Every finding on record at UNC Rex Rehab & Nursing Care Center of Apex

Based on observations and interviews with facility staff the facility failed to keep the dumpster area free of debris for 1 of 1 enclosed dumpster area observed. The findings included: An observation of the dumpster area was conducted on 4/5/23 at 12:20 PM with the Dietary Coordinator and the Administrator. The observation revealed there were 4 wheelchairs located behind the dumpster on the right side of the enclosed dumpster area. Behind the middle dumpster was a broken metal office desk. There was also a 6-foot-tall wall cabinet with the top sagging from being wet and the shelves were broken and had the appearance of being wet. The back of the wall cabinet had fallen off and was laying on the ground behind the wall cabinet. It also appeared to have been wet. There was a 6-foot-long piece of countertop behind the dumpster on the left side of the enclosure. During the observation on 4/5/23 at 12:20 PM the Administrator stated the items appeared to be discarded from the Occupational Therapy (OT) room renovation. He said the items were too large to fit into the dumpster, so they needed to have a dump truck from the main facility to come to this facility to pick up the items. On 4/6/23 at 9:20 AM the Occupational Therapist stated the OT room was demolished in November 2022. On 4/6/23 at 9:30 AM the Facilities Maintenance Coordinator said the desk was put into the dumpster area in November 2022 and the 6-foot-tall wall cabinet was placed there in early December 2022. He said he was responsible to call for the dump truck to pick up the items that would not fit into the dumpster but he was waiting until he had a full load before he called for the dump truck. The Facilities Maintenance Coordinator said he thought placing the items in the dumpster area was better than just having them sitting in the parking lot. On 4/6/23 at 9:53 AM the Administrator said he was not aware the items had been in the dumpster area since November 2022. He said he had them removed.

Based on observations, interviews with facility staff and record review the facility failed to maintain the call light in working condition which caused a Resident (Resident #3) to be unable to obtain assistance while in the shower room for 1 of 1 shower room with a malfunctioning call system. The findings included: Resident #3 was admitted to the facility on [DATE]. Her diagnoses included spinal cord dysfunction and diabetes. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #3 was cognitively intact. On 4/4/23 at 9:46 AM Resident #3 said she was in the shower room for her shower on 4/1/23 when the Nursing Assistant (NA) went back to Resident #3's room to make her bed. Resident #3 said she told the NA to do it quickly and to come back to the shower room to get her. She said when she finished her shower she pulled the call light, but no one came so she began to call out. She said no one could hear her calling out for assistance. She said she thought the call light was not working so that was the reason she started hollering out for help. Resident #3 said it took a long time, but the NA finally came back. On 4/6/23 at 10:14 AM an observation of the shower room used by Resident #3 revealed there were 2 call pull stations. One was in the shower area near the rear of the room and the other was near the front of the shower room near the entry door. During this observation the call lights were activated. The activation of the call lights did not light up call light system in the hall on the outside the shower room. No sound from the alarm was heard coming from the nursing station located just across the hall from the shower room door. On 4/6/23 at 10:20 AM the Facilities Maintenance Coordinator stated he was aware the call light in the shower room was not functioning. He added the call light in the resident room to the left of the shower room was also not functioning and the resident had an alternative means of communication since his call light did not work. He stated the call lights had not been working for about 1 month. He added he had tried to determine why the call light was not working and was unable to fix it. He said he had an email to verify he had contacted the biomed support person when he was not able to repair the call light. A review of the email from the Facilities Maintenance Coordinator to the biomed engineering department was dated 3/9/23 and read the call bell is not working in the wall. Attempted multiple call bells that were verified to work. The system is not making any noises/alerts on the system in the wall, visible alert in the hall or audible alert at the nursing station. On 4/6/23 at 10:28 AM NA #6 stated she was the NA assigned to resident #3 on 4/1/23. NA #6 said she took Resident #3 to the shower room. She said Resident #3 was able to complete her own shower after everything was set up for her. She said Resident #3 gave her permission to go back to the Resident's room to make her bed. She said she did go to make up the bed, but she needed some other supplies, so she went to the supply room to obtain the needed items. She said when she returned to the hall and as she was going to the shower room, she could hear Resident #3 calling her, so she went straight into the shower room. NA #6 said it was about 15 minutes from the time she left Resident #3. NA #6 said she was not aware the call light in the shower room was not working. On 4/6/23 at 10:58 AM NA #7 said she worked on 4/1/23 and she was not aware the call light in the shower room was not working until 4/1/23 when Resident #3 was in the shower room. On 4/6/23 at 10:38 AM the Administrator stated he was aware the call light in the shower room was not working and he was aware that someone came and looked at the call light. The Administrator said he was told the unit needed to be replaced but it had not been replaced yet. He added if someone needed assistance they could just call out because the shower room was just across the hall from the nursing station. The Facilities Maintenance Coordinator was interviewed again on 4/6/23 at 10:38 AM and stated it was in January or February 2023 when he replaced the call light in both the shower room and the room to the left of the shower room but that did not fix the problem. He said he asked the biomed engineer for assistance because he thought the problem could be related to the moisture from when the pipe in the shower room ceiling burst and flooded the whole hall on 12/25/2022. On 4/6/23 at 11:00 AM the Clinical Manager stated they began moving residents back onto the hall at the end of February 2023, but the shower room was not in use until 2 weeks ago because the floor in the shower room was not finished until then. On 4/6/23 at 11:24 AM the Administrator said the biomed engineer had received emails about the shower room call light not working and the [NAME] President of the health care system was now trying to get this worked on. During the interview with the Administrator on 4/6/23 at 11:24 AM the Facilities Maintenance Coordinator was also present. He said had called a consulting clinical engineering biotechnology service and they were on the way to look at the shower room call light system.

Based on observations and staff interviews the facility failed to lock a treatment cart while unattended for 1 of 2 treatment carts observed (Treatment Cart #1). Findings included: During a continuous observation on 4/4/23 from 7:50 AM until 7:55 AM Treatment Cart #1 was observed next to the 300-hall nursing station unlocked and unattended. No residents were observed passing by the treatment cart during the observation. During an interview on 4/4/23 at 7:55 AM Nurse #3 stated the treatment cart was the responsibility of herself and the other hall nurse on 300-hall. The nurse stated they had not needed the treatment cart that morning and she did not notice the cart was unlocked. She concluded Treatment Cart #1 should have been locked when unattended. During observation with Nurse #3 on 4/4/23 at 7:56 AM the treatment cart was observed to contain items including triamcinolone cream 0.1%, gold bond cream 1-1%, hydrocortisone cream 1%, 10% povidone-Iodine, and triple antibiotic cream. During an interview on 4/4/23 at 9:22 AM the Director of Nursing stated treatment carts should be locked when unattended.

Based on observations, record review, resident and staff interviews, the facility failed to provide a working Packaged Terminal Air Conditioner (PTAC) unit (a type of heating and air conditioning system used in a single living space) in the resident's room for 1 of 1 resident (Resident #281) reviewed for a clean and homelike environment. Findings included: Resident #281 was admitted to the facility on [DATE]. The physician's history and physical for Resident #281 dated 3/22/23 read in part that he was alert and oriented to person, place, and time. An observation on 4/03/23 at 11:33 AM Resident #281 was observed to be sitting in a wheelchair in his room. He was observed to be wearing a toboggan, shirt, hooded sweatshirt with the hood pulled over his head, and a jacket. He was not observed to be shivering. There were no other sources of heat noted in the room and the PTAC unit under the window was not plugged in. An interview on 4/03/23 at 11:33 AM with Resident #281 revealed his PTAC had not worked since he was admitted to the facility. He stated he did not remember which staff members he had notified but had told several staff members. He also stated he was very cold natured. A review of www.wunderground.com revealed the outside temperature on 4/3/23 was 45 degrees Fahrenheit at 1:51 AM and was 64 degrees Fahrenheit at 10:51 AM. An observation and interview on 4/03/23 at 11:43 AM with the Facilities Maintenance Coordinator revealed the PTAC unit was unplugged. He also revealed he was unaware the PTAC unit in Resident #281's room was not functioning and had not received a work order or any other type of notification that the unit needed repair. Another interview on 4/03/23 at 11:55 AM with the Facilities Maintenance Coordinator revealed the PTAC unit in Resident #281's room heating element trip switch had been tripped. He revealed he reset the trip switch, plugged in the unit and it was now working. An interview on 4/03/23 at 2:43 PM with Nurse #1 revealed when Resident #281 had told her he was cold, she opened the window blinds so he could get sunshine to get warm. She stated she had not attempted to turn on his heat or noticed his PTAC unit was not working. She had not notified maintenance or entered a work order or notified maintenance. An interview on 4/03/23 at 2:56 PM with the Director of Nursing (DON) revealed the facility process was for staff to enter a work order for maintenance for repairs or to move the resident to a room with a functional heater. She was unaware if a work order had been entered for the heating unit in Resident #281's room. An interview on 4/05/23 at 11:22 AM with the Administrator revealed he did not know why the work order process did not go as planned for notification of maintenance for the PTAC unit in Resident #281's room. An interview on 4/06/23 at 8:44 AM with Nursing Assistant #1 revealed that Resident #281 had told her he was cold, and she had offered him another jacket. She also revealed she was aware the PTAC unit was not plugged in or working and thought maintenance knew.

Based on observations, interviews with residents and facility staff and record review the facility failed to maintain residents' dignity by not providing assistance when requested while a resident was in the shower room(Resident #3) and when staff did not announce their presence prior to entering the Resident's room (Resident # 272) for 2 of 4 residents reviewed for dignity. Resident #3 stated this made her feel angry and like a piece of trash. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #3 was cognitively intact. On 4/4/23 at 9:46 AM Resident #3 said she was in the shower room for her shower on 4/1/23 when Nursing Assistant (NA) #6 went back to Resident #3's room to make her bed. Resident #3 said she told the NA to do it quickly and to come back to the shower room to get her. She said she pulled the call light when she was finished with her shower, but no one came so she began to call out. She said no one could hear her calling out for assistance. She said she thought the call light was not working so she started hollering. She said it was about an hour she thought. She said she did not see a clock in the shower room. On 4/6/23 at 11:05 AM Resident #3 reported having to holler and wait for someone to come and get her from the shower room on 4/1/23 made her feel angry and like a piece of trash. On 4/6/23 at 10:28 AM NA #6 stated she was the NA assigned to Resident #3 on 4/1/23. NA #6 said she took Resident #3 to the shower room. She said Resident #3 was able to complete her own shower after everything was set up for her. She said Resident #3 gave her permission to go back to the Resident's room to make her bed. She said she did go to make up the bed, but she needed some other supplies, so she went to the supply room to obtain the needed items. She said when she returned to the hall and was going to the shower room, she could hear Resident #3 calling her, so she went straight into the shower room. NA #6 said it was about 15 minutes from the time she left Resident #3. On 4/6/23 at 10:58 AM NA #7 who was also working on 4/1/23 stated she was not aware of the call bell not working in the shower room until Resident #3 told her she was not able to get help while in the shower room because the call light was not working and there were no staff members at the nursing station just across from the shower room. On 4/6/23 the Director of Nursing was not available to interview. 37468 2. Resident #272 was admitted to the facility on [DATE]. Review of Resident #272's admission health and physical dated 3/31/23 revealed the resident was alert and oriented to person, place, and time. During observation on 4/3/23 at 10:31 AM Nurse #4 was observed to enter Resident #272's room through the open door without knocking or announcing her presence. During an interview on 4/3/23 at 10:33 AM Resident #272 stated it bothered her when staff entered her room and did not knock or announce her presence. During an interview on 4/3/23 at 10:38 AM Nurse #4 stated it was facility culture to knock or announce presence prior to entering resident rooms to provided privacy and dignity to the residents. She concluded she thought she had announced her presence at the door and should have done so. During an interview on 4/4/23 at 9:22 AM the Director of Nursing stated staff were to announce their presence prior to entering the resident's room for privacy and dignity.

Based on record review and staff interviews the facility failed to base their routine staff testing schedule for COVID-19 on the level of community COVID-19 transmission reported in the past week. This was for one of four employees reviewed for COVID-19 testing. The findings included: Review of the facility's COVID-19 Protocols, last updated on 4/18/22, revealed the facility would test staff per the county transmission rate per CDC guidelines (Centers for Disease Control). Review of the facility's Staff Vaccination Status Roster revealed Staff Member # 1 was vaccinated but not up to date with boosters. Review of routine testing for the last four weeks for Staff Member # 1 revealed four COVID-19 tests had been performed. These were on the following dates: 6/20/22; 6/28/22; 7/6/22; and 7/12/22. A review of CDC's Data Tracker of COVID-19 transmission rates for the facility's county revealed the rate of transmission was high for all the dates with data from 6/6/22 through 7/13/22. These included the dates of 6/6/22 to 6/17/22 and 6/21/22 to 7/13/22. The facility's Infection Preventionist (IP) was interviewed on 7/13/22 at 12:50 PM. At this time the CDC's data tracker was also reviewed with her. The IP pointed to the rate of community level for the facility's county; which was medium. She stated she had been basing her routine testing for all employees who were not up to date with COVID-19 on the county positivity rate and not the transmission rate. According to the facility IP she had misunderstood the guidance about where to find the transmission rate on the tracker and thought by testing according to the positivity rate she had been doing it correctly. The facility IP stated she should have been testing the not up to date staff twice per week according to policy and procedures since the transmission rate was high. Review of facility COVID-19 resident cases revealed there were no current resident cases. The last resident COVID case was listed as 6/14/22.

Based on observation and staff interviews the facility failed to assure staff wore eye protection as source control for COVID-19 during a time period when the county COVID-19 transmission rate was high on one (Hall 100) of four halls. This occurred during a coronavirus pandemic. The findings included: Review of the facility's Infection Control, Prevention and Surveillance Program, last revised on 10/29/19 revealed, The center's infection control includes, but is not limited, to the following components: a: Implementing policies and procedures to prevent the spread of infections that include promoting consistent adherence to standard precautions and other infection control practices. At the end of the program details, it was noted, Resources Center for Disease Control (CDC) http://www.CDC.gov. Under the facility's COVID-19 protocol, last updated on 4/18/22 it was noted, Staff will wear a mask at all times when on halls or in resident/patient rooms. When providing direct patient care with high risk patients, staff member must wear protective eye coverings (face shield, goggles, . prescription glasses do not qualify as protective eye coverings) along with a mask. Review of CDC guidelines for Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) during the Coronavirus Disease 2019 Pandemic, last updated on 2/2/2022, revealed HCP working in facilities located in counties with substantial or high transmission should use eye protection during all patient (resident) encounters. A review of CDC's Data Tracker of COVID-19 transmission rates for the facility's county revealed the rate of transmission was high for the current date of 7/13/22 and all the dates with data from 6/6/22 through 7/13/22. Review of the facility's infection control tracking records revealed there were no residents on the 100 hall who were in need of transmission-based precautions for COVID or other infections on the date of 7/13/22. On 7/13/22 at 9:02 AM Student NA (Nurse Aide) # 1 was observed going in and out of room [ROOM NUMBER] where a resident resided. After she exited the room, she was interviewed about the use of eye protection and stated she did know anything about using goggles and no one else was wearing them on the unit. NA # 2 was observed on 9:07 AM on the 100-hall. She was observed to have glasses but no eye protection. NA # 2 was interviewed about this and stated there were no COVID cases and therefore she did not wear eye protection when caring for residents. Resident # 4, who was coded cognitively intact on her quarterly 6/8/22 Minimum Data Set assessment, was interviewed on 7/13/22 at 9:10 AM. Resident # 4 resided on the 100-hall. Resident # 4 reported she saw staff wear masks, but she did not see them wear goggles or face shields when they cared for her. The facility's Infection Preventionist was interviewed on 7/13/22 at 11:55 AM and reported the 100-hall was where long-term residents resided. She had interpreted that eye coverings needed to be worn when there was an internal risk for high transmission, and she evaluated the risk of the 100-hall as not high since the residents did not come and go. Therefore, she had not instructed the staff to use eye protection on the 100-hall. The facility's IP stated she had interpreted the guidance incorrectly and based on the CDC guidelines the staff should have been wearing eye protection as source control on the 100-hall. According to the facility's IP she was aware that the CDC data tracker had both the county positivity rate and the transmission rate, but the tracker page could be confusing at times in that the positivity rate always stood out at the top of the online statistical page and that is what she had been most often referencing.

Based on staff and family interviews, and record review the facility failed to accurately complete the Brief Interview for Mental Status (BIMS) on a Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for communication (Resident #43). Findings included: Resident #43 was admitted to the facility on [DATE]. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #43's minimum data set assessment dated [DATE] revealed Resident #43 needed or wanted an interpreter to communicate with a doctor or health care staff. The BIMS assessment was not completed as the resident was checked as rarely/never understood. Resident #43's care plan dated 11/5/20 revealed she was care planned for hearing deficit and English as a second language. The interventions included to provide an interpreter as needed and involve family to facilitate communication. During an interview on 8/10/21 at 11:13 AM MDS Nurse #1 stated the social worker (SW) performed the BIMS interview and then populated the results into her MDS system. She further stated when a BIMS score was performed, and the resident needed or wanted a translator, then the BIMS interview should be done with a translator. During an interview on 8/10/21 at 11:23 AM the SW stated when she did the BIMS score for Resident #43 for the 7/5/2021 MDS she did not attempt to use a translator. She further stated she did not have a reason she did not try to use a translator. She concluded she should have attempted to get a translator to complete Resident #43's BIMS score. During an interview on 8/10/21 at 11:37 AM the Administrator stated he would agree with what the SW had said as BIMS scores were not his area of expertise, and if she indicated she should have attempted to get a translator for the BIMS score assessment then he would agree. During an interview on 8/10/21 at 12:30 PM a family member of Resident #43 stated the resident did have dementia however Resident #43 was able to speak to the family member in her native language about who the president was when watching the television and could speak about current news. She stated her mental status was different on different days but believed it was appropriate to attempt to provide a translator during mental assessments.

Based on observations and staff interviews the facility failed to discard 1 container of diced ham by the use by date and failed to maintain cooked peach cobbler at a temperature above 135 degrees Fahrenheit during 2 of 3 kitchen observations. The findings included: 1) During an observation of the walk in cooler on 5/28/19 at 10:02 AM a container of left over diced ham was observed to have plastic wrap over the container. A label was on the plastic wrap. The label on the container was dated 5/22/19. During an interview with the Certified Dietary Manager (CDM) on 5/28/19 at 10:02 AM he stated the date on the label was the date the ham was placed inside the cooler. He said the ham should have been discarded yesterday (5/27/19) because the diced ham was only acceptable for use for 5 days from when it was put in the refrigerator. 2) During an observation of the lunch meal service on 5/30/19 from 11:30 AM through 12:30 PM the peach cobbler was observed stored in individual serving bowls on a sheet pan in the temperature regulated holding unit inside the kitchen near the cooking area. One sheet pan was removed and placed in a rack near the servicing line and when that sheet pan was almost empty a new sheet pan was removed from the holding unit and placed on the serving rack. On 5/30/19 at 12:20 PM the temperature of the peach cobbler was taken with a calibrated thermometer. The temperature of the peach cobbler registered 91 degrees Fahrenheit. During an interview with the CDM on 5/30/19 at 12:30 PM he stated the peach cobbler temperature should be maintained above 135 degrees Fahrenheit.

Based on record review and resident and staff interview the facility failed to secure a prescription medication for 1 of 1 resident (resident #68) whose inhaler was left at the bedside. Findings included: Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #68's Minimum Data Set assessment dated [DATE] coded as an admission assessment revealed resident #68 was independent with daily decision making. It further revealed he exhibited no behaviors or refusal of care. A review of resident #68's medical record revealed a physician order [REDACTED].#68's record. A review of resident #68's care plan revealed no focus area for self-administration of [MEDICATION NAME] HFA inhaler. On 05/29/19 at 10:21 AM, in an interview, resident #68 indicated the facility had lost his [MEDICATION NAME] HFA inhaler. He went on to indicate nurse #1 left the inhaler in his room the evening of 05/28/19. He indicated after nurse #1 left his room, he placed the inhaler on his bedside table. He further indicated nurse #2 asked him this morning if he had it. He went on to indicate when his inhaler couldn't be found, a new inhaler was ordered. In an interview on 05/29/19 at 3:07 PM nurse #1 indicated she had administered medication including [MEDICATION NAME] HFA 115/21 mcg to resident #68 on 05/28/19 during the 7pm-11pm shift. She went on to indicate she had been busy that evening but not more busy than usual. She went on to say she may have inadvertently left resident #68's inhaler at his bedside rather than securing it in the medication cart after administration. An interview on 5/29/19 at 3:18 PM with nurse #2 revealed a new [MEDICATION NAME] HFA inhaler had been ordered for resident #68. She further indicated she had been the first to open it that morning. On 05/29/19 at 3:21 PM an interview with nurse Team Leader #1 revealed resident #68's [MEDICATION NAME] HFA inhaler had been left in his room on 05/28/19 on the 7pm-11pm shift. She further indicated when it could not be found a new inhaler had been ordered. In an interview on 5/30/19 at 2:22 PM nurse #3 indicated it would not be acceptable practice to leave a prescription medication unsecured at the bedside of a resident. She indicated the prescription medication should have been returned to the medication cart and secured after administration. On 05/30/19 at 2:30 PM, in an interview, nurse Team Leader #2 indicated it would not be acceptable practice to leave an [MEDICATION NAME] HFA inhaler at the bedside of resident #68. She indicated the medication should have been returned to the medication cart and secured after administration. In an interview on 05/30/19 at 2:40 PM the facility's Director of Nursing indicated it would not be acceptable practice to leave an [MEDICATION NAME] HFA inhaler at the bedside resident #68. She went on to say the inhaler should have been returned to the medication cart and secured after administration.

Based on record review and staff interviews the facility failed to complete a quarterly minimum data set (MDS) assessment for 1 of 7 residents who had quarterly MDS assessments reviewed (Resident #22). The findings included: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #22's quarterly minimum data set (MDS) assessment dated [DATE] revealed Section D, questions D0500A-D0500J were not completed. The unanswered questions D0500A-D0500J related to staff 's assessment of the resident's mood. During an interview with Social Worker #1 on 5/30/19 at 4:30 PM she stated she normally codes Section D of MDS assessments. She stated she did not complete Section D of the 3/25/19 assessment for Resident #22. Social Worker #1 indicated she was not sure why questions D0500A-D0500J were not completed on the assessment dated [DATE]. An interview was conducted with MDS Nurse #1 on 5/30/19 at 5:00 PM who indicated questions D0500A-D0500J were not completed on the assessment dated [DATE]. She stated she was unsure the reason these questions were not completed and felt the computer system should have caught the error. An interview was conducted with the Administrator on 5/30/19 at 5:38 PM who indicated it was his expectation that MDS assessments are reviewed for accuracy prior to submission.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of hospice services (Resident #21) and discharge status (Resident #96) for 2 of 24 residents whose MDS assessments were reviewed. The findings included: 1. Resident # 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #21 was severely cognitively impaired and required total assistance with activities of daily living. In Section O, question 0100 item K, the MDS indicated Resident #21 was on hospice services. A review of the medical record revealed the face sheet did not indicate Resident #21 was on hospice services. The record review also revealed there were no physician orders for hospice services nor any records of hospice services being provided. During an interview with MDS nurse #1 on 5/31/19 at 8:37 AM she stated Resident #21 was not receiving hospice services. She stated Section O question 0100 item K was an error on the MDS and she needed to complete a modification to the MDS to correct the error. 2. Resident #96 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A review of social worker notes dated 3/1/2019 revealed the social worker met with Resident #96's niece and spouse and discussed the resident's pending discharge. The goal was for her to return home with home health services. Resident #96's physician order dated 3/7/2019 revealed an order to discharge home with home health services. A review of the resident's discharge Minimum Data Set ((MDS) dated [DATE] revealed the MDS specified discharge status as to acute hospital. During an interview with the MDS nurse on 05/30/2019 at 10:05 am, she stated Resident #96 had been discharged to the hospital, but she would check the paperwork to make sure. After she checked the paper work, the MDS nurse stated that it looked like Resident #96 was discharged home with home health. She further stated that it was an error on the MDS and she would modify it right away. An interview with the Director of Nursing on 5/29/2019 at 5:00 pm revealed she was unaware of the incorrect coding and the MDS should have been coded to show that Resident #96 was discharged home.

Based on record review and staff interviews the facility failed to provide written notice of discharge to the resident's representative for a facility-initiated discharge for 1 of 1 residents reviewed for hospitalization s (Resident #22). The findings included: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note dated 4/27/19 revealed Resident #22 was sent to the hospital due to being nonresponsive. The note indicated the family was notified of the transfer by phone. Resident #22's medical record revealed no information regarding the resident's responsible representative being provided with written notice of the resident's hospital transfer on 4/27/19. A nurse's note dated 5/5/19 revealed Resident #22 was readmitted to the facility from the hospital on [DATE]. During an interview on 5/30/19 at 4:11 PM with Nurse #3 she stated when a resident was sent to the hospital the paperwork sent included the face sheet, the list of diagnoses, code status, Medication Administration Record [REDACTED]. During an interview on 5/30/19 at 4:30 PM Social Worker #1 stated she did not send written notice of discharge to the resident or the resident's representative for the resident's hospital transfer on 4/27/19. The Social Worker stated she was not aware a written notice was required to be provided when a resident was transferred to the hospital. During an interview with the Administrator on 5/30/19 at 5:38 PM he indicated he was not aware of the requirement to provide written notification to the resident or the responsible party for emergent hospital transfers.

Based on observation, staff interviews, and record review the facility failed to keep a catheter bag from coming in contact with the floor for 1 of 2 residents reviewed for catheter care (Resident #86). Findings included: Resident #86 was admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. Review of Resident #86's baseline care plan dated 5/21/18 revealed the resident was care planed for having a catheter. The interventions included catheter care per protocol. During observation on 5/23/18 at 1:12 PM the Physical Therapy Assistant was observed pushing Resident #86 in a wheelchair down the main hall of the facility to his room. The resident's catheter bag was observed to have the bottom of the collection bag in contact with the floor dragging across the floor as she was pushing him. During an interview on 5/23/18 at 1:16 PM the Physical Therapy Assistant stated catheter bags should not touch the ground for infection control concerns. Upon observing the catheter bag she stated one of the catheter bag clips had come off the wheelchair which caused the bag to come in contact with the ground and it should not have been in contact with the ground. During an interview on 5/23/18 at 1:35 PM the Infections Control Nurse stated neither catheter bags nor catheter tubing were to come in contact with the floor. She further stated it was her expectation that the resident's catheter bag not touch the floor during transport. During observation on 5/24/18 at 8:53 AM Resident #86 was observed in bed. The bottom of the catheter bag was observed to be in contact with the floor. During an interview on 5/24/18 at 8:56 AM Nurse #1 stated catheter bags were to be stored off the floor. Upon observation of Resident #86's catheter bag she stated the bag should not have been in contact with the floor and she would adjust it. She stated someone must have lowered the bed and not noticed it was in contact with the floor. During an interview on 5/24/18 at 8:59 AM the Director of Nursing stated catheter bags were not to touch the floor. She further stated it was her expectation that catheter bags be stored high enough that they were not in contact with the ground at any time.

Based on record review and staff interview for one (Resident # 2) of three sampled residents with indwelling catheters the facility failed to follow standards of practice for monitoring the resident per her plan of care. The staff failed to obtain a rectal temperature when the resident's temperature would not register by other routes. The findings included: Record review revealed Resident # 2 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Also, according to the record the resident was admitted with a urinary catheter secondary to a [DIAGNOSES REDACTED]. Review of the resident's admission minimum data set (MDS), dated [DATE], revealed the resident was cognitively intact and had an indwelling urinary catheter. Review of the resident's care plan, last revised on 10/17/17, revealed it included interventions for the resident's urinary catheter. One of the interventions was to monitor the resident for infection. Review of nursing notes revealed on 10/26/17 at 12 noon, Nurse # 2 documented the following information. The resident had been up in her wheelchair and ambulating with a rolling walker. The resident's catheter was draining clear yellow urine. On 10/26/17 at 2:15 PM, Nurse # 2 documented the resident had lost her balance while transferring/walking with the rolling walker, and she had been lowered to the floor without injury by a nurse aide (NA). Nurse # 2 documented the resident's vital signs as: B/P (blood pressure) 145/67; respirations 24; heart rate 40; and oxygen saturation 91 percent. There was no documented temperature reading. There was documentation the physician was notified. Interview with Nurse # 2 on 12/4/17 at 2:45 PM revealed the physician/ nurse practitioner had been making changes in one of the resident's cardiac medications during this time, and she had called to inform them of the heart rate on 10/26/17. According to the nurse the resident varied daily in how well she felt, and a urine specimen had been obtained recently due to an isolated occurrence of some blood clots on 10/25/17. According to the nurse, as of dayshift on 10/26/17, she had not noted a significant change in the resident's status, and although the resident's heart rate was low the physician/nurse practitioner was aware and addressing the issue. The nurse could not recall the resident's temperature reading for her day shift of 10/26/17. Review of the resident's nursing notes revealed, on 10/26/17 at 5:30 PM, Nurse # 3 documented the following information. The nurse aide had not been able to obtain Resident # 2's vital signs at the beginning of the shift. A new blood pressure machine was used and there was no reading. The resident's temperature would not register an oral or axillary temperature. The registered nurse team leader (RNTL) was notified. At the time of the 5:30 PM nursing entry, the RNTL obtained a manual blood pressure of 138/48 and a manual heart rate of 40. The resident's oxygen saturation was 95 percent, and her blood sugar had registered 111 at 4 PM. The resident was sitting up in bed, verbally responsive, and eating her meal. There were no signs of physical distress noted, and the RN team leader stated she would call the physician. On 10/26/17 at 10:15 PM Nurse # 3 documented the following information in the nursing notes. She had been called to Resident # 2's room by the NA. The NA reported to Nurse # 3 that she (the NA) had been washing the resident and talking with the resident when her breathing changed, and the resident became unresponsive. Nurse # 3 shook the resident, shouted to the resident, and performed a sternal rub without response. The team leader was called and obtained a manual blood pressure of 152/54, heart rate of 40, oxygen saturation of 97%, and blood sugar of 155. There was no temperature reading. The resident mumbled and would not open her eyes. On 10/26/17 at 10:30 PM, Nurse # 3 documented the physician was notified by the team leader, and EMS (emergency medical services) had been called and was present. Nurse # 3 documented EMS was unable to obtain a temperature also. Record review revealed the resident was transferred to the hospital where she was found to have hypothermia secondary [MEDICAL CONDITION]. According to hospital records, the resident's temperature on 10/27/17 at 12:57 AM was 89.2 degrees Fahrenheit. Nurse aide (NA) # 1 was the nurse aide, who had cared for Resident # 2, on 10/26/17 during the 3 PM to 11 PM shift. NA # 1 was interviewed on 12/4/17 at 3:30 PM and reported the following. She tried to obtain the resident's temperature three different times and tried both orally and axillary. When it did not register, she informed Nurse # 3. The resident was a little quieter during the shift, but appeared okay. The resident ate her evening meal, and didn't seem any different until she was washing the resident at the end of the shift. During the care the resident had been talking to her, and then suddenly she started having trouble breathing. NA # 1 stated, it was as if the resident was fine one second and then the next she wasn't. The NA reported she immediately went to get the nurse when she noticed the change. Nurse # 3 was interviewed on 12/5/17 at 12:05 PM. Nurse # 3 reported the following information. It had been reported to Nurse # 3 by the dayshift nurse that Resident # 2's temperature had been low normal during the dayshift. The 3 PM- 11 PM NA informed Nurse # 3 around 3:30 to 4 PM the resident's temperature would not register. Nurse # 3 checked the resident and the resident didn't open her mouth well, and so she tried to obtain the temperature by the axillary route with three or four different thermometers. The thermometers would blink or show an E, but would not register a reading. She placed a blanket on the resident to warm her. She told Nurse # 4, who was the RN supervisor, that she was having trouble getting the resident's vital signs. Nurse # 4 came to check the resident. Nurse # 4 obtained the manual B/P that was documented in the record and stated she would call the physician. Nurse # 3 felt the resident's evening was her normal evening otherwise. The nurse reported she did not try to obtain a rectal temperature because the resident was large, and she kept hoping the resident would warm up so that the temperature would register. The nurse also reported she did not recall trying to retake the resident's temperature after 7 PM. When the NA alerted her near the end of the shift the resident was having trouble, she immediately went, found the resident to be unresponsive, and called EMS. Nurse # 4 was interviewed on 12/5/17 at 11:35 AM. This interview revealed the following information. A little after 5 PM, Nurse # 3 told her she could not get the B/P pressure machine to work for Resident # 2. Nurse # 4 was aware the resident was being monitored for [MEDICAL CONDITION] (low heart rate) episodes that week. When she entered the room to check the resident, the resident was eating, responding appropriately, and verbalized she was okay. The resident did not appear in distress. She checked her blood pressure manually and obtained a reading which was within normal limits. Her apical heart rate was 40. She immediately called NP # 1, who told Nurse # 4 she was aware the resident had been having problems and to schedule a cardiology consult in the morning. It was Nurse # 4's understanding that the B/P had not registered on the machine, and Nurse # 4 did not recall Nurse # 3 telling her the resident's temperature did not register. Therefore she did not try to obtain the resident's temperature or report this to the following team leader. Nurse # 4 left around 7 PM and was replaced by Nurse # 5 as team leader. Nurse # 5 was interviewed on 12/5/17 at 12:35 PM. Nurse # 5 reported the following information. After obtaining report from Nurse # 4, she looked in on the resident, who appeared without distress and was observed by her to be visiting with family members and watching television. Therefore she did not check the resident's temperature or do a further physical assessment until she was notified near the end of the shift the resident was not responding. Nurse # 5 had not been made aware the resident's temperature was not registering earlier. Interview with NP # 1 on 12/4/17 at 3:20 PM revealed the staff had talked with her regarding the resident's heart rate, and she had been evaluating and addressing this. The NP stated she was not made aware the resident's temperature would not register. Interview with the director of nursing on 12/5/17 at 10:40 AM revealed it was expectation as a standard of practices that if a temperature did not register then her staff should change the probe and try again to take it. If the temperature still did not register, then it was her expectation the staff member should obtain a rectal temperature. Interview with Resident # 2's physician on 12/6/17 at 1:15 PM revealed the following. On rare occurrences, a resident's temperature will decrease as they become septic rather than suddenly spike to a high reading. The temperature change can occur very rapidly. It was his medical opinion that although the nursing staff had not followed standards of practice in obtaining the temperature rectally, Resident # 2's course of treatment and outcome would have been unchanged considering the complexity of her medical conditions.

Based on observations and interviews the facility failed to keep the dumpster area free from debris for 4 of 4 dumpsters. The findings included: On 5/22/16 at 4:55 PM an observation of the dumpster area was conducted with Food Service Worker (FSW) #1. The observation revealed 4 dumpsters located within a closed in fenced area. On the ground were a minimum of 20 pairs of used blue gloves, a bottle of stool softener and numerous pieces of paper and 3 small cardboard boxes scattered throughout the fenced in area. FSW #1 stated she did not know why the items were there and they appeared to have been there for a while. On 5/22/16 at 6:10 PM an observation of the dumpster area was conducted with the Food Service Director (FSD) and the Administrator. The same items were present. The FSD stated he had cleaned the area last Wednesday (5/18/16) when the trash removal company had lifted the dumpsters and he had cleaned under and around them. He stated the reason the items appeared to have been there for an extended time was because of the large amount of rain. On 5/22/16 at 6:10 PM the Administrator stated the dumpster area needed to be cleaned and free from debris on the ground. On 5/25/16 at 11:45 PM the FSD stated he had not worked since Wednesday so the area may not have been cleaned since that time.

Based on observation, record review and staff interviews the facility failed to be free of a medication error rate greater than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 1 of 5 residents (resident #40) observed during medication pass. The findings included: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. On 5/24/2016 at 8:19 AM, Nurse #1 was observed preparing and administering medications for Resident #40. The Nurse administered [MEDICATION NAME] 0.1% 1 drop to each eye at 8:26 AM. She then opened the second eye medication, Dorzolamide HCl and administered 1 drop to each eye at 8:27 AM. On 5/24/2016 at 8:44 AM, an interview with Nurse #1 was conducted following the medication administration. The nurse stated eye drops were supposed to be given a couple of minutes apart, but these drops were probably less than that. She indicated she usually times the drops, but did not do that this time. On 5/25/2016 at 10:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she expects eye drops to be given 3 to 5 minutes apart.

Based on interviews with the Responsible Party (RP) and staff and record review, the facility failed to provide a shower consistent with the resident's prior routine and current preference for 1 of 1 resident (Resident #327) reviewed for choices in bathing. Findings included: Resident #327 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5/18/16 Admission Minimum Data Set (MDS) indicated Resident #327 was assessed with [REDACTED]. Refusal of care was not identified on the MDS for Resident #327. The section of the MDS, titled, customary routine and activities, indicated it was very important for Resident #327 to choose between a tub bath, shower, bed bath or sponge bath and very important to choose the number of times per week he received a bath. The MDS also indicated the resident required extensive assistance of staff for personal hygiene and was totally dependent on staff for a bath. Review of the shower schedule, kept at the nurse's station, revealed Resident #327 was scheduled for showers on Monday and Friday on the 3-11 shift. Review of the activities of daily living book, used for nursing assistant (NA) documentation of care given, revealed since his 5/6/16 admission, the resident had received 3 showers. Documentation failed to indicate the resident had refused any showers. The shower scheduled for Monday, 5/23/16, had not been documented as given. The RP was interviewed on 5/23/16 at 3:50 PM. She stated prior to admission, the resident received showers on a daily basis. Since admission to the facility, no one had requested information about Resident #327's prior schedule or past routine with bathing/showering. She stated staff told her he would receive showers twice weekly; and she was left with the thought that was not negotiable. The RP stated she while the facility may not be able to provide daily showers, she would like for Resident #327 to receive more than 2 showers per week. NA #1 was interviewed on 5/24/16 at 2:45 PM. The NA stated residents received showers twice a week according to the shower schedule found at the nurse's station. She added if a resident refused a shower, the NA was expected to ask again, report the resident refusal to the nurse and document the refusal in the activity of daily living book also kept at the nurse's station. NA #1 stated she was unaware of any residents that had requested more than the 2 showers per week. She added prior to providing more than two showers per week, she would need the nurse's approval. She added the resident that requested more than two showers per week would receive those showers if the NA schedule permitted. A telephone interview was held with NA #2 on 5/25/16 at 12:10 PM. She acknowledged she had been assigned to care for Resident #327 during the 3-11 shift on Monday, 5/23/16. The NA stated Resident #327 had not refused care; adding if any resident refused care, the refusal was reported to the nurse and documented in the activity of daily living book. She added Monday night was really busy and she had not offered the resident a shower. The NA added she must have overlooked the resident's scheduled shower. The Director of Nursing (DON) was interviewed on 5/25/16 at 12:20 PM. She stated residents were expected to receive a minimum of 2 showers per week. Any refusals of care were expected to be reported to the nurse for further encouragement and both the nurse and the NA were expected to document the refusal. The DON was unaware Resident #327 had not received his scheduled showers.

Based on observation, record review and staff interviews, the facility failed to accurately code the Minimum Data Set dental section for broken/fragmented teeth for 1 of 2 residents (resident # 13) reviewed for dental services. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident ' s annual Minimum Data Set (MDS) assessment dated [DATE], indicated she was moderately cognitively impaired. The Oral/Dental section was coded as none of the above present, which indicated the resident did not have broken or ill-fitting dentures, no natural teeth or tooth fragments, abnormal mouth tissue, cavities or broken natural teeth, inflamed or bleeding gums, mouth or face pain, discomfort or difficulty chewing. The Care Area Assessment (CAA) did not trigger for Dental Care. A note under the CAA Activities of Daily Living Functional Status revealed the resident had broken teeth, but denied oral pain or chewing problems. On 7/27/2015 at 12:18 PM, an observation of was resident #13, revealed her visible lower teeth were broken and discolored brown. An interview was conducted with the MDS nurses (MDS #1, and MDS #2) on 7/30/2015 at 10:18 AM. The MDS nurse #1 stated she had documented the broken teeth in the CAA note. The MDS nurse #2 stated that the resident ' s teeth had been that way since she was admitted and she did not code the dental section on the annual assessment, because the resident was not having any problems with her teeth. She stated that was a mistake.

Based on observations and staff interviews, the facility failed to serve residents sitting at the same table breakfast at the same time for 1 of 2 Residents (Resident #138) in the dining area. The facility also failed to call a 1 of 2 residents (Resident #138) sitting at the same dining by her preferred name. Findings included: Resident #138 was admitted [DATE] with Alzheimer ' s disease, diabetes and arthritis. The resident ' s quarterly Minimum Data Set (MDS) indicated the resident had short and long term memory impairment and severely impaired cognitive skills for daily decision making. Resident #138 was coded as totally dependent on staff for eating. An observation was made on 7/29/15 beginning at 8:40 AM of the breakfast meal in the 200 hall dining room. The first resident at the table was served her breakfast at 8:45 AM and was assisted by Nursing Assistant (NA) #1. At 8:48 AM, Resident #138 was brought into the dining room by NA #2. NA #1 stated to NA #2 to sit the resident at the table, adding that since Resident #138 was a feeder she would feed her when she completed assisting the resident sitting at the table. Resident #138 was served at 9:10 AM. NA #1 was interviewed on 7/29/15 at 11:06 AM. The NA stated she had not been taught to serve all residents at a single table at one time, but had been taught to serve residents the ways in the dining carts were stacked. She stated Resident #138 was not fed at the same time as her table-mate because she had been taught to not take the feeder trays off the dining cart until the resident was ready to be fed. NA #1 stated she had not received any training regarding calling residents feeders and had no idea it was a dignity issue to refer to residents as feeders. On 7/29/15 at 11:26 AM NA #2 was interviewed. NA #2 stated she had not been taught that all residents at one table needed to be served at the same time. She added she would not like to sit and watch others eat while she had no food. The NA stated she had been taught to not refer to residents requiring assistance with meals as feeders . The Staff Development Coordinator was interviewed on 7/30/15 at 9:12 AM. The SDC stated she was responsible for all the facility education. The SDC stated NAs were taught to pass trays in the dining room by room number, since the dining cart was set up by room number and not table. The SDC stated she thought there was an issue with residents sitting at the same table served their meal at different times. The SDC added one resident should not be eating in front of another without the other resident being offered food. The SDC stated she saw this as a dignity issue. The SDC added staff had been taught to call residents by their preferred name.