Every finding on record at Villa Crest Nursing and Retirement Center

Based on interview and record review, the facility failed to include all the required components in the facility water management program to prevent the potential growth and spread of waterborne pathogens in a facility with a census of 124 residents. Findings include:Review on 8/4/26 of the facilities Legionella Water Management Plan, undated revealed the following areas were not identified as a potential risk: eye wash stations or oxygen humidification and continuous positive airway pressure (CPAP) machines.Observation on 8/4/26 at approximately 11:20 a.m. of a resident room revealed oxygen with humidification and a CPAP machine that requires humidification.Observation on 8/6/26 at approximately 8:45 a.m. of facility laundry room revealed an eye wash station.Interview on 8/6/26 at approximately 8:45 a.m. with Staff A (Infection Preventionist) revealed the facility used US Center for Disease Control and Prevention (CDC) standards for infection control and further revealed that he/she was unable to speak to the water management plan and deferred to the Maintenance Director. Review on 8/4/26 of the facilities Legionella Water Management Plan, revealed Cold Water Distribution: Ice Machine with no identified control measures identified. Further review revealed no intervals for flushes for low use plumbing, testing of water (chlorine and Legionella), or filter changes.Review on 8/6/26 of the CDC at website: Controlling Legionella in Potable Water Systems | Control Legionella | CDC revealed, .Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits.Review on 8/4/26 of the facilities Legionella Water Management Plan, revealed description of water flow did not specify where water was stored. Further review revealed water storage tanks should have routine maintenance and temperatures maintained above 140 degrees Fahrenheit, without intervals of when to check temperatures or complete tank maintenance.Review on 8/6/26 of the CDC (Centers of Disease Control and Prevention) Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings Version 1.2, found at https://www.cdc.gov/control-legionella/php/toolkit/wmp-toolkit.html, updated 9/30/25, revealed.Elements of a water management) program.Describe your building water system using text.This description should include details like where the building connects to the municipal water supply, how water is distributed, and where.water heaters or boilers are located.Observation on 8/6/26 at approximately 2:45 p.m. of hot water tanks revealed 1 of 6 tanks had no thermometer.Review on 8/4/26 of the facility Legionella Water Management Plan, undated, revealed no identified corrective actions when control limits were not met.Interview on 8/5/26 at approximately 2:45 p.m. with Staff B (Maintenance Director) confirmed he/she was unable to provide evidence of filter changes, water chlorine testing, or water storage tank maintenance or temperature monitoring.

Based on observation, interview, and record review, the facility failed to ensure that medications were stored according to manufacturer's instructions for 1 of 2 medication rooms observed. Findings include:Observation on 8/4/26 at approximately 10:33 a.m. with Staff C (Licensed Practical Nurse) of the North Medication Room revealed that the thermometer in the medication refrigerator read 52 F (degrees Fahrenheit). Further observation revealed that the following unopened residents' medications were stored in the refrigerator:Two Lantus (insulin glargine) pensSeven Latanoprost Ophthalmic Solution 0.005% (percent) bottlesFive Novolin N (insulin isophane human) pensThirteen Novolin R (insulin human) pens Interview on 8/4/26 at approximately 10:33 a.m. with Staff C confirmed the above findings of the thermometer reading and the medications stored in the refrigerator. Staff C also confirmed that the refrigerator temperature was out of range and that the temperature should be between 36 F to 46 F. Review on 8/4/26 of the manufacturer's instructions for the above medications revealed the following: Lantus - store unused Lantus in a refrigerator between 36 F to 46 FLatanoprost - store unopened bottle(s) under refrigeration at 36 F to 46 FNovolin N - unopened store refrigerated at 36 F to 46 FNovolin R - unopened store refrigerated at 36 F to 46 F Review on 8/4/26 of the facility's policy titled Refrigerator Temperature Monitoring Policy, reviewed on 1/23/26, revealed that . Medication refrigerators shall be maintained according to manufacturer recommendations, generally 36 F to 46 F . unless otherwise specified.

Based on observation, interview and record review, it was determined that the facility failed to ensure that the dishes were sanitize according to manufacturer's instruction for 1 of 1 kitchen observed. Findings include:Observation on 7/29/25 at approximately 8:40 a.m. in the kitchen with Staff B (Dietary Services Director) revealed that two dietary aides were using the low temperature dishwasher. Staff B used a chlorine test strip and tested the chemical sanitizer (chlorine) of the dishwasher. The chlorine test strip did not change color indicating a lack of chlorine. Interview on 7/29/25 at approximately 8:40 a.m. with Staff B revealed that the dishwasher was a low-temperature chemical sanitizing dishwasher. Staff B stated that above tested failed because the chemical sanitizer needed to be replaced as it was low. Staff B stated that the dietary aides did not check the chemical sanitizer before washing the dishes through the dishwasher. Observation on 7/29/25 at approximately 9:00 a.m. with Staff B revealed that the dishwasher had a new chemical sanitizer bottle attached and that the dishwasher was in use. Staff B retested the chemical sanitizer with the chlorine test strip. The chlorine test strip did not change color indicating lack of chlorine.Interview on 7/29/25 at approximately 9:00 a.m. with Staff B confirmed the chemical sanitizer test failed and revealed that the dietary aides had not retested the chlorine prior to resuming dishwashing. Review on 7/30/25 of the facility's operation procedure for Machine Warewashing, undated, revealed .2. Make sure detergent and sanitizer dispensers are properly loaded 8. Check temperatures and chemical concentration for adequacy and record results. Follow manufacturers recommendations.Review on 7/31/25 of the Machine Warewashing Dishwasher manufacturer's instruction revealed a minimum temperature of 120 degrees Fahrenheit and required: 50 parts per million (ppm) available chlorine rinse.

Based on record review and interview, it was determined that the facility failed to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 24 residents. (Resident identifier is #76.)Findings include:Review on 7/31/25 of Resident #76's medical record revealed that the Resident #76 was admitted to the facility in 2014 and had a diagnosis of dementia with psychotic disturbance. Review on 7/31/25 of Resident #76's physician's orders revealed that Resident #76 had been receiving Risperdal (antipsychotic) 2 milligrams (mg) daily for Psychosis since 1/13/22.Review on 7/31/25 of Resident #76's Geriatric Psychiatry Progress Notes revealed the following entries:On 1/20/25, Resident #76 was at baseline, no acute concerns regarding mood, behaviors, appetite, sleep or safety, with no overt psychosis. Resident was due for a GDR but family will not agree;On 3/13/25, Resident #76 was stable and the Durable Power of Attorney (DPOA) continue to request that resident stays on current pharmacological treatment. No mental health issues documented; [NAME] 7/13/25, Resident #76 was at his/her baseline and had no psychiatric or behavioral concerns. Further review revealed .Patient's DPOA with long history of refusing GDR of risperdone in the past, thus will not attempt GDR of this medication unless patient develops apparent adverse effects.Review on 7/31/25 of Resident #76's nursing progress notes from June 2025 and July 2025 revealed there were no documentation of behaviors for Resident #76. Interview on 7/31/25 at 9:33 a.m. with Staff A (MDS Coordinator) confirmed that a GDR had not been attempted for Resident #76 and that there was no documentation of a clinical contraindication for a GDR.Interview on 7/31/25 at 11:17 a.m. with Staff C (RN) revealed that Resident #76 was pleasant and quiet. Staff C also revealed they had never seen Resident #76 with any psychotic or hallucination episodes. Review on 7/31/25 of the facility's policy, Tapering Medication and Gradual Dose Reduction revealed .3. The staff and practitioner will consider tapering of medications as one approach to finding an optimal dose of determining whether the continued use of a medication is benefiting the resident. 4. The staff and practitioner will consider tapering under certain circumstances, including when: a. the resident's clinical condition has improved or stabilized . 19. Residents who use psychotropic medication shall receive gradual dose reduction, unless clinically contraindicated, in an effort to discontinue the use of such drugs .

Based on observation, interview, and record review, it was determined that the facility failed to follow infection control and prevention guidelines to prevent cross-contamination by not wearing gowns when handling soiled linen and clothing in the laundry. Findings include: Review on 6/20/24 of the Centers for Disease Control and Prevention (CDC) Environmental Infection Control Guidelines, Section G. Laundry and Bedding, retrieved 6/20/24 from: https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html#:~:text=Handling%20contaminated%20laundry%20with%20a,aerosols%20in%20patient%2Dcare%20areas.&text=Sorting%20or%20rinsing%20contaminated%20laundry,occurred%20is%20prohibited%20by%20OSHA. revealed: .Although contaminated textiles and fabrics in health-care facilities can be a source of substantial numbers of pathogenic microorganisms, reports of health-care associated diseases linked to contaminated fabrics are so few in number that the overall risk of disease transmission during the laundry process likely is negligible. When the incidence of such events are evaluated in the context of the volume of items laundered in health-care settings . existing control measures (e.g., standard precautions) are effective in reducing the risk of disease transmission to patients and staff. Therefore, use of current control measures should be continued to minimize the contribution of contaminated laundry to the incidence of health-care associated infections. The control measures described in this section of the guideline are based on principles of hygiene, common sense, and consensus guidance; they pertain to laundry services utilized by health-care facilities . Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles . Review on 6/20/24 of the facility's policy Linen Processing, updated 9/2022, revealed, .Soiled laundry/bedding shall be handled, transported and process according to best practices for infection and control . 1. All used laundry is handled as potentially contaminated using standard precautions (e.g. gloves and gowns when sorting, if necessary) . Laundry Processing 1. Hand hygiene products, as well as appropriate PPE [Personal Protective Equipment] (i.e., gloves and gowns) are available and used while sorting and handling contaminated linens . Observation on 6/20/24 at 9:50 a.m. of the main laundry room revealed that there was no gowns visible for staff to use when sorting and/or loading soiled laundry in the washing machine. Interview on 6/20/24 at 9:50 a.m. with Staff F (Laundry Aide) revealed that there were no gowns available in the laundry room. Staff F stated that he/she had worked in the laundry for about 7 months and had never used or seen gowns being used by other laundry staff when sorting and touching soiled linen and clothing. Interview on 6/20/24 at 10:05 a.m. with Staff G (Housekeeping Supervisor) revealed that it was the facility's practice that laundry staff did not need to wear Personal Protective Equipment (PPE) other than gloves when sorting and handling soiled linens. Staff G stated that a gown should be used when handling soiled linen that comes from residents that were on transmission based precautions. Interview on 6/20/24 at 10:10 a.m. with Staff H (Laundry Aide) revealed that he/she had worked at the facility approximately one month full time in the laundry department. Staff H revealed that he/she had never seen or used a gown when sorting and processing soiled laundry. Staff H revealed that he/she had not been educated that a gown was needed when dealing with soiled laundry. Observation on 6/20/24 at 11:00 a.m. of Staff F revealed him/her loading soiled laundry into the washer. Staff G was not wearing a gown. Interview on 6/20/24 at 11:04 a.m. with Staff G confirmed that no gowns were available in the laundry room. Interview on 6/20/24 at 11:19 a.m. with Staff E (Infection Preventionist) revealed that it was the facility's practice that laundry staff did not need to wear a gown when processing soiled linen/laundry unless the resident was on transmission based precautions. Interview on 6/20/24 at 11:43 a.m. with Staff B (Director of Nurses) revealed that it was the facility's expectation that laundry staff wear a gown when handling contaminated linen/clothing. Interview on 6/20/24 at 12:29 p.m. with Staff I (Corporate Director of Nurses) revealed that the facility follows CDC guidelines for infection control policy and procedures.

Based on observation, record review,and manufacturers instructions, it was determined that the facility failed to follow professional standards when administering insulin for 1 out of 31 medications observed (Resident Identifier #83). Findings include: Observation on 6/19/24 at approximately 7:45 a.m. of Staff A (Licensed Practical Nurse) administering Resident #83's insulin revealed that the Lantus Glargine insulin pen was held for 4 seconds when administering the dose. Interview on 6/19/24 at approximately 7:45 a.m. of Staff A confirmed the above findings. Review on 6/19/24 of the manufacturers instructions for Lantus insulin Glargine injection 100 Units/ml (milliliters), dated 8/2022, revealed: .Step 5. Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.) .

Based on record review and interview, it was determined that the facility failed to ensure that as needed (PRN) psychotropic drugs were limited to 14 days for 2 residents in a final sample of 26 residents (Resident Identifiers are #112 and #11). Findings include: Resident #112 Review on 6/19/2024 of Resident #112's current physician orders revealed and order for Lorazepam Intensol 0.5 mg [milligrams] by mouth every 4 hours PRN for anxiety/restlessness that was initiated on 5/28/2024. Review on 6/19/2024 of Resident #112's June Medication Administration Record (MAR) revealed that 3 doses of as needed Lorazepam Intensol had been given in the month of June. Interview on 6/20/2024 at approximately 8:30 a.m. with Staff B (Director of Nursing) confirmed that there was no 14 day stop date or evaluation for continued use for the PRN Lorazepam since its origination date of 5/28/24. Staff B further confirmed that there should have been either an evaluation of the need to continue the order or a stop date 14 days after the start date of 5/28/24. Resident #11 Review on 6/19/24 of Resident #11's current physician orders revealed an order for Lorazepam Intensol 0.5 mg -Schedule IV concentrate: 2 mg/mL [milliliter] PRN every 4 hours for restlessness/agitation that was initiated on 5/10/24. Review on 6/19/24 of Resident #11's June MAR revealed that Resident #11 had not used the medication. Interview on 6/19/24 at approximately 2:48 p.m. with Staff B confirmed that there was no 14 day stop date or evaluation for continued use for the PRN Lorazepam since its origination date of 5/10/24. Staff B further confirmed that there should have been either an evaluation of the need to continue the order or a stop date 14 days after the start date of 5/10/24. Review on 6/20/24 of facility policy titled Psychotropic Medication, dated 9/2022, revealed: 11 . (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .

Based on interview and record review, it was determined that the facility failed to ensure admission medications were available for 1 of 1 newly admitted resident reviewed for medications (Resident Identifier is #221). Findings include: Interview on 5/31/23 at 1:20 p.m. with Resident #221 revealed that he/she admitted to the facility on [DATE] and was not administered any medications that evening. Review on 5/31/23 of Resident #221's face sheet revealed that Resident #221 admitted to the facility on [DATE] at 3:21 p.m. Review on 5/31/23 of Resident #221's May 2023 Medication Administration Record revealed the following medications ordered: Clonazepam tablet 0.5 milligrams (mg) - due at 9:00 p.m. - not administered: drug/item unavailable - comment: New admit. Donepezil 10 mg - due at 9:00 p.m. - not administered: drug/item unavailable - comment: Busy on unit Klor-Con (potassium) 20 milliequivalent (mEq) give 60 mEq - due at 9:00 p.m. - not administered: drug/item unavailable - comment: Busy on unit. Metformin 500 mg give 1000 mg - due at 9:00 p.m. - not administered: drug/item unavailable. The above notations were documented by Staff F (Registered Nurse). Interview on 6/01/23 at 2:58 p.m. with Staff B (Unit Manager) confirmed that Resident #221 admitted [DATE] in the afternoon. Staff B revealed that he/she was aware that Resident #221 did not receive his/her Klor-Con and that he/she had received an additional dose of potassium on 6/1/23 due to his/her lab value being low. Review on 6/1/23 of the facility's Cubex/Medbank Content (an automated medication administration system) revealed that the above four medications were available in the facility. Interview on 6/1/23 at 3:05 p.m. with Staff F revealed that he/she did not have access to the Cubex/Medbank Content system. Staff F confirmed that he/she did not administer Resident #221's medications that evening and stated that it had been a busy night. Interview on 6/1/23 at 3:31 p.m. with Staff F revealed that he/she did not notify the physician that Resident #221 did not get his/her medications. Review on 6/2/23 of Resident #221's potassium lab drawn on 5/31/23 at 7:55 a.m. revealed it was 2.8 [low]. Review on 6/2/23 of Resident #221's progress note dated 5/31/23 at 9:55 a.m. revealed Resident noted to miss evening medication, provider aware and labs drawn this AM [sic], and received an extra dose of potassium . This note was recorded as a late entry note on 6/1/23 at 3:57 p.m. Interview on 6/2/23 at 9:19 a.m. with Staff D (Director of Nursing) revealed that he/she had not been aware that Resident #221 did not receive his/her medications on 5/30/23 until 6/1/23. Staff D confirmed that he/she would expect Staff F to notify the supervisor if he/she needed assistance with obtaining the medications from the Cubex/Medbank Content system. Review on 6/2/23 of the facility's policy titled Administering Mediations dated 9/22 revealed, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders . 17. If a medication is unavailable and licensed nurse is unable to obtain medication, the licensed nurse shall document as not administered and the reason for not administering the ordered medication. The nurse should alert the Provider for approval or for an alternative medication until the originally scheduled medication becomes available .

Based on observation, interview, and record review, it was determined that the facility failed to store thickened liquids according to manufacturer's instructions in 1 of 3 kitchenettes observed, 1 of 1 main dining room, and 1 of 1 main kitchen observed. Findings include: Observation 5/31/23 at 9:35 a.m. of the main dining room refrigerator revealed a carton of thickened apple juice and a carton of thickened water, both with no dates of opening. Further observation revealed that both cartons had manufacturer's instructions which read .After opening, may be kept up to 7 days under refrigeration . Observation on 5/31/23 at 9:40 a.m. of the North side kitchenette refrigerator revealed one carton of thickened orange juice with no date of opening. Further observation revealed the carton had manufacturer's instructions which read .After opening, may be kept up to 7 days under refrigeration . Observation on 5/31/23 at 9:45 a.m. of the main kitchen dining room refrigerator revealed a carton of thickened cranberry juice and a carton of thickened orange juice with no dates of opening. Further observation revealed the carton had manufacturer's instructions which read .After opening, may be kept up to 7 days under refrigeration . Interview on 5/31/23 at 9:45 a.m. with Staff E (Director of Food and Nutrition) confirmed that the cartons were not dated when they had been opened. Review on 5/31/23 of the facility's policy titled Safety & Sanitation Best Practice Guidelines revised in 2019, revealed, .Juices and thickened juices . Storage time . 7 days once opened .

Based on interview and record review, it was determined that the facility failed to ensure that a newly admitted resident received potassium medication as ordered for 1 of 1 newly admitted resident reviewed for medications (Resident Identifier is #221). Findings include: Interview on 5/31/23 at 1:20 p.m. with Resident #221 revealed that he/she admitted to the facility on [DATE] and was not administered any medications last evening. Review on 5/31/23 of Resident #221's face sheet revealed that Resident #221 admitted to the facility on [DATE] at 3:21 p.m. Review on 5/31/23 of Resident #221's May 2023 Medication Administration Record revealed a physician's order for Klor-Con (potassium) 20 milliequivalent (mEq) give 60 mEq scheduled to be administered at 9:00 p.m. Further review revealed that Staff F (Registered Nurse) documented that the Klor-Con was not administered: drug/item unavailable comment: busy on unit. Interview on 6/01/23 2:58 p.m. with Staff B (Unit Manager) revealed that Resident #221 did not receive his/her Klor-Con and that he/she had received additional dose of potassium on 6/1/23 due to his/her lab value being low. Interview on 6/1/23 at 3:05 p.m. with Staff F revealed that he/she did not administer Resident #221's medications that evening, including the Klor-Con. Interview on 6/1/23 at 3:31 p.m. with Staff F revealed that he/she did not notify the physician that Resident #221 did not get his/her Klor-Con. Review on 6/2/23 of Resident #221's potassium lab drawn on 5/31/23 at 7:55 a.m. revealed it was 2.8 [low]. Review on 6/2/23 of Resident #221's progress note dated 5/31/23 at 9:55 a.m. revealed Resident noted to miss evening medication, provider aware and labs drawn this AM [sic], and received an extra dose of potassium . This note was recorded as a late entry note on 6/1/23 at 3:57 p.m. Review on 6/2/23 of the facility's policy titled Administering Mediations dated 9/22 revealed, .Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders . 17. If a medication is unavailable and licensed nurse is unable to obtain medication, the licensed nurse shall document as not administered and the reason for not administering the ordered medication. The nurse should alert the Provider for approval or for an alternative medication until the originally scheduled medication becomes available .

Based on observation, interview, and review of manufacturer's instructions, it was determined that the facility failed to label opened glucometer control solution bottles with expiration dates to ensure glucometers were in safe operating condition. Findings include: Observation on 5/31/23 at approximately 12:30 p.m. of opened high and low control solution bottles revealed no opened dates or open expiration dates in the South unit medication room. Interview on 5/31/23 at approximately 12:40 p.m. with Staff B (Licensed Practical Nurse / Nurse Manager) confirmed the above finding. Review of control solution manufacturer's instructions, dated 7/16, revealed: Discard any unused control solution 90 days after first opening or after expiration date, whichever comes first. Review of policy titled, EvenCare G3 Blood Glucose Monitoring, last revised 3/2/23, revealed: Record the date on the bottle when opening a new bottle of control solution. Discard any unused control solutions 3 months after opening date or until expiration date on on the bottle, whichever comes first.

Based on observation, interview and record review, it was determined that the facility failed to follow acceptable professional principles of labeling and/or storing drugs for 2 out of 2 medication storage rooms and 1 out of 3 medication carts observed during a standard survey. Findings include: Observation on [DATE] at approximately 10:40 a.m. of the North wing medication storage room refrigerator with Staff A (unit manager) revealed an open box of Acetaminophen 500 mg (milligram) suppositories with a manufacturer's expiration date of ,d+[DATE]. Interview on [DATE] at approximately 10:40 a.m. with Staff A confirmed the above findings. Observation on [DATE] at approximately 10:50 a.m. of the North wing medication storage room with Staff B (unit manager) revealed an unopened bottle of Acetaminophen 500 mg tablets with a manufacturer's expiration date of ,d+[DATE]. Interview on [DATE] at approximately 10:50 a.m. with Staff B confirmed the above findings. Observation on [DATE] at approximately 11:10 a.m. of the South wing 2nd medication cart with Staff B revealed, Resident #19's Glucogon emergency kit labeled with a manufacturer's expiration date of ,d+[DATE]. Further observation revealed, Resident #36's Glucogon emergency kit labeled with a manufacturer's expiration date of ,d+[DATE]. Further observation revealed, Resident #67's open vial of [MEDICATION(S)] R 1000 labeled with an opened date of [DATE] and a pharmacy label that read Discard 31 days after opening. Interview on [DATE] at approximately 11:10 a.m. with Staff B confirmed the above findings. Staff B confirmed that Resident #67 has an active order for [MEDICATION(S)] R. Review on [DATE] at approximately 2:00 p.m. of Resident #67's May and June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on [DATE] at approximately 9:00 a.m. of facility policy titled Disposal/Destruction of Expired or Discontinued medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility should place all discontinued or outdated medication in a designated secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction . Review on [DATE] at approximately 9:00 a.m. of [MEDICATION(S)] R manufacturer's instructions revealed, .After vials have been opened: .Throw away all open vials after 31 days, even if there is still insulin left in the vial .

Based on observation, interview and record review, it was determined that the facility failed to meet accepted professional standards of practice for oxygen therapy in 2 residents out of 2 residents reviewed for oxygen therapy in a survey sample of 23 residents. Professional Standard: Patricia A. Potter & Ann Griffin Perry, Fundamentals of Nursing. 7th edition St. Louis, Missouri: Mosby Elsevier, 2009 Page 336: .Physicians' Orders. The physician is responsible for directing medical treatment . Findings include: Resident #82 Observation on 6/09/21 at approximately 9:27 a.m. of Resident #82 revealed oxygen in use at a rate of 0.5 liters per minute. Further observation of oxygen tank revealed that the lowest setting of delivery was 0.5 liters. Review on 6/9/21 at approximately 9:30 a.m. of Resident # 82's June 2021 MAR (Medication Administration Record) revealed an active order for Titrate O2 (oxygen) via NC (nasal cannula) to keep SATS (oxygen saturation) between 89-90 no higher. Further review of June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/10/21 at approximately 10:00 a.m. of resident #82 revealed oxygen running at 0.5 liters per min. Review on 6/10/21 at approximately 10:09 a.m. of resident #82's June MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/10/21 at approximately 2:50 p.m. with Staff C (Registered Nurse) confirmed the above findings. Staff C stated that resident #82 was given the wrong tank and said she would change tank to the tank that delivers the lowest setting of 0.25 liters. Observation on 6/11/21 at approximately 8:30 a.m. of Resident #82's oxygen tank revealed setting at 0.5 liters per minute. Further observation revealed the lowest setting on oxygen container was 0.5 liters Review on 6/11/21 at approximately 8:35 a.m. of Resident #82's June MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/11/21 at approximately 8:30 a.m. with Staff C revealed that nursing staff are responsible for adjusting oxygen amount based on oxygen saturation. Staff C stated that there are 2 tank options one that goes as low as 0.25 liters per minute and one that goes as low as 0.5 liters per minute. Staff C stated it is up to nursing staff to switch out the tanks. Staff C was asked what the process is if the oxygen saturation goes above 90%. Staff C stated they would lower the rate down. Review on 6/11/21 at approximately 9:15 a.m. of Resident #82's June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . June 1 Day shift- 0.2 Liters -91% saturation Evening shift-0.25 liters -92% saturation Night shift- 0.5 liters - 88% saturation June 2 Day shift- 0.2 liters- 91% saturation June 3 Day shift- 0.2 liters- 91% saturation Night shift- 0.5 liters-88% saturation June 4 Night shift- 0.5 liters- 96% saturation June 5 Day shift- 0.25 liters- 91% saturation Evening shift- 0.2 liters- 91% saturation Night shift- 1 liter- 96% saturation June 7 Night shift- 0.5 liters- 88% saturation June 9 Evening shift- 0.25 liters-95% saturation Night shift- 0.5 liters- 93% saturation June 10 Night shift- 0.5 liters- 91% saturation June 11 Day shift- 0.5 liters- 91% saturation Interview on 6/11/21 at approximately 9:52 AM with Staff D (Director of Nursing) confirmed the above findings. Interview on 6/11/21 at approximately 9:52 a.m. with Staff E (Registered Nurse) revealed that the nurses would routinely check the oxygen rate and oxygen saturation rate throughout the shift and adjust it to stay within ordered range. Staff E confirmed there is no documentation stating that rechecking or adjustments were made. Resident #22 Review on 6/11/21 at approximately 9:00 a.m. of Resident # 22's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed 9 entries out of 10 entries in June the oxygen saturations were above 92 and no documentation that the rate was adjusted and oxygen saturation rechecked. June 2-0.75 liters-95% saturation June 3- 0.75 liters- 95% saturation June 4- 0.5 liters- 94% saturation June 5- 0.5 liters- 94% saturation June 6- 0.75 liters- 95% saturation June 7- 0.75 liters- 95% saturation June 8- 0.75 liters- 94% saturation June 9- 0.5 liters- 95% saturation June 10- 0.75 liters- 94% saturation Review on 6/11/21 at approximately 9:30 a.m. of Resident #22's medial record revealed no documentation of rechecking or changing of oxygen administration level to keep oxygen saturation within ordered range. Interview on 6/11/21 at approximately 9:52 AM with Staff D confirmed the above findings. Review on 6/11/21 of facility policy titled Oxygen Policy revised on 5/25/20 revealed, .Documentation must adhere to NHC [National Healthcare Corporation] Documentation Guidelines. 1. Assess findings and oxygen monitoring results such as pulse oximetry. 2. Oxygen flow rate. 3. Document any changes in patient response to oxygen therapy. 4. Any change of equipment or maintenance of equipment .

Based on medical record review and interview, it was determined that the facility failed to ensure that services being provided meet professional standards for 1 resident whose weights were not properly documented and for 1 resident for whom physicians' orders were not followed in a final survey sample of 29 residents. (Resident identifiers are #55 and #77.) Findings include: [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 564: If the client has lost more than 5% of body weight in a month or 10% in 6 months, the loss is significant. You need to weigh clients at the same time of day, on the same scale, and in the same clothes to allow an objective comparison of subsequent weights. Accuracy of weight measurement is important because health care providers will base medical and nursing decisions . on changes [NAME] [NAME] Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the client suffers Resident #55 Review on 8/27/19 of Resident #55's medical record revealed under the vital sign section of the chart that the last weight that was done was on 8/22/19 showing 154.6 pounds. The prior weight done on Resident #55 was on 8/15/19 which was 167.7 pounds, a 7.8 % weight loss in one week. On 8/8/19 Resident #55's weight was 169.2 pounds, and on 8/1/19 was 163 pounds. Interview on 8/27/19 at 8:44 a.m. with Staff B (Unit Manager) who was shown the weight logs, Staff B stated Resident #55 had been ill for a short period of time, but felt that he never could have weighed 167.7 lbs (pounds) and was closer to weighing between 155 and 160 lbs. Staff B stated that she will get a reweigh which was performed and Resident #55's weight is 157.6 as of 8/27/19 at 2:30 p.m. Staff B also revealed that they did do a medication reduction of [MEDICATION NAME] which caused decrease in appetite and increase in behavior. Medications were reordered with a GDR (Gradual Drug Reduction) failure. Staff B went on to say the issue stems from the staff using different types of equipment when weighing residents and not deducting the equipment being used. Resident #77 Review on 8/30/19 Resident #77's MAR (Medication Administration Record) revealed a physician order [REDACTED]. [MEDICATION NAME] R Regular U-100 Insulin (insulin regular human) (OTC (over the counter)) solution; 100 unit/ml; Amount to Administer: Per Sliding Scale; If Blood Sugar is 0-180, give 0 units. If Blood Sugar is 181 to 240, give 2 Units. If Blood Sugar is 241 to 300, give 4 Units. If Blood Sugar is 301 to 350, give 6 Units. If Blood Sugar is 351 to 400, give 8 Units. If Blood Sugar is greater than 400, give 10 Units. If Blood sugar is greater than 400, call MD (physician). injection Further review of the MAR indicated [REDACTED]. Then the next scheduled time for Resident #77's Blood Sugar was at 11:00 a.m. with a charted date-time of 10:22 Not Administered: Due to Condition and no Blood Sugars were documented. Review on 8/30/19 at 10:02 a.m. of Resident #77 medical record revealed has a nurses note dated 8/4/19 that revealed 12 p.m. resident unresponsive. Clammy and pale. Blood sugar done: 23 [MEDICATION NAME] given IM (Intramuscularly) . 12:15 BS-49 12:15 [MEDICATION NAME] IM repeated. 12:30-BS-67 1:00 BS (Blood Sugar)-71 115 BS -131 1:30 BS-302. Resident alert and oriented. Had 100% of lunch. Used BR (bathroom) facilities. Lg (large) Void and med bm (bowel movement). No further hypoglycemic signs noted on this shift. Review on 8/30/19 of the MAR indicated [REDACTED].Amount to Administer: 1 mg; injection Resident #77 was administered this medication two times. Review on 8/30/19 of the MAR indicated [REDACTED]. If this occurs at meal time-order tray. Hold insulin dose and call provider. On review of the MAR for 8/25/19 at 6:20 a.m. Blood Sugar was at 51 mg and there was no documentation of administration of the above order. This also happened on 8/26/19 at 6:31 am with Blood Sugar at 58 mg. Review on 8/30/19 of the MAR indicated [REDACTED]. If Blood sugar is greater than 400, call MD. injection On review of the MAR for 8/4/19 at 7:33 p.m. Blood Sugar was at 415 mg and there was no documentation showing that the physician was called in the nurses notes or anywhere else in the chart. Interview on 8/30/19 at 1:30 p.m. with Staff A (Director of Nurses) who was shown all the information written above and Staff A confirmed the above findings.

Based on observation and interview, it was determined that the facility failed to properly maintain supplementary products in 2 of 3 nourishment kitchens, and failed to ensure proper sanitizing solution used in the kitchen's three compartment sink. Findings include: Observation on 7/27/16 at approximately 9:15 a.m. of the nourishment kitchen on the south unit revealed approximately 25 undated thawed supplemental shakes in the refrigerator. Observation on 7/27/16 at approximately 9:20 a.m. of the nourishment kitchen on the special care unit revealed approximately 12 undated thawed supplemental shakes in the refrigerator. Interview on 7/27/16 at approximately 9:20 a.m. with Staff A (Director of Food Services) confirmed the above findings. Review of the supplemental shake carton revealed the following instructions: After thawing, keep refrigerated. Use within 14 days after thawing. Observation on 7/27/16 at approximately 9:00 a.m. of pHydrion testing of the Oasis 146 Multi-Quat Sanitizer in the kitchen's three compartment sink performed by Staff B (Kitchen Manager), revealed a result of 500 parts per million (ppm). The water in the sanitizing sink was approximately 6 inches above the designated fill line at the time of testing. Observation on 7/28/16 at approximately 9:15 a.m. of the pHydrion testing of the Oasis 146 Multi-Quat Sanitizer in the kitchen's three compartment sink performed by Staff B (Kitchen Manager), revealed a result of 500 ppm. The water in the sanitizing sink was approximately 6 inches below the fill line at the time of testing. Review of the manufacturer's directions for use for the Oasis 146 Multi-Quat Sanitizer revealed that the sanitizing solution should be between 150-400 ppm. Interview on 7/28/16 at 9:15 a.m. with Staff A and Staff B confirmed the facility used the manufacturer's range of 150-400 ppm for the sanitizing solution in the three compartment sink and that the water in the sanitizing sink should be at the designated fill line in order to mix an effective solution.

Based on observation and interview, it was determined that the facility failed to follow the professional standards of practice along with the facility policy and procedure for the disposal of medications for 1 out of sample resident. (Resident identifier is #25.) Findings include: The facility policy tilted Discarding and Destroying Medications with a revision date of October 2014 .6. revealed, For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA (Environmental Protection Agency) recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medications, either liquids or solid, with an undesirable substance. Undesirable substance include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. c. Dispose with the solid waste (i.e., regular trash) d. Document the disposal on the medication disposition record . 9. Ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room. Observation on 7/27/16 at approximately 7:50 a.m. during a medication pass with Staff C (Licensed Practical Nurse) revealed Staff C preparing multiple medication tablets for Resident #25. Staff C dropped these medication tablets on the medication cart. Staff C picked the medication tablets up and placed the tablets into a medication cup and discarded this medication cup into the trash container attached to the medication cart which can be accessed by unauthorized individuals.

Based on observations and interviews the facility failed to maintain food preparation equipment, store ice scoops in clean areas and monitors temperatures to ensure sanitary conditions. Findings include: Observation during the initial tour of the kitchen on 9/2/15 at 8:00 a.m. revealed that the electric meat slicer had pieces of dried meat on the shelf under the meat slicer. Inspection of the kitchen mixer revealed dried food caked along the back splash. Interview with Staff A (Food Services) at 8:15 a.m. confirmed the above findings. Staff A revealed it would be the kitchen's policy to clean equipment immediately following use and that neither the meat slicer or kitchen mixer had been used that morning. Observation on 9/2/15 at 8:30 a.m. of the portable ice coolers kept on the units revealed that there were ice scoops that were not stored in clean areas. On the south unit, the ice scoop was laying horizontal in its holder touching a brown moist substance on the bottom of the holder. On the special care unit, the ice scoop was in a vertical scoop holder and the scoop end was touching water that had accumulated in the bottom of the holder. The ice scoop holder on the special care unit also had a brown substance on the bottom of the holder. Interview with Staff B (Assistant Food Services Supervisor) on 9/2/15 at 8:50 a.m. confirmed the above findings and revealed that the ice from the coolers on the units were for consumption. Staff B was able to wipe away the brown substance from the scoop holder on the south unit. Interview with Staff B on 9/2/15 at 9:00 a.m. revealed temperatures are not taken from the food on the food tray line or the high temperature dishwasher in the kitchenette on the special care unit. Interview also revealed that breakfast, lunch, and dinner are served from the special care unit food tray line and the special care unit dishes are cleaned in the kitchenette's high temperature dishwasher.

Based on record review, the facility failed to ensure that physician's orders were clear and complete for 3 residents in a survey sample of 24 residents. (Resident identifiers are #13, #14, and #21) Findings include: Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009, on page 336 relates The physician is responsible for directing medical treatment. Nurses follow physicians ' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary And on page 708 it relates The prescriber often gives specific instructions about when to administer a medication The text also relates on page 707 The six rights of medication administration include . The right medication . The right dose . The right route . The right time and on page 691 Excess amounts of a medication within the body sometimes have lethal effects, depending on the medication's action The facility made available for review an undated Administration of Drugs Policy Statement which states, in part, All medications ordered will be administered orally unless otherwise indicated by the provider. Resident #14 Review of Resident #14's August 2015 Physician's Orders sheets, signed by the physician on 8/17/15 reveals two prn (as needed) pain medication orders with no parameter provided to specify when one medication should be selected over the other: [MEDICATION NAME] 650 mg by mouth every 4 hours, and [MEDICATION NAME] 50 mg by mouth every 6 hours. Review of documented Physician's Orders reveals an 8/10/15 order for Healthshakes daily which lacks a dose. Resident #21 Review of Resident #21's August 2015 Physician's Orders sheets, signed by the physician, reveals an order for [REDACTED]. Resident #13 Review of Resident #13's Physician orders on the Medication Administration Record [REDACTED] pg 1 [MEDICATION NAME]: NOT TO EXCEED 3 GM/24HRS FROM ALL SOURCES dated 2/9/12 pg 2 [MEDICATION NAME] ([MEDICATION NAME]) 500MG CAPLET IC:Tylenol 2 CAPLETS (1000 MG) BY MOUTH THREE TIMES A DAY - MAX ACETAM 3-4 g (grams); ck DAILY TOTAL dated 10/2/14 pg 4 [MEDICATION NAME] (GENEBS) 325MG TABLET IC:Tylenol 325MG 2 TABS (650MG) PO (by mouth) EVERY 4 HOURS AS NEEDED PAIN/TEMP 101 OR > (GREATER) dated 6/5/09 The MARs' documents [MEDICATION NAME] 2 Caplets (1000mg) were administered 3 times per day at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Resident #13 received 3000mg or 3 grams per day for the months June, July and August 2015. If the order for scheduled Tylenol 1000 mg is followed and given 3 times per day the Resident #13 will have received the 3 grams or 3000 mg maximum as noted on pg 1. If the PRN (as needed) dose of 650 mg order (pg 4) is administered in addition to the scheduled dose of total 3000mg/ 3 grams the facility will exceed the Physicain parameter not to exceed 3 grams in 24 hours. If a second PRN dose of 650 mg were given the Resident dose of 3000mg plus 2 doses of 650 would exceed the 4 Gram or 4000 mg limit noted on page 2. If the PRN orders were to be administered the facility would be exceeding either the 3 gram limit (pg 1) and or 4 gram limit (pg2); violating the Physician's ordered parameters.

Resident #2 and #25 On 9/15/10, at approximately 8:30 a.m., during a morning medication pass observation with Staff A, (LPN), a staff nurse on 1 of 3 med carts on the South unit, it was observed that Resident #2 had an order for [REDACTED].). When Staff A started to document the pending administration of the [MEDICATION NAME] to Resident #2 on the Controlled Medication Administration Record (Narcotics Log Sheet), it was observed that there was an entry already noted on the line above for 9/15/10 at 6 a.m. for Resident #2. When asked, Staff A stated that the 6 a.m. entry had been made by Staff B, (RN), on the 11 - 7 shift. Staff A, immediately, in the presence of this surveyor, checked Resident #2's MAR and confirmed no [MEDICATION NAME] had been documented as administered to Resident #2 at 6:00 a.m., either scheduled or prn (as needed). Staff A then looked at the MAR for Resident #25 and noted that there was a 5:00 a.m. entry indicating [MEDICATION NAME] "ER" 60 mg had been administered to Resident #25 that day. Review of the Controlled Medication Utilization Record for Resident #25 revealed no evidence of any narcotics entries for 9/15/10. Staff A then went to speak with her Unit Manager, Staff C, (RN, South Unit Manager / Acting DON), asking Staff C to call Staff B at home to discern exactly what had happened earlier that day on the 3rd shift. A few minutes later Staff C, returned to Staff A's medication cart to inform Staff A and this surveyor that Staff B had stated that she had accidentally removed a dose of [MEDICATION NAME] "ER" 60 mg from Resident #2's medication card instead of Resident #25's medication card and that she had administered that dose to Resident #25 at the correct time, medication and dosage. Staff C further stated that Staff B confirmed no medications were removed from Resident #25's medication card that morning (9/15/10). Based on Staff C's investigation, Staff A was observed to administer Resident #2's [MEDICATION NAME] "ER" 60 mg, on schedule. Resident #15. Record review on 9/16/10 of the facility "MASTER [DIAGNOSES REDACTED]. "9-11-10 [MEDICAL CONDITION], Depression/Anxiety, Chronic [MEDICAL CONDITION], RA/OA ([MEDICAL CONDITION] arthritis/[MEDICAL CONDITION]), Varicose Veins,[MEDICAL CONDITION](hypertension), Rosacea, Advanced [MEDICAL CONDITION] arthritis, Polyuria, Poor Nutritional Status, Vitamin D deficiency, Osteopenia, L (left) anterior hemiblock, Dementia and Chronic constipation." Review of the "SOCIAL SERVICES" notes for Resident #15 dated "9/13/10" revealed that Resident #15 was a "Hospice patient with end stage dementia" and "will stay at the facility until 9/19 for respite care" Review of the "HOSPICE NURSE VISIT NOTE AND CARE PLAN" for Resident #15 dated "9/14/10" revealed the following documentation: "L hand/limb contracted dependent for all care" and "currently here for Respite care." Review on 9/16/10 of the facility "INITIAL CARE PLAN" for Resident #15 revealed that the facility failed to develop a plan of care for the newly admitted Resident #15 by not identifying and care planning with interventions and goals for the following areas related to the documented admitting Diagnoses: [REDACTED]. 1. ADL (activities of daily living) Decline, related to dependent for care due to the left hand and limb contracture. 2. Bowel elimination, related to a [DIAGNOSES REDACTED]. 3. Communication, related to end stage dementia. 4. Pain, related to [DIAGNOSES REDACTED]. 5. Palliative Care, related to respite admission and Hospice services. 6. Nutrition, related to poor nutritional status diagnosis. During interview with Staff C (Registered Nurse) and Staff D (Licensed Practical Nurse, Assistant Director of Nursing) on 9/16/10 at approximately 10:30 a.m. after Staff C and Staff D reviewed the above listed findings for Resident #15, Staff C and Staff D confirmed that the "INITIAL CARE PLAN" for Resident #15 was not complete and accurate with sufficient documented information to identify areas of care with interventions and goals related to the admitting [DIAGNOSES REDACTED].

Based on observation, record review and interview the Facility failed to ensure that narcotic medication was properly dispensed for 2 residents in a standard survey sample of 24 and failed to ensure that the interim care plan was complete for 1 resident in a standard survey sample of 24. (Resident identifiers are: #2, #25, and #15.) Findings include: Standards: Review of Fundamentals of Nursing, 7th Edition, by Potter and Perry, Philadelphia, PA, Copyright 2009 by Mosby, Inc., an affiliate of Elsevier Inc., Unit VI, Scientific Basis for Nursing Practice, page 719, Skill Table ,[DATE], Administering Oral Medications, reveals at Step 1. Check accuracy and completeness of each MAR or computer printout with the prescriber's original medication order. Check client's name and medication name, dosage and route and time for administration. ... Step 7. Prepare medications: section e. Select correct medication from stock supply or unit-dose drawer. Compare label of medication with MAR, computer printout or computer screen. Review of the pharmacy manual, provided by Staff D, (LPN, ADON) and confirmed by Staff D to be the current guidelines the facility is utilizing, reveals at Section 5.02 MEDICATION ADMINISTRATION PROCEDURES, notation #6: If a dose of regularly scheduled medication is withheld or refused, the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes or in the PRN nurses notes section of the medication administration record. Review of the pharmacy manual reveals at Section 5.02 MEDICATION ADMINISTRATION PROCEDURES, notation #12: "Medications prescribed for one resident are not to be administered to any other resident. Further review of the facility's pharmacy manual reveals at notation #16: There shall be a narcotic audit at each change of shift to ensure against any discrepancy. Upon a correct audit, the nurses involved will sign the Controlled Substance Shift Count Sheet.... At the time of the audit, the nurses are to observe for correct count and correct medication. Residents #2 and #25 On [DATE], at approximately 8:30 a.m., during a morning medication pass observation with Staff A, ( LPN) a staff nurse on 1 of 3 med carts on the South unit, it was observed that Resident #2 had an order for [REDACTED].). When Staff A started to document the pending administration of the [MEDICATION NAME] to Resident #2 on the Controlled Medication Administration Record (Narcotics Log Sheet), it was observed that there was an entry already noted on the line above for [DATE] at 6 a.m. for Resident #2. When asked, Staff A stated that the 6 a.m. entry had been made by Staff B, (RN), on the 11 - 7 shift. Staff A, immediately, in the presence of this surveyor, checked Resident #2's MAR and confirmed no [MEDICATION NAME] had been documented as administered to Resident #2 at 6:00 a.m., either scheduled or prn (as needed). Staff A then looked at the MAR for Resident #25 and noted that there was a 5:00 a.m. entry indicating [MEDICATION NAME] "ER" 60 mg had been administered to Resident #25 that day. Review of the Controlled Medication Utilization Record for Resident #25 revealed no evidence of any narcotics entries for [DATE]. Staff A then went to speak with her Unit Manager, Staff C, (RN, South Unit Manager / Acting DON), asking Staff C to call Staff B at home to discern exactly what had happened earlier that day on the 3rd shift. A few minutes later Staff C, returned to Staff A's medication cart to inform Staff A and this surveyor that Staff B had stated that she had accidentally removed a dose of [MEDICATION NAME] "ER" 60 mg from Resident #2's medication card instead of Resident #25's medication card and that she had administered that dose to Resident #25 at the correct time, medication and dosage. Staff C further stated that Staff B confirmed no medications were removed from Resident #25's medication card that morning ([DATE]). Based on Staff C's investigation, Staff A was observed to administer Resident #2's [MEDICATION NAME] "ER" 60 mg, on schedule. Standard: Review excerpt from the HCPro Book, The Long-Term Care Nursing Desk Reference, Second Edition by Barbara Acello, MS, RN. "Use the nursing process to develop an interim care plan upon admission......should address the most important problems and high-risk conditions." Resident #15. Record review on [DATE] of the facility "MASTER [DIAGNOSES REDACTED]. "[DATE] [MEDICAL CONDITION], Depression/Anxiety, Chronic [MEDICAL CONDITION], RA/OA ([MEDICAL CONDITION] arthritis/[MEDICAL CONDITION]), Varicose Veins,[MEDICAL CONDITION](hypertension), Rosacea, Advanced [MEDICAL CONDITION] arthritis, Polyuria, Poor Nutritional Status, Vitamin D deficiency, Osteopenia, L (left) anterior hemiblock, Dementia and Chronic constipation." Review of the "SOCIAL SERVICES" notes for Resident #15 dated "[DATE]" revealed that Resident #15 was a "Hospice patient with end stage dementia" and "will stay at the facility until ,[DATE] for respite care" Review of the "HOSPICE NURSE VISIT NOTE AND CARE PLAN" for Resident #15 dated "[DATE]" revealed the following documentation: "L hand/limb contracted dependent for all care" and "currently here for Respite care." Review on [DATE] of the facility "INITIAL CARE PLAN" for Resident #15 revealed that the facility failed to develop a interim plan of care for the newly admitted Resident #15 by not identifying and care planning with interventions and goals for the following areas related to the documented admitting diagnoses. 1. ADL (activities of daily living) Decline, related to dependent for care due to the left hand and limb contracture. 2. Bowel elimination, related to a [DIAGNOSES REDACTED]. 3. Communication, related to end stage dementia. 4. Pain, related to [DIAGNOSES REDACTED]. 5. Palliative Care, related to respite admission and Hospice services. 6. Nutrition, related to poor nutritional status diagnosis. During interview with Staff C and Staff D at approximately 10:30 a.m. after Staff C and Staff D reviewed the above listed findings for Resident #15, Staff C and Staff D confirmed that the "INITIAL CARE PLAN" for Resident #15 did not identify and sufficiently list all the areas of care with interventions and goals related to the admitting [DIAGNOSES REDACTED].