Every finding on record at Warde Health Center

Based on observation, interview, and record review, the facility failed to ensure medications were stored safely by removing expired medications and properly labeling medications with a shortened shelf-life (such as multi-dose vials) for 1 of 1 medication carts (Resident identifiers are #3, #6, and #19.) Findings include: Observation on 3/3/26 at approximately 8:30 a.m. of the Mercy Hall Medication Cart revealed:Resident #3's Latanoprost 0.005% (percent) Opthalmic Drops, opened and not labeled with a date of opening or expiration.Resident #6's Lantus Solostar Insulin Pen, opened and not labeled with a date of opening or expiration.Resident #19's Rhopressa 0.02% Opthalmic Drops, opened and labeled with a date of opening of 1/12/26. Interview on 3/3/26 at approximately 8:35 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Review on 3/3/26 of the manufacturer's instructions for Rhopressa Opthalmic Drops, dated 2024, revealed, . after opening the product may be kept at, . for up to 6 weeks.Review on 3/3/26 of the manufacturer's instructions for Lantus Insulin, dated 2019, revealed, The opened (in-use) Solostar device must be discarded 28 days after being opened.Review on 3/3/26 of the manufacturer's instructions for Xalatan (Latanaprost Opthalmic Solution) 0.005%, dated 5/23, revealed, Once a bottle is opened for use, it may be stored at room temperature, ., for 6 weeks. Review on 3/3/26 of the facility policy titled, Medication Administration, General Guidelines, dated 1/21 revealed, 8. b. The nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. C. Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency.

Based on interview and record review, it was determined that the facility failed to develop a care plan for psychotropic medications in 1 out of 5 residents reviewed for unnecessary medications in a final sample of 12 residents (Resident Identifier #2). Findings include: Review on 3/27/24 of Resident #2's current electronic Medication Administration Record (eMAR) revealed 3 psychotropic medications (Prozac start date 7/5/23, Wellbutrin start date 7/5/23, Buspar start date 1/23/24) administered between 3/1/24 and 3/27/24. Review on 3/27/24 of Resident #2's Psychotropic Medication Use Monthly Review dated 3/10/24 revealed the reason for medication use was depression. Symptoms observed in the past month were the resident staying in his/her room, occasionally attending meals, and sleeping late. Individual non-pharmacological approaches included: life enrichment, room visits, reading, and movies. Review on 3/27/24 of Resident #2's comprehensive care plan revealed no care plan for psychotropic (antidepressant, antianxiety) medications or symptom management. Interview on 3/27/24 at approximately 10:30 a.m. with Staff A (Directors of Nursing) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 of 1 resident reviewed for constipation/diarrhea and 1 of 5 residents reviewed for unnecessary medications in a final sample of 12 residents (Resident Identifiers #7 and #24). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's 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 . Resident #7 Review on 3/27/24 of Resident #7' Medication Administration Record (MAR) revealed the following physician orders: Milk of Magnesia Suspension 1200 mg/ml [milligram per milliliter] (Magnesium Hydroxide), give 30 ml by mouth every 24 hours as needed for constipation, may offer after second day without a bowel movement (30 ml), start date 7/5/23; stop date 2/29/24. Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)), Give 17 grams by mouth every 24 hours as needed for constipation, mix with 4-6 ounce (oz) liquid of choice, start date 7/5/23. Senna S Oral Tablet, 8.6 - 50 mg (Sennosides-Docusate Sodium), give 2 tablets by mouth as needed for constipation PRN [as needed] for constipation PRN 1x [time] /day, Start Date 7/5/23. Review on 3/27/24 of Resident #7's Bowel Elimination Record from 2/1/24 through 3/26/24 revealed that Resident #7 did not have a bowel movement for two or more days during the following days: on 2/4/24, 2/5/24, and 2/6/24; on 2/25/24, 2/26/24, and 2/27/24; and on 3/5/24, 3/6/24, and 3/7/24 Interview on 3/27/24 at approximately 8:45 a.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A revealed that the facility did not have a bowel policy/protocol. Resident #24 Review on 3/27/24 of Resident #24's March 2024 MAR revealed the following physician order: Blood glucose monitoring, two times a day, start date 7/5/23. Further review revealed no documentation of morning glucose monitoring on 3/2/24, 3/7/24, 3/8/24, 3/14/24, 3/15/24, and 3/22/24. Interview on 3/27/24 at approximately 11:15 a.m. with Staff A confirmed the above findings.

Based on observation, record review, and interview it was determined that the facility failed to follow the comprehensive care plan for 1 of 1 residents reviewed for skin conditions in a final sample of 15 residents (Resident identifier is #19). Findings include: Observation on 2/8/23 of Resident #19 at 10:00 a.m. revealed Resident #19 in bed. Further observation revealed Resident #19's soft ankle position booties on his/her side table. Observation on 2/8/23 of Resident #19 at 2:25 p.m. revealed Resident #19 in bed. Further observation revealed Resident #19's soft ankle position booties on his/her side table. Observation on 2/8/23 of Resident #19 at 9:45 a.m. revealed Resident #19 in bed. Further observation revealed Resident #19's soft ankle position booties on his/her side table. Review on 2/9/23 of Resident #19's current care plan (Creating Home as a Team (CHAT) biography) for skin revealed the following: .At risk for pressure ulcers or other skin abnormalities . [name omitted] has a history of vascular ulcers on [pronoun omitted] LE's [lower extremities] . care team can do the following to keep skin intact . soft blue booties when in bed to protect heels . Interview on 2/9/23 at 1:15 p.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed Resident #19's soft ankle position booties on his/her side table. Interview also revealed Licensed Nursing Assistants (LNAs) are responsible for applying Resident #19's soft ankle position booties. Observation on 2/9/23 at 1:20 p.m. with Staff H revealed Resident #19 awake in bed with slipper socks and a pillow under his/her legs. Further observation revealed Resident #19's heels were pink and intact. Interview on 2/9/23 at 1:30 p.m. with Staff I (LNA) revealed he/she did not apply Resident #19's soft ankle position booties while in bed because it was not in his/her care plan. Interview on 2/9/23 at 2:36 p.m. with Staff G (Charge Nurse, LPN) revealed Resident #19 should have soft ankle position booties on while in bed and LNAs would have access to the care plan. Interview on 2/9/23 at 2:45 p.m. with Staff F (Director of Nursing) confirmed Resident #19 should have soft ankle position booties on while in bed. Review of the facility policy titled, Skin Care, Guidelines; Wounds; Treatment Modalities revealed the following: .Skin Care and Treatments . #9 . Utilize pressure-reducing overlays, mattresses, chair cushions, individualized positioning schedules and devices . Procedure: 5. Chat/Care Plan interventions will be reviewed .

Based on interview and record review, it was determined that the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committe met quarterly and consisted of the required members in 2022. Findings include: Review on 2/10/23 of the facility's QAPI meetings for 2022 revealed that meetings were conducted on 3/10/22, 9/13/22, and 12/13/22. Interview on 2/10/23 at 3:11 p.m. with Staff D (Administrator) confirmed that there were no documented QAPI meeting between 3/10/22 and 9/13/22. Review on 2/10/23 of the facility's form titled QAPI Meeting-Attendance dated 3/10/22 revealed that the Medical Director was not listed or documented as being in attendance. Interview on 2/10/23 at 3:11 p.m. with Staff D confirmed that there was no documentation that the Medical Director attended the 3/10/22 QAPI meeting. Review on 2/10/23 of the facility's Quality Assurance/Performance Improvement Plan revealed, .The QAPI Steering Committee will be comprised of the Medical Director . each team will report their activities and progress to the QAPI Committee at least quarterly .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that masks were worn in accordance to CDC (Center for Disease Control and Prevention) standards for 1 of 1 kitchen observed , 1 of 1 residential care unit observed, and 1 of 1 laundry room observed. Findings include: Standards: Review on 02/01/22 of Centers for Disease Control document titled, Types of Masks and Respirators, updated 01/28/22, revealed .Procedure Masks .Disposable procedure masks are widely available. They are sometimes referred to as surgical masks or medical procedure masks . .Wear procedure masks with . .A proper fit over your nose, mouth, and chin to prevent leaks . .Respirators . .Respirators have markings printed on the product to indicate they are authentic, see appropriate N95 markings and KN95 markings . .it is important to wear your respirator properly, so it forms a seal to your face. Gaps can let air with respiratory droplets leak in and out around the edges of the respirator . Kitchen Observation on 02/01/22 at 6:45 p.m. revealed Staff I ( Dietary Cook) was observed not wearing a facemask in dishwasher room. Interview on 02/01/22 at 6:47 p.m. with Staff I confirmed above findings. Staff I stated that per facility policy he/she should wear facemask while in the facility. Observation on 02/01/22 at 6:49 p.m. revealed that Staff I was wearing a facemask below his nose. Residential Care Unit Observation on 02/01/2022 at 07:00 p.m. revealed Staff H (Licensed Nurse Assistant) in unit hallway wearing a N95 mask not snug against their face. Observation on 02/01/2022 at 07:01 p.m. revealed Staff A (Licensed Practical Nurse) standing at medication cart in unit hallway wearing a N95 mask placed below nose with nostrils visible. Observation on 02/02/22 at 09:22 a.m. revealed Staff F (Registered Nurse) wearing a N95 mask with nose piece not fitted snugly against their nose bridge area while standing at medication cart in unit hallway. Further observation revealed that Staff F entered Resident #22's room to give medications to Resident #22. Interview on 02/02/22 at 09:23 a.m. confirmed above findings with Staff F. Observation on 02/02/2022 at 11:08 a.m. revealed Staff G (Housekeeper) in unit hallway wearing N95 mask covering mouth only. Interview on 02/02/22 at 11:09 a.m. with Staff G confirmed above findings. Observation on 02/03/2022 at 01:30 p.m. revealed Staff B (Registered Nurse) at nursing station on unit wearing a N95 mask placed below nose with nostrils visible. Interview on 02/03/22 at 1:33 p.m. with Staff B confirmed above findings. Laundry Observation on 02/03/22 at 2:00 p.m. revealed Staff K (Laundry Director) in laundry room wearing a N95 mask with nose piece not fitted snugly against their nose bridge. Interview on 02/03/22 at 2:10 p.m. with Staff K confirmed that most recent N95 mask training had occurred on 02/03/22. Staff K confirmed that the mask should fit tighly around the nose and face. Policy Review: Review on 02/03/22 of the facility policy titled, N95 Respirator Qualitative Fit Testing, established 09/01/20, revealed that .the N95 mask fits and seals properly so potentially contaminated air cannot leak into the mask and hazardous substances are kept out

Based on interview and record review, it was determined that the facility failed to ensure that the attending physician document in the resident's medical record that the identified irregularity has been reviewed for 1 resident out of 5 resident reviewed for unnecessary medications in a final sample of 10 residents. (Resident identifier is #8) Findings include: Review on 2/3/22 of Resident #8's pharmacist recommendation to physician dated 11/7/21 revealed a recommendation to attempt a gradual dose reduction on Resident #8's [MEDICATION(S)] (antidepressant) 7.5 mg (milligram) to 3.75 mg. Further review revealed that there was no documentation that this recommendation was reviewed by the physician. Review on 2/3/22 of Resident #8's active physician orders revealed a current order for [MEDICATION(S)] 7.5 mg by mouth at bedtime. Interview on 2/3/22 at 3:08 p.m. with Staff D (Clinical Regional Registered Nurse) confirmed the above findings. Staff D stated that the pharmacist recommended that pharmacist recommendations be reviewed by physician within 30 days of the recommendation.

Based on observation, interview, and record review, it was determined that the facility failed to ensure proper storage of medication according to manufacturer's instructions for 2 out of 2 medication carts observed. (Resident identifiers are #7 and #200) Findings include: Observation on 2/1/22 at approximately 7:00 p.m. with Staff A (Licensed Practical Nurse) at the Long Hall unit medication cart revealed 1 opened Acidophilus with Pectin (probiotic) medication bottles with a manufacturer's instruction to refrigerate after opening. Interview on 2/1/22 at approximately 7 :05 p.m. with Staff A confirmed above findings on the Long Hall unit medication cart. Staff A did not notice this Acidophilus with Pectin needed to be refrigerated after opening and had given it that night to Resident #7. This bottle of Acidophilus with Pectin had been opened on 1/4/2022. Observation on 2/1/22 at approximately 7:15 p.m. with Staff C (Registered Nurse) at the Short unit medication cart revealed a opened Acidophilus with Pectin medication bottle with a manufacturer's instruction to refrigerate after opening. Interview on 2/1/22 at approximately 7:15 p.m. with Staff C confirmed above findings at the Short hall unit medication cart. Staff C stated that the Acidophilus with Pectin has been in the cart and that Staff C had given the Acidophilus with Pectin that night to resident #200. Review on 2/2/22 of Resident #7's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 2/2/22 of Resident #200's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 2/2/22 at approximately 9:00 a.m. with Staff D (Clinical Regional Registered Nurse) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that services provided met professional standards for medication administration for 1 resident out of 4 residents observed during the medication pass. (Resident identifier is #7) Findings include: Review on 2/2/22 of the Facility's policy titled, Medication Administration: General Guidelines, revision date 1/21, revealed that .page 1 of 6 .hands are washed with soap and water and gloves applied prior to handling tablets . Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. pg. 720; 'Administering Oral Medications'; Step 7; item h Do not touch medication with fingers. Observation on 2/1/22 at approximately 7:00 p.m. of the medication administration for Resident #7 with Staff A (Licensed Practical Nurse) revealed that Staff A had placed (1) 25-200 mg (milligrams) Aspirin / ER (extended release) [MEDICATION(S)], (1) Acidophilus capsule, (1) Tylenol 650 mg tablet, (1) house stool softener, (1) pravanstantin sodium 10 mg, and (1) mirtazpine 7.5 mg. into a medication cup. During administion, Staff A dropped the pravanstantin onto Resident #7's lap, picked the pravanstantin up with his/her bare hands, and administered the pill to Resident #7. Interview on 2/1/22 at 7:05 p.m. with Staff A confirmed the above findings. Interview on 2/2/22 at 8:30 a.m. with Staff B (Unit Manager) revealed that medications should not be touched with bare hands.

Based on observation, interview, and record review, it was determined that the facility failed to monitor for expired food items the dry goods storage room in the main kitchen in accordance with professional standards for food service safety. Findings include: Observation on [DATE] at approximately 10:30 a.m. of the dry goods storage room in the main kitchen revealed the following: - Four boxes of cream of wheat with a best by date of [DATE]; - Two 32 ounce bags of cashews with a best by [DATE]; - Twenty bags of navy beans with a best by date of [DATE]; - Two bags of split green peas (one was open and half empty) with a best by date of [DATE]; - One large box that contained loose lentils with a best by date of [DATE] on the box; - Four silver bags that contained croutons or stuffing mix (they were not labeled) and did not have a date on them (neither manufactured nor best by); - One bag of crushed Ritz-type crackers with no date on it (neither manufactured nor best by); Interview on [DATE] at approximately 10:30 a.m. with Staff A (Director of Dietary Services) confirmed that the above food items were past their best by dates and should have been discarded. Staff A stated that he/she could not be sure of when the crackers and crouton/stuffing mix best by dates were since there was no date on the packaging. Staff A stated the food items should have been labeled with a received date. Review of the facility's policy titled Food Labeling with an effective date of [DATE] read, in part, .Purpose: To ensure that all refrigerated, frozen and dry goods items are used or disposed of in a timely manner Procedure: Dry Goods Storage: 1. Items will be labeled with a received on date (month, date, year) when placed into the dry goods storeroom [ROOM NUMBER]. All other dry goods i.e. cookies, crackers, cereal, mixes, etc. will be utilized by the manufacturer's use by date.

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan for 2 residents in a final sample survey of 12 residents. (Resident identifiers are #4 and #23.) Findings include: Resident #23 Observation on 5/9/19 at 1:26 p.m. revealed that Resident #24 had a urinary drainage leg bag on their left thigh. Interview on 5/9/19 at 1:26 p.m. with Resident #23 revealed that Resident #23 had an indwelling catheter inserted on 4/29/19 at the urologist's office. Interview on 5/9/19 at 1:30 p.m. with Staff B (Licensed Nursing Assistant) revealed that Staff B had been assigned to Resident #23 for morning care and Staff B had stated that they had emptied Resident #23's urinary drainage bag. Staff B also stated that they would change Resident #23's urinary drainage bag to a urinary leg bag in the morning and empty the urinary leg bag or urinary drainage bag after every shift or when full. Review on 5/9/19 of Resident #23's electronic treatment administration record for (MONTH) 2019 and (MONTH) 2019 revealed no treatments for Resident #23's urinary indwelling catheter maintenance. Review on 5/9/19 of Resident #23's current care plan revealed no care plan related to Resident #23's use and maintenance for the indwelling catheter. Review on 5/9/19 of Resident #23's urology consult note dated 4/29/19 revealed that Resident #23 had [MEDICAL CONDITION] and Resident #23 had an indwelling catheter inserted. Review on 5/9/19 of Resident #23's nurses note dated 5/1/19 revealed that Resident #23 was concerned about placement of bag on their leg and prompt emptying of the urinary drainage bag. Review on 5/9/19 of Resident #23's nurses note dated 5/4/19 at 5:17 p.m. revealed that Resident #23 was frustrated and that Resident #23 stated that nobody came to check on my Foley bag (urinary drainage bag) all day today. Interview on 5/9/19 at 1:35 p.m. with Staff A (Director of Nursing) confirmed that Resident #23 had no care plan for Resident #23's use and care for the indwelling catheter. Staff A stated that there should be a care plan for Resident #23's use and maintenance for the indwelling catheter. Staff A also stated that the nursing staff would empty the urinary drainage bag after every shift. Resident #4 On 5/9/19 at 1:26 p.m. review of Resident #4's Electronic Medical Record (EMR) reveals that resident was placed on Hospice care on 8/2/18. Review of CHAT Biography (Facility's name for what is known as a CARE PLAN) in EMR reveals no determination of services to be provided by the Hospice provider to Resident #4 at the facility. On 5/10/19 at 9:30 a.m. review of Resident #4's Hospice Ledger reveals a specific care plan for Hospice care to be provided to Resident #4. There is no coordination with the CHAT biography in the EMR. On 5/10/19 at 11:24 a.m. interview with Staff A (Registered Nurse) confirmed the above findings.

Based on interview, record review and facility policy review, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident identifiers are #7, #13, and #14.) Findings include: Professional reference: Potter, Patricia A., and Perry, Anne Griffin. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-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 . Resident #13 Review on 7/25/18 of Resident #13's Nutritional Assessment, dated 6/11/18 revealed that Resident #13 had a weight loss, and was not on a physician-prescribed weight-loss regimen. Review revealed that the weight loss was documented by the Registered Dietitian as >= 10% within 6 months. Review on 7/25/18 of Resident #13's Current Chat Biography, Dining and Nutrition, revealed that the question of My weight status is was answered with Weight Loss . Review on 7/25/18 of Resident #13's (MONTH) (YEAR) Treatment Sheets revealed an order to Weigh Resident by shift starting 4/23/18 . Interview on 7/25/18 at approximately 9:00 a.m. with Staff N (Licensed Practical Nurse, Supervisor) revealed that the order written as Weigh Resident By Shift meant that the resident was to have weekly weights. Review on 7/25/18 of the Facility's policy, titled Resident Weights, revised 3/21/11, revealed that .The LNA (Licensed Nursing Assistant) is responsible to immediately notify the nurse of any change in a resident's weight. Any increase or decrease of three (3) or more pounds must be reported .The licensed nurse is responsible for validating the reported weight change .If the resident's weight is plus or minus three (3) pounds from the previous weight, the resident must be reweighed within 24 hours and verified by the nurse .The following members of the interdisciplinary team are notified upon licensed nurse validation of significant weight change, Physician .If a resident cannot be weighed, there must be a documented medical reason that prevents the resident from being weighed .Notify physician . Review on 7/25/18 of Resident #13's Weight Listing sheet revealed that Resident #13 had a documented weight on 6/26/18 of 110 pounds. The next weight documented for Resident #13 was on 7/10/18, which was 102 pounds. This was an 8 pound, 7.2 %, weight loss in 14 days. There was no documented reweight on the 7/10/18 weight. The next documented weight was on 7/16/18, which was 6 days later. The documented weight on 7/16/18 was 99.10. This was another 2.9 pound loss in 6 days making the total loss of 9.9% in 20 days. Review on 7/25/18 of Resident #13's nurses notes revealed that there was no documented evidence that Resident #13's physician was notified of their weight loss or that Resident #13 was not weighed weekly, as ordered. Resident #14 Review on 7/25/18 of Resident #14's Current Chat Biography, Dining and Nutrition, revealed that the question of My weight status is was answered with Weight Loss. Review on 7/25/18 of Resident #14's (MONTH) (YEAR) Treatment Sheets revealed an order to Weigh Resident by shift starting 6/11/18 . Review on 7/25/18 of Resident #14's Weight Listing sheet revealed that Resident #14 had a documented weight on 4/9/18 of 147.4 pounds. Review revealed that Resident #14 had a documented weight on 5/1/18 of 129.8 pounds. This was a 17.6 pound, 11.9 %, weight loss in 22 days. There was no documented reweight on the 5/1/18 weight. The next documented weight was not until 5/8/18, which was 7 days later. Review on 7/25/18 of Resident #14's Weight Listing sheet revealed that Resident #14 had a documented weight on 5/29/18 and the next documented weight was not until 7/9/18, which was 6 weeks later. Review on 7/25/18 of Resident #14's nurses notes revealed that there was no documented evidence that Resident #14's physician was notified that Resident #14 was not weighed weekly, as ordered. Resident #7 Review on 7/25/18 of Resident #7's Nutritional Assessment, dated 5/16/18 revealed that Resident #7 had a weight loss, and was not on a physician-prescribed weight-loss regimen. Review revealed that the weight loss was documented by the Registered Dietitian as >= 5% weight change in 30 days. Review on 7/25/18 of Resident #7's Current Chat Biography, Dining and Nutrition, revealed that the question of My weight status is was answered with Weight Loss. Review on 7/25/18 of Resident #7's (MONTH) (YEAR) Treatment Sheets revealed an order to Weigh Resident by shift starting 4/23/18 . Review on 7/25/18 of Resident #7's Weight Listing sheet revealed that Resident #7 had a documented weight on 4/27/18 of 136.1 pounds. The next weight documented for Resident #7 was on 5/11/18, which was 110 pounds. This was a 26.18 pound, 19.18 %, weight loss in 14 days. There was no documented verification of the 5/11/18 weight until 5/16/18, which was 5 days later. Review on 7/25/18 of Resident #7's Weight Listing sheet revealed that Resident #7 had a documented weight on 6/15/18 of 113.2 pounds. The next weight documented for Resident #7 was on 6/30/18, which was 106.4 pounds. This was a 6.8 pound, 6.01 %, weight loss in 15 days. There was no documented verification of the 6/30/18 weight until 7/6/18, which was 6 days later. Review on 7/25/18 of Resident #7's nurses notes revealed that there was no documented evidence that Resident #7's physician was notified that Resident #7 was not weighed weekly, as ordered. Interview on 7/26/18 at approximately 11:00 a.m. with Staff B (Director of Nursing) confirmed that all 3 residents had orders for weekly weights, that if they were not weighed weekly their physicians should have been notified and that the weight discrepancies should have been verified within 24 hours.

Based on record review and interview, it was determined that the facility failed to accurately document the resident choice of advance directive for 1 resident in a survey sample of 12 residents. (Resident identifiers is #176.) Findings include: Review on 7/24/18 of Resident #176's Advance Directive file, revealed that Resident #176 has signed a Portable DNR (Do Not Resuscitate) form on 7/17/18 Review on 7/24/18 of Resident #176's (MONTH) (YEAR) Physician order [REDACTED]. Review on 7/25/18 of Resident #176's Chat Biography, Advance Care Planning, revealed that the question of My care decisions are: was answered with Full Code (staff initials) 7/19/18. Review on 7/25/18 of the facility report roster with all the resident names and room numbers had a notation on the top which read, ***Indicates A Full Code. Review revealed that *** was typed in on the roster next to Resident #176's name. Interview on 7/25/18 at approximately 8:28 a.m. with Staff N (Licensed Practical Nurse, Supervisor) regarding where Staff N would go to find what a resident's Advance Directives were, Staff N stated that they would go to the Advance Directive file, to see if there was a Portable DNR, but that if it was missing, they would look at the resident roster to see what the resident's Advance Directives were. Staff N confirmed that the Advance Directive information for Resident #176 was inaccurate on the Chat Biography and on the Resident Roster.

Based on observation, policy & procedure review, and interview, it was determined that the facility failed to prevent the possible spread of pathogens between two residents during an observation of medication administration between two residents. (Resident identifiers are #19 and #10) Findings include: Potter, Patricia A., and Perry, Anne Griffin. Fundamentals of Nursing. 7th Edition, St Louis, Missouri: Mosby Elsevier, 2009. Page 719-Administering Oral Medications; Step 7: Prepare medications; line a, Perform hand hygiene. Review of the facility policy Medication Administration General Guidelines (2007) page 4, section 11, Hands are washed with soap and water again after administration and with any resident contact. Observation on 7/25/18 at approximately 8:30 a.m. of a medication pass with Staff M, Registered Nurse, revealed that Staff M had completed administering medications to Resident #19. It was observed that Staff M did not perform hand hygiene prior to assembling the medications for Resident #10. Interview on 7/25/18 at 8:40 a.m. with Staff M at the end of Resident #10's medication pass. Observation of the lack of hand hygiene between residents was revealed to Staff M. Staff M's reply was that it only, had to be done after every 3rd resident unless the resident was physically contacted. Interview on 7/26/18 at approximately 3 p.m. with Staff B, Director of Nursing, the findings of the lack of hand washing between residents and the comments by Staff M were discussed. Staff B's reply was that the facility policies and procedures needed to be updated.

Based on observations and interviews conducted on 5/18/15 during an initial tour of the main kitchen the Facility failed to ensure that food was prepared under sanitary conditions. Findings include: During the initial tour of the of the main kitchen on 5/18/15 this State Agency (SA) Surveyor accompanied by the SA Life Safety Inspector were joined by Staff A (Facility Cook Supervisor) and Staff B (Administrator). During the initial tour of the main kitchen, on 5/18/15 at approximately 9:44 a.m. it was observed that there were numerous particles of what appeared to be tufts of dried meat under the blade of the food slicer machine. During the initial tour of the main kitchen, 5/18/15, dust and particulate matter were observed: on top of the reach in coolers, on top of a "hot box" (used to keep foods hot, after preparation and before serving), on top of paper towel dispensers attached to the walls, on the top edge of a small bulletin board attached to a reach-in cooler, on the floor under and behind the range, and on the floor under the preparation table. Also observed on 5/18/15 during the initial tour of the kitchen were the two steam tables that had both been in service. Upon opening the sliding doors on the bottom of the main body of the portable steam table it was noted that there was a stack of plastic plates with lipped (built up) edges on the left side of the bottom shelf. It was further noted that the plates were surrounded by a thick layer of dust and what appeared to be particles of dry food crumbs. Observed to the right side of the shelf was an electric cable. Dust and particulate matter were observed in this location as well. Upon reviewing the components of the serving line for the main dining room it was noted that the lower shelf of the stationary steam table was coated in a layer of dust and particulate matter as well as a dark stain. Upon asking kitchen staff, on 5/18/15 at approximately 10:25 a.m., who was responsible for the cleaning of this lower shelf we were told by Staff C (cook) that maintenance had told kitchen staff they shouldn't clean that area due to the proximity of a square electrical junction box mounted in the approximate center of the shelf. (CROSS REFER TO F456) On interview Staff B stated that the stationary steam table was built in 1952. Observation of the left side of the serving line revealed a lower shelf with a hot beverage dispenser labeled "Tea" and an unlabeled hot beverage dispenser. This stainless steel shelf was noted to be dusty and to have a large area of darkened stain to the left of the above noted dispensers. During a subsequent tour, 5/18/15, of the dishwashing room it was observed that 2 vent ducts; a larger diameter duct attached to a ventilation hood over the automatic dishwasher (ADW) and a smaller diameter duct which appeared to exhaust excess steam to the outside. Behind the larger diameter duct was a metal strap, extending down from the ceiling, coated with a large amount of dust down its entire length (approximately 6 to 8 inches). On the back of the large diameter duct was some short, hanging, ribbons of dust. On top of each of these ducts was a thin layer of dust. Please note that these ducts pass over the back edge and along the left end of the clean exit side of the ADW, posing a potential for dust to end up on clean dishes.

Based on observations and interviews the Facility failed to ensure that all essential electrical equipment was in safe operating condition. Findings include: Upon reviewing the components of the serving line for the main dining room it was noted that the lower shelf of the stationary steam table was coated in a layer of dust and particulate matter as well as a dark stain. Upon asking kitchen staff, on 5/18/15 at approximately 10:25 a.m., who was responsible for the cleaning of this lower shelf we were told by Staff C (cook) that maintenance had told kitchen staff they shouldn't clean that area due to the proximity of a square electrical junction box mounted in the approximate center of the shelf. On interview Staff B (Administrator) stated that the stationary steam table was built in 1952. Further observation of the electrical junction box in question revealed that it was open at one of the inlet ports. Several black insulated wires could be visualized. As a precaution the Facility took this steam table out of service until the electrician could effect repairs. It is noted that the electrician installed a new, intact, waterproof box above the spot where the old one had been mounted.

Based on observation, review of food service records and interview the facility failed to ensure that the temperatures of the foods on the steam table were monitored to be within proper safe holding temperatures (less than 41 degrees F (Fahrenheit)) for cold foods and greater than 135 degrees F for hot foods). Findings include: On 5/27/14 at the end of the initial tour of the kitchen, this surveyor asked Staff F, Food Service Director (FSD) to outline the process to be followed during food service delivery on the long term care skilled unit on the second floor. When asked if they performed secondary food service line temperatures upstairs to monitor the steam table Staff F stated "no". On 5/28/2014 at 10:57 a.m., during a Group Interview session, Resident #9, responding to a question posed by this writer, stated: "Sometimes the hot food is fairly tepid." On 5/28/14, at approximately 11:41 a.m. the temperature of the food in the hotel pans was checked to ensure that the food on the steam table was being held within the acceptable safe food holding temperature range. Both hot foods and cold foods were checked and those foods checked were all within the safe holding temperature range. On 5/28/14, at approximately 11:42 a.m. the steam table left the kitchen. On 5/28/14, at approximately 11:44 a.m. the steam table was on the unit. At this time this surveyor, performed an observation of the food delivery system for the second floor of the facility. The facility did not check the temperature of the foods after the steam table was brought to the second floor. Initially, the food was plated and covered for delivery to the individual resident rooms where residents had requested to dine in their rooms. After all trays had been delivered to these resident rooms the residents gathered in the dining room were served. At no time were the food temperatures monitored during the serving process in the second floor dining room. On 5/28/14 at approximately 12:30 p.m. a test tray was prepared immediately after all residents had been served in the dining room. Five items were selected to be tested for temperature and palatability. The test tray temperatures were compared to the initial steam table temperatures that had been taken on the first floor at approximately 11:41 a.m. The items and associated temperatures, both initial and the test tray temperatures are as follows: Hamburger patties (previously frozen, preformed and precooked patties) initial temperature on the steam table at approximately 11:41a.m. was 188 degrees F. The test tray temperature of the hamburger pattie at approximately 12:30 p.m.was 110 degrees F. The initial temperature of the hotdogs on the steam table at approximately 11:41a.m. was not written in on the log sheet. The test tray temperature of the hotdog at approximately 12:30 p.m. was 130 degrees F. The initial temperature of the potato salad at approximately 11:41 a.m. was 38 degrees F. The test tray temperature of the potato salad at approximately 12:30 p.m. was 51 degrees F. The initial temperature of the ground hamburger on the steam table at approximately 11:41a.m. was 173 degrees F. The test tray temperature of the ground hamburger at approximately 12:30 p.m. was 116 degrees F. The initial temperature of the ground hotdogs on the steam table at approximately 11:41a.m. was not written in on the log sheet. The test tray temperature of the ground hotdog at approximately 12:30 p.m. was 107 degrees F. Review of the (Company name redacted) Production Sheet Record reveals that not all menu choices were monitored for initial temperatures on the first floor. The steam cart temperatures were not rechecked. Facility does not have documented evidence of the serving temperature at the time of plating food.

Based on observation and interview the facility failed to monitor and dispose of expired medications in 1 of 4 medication storage areas. Findings include: During observation of the OTC (Over The Counter) medication storage closet on the Long Hall of the nursing unit on 4/30/13 at approximately 10:00 a.m. the following 8 unopened containers of medications being stored in the closet were identified as having expiration dates on the bottles showing that the medications were expired: 1. iron supplement elixir 220mg/5cc 473ml with expiration date 3/13. 2. lactaid original enzyme 9000 units 120 capsules with expiration date 1/13. 3. slow magnesium chloride with calcium 64mg 60 tablets with expiration date 12/12. 4. zinc 30mg 100 tablets with expiration date 3/11. 5. folic acid 800mg 100 tablets with expiration date 12/10. 6. oystershell calcium 500mg plus vitamin D 60 tablets with expiration date 4/12. 7. ferrous gluconate 240mg 100 tablets with expiration date 1/13. 8. zinc 30mg 100 tablets with expiration date 3/11. During an interview on 4/30/13 with Staff A, (RN, Charge Nurse), Staff A verified the medications listed above had expired. At the conclusion of the interview, Staff A removed the medications from the storage closet and disposed of them.

Based on interview and record review, the facility failed to accurately complete the Resident Assessment Instrument for 3 residents in a standard survey sample of 10 residents. (Resident identifiers are #2, #5, and #10.) Findings include: Reference to CMS's RAI version 3.0 Manual, April 2012 Chapter 3, pages C-1 through C-15 for coding instructions for (Section C0100 - C0500). The instructions reveal that under Section C0100 when coded as a 1, the interview should be attempted and sections C0200 through C0500 be completed as part of the interview process. Reference to CMS's RAI version 3.0 Manual, April 2012 Chapter 3, pages D1 through D9 for coding instructions for (Section D0100 - D0300). The instructions reveal that under Section D0100 when coded as a 1, the interview should be attempted and sections D0200 through D0300 be completed as part of the interview process. Reference to CMS's RAI version 3.0 Manual, April 2012 Chapter 3, pages J5 through J14 for coding instructions for (Section J0200 - J0600) The instructions reveal that under Section J0200 when coded as a 1, the interview should be attempted and sections J0300 through J0600 be completed as part of the interview process. Resident #2. During medical record review on 4/30/13 of the MDS with ARD of 1/7/13 for Resident #2 it was revealed that Section C0100 was coded as 1. Further review of the MDS sections C0200 through C0500 revealed they were not completed according to the manual instructions and had dashes in the coding areas for the resident interview. Section D0100 was coded as 1. Further review of the MDS sections D0200 through D0300 revealed they were not completed according to the manual instructions and had dashes in the coding areas for the resident interview. Section J0200 was coded as 1. Further review of the MDS revealed sections J0300 through J0600 were not completed according to the manual instructions and had dashes in the coding areas for the interview. On 4/30/13 during an interview with Staff B, (RN, ADON Assistant Director of Nursing), Staff B confirmed the interview sections of the MDS with ARD of 1/7/13 for Resident #2 for Sections C, D and J were not completed according to the manual instructions and had dashes in the coding areas for the resident interviews. Resident #5. During medical record review on 4/30/13 of the MDS with ARD of 4/8/13 for Resident #5 it was revealed that Section C0100 was coded as 1. Further review of the MDS sections C0200 through C0500 revealed they were not completed according to the manual instructions and had dashes in the coding areas for the resident interview. Section D0100 was coded as 1. Further review of the MDS sections D0200 through D0300 revealed they were not completed according to the manual instructions and had dashes in the coding areas for the resident interview. Section J0200 was coded as 1. Further review of the MDS sections J0300 through J0600 revealed they were not completed according to the manual instructions and had dashes in the coding areas for the resident interview. On 4/30/13 during an interview with Staff B, Staff B confirmed the resident interview sections of the MDS with ARD of 4/8/13 for Resident #5 for Sections C, D and J were not completed according to the manual instructions and had dashes in the coding areas for the interviews. Resident #10. During medical record review on 5/2/13 of the MDS with ARD of 3/27/13 for Resident #10 it was revealed that Section J0200 was coded as 1. Further review of the MDS sections J0300 through J0600 revealed they were not completed according to the manual instructions and had dashes in the coding areas for the resident interview. On 5/2/13 during an interview with Staff B, Staff B confirmed the interview sections of the MDS with ARD of 3/27/13 for Resident #10 for Section J were not completed according to the manual instructions and had dashes in the coding areas for the resident interviews.

Based on record review and interview it was determined that the facility failed to document INITIAL ALTERATION IN SKIN INTEGRITY form and/or WEEKLY PRESSURE ULCER ASSESSMENT form and/or SKIN CONDITION REPORT for Non-Pressure Ulcer Skin Conditions form for assessment and monitoring of residents' skin conditions for 3 residents out of a standard survey sample of 10 residents. (Resident identifiers are #2, # 3, and #6.) Findings include: Review of facility's "SKIN CARE PROTOCOL" policy effective 6/9/05 revealed the following: on page 5: "Procedure-When a skin issue is observed: redness, rash, skin tear, blister, or actual break- down, the 'Initial Alteration in Skin Integrity Assessment' form is completed by the nurse on duty. The completed form is to be given to the wound team."... "Weekly skin care rounds will take place on a day determined at each facility. The nurses will have completed, by the time of the meeting, the Weekly Pressure Ulcer Assessment form or the Non-Pressure Ulcer Skin Condition Report. "... "Weekly skin team rounds will be conducted on all residents with skin integrity issues..." Resident #6. Review of Resident #6's medical record on 4/10/12 revealed the following nurse's note dated 10/18/11: "Resident has dry patch and redness on R (right) heel. N.O. (New Order) Vaseline gauze, [MEDICATION NAME] and Kling (types of dressings) daily....Seen by MD.... Will monitor." Record review revealed no documentation of the facility's "INITIAL ALTERATION IN SKIN INTEGRITY" form nor the facility's "WEEKLY PRESSURE ULCER ASSESSMENT" form. Further record review revealed the following nurse's note dated 10/19/11: "Resident has N.O. to D/C (discontinue) tx (treatment) to R (right) heel and start cleanse area R heel (abbreviation for "with") NACL (sodium chloride)...Area has small pinhole openings, Pt (patient) denies pain, scant amount serous drainage..." Review of the resident's TARs (Treatment Administration Record) revealed periodic, less than weekly documentation of skin integrity of right heel present on section of "Treatment Flow Sheet" titled "Nursing Observations/Comments." Documentation for month of November 2011 revealed documentation dated 11/12/11 and the next chronological documentation was dated 11/28/12, a gap of 15 days. Further record review of APRN (Advanced Practice Registered Nurse) revealed a new [DIAGNOSES REDACTED].#6's right heel as "psoriatic arthritis". Record review revealed no documented "SKIN CONDITION REPORT for Non-Pressure Ulcer Skin Conditions" form. Interview of Staff A (DON) in afternoon of 4/11/12 confirmed that there was no documented "INITIAL ALTERATION IN SKIN INTEGRITY" form nor "WEEKLY PRESSURE ULCER ASSESSMENT" form nor "SKIN CONDITION REPORT for Non-Pressure Ulcer Skin Conditions" form for Resident #6's right heel. Resident #2. During review of Resident #2's medical record on 4/10/12 it was found that a nurses note dated 3/5/12 states "...2 open areas (right) buttocks ...measures 1 cm X 0.5 cm. and lower one is 0.5 x 0.5 cm. stage 2..." On review of the facility's "SKIN CARE PROTOCOL" dated 6/9/05 page 5 reveals "When a skin issue is observed: redness, rash, skin tear, blister, or actual breakdown, the Initial Alteration in Skin Integrity form is completed by the nurse on duty. The completed form is to be given to the wound team..." On review of the medical record and interview with Staff A (Director of Nurses) it was confirmed that the "INITIAL ALTERATION IN SKIN INTEGRITY" form had not been completed at the time of the finding as written in the nurses notes dated 3/5/12. Resident #3 During review of Resident #3's medical record on 4/10/12 it was found that a nurses note dated 4/5/12 states " [MEDICATION NAME] ointment to buttocks (gluteal crease) twice a day until healed." On review of the facility's "SKIN CARE PROTOCOL" dated 6/9/05 page 5 "When a skin issue is observed: redness, rash, skin tear, blister, or actual breakdown, the Initial Alteration in Skin Integrity assessment form is completed by the nurse on duty. The completed form is to be given to the wound team..." On 4/11/12 review of the medical record and interview with Staff A (Director of Nurses) it was confirmed that the "INITIAL ALTERATION IN SKIN INTEGRITY" form had not been completed at the time of the finding as written in the nurses notes dated 4/5/12.