no food or debris on either top or bottom of the denture. When asked what happened when Resident #33 refuseed oral care, Nurse #1 stated the NA must report that to the nurse. Nurse #1 reported she could not remember it ever being reported to her that Resident #33 had refused oral care. Nurse #1 looked up current data for Resident #33 for ADLs and reported that it had been documented that grooming had been provided that day with no refusals. During an interview on 05/02/13 at 3:50 PM, the Director of Nursing (DON) revealed her expectation regarding oral care for residents that it would be provided twice daily and as needed. The DON reported she would expect at that time, a resident's dentures would not be coated with food. When asked about resident refusals, the DON reported that resident refusals of ADL care was documented on the monthly summaries. During a follow up interview on 05/02/13 at 3:55 PM, the DON reported no refusals of care had been reported by NAs working with Resident #33. According to Resident #33's Care Plan, the following was recorded as a Problem/Need: Alteration in ADL function due to unsteady gait and weakness. (Handwritten here: "She is dependent upon staff for bed mobility, transfers, toileting, eating, bathing, and grooming"). According to Resident #33's Care Card/Nurse Aide's Information Sheet, the following was recorded as needs for mouth care: "No Teeth" and "Total Care" (the box for dentures was NOT checked). According to Beystone Health and Rehab's Policy and Procedure for Dental Care, the following was written: "5. The Nursing Assistant will a. Assist the resident with dental care during a.m. and p.m. care, after meals, and as needed. b. Monitor for loose, missing, decayed, or broken teeth and poorly fitting or broken dentures. c. Monitor for any oral problems and notify nurse."

Based on observations, staff interviews and record reviews the facility failed to identify a change in skin conditions and initiate timely treatment for two (2) of five (5) residents with facility acquired pressure sores. (Residents #42 and #33) The findings are: 1. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #42's Minimum (MDS) data set [DATE] revealed he required total assistance with bed mobility, required extensive assistance with transfers and personal hygiene and required staff assistance to move sufficiently to relieve pressure over any one site. The assessment specified that Resident #42 did not have pressure ulcers at this time. Review of Resident #42's current care plan revealed a "Problem/Need", with an onset date of 12/17/10, identified him as being at risk for skin breakdown due to incontinence of bladder and bowel. The care plan's goal specified to monitor for skin breakdown daily. A care plan approach included; to check the resident periodically, offering toileting and change as needed for skin maintenance and hygiene. Further review of the resident's current care plan revealed "Problem" areas, with onset dates of 12/17/10, that addressed his [DIAGNOSES REDACTED]. Approaches included for these care plans areas included; "Special monitoring of skin for redness or circulatory problems", "Monitor and assure position changes", "Check resident frequently for positioning" and "Monitor skin for redness or breakdown." Review of Direct care Activity of Daily Living (ADL) Documentation from 01/12/12 to 01/14/12 revealed that Resident #42 was dependent on staff for bed mobility, transfer and personal hygiene. Review of the resident's nursing notes revealed a note written on 01/14/12 that specified the resident had developed a black area on his left heel which measured 1.3 centimeters (cm) wide by 2 cm long by 0.1 cm deep with no signs and symptoms of infection. On 01/14/12 a physician's orders [REDACTED]. On 02/29/12 at 2:41 PM an observation was made of the Director of Nursing (DON) performing a dressing change to Resident #42's left heel. During this dressing change the resident's left heel pressure ulcer was observed to measure 3 cm wide by 2 cm long by 0.2 cm deep with black eschar. The DON confirmed Resident #42's left heel wound was a pressure ulcer that had become larger since it was initially observed by staff on 01/14/12. On 03/01/12 at 3:50 PM Nursing Assistant (NA) #8, who regularly provided care to Resident #42 during the previous 3 months, was interviewed. NA #8 stated that Resident #42 was dependent on staff for care, including turning and repositioning. NA #8 further stated that staff were to check Resident #42's skin during care and were expected to report any signs of breakdown, including skin redness, to the nurse. On 03/02/12 at 12:50 PM Licensed Nurse #4, who was familiar with Resident #42, was interviewed. LN #4 stated that Resident #42 required extensive and total care during the months of December 2011 and January 2012. The LN stated that she recalled the expectation was that nursing assistants would check Resident #42's skin every two (2) hours during care rounds which included turning and repositioning and during showers and were to report anything that was not normal including the development of reddened areas. LN #4 further stated that since Resident #42 was diabetic the NAs should have monitored his feet closely for problems, but was unsure if the resident's Nursing Assistant Flow record noted any information for special skin monitoring. On 03/02/12 at 1:30 PM an interview was conducted with the facility's Director of Nursing (DON). The DON confirmed that Resident #42's wound on the left heel was a pressure ulcer that was facility acquired. The DON stated that the resident's current Nursing Assistant worksheet, which was in place prior to 01/14/12 did not note any special skin monitoring, but since Resident #42 was a diabetic staff should have monitored his skin and feet closely. The DON stated that she would have expected for staff to have identified and reported any concerns about the resident's left heel ulcer to the nurse before it progressed to a blackened area as first identified by staff on 01/14/12. 2. Resident #33 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #33's physician orders [REDACTED]. Review of Resident #33's most recent Minimum Data Set ((MDS) dated [DATE], revealed the resident had long and short term memory loss and was not able to participate in daily decision making. Further review of the MDS revealed Resident #33 was totally dependent for bed mobility and transfers and had two (2) stage two pressure ulcers. The MDS further revealed the resident was incontinent of bowel. Further review of the medical record revealed Resident #33 was assessed to be at high risk for pressure ulcers. Review of Resident #33's current care plan, updated on 12/26/11, identified him as being at risk for skin breakdown due to daily incontinence of bowel and bladder, having an inability to reposition self without assistance and having an alteration in Activity of Daily Living (ADL) function due to impaired cognition. Approaches within this resident's plan of care included; "Good pericare after each incontinent episode," "Turn and reposition Resident on routine rounds and PRN (as needed)" and "Monitor skin for redness or breakdown." Review of bowel records dated February 2012 revealed the resident averaged between two (2) and eight (8) bowel movements per day. Review of the February 2012 Treatment Administration Records (TAR) revealed Resident #33 had two (2) new facility acquired stage two pressure ulcers noted on 02/01/12, one on the right buttock and one on the left buttock. Review of a physician's note dated 02/17/12 revealed the resident had diarrhea from all the laxatives he was taking which were ordered due to history of bowel obstruction. The physician further noted Resident #33 had developed pressure ulcers on either side of his buttocks due to the diarrhea and immobility. A physician's orders [REDACTED]. On 02/29/12 at 4:00 PM an observation was made of Resident #33's pressure ulcer. A pressure ulcer was noted on each buttock. The pressure ulcers were covered with a clear dressing. The wounds showed no sign or symptoms of infection. On 03/02/12 at 11:40 AM an interview was conducted with Nursing Assistant (NA) #7 who frequently cared for Resident #33. NA #7 reported for the last few months Resident #33 had been having frequent large, liquid stools. He reported on 03/01/12 Resident #33 had at least four (4) very large, liquid stools on his shift (7AM-3PM). On 03/02/12 at 9:10 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #33 had two (2) pressure ulcers that were caused by uncontrollable diarrhea. She further reported the doctor was aware of the diarrhea but she did not know if he was aware of the frequency of the loose stools. The interview further revealed the resident had a pressure ulcer on his coccyx that was discovered on 10/02/11 which had healed but reopened 02/01/12 due to the uncontrollable diarrhea. The DON was not able to produce documentation regarding when the original pressure ulcer on his coccyx healed. On 03/02/12 at 12:00 PM, an interview was conducted with Resident #33's physician. The physician reported he knew the resident was having diarrhea but was unaware of the frequency of the diarrhea. The physician stated that had he been made aware of the frequency of Resident #33's diarrhea he probably would have decreased the resident's laxative medication sooner than 02/17/12.

Based on medical record review and staff interviews the facility failed monitor use of laxatives for one (1) of ten (10) sampled residents reviewed for unnecessary medications. (Resident #33) The findings are: Resident #33 was most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #33's physician orders [REDACTED]. Review of Resident #33's most recent Minimum Data Set ((MDS) dated [DATE], revealed the resident had long and short term memory loss and was not able to participate in daily decision making. Further review of the MDS revealed Resident #33 was totally dependent for bed mobility and transfers and had two (2) stage two pressure ulcers. The MDS further revealed the resident was incontinent of bowel. Further review of the medical record revealed Resident #33 was assessed to be at high risk for pressure ulcers. Review of a physician note dated 02/17/12 revealed the resident had diarrhea from all the laxatives he was taking which were ordered due to history of bowel obstruction. The physician further noted Resident #33 had developed pressure ulcers on either side of his buttocks due to the diarrhea and immobility. Review of the December 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The January 2012 MAR indicated [REDACTED]. The February 2012 MAR indicated [REDACTED]. A physician order [REDACTED]. Review of bowel records dated February 2012 revealed the resident averaged between two (2) and eight (8) bowel movements per day. On 03/01/12 at 9:28 AM an interview was done with the facility's consultant pharmacist. The pharmacist reported that he was unaware that Resident #33 had experienced frequent diarrhea. He stated these drugs ([MEDICATION NAME] and Senna) should be held if the resident had frequent diarrhea. He also reported that he should have been informed by staff if the diarrhea had become a problem so he could have made recommendations to the physician regarding the resident's medications and laxative use. On 03/02/12 at 10:04 AM an interview was conducted with Licensed Nurse (LN) #4. The nurse stated that she notified Resident #33's medical doctor about the resident's frequent diarrhea. LN #4 stated that she told the doctor the resident had been having three to four loose stools per day not per shift. She also reported the doctor discontinued the resident's [MEDICATION NAME] twice daily. LN #4 stated that she had not reviewed the resident's bowel records since the medication was discontinued. On 03/02/12 at 9:10AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #33 had two (2) pressure ulcers that were caused by uncontrollable diarrhea. She further reported the doctor was aware of the diarrhea but she did not know if the he was aware of the frequency of loose stools the resident experienced. The interview further revealed the resident had a pressure ulcer on his coccyx that was discovered on 10/02/11 which had healed but reopened 02/01/12 due to the resident's uncontrollable diarrhea. On 03/02/12 at 12:00 PM, an interview was conducted with Resident #33's Medical Doctor. The Doctor reported that he was aware the resident was having diarrhea, but was unaware of the frequency of the diarrhea. He further stated had staff made him aware of the frequency of Resident #33's diarrhea he probably would have decreased the resident's laxative medication sooner than 02/17/12.