Every finding on record at Thornton Manor Nursing and Care Center

Based on record review, staff interviews, and policy review the facility failed to ensure the Infection Preventionist (IP) had sufficient time to perform the duties of the infection control program, when the IP worked 1 to 2 hours a week on average in the IP role while working full time as a floor nurse. During April 2026, the facility's infection logs showed that 7 of 28 residents were diagnosed with a Urinary Tract Infection (UTI) (Resident #11, #13, #35, #18, #20, #23, and #26), and the IP had not yet completed staff training or audits to address the UTI rate. The facility reported a census of 29 residents. Findings include: During an interview on 05/06/2026 at 11:53 AM, Staff A, the Licensed Practical Nurse (LPN) and Infection Preventionist (IP), stated she has held the IP position for two and a half months. Staff A confirmed she works as the IP for one to two hours a week, totaling four to six hours a month, while working full-time as a floor nurse. She reviews infection reports every other week unless she notices a resident is on an antibiotic. Staff A reported that the facility's April 2026 infection log identified 7 out of 28 residents with Urinary Tract Infections (UTIs), specifically Residents #11, #13, #35, #18, #20, #23, and #26. Staff A confirmed she has not completed any hands-on audits or training with staff since identifying the April 2026 UTI infection rate of 25%. She also stated the facility has no set toileting programs for residents. At 12:21 PM, Staff A stated she has not yet started audits or programs to address the April UTIs but might begin them now.The facility's Antibiotic Stewardship program, dated 10/5/2023, required the Infection Preventionist (IP) to review infection data every three months during Quality Assessment and Assurance (QAPI) meetings. The policy stated the IP must work with the Pharmacist, Medical Director, and leadership team to look for patterns in antibiotic use. The team must then create an action plan to improve resident health outcomes based on the trends of the data.The facility's General Infection Prevention and Control Surveillance policy, dated 10/5/2023, failed to provide specific instructions on when the Infection Preventionist must perform audits or staff training. While the policy required the review of infection data, it did not set a schedule or define triggers to complete audits and train after the facility identified a high number of resident infections. Review of the facility's Assessment Tool, last updated 04/06/2026, showed that the facility identified residents were at risk for infections and needed care for infection prevention and containment. The Assessment Tool identified the need for Infection Control and Prevention included as part of the Administration staff category.

Based on observation, staff interviews, and policy review the facility failed to follow standard precautions and safe handling/disposal of sharps during blood glucose testing by placing used lancets into personal scrub pocket instead of a designated sharps container and failed to disinfect the blood glucose meter and its storage container between uses for 1 of 1 resident reviewed for blood glucose checks (Resident #23). The facility reported a census of 29 residents.Findings include: On 5/6/26 at 11:12 AM Staff A, Licensed Practical Nurse (LPN), performed a blood glucose (sugar) check for Resident #23. She used a community container of supplies including lancets (small needles), alcohol wipes, cotton pads, and a blood sugar machine. She placed these items directly onto Resident #23's personal papers. After she performed a fingerstick and wiped the blood with a cotton pad, she placed the used cotton pad on the inside lid of the plastic container. When the first attempt failed, she placed the used lancet into her right scrub pocket. She repeated the process and got a reading of 403. She placed the second used lancet in her right scrub pocket and put the blood sugar machine back into the community container without cleaning it. Staff A then returned to the medication cart and placed the contaminated container on top of it without cleaning.On 5/6/26 at 12:24 PM Staff A admitted she placed the used lancets into her right scrub pocket and didn't clean the blood glucose machine or the community container. She confirmed she knew the infection control risks and said she'd immediately discard all contaminated supplies.The Review of Competency for Finger Stick Blood Glucose procedure dated May 2021 directed staff of a 16 step process for completing a blood glucose check. Step 1 instructed staff to gather supplies, and did not provide additional guidance as to what supplies specifically were required. Step 10 directed staff to place a strip into the meter and pierce the skin with a disposable lancet, then place the used lancet in a sharps container (puncture-proof box for needles). Step 12 instructed staff to remove the strip at the completion of the test, turn the meter off, and place the used strip into a sharps container. Step 15 directed staff to cleanse equipment with a disinfecting wipe . or other approved agent and put it away.

Based on observation, policy review, document review, consulting dietician and staff interviews, the facility failed to serve approved menu substitutions of similar nutritional content. The facility identified a census of 31 residents. Findings include: On 3/31/25 (Monday) the Certified Dietary Manager (CDM) provided a copy of the Week 4 Tuesday Menu which included to provide a Mandarin spinach salad at the noon meal. The Week 4 Tuesday Noon menu lacked documentation of the substitution and reason why the substitution was needed on the actual menu. The CDM reported they had tried to serve the Mandarin spinach salad a few times and it didn't go over well. She stated she would be substituting a seven-layer salad in its place. During an interview on 4/01/25 at 11:09 AM the CDM reported the seven-layer salad contained cucumbers, bacon, cheese, peas, eggs, lettuce, and a sugar mayonnaise dressing. Observation on 4/01/25 from 11:20 AM to 11:50 AM revealed the CDM served 19 resident the seven-layer salad. During an interview on 4/01/25 at 2:17 PM the Consulting Dietician reported she had not approved any substitutions for the Week Four Tuesday Noon Menu. She stated the seven-layer salad would not be an appropriate substitution for the Mandarin spinach salad. The menu substitution would need to be a similar option with similar nutritional content. The seven-layer salad and the Mandarin spinach salad were not the same nutritional content. On 4/02/25 at approximately 8:35 AM the CDM provided the Seven-Layer Lettuce Salad recipe which included: a. 4 cups chopped celery b. 1 cup onion c. 6 cups frozen peas d. 4 chopped cucumbers e. 6 cups chopped bacon f. 2 dozen chopped eggs g. 4 cups shredded cheese h. 5 cups salad dressing i. 1/2 sugar The Seven-Layer Lettuce Salad recipe contained no nutrient analysis (calories, carbohydrate, protein, fat, sodium, or micronutrient breakdown). On 4/02/25 at 8:35 AM the CDM provided a small tablet of hand-written menu substitutions. The tablet documented on 4/1/25 the seven-layer salad in place of the spinach salad. The untitled tablet noted ten hand written substitution entries from 1/23 (no year) to April 1 (no year). None of the substitution entries had been signed off as approved by the Dietician. On 4/02/25 at 9:05 AM the CDM reported they had just changed Dietician's two months ago and the prior Dietician did not require her to notify her of substitutions and didn't require anything to be sign off on menu substitutions. On 4/02/25 at 9:00 AM the CDM provided the following: a. Mandarin Spinach Salad with Poppy seed dressing recipe (based on 36 servings): 1. Fresh spinach - 2 pounds, plus 4 ounces. 2. Slivered, toasted almonds - 2 1/4 cups 3. Mandarin oranges, drained - 2 quarts, plus 1 cup 4. Poppyseed dressing, prepared - 2 1/4 cups dressing. The Mandarin Spinach Salad Analysis documented each serving provided 143.8 calories, 17.74 carbohydrates, 2.52 grams of protein, 8.14 grams of fat, 14.76 grams sugar, 266.13 milligrams of potassium, 1.29 MG iron, 59.48 MG calcium, 1.92 G fiber and 85.92 milligrams of sodium. b. Creamy Lettuce Salad (based on 36 servings)(the CDM stated it was a similar recipe with the seven-layer salad having the addition of cucumbers and bacon). 1. Lettuce salad - 3 pounds, plus 9 1/2 ounces 2. Fresh tomato, chopped - 4 1/3 each 3. Fresh onion, chopped - 3/4 cup 4. Diced hard cooked eggs - 3 cups 5. Salad dressing - 3 1/4 cups 6. Milk - 5 fluid ounces, plus 1 tablespoon, plus 1 1/2 teaspoons 7. [NAME] sugar - 1/2 cup 8. Cider or white vinegar - 1/2 cup The Creamy Lettuce Salad Analysis documented each serving provided 70.04 calories, 9.83 grams of carbohydrate, 2.84 grams of fat, 7.21 grams of sugar, 113.48 MG potassium, 0.3 MG iron, 19.74 MG calcium, 0.78 G fiber and 215.33 milligrams of sodium. During an interview on 4/02/25 at 9:10 AM the CDM affirmed the kitchen did not have a system in place regarding substitutions and again stated the prior Dietician did not require her to document or have menu substitutions approved. She did not have an approved menu substitution exchange in the kitchen. The Substitution Policy provided by the facility dated 2001 directed the Food Services Manager (CDM), in conjunction with the Clinical Dietician, may make food substitutions as appropriate and necessary. The Food Services Manager would maintain an exchange list identifying the seven exchanges of food groups. When in doubt about an appropriate substitution, the Food Services Manager would consult the Dietician prior to making the substitution. All Substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitution.

Based on observation, policy review, and staff interview the facility failed to prevent bare hands from contacting serving utensils and failed to recognize proper cold food temperatures and served 6 of 19 residents a seven-layer salad that had temperatures from 45.3 to 47.9 degrees Fahrenheit prior to serving. The facility identified a census of 31 residents. Findings include: On 4/01/25 at 10:26 AM the following kitchen observations were made: a. At 10:26 AM the Surveyor entered the kitchen and observed a large stainless steel bowl of seven-layer salad sitting on top of a cart without a cold container or ice under the bowl to keep cold. b. At 10:32 AM the Certified Dietary Manager (CDM) pureed three servings of the seven-layer salad and placed one serving in a nosey cup for Resident #4 and another serving in a small bowl for Resident #24, then placed the nosey cup and the bowl inside a cold container that sat on top the cart. c. At 10:52 AM the CDM prepared seven mechanical soft servings of the seven-layer salad and placed the mixture in a large measuring cup, placing the measuring cup inside the cold container on the cart. d. At 11:02 AM the CDM completed temperature checks on the seven-layer salad which remained sitting out on the cart. Resident #4's nosey cup of pureed seven-layer salad temped at 47.9 degrees Fahrenheit (F); Resident #24 bowl of seven-layer salad did not have a temperature check completed; the measuring cup of mechanical soft seven-layer temped at 45.3 degrees. The CDM stated at that time she planned to serve the seven-layer salad and did not place any of the seven-layer salad in the refrigerator or freezer to cool. At 11:09 AM the CDM verbalized the seven-layer salad contained cucumbers, bacon, cheese, peas, boiled eggs, lettuce, and a sugar-mayonnaise dressing. e. Observation on 4/01/25 at 11:11 AM the Certified Dietary Manager (CDM) picked up tongs from the utensil bin by the bottom of the tongs with her bare hands after touching the menu and moving to the serving table and placed in the apricot chicken. f. At 11:20 AM the CDM started plating up food for the residents. The CDM served out four servings of the mechanical soft seven-layer salad to residents #8, #15, #18, and #30. g. At 11:35 AM the CDM added a small amount of water to Resident #4 nosey cup of seven-layer salad to improve the consistency and served out the nosey cup of seven-layer salad. h. At 11:37 AM the CDM served out the bowl of seven-layer salad to Resident #24. i. Ten residents were served the apricot chicken with the soiled tongs. The CDM finished meal service at 11:55 AM and completed the following post meal temperatures: 1. Milk - 41.8 degrees 2. Mechanical soft seven-layer salad - 44 degrees. 3. Pureed salad - served out as above. On 4/01/25 at 12:01 PM the CDM voiced they use the Serv Safe training as their guide for safe food temperatures. The kitchen did not have a system in place to obtain the temperature of cold food items to ensure those food items were below 41 degrees and safe to serve prior to or during meal service. On 4/01/25 at 12:07 PM Staff M, Dietary Assistant/Cook reported cold food items should be kept below 40 degrees. She voiced the only cold food item they record a temperature for is milk. They do not do temperature checks on any cold salads and document the temperatures. On 4/01/25 at 12:08 PM the CDM reported they would implement checking cold food items and documenting the temperatures to assure food safety. She voiced she didn't realize she had touched the tongs by the end used to serve out the apricot chicken, but utensils should be handled so that bare hands do not touch the serving end. The Preventing Foodborne Illness, Food Handling Policy revised December 2008 directed food would be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The Policy specified food service employee would be trained in the proper use of utensils such as tong to prevent foodborne illness. The Policy lacked direction to the staff on holding cold food temperatures and monitoring of temperatures. The Center for Medicare and Medicaid States Operation Manual, Issue Date 8/8/24 defines Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). The temperature of PHF/TCS foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures are maintained. Refrigerated foods are to be held at 41 degrees or colder.

Based on observation, clinical record review, and staff interview the facility failed to revise the Care Plan to reflect the use of Paid Nutritional Assistants (PNAs) for 1 of 1 resident reviewed for meal assistance (Resident #24). The facility reported a census of 31 residents. Findings include: Resident #24 Minimum Data Set (MDS) assessment dated [DATE] documented Resident #24 with severely impaired decision making and a long/short term memory problem. Resident #24 exhibited inattention (difficulty in ability to focus; easily distracted) and disorganized thinking (rambling/irrelevant conversations) which were continuously present. The MDS further documented Resident #24 was dependent upon staff for eating (bringing food/fluids to the mouth), but did not exhibit any swallowing difficulties. The MDS detailed Resident #24 with diagnoses of stroke, anxiety, and Alzheimer's Disease. A Physician Order Sheet signed by the Provide on 3/07/25 showed an order for a pureed diet as of 3/03/25. Resident #24 Care Plan directed she needed a general, pureed diet with thin liquids and could become restless at meals and turn her head away when eating. The Care Plan directed the aides to feed her all of her meals with a goal to be comfortable eating without coughing or choking. The Care Plan further directed Resident #24 required the assistance of one person for assistance with eating, but did not define if that could be a PNA. Interview on 4/01/25 at 1:22 PM the DON voiced she was not aware of the need to Care Plan if a resident could be safely assisted by a PNA. On 4/01/25 at 1:55 PM Staff D, Licensed Practical Nurse (LPN) provided a list dated 3/10/25 which read these staff are certified to feed resident's if needed and short staffed: Staff A Activity Assistant, Staff E Activity Coordinator, Staff G PNA, Staff H Cook/Dietary Aide, Staff J Social Services, and Staff F, I, and K Environmental Services. The 3/10/25 list did not entail any actual resident names these staff could assist or reference to see the resident Care Plans. During an interview on 4/01/25 at 2:04 PM Staff L, RN, Case Manager, reviewed Resident #24 Care Plan and reported the Care Plan references the resident needed a one assist for eating. The Care Plan did not address if the one person assist needed to be a Certified Nursing Assistant or PNA. Staff L voiced she was not aware resident Care Plans needed to address if a PNA could assist a resident with their meals, so there would be no documentation of PNAs on any of the resident Care Plans. On 4/01/25 at 2:05 PM the DON reported she had not been aware of the requirement for the PNA use to be reflected in the Care Plan and the would start going forward. On 4/03/25 at 10:15 AM the facility provided a list of seven residents requiring assistance with meals. During an interview on 4/03/25 at 10:40 AM the DON reported she would expect the Care Plans to be updated to include if a PNA could safely assist a resident with eating and she expected resident Care Plans to be revised when needed. She stated the facility did not have a policy on revising the Care Plan but would writing a policy soon.

Based on observation, record review, staff interview, and policy review the facility failed to track prophylactic antibiotics (ATB) for 1 of 1 residents reviewed (Resident #12). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) for Resident #12 dated 1/8/25 documented had diagnoses of hemiplegia, depression, and anxiety. The MDS also documented that she takes an ATB daily. During an observation of Resident #12 current Medication Administration Record (MAR) on 4/1/25 at 10:07 AM revealed she had been on Doxycycline 100 milligrams (mg), daily, since 9/28/24 for keratitis (an inflammation of the cornea, the clear, dome-shaped front window of the eye) and Erythromycin eye ointment, twice a day, since 9/27/24 for keratoconjunctivitis (inflammation of both the cornea (keratitis) and conjunctiva (conjunctivitis), the clear tissues covering the surface of the eye, often causing symptoms like redness, pain, and blurry vision) of left eye. Record review of Resident #12 Ophthalmology visit note on 9/27/2024 gave orders for Erythromycin (ATB) ointment to both eyes twice daily and Doxycycline (ATB) 100 mg daily. Record review of Resident #12 Ophthalmology visit note on 3/20/2025 documented she has a history of superficial keratitis in both eyes, and continues to use Doxycycline 100 mg daily and Erythromycin ointment twice a day to both eyes. During an observation on 4/2/25 at 1:19 PM of the facilities Infection Control Logs for the months of January, February, and March 2025 lacked tracking of Resident #12 ATB's (Erythromycin and Doxycycline). During an interview on 4/2/25 at 1:19 PM with the Infection Preventionist (IP) revealed she does not track Resident #12 ATB on the facilities Infection Control Logs as they are prophylactic ATB. Record review of Resident #12 Pharmacy Review Logs for 2024 lacked documentation her ATB's were reviewed during the routine monthly pharmacist reviews. During an interview and observation on 4/3/25 at 9:38 AM with the Infection Preventionist revealed she has updated the Infection Control Logs for January, February, and March 2025 and they now include all prophylactic ATB. She revealed they were not on there on 4/2/25 at 1:19 PM during initial review. During an interview and observation on 4/3/25 at 10:19 AM the Infection Preventionist provided an undated form, Total Number of Infections 1st Quarter 2025, she revealed she updated the form today on 4/3/25 to include the total number of prophylactic ATB's to review to Quality Assurance (QA) and informed it did not have prophylactic ATB's on it till now. During an interview 4/3/25 at 10:43 AM with the Director of Nursing (DON) revealed she would expect all prophylactic ATB to be tracked on the monthly Infection Control log. She revealed she was informed on 4/2/25 they were not being tracked. Record review of the facilities Antibiotic Stewardship Policy, dated 2/2024 lacked instruction to monitor for prophylactic antibiotics. The policy instructed the Pharmacy Consultant to review the antibiotic use for each resident during the Medication Regimen Review.

Based on observation, clinical record review, document review, and staff interview the facility failed to safely utilize Paid Nutritional Assistants (PNA's used interchangeably with Paid Feeding Assistant (PFA) based on resident assessment and Care Plan for 1 of 1 residents sampled (Resident #24). The facility identified a census of 31 residents. Findings include: Resident #24 Minimum Data Set (MDS) assessment dated [DATE] documented Resident #24 with severely impaired decision making and a long/short term memory problem. Resident #24 exhibited inattention (difficulty in ability to focus; easily distracted) and disorganized thinking (rambling/irrelevant conversations) which were continuously present. The MDS further documented Resident #24 was dependent upon staff for eating (bringing food/fluids to the mouth), but did not exhibit any swallowing difficulties. The MDS detailed Resident #24 with diagnoses of stroke, anxiety and Alzheimer's Disease. A Physician Order Sheet signed by the Provide on 3/07/25 showed an order for a pureed diet as of 3/03/25. Resident #24 Care Plan directed she needed a general, pureed diet with thin liquids and could become restless at meals and turn her head away when eating. The Care Plan directed the aides to feed her all of her meals with a goal to be comfortable eating without coughing or choking. The Care Plan further directed Resident #24 required the assistance of one person for assistance in eating, but did not define if that could be a PNA. Resident #24 Care Plan also directed to observe her for seizure activity. Observation on 3/31/25 at 11:45 AM revealed Staff A, PNA assisting Resident #24 with her pureed lunch from a divided plate. Resident #24 did not exhibit coughing or choking at this time. Observation on 4/01/25 at 7:45 AM revealed Staff A, PNA assisting Resident #24 with her pureed breakfast meal. Resident #24 did not exhibit coughing or choking at this time. During an interview on 4/01/25 at 9:02 AM Staff A reported to her knowledge Resident #24 did not cough or choke with her meals. She reported she wasn't aware of any list or guidance from nursing that detailed what residents she could assist for meals. She reported she had just been told she couldn't feed Resident #4 because she does have swallowing and choking problems. She reported it was the Director of Nursing (DON) that had told her she could not assist Resident #4. Staff A further voiced she wasn't sure who actually supervised the PNA's, but she would probably report to the Director of Nursing (DON) if she had any concerns on a resident. On 4/01/25 at 1:15 PM Staff B, Registered Nurse (RN) reported she didn't think Resident #24 had any choking or swallowing issues. She was not sure who supervised the PNA's. She did not do any resident assessment regarding meal assistance. Interview on 4/01/25 at 1:22 PM the DON reported she was not sure if there was an assessment in the resident charts or any type of assessment to address which residents the PNA's could safely assist. She reported she would need to check with Staff C, RN. The DON voiced she was not aware there needed to be an assessment or of the need to care plan if a resident could be safely assisted by a PNA. On 4/01/25 at 1:55 PM Staff D, Licensed Practical Nurse (LPN) reported she is a travel nurse and she had not been necessarily trained on which resident's the PNA's could assist, but they have an assistive table and the resident's that require assistance and supervision sit at that table. Staff D stated there is a Certified Nursing Assistant (CNA) that sits at the table that can watch the PNA's. They were provided with a list of the staff that could assist resident's with meals. Staff D provided a list dated 3/10/25 which read these staff are certified to feed resident's if needed and short staffed: Staff A Activity Assistant, Staff E Activity Coordinator, Staff G PNA, Staff H Cook/Dietary Aide, Staff J Social Services, and Staff F, I, and K Environmental Services. During an interview on 4/01/25 at 2:04 PM Staff L, RN, Case Manager, reported she was not aware there needed to be an assessment or the use of PNA's needed to be addressed in the resident's care plan. Staff L further stated she wasn't aware so there would be no documentation of an assessment and no documentation of PNA use on any of the resident Care Plans. On 4/01/25 at 2:05 PM the DON reported she had not been aware of the requirement for an assessment or for the PNA use to be reflected in the Care Plan and the would start going forward. Interview on 4/01/25 at 2:14 PM the Consulting Dietician reported she had not had to review any residents for choking since she started with the facility in January 2025. On 4/03/25 at 10:15 AM the facility provided a list documenting seven residents in the facility that required staff to assist with meal assistance. The Paid Feeding Assistant (PFA) Policy revised 1/2017 provided by the facility directed the following: 1. The PFA will be under the supervision of a registered nurse or licensed practical nurse. The nurse may not be in visual contact with the PFA but within close proximity to the dining room. 2. In an emergency the PFA must call for a supervisory nurse by voice, the resident call system or the facility paging system. 3. The RN/LPN will assign the PFA to a resident who do not have complicated feeding problems. Complicated feeding problems include, but are not limited to difficulty swallowing, recurrent lung aspirations and tube, parenteral and intravenous feedings. Resident selection will be based on the charge nurse assessment, resident's last assessment and plan of care.

Based on observation, policy review, and staff interview the facility failed to keep bare hands off the drinking surface of glasses to prevent possible contamination. The facility reported a census of 31 residents. Findings include: During an observation of the noon meal on 5/28/24 from 11:28 AM to 12:00 PM Staff A, Dietary Aide served 12 glasses to 9 residents with bare fingers touching the drinking rim surface of the glass. During an observation of the noon meal on 5/29/24 from 11:05 AM to 11:30 AM Staff B, Dietary Aide served 25 glasses to 14 residents with bare fingers touching the drinking rim surface of the glass. The facility lacked a policy regarding hand placement during dining service. In an interview on 5/29/24 at 1:06 PM Staff C, Dietary Supervisor, explained there is no policy on dining service. Staff are educated through an online program to hold cups from the side and keep the ends of the silverware wrapped. Staff must complete the education before they start working. She further explained she expected staff to touch the napkin only and not the silverware itself. They are to grab glasses from the side or the handle of a coffee cup - not where residents will drink from.

Based on record review, interview, and facility policy review, the facility failed to ensure the physician documented their rationale for extending as-needed (PRN) antianxiety medication beyond 14 days, ensured there was a specific duration for the PRN order, and failed to ensure the order was reviewed timely for 3 (Residents #5, #14, and #24) of 4 residents reviewed for unnecessary medications who had a PRN order for a psychotropic medication. Findings included: Review of a facility policy titled, PRN Psychotropic Medication Prescribing and Monitoring, undated, revealed, PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the medical record and indicate the duration for the PRN orders. 1. A review of an ICD-10 Diagnosis List revealed the facility admitted Resident #14 with diagnoses that included major depressive disorder and anxiety disorder. The quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) could not be completed with Resident #14 due to being rarely/never understood. The Staff Assessment for Mental Status indicated Resident #14 had short-term and long-term memory problems and was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident #14 received antianxiety medication and exhibited verbal and physical behavioral symptoms directed towards others on one to three days of the seven-day look back period. The resident also exhibited other behavioral symptoms not directed towards others on four to six days during the seven-day look back period. A review of Resident #14's Care Plan, dated 12/02/2022, revealed Resident #14 had periods of being confused, anxious, and agitated. The Care Plan also indicated Resident #14 would yell, strike out, and be restless. A review of Resident #14's Physician Orders, signed by Attending Physician (AP) #1 on 07/25/2022, revealed an order dated 06/09/2022 for lorazepam (an antianxiety agent and sedative/hypnotic) gel 1 milligram/milliliter (mg/ml) with a dose of .5 ml, every six hours as needed for anxiety and agitation. The order indicated the use of lorazepam was to be reviewed every 60 days or as needed. A review of Resident #14's Physician Orders. signed on 01/11/2023, revealed an order dated 07/25/2022 for lorazepam gel 1 mg/ml, every six hours as needed for anxiety and agitation. The order indicated the use of lorazepam would be reviewed every 60 days or as needed and was reviewed on 07/25/2022. A review of Resident #14's medication administration record (MAR) from 11/01/2022 to 02/14/2023 revealed Resident #14 was administered PRN lorazepam on 11/27/2022, 12/01/2022, 01/18/2023, 01/23/2023, 01/29/2023, 02/06/2023, 02/08/2023 and 02/10/2023. A review of Resident #14's medical record revealed no documentation of a rationale for the continued use of lorazepam and there was no documentation to indicate the duration for the PRN order. During an interview on 02/14/2023 at 9:55 AM, the Registered Health Information Technician (RHIT) said the dates the medications were reviewed were not indicated in the PRN lorazepam order. The RHIT said that when the doctor reviewed the medication, they usually documented next to the order on the list. The RHIT agreed the order did not appear to have been reviewed after 07/25/2022. During an interview on 02/15/2023 at 10:17 AM, the Director of Nursing (DON) revealed Resident #14's PRN lorazepam order was not updated or reviewed. The review date had passed. During an interview on 02/15/2023 at 10:28 AM, the Administrator revealed PRN orders should be updated with current review dates. During an interview on 02/15/2023 at 11:42 AM, the Pharmacist revealed the primary care physician would review PRN orders. She said the dates would need to be updated when they were reviewed. 2. A review of an ICD-10 Diagnosis List revealed the facility admitted Resident #24 with diagnoses that included bipolar II disorder and Parkinson's disease. A review of Resident #24's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS indicated Resident #24 received antianxiety medications. A review of Resident #24's Care Plan, dated 12/23/2022, revealed Resident #24 had the potential to feel anxious, scared, and sad. A review of a document from Resident #24's medical record, dated 01/24/2023, revealed a note to Attending Physician (AP) #2 indicating Resident #24 no longer wanted to take lorazepam (an antianxiety agent and sedative/hypnotic). The note asked if AP #2 would like to discontinue the medication or change to PRN. AP #2 responded, OK to change the order to PRN. A review of Resident #24's Physician Orders, dated 02/14/2023 but unsigned, revealed an order dated 01/25/2023 for lorazepam .5 milligram (mg) at bedtime PRN for anxiety. The order did not indicate an end date. During an interview on 02/14/2023 at 9:55 AM, the Registered Health Information Technician (RHIT) revealed the dates the medications were reviewed were not indicated in the PRN lorazepam order. The RHIT said that when the doctor reviewed the medication, they usually documented next to the order on the list. During an interview on 02/15/2023 at 10:17 AM, the Director of Nursing (DON) said Resident #24's PRN lorazepam order was not updated and should have been discontinued after 14 days. During an interview on 02/15/2023 at 10:28 AM, the Administrator said medication orders should be updated with current review dates. During an interview on 02/15/2023 at 11:42 AM, the Pharmacist said the primary care physician would review PRN orders. She said the dates would need to be updated when they were reviewed. She indicated she reviewed all orders with every monthly medication review 18639 3. A review of an ICD-10 Diagnosis List revealed the facility admitted Resident #5 with a diagnosis that included epilepsy. Resident #5's quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #5's cognitive skills were severely impaired for daily decision making, per the Staff Assessment for Mental Status. The MDS indicated Resident #5 was dependent upon staff for all activities of daily living and received no special treatments. Review of Resident #5's Care Plan, reviewed/revised 11/22/2022, revealed the resident required monitoring for seizure activity and the use of PRN lorazepam for seizure activity. Appropriate goals and approaches for the problems were addressed in the care plan. Review of Resident #5's Physician Orders, signed on 01/11/2023, revealed an order, dated 11/03/2022, for lorazepam (an antianxiety agent and sedative/hypnotic) 2 milligrams/milliliter (mg/ml) with a dose of .5 ml/1mg by mouth as needed for seizure. The administration instructions included for seizure activity 5 minutes or longer. May repeat in 15 minutes if needed. No more than 2 mg in 24 hours. Review use of PRN Lorazepam every 60 days and/or as needed. Reviewed 11/03/2022. Review of Resident #5's Physician Orders, dated 02/14/2023 but unsigned, revealed the PRN lorazepam order was reviewed 11/03/2022. During an interview on 02/14/2023 at 12:59 PM, the Director of Nursing (DON) stated the physician/physician's assistant reviewed the physician's orders and signed them. She stated the facility considered that signature a review or extension of the PRN lorazepam order. During an interview on 02/14/2023 at 1:33 PM, the DON stated the order for Resident #5's PRN lorazepam had not been reviewed within 60 days as specified in the order. During an interview on 02/14/2023 at 2:45 PM, the Administrator stated the physician's review of Resident #5's PRN lorazepam order was late. During an interview on 02/15/2023 at 11:46 AM, the Pharmacist stated it was the facility's policy to have the primary care physician (PCP) review PRN psychotropic medication orders. She stated the PCP should review the PRN psychotropic order within the time limit designated in the order.

Based on clinical record review and staff interview, the facility failed to ensure appropriate information was communicated to the receiving institution or provider when transferring two of two resident from the facility. (Resident #12 & #41) The facility census was 42 residents. Findings include: 1. Progress Notes dated 5/6/19, revealed Resident #12 was transferred to a hospital and returned to the facility on [DATE]. The progress note failed to document pertinent information was communicated to the hospital regarding the residents condition and reason for transfer. The MDS (Minimum Data Set) assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . Progress Notes dated 5/15/19 revealed the resident was transferred to the hospital and returned on 5/21/19. The progress note failed to document pertinent information was communicated to the hospital regarding the residents condition and reason for transfer. The MDS assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . 2. Progress Notes dated 12/20/18, revealed Resident #41 was transferred to the hospital and returned 12/26/18. The progress note failed to document pertinent information was communicated to the hospital regarding the residents condition and reason for transfer. The MDS assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . Progress Notes dated 6/5/19, revealed Resident #41 was transferred to the hospital and returned on 6/13/19. The progress note failed to document pertinent information was communicated to the hospital regarding the residents condition and reason for transfer. The MDS assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . During interview on 8/21/19 at 2:00 p.m., the Director of Nursing (DON) stated a transfer form was filled out and sent with the resident. The DON stated they do not document the transfer form was sent nor do they keep a copy of the transfer form. During interview on 8/21/19 at 2:30 p.m., the Social Services Director stated there was no documentation showing the required transfer information was reported to the hospital.

Based on clinical record review and staff interview, the facility failed to notify the Ombudsman of a residents transfer to the hospital for two of two residents reviewed. (Resident #12 & #41) The facility census was 42 residents. Findings include: 1. Progress Notes dated 5/6/19, revealed Resident #12 was transferred to a hospital and returned to the facility on [DATE]. The progress note failed to document the Ombudsman was notified of the transfer. The MDS (Minimum Data Set) assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . Progress Notes dated 5/15/19 revealed the resident was transferred to the hospital and returned on 5/21/19. The progress note failed to document the Ombudsman was notified of the transfer. The MDS assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . 2. Progress Notes dated 12/20/18, revealed Resident #41 was transferred to the hospital and returned 12/26/18. The progress note failed to document the Ombudsman was notified of the transfer. The MDS assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . Progress Notes dated 6/5/19, revealed Resident #41 was transferred to the hospital and returned on 6/13/19. The progress note failed to document the Ombudsman was notified of the transfer. The MDS assessment dated [DATE], documented the resident was readmitted to the facility after an acute hospitalization . During interview on 8/21/19 at 1:32 p.m., the Social Services Director stated she was unaware of the need to notify the Ombudsman.

Based on clinical record review, resident and staff interview, the facility failed to follow physician orders [REDACTED]. (Resident #1 & #3) The facility census was 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 12/7/16, included [DIAGNOSES REDACTED]. A Physician order [REDACTED]. Clinical record review revealed no AST results. The Director of Nursing (DON) stated on 3/1/17 at 11:30 a.m., they were unable to find results for the lab draw and missed the order. The DON stated they had the lab drawn after being questioned about it. 2. The MDS assessment for Resident #3 dated 1/11/17, included [DIAGNOSES REDACTED]. The care plan dated 5/11/16, included a problem of potential for alteration in urinary elimination pattern. The problem included a goal for supra-pubic catheter (catheter into an artificial opening) will remain patent. The problem included the following interventions: a. Supra-pubic catheter care per resident request daily only by trusted staff. b. Supra-pubic is a closed system. c. Change supra-pubic as directed by the doctor. A Physician order [REDACTED]. The order had a start date of 9/30/15. Nurse note dated 12/24/16 at 9:30 p.m., documented supra-pubic Foley catheter changed per resident request. Balloon inflated with 10 milliliters of sterile water. Small amount of blood tinged urine with a few blood clots was visible in new tubing. The nurses note did not include the catheter size. Nurse note dated 12/29/16 at 2:31 p.m., documented the resident requested the catheter be changed due to having the wrong size in. After several attempts to get catheter in, resident requested to just get up in wheel chair to play on computer. Evening nurse will attempt to put catheter in when resident gets back in bed. Physician assistant notified. The resident stated during interview on 2/27/17 at 1:15 p.m., a nurse had inserted the wrong size supra-pubic catheter which had caused problems getting the right size back in. The DON verified on 2/28/17 at 10:30 a.m., the nurse caring for the resident had grabbed the wrong size catheter and inserted it into the resident's cystostomy (opening into the bladder) which resulted in the resident requiring a surgical procedure to have a catheter inserted. The DON stated the nurse had been counseled on following physician orders [REDACTED].

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff completed proper incontinence care for two of five residents observed during personal cares. (Resident #2 & #5) The facility census was 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #2 dated 1/25/17, included [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two for bed mobility, transfer and toilet use. The care plan updated 12/14/16, included a problem of urge incontinence with a goal of no urinary tract infections. The problem included an intervention for staff to provide perineal care when incontinent. During observation on 2/28/17 at 8:40 a.m., Staff A, Certified Nurse Aide, CNA placed several disposable cloths on the inside surface of the sink. Staff A turned the water on and wet the cloths. Staff A assisted the resident to use the toilet then used the cloths to cleanse the resident's left and right groin. Staff A used a cloth to cleanse through the center of the resident perineal area. Staff A used another cloth to cleanse the resident's posterior perineal area in a back to front motion over the residents rectal area and through the center of the perineal area. During interview at 1:45 p.m., Staff B, housekeeping, stated the resident's bathroom did not get cleaned and sanitized until after 12:00 p.m. The Director of Nursing (DON) stated on 3/2/17 at 7:30 a.m., staff were instructed to use a basin when doing perineal care and always use front to back wipes. 2. The MDS assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The care plan with updates on 2/3/17, identified the resident required extensive assistance with all perineal cares. The care plan documented the resident at risk for recurrent urinary tract infections related to his/her frequent incontinency. Observation on 2/28/17, at 7:00 a.m., revealed Staff C, CNA and Staff D, CNA, assisted the resident with perineal care. Staff C placed dry peri-cloths into the sink where staff had washed their hands. Staff C placed the dry cloths in a layered stack with perineal cleanser applied to each dry cloth. Staff C used the cloths from the sink to cleanse the resident's perineal area. Staff C cleansed the resident's front center and right and left groin with the same side of the peri-cloth with a back and forth motion. Staff C rinsed the front areas with a washcloth with the same side of the cloth with a back and forth motion. Staff C used the same technique with the towel to dry the areas. Staff C cleansed, rinsed and dried the right and left buttocks with a back and forth and up and down motion. The facility policy dated April 2015 titled Nurse Aide Perineal Care Policy directed the staff to use a basin of warm water, wash the perineal areas in a front to back direction and to change the cloth surface with each wipe. The policy directed staff to wash the resident's buttocks, hips and upper thighs.

Based on observation, clinical record review and staff interview, the facility failed to implement interventions in a timely manner to prevent a pressure sore for one resident reviewed who developed a facility acquired pressure sore after a decline in condition. (Resident #1) The facility census was 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 12/7/16, included [DIAGNOSES REDACTED]. The MDS documented the resident required no assistance for bed mobility and required supervision of one for transfer. The MDS documented the resident not at risk of pressure sores at that time. The care plan updated 1/13/17 included a problem of potential for impairment of skin integrity. The plan included the following interventions: a. Assess skin, note changes. b. Instruct on the importance of good skin care. c. Ensure adequate hydration. d. Encourage frequent reposition. A hospital Discharge Summary dated 2/11/17 documented the resident admitted on [DATE] for intractable hip pain after a fall. Nurse notes dated 2/11/17 at 2:08 p.m., documented on re-admission to the facility the resident had all skin intact. Nurse notes dated 2/21/17 at 10:16 a.m., documented the resident had an open area on both buttocks measuring 0.2 centimeters (cm) across. Had bleeding when skin care given this morning. Skin barrier applied. Resident will need to change position to keep pressure off of buttocks. Clinical record review revealed a physician order [REDACTED]. Nurse notes dated 2/23/17 at 10:03 a.m., documented the resident had 3 open areas, partial thickness loss of skin layers that presents as an abrasion or blister, pressure Stage 2. At very top of buttock crease, all with irregular borders and blending together. Left of crease 1.5 cm to side and 2.0 cm head to toe. Directly above crease, 1.5 cm side to side and 2.0 cm head to toe. Right of crease 1.5 cm side to side and 1.0 cm head to toe. No drainage present at time of observation, however, Certified Nurse Aide staff did state it was bleeding this morning. A wound assessment flow sheet dated 2/23/17, documented the resident had a 1.5 cm x 2.0 cm open area above the buttock crease, a 1.5 cm x 2.0 cm open area to the left of the buttock crease and a 1.5 cm x 1.0 cm. open area to the right of the buttock crease. All areas blending together with irregular borders, Stage 2. The assessment documented the treatment had been barrier cream, with a comment to encourage reposition change. The care plan included an addendum to the problem of potential for impairment of skin integrity dated 2/27/17, of decreased mobility manifested by breakdown to buttocks. The problem had an added goal for breakdown to buttocks will heal, resident will verbalize understanding importance of regular position changes. The addendum on 2/27/17, also included the following interventions: a. Barrier cream to buttocks b. ROHO (air filled) cushion to recliner During observation on 2/28/17 at 2:20 p.m., Staff F (licensed practical nurse) measured the open areas on the residents bottom upon surveyor request. Staff F measured the following open areas: a. 1.0 cm x 0.5 cm, right inner buttock b. 1.2 cm x 0.3 cm, left inner buttock c. 0.4 x 0.3 cm, left inner buttock During interview on 3/1/17 at 1:20 p.m., the Director of Nursing (DON) verified the resident had returned from the hospital on [DATE], with a decline in function and requirement for assistance of two for position changes due to a fall. The director of nursing stated they did not know why the resident did not have a cushion added to the recliner upon return from the hospital rather than waiting a week after the open area developed. The DON stated the cushion should have been added upon return from the hospital. The DON stated the change in condition MDS had been underway at that time.

Based on observation, clinical record review, staff interview and review of State Fire Marshall guidelines, the facility failed to ensure safety devices were in place for one of four residents reviewed (Resident #2) and failed to utilize appropriate electrical equipment in a resident area. The facility census was 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #2 dated 1/25/17, included [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two for bed mobility and transfer. During observation on 2/28/17 at 8:40 a.m., Staff A, Certified Nurse Aide, CNA pushed the resident from the dining room to his/her room. The resident had no pedals on the wheel chair and sat in the chair with the right leg crossed over the left leg. The resident's left foot slid along the floor while being pushed. The resident wore tennis shoes. Staff A wheeled the resident into the bathroom and assisted the resident to toilet. Upon completion Staff A pushed the resident from the bathroom into the room with both feet sliding on the floor. The Administrator stated on 3/2/17 at 9:30 a.m., they had been concerned about staff placing wheel chair pedals on the resident's wheel chair when the resident needed to be pushed because staff could potentially forget to remove them and cause the resident to fall if the resident attempted to get out of the wheel chair. 2. During environmental tour on 3/1/17 at 9:30 a.m., observation revealed a large plastic surge protector in an office area of the activity room which had numerous items plugged into it. During interview on 3/2/17 at 8:30 a.m., the Administrator verified the facility had been aware of the State Fire Marshall guidelines but since the space had been for office use had been under the impression it had been acceptable. The Administrator did not disagree the area had not been a separate room but instead a cubicle office area within the activity room. On the Iowa State Department website in the February 2004 Insight, the State Fire Marshal's Office documented clarification on use of surge protectors. The posted information documented the electrical surge protector shall be of metal or steel construction and approved by Underwriters Laboratories or another recognized laboratory. The paper documented items that could be used with an electrical surge protector and items prohibited from use with a surge protector that included clocks, lamps, personal grooming and care devices, battery chargers, and motor drive appliances.

Based on record review and interview, the facility failed to ensure residents on anti-depressant medications had a dose reduction attempt as required for 4 of 4 residents reviewed (Resident #1, #3, #4 & #8 ). The facility census was 38 residents. Findings include: 1. A Physician order [REDACTED].#1 signed 2/24/16, included an order for [REDACTED]. A review of the monthly pharmacy records revealed the pharmacist had identified the resident had been on [MEDICATION NAME] since 7/23/14. However, the pharmacist had made no recommendations for a review by the physician for a gradual dose reduction attempt since the resident had been started on the medication. 2. The Physician order [REDACTED].#4 signed 1/27/16, included an order for [REDACTED]. A review of the monthly pharmacy records revealed the pharmacist had identified the resident had been on [MEDICATION NAME] (anti-depressant) 10 mg every day since 2/13/15. However, the pharmacist made no recommendations for a review by the physician for a gradual dose reduction attempt since the resident had been started on the medication. The Director of Nursing stated on 2/24/16 at 9:30 a.m., they had not been able to find any gradual dose reduction attempt or request to be sent to the physician to consider such since the resident started on the medication. A physician's orders [REDACTED].#4 [MEDICATION NAME] 15 mg daily for symptoms of depression, beginning 3/12/09. Review of the Drug Regimen Review for Resident #4, completed monthly by the consultant Pharmacist, revealed no GDR (gradual dose reduction) requests sent to the primary physician for Resident #4 in the past year to inquire if a lower dose of this medication might be effective. Review of the MAR (medication administration record) showed the physician did not order a change in dose of this medication in the past year. 4. A physician's orders [REDACTED].#8 [MEDICATION NAME] 45 mg daily for symptoms of depression, beginning 3/26/13. Review of the Drug Regimen Review for Resident #8, completed monthly by the consultant Pharmacist, revealed no GDR requests sent to the primary physician for Resident #8 in the past year to inquire if a lower dose of this medication might be effective for this resident. During an interview on 2/24/16 at 1:35 p.m., the Director of Nursing stated they had spoken with their consultant Pharmacist who verified that they do not and had not made any GDR requests for antidepressant medications, as they were not aware they were required to do this for antidepressant medications.

Based on observation and staff interview the facility failed to follow the planned menu for one of one breakfast meal observed. The facility also failed to ensure six of six residents on a pureed diet received the appropriate portion size. The facility census was 38 residents. Findings include: 1. A review of the breakfast menu for 2/23/16, revealed one of the planned items had been two sausage links. During observation in the dining room on 2/23/16 at 7:50 a.m., a resident asked Staff A (Dietary Aide) what the breakfast meat had been on the menu. Staff A informed residents in the dining room there had been no meat item on the breakfast menu. At 11:55 a.m., Staff B (cook) verified they had not made sausage links for breakfast that day. Staff B stated they had not offered or served sausage links because it had not been on the menu. At that time Staff B looked and the menu and verified that sausage links had in fact been on the menu and they had missed that. 2. A review of the lunch menu for 2/23/26, revealed the planned meal included a #6 scoop of pureed tater tot casserole and a #16 scoop of pureed chocolate revel bar. During observation of the puree process at 10:25 a.m., Staff A placed six chocolate dessert bars into a blender with eight ounces of apple juice and blended the bars to a pureed consistency. Staff A did not measure the amount of the pureed bars and instead, used six #6 (2/3 cup) scoops to divide the dessert between six separate bowls. Staff A stated they had just over 8 ounces of pureed dessert bars left in the blender. Staff A discarded the remainder of the pureed bars. During the same observation, Staff B placed seven 6 ounce scoops of tater tot casserole into a Robo Coupe and blended it to a pureed consistency. Staff B did not measure the final amount and instead poured it into a steam table pan. During observation of lunch plating at 11:55 a.m., Staff B used a #6 scoop and served the final of six residents the pureed tater tot casserole. Upon completion of the meal the surveyor asked Staff B how many servings were left. Staff B scooped two heaping #6 servings of the tater tot casserole out of the steam table pan with a small amount still left in the pan as well. Seven servings were made, six residents were served, and two plus servings remained after the meal. The Dietary Manager stated on 2/25/16 at 9:25 a.m., the facility did not have any kind of chart or system for cooks to determine appropriate scoop sizes for purees.

Based on observation and staff interview the facility failed to ensure refrigerated food items were covered, dated and/or labeled. The facility reported a census of 38 residents. Findings include: During the initial dietary tour on 2/22/16 at 9:20 a.m., observation of the walk-in cooler revealed the following: - a pan of dessert bars with no label dated 2/18/16, and not completely covered. At that time the Dietary Manager stated the bars would need to be discarded. - two large tubes of ground beef and another large meat item all in plastic wraps, along with a partially used opened tube of ground beef. All four of the items sat on a shallow plastic pan with a large amount of bloody liquid under them. The opened tube of hamburger had no date or label with one end loosely covered with plastic wrap. At that time the Dietary Manager stated the meat should be dated and sealed tightly and it all needed to be discarded. During the same tour observation of the walk-in freezer revealed the following: - a clear zip-lock bag of dark berries with a large amount of frost build-up on them and no date or label on the bag. - a clear zip-lock bag with an unidentifiable frozen meat and no date or label on the bag. At that time the dietary manager stated the bags should be labeled and dated. The Dietary Manager discarded both bags. During the same tour, observation also revealed a large area on the back splash of the gas stove to have peeling, chipped or bubbling paint, directly behind the gas stove top and grill surface. On 2/23/16 at 11:59 the Dietary Manager stated many of the pans the facility placed on the top of the stove had sides which rose higher than the areas of peeled or bubbling paint. The Dietary Manager agreed that paint chipping from the area could potentially get into food because the area had been directly behind the grill as well as the gas stovetop. On 2/24/16 at 11:30 a.m., the Dietary Manager stated they had completely re-arranged the walk-in freezer and cooler, moving thawing meats to separate trays and ensuring all items were now dated and labeled.

Based on clinical record review and staff interview the facility failed to follow physician orders [REDACTED].#2). The facility census was 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool for Resident # 2 dated 2/1/16, documented [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of one staff for bed mobility and transfer. A hospital discharge summary dated 1/18/16, included a discharge [DIAGNOSES REDACTED]. The summary directed staff to check weight daily; if (resident) gains more than 5 pounds in a week, or more than 2 pounds in a day, contact Heart Failure Clinic. A Physician order [REDACTED]. A weight record for the month of February 2016, documented the resident weighed 125.4 on 2/19/16, and 127.8 on 2/20/16 for a 2.4 pound gain over night. Clinical record review revealed staff did not notify the physician of the weight gain. On 2/24/16 at 9:25 a.m., the Director of Nursing stated they were unable to find any physician notification of the weight gain. Clinical record review revealed the Physician order [REDACTED].#2 also directed staff to draw a complete metabolic profile and a magnesium level every two weeks, starting 1/21/16. Record review revealed a metabolic profile had been completed on 1/21/16, but no magnesium level. Record review revealed the resident had both a complete metabolic profile and a magnesium level drawn on 2/4/16. Record review revealed a complete metabolic profile had been done on 2/17/16, but no magnesium level. On 2/24/16 at 1:25 p.m., the facility Director of Nursing stated they had just informed the physician of the missed lab draws, and had received an order to draw a magnesium level. The DON stated they had just drawn blood from the resident for the test and sent it out.

Based on observation, interview and clinical record review, the facility failed to follow standard nursing guidelines for administering medications to residents during medication pass. The facility reported a census of 50 residents. Finding include: 1. An observation on 3/17/15 at 7:35 a.m., revealed Staff D (Registered Nurse) removed bottles of medications from the medication cart, opened a bottle, emptied a pill into his/her bare hand and then placed the pill into a paper souffle cup. Staff D continued to do this with each bottle of medication. Staff D failed to reconcile the label on the bottle with the Medication Administration Record [REDACTED] At 7:40 a.m., Staff D returned to the medication cart, removed 7 medication cards from a drawer, and dispensed the medications into a paper souffle cup. Staff D failed to reconcile the label on the card with the MAR. At 7:43 a.m., Staff D returned to the medication cart, unlocked it, then opened a drawer and removed 6 punch cards that contained medications from the cart. Staff D dispensed the medication into a paper souffle cup, but failed to reconcile the label on the card with the MAR. 2. On 3/18/15 at 7:20 a.m., observation revealed Staff E (licensed practical nurse) stood at the medication cart in the main dining room. He/she removed medication cards from the cart, placed them on the top of the cart and began to dispense the medication into a paper souffle cup. Staff E failed to verify the reconcile the labels on the cards with the MAR 3. Observation on 3/18/15 at 9:12 a.m., revealed Staff F (Registered Nurse) stood at the medication cart by the nurses station. Staff F unlocked the cart and removed medication cards from one of the drawers. Staff F then dispensed medications into a plastic medication cup, but failed to verify the label on the cards with the MAR. During an interview on 3/19/15 at 7:44 a.m., the facility director of nursing reported the facility's expectation that nurses compare the label on the residents' medication punch cards' to the MAR.

Based on clinical record review, review of the facility policy/procedures, staff and physician interviews, the facility continued to assess Resident #1 after a fall with head trauma, but failed to provide timely interventions after the resident displayed adverse symptoms related to a head injury and failed to notify the physician immediately of the accident, injury and adverse change in condition. The facility census was 55 residents. Findings include: 1. A Cumulative [DIAGNOSES REDACTED]. An admission note dated [DATE], documented the resident required a rolling walker and the assistance of one staff with mobility. The admission nursing note identified the resident had normal vital signs with blood pressure reading of ,[DATE], pulse 62, respirations 18 and temperature of 97 degrees Fahrenheit. Nurse notes reflected the resident continued to have normal vital signs with blood pressure reading on [DATE] at 6:10 a.m. of ,[DATE], pulse of 52, respirations of 16 and temperature of 97.1 Fahrenheit. Review of the Nursing Charting revealed the following documentation: a. On [DATE] at 1:38 a.m., the resident fell at 1:00 a.m. The resident could not remember the fall and voiced complaints of a headache. The resident had a hematoma on the left side of his/ her forehead. The resident's blood pressure (B/P) was ,[DATE], pulse 68 and respirations 18. The note reflected the resident had apparently self transferred into the bathroom and fell upon return to the bed. The staff applied ice to the raised area located on the side of forehead. b. On [DATE] at 4:05 a.m. - With each set of neurological checks performed, the resident's blood pressure reading appeared to have been elevating. The nurse documented she/he would continue to monitor the resident and report changes to the physician. The resident reported no pain or headache. c. On [DATE] at 4:34 a.m. - The resident became very nauseated and had dry heaves. The nurse administered [MEDICATION NAME] (to prevent nausea). d. On [DATE] at 9:18 a.m. - The resident continued to be confused. The right side of his/her forehead continued with a hematoma with a bruise to the forehead and left eye. When the resident had been asked a question he/she chanted a prayer and would not answer any questions. B/P had been ,[DATE]. The vital signs at 7:00 a.m. had been B/P ,[DATE], pulse 86 and respirations 18. The family had been called and the physician notified. Plan to transfer to the emergency room for an evaluation. The note indicated the resident had been transferred to the emergency room at 9:18 a.m. on [DATE]. At 12:45 p.m. the hospital notified the facility the resident had been admitted to the hospital for a bleed (brain). Review of a Neurological Clinical Flow sheet revealed the following documentation on [DATE]: a. At 1:00 a.m. the resident's B/P read ,[DATE], pulse 66 and respirations 18. b. At 1:15 a.m. the resident's B/P read ,[DATE], pulse 68 and respirations 18. c. At 1:30 a.m. the resident's B/P read ,[DATE], pulse 62 and respirations 18. d. At 1:45 a.m. the resident's B/P read ,[DATE], pulse 68 and respirations 18. e. At 2:00 a.m. the resident's B/P registered at ,[DATE], pulse 60 and respirations 18. f. At 2:30 a.m. the resident's B/P registered ,[DATE], pulse 64 and respirations 18. g. At 3:00 a.m. the resident's B/P read ,[DATE], pulse 63 and respirations 16. h. At 4:00 a.m. the resident's B/P read ,[DATE], pulse 69 and respirations 18. i. At 5:00 a.m. the resident's B/P registered ,[DATE], pulse 80 and respirations 18. j. At 6:00 a.m. the resident's B/P registered at ,[DATE], pulse 80 and respirations 18. k. At 7:00 a.m. the resident's B/P ,[DATE], pulse 86 and respirations 18. Review of the hospital emergency room record revealed the resident arrived to the hospital on [DATE] and had a CT (Computed Tomography) scan. The physician History and Physical report dated [DATE], indicated the reason for the residents admission was a subdural hematoma. The discharge summary dated [DATE], indicated the resident died secondary to complications of subdural hematoma with extended bleed; history of recent left [MEDICAL CONDITION] and a history of metastatic [MEDICAL CONDITION]. The report indicated comfort care began on [DATE], when the resident showed a neurological decline. The resident expired on [DATE]. During interview on [DATE] at 1:35 p.m., Staff C, (Registered Nurse) confirmed he/she should have called the physician and family immediately and should have used his/her own nursing judgment to override the residents request to not call the physician because the resident may not have been thinking clearly. During interview on [DATE] at 12:45 p.m., Staff B, (Registered Nurse) confirmed he/she had been the nurse that began work at 6:00 a.m. the morning the resident had fallen and that it had been facility policy to call the physician immediately following a fall with an injury. Staff B confirmed they should have called the physician per nursing judgment even if the resident had requested the staff not call the physician especially when there had been a visible sub-dermal hematoma. During interview on [DATE] at 1:15 p.m., Staff A, (Licensed Practical Nurse) confirmed he/she would expect staff to notify a physician promptly if a resident had fallen and received a sub-dermal hematoma. During interview on [DATE] at 12:40 p.m., the physician confirmed the resident had passed away related to complications from the sub-dermal hematoma but the outcome probably would not have changed if the physician had been notified promptly. Review of the facilities Fall Policy dated [DATE], documented if a resident had a suspected injury or had struck their head, a physician, family member and/or power of attorney for healthcare should have been called immediately.