Every finding on record at The Waters of Roan Highlands,Llc

Based on medical record review and interview the facility failed to conduct an accurate assessment for 1 resident (Resident #58) for 28 residents reviewed. The findings included: Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #58's had admission [DIAGNOSES REDACTED]. Interview with Registered Nurse (RN) #1 on 4/26/17 at 9:06 AM at the 100/200 hall nurse's station, confirmed Resident #58 had not had [DIAGNOSES REDACTED]. Interview with Assistant Director of Nursing on 4/26/17 at 9:45 AM, in the conference room confirmed the facility failed to provide an accurate assessment for Resident #58.

Based on review of facility policy, observation, and interview, the facility failed to properly store medications for 3 of 9 storage areas observed. The findings included: Review of the facility policy, Storage of Drugs, dated ,[DATE], revealed .Drugs requiring refrigeration shall be kept in the refrigerator . Review of facility policy, Inspection of Drug Storage Areas, dated ,[DATE], revealed .Pharmacy Performance Improvement will check the medication cart and drug storage areas quarterly. The inspection shall include .(c) that there are no outdated medications stocked . Observation with Licensed Practical Nurse (LPN) #1 on [DATE] at 8:15 AM, on the 200 hallway, revealed the acidophilus was stored on the medication cart. Interview with LPN #1 on [DATE] at 8:15 AM, on the 200 hallway, confirmed the storage recommendations on the medication label for acidophilus were .refrigerate after opening . Continued interview confirmed the medication had not been refrigerated. Interview with the Director of Nurses on [DATE] at 2:19:18 PM, at Station II Nurses Station, confirmed the facility had failed to store the medication properly. Observation of the emergency cart with LPN #1 on [DATE] at 9:30 AM, on the 200 hallway, revealed (2) 10 cc (cubic centimeter) saline flushes with an expiration date of ,[DATE] and ,[DATE]. Further observation revealed (1) 1000 cc bag of Normal Saline with an expiration date of [DATE]. Interview with LPN #1 on [DATE] at 9:35 AM, in the 200 Hallway nurse's station, confirmed the saline flushes and the bag of Normal Saline were expired and were avaliable for use. Observation of the emergency cart with the Assistant Director of Nursing (ADON) on [DATE] at 9:50 AM, on the 400 hallway, revealed (1) 10 cc saline flush with an expiration date of ,[DATE]. Interview with the ADON on [DATE] at 9:55 AM, in the 400 hallway nurse's station, confirmed the saline flush was expired and was avaliable for use.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to implement the abuse policy for two residents (#7, #32) of twenty residents reviewed for abuse. The findings included: Review of facility policy, Abuse, revised September 2001 revealed, "...The administrator will notify the following of any/all such reports...The appropriate State Health Department office or Licensing and Regulation office in accordance with specific state...time frames...Results of the investigation will be reported within five (5) working days in accordance with State law to the State Survey and Certification Agency..." Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated January 20, 2015, at 8:00 a.m., revealed, "...observed resident standing in front of roommate...Roommate crying et (and) stated '(Resident #7) slapped me.' Resident (#7) states '(Resident #32) stole from me et (and) I've had enough.' Resident separated immediately..." Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview of Mental Status score of 2, indicating severe cognitive impairment. Resident #32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated January 20, 2015, revealed "...resident (#32)slapped by another resident (#7)..." Continued medical record review of a Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview of Mental Status score of 15, indicating cognitively intact. Interview with resident #32 on April 14, 2015, at 11:18 a.m., in the resident's room revealed resident #7 thought the resident was taking something from a bedroom dresser and slapped the resident. Continued interview with resident #32 revealed the bedroom dresser was actually the residents and not resident #7's. Interview with the Administrator on April 14, 2015, at 9:50 a.m., in the conference room revealed the facility did not report the allegations of abuse and confirmed the facility failed to implement the abuse policy for Residents #7 and #32.

Based on medical record review and interview, the facility failed to communicate with the readmission screening and resident review (PASRR) program to obtain a PASRR report (an individualized list of special services recommended after state assessment for diagnosed mentally ill or mentally retarded individuals) for one resident (#98) of twenty-three residents reviewed in stage 2. The findings included: Resident #98 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Certificate of Need for Emergency Involuntary admitted d March 5, 2015, revealed "Pt (patient) presents w (with) paranoid delusions, bizarre behaviors, poor insight, judgment, impulse control..." Interview with the Director of Nursing (DON), on April 14, 2015, at 10:30 a.m., in the DON's office, confirmed the facility failed to apply for a PASSR report.

Based on observation, facility policy review, and interview, the facility failed to ensure staff performed hand hygiene for one of three nurses observed during medication pass. The findings included: Observation during medication pass on February 20, 2014, at 8:05 a.m., revealed Licensed Practical Nurse (LPN) #1 donned gloves at the medication cart and entered the resident's bathroom to retrieve a paper towel. Continued observation revealed LPN #1 returned to the medication cart, removed the gloves, donned another pair of gloves, and proceeded to cut a scored tablet to be administered to the resident. Review of the facility's policy Hand Washing revealed, "...Note: The use of gloves does not replace hand washing. Once gloves are removed, proper hand washing should be performed..." Interview on February 20, 2014, at 8:10 a.m., with LPN #1, confirmed the hands were to be disinfected after removing the gloves.

Based on medical record review, observation, facility policy review, and interview, the facility failed to develop a comprehensive care plan for three residents (#47, #3, and #9) of thirty-one residents reviewed. The findings included: Resident #47 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent, required two person assist for activities of daily living, and had functional limitation in range of motion of the lower extremities with impairment on both sides (contractures). Review of the resident's revised care plan dated January 24, 2014, revealed the resident's positioning needs for the contractures had not been addressed. Observation of the resident on February 19, 2014, at 9:46 a.m., revealed the resident's bilateral lower extremities (legs) were in a flexed position. Continued observation revealed no positioning devices were in place. Interview with the Director of Nursing on February 20, 2014, at 3:00 p.m., in the activities room, confirmed care for the resident's contractures had not been addressed in the care plan. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Pain Evaluation dated December 27, 2013, revealed, "...Hx (history) of pain able to verbalize needs...lengthy hx (history) of pain per resd (resident) hx hip/back/stomach..." Medical record review revealed the resident was initially admitted with a physician's orders [REDACTED]. Continued review revealed the [MEDICATION NAME] (over the counter [MEDICATION NAME]) was discontinued on December 31, 2013, and [MEDICATION NAME] (narcotic [MEDICATION NAME]) 5/325 mg (milligram) had been prescribed. Continued review revealed, when the resident returned from the hospital on January 21, 2014, following removal of a kidney stone, the resident continued on the [MEDICATION NAME] 5/325 mg three times a day for pain management. Review of the facility's policy, Pain Management, revealed, "...4. Include the resident and family in the assessment of pain, potential interventions, and goals for the development of the plan of care. 5. Identify the potential cause(s) for the resident in pain. 6. Determine the appropriate interventions to manage the resident's pain and any side effects..." Interview with the Licensed Practical Nurse/Assessment Coordinator, at station 2, on February 20, 2014, at 9:50 a.m., and review of the resident's care plan, confirmed the resident's care plan did not include interventions for pain management. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Wound Tracking Assessment tool, dated November 17, 2013, revealed a Stage III pressure ulcer of the right heel was identified with "Description of the Peri-Wound" (area immediately surrounding the ulcer) as "...dry scaly." Observation of the Stage III pressure ulcer, with the wound care nurse, on February 20, 2014, at 10:00 a.m., in the resident's room, revealed the resident had dry scaly skin of the right foot. Interview with the resident, at the time of the observation, revealed a longstanding problem with "dry cracking skin." Interview continued and the resident stated "in the past" a dermatologist had been seen for the chronic skin problem, but not recently. Further interview revealed the right heel had become painful and "told the nurse about it" on the same day the ulcer was identified, November 17, 2014. Interview with the wound care nurse, at the time of the observation, confirmed the resident had a chronic dry skin problem. Medical record review of the Treatment Record and the current Plan of Care revealed the problem of the dry and cracking skin of the resident's right foot was not addressed. Interview with the Assistant Director of Nursing on February 20, 2014, at 10:30 a.m., in the activities room, confirmed the resident had Chronic Venous Stasis [MEDICAL CONDITION], a chronic skin condition, and the problem had not been addressed in the plan of care. .

Based on medical record review, observation, and interview, the facility failed to prevent a significant medication error for one (#5) of fifteen residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the nursing notes dated May 3, 2011, at 7:00 a.m., revealed "Resident inadvertently received rm (room) mates medication. MD (Medical Doctor) immediately notified. allergies [REDACTED]. Resident up in w/c (wheelchair) talkative & alert. Resident aware of receiving medications. (no) c/o (complaints) voiced. MD stated to monitor resident." Medical record review of a nursing note dated May 3, 2011, at 7:15 a.m., revealed "R/P (responsible party) @ facility to transport resident to appt. (appointment) @...R/P informed of medications adm. (administered). R/P request to take to appt. stated 'I'm sure...will be fine.' MD notified & stated to continue with appt & inform MD @ appt. B/P 100/60 HR (heart rate) 38 @ this time. Resident Up in w/c alert & oriented. Color pink, (no) c/o discomfort." Medical record review of a nursing note dated May 3, 2011, at 7:30 a.m., revealed "B/P 90/60, HR 35, MD notified of vital signs & order received to send to...ER (emergency room ) for eval (evaluation)...R/P here & aware. Resident laughing & stated 'My heart rate is always like this, I'm fine.' Color pink, (no) discomfort voiced..." Medical record review of a nursing note dated May 3, 2011, at 12:00 p.m., revealed the resident was admitted to the hospital. Review of documentation provided by the facility revealed the following: "(Licensed Practical Nurse, LPN #1) stated the following concerning the med (medication) error on 5/3/11 at 7am. (LPN #1) stated...was preparing to give (resident #10)...medications and was putting them in the med cup when...heard a call light across the hall going off so...put (resident #10's) medication which was now in a med cup into the med cart drawer and locked it up. (LPN #1) then went across the hall and assisted the other resident to the bathroom. When (LPN #1) finished with the resident in the restroom, (LPN #1) went back to the med cart to get the meds. (LPN #1) now had (resident #5) on...mind because (LPN #1) knew (resident #5) was going to be leaving at around 7am to go to a podiatry appointment and needed...meds quickly. (LPN #1) took the meds out of the drawer and went to the resident's room and administered them to (resident #5). These were the meds that (LPN #1) had prepared for (resident #10). (LPN #1) then went and checked off the MAR (Medication Administration Record) that...had given (resident #5's) meds. (LPN #1) went to the nurses' desk and the nurse coming on day shift commented that they needed to quickly give (resident #5's) meds since he was leaving for an appointment. (LPN #1) stated that...thought...already had and then the other nurse stated that they were still in the med cart. They went to the resident's room and (resident #5 told them that (LPN #1) had already given meds...(LPN #1) then went to the med cart and realized what...had done. (LPN #1) immediately checked to see if the resident had any allergies [REDACTED]. (LPN #1) called the DON (Director of Nursing) who instructed (LPN #1) to immediately contact the physician." Continued review of documentation provided by the facility revealed resident #5 received the following medications in error on May 3, 2011: [MEDICATION NAME] (antidepressant) 10 mg (milligrams); [MEDICATION NAME] (stool softener) 100 mg; [MEDICATION NAME] (antihypertensive medication with a possible side effect of [MEDICAL CONDITION]) 3.125 mg; [MEDICATION NAME] (anytihypertensive) 0.2 mg; Folic acid (vitamin) 1 mg; Klor-con (potassium) 10 meq (milliequivalent); and [MEDICATION NAME] (antihypertensive) 20 mg. Medical record review of a hospital History and Physical dated May 3, 2011, revealed "...is brought to ER as...got wrong medication [MEDICATION NAME] 3.125 and is bradycardic. Initially on evaluation...denies any complaints...denies any chest pain, any sob (shortness of breath)...hr (heart rate) is ranging from 30-35 and...was on IV (intravenous) fluids. But later on...heart rate dropped to < (less than) 30 and glucogon was given 3 times...has the history of [MEDICAL CONDITION] for years and...has been evaluated in past for pacemaker and...was not considered a candidte for pacemaker bec (because) of no symptoms and high risk...Assessment/Plan 1. [MEDICAL CONDITION] in a pt (patient) with previous h/o (history of) chb (complete heart block), who received [MEDICATION NAME] (accidently) early morning, now heart rate running in 30s...received 3 doses of [MEDICATION NAME] in ER and a dose of [MEDICATION NAME] asymptomatic and...B.P is 96/40..." Medical record review of a hospital Discharge Summary dated May 5, 2011, revealed "...Discharge Diagnosis 1. [MEDICAL CONDITION]-most likely from [MEDICATION NAME] 2. [MEDICAL CONDITION] Fibrillation...condition on discharge: stable..." Medical record review of a nursing note dated May 5, 2011, at 11:00 p.m., revealed the resident returned to the facility, was alert and talkative, with a heart rate of thirty-six. Observation on June 27, 2011, at 1:15 p.m., revealed the resident sitting in a wheelchair, in the resident's room, eating lunch. Telephone interview on June 27, 2011, at 1:30 p.m., with LPN #1 confirmed resident #5 received resident #10's medications in error on May 3, 2011, at 7:00 a.m. Interview on June 28, 2011, at 8:30 a.m., with the Director of Nursing (DON), in the conference room, revealed after LPN #1 administered resident #10's medications in error to resident #5, on May 3, 2011, LPN #1 was re-inserviced on medication administration, and an observation of a medication pass was conducted with LPN #1 on May 4, 2011. Continued interview revealed 100% of the facility's medication nurses were re-inserviced with observations of medication administration.

Based on medical record review, review of facility policy, observation, and interview, the facility failed to implement interventions timely for a pressure ulcer for one (#13) of fifteen residents reviewed. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Braden Scale for Predicting Pressure Ulcer Risk dated April 12, 2011, revealed the resident was at very high risk. Medical record review of a laboratory report dated May 12, 2011 revealed "...Total Protein 6.8 reference range 6.4-[MEDICATION NAME] 3.3 reference range 3.2-4.6..." Medical record review of the interdisciplinary progress note (dietary note) dated May 20, 2011, revealed "...wt (weight) review. Wt. 186.7...wt increase noted...100% intake...no skin breakdown noted..." Medical record review of the interdisciplinary progress note dated May 24, 2011, revealed "...Two new stage II's discovered to right foot. 4th digit 1x1 5th digit 1x1...wound beds are red (with) 20% maceration. Appears to have began as a fluid filled blister that ruptured after rubbing against each other. 4 (plus) [MEDICAL CONDITION] noted to (right) leg (and) foot..." Medical record review of a physician's orders [REDACTED]. Apply...bandaid. Use [MEDICATION NAME] to separate (right) 4th (and) 5th digit...MVI (multivitamin) q (every) am (morning)..." Medical record review of the Medication Record dated June 1, 2011, through June 30, 2011, revealed no documentation the resident received the MVI from June 1, 2011, through June 28, 2011. Medical record review of the wound evaluation flow sheet dated June 28, 2011, revealed "...(right) 4th digit (1x1) stage II...(right) 5th digit (1.6x1) stage IV..." Medical record review of the Nutritional Progress Notes dated June 28, 2011, revealed "...Res (resident) (with) new skin breakdown...Rec (recommend) Prostat 101 30 ml (milliliters) BID (twice a day) to promote wound healing..." Review of facility policy, Wound Prevention and Management Program, revealed "...Maximize nutritional status...Consult nutritionist for all residents at risk..." Observation of the pressure ulcers with the wound care nurse on June 29, 2011, at 7:40 a.m., revealed the pressure ulcer on the right 4th digit 1 cm x 1 cm with no drainage, 5th digit 1.6 cm x 1 cm with no drainage, scabbed area in the center as described by the wound care nurse. Interview on June 28, 2011, at 2:45 p.m., with the Director of Nursing, in the conference room, confirmed no documentation the resident received the MVI from June 1, 2011, through June 28, 2011. Interview on June 29, 2011, at 9:15 a.m., with the Director of Nursing, in the conference room, confirmed the resident was not evaluated by the Registered Dietician until June 28, 2011, (four weeks after the development of the pressure ulcers). Interview on June 29, 2011, at 10:55 a.m., with the resident's physician, confirmed the delay in the nutritional consult and not receiving the MVI did not affect the healing of the pressure ulcers on the toes.

Based on medical record review, observation, facility policy review, and interview, the facility failed to provide appropriate perineal care for one (#4) of fifteen residents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident required extensive assistance with transfers, hygiene, and bathing. Observation on June 29, 2011, at 9:50 a.m., revealed the resident lying on the bed. Continued observation revealed Licensed Practical Nurse (LPN) #2 removed a bedpan from under the resident, containing urine. Continued observation revealed LPN #1 used a washcloth to cleanse the resident's buttocks, then positioned the resident on the back. Continued observation revealed LPN #2 used a second washcloth and wiped from the rectal area towards the vaginal area (back to front) three times, and placed the sheet over the resident and exited the room. Review of the facility's policy Perineal Care revealed "...Separate the labia with one hand and wash with the other, using gentle down [MEDICAL CONDITION] from the front to the back of the perineum..." Interview on June 29, 2011, at 9:55 a.m., with LPN #2, in the hallway, confirmed the resident's perineal area was cleansed back to front, and confirmed the facility's policy was not followed.

Based on medical record review, observation, policy review, and interview, the facility failed to maintain infection control for one resident (#8) of fifteen residents reviewed. The findings included: Resident #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was non-ambulatory, incontinent of bowel and bladder, and required extensive assistance for personal hygiene. Observation on June 27, 2011, at 2:50 p.m., in the resident's room, revealed two CNAs (certified nursing assistant) providing incontinent care. Continued observation revealed the resident had been incontinent of bowel; both CNAs wore gloves. Further observation revealed CNA #1 had cleaned the buttocks area, without changing gloves or washing hands opened the bedside table drawer, removed protective cream from a plastic bag, applied the cream to the buttocks area, replaced the cream in the plastic bag and placed in the drawer, removed gloves and washed hands. Review of the facility policy Infection Control revealed "...maintain a sanitary environment. All employees shall utilize proper hand washing for each...9. Before and after incontinence care ..." Interview with CNA #1 on June 27, 2011, at 2:55 p.m., in the hallway, confirmed had not removed gloves or disinfected hands after providing incontinent care. Interview with Director of Nursing (DON) on June 29, 2011, at 8:35 a.m., in the DON's office, confirmed gloves are to be removed and hands washed after providing incontinent care. .

Based on medical record review and interview the facility failed to accurately document the medical record for one (#5) of fifteen residents reviewed. The findings included: Medical record review of resident #5's nursing notes dated May 3, 2011, at 7:00 a.m., revealed "Resident inadvertently received rm (room) mates medication. MD (Medical Doctor) immediately notified. allergies [REDACTED]. Resident up in w/c (wheelchair) talkative & alert. Resident aware of receiving medications. (no) c/o (complaints) voiced. MD stated to monitor resident." Review of documentation provided by the facility revealed resident #5 received the following medications (medications ordered for resident #10) in error, on May 3, 2011: [MEDICATION NAME] (antidepressant) 10 mg (milligrams); [MEDICATION NAME] (stool softener) 100 mg; [MEDICATION NAME] (antihypertensive medication with a possible side effect of [MEDICAL CONDITION]) 3.125 mg; [MEDICATION NAME] (anytihypertensive) 0.2 mg; Folic acid (vitamin) 1 mg; Klor-con (potassium) 10 meq (milliequivalent); and [MEDICATION NAME] (antihypertensive) 20 mg. Medical record review of the May 2011, Medication Record revealed Licensed Practical Nurse (LPN) #1 initialed as having administered the following medications (medications ordered for resident #5) to resident #5 on May 3, 2011: [MEDICATION NAME] (antihypertensive) 5mg (milligrams); [MEDICATION NAME] (antihypertensive) 4 mg; [MEDICATION NAME] (anticonvulsant) 200 mg; Levothyroxin ([MEDICAL CONDITION] hormone replacement) 50 mcg (micrograms); Mag Oxide (antacid) 400 mg; and [MEDICATION NAME] (antiulcer) 20 mg. Interview on June 28, 2011, at 8:20 a.m., with LPN #1, in the dining room, revealed LPN #1 did not administer resident #5's ordered medications on May 3, 2011, after administering resident #10's medications to resident #5 in error. Continued interview with LPN #1 confirmed resident #5's Medication Record for May 3, 2011, indicated LPN #1 had administered resident #5's ordered medications and confirmed the medical record was not accurate.

Based on medical record review, and interview, the facility failed to report alleged instances of abuse for one (#3) of five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's current care plan dated December 14, 2008, revealed the resident had behaviors of being loud and disruptive. Interview with Certified Nurse Assistant (CNA) #6 per telephone on January 23, 2009, at 12:55 p.m., revealed this CNA witnessed CNA #2 push resident #3's nose and stuck the finger in the resident's ear "to agitate" the resident (date unknown). Interview also revealed CNA #6 observed CNA #1 take pictures of resident #3 without the resident's consent. Interview also revealed CNA #6 did not report the allegations to supervisory staff, and was aware all allegations of abuse of a resident are to be reported immediately. Interview with CNA #5 per telephone on January 23, 2009, at 10:40 a.m., revealed this CNA witnessed CNA #1, #2, and #3, on multiple occasions (dates unknown) "verbally tease" resident #3 to "agitate" the resident. Interview also revealed CNA #5 did not report the allegations to supervisory staff, and was aware all allegations of abuse of a resident are to be reported immediately. Interview with CNA #4 on January 23, 2009, at 4:18 p.m., and 7:45 p.m., revealed this CNA witnessed CNA #2 (date unknown) "verbally tease" resident #3 and touch the resident's nose knowing the resident does not like that. Interview also revealed CNA #4 did not report allegations to supervisory staff, and was aware all allegations of abuse of a resident are to be reported immediately. Review of the facility's Abuse protocol revealed " ...Staff who witness abuse of any type are to immediately stop the abuse and to immediately report what they observed to their supervisor or person in charge ..." Interview on January 22, 2009, at 1:10 p.m., with the administrator and the director of nursing, in the administrator's office revealed no allegations of abuse were reported to supervisory staff. Interview with the administrator and the director of nursing per telephone on February 4, 2009, 1:20 p.m., confirmed staff did not report incidents to supervisors as per their policy. C/O #