Every finding on record at Wesley Pines Retirement Community

Based on observations, record review, resident, Nurse Practitioner, and staff interviews the facility failed to notify the Physician when nursing staff were not following a physician order for daily administration of one capsule of Linzess (a medication for long-lasting or chronic constipation from unknown reasons) and were administering 3 capsules of Linzess twice weekly per the resident's request for 1 of 1 resident reviewed (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE]. Diagnoses included chronic idiopathic (unknown reason) constipation, and gastroparesis (food and liquid remaining in body for prolonged period of time). The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #19 was cognitively intact. An observation was conducted on 01/27/26 at 1:30 PM of Resident #19's room. It was observed there was a medication cup filled with 3 capsules sitting on her bed whilst she sat in her wheelchair to the right of the bed. An interview was conducted with Resident #19 on 01/27/26 at 1:30 PM. Resident #19 was alert and oriented and reported that the three capsules in the medication cup was her Linzess and they were for her to take to help move her bowels due to her rectal paralysis. A Physician's order written on 04/16/25 revealed Linzess 290 micrograms (mcg) one capsule by mouth daily on Sunday, Monday, Tuesday, Wednesday, Thursday, and Friday and Linzess 290 mcg one capsule by mouth daily on Saturday. Review of the Medication Administration Record from 01/01/26 through 01/28/26 revealed the Linzess 290 mcg one capsule was being signed off as administered daily between 7:00 AM and 11:00 AM on Sunday, Monday, Tuesday, Wednesday, Thursday and Friday as evidenced by nursing initials. A follow up interview was conducted with Resident #19 on 01/28/26 at 3:50 PM. Resident #19 revealed she did not take the Linzess capsule daily. Resident #19 explained that the nursing staff put the daily capsule in an empty medication bottle which was on her bedside table and that there was one capsule of Linzess in the bottle now. She stated on Tuesdays and Fridays, the nursing staff would take the 3 tablets out of that bottle and place them in a medication cup and leave them in her room for her to take at 4:50 PM. An interview was conducted with Nurse #1 on 01/28/26 at 4:05 PM. Nurse #1 stated she was aware that Resident #19 was requesting that the nursing staff (including herself) put the Linzess capsule in an empty bottle kept on her bedside table daily. Nurse #1 stated Resident #19 expressed that she wanted to take 3 capsules of her Linzess on Tuesdays and Fridays instead of one capsule daily. Nurse #1 stated Resident #19 was insistent on taking her Linzess this way and that was why it was administered it that way. Nurse #1 stated she should have notified the Physician or Nurse Practitioner that Resident #19 was refusing the ordered dose of one capsule daily of the Linzess and wanted to take 3 capsules twice weekly instead. Nurse #1 stated she should have notified the provider instead of honoring Resident #19's request. An interview was conducted with Medication Aide #1 on 01/29/26 at 7:30 AM. Medication Aide (MA) #1 stated she placed the Linzess capsule in a bottle that was kept on Resident #19's bedside table whenever she worked. MA #1 stated if she was assigned to Resident #19 on Tuesdays and Fridays, she would remove the capsules from the bottle that they were stored in and put them in a medication cup in the morning for Resident #19. MA #1 reported that on Tuesday 01/27/26 she put the 3 tablets from the bottle in the medication cup for resident #19. MA #1 stated she never questioned the physician order and should have because it was not being given as written. MA #1 added she would not have been responsible notifying the Physician or Nurse Practitioner because the nurses were responsible for notifying them. An interview with Medication Aide #2 on 01/29/26 at 8:40 AM revealed she had worked for the facility for 4 years and since she has been here, she has been leaving the Linzess capsule in an empty bottle on her bedside table. MA #2 stated Resident #19 liked to take all 3 capsules together and that was how she requested it. MA #2 stated she should have notified the Director of Nursing about the way this medication was being administered because the way Resident #19 was taking it was not how the order was written. MA #2 stated she would not have notified the Physician or Nurse Practitioner because the nurses were responsible for notifying them. An interview with Nurse #4 on 01/29/26 at 8:40 AM stated she had been working at the facility on and off for several years and Resident #19 had been taking the 3 capsules of Linzess every Tuesday and Friday for as long as she could remember. Nurse #4 stated Resident #19 was very adamant about the way she wanted to take her medications. Nurse #4 stated she knew that administering 3 capsules twice weekly instead of one capsule daily as ordered was wrong and she should have notified the Physician or Nurse Practitioner that Resident #19 refused to take the Linzess daily and wanted to take it twice weekly. An interview was conducted with the Director of Nursing (DON) on 01/28/26 at 4:30 PM. The DON revealed she had no knowledge that the nurses and medications aides were leaving the Linzess capsule in an empty bottle in Resident #19's room instead of administering the medication daily as ordered nor did she have any knowledge that Resident #19 was taking 3 capsules twice weekly. She stated had she known Resident #19 was refusing to take the medication as ordered, she would have consulted the Nurse Practitioner to see if the order could be revised to meet the residents' needs. The DON stated she expected the nurses to notify the Physician or Nurse Practitioner if a resident was consistently refusing to take a medication as ordered. An interview was conducted with the Nurse Practitioner on 01/29/26 at 10:15 AM. The Nurse Practitioner stated she was made aware by the DON on 01/28/26 that Resident #19 was taking 870 mcg of Linzess twice per week instead of 290 mcg daily as ordered. The Nurse Practitioner stated she had no knowledge that Resident #19 was taking the medication this way. The Nurse Practitioner stated the biggest risk of taking this high of a dose of Linzess twice per week was dehydration and that had she been made aware of Resident #19's request and how the nurses were administering Resident #19 this medication, she would have intervened much sooner and revised the bowel regimen with another type of laxative that would have been safer and stronger for her. The Nurse Practitioner stated she would have expected the nursing staff to have notified her of the refusal of the daily dose of Linzess, and added, that it was not up to the nursing staff to administer the medication the way Resident #19 requested instead of how it was ordered.

Based on observations, record review, and staff, resident, Consulting Pharmacist and Nurse Practitioner interviews, the facility failed to follow a physician's order as written to administer Linzess (a medication for chronic constipation) daily for 1 of 1 resident reviewed (Resident #19). The nursing staff were dispensing the medication into a bottle on Resident #19's bedside table labeled with a different medication name and then Resident #19 was taking the 3 capsules of the medication on Tuesdays and Fridays. (Resident #19 was not assessed to be able to self-administer medications). Findings included: Resident #19 was admitted to the facility on [DATE]. Diagnoses included paraplegia, contractures to right and left elbow/hand wrist, chronic idiopathic (unknown reason) constipation, and gastroparesis (food and liquid remaining in body for prolonged period of time). Review of the self-administer medication assessment written on 02/10/23 revealed Resident #19 was assessed to self-administer medication and it was determined that she was not able to self-administer medication. This assessment was updated and last reviewed on 01/07/25. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #19 was cognitively intact, demonstrated no behaviors during this assessment and was frequently incontinent of bowel and bladder. She was coded as having range of motion impairments to upper and lower extremities. Resident #19's care plan dated 12/03/25 revealed refusal of medications and care at times per resident's choice/routine. History of refusing medications. Resident was aware of the importance of complying with physician orders, however, had a routine that she followed which caused her to refuse medications and care at times. Resident was at risk for constipation related to impaired mobility. Resident had stated that she usually wanted a laxative once a week even if bowel movement has happened in 3 days and would only take laxatives as she desired. An observation was conducted on 01/27/26 at 1:30 PM of Resident #19's room. It was observed there was a medication cup filled with 3 capsules sitting on her bed whilst she sat in her wheelchair to the right of the bed. Resident #19 was noted to have bilateral hand and wrist contractures. An interview was conducted with Resident #19 on 01/27/26 at 1:30 PM. Resident #19 was alert and oriented and reported that the capsules in the medication cup were for her to take to help move her bowels due to her rectal paralysis. Resident #19 explained that the nursing staff left the cup at the bedside on Tuesday and Friday mornings for her to take at 4:50 PM on these days. Resident #19 was asked how she took the medications and she demonstrated (using her head since she was not able to her hands) bending her head toward the medication cup on the bed, picking up the medication cup with her mouth, and emptying the pills into her mouth without the use of her hands. Resident #19 stated she took 3 capsules of Linzess (a medication for adults with long-lasting or chronic constipation from unknown reasons) on Tuesdays and Fridays at 4:50 PM and then at 1:30 AM on Wednesday and Saturday the night nurse administered her Magnesium Citrate (a supplement and laxative to help with constipation). Resident #19 explained that Tuesday and Friday were her hydrate days and she drank a lot of water on these days to help loosen her stools. She stated she had been doing this bowel regimen for years and it had been the best way for her to evacuate her bowels due to her rectal paralysis. Physician's orders written on 04/16/25 revealed the following: Linzess 290 micrograms (mcg) one capsule by mouth daily on Sunday, Monday, Tuesday, Wednesday, Thursday, and Friday. Linzess 290 mcg one capsule one capsule by mouth daily on Saturday. Magnesium Citrate Solution give 10 ounces by mouth 2 times a week with 8 ounces of water for constipation. A Physician's order written on 05/23/25 revealed the following order: Simethicone 180 milligrams take 2 capsules by mouth every 4 hours as needed for gas and bloating. Review of the Medication Administration Record from 01/01/26 through 01/28/26 revealed the Linzess medication was being signed off as administered daily between 7:00 AM and 11:00 AM on Sunday, Monday, Tuesday, Wednesday, Thursday and Friday as evidenced by nurse initials and the Linzess medication was also being signed off as administered daily on Saturday as evidenced by nursing initials. Review of the Medication Administration Record from 01/01/26 through 01/28/26 revealed the Magnesium Citrate Solution 10 ounces by mouth was being administered on Wednesdays and Saturdays at 1:30 AM as evidenced by nurse initials. Review of the Medication Administration Record from 01/01/26 through 01/28/26 revealed the Simethicone medication had been given as needed as evidenced by nurse initials and time of administration. An interview was conducted with Nurse #1 on 01/28/26 at 3:40 PM. Nurse #1 reported she and Medication Aide (MA) #1 worked together to administer medications on this unit. She stated she was responsible for dispensing the medications in a medication cup and Medication Aide #1 would administer the medications to the residents. Nurse #1 stated she pulled the Linzess capsule for Resident #19 on 01/27/26 for MA #1 to administer. Nurse #1 stated she was not aware that Resident #19 did not take the Linzess from MA #1 and MA #1 never told Nurse #1 that Resident #19 did not take the medication or that she left the medication at her bedside. Nurse #1 stated Resident #19 did not have an order that she could self-administer medications due to her bilateral hand contractures. Nurse #1 stated she would have expected MA #1 to let her know that Resident #19 did not take the Linzess from the MA #1 at that time and that she left the medication at her bedside. A follow up interview was conducted with Resident #19 on 01/28/26 at 3:50 PM. Resident #19 revealed she did not take the Linzess capsule daily. Resident #19 explained that the nursing staff put the daily capsule in an empty medication bottle which was on her bedside table and that there was one capsule of Linzess in the bottle now. She stated on Tuesdays and Fridays, the nursing staff would take the 3 tablets out of that bottle and place them in a medication cup and leave for her to take at 4:50 PM. Resident #19 stated each Tuesday and Friday were her hydrate (drink a lot of water) days and she would drink water all day long because the medication worked by drawing fluid into the intestines to make stools softer and easier to pass. Resident #19 stated she took the medications at 4:50 PM because she wanted to hydrate all day and take it closer to the time she received her Magnesium Citrate. Resident #19 stated she had been doing this regimen for years and it was recommended by her Gastroenterologist (GI) doctor. During this interview, the Director of Nursing (DON) entered the room to discuss the administration of the Linzess medication with Resident #19. Resident #19 explained to the Director of Nursing how she took her Linzess. The Director of Nursing opened the medication bottle with the pink cap located on her bedside table and it was labeled Simethicone and there was one capsule of the Linzess medication in this bottle. The DON stated to Resident #19 that it was a huge no, no to have pills left in another pill container and that the nurses and medication aides should be making sure she took the medication as ordered and while in their presence. The DON stated to Resident #19 that she understood Resident #19 had a certain bowel regimen she wanted to follow that had been working but she (the DON) would have to check with the Nurse Practitioner to see if she could change the current order to take the Linzess 3 capsules on Tuesday and 3 capsules on Friday. Review of Resident #19's medical record revealed there was no order from Resident #19's Gastroenterologist (GI) Physician to take 3 Linzess capsules twice per week. A follow up interview was conducted with Nurse #1 on 01/28/26 at 4:05 PM. Nurse #1 stated she was aware that Resident #19 was requesting that the nursing staff (including herself) put the Linzess capsule in an empty bottle kept on her bedside table. Nurse #1 stated she should not have left the Linzess capsule in the empty Simethicone bottle at any point and neither should have Medication Aide #1 and when Resident #19 expressed that she wanted to take her Linzess capsules on Tuesdays and Fridays instead of daily, she should have explained the policy to Resident #19 and followed the physician order as written. Nurse #1 stated she had been placing the daily Linzess capsule in the bottle for a while and added she could not remember how long. Nurse #1 stated the resident was insistent on taking her Linzess this way and that was why she administered it that way. An interview with Nurse #3 on 01/29/26 at 7:15 AM revealed she worked night shift and she would administer the Magnesium Citrate at approximately 1:30 AM on Wednesday and Saturday mornings. Nurse #3 stated on Saturday AM when she brought in Resident #19's ordered Linzess, she would stay with the resident until she took the medication. Nurse #3 stated Resident #19 always asked Nurse #3 to put it in the bottle stored on her bedside table, but Nurse #3 stated she would never leave a medication in a different bottle in a resident's room and she always made sure residents took their medications, including Resident #19, as ordered before she left the room. An interview was conducted with Medication Aide #1 on 01/29/26 at 7:30 AM. Medication Aide #1 stated she had been working at the facility for 6 months. MA #1 stated she placed the Linzess capsule in a bottle that was kept on Resident #19's bedside table whenever she worked. MA #1 stated if she was assigned to Resident #19 on Tuesdays and Fridays she would remove three capsules from the bottle that they were stored in and put them in a medication cup in the morning for Resident #19 to take at a later time so that she could hydrate herself throughout the day before taking them. MA #1 stated she was told by the nurse that trained her (could not remember who it was) that was how Resident #19 took her Linzess. MA #1 stated she never questioned the physician order and should have because it was not being given as written. MA #1 thought that was the way the Linzess should be administered for this resident. MA #1 stated she should have questioned this process because she was trained as a Medication Aide to follow the physician's order. An interview with Medication Aide #2 on 01/29/26 at 8:40 AM revealed she had worked for the facility for 4 years and since she has been here she has been leaving the Linzess capsule in the bottle with the pink cap (Simethicone bottle). MA #2 stated on Wednesday and Saturday, Resident #19 received Magnesium Citrate on the night shift and on Tuesdays and Fridays she would take all 3 of her Linzess capsules. She stated she liked to take all 3 capsules together and that was how she requested it. MA #2 stated Resident #19 would hydrate all day long on Tuesdays and Fridays with water at her bedside and was able to drink her water because it was set up beside her on her bedside table and she was able turn her head and drink her water from a straw. MA #2 stated she should have asked the Nurse Practitioner or Director of Nursing about the way this medication was being administered because the way Resident #19 was taking it was not how the order was written. MA #2 stated that was how she was told to administer the medication from the nurses (She could not recall any specific nurse). An interview with Nurse #4 on 01/29/26 at 8:40 AM stated she had been working at the facility on and off for several years and Resident #19 had been taking the 3 capsules of Linzess every Tuesday and Friday for as long as she could remember. Nurse #4 stated Resident #19 was very adamant about the way she wanted to take her medications. Nurse #4 stated she knew that leaving the pills in the room was wrong and that she was not following the physician order as written and she should have been. An interview was conducted with the Director of Nursing on 01/28/26 at 4:30 PM. She stated she had no idea Resident #19 was taking her Linzess this way and that the nursing staff should have been following the order as written. She stated she spoke with the Nurse Practitioner and the Consulting Pharmacist regarding the Linzess and that Resident #19 was taking 870 micrograms twice per week instead of 290 mcg daily as ordered. An interview was conducted with the Nurse Practitioner on 01/29/26 at 10:15 AM. The Nurse Practitioner stated she was made aware by the DON that Resident #19 was taking 870 mcg of Linzess twice per week instead of 290 mcg daily as ordered. The Nurse Practitioner stated she had no knowledge that Resident #19 was taking the medication this way and spoke with the Consulting Pharmacist and the facility Physician on 01/28/26 regarding this dose and it was discussed that this dose exceeded the recommended dose. The Nurse Practitioner stated the biggest risk of taking this high of a dose of Linzess twice per week was dehydration. The Nurse Practitioner stated it was very important to hydrate while taking this type of laxative. The Nurse Practitioner stated had she been made aware of Resident #19's request and how the nurses were administering Resident #19 this medication, she would have intervened much sooner and revised the bowel regimen with another type of laxative that would have been safer and stronger for her. The Nurse Practitioner reviewed Resident #19's lab results to check for any indication of dehydration. The most recent labs ordered was on 10/27/2025, and the Resident's lab values to assess dehydration were all within in normal limits and did not indicate Resident #19 was dehydrated. The Nurse Practitioner stated she reviewed Resident #19's medical record and there was no order from the GI doctor to administer Linzess 3 capsules twice per week. She stated if the GI physician wanted her to take the medication that way, there would have been order for it. The Nurse Practitioner added, Resident #19 had not seen this GI doctor since 2019. The Nurse Practitioner added she was made aware by Resident #19 that she was doing more hydration on Tuesdays and Fridays and called them her hydration days. The Nurse Practitioner stated she would have expected the nursing staff to follow the physician order as prescribed and that it was not up to the nursing staff to administer the medication the way Resident #19 requested. An interview was conducted with the Consulting Pharmacist on 01/30/26 at 1:00 PM. The Consulting Pharmacist stated the purpose of the Linzess medication was meant to increase the intestinal motility to aide in evacuating stool. She stated the medication worked by absorbing fluid into the colon to help loosen contents of the colon and if Resident #19 was not hydrating enough it could cause dehydration. She stated the side effects were similar to a laxative such as diarrhea, gas, bloating, and too much water loss. The Consulting Pharmacist stated that Linzess 290 mcg was the highest recommended maximum dose to take daily and that was how the medication was ordered and Resident #19 should have been taking the medication as prescribed. The Consulting Pharmacist stated she reviewed Resident #19 labs and there were no concerns with dehydration. A follow up interview was conducted with the Director of Nursing on 01/30/26 at 1:30 PM. The DON revealed she had no knowledge that the nurses and medications aides were leaving the Linzess capsule in the Simethicone bottle instead of administering the medication daily as ordered nor did she have any knowledge that Resident #19 was taking 3 capsules twice weekly. She stated had she known she would have consulted the Nurse Practitioner to see if the order could be revised to meet the resident's needs. She stated she reviewed Resident #19's record and did not see any notes or orders from Resident #19's GI doctor ever indicating that Resident #19 should take 3 tablets twice per week of Linzess instead of daily. The DON stated she would have expected the nurses and medication aides to explain the policy to Resident #19 that they could not leave medications stored in the room and that the nursing staff should not leave the room until the resident has taken the medication. The DON stated the nurses and medications aides have been trained to follow the 5 rights of drug administration to include right resident, right drug, right dose, right route and right time and they should have been following the policy as well as the physician's order.

Based on observations, record review, and staff and resident interviews, the facility failed to store medications in a secured medication cart when medications were observed stored in a resident's room and two of the medications were expired for 1 of 1 resident with medications observed at the bedside (Resident #19). In addition, the facility failed to date an opened insulin pen and discard an expired insulin pen for 1 of 2 medication carts observed for medication storage (Lantana Cart). Findings included: a). Resident #19 was admitted to the facility on [DATE]. The Minimum Data Set, dated [DATE] revealed Resident #19 was cognitively intact. The following physician orders were in place for Resident #19: Clobetasol Propionate 0.05% spray (a steroid medication to treat skin conditions) apply to scalp as needed daily. This order was written on 04/15/25. Linzess (a medication for chronic constipation) 290 micrograms (mcg) one capsule by mouth daily on Sunday, Monday, Tuesday, Wednesday, Thursday, and Friday. Linzess 290 mcg one capsule one capsule by mouth daily on Saturday. These orders were written on 04/16/25. Simethicone (a medication to treat gas or bloating) 180 milligrams take 2 capsules by mouth every 4 hours as needed for gas and bloating. This order was written on 05/23/25. Biotin (a type of Vitamin B) 5,000 mcg one tablet daily. This order was written on 08/06/25. An interview and observations were conducted with Resident #19 in her room on 01/28/26 at 3:50 PM to inquire about her Linzess order. Resident #19 explained that the nursing staff put the daily capsule of Linzess in an empty medication bottle which was left on her bedside table and that there was one capsule of Linzess in the bottle now. During this interview, the Director of Nursing (DON) entered the room and asked Resident #19 about the Linzess being left in the room. The DON stated she understood that Linzess capsules were being stored in Resident #19's room. At this time, she opened the medication bottle stored on Resident #19's bedside table which was labeled Simethicone and there was one capsule of the Linzess medication in the bottle. The DON also observed that there were also two opened bottles of Biotin. One bottle of the Biotin contained 1,000 mcg tablets and the other bottle contained 5,000 mcg tablets which had an expiration date of 04/2024. Additionally, she observed there was an opened bottle of Simethicone with an expiration date of 01/24/2024, and a spray bottle of Clobetasol Propionate 0.05%. These were all stored on her bedside table. The DON explained to Resident #19 that medications were not allowed to be stored in her room. Resident #19 stated she was not taking this Biotin or Simethicone or using the Clobetasol and that they had been in her room for a while. Resident #19 could not say who brought the medications in her room or why they were stored in her room. An interview was conducted with Nurse #1 on 01/28/26 at 4:05 PM. Nurse #1 stated she did not administer the Linzess on 01/28/26 and she was aware that Resident #19 was requesting that the nursing staff (including herself) put the Linzess capsule in an empty bottle kept on her bedside table. Nurse #1 stated she should not have left the Linzess capsule in the empty Simethicone bottle at any point. Nurse #1 did not realize the bottle was labeled Simethicone. Nurse #1 stated she was not aware the Biotin, Simethicone or Clobetasol Spray were being stored in Resident #19's room or where Resident #19 would have gotten them because she administered them to her from the medication cart. Nurse #1 stated there should be no medications kept in a resident's room.An interview was conducted with Medication Aide #1 on 01/29/26 at 7:30 AM. Medication Aide #1 indicated she had been working at the facility for 6 months and she placed the Linzess capsule in a bottle that was kept on Resident #19's bedside table whenever she worked. Medication Aide #1 stated she had not seen the opened Biotin, Clobetasol or Simethicone bottles in Resident #19's room. Medication Aide #1 stated she was only aware of the empty Simethicone bottle that Resident #19 stored the Linzess capsules in. Medication Aide #1 stated she left the Linzess in the bottle on 01/28/26 at Resident #19's request when she brought in her medications to her room and she knew she should not have left the medication in the bottle. Medication Aide #1 stated all medications should be stored in the medication cart and should not be left in the residents' rooms. An interview with Medication Aide #2 on 01/29/26 at 8:40 AM revealed she had worked for the facility for 4 years and since she has been here, she has been leaving Resident #19's Linzess capsule in the bottle with the pink cap (Simethicone bottle). Medication Aide #2 stated she had no knowledge of the other medications stored in Resident #19's room, and that she administered those medications directly from the medication cart. Medication Aide #2 stated she should not have stored the Linzess capsules in Resident #19's room in the empty Simethicone bottle when she brought her medications to her room and all medications should be stored in the medication cart and not in a Resident's room. An interview was conducted with Nurse #4 on 01/29/26 at 8:40 AM. Nurse #4 stated she was aware that the Linzess capsules were being stored in the labeled Simethicone bottle in Resident #19's room until Resident #19 took them on Tuesdays and Fridays, but she was not aware of the other medications that were stored in her room. Nurse #4 stated she had placed the Linzess capsules in the bottle in Resident #19's room at her request when she brought her medications to her room even though she knew residents were not to have medications at the bedside. Nurse #4 stated all medications should be stored in the Medication Cart and if any medications were expired, they should be disposed of. An interview with the Director of Nursing on 01/30/26 at 10:30 AM revealed the nursing staff were aware that medications should never be stored in the resident's room without a physician order and she expected the nursing staff to make sure all medications were stored on the medication cart. The DON added, the medications left in Resident #19's room were located next to the empty Simethicone bottle the staff were using to store the Linzess in and they should have been removed from her room. b) An observation of the Lantana hall medication cart on 01/29/26 at 8:10 AM with Nurse #2 revealed the follow medications: Novolog prefilled insulin pen was opened with no opened date indicated on the pen.Lantus prefilled insulin pen was opened and expired on 11/24/25. The manufacturer's instructions for both the NovoLog and Lantus insulin pens read to discard after 28 days once opened. An interview with Nurse #2 on 01/29/26 at 8:12 AM revealed nurses and medications aides were responsible for checking the medication carts daily to make sure there were no expired medications. Nurse #2 stated nurses should be making sure all insulin pens were dated once opened and disposing them if expired. Nurse #2 stated she had not administered the Novolog or the Lantus insulins this morning. An interview was conducted with the Director of Nursing (DON) on 01/30/26 at 10:30 AM. The DON reported her expectation was that once an insulin pens were opened the nurses should be putting an opened date on them. She stated insulins pens have a manufacturer's instruction to discard after so many days once opened and without having the initial opened date recorded on the on the pen, nurses would not be able to determine if the medication was still good for use. The DON also stated she would have expected the nurses to remove the expired medication from the cart.

Based on record review, observation, and staff and Nurse Practitioner (NP) interviews, the facility failed to provide incontinence care safely for a resident who was agitated, combative and dependent on staff for all care for 1 of 4 residents reviewed for falls (Resident #5). On 4/10/25 Nurse Aide (NA) #2 was providing incontinence care to the resident when the resident, who was holding onto the bed frame, rolled off the bed striking his head on a dresser as he fell. Resident #5 was treated at the hospital for a soft tissue skin tear to the forehead that required cleansing and the application of steri-strips.Findings included:Resident #5 was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, Parkinson's disease without dyskinesia (a movement disorder causing involuntary, uncontrolled muscle movements like writhing, fidgeting, or grimacing), history of transient ischemic attack (mini stroke), primary insomnia, chronic pain syndrome, essential hypertension, major depressive disorder, and orthostatic hypotension.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had long and short-term memory problems with no recall ability and severely impaired cognitive skills for daily decision making. He had no signs of delirium, behaviors, or moods identified. He had no range of motion impairments of his upper extremities but had impairments of both lower extremities. Resident #5 was dependent for all care, and he had an indwelling urinary catheter and bowel incontinence. His primary diagnosis was non-traumatic brain dysfunction. He had one fall since admission or prior assessment with minor injury. He had received antibiotic, opioid, and antipsychotic medication during the assessment period. He had received hospice care.The care plan for Resident #5 initiated on 03/11/25 included the categories:1. Falls. The problem was identified as at risk for falls related to using the lift for transfers. He had a history of recurrent falls in calendar year 2024 including on 12/22/24. The goal was for Resident #5 to remain free from injury for 90 days.2. Behavior. The problem was identified as at risk for behavior problems related to dementia and refusing care/medications at times. He had a history of anxiety, refusing medications and care, choking a staff member, restlessness, wandering, suicidal ideations, and being combative. Staff reports that some of the residents behaviors are during care or when staff is assisting him with needs-reports that resident will hit or kick at staff. Resident does not like to be bothered per staff. Resident has been redirected per team however it has not decreased his need to be physically abusive to staff. Staff is to continue to re-educate and allow him time to process before providing the care. The resident has displayed the following behaviors: start date 03/11/25:- 4/5/25: 7:00 AM to 3:00 PM shift: during care the resident was swinging his hands with balled up fists, grabbing onto staff and squeezing their hands.- 4/6/25: 3:00 PM to 11:00 PM shift: Combative to staff when providing incontinence care.- 4/7/25: During morning care, resident grabbing at staff and digging his nails into their skin. Clinches up arms and legs while trying to bath to prevent care. Staff will place stuffed animals or wash clothes in resident's hands, but he will throw to floor and grab onto staff's clothing or arms.- 4/8/25: Nurse in to change his pain patch and the resident hit the nurse with an open hand. He attempted to hit the nurse again, but the nurse was able to move away from his reach.The goal was for the resident to have no reported behaviors that were not easily altered x 90 days. Interventions included, in part: Assist with self-care needs (specialized chair when up and mechanical lift with two person assist with transfers); determine if behaviors are stimulated by certain activities, noise levels, persons involved, or time of day; intervene as needed to ensure my safety and the safety of others; pancake call pads on each side of resident; administer and monitor effectiveness/side effects of my medications; offer comfort measures that may help with behaviors; notify physician and Responsible Party if refusal of care or if resident falls; call family for 1:1 support if unable to successfully redirect; monitor closely for negative statements made by resident; when providing care staff to monitor resident hand placement and ensure resident is not in a position to grab at staff face/throat area as able; and gently hold residents hands during care as able and ensure not to restrict residents movement.An interview was conducted with NA #2 on 01/28/26 at 1:45 PM. She stated Resident #5 had a bowel movement on 04/10/25 at suppertime but that the trays had not come to the unit yet, so she decided to provide incontinent care to him prior to the meals arrival. She explained she provided care for the first bowel movement, and he had remained calm as she talked to him during care; however, after she put the adult brief on the resident he had a second bowel movement, so she started incontinence care again. She explained that was when Resident #5 started to hit and pinch her as she was attempting to clean him. She stopped care and used her radio to summon a second person to help but all other staff were also providing care in other resident rooms. She explained as she waited for help, she managed to talk to the resident and calm him down, so she resumed care. She noted Resident #5 was not care planned for a two person assist during activities of daily living (ADL) care. NA #2 stated she would have waited for the second person if Resident #5 had remained combative. It was during the second attempt to provide incontinence care that Resident #5 grabbed the metal frame under the bed and fell hitting his head on the dresser beside the bed on the way down. She noted the resident was facing away from her and she tried to hold onto him, but he slipped out of her grasp. She recalled it was normal for him to hold onto the bed frame during care. She thought it was a comfort measure for the resident to hold onto something during care. NA #2 concluded if she had waited for a second person to come and help her provide care to the resident, the accident may have been avoided. NA #2 explained she was trained to calm the resident by talking to him and offering him a stuffed animal to hold during care.Nurse #6 documented in a progress note dated 04/10/25 at 5:17 PM that NA #2 called her for assistance in the resident's room. NA #2 informed her the resident had a large soft bowel movement and while she was cleansing him he pulled himself off the bed, hit his head on the dresser causing a laceration to his forehead. Nurse #6 documented that she contacted the provider and received an order to send the resident to the emergency department for further evaluation. She called 911 and the hospital. Nurse #6 called the family and made the Hospice nurse aware at the request of the family. Resident #5's vital signs were blood pressure 176/110, heart rate 73, temperature 98.3, and oxygen saturation 98% on room air. Resident #5 left the facility by ambulance at 6:06 PM.An interview was conducted with Nurse #6 on 01/28/26. She stated she was the nurse caring for Resident #5 on 04/10/25. She recalled NA #2 called her on the radio to the resident's room and she responded immediately. She did not recall any other request for assistance from NA #2 over the radio until after Resident #5 had fallen. Nurse #6 stated Resident #5 was lying on the floor between the bed and the dresser when she arrived. He was bleeding from his forehead, so Nurse #6 called the provider and 911. She notified the family and the Hospice provider. She explained the family wanted to wait until the Hospice provider came to the facility and assessed the resident. When the Hospice provider and EMS (Emergency Management Systems) arrived, the resident was taken to the hospital. Nurse #6 stated she was familiar with Resident #5 and knew he became combative during ADL care. She remarked that since the last fall having two staff members present for all care has helped along with the side rails on the bed for the resident to grab during care. Nurse #6 could not recall NA #2 asking for help on the night he fell. She stated the accident could have potentially been avoided had two staff members been in the room.Review of the hospital emergency department physician progress note dated 04/10/25 revealed Resident #5 was treated for a soft tissue skin tear to the forehead. The wound was cleansed and steri-strips were applied. Diagnostic imaging of the head was nonacute. A plain film of the pelvis was also ordered and showed no acute fracture. A head CT exam was performed and was negative for any new injury. Resident #5 was released back to the nursing home from the emergency room on [DATE] to follow up with his provider as needed.An interview with the Nurse Practitioner was conducted on 1/29/26 at 10:32 AM. Stated she cared for Resident #5. She stated she assessed Resident #5 the next day on 04/11/25 and he was at his baseline with no new issues or concerns.An interview was conducted with the Director of Nursing (DON) on 01/29/26 at 9:45 AM. She stated she was notified on 04/10/25 that Resident #5 had fallen during care. She explained that when she returned to work on 04/11/25 she interviewed NA #2 to learn what had happened. The DON learned from the interview with NA #2 that NA #2 had called for help on her radio from other staff members when Resident #5 became combative and agitated during incontinence care. While NA #2 waited for assistance to arrive she was able to calm the resident and NA #2 resumed incontinence care. The DON stated that NA #2 explained to her that Resident #5 was holding onto the bed frame during care and pulled himself off the bed. The [NAME] stated that NA #2 who was standing behind him to wipe his rectal area could not hold onto him as he fell. The DON determined there had been no deviation from NA #2's practice identified because Resident #5 was not determined to be a 2 person assist for incontinent care prior to the fall on 04/10/25 and NAs were trained according to the facility procedure guide to turn a resident on his or her side away from the caregiver. The DON explained NA #2 had worked with Resident #5 for many years and she was usually able to calm Resident #5 and provide incontinent care to him. The DON reiterated that during the second brief change NA #2 had been able to calm the resident before she proceeded but that Resident #5 then pulled himself off the bed.An interview was conducted with the Administrator on 01/28/26 at 3:43 PM. She stated she conducted a full investigation and NA #2 explained to her that it was dinnertime and NA #2 wanted to provide incontinence care to the resident prior to the evening meal being served. NA #2 explained to the Administrator that Resident #5 began to be resistive to care so she called over the radio for assistance and while NA #2 waited for assistance the resident calmed down so she resumed care. The Administrator stated that the fall may have potentially been avoided had there been another staff member on the other side of the bed or if he had quarter side rails to grab onto, but the side rails had been removed previously during a re-evaluation of side rail use assessment that determined that it was unsafe to have rails on the bed because he was putting his arms through the bed rails.

Based on observations and staff interviews, the facility failed to ensure the outside area surrounding the kitchen exit and outdoor equipment cleaning area remained free of debris, leaves, and broken equipment for 1 of 1 kitchen/housekeeping/maintenance cleaning area observed. This failure had the potential to attract pests and rodents. Findings included: An observation of the kitchen's outside cleaning area (4 feet from the kitchen's exit door) with the Dietary Manager (DM) on 01/27/26 at 1:00 PM revealed scattered debris, leaves, broken sauna bathtub, broken recliner, with additional discarded broken equipment from maintenance, housekeeping, and kitchen, as well as blown debris and leaves around the sides and back area of the enclosed brick cleaning area. The cleaning area was unable to be utilized due to the large amount of debris, broken metal racks, sauna tub, recliner, all stored in the enclosed cleaning area. An interview was conducted with the Dietary Manager on 01/27/26 at 1:15 PM. He stated it was the responsibility of the Maintenance, Housekeeping, and Dietary Departments to keep the outside cleaning area clean and functional, with trash removed from the area, allowing the cleaning area's drain to function when using water pressure hoses to clean kitchen items, wheelchairs, and beds. The DM stated currently the area could not be utilized due being full of discarded broken equipment, blown debris, leaves blocking the drain, which would not allow for water drainage when water pressure hoses were used. An interview and tour of the cleaning area behind the kitchen on 01/27/26 at 1:45 PM was conducted with the Maintenance Director and Administrator. The tour revealed scattered debris, leaves, broken sauna bathtub, broken recliner, multiple discarded items from maintenance, housekeeping, and kitchen, with leaves around the sides and back of the enclosure area, open to the elements available to pests and rodents. The Maintenance Director stated it was the responsibility of Dietary, Housekeeping, and Maintenance Departments to ensure the area around the kitchen exit to be clean and free of debris, allowing the cleaning area to be utilized by all departments. A follow-up interview and tour of the kitchens outside cleaning area was conducted with the Administrator and Maintenance Director on 01/29/26 at 1:35 PM. The Administrator expected maintenance to ensure the cleaning area was usable and free of debris and broken facility equipment.

Based on observation, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to maintain infection control procedure for the care of a nephrostomy tube (a thin catheter that drains urine directly from the kidney into a urinary drainage bag) when a nurse failed to perform hand hygiene after she had removed her soiled gloves and donned a pair of sterile gloves to apply the new dressing during the dressing change. This deficient practice occurred for 1 of 2 staff members observed for infection control practices (Nurse #3).The findings included:Review of the facility Policy and Procedure for Care of a Nephrostomy Tube (undated) revealed the following, in part: Dresing Changes: 4) Carefully remove the wet or soiled dressing; 5) Discard the dressing in the disposable waste bag; 6) Observe the dressing site for signs of skin breakdown, infection, or drainage; 7) Remove gloves and discard in the disposable waste bag; 8) Wash and dry your hands; 9) Put on sterile gloves.An observation of nephrostomy tube care was completed on 1/29/26 at 11:03 AM. The care was provided by Nurse #3 for Resident #15. Nurse #3 donned a gown and gloves and set up supplies for a sterile cleansing of the nephrostomy area. The old dressing was removed by Nurse #3, and no drainage was noted on the old dressing. The nurse discarded the old dressing and cleansed the tubing with alcohol pads along with the tube to the drainage connection port. Nurse #3 discarded the soiled items and removed her gloves and discarded them. Nurse #3 donned sterile gloves and did not wash her hands prior to donning the sterile gloves. Nurse #3 applied the new sterile dressing to the nephrostomy tube insertion site. Nurse #3 discarded her gown and gloves and washed her hands prior to exiting the resident's room.During an interview with Nurse #3 on 01/29/26 at 11:20 AM she stated she should have washed her hands after she removed the gloves she wore while changing the old dressing and before donning the sterile gloves, but she forgot to do it. She explained she understood proper handwashing was an important part of infection control.An interview was conducted with the Infection Preventionist (IP) on 01/30/26 at 8:48 AM. She stated Nurse #3 should have performed hand hygiene after she removed the old dressing and prior to donning the sterile gloves. The IP explained that hand hygiene was one of the most important steps in preventing infections.An interview was conducted on 1/30/26 at 1:40 PM with the NP who was the physician extender for Resident #15. The NP stated Nurse #3 should have washed her hands between the old dressing and the new dressing application. The NP further explained that when Nurse #3 did not follow the protocol to wash her hands prior to applying the new dressing Nurse #3 put the resident at risk for introduction of bacteria to the ostomy site which could cause infection. The NP stated that even though Nurse #3 did put on sterile gloves prior to applying the new dressing, she should have washed her hands after she had removed the old dressing before putting on the sterile gloves.An interview was conducted with the Director of Nursing (DON) on 01/29/26 at 2:37 PM. She stated a nurse changing any dressing should wash his or her hands before beginning, after removing the old dressing, before applying the new dressing, and after completing the dressing change. She stated Nurse #3 should have washed her hands after removing the old dressing and her gloves before donning the sterile gloves to apply the new dressing.

Based on observations, record review, and Nurse Practitioner, Consulting Pharmacist, staff and resident interviews, the facility failed to accurately document the administration of Linzess (a medication for long-lasting or chronic constipation from unknown reasons) for 1 of 1 resident reviewed (Resident #19).Findings included: A Physician's order written on 04/16/25 revealed Linzess 290 micrograms (mcg) one capsule by mouth daily on Sunday, Monday, Tuesday, Wednesday, Thursday, and Friday. Review of the November Medication Administration Record (MAR) from 11/01/25 through 11/30/25 revealed the Linzess 290 mcg one capsule was being signed off as administered to Resident #19 on the following days: Nurse #1 documented she administered one capsule on 11/02/25, 11/05/25, 11/06/25, 11/10/25, 11/12/25, 11/16/25, 11/17/25, 11/19/25, and 11/26/25. Nurse #4 documented she administered one capsule on 11/03/25 and 11/13/25. Medication Aide #1 documented she administered one capsule on 11/09/25, 11/20/25, 11/24/25 and 11/27/25. Medication Aide #2 documented that she administered one capsule on 11/30/25. Review of the December Medication Administration Record from 12/01/25 through 12/31/25 revealed the Linzess 290 mcg one capsule was being signed off as administered to Resident #19 on the following days: Nurse #1 documented she administered one capsule on 12/03/25, 12/04/25, 12/08/25, 12/10/25, 12/22/25, 12/24/25, 12/25/25, 12/28/25, and 12/29/25. Medication Aide #1 documented she administered one capsule on 12/01/25, 12/18/25, and 12/31/25. Medication Aide #2 documented that she administered one capsule on 12/11/25, 12/14/25, and 12/15/25. Review of the January Medication Administration Record from 01/01/26 through 01/28/26 revealed the Linzess 290 mcg one capsule was being signed off as administered to Resident #19 on the following days: Nurse #1 documented she administered one capsule on 01/01/26, 01/05/26, 01/11/26, 01/14/26, 01/19/26, 01/25/26, and 01/28/26. Nurse #4 documented she administered one capsule on 01/21/26 and 01/26/26. Medication Aide #1 documented that she administered one capsule on 01/15/26 and 01/22/26. An interview was conducted with Nurse #1 on 01/28/26 at 4:05 PM. Nurse #1 confirmed she was documenting the administration of Resident #19's Linzess capsule on Sundays, Mondays, Wednesdays and Thursdays on the Medication Administration record and had been doing so for an unknown period of time. Nurse #1 stated she should not have documented that the medication was given on the days that she signed off on the MAR since Resident #19 did not take the medication on those days and the medication was left at the bedside. An interview was conducted with Medication Aide #1 on 01/29/26 at 7:30 AM. Medication Aide (MA) #1 confirmed she had documented the administration of the Linzess capsule to Resident #19 on Sunday, Monday, Wednesday, and Thursday on the Medication Administration Record for the last 6 months. MA #1 stated she should not have documented that the medication was given on those days since the medication was not administered to Resident #19 and was instead stored in her room. During an interview with Medication Aide #2 on 01/29/26 at 8:40 AM she confirmed that she was documenting the administration of the Linzess capsule to Resident #19 on Sunday, Monday, Wednesday and Thursday on the Medication Administration Record for as long as she could remember. MA #2 stated this was a documentation error because Resident #19 did not actually take the medication on those days and she should not have documented that she did. An interview was conducted with Nurse #4 on 01/29/26 at 8:40 AM. Nurse #4 stated she had been working at the facility on and off for several years and Resident #19 had been taking the 3 capsules of Linzess every Tuesday and Friday for as long as she could remember. Nurse #4 confirmed that she should not have documented that Resident #19 received the medication on 11/03/25 and 11/13/25 and 01/21/26 and 01/26/26 since the resident did not actually take the medication on those days. An interview was conducted with the Nurse Practitioner on 01/29/26 at 10:15 AM. The Nurse Practitioner stated she relied on what nursing staff was documenting in the Medication Administration Record to determine if there should be any changes to the medications. The Nurse Practitioner stated she expected the nursing staff to document accurately on the Medication Administration Record at all times. An interview with the Consulting Pharmacist on 01/30/26 at 1:00 PM revealed she would have expected nursing staff to accurately document the refusal of the daily dose of Linzess. She stated it was important for nursing staff to accurately document on the Medication Administration Record because it was used to make clinical decisions and if the documentation to support the refusal of the medication was accurate, an earlier intervention, such as a medication change, could have been implemented. An interview was conducted with the Director of Nursing (DON) on 01/30/26 at 1:17 PM. The DON stated the nursing staff should have been accurately documenting the refusal of the Linzess medication. The DON added the Medication Administration Record was an important clinical tool to evaluate the administration of medications and needed to be accurate at all times.

Based on record review and staff interviews, the facility neglected to provide a breakfast tray for a dependent Resident (Resident #212) for 1 of 3 residents reviewed for neglect. Findings included: Resident #212 was admitted to the facility on [DATE]. Her diagnoses included hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) and aphasia (loss of ability to understand or express speech). Resident #212's quarterly Minimum Data Set Assessment (MDS) dated [DATE] coded the Resident as cognitively impaired. She was coded as dependent with personal hygiene, toileting, oral hygiene and eating. Review of Resident #212's care plan revealed a care focus area initiated 3/11/24 that indicated that Resident #212 was at nutritional risk and interventions included staff to assist with feeding Resident at mealtimes. Facility investigation report dated 5/20/24 indicated Resident #212 was not provided with a breakfast tray on 5/15/24. The report indicated the Director of Nursing (DON) became aware of the incident at 11:20 AM when the Dining Assistant notified her that Resident #212's breakfast tray was still in the warmer in the kitchen. The DON went to inquire about the tray with Nursing Assistant #1 (NA #1) who was assigned to care for Resident #212 on 5/15/24 7:00 AM - 3:00 PM shift and NA #1 stated she forgot. During an interview on 11/13/24 at 11:40 AM with the Dining Assistant, she stated nursing assistants were responsible for obtaining trays from the food cart or kitchen for residents that ate meals in their rooms and required feeding assistance. The Dining Assistant stated she found Resident #212's tray in the warmer in the kitchen on 5/15/24 at around 11:20 AM and notified Nurse #1 that the tray was still in the kitchen. During an interview on 11/13/24 at 11:55 AM with Nurse #1, she stated she became aware that Resident #212 did not receive a breakfast tray on 5/15/24 when she was notified by the Dining Assistant at around 11:20 AM that Resident #212's tray was still in the kitchen. When she asked NA #1 about the tray, NA #1 stated she forgot about the tray. Nurse #1 explained that Resident #212 was dependent on staff for feeding and NA #1 should have obtained the tray from the kitchen to feed the Resident. She further stated that if NA #1 was busy she should have informed her that she needed assistance and she would have obtained the tray and fed Resident #212 herself. Attempts to interview NA #1 were unsuccessful. An Interview was conducted with the Director of Nursing (DON) on 11/13/24 at 12:06 PM. The DON stated that breakfast was normally served between 7:30 AM and 9:00 AM. She indicated that NA #1 stated she had forgotten to feed Resident #212 and when asked why she did not ask for assistance, NA #1 stated she was not running behind and that she got sidetracked and forgot about the tray. The DON verbalized Resident #212 ate her meals in her room with feeding assistance and NA #1 should have retrieved the breakfast tray from the kitchen and fed the Resident or asked for assistance from another staff member.

Based on record review, resident interview and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of property when a staff member (Nurse #2) took a Duragesic pain patch that was ordered for a Resident. The deficient practice was reviewed for 1 of 3 residents for misappropriation of residents' property (Resident #29). Finding included: Resident #29 was admitted to the facility on [DATE] with diagnosis including chronic back pain. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident#29 coded as cognitively intact. The care plan dated 11/07/2024 had focus of pain due to chronic back pain, osteoarthritis, and muscle spasms. The interventions included to please give me my pain medication as ordered. Monitor for narcotic overdose and follow protocol as ordered. The Initial Allegation Report dated 11/30/2023 completed by the Director of Nursing (DON) was reviewed. On 11/30/2023 staff notified the DON that Nurse #2 came into the facility during his off hours. Nurse #2 entered Resident #29's room to utilize a Duragesic patch. Later, Nurse #2 became pale, blood pressure 70/50, with low oxygenation. The Investigation Report dated 12/07/2023 completed by the DON was reviewed. On 11/30/2023 Nurse #2 provided enough information to substantiate allegation of deviating medication from Resident #29. The employee was terminated and support for professional assistance was provided. The North Carolina Board of Nursing (NCBON) and local police department were performing their own investigations. The employee was terminated. The staff had an in-service on communication, reporting, medication administration, and protecting your license. The Lumberton Police Department Incident Report dated 12/01/2023 by Officer #1 was reviewed. On 11/30/2023 the complainant (DON) reported Nurse #2 for larceny by employee of Fentanyl patch $1.00 value. The employee allegedly deviated Duragesic. Soon after, he became hypotensive with a low oxygen saturation. The emergency medical services (EMS) were notified but the employee refused transport. He later agreed to go to the emergency department (ED) with his parents. The allegation had been emailed to the NCBON. The November narcotic dosage form for Fentanyl 75mcg/hour for Resident #29 revealed all the medications for November were signed out as given and there were no patches missing. The November 2023 Medication Administration Record (MAR) for Resident #29 revealed an order for Duragesic (Fentanyl) 75 MCG/hour topical every other day for chronic pain syndrome was given as directed. Nurse #2 was not available for interview. An interview with Resident #29 was conducted on 11/12/2024 at 3:40 PM. The Resident stated he has been using pain patches for a while now and they are helping to control his pain. He has always received his patches and did not recall ever missing any doses. An interview with Officer #1 was conducted on 11/13/2024 at 10:16 AM. The officer stated he was the officer that responded to the report of larceny by an employee at the nursing home. Nurse #2 was accused of taking a Duragesic patch from the resident at the facility. The District Attorney (DA) did not press charges because the employee went to get treatment at a center for substance abuse. An interview with Nurse #3 was conducted on 11/13/2024 at 12:25 PM. The nurse stated she was the nurse working with Resident #29 on 11/30/2023. That morning, Nurse #2 was at the facility, and she thought he was still there from the prior shift. He came to her cart with Resident #29's old patch in a cup. The Nurse thought it had come off because she saw Nurse #2 go into Resident #29's room to check the resident because his light was on. She and Nurse #2 disposed of the old patch properly and signed out a new patch and she then gave the patch to Nurse #2 to place on Resident #29. She continued her medication pass and was told Nurse #2 was about to pass out. She thought about the patch he was supposed to change and went into the residents' room and did not see the replacement patch on the Resident. She reported it to the Assistant Director of Nursing (ADON). A telephone interview with Nurse #4 was conducted on 11/13/2024 at 2:04 PM. The nurse stated she worked 11/29/2023 third shift and Resident #29's patch was in place the last time she saw him at around 6:30 to 7:00 AM. An interview with ADON was conducted on 11/13/2024 at 3:04 PM. The ADON stated the morning of 11/30/2023 she was coming in to work around 7:30 AM and received a report that nurse #2 was going to the hosp. EMS was there but Nurse #2 would not allow them to perform a drug test. She was updated by Nurse #3 that Nurse #2 had gone into Resident #29's room to answer a call light and came out with a patch in a cup. The Nurse thought it had come off. The nurses discarded the old patch and Nurse #3 gave Nurse #2 a new patch to apply to the Resident and saw him go in Resident #29's room. The nurse did not think anything of it because Nurse #2 would work third shift regularly and answer call lights while charting. The ADON also stated she assisted in assessing residents that had patches and there were no complaints of pain from the residents. The Nurse Practitioner (NP) was in the facility and a one-time order for Resident #29 to have another patch was ordered and applied. An interview with the NP was conducted on 11/13/2024 at 3:20 PM. The NP was called to supply room because Nurse #2 was not acting right. He looked lethargic and 911 was called because his bp was low. She started an IV of normal saline and let it hang with gravity. She placed him in the Trendelenburg position, and he became more aware and coherent. When EMS arrived, he started walking and signed a waiver to not go to hospital. She thought he was tired at first and she did not know what was going on with him but was concerned about low bp. She then was updated on the missing Duragesic patch and ordered a one-time order for a new patch to be placed, and the nursing staff applied for the patch without any issues. The missing patch was long acting and there were no adverse reactions or pain while the patch was missing. An interview with the DON was conducted on 11/13/2024 at 3:37 PM. The morning of 11/30/2024 she received a call from her ADON stating Nurse #2 came in when he was not scheduled and helped Nurse#2 dispose of an old patch and was supposed to apply a new patch to Resident #29. The old patch that Nurse #2 brought to Nurse #3 was disposed of by the two nurses. Nurse #3 did not think anything of it when Nurse #2 was in the facility in the morning because he often would do double shifts. Nurse #2 became ill and found to have low blood pressure. He refused to go with the EMS to the hospital. He was escorted to the car at the back door, and she asked Nurse #2 if he remembers taking a patch from Resident #29, and Nurse #2 stated he did take the patch. After Nurse #2 left the facility, the police were called, and an investigation began. They assessed the three residents with pain patches and there were no complaints of pain. The police were called, and they also reported this incident to North Carolina Department of Health and Human Services (NCDHHS) and the NCBON. Nurse #2 was terminated, and staff were educated. An interview with the Administrator was conducted on 11/13/2024 at 4:08 PM. The Administrator stated it was an unfortunate incident with Nurse #2. He was loved by all staff and Residents. This was a shock that he had a problem. He had just gone through a bad break up with his significant other and they felt that was what sparked this incident. He had since gone to a rehab facility. They completed a Plan of Correction (POC) and there was no harm to any residents or pain voiced due to the removal of the patch. The Residents were assessed and there were no missing patches found during the count of narcotics and all patches were signed as administered as ordered. POC Problem: On 11/30/2023 Nurse #2 was supposed to replace a Duragesic (Fentanyl) 75 microgram (mcg) patch for Resident #29, but the patch was not replaced. o Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice include: Resident #29 was assessed, and the pain patch was missing. Resident #29 was interviewed and assessed and there were no reports of pain or any memory of him going without the patch in the past. A new Duragesic patch for Resident the resident was placed. It is the practice of [NAME] Pines to ensure that resident's pain medication patches are administered as ordered and residents are free from medication diversion. o Address how the facility will identify other residents having the potential to be affected by the same deficient practice include: All three of the Residents in the facility with Duragesic patches had the potential to be affected and all residents were assessed and assured the patches were placed as ordered. The Medication Administration Records (MAR) and narcotic medication sheets of the three Residents with Duragesic patches were checked for accuracy. o Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur include: The police were called 11/30/2023. A report was filed with NCDHHS on 11/30/2023. NCBON was made aware of the incident on 11/30/2023. The DON will in-service the nursing staff on 11/30/2023 and/or prior to working the next scheduled shift. Topics to include Communication, Reporting, Medication Administration, and Protecting Your license. Terminate Nurse #2. o Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The DON/Designee will monitor all MARs and controlled medication count sheets from 11/30/2023 to 12/30/2023 with audits to ensure all Duragesic patches are accounted for and in place. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the interdisciplinary team on December 1, 2023, concerning the drug diversion and this plan of correction that was developed and implemented. The facility's QAPI Committee will review this POC for the next 3 months. The Administrator stated she was responsible for this POC. Corrective action completion date: December 6, 2023 Validation On 11/15/2024 the facility's plan of correction was validated by the following: Audits conducted by the facility were reviewed and were found to be completed according to the plan of correction. Auditing started 11/30/2023 and was completed on 12/30/2023. No issues found. Reviewed all narcotic medications for the three residents that received a Duragesic patch in November and December to assure the count was equal. No issues noted. All residents on the Duragesic patch in November and November 2023 were checked to make sure they received their patches, and the residents received their doses as ordered. The Lumberton City Police Department report dated 11/30/2023 was reviewed and the police officer that conducted the investigation was interviewed on 11/13/2024 and stated the case was investigated and closed without prosecution. NCDHHS 24-hour report was submitted on 11/30/2023. 11/30/2023 to 12/06/2023 signed in-services were held for nursing staff by DON with topics including Communication, Reporting, Medication Administration, and Protecting Your license. Nursing staff voiced understanding of education. The training check-off sheets were noted to have DON's signature as the instructor. A review of the certified letter dated 12/01/2023 indicated Nurse #2s termination was sent out by the Human Resources Director. The DON stated she completed the auditing of the narcotic sheets and the MARs of the three Residents during the months of November and December 2023 and did not find any discrepancies. She completed the education for all nurses prior to their next shift. The Administrator stated she ensured the DON audited the MARs and narcotic controlled sheets and in-serviced all nursing staff including communication; to especially include knowing what staff that are on the schedule and not allowing any other nurse to administer any medications for them. They completed their monitoring of this medication deviation in March 2023. Reviewed NCBON complaint form dated 12/01/2023. The facility's plan of correction was validated to be completed as of 12/06/2023.

Based on record review and staff interviews, the facility failed to administer the antibiotic [MEDICATION(S)] per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission MDS (Minimum Data Set) assessment dated [DATE] documented Resident #42 had intact cognition. She had one venous/arterial ulcer on admission. Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's April 2022 eMAR (electronic Medication Administration Record) revealed the following: [MEDICATION(S)] 100 MG by mouth twice a day x 30 days-take 2 hours prior/after Iron or a multivitamin in the AM, Iron 325 MG by mouth at 8:00 AM and a multivitamin with iron 8 MG tablet by mouth daily at 8:00 AM. The AM dose of [MEDICATION(S)] was administered with the Iron and the multivitamin with iron on 04/01/22, 04/02/22, 04/03/22, 04/04/22, 04/05/22, 04/06/22, 04/07/22, 04/08/22, 04/09/22, 04/10/22, 04/11/22, 04/12/22, and 04/13/22 (a total of 13 doses). In an interview on 04/13/22 at 8:05 AM with the DON (Director of Nursing) she explained she was passing medications that morning because two nurses had called in sick. She stated she had administered medications to Resident #42 that morning. She indicated she had administered the [MEDICATION(S)], Iron and multivitamin with iron at the same time. She stated after she given Resident #42 her medication, she returned to the cart to sign them off as given and noticed the parameters documented for the [MEDICATION(S)]. She knew at that point she had administered the [MEDICATION(S)] incorrectly. In a second interview on 04/13/22 at 11:50 AM with the DON she reviewed the administration times for the [MEDICATION(S)] from 04/01/22 through 04/13/22 and realized every morning dose had been documented as given at the same time as the Iron and multivitamin with iron. The evening doses had been given as ordered by the physician. She stated she would change the administration time for the [MEDICATION(S)] to ensure it would not be given within 2 hours before or after the Iron or the multivitamin with iron. In an interview on 04/14/22 at 11:00 AM with Nurse #5 she stated she worked full time and was routinely assigned to care for Resident #42. She reported she had given the [MEDICATION(S)] every morning at the same time as the Iron and the multivitamin with iron. She had not realized the [MEDICATION(S)] was to be given either 2 hours before or 2 hours after the Iron and the multivitamin with iron. She explained she had received education that morning on how to give the medication. In a telephone interview on 04/14/22 at 11:13 AM with Nurse #6 she stated she realized there was supposed to be a 2- hour gap between the [MEDICATION(S)] and the Iron and the multivitamin with iron. She explained she gave Resident #42 the [MEDICATION(S)] at 8:00 AM each day, went down the hall giving medications, then gave the Iron and the multivitamin with iron to Resident #42 when she came back up the hall, but she documented all three at the same time. Record review revealed she documented she gave the Iron and multivitamin with iron on 04/09/22 at 8:27 and the [MEDICATION(S)] at 8:28 AM; and on 04/10/22 she documented she gave all three at 8:56 AM not leaving a gap of two hours either day had she given the [MEDICATION(S)] at 8:00 AM. When the sign off times were reviewed with Nurse #2 she had no response. In a telephone interview on 04/14/22 at 11:40 AM with Nurse #7 she stated she had administered medication to Resident #42 on 04/04/22 on day shift but had not had time to document that the medications were given because she had to leave to pick up her children and did not return to complete her charting. She did remember a resident who had to be given an antibiotic 30 minutes before other medications and two hours before eating but could not recall the resident. She was not aware the [MEDICATION(S)] she had given was ordered to be given either 2 hours before or after the Iron and the multivitamin with iron. In an interview on 04/13/22 at 10:42 AM with the Physician she stated she would need to review the orders because she had just taken over beginning on 04/01/22 and was not very familiar yet with the residents. She explained, in general, [MEDICATION(S)] should not be given with Iron or a multivitamin with iron because the Iron decreased the effectiveness of the antibiotic and the ability to manage the infection. She stated she may have recommended the facility hold the Iron and the multivitamin with iron during the 30 days the antibiotic was to be given or had the medication time altered to either 2 hours before or after the other medications. She commented because the resident was ordered to receive the antibiotic for 30 days and had the rest of the month remaining the medication would be effective if the rest of the remaining prescription was given as ordered and not given at the same time as the Iron or the multivitamin with iron. In an interview on 04/13/22 at 3:27 PM with the facility Pharmacy Consultant she stated when [MEDICATION(S)] was given at the same time as Iron or a multivitamin with iron, the iron bound to the [MEDICATION(S)] and could decrease the effectiveness of the medication. She stated the resident would not experience any negative outcome overall but concluded the best practice was to give the [MEDICATION(S)] either 2 hours before or 2 hours after giving the Iron or the multivitamin with iron. She concluded she would contact the DON and discuss the correct time to administer the [MEDICATION(S)].

Based on record review and staff interview the facility failed to inform resident representatives (RP) and families by 5:00 PM the next calendar day following the occurrence of sixteen confirmed staff and eleven confirmed resident COVID-19 infections from 01/05/22 through 02/03/22 for thirteen instances the facility did not contact family/RP of sixteen staff and eleven residents reviewed for COVID-19 reporting. Findings included: Review of the facility COVID-19 testing log revealed 2-staff tested positive on 01/05/22 and 01/06/22. An interview with the Administrator on 04/11/22 at 11:00 AM revealed the 2-staff who tested positive for COVID-19 on 01/05/22 and 01/06/22 were notified of positive COVID-19 status via facility-rapid test the same day. The Administrator stated he did not think about notifying residents or residents' responsible parties of the 16-staff and 6-Residents who tested positive on 01/05/22 thru 02/03/22, because he was an interim Administrator and just forgot to send a letter out to all facility's resident families until 02/03/22. The Administrator confirmed he was aware the facility was required to report subsequent confirmed COVID-19 cases, so the facility did not contact families and/or responsible parties of 2-staff who were COVID-19 positive on 01/06/22.

Based on record review and staff interviews the facility failed to implement Care Plan interventions for 4 of 4 residents (Resident #31, Resident #38, Resident #32, and Resident #19) whose Care Plans were reviewed for falls. Findings included: 1. Resident #31 was re-admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed Resident #31 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. Resident #31's Care Plan dated 09/13/19 revealed a risk for falls with an intervention of Please complete a fall risk assessment on me quarterly. In an interview on 09/19/19 at 10:37 AM the Charge Nurse stated that at one time there had been a nurse assigned to complete quarterly fall assessments. She indicated that the nurse had been unassigned from that duty and that another nurse had not been assigned to do the task. She expressed that the fall assessments had not been getting done because no one had been assigned to complete them and they had fallen through the cracks. In an interview on 09/19/19 at 4:56 PM the Director of Nursing (DON) verified that the fall assessments were not being completed because the assigned nurse had been pulled to work the floor and no one else had been assigned to do them. The DON expressed that the assessments were important so that interventions could be put in place to try to prevent falls from happening. 2. Resident #38 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired and did not reject care. Resident #38 had impairments on both lower extremities but had no falls since the prior assessment or last re-entry period. The Care Plan dated 04/25/19 revealed that Resident #38 was at risk for falls related to weakness and a [DIAGNOSES REDACTED]. In an interview on 09/17/19 at 2:45 PM the MDS Nurse verified that no quarterly fall assessments had been completed on Resident #38 since her admission on 10/29/18. She indicated that she input the information into the Care Plan but that she was not responsible for making sure that the assessments had been completed. In an interview on 09/19/19 at 10:37 AM the Charge Nurse stated that at one time there had been a nurse assigned to complete quarterly fall assessments. She indicated that the nurse had been unassigned from that duty and that another nurse had not been assigned to do the task. She expressed that the fall assessments had not been getting done because no one had been assigned to complete them and they had fallen through the cracks. In an interview on 09/19/19 at 4:56 PM the Director of Nursing (DON) verified that fall assessments were not being completed because the assigned nurse had been pulled to work the floor and no one else had been assigned to do them. The DON expressed that the assessments were important so that interventions could be put in place to try to prevent falls from happening. 3. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set comprehensive assessment dated [DATE] documented Resident #32 had one fall with no injury during the assessment reference period. The care plan for Resident #32 dated 9/17/19 included a problem that read: I am at risk for falls related to a history of falls with fractures. The goal was for the resident to remain free from injury for 90 days. One of the interventions in place was to complete a fall risk assessment for the resident quarterly. Resident #32 had a fall risk assessment completed on 06/22/18 as part of a Nursing Admission Assessment and again on 09/18/19 (after the survey team had alerted the facility that fall risk assessments had not been completed for the resident as care planned). Nursing progress notes documented on 07/23/19 at 6:15 AM Resident #32 fell with no injuries reported. The fall involved a broken toilet paper rack. An observation of the toilet paper rack was made on 09/19/19 at 12:05 PM. The rack was found to be fully functional with a roll of toilet paper in place. During an interview with the Plant Operations Manager at the time of the observation he stated if a resident had an incident that involved a needed repair by maintenance it was done immediately without the generation of paperwork. In an interview conducted with the Nurse Supervisor on 09/19/19 at 10:37 AM she stated there had been a nurse assigned to complete quarterly fall assessments, that nurse was unassigned from the duty and another nurse had not been assigned. The fall assessments had not been getting done because no one had been assigned to complete them. She commented the fall risk assessments had fallen through the cracks. Since it had come to the attention of the facility during the survey, they had reassigned the original nurse who had been doing the assessments to do them again. In an interview with the Director of Nursing on 09/19/19 at 4:55 PM she stated there had been a nurse assigned to complete the quarterly fall assessments. When that nurse was assigned to a different duty the facility failed to assign another nurse to complete the fall assessments. She concluded the fall risk assessments were not being completed as planned. She stated going forward she herself would be completing the fall risk assessments for residents as care planned. 4. Resident #19 was admitted to the facility on [DATE]. Her documented [DIAGNOSES REDACTED]. Record review revealed a fall risk assessment was completed for Resident #19 on 11/28/18. A 12/02/18 incident report documented Resident #19 told staff that she had experienced a fall. On 12/05/18 Resident #19's care plan documented the resident was a risk for falls due to having poor balance, dizziness and a history of falls. Interventions to this care plan problem included, Please complete a fall risk assessment on me quarterly. Record review revealed a fall risk assessment was completed for Resident #19 on 12/05/18. Record review revealed another fall risk assessment was not completed for Resident #19 until 06/17/19 following a fall on 06/10/19 which resulted in the resident having a [MEDICAL CONDITION] hip. During an interview with the Charge Nurse on 09/19/19 at 10:37 AM she stated previously there had been a nurse assigned to complete quarterly fall risk assessments, but that duty was removed from the nurse, and was not reassigned to anyone else. She reported as a result fall risk assessments were not getting completed. During an interview with the Minimum Data Set (MDS) Nurse on 09/19/19 at 2:57 PM she stated she expected care plan interventions to be implemented. She reported the care plan interventions were communicated verbally to direct care staff by herself, the Director of Nursing (DON), or the Nurse Supervisor. She commented the care plan interventions were also documented on the care plan which all direct care staff had access to. According to the MDS Nurse, a new electronic alerts feature in the e-charting system also alerted staff when new care plan interventions were put in place. During an interview with the acting DON on 09/19/19 at 4:55 PM she stated care plan interventions should be implemented. She reported staff should be aware of these interventions because they were passed on verbally, were documented on 24-hour reports, and were sent to staff via alerts in electronic charting.

Based on observation, record review and staff and Registered Dietician interviews, the facility failed to provide a nutritional supplement in the amount ordered by the physician for a resident with continued weight loss for 1 of 4 residents (Resident #31) whose nutrition was reviewed. Findings included: The (MONTH) 2019 paper Medication Administration Record (MAR) revealed an order to administer Medpass 2.0 (a nutritional supplement) 120 mls (milliliters) by mouth three times daily. Resident #31 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 04/01/19-09/17/19 electronic MARs revealed orders to administer Medpass 2.0 by mouth three times daily for nutritional supplementation. The orders did not contain an amount of the supplement to be provided. Resident #31's weights were recorded as follows: 03/01/19 112.20 pounds 04/01/19 108.40 pounds 05/02/19 106.80 pounds 06/03/19 105.00 pounds 07/02/19 100.20 pounds 08/01/19 101.40 pounds 08/07/19 101.80 pounds 08/21/19 98.60 pounds 08/29/19 98.20 pounds 09/03/19 98.10 pounds 09/12/19 97.60 pounds The annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #31 had short-term and long-term memory problems and was severely impaired in cognitive skills for daily decision making. Resident #31 needed the extensive assistance of one person for eating. Resident #31 weighed 101 pounds and had a weight loss of 5% or more in the last month or a weight loss of 10% or more in the last six months. The Registered Dietician (RD) note dated 09/10/19 revealed that Resident #31 had a significant weight loss trend in place. Resident #31's intake had been good over the last seven days with an average intake amount of 71%. Multiple therapeutic supplements were in place to aid with needs including Medpass 2.0 120 ml three times daily. According to the note Resident #31's weight loss may be unavoidable due to disease progression. Resident #31's Nutrition Care Plan updated 9/13/19, listed interventions of diet as ordered and to monitor weights as ordered. In an observation on 09/17/19 at 5:06 PM Resident #31 was up in the dining room eating a peanut butter and jelly sandwich. Approximately 90% of the sandwich had been eaten. In an interview on 09/18/19 at 9:08 AM Nurse #4 stated she worked with Resident #31 4-5 days per week. She reviewed the order in the computer for the Medpass 2.0 and stated that there was no dosage amount listed, but that she usually administered 60 ml of the Medpass 2.0 to Resident #31. Nurse #4 indicated that it was a problem that no dosage amount was listed on the order and that she should have clarified the order. Nurse #4 explained that Resident #31 received the Medpass 2.0 because the resident did not eat well. In an observation on 09/18/19 at 11:38 AM Resident #31 was up in the dining room and was served macaroni and cheese, greens, chicken, and corn bread. Approximately 25% of the meal was eaten. In an interview on 09/18/19 at 5:05 PM Nurse #5, who worked with Resident #31 on the 3PM-11PM shift, stated she had been administering 60 ml of Medpass 2.0 to Resident #31 on her shift. In an interview on 09/19/19 at 11:07 AM the MDS Nurse clarified that diet as ordered on the Care Plan consisted of anything related to nutrition including supplements, meals, and snacks. In a telephone interview on 09/19/19 at 12:05 PM Nurse #6 stated that the facility had begun using electronic charting for medication administration on 04/01/19. She indicated that she transferred the order for the Medpass 2.0 from the paper MAR to the electronic MAR and did not check to see that the order had transferred with all the needed information which would have included the amount to be given. In a telephone interview on 09/19/19 at 2:23 PM the RD stated that generally she looked at a resident's MAR each time she assessed them. She indicated that she must have missed that there was no amount listed for the dispensing of the Medpass 2.0 on the May, July, (MONTH) and (MONTH) 2019 MARs when she assessed Resident #31 during those months. She verified that she expected nutritional interventions to be followed and would expect orders to be entered into the electronic record correctly when the facility changed from paper to electronic charting. The RD indicated that although Resident #31 only received one half the Medpass 2.0 that was ordered, other interventions were in place and she did not feel this contributed heavily to the continued weight loss. In an interview on 09/19/19 at 4:56 PM the Director of Nursing (DON) stated that interventions were put in place for a reason and that she expected them to be followed. She indicated that she expected orders to be followed and that when the MAR went from paper to electronic the orders should have been checked to make sure they were input correctly. The DON expressed that it was important to provide nutritional supplements as ordered to prevent continued weight loss. The DON clarified that it was also the responsibility of the RD to look at the MAR to make sure supplements were given as ordered.

Based on observation, record review and staff, therapist, and physician interviews, the facility failed to prevent a right ankle, Deep Tissue Injury (DTI) caused by a knee brace not being positioned on the knee which allowed the brace to press against the resident's ankle for 1 of 3 residents (Resident #38) whose pressure wounds were reviewed. Findings included: Resident #38 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. Resident #38's Care Plan initiated on 06/26/19 revealed under activities of daily living (ADL), interventions of: Right Leg precautions - No leg bending, no abduction, no bending of the hip more than 90 degrees. Knee immobilizer as ordered - T scope (hinged knee brace). Check skin every two hours and as needed. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #38 was severely cognitively impaired and did not reject care. Resident #38 required the extensive assistance of one person for bed mobility, dressing, and hygiene, and was dependent on one person for transfers, toilet use, and bathing. Resident #38 was at risk for but had no pressure ulcers. In an interview on 09/18/19 at 7:07 AM Nurse #1 stated that Resident #38's knee brace should be loosened, and the skin checked every two hours. He stated that the last time he had checked Resident #38's knee brace was at 2:00 AM that morning. In an interview on 09/18/19 at 8:30 AM Nurse #2 stated she had last checked the skin on Resident #38's right leg at 7:45 AM and would check it again at 10:00 AM. In an observation of Resident #38's knee brace and the skin beneath it on 09/18/19 at 9:59 AM and an interview with Nurse #2 at the same time, she stated the knee brace was not in the right position. The brace was positioned so that the bottom of the knee brace was on the right ankle. Nurse #2 loosened the straps on the brace to check the skin on Resident #38's leg. A dark red area, approximately the size of ½ of a dime, with a dark purple center was noted on Resident #38's right medial ankle. The area was not open. The skin around the wound was also red. Nurse #2 stated she had discovered the area when she checked Resident #38's skin at 7:45 AM. She indicated that she had not documented the wound, notified the physician or notified the Responsible Party when the wound was discovered. She indicated she had not provided any treatment or protection to the wound on discovery. She indicated she would go and bring a therapist back to the room to correctly position Resident #38's brace. Resident #38 did not appear to be in any pain from the pressure wound. In an observation and interview with Physical Therapist (PT) #1 on 09/18/19 at 10:06 AM he adjusted Resident #38's knee brace approximately 6 inches up the leg to the correct position. He stated that the pressure injury on the ankle was caused by the knee brace pressing against the ankle. In a telephone interview on 09/18/19 at 3:46 PM Resident #38's physician stated that Resident #38 should not have developed a pressure injury on the ankle from a knee brace. He indicated that the brace should have been monitored for its position and the skin should have been monitored to prevent this type of injury. He stated that the pressure injury was avoidable and should not have happened. The Skin Evaluation Form dated 09/18/19 revealed the wound was reddish/purple in color, was non-blanchable, and measured 0.8 by 0.4 cm (centimeters). The surrounding skin was red, and the wound was staged as a DTI. In an interview on 09/19/19 at 10:37 AM the Charge Nurse stated that she had assessed Resident #38's ankle wound and that she had classified it as a DTI. In an interview on 09/19/19 at 2:00 PM Nursing Assistant (NA) #1 stated she had been instructed on the proper positioning of Resident #38's knee brace. She indicated she observed the pressure area on Resident #38's right ankle on 09/16/19 but did not tell the nurse because she thought it was an old wound. In an interview on 09/19/19 at 4:56 PM the acting Director of Nursing (DON) stated that all orders should be followed. She indicated that interventions were put in place for a reason and in this case, they were put in place to prevent injury. She stated that the skin and knee brace checks needed to be done as ordered to maintain Resident #38's skin integrity. She indicated that Resident #38 should not have developed an ankle pressure injury from a knee brace that was improperly positioned. The DON stated that the Nursing Assistants should always report any skin injury to the nurse even if they think it is an old injury because it might not have been reported.

Based on physician assistant interview, staff interview, and record review the facility failed to provide anticoagulation coverage for seven days after a sub-therapeutic lab value was obtained for 1 of 2 sampled residents (Resident #45) receiving anticoagulant medication ([MEDICATION NAME]). The facility also failed to hold the administration of an anticoagulant (medication used to treat/prevent the formation of blood clots) as ordered by the physician for 1 of 2 sampled residents (Resident #45) who was on [MEDICATION NAME]. Findings included: 1. a. Resident #45 was admitted to the facility of 07/12/19. The resident's documented [DIAGNOSES REDACTED]. Resident #45's 07/19/19 admission minimum data set (MDS) assessment documented her cognition was moderately impaired and she was receiving anticoagulant medication daily. On 07/23/19 Risk for unexplained bruising or bleeding r/t (due to) taking anticoagulant medication was identified as a problem in Resident #45's care plan. Interventions to this problem included Please give me anticoagulant med as ordered. On 08/13/19 Physician Assistant (PA) #1 wrote an order to discontinue Resident #45's [MEDICATION NAME] once her international normalized ratio (INR) was below 2, and at that point, to start the resident on Eliquis 2 milligrams (mg) twice a day (BID). 08/26/19 lab results documented Resident #45's [MEDICATION NAME] time (PT) was 40.5 and her INR was 4.3 (these lab values were calculated based on the time it took the resident's blood to clot). In response to these lab results PA #1 ordered for the [MEDICATION NAME] to be temporarily discontinued with a repeat PT/INR to be drawn on 08/29/19. 08/29/19 lab results documented Resident #45's PT was 34.8 and her INR was 3.7. In response to these lab results PA #1 ordered the [MEDICATION NAME] to remain on hold with a repeat PT/INR to be drawn on 09/05/19. 09/04/19 lab results documented Resident #45's PT was 15.3 and her INR was 1.5. There was no documentation on the lab results to indicate that they were called in to the PA or primary physician. Review of Resident #45's (MONTH) 2019 and (MONTH) 2019 electronic medication administration record (e-MAR) revealed the resident did not receive any more [MEDICATION NAME] after 08/25/19, and the resident did not receive Eliquis on 09/04/19 after her INR fell below 2 as ordered by the P[NAME] On 09/10/19 PA #1 wrote an order to start Resident #45 on Eliquis 2 mg every 12 hours. Review of Resident #45's (MONTH) 2019 e-MAR revealed the resident received her first dose of Eliquis on 09/12/19. The resident did not receive any anticoagulant medication for seven days. Review of Resident #45's electronic medical record revealed she did not experience any signs and symptoms of a stroke or heart problems between 09/04/19 and 09/12/19. During an interview with the Charge Nurse on 09/19/19 at 3:40 PM she stated she could not explain why Resident #45 went without anticoagulant medications between 09/04/19 and 09/11/19. She commented maybe the PA wanted to assess the resident in person before making a decision on how to best continue the resident's anticoagulant therapy. The Charge Nurse explained because of an in-coming hurricane the Medical Director gave permission for labs scheduled on 09/05/19 to be drawn early on 09/04/19. During a telephone interview with PA #1 on 09/19/19 at 4:30 PM he stated Resident #45 should have been transitioned from [MEDICATION NAME] to Eliquis before 09/12/19. He reported he could not recall if the facility made him aware of Resident #45's 09/04/19 lab results, but remarked that he ordered Resident #45 to be transitioned to Eliquis again on 09/10/19 since the facility had not done so yet per his 08/13/19 order to make the change after the resident's INR fell below 2. The PA explained Resident #45 was receiving anticoagulation therapy for control of her [MEDICAL CONDITION], and the resident's heart rate was currently under very good control so the [MEDICATION NAME] was being used for preventative measures. Thus, he commented there was a lower risk that Resident #45 could have experienced any harm from going without anticoagulant therapy for seven days. During an interview with the acting Director of Nursing (DON) on 09/19/19 at 4:55 PM she stated Resident #45 should not have gone from 09/04/19 through 09/11/19 without anticoagulant medication. She reported a nurse should have documented a PA or physician response if they were contacted with lab results on 09/04/19 and clarified whether or not the resident was still to be transitioned to Eliquis after the INR was below 2 as ordered back on 08/13/19. She commented the resident going seven days without anticoagulant therapy increased the chance the resident could have experienced a stroke. 1. b. Resident #45 was admitted to the facility of 07/12/19. The resident's documented [DIAGNOSES REDACTED]. Resident #45's 07/19/19 admission minimum data set (MDS) assessment documented her cognition was moderately impaired and she was receiving anticoagulant medication daily. On 07/23/19 Risk for unexplained bruising or bleeding r/t (due to) taking anticoagulant medication was identified as a problem in Resident #45's care plan. Interventions to this problem included Please give me anticoagulant med as ordered. A 08/16/19 hospital discharge summary documented Resident #45's [MEDICATION NAME] was to be resumed at 1.5 milligrams (mg) daily (QD) starting on 08/19/19. 08/22/19 lab results documented Resident #45's [MEDICATION NAME] time (PT) was 31.5 and her international normalized ratio (INR) was 3.3 (these lab values were calculated based on the time it took the resident's blood to clot) . It was documented on these lab results that Physician Assistant (PA) #1 wanted Resident #45's [MEDICATION NAME] to be held on 08/22/19 and 08/23/19 with [MEDICATION NAME] 1 mg QD to start on 08/24/19 and a PT/INR to be drawn on 08/26/19. Review of Resident #45's (MONTH) 2019 electronic medication administration record (e-MAR) revealed the resident's [MEDICATION NAME] was held on 08/22/19, but the resident received [MEDICATION NAME] 1.5 mg on 08/23/19. The resident received [MEDICATION NAME] 1 mg on 08/24/19 and 08/25/19. 08/26/19 lab results documented Resident #45's PT was 40.5 and her INR was 4.3. In response to these lab results PA #1 ordered for the [MEDICATION NAME] to be temporarily discontinued with a repeat PT/INR to be drawn on 08/29/19. 08/29/19 lab results documented Resident #45's PT was 34.8 and her INR was 3.7. In response to these lab results PA #1 ordered the [MEDICATION NAME] to remain on hold. Review of Resident #45's electronic medical record revealed the resident did not experience any episodes of bleeding between 08/23/19 and 08/29/19. During an interview with Nurse #2 on 09/19/19 at 2:57 PM she stated if the PA conveyed he wanted [MEDICATION NAME] held, the nurse receiving this communication put the medication on hold in the e-MAR. She also commented that it was her general routine to pull the medication card out of the cart and leave it in the locked medication room with a note on the card documenting the medication was being held. During an interview with the Charge Nurse on 09/19/19 at 3:40 PM she stated the nurse who received communication from the PA to hold medications placed them on hold in the e-MAR so the medications were flagged with a red 'H in the administration section on the affected dates . She explained a nurse, although it could not be determined which one, forgot to document in the e-MAR that Resident #45's [MEDICATION NAME] was placed on hold on 08/23/19. She commented that because Resident #45's [MEDICATION NAME] was not held on 08/23/19 it increased the risk the resident could have experienced bleeding. During a telephone interview with PA #1 on 09/19/19 at 4:30 PM he stated if he gave orders to hold [MEDICATION NAME] on certain dates then he would expect the facility to follow through and make sure the residents did not receive the medication. He explained the treatment goal for Resident #45 was to transition the resident from [MEDICATION NAME] to Eliquis, and in order to do so the resident's INR needed to be below 2. Therefore, he commented not holding the [MEDICATION NAME] on 08/23/19 slowed down Resident #45's progress toward attaining her INR goal and transitioning off [MEDICATION NAME]. The PA stated Resident #45 received [MEDICATION NAME] to manage her [MEDICAL CONDITION]. During a 09/19/19 4:12 PM interview with Nurse #2, who did not hold Resident #45's [MEDICATION NAME] on 08/23/19, she stated she administered [MEDICATION NAME] to the resident on 08/23/19 because there was no red H (designating a hold) in the e-MAR on that date and there was no note on the resident's [MEDICATION NAME] bubble pack to hold the medication on 08/23/19. During an interview with the acting Director of Nursing (DON) on 09/19/19 at 4:55 PM she stated it was the responsibility of the staff nurses to make sure medications that the PA wanted held were placed on hold in the e-MAR and did not get administered to the residents. She reported not holding [MEDICATION NAME] as ordered by the PA increased the chances that Resident #45 could have experienced bleeding and delayed the goal of getting the resident's INR below 2.

Based on staff interview and record review the facility failed to establish a Quality Assurance/ Performance Improvement Program (QA/PIP) for an issue identified in (MONTH) 2019 (falls) to include a root cause analysis, monitoring, and review of audit results. Findings included: The facility Quality Assessment Performance Improvement Plan Policy (Effective Date (MONTH) 30, (YEAR)) defines the responsibilities of the Governing Body of the facility, (the Executive Director/Administrator, Director of Nursing Services, Assistant Director of Nursing Services and the Medical Director), as responsible for the development and implementation of the QAPI program. The Governing Body is responsible for: 1. Identifying and prioritizing problems based on performance indicator data. 2. Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents. 3. Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 4. Setting clear expectations for safety, quality, rights, choice, and respect. 5. Ensuring adequate resources exist to conduct QAPI efforts. The Quality Assurance Performance Improvement (QAPI) Committee reports to the executive leadership and Governing Body and is responsible for: 1. Meeting, at a minimum, on a quarterly basis; more frequently, if necessary 2. Coordinating and evaluating QAPI program activities 3. Developing and implementing appropriate plans of action to correct identified quality deficiencies 4. Regularly reviewing and analyzing data collected under the QAPI program and data resulting from drug regiment review and acting on available data to make improvements. 5. Determining areas for PIPs and Plan-Do-Study-Act (PDSA) rapid cycle improvement projects. 6. Analyzing the QAPI program performance to identify and follow up on areas of concern and/or opportunities for improvement. The facility Monthly QAPI Reports and Event Logs for May, (MONTH) and (MONTH) 2019 were reviewed. A brief summary of the number of falls that occurred was reported. The documentation did not include an individual plan for structured monitoring, auditing, staff education or evaluations pertaining to falls. In an interview conducted with the Director of Nursing on 09/19/19 at 4:55 PM she stated she had been looking at the high incidence of falls in the facility. She commented she had not developed a PIP (Performance Improvement Plan), monitoring or measuring tools or tangible auditing tools. She acknowledged the facility had a Quality Assurance policy she had not been following to establish and monitor Quality Assurance issues. She stated she had never been taught how to formally develop Quality Assurance PIP's after issues had been identified. She reported when she took over quality assurance in (YEAR), she had no examples to refer to because the previous nurse who was in charge of Quality Assurance had been let go promptly and did not have a QA process in place.

Based on observation, physician assistant (PA) interview, resident interview, staff interview, and record review the facility failed to draw three [MEDICATION NAME] time/international normalization ratio (PT/INR) labs ordered by the PA or the physician for 1 of 1 residents (Resident #35) receiving anticoagulant (blood thinning) medication. After one of the missed PT/INR labs Resident #35 was found to have an INR level in the high critical range. Findings included: Record review revealed Resident #35 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. 12/04/17 lab results documented Resident #35's PT/INR was 37.5/ 3.5 (with the PT normal range being 9.3 - 11.5 seconds and the INR normal range being 0.9 - 1.1). The lab results documented the resident's desired INR therapeutic range was 2.0 - 3.0. A 12/05/17 physician order [REDACTED]. A 12/11/17 progress note documented the lab called to inform the facility that Resident #35's INR was at a critical level with lab results documenting a PT/INR of 86.3/7.8. A 12/11/17 physician order [REDACTED]. 12/12/17 lab results documented Resident #35's PT/INR was 50.2/4.6, and the physician wanted the resident's [MEDICATION NAME] held on 12/12/18 and 12/13/18 (which was done as documented on the MAR) with a repeat PT/INR on 12/14/17. 12/14/17 lab results documented the resident's PT/INR was 16.3/1.6. A 12/15/17 PA order restarted [MEDICATION NAME] at 3 mg QD (which was done as documented on the MAR) and requested a repeat PT/INR on 12/18/17. A 12/15/17 progress note documented Resident #35 was found with a bruise to the right leg measuring 20.5 x 6.5 centimeters (cm) from the knee to the top of the ankle which was reddish purple in color. At this time the resident reported a couple days before she was hit by the leg extender on another resident's wheelchair. The physician was notified with orders to monitor the area closely. Review of lab results in the medical record and of the electronic laboratory system revealed no PT/INR was drawn on 12/18/17 (as ordered on [DATE]). 12/26/18 lab results documented Resident #35's PT/INR was 20.9/2.0. 01/04/18 lab results documented Resident #35's PT/INR was 13.2/1.3. A 01/15/18 physician order [REDACTED]. This change was made per review of the resident's MAR. A 03/29/18 physician order [REDACTED]. This change was made per review of the resident's MAR. 04/02/18 lab results documented the resident's PT/INR was 10.6/1.0. A 04/02/18 physician ordered increased the resident's [MEDICATION NAME] to 4 mg QD (which was documented on the resident's MAR) and requested a PT/INR be drawn on 04/05/18. Review of lab results in the medical record and of the electronic laboratory system revealed no PT/INR was drawn on 04/05/18 (as ordered on [DATE]). A 04/27/18 physician order [REDACTED]. PT/INR not obtained on 04/05/18. Notified _____ (name of PA). 04/27/18 lab results documented Resident #35's PT/INR was 70.3/6.8 with the INR being in the high critical range. A 04/27/18 physician order [REDACTED].). 05/02/18 lab results documented the resident's PT/INR was 11.3/1.1. A 05/02/18 physician order [REDACTED]. PT/INR labs were drawn on 05/11/18, 05/18/18, 05/24/18, and 05/31/18. 05/31/18 lab results documented Resident #35's PT/INR values were high with a PT/INR of 61.4/5.9. 06/04/18 lab results documented the resident's PT/INR was 46.1/4.4. A 06/05/18 physician order [REDACTED]. 06/11/18 lab results documented the resident's PT/INR was 44.2/4. A 06/12/18 PA order held the resident's [MEDICATION NAME] on 06/12/18 and 06/13/18 and restarted [MEDICATION NAME] at 2 mg QD on 06/14/18 (which was done per the MAR) with a repeat PT/INR to be obtained on 06/18/18. Review of lab results in the medical record and of the electronic laboratory system revealed no PT/INR was drawn on 06/18/18 (as ordered on [DATE]). A 06/24/18 progress note documented Resident #35 had a bruise to her left upper arm shaped like fingers. The physician was notified with orders to monitor the area closely, and an investigation ruled out abuse. A 07/05/18 PA order documented, 1. PT/INR on 07/02/18 = 12.8 and 1.2. 2. (Increase) [MEDICATION NAME] to 2 mg alternating (with) 3 mg A-fib. 3. Obtain PT/INR on 07/12/18 (which was done per order review). 4. PT/INR ordered on [DATE] not obtained. Notified _____ (name of PA). Resident #35's 07/18/18 quarterly minimum data set (MDS) documented her cognition was intact, she was tired and experienced some hallucinations, she rejected care for 1 -3 days in the look-back period, she required extensive assist from staff to being dependent on the staff for her activities of daily living (other than being independent when eating), her weight was stable, and she received an anticoagulant medication one day during the look-back period. The resident's care plan, last updated on 07/20/18, identified At risk for unexplained bleeding and bruising r/t (due to) administration of anticoagulant (sick sinus syndrome, a-fib,[MEDICAL CONDITION] left [MEDICAL CONDITION]) as a problem. Interventions to this problem included drawing labs as ordered. On 8/23/18 at 9:38 AM the Director of Nursing (DON) stated the facility had not completed monthly tracking forms, recapitulations, or audits on labs associated with [MEDICATION NAME] usage because the facility had never had many residents on the medication. She reported all residents on anticoagulants currently in the facility, except Resident #35, were receiving medications beside [MEDICATION NAME] which did not require lab monitoring. According to the DON, the danger of missed PT/INRs was that a resident could experience severe bleeding before labs identified the resident as having critical INR levels. The DON commented she had reviewed Resident #35's chart, and saw no documentation of bleeding for the resident, and confirmed that there were no PT/INR labs drawn for Resident #35 on 12/18/17, 04/05/18, and 06/18/18. On 08/23/18 at 11:05 AM Charge Nurse #1 stated she usually wrote PT/INR orders, placed copies of the orders in the lab basket, and the night shift nurses scheduled the labs on the lab calendar. She reported she was responsible for checking to make sure the the PT/INR labs were drawn. This Charge Nurse commented that an electronic PT/INR tracking log had been discontinued sometime in (YEAR) because the rest of the staff did not really think it was necessary. She confirmed that the goal was to keep Resident #35's INR level in the 2.0 - 3.0 therapeutic range. According to Charge Nurse #1, when PT/INR labs were missed there was the danger that the INRs could be 6.0 or greater without the facility knowing which increased the chance that residents could bleed out. She stated there had been no in-servicing about how to correct the problem with missed PT/INR labs. However, she reported the Quality Assurance (QA)/Staff Development Coordinator (SDC) had compiled a list of residents receiving any type of anticoagulant medication which was placed in front of the MARs. On 08/23/18 at 11:28 AM the QA/SDC nurse stated she had not held any in-servicing on how to avoid missing PT/INR labs. However, she reported she had developed a list of all residents on any type of anticoagulant medication, and placed a copy of the list in front of all MARs and at all Nursing Assistant (NA) kiosks. She commented that she had 1:1 educations sessions with all NAs, stressing the importance of taking extra time when transferring, shaving, and caring for these residents. This nurse also reported she instructed the NAs on the importance of immediately reporting bruising and bleeding for these residents to the nursing staff. On 08/23/18 at 12:02 PM, during a telephone with the facility's PA, he stated the goal was to keep Resident #35's INR between 2.0 and 3.0 to help control her [MEDICAL CONDITION], but it was a difficult task because the resident's INR varied greatly with the slightest adjustment in her [MEDICATION NAME] regimen. He reported he liked to draw repeat PT/INR labs about three to four days after dosage changes. He commented he expected the nursing staff to draw all the PT/INR labs he ordered and to notify him immediately when the resident's INR values were drastically out of the therapeutic range so he could make dosage changes quickly. He also remarked that when the INR rose close to or above 6.0 holding doses of [MEDICATION NAME] and the administration of vitamin K were often used to bring the resident closer to the therapeutic range. The PA stated he did not remember being notified about missed PT/INR labs for Resident #35, but he reported he thought he had been notified several times about her critically high INR values. According to the PA, he had serious concern when a PT/INR had not been drawn as ordered, and the resident's INR level was critically elevated for four to five days without the facility being made aware through lab monitoring. He commented that he expected facility staff to monitor residents on [MEDICATION NAME] carefully for bleeding, bruising, slurred speech, and drastic drops in hemoglobin and hematocrit levels. The PA stated he did not have concern even though Resident #35's hemoglobin had gradually dropped from 12.9 grams per deciliter (g/dL) on 11/06/17 to 10.4 g/dL on 06/04/18, and her hematocrit had gradually dropped from 40.2% on 11/06/17 to 33.9% on 06/04/18. He explained the gradual drop was probably due to aging and the many co-morbidities the resident experienced. On 08/23/18 at 1:27 PM Charge Nurse #1 provided copies of the facility's lab calendars, and missed PT/INR labs for Resident #35 on 12/18/17, 04/05/18, and 06/18/18 had not been entered on the calendars to be drawn. She stated she thought part of the problem which caused the PT/INR labs not to be scheduled was that the facility Physician/Medical Director at the time always drew his PT/INR labs monthly, but the newer PA wanted closer monitoring and tighter therapeutic control over INRs so he ordered the PT/INRs more frequently, especially following dosage adjustments. According to the Charge Nurse, she thought Resident #35's labs might have been overlooked because the night nurse was used to only drawing PT/INRs monthly. Charge Nurse #1 stated she could not explain why she did not more quickly identify that Resident #35's 12/18/17, 04/05/18, and 06/18/18 PT/INRs were not drawn. On 08/23/18 at 1:45 PM, during a telephone conversation, Nurse #1, who worked nights in the facility, stated she was used to scheduling PT/INR labs and a CBC (complete blood count) for Resident #35 on the first Monday of each month. She reported copies of the orders to draw the resident's 12/18/17, 04/05/18, and 06/18/18 PT/INRs might have not been placed in her lab basket, or she might have overlooked them because they were outside of the resident's regular PT/INR schedule. She commented that sometimes the PA ordered repeat or additional PT/INRs when [MEDICATION NAME] dosages were changed or there were abnormal lab values. According to Nurse #1, Mondays and Thursdays were the lab draw days for the facility. She stated a lab technician from the hospital drew the labs based on her lab calendars unless during holidays facility staff members might have to draw the labs themselves. On 08/23/18 at 2:40 PM Nurse #2 stated Resident #35 was very confused for two or three months prior to (MONTH) (YEAR), but her cognition had improved recently. She reported she frequently cared for the resident, and she was unaware of the resident ever experiencing bleeding or having unexplained bruising. On 08/23/18 at 2:45 PM Resident #35 was very alert and oriented, and reported that she had not experienced any bleeding or unexplained bruising while in the facility. She commented she had felt very tired for a while now, but was told by the doctors that this was a side effect of some of her medications. There were no visible bruises on the resident's body.

Based on observation and staff interview the facility failed to air-dry kitchenware before stacking it in storage and placing ice and beverage in it. The facility also failed to ensure adequate hair net coverage for 1 of 3 staff members working in the unit kitchen. Findings included: 1. At 9:42 AM on 08/22/18 6 of 18 eight-ounce cups, stacked on top of one another in one unit dining room had moisture trapped inside of them. 1 of 13 eight-ounce cups stacked on top of one another in the other unit dining room had moisture trapped inside of them. At 9:58 AM on 08/22/18 1 of 21 tray pans stacked on top of one another on a storage rack in the main kitchen had moisture trapped inside of it. At 10:17 AM on 08/22/18 surveyor intervention prevented a dietary employee in the unit/auxiliary kitchen from placing ice and beverage in 5 of 13 eight-ounce cups which still had moisture inside of them. At 10:46 AM on 08/23/18 the Food and Beverage Director stated it was okay to stack pieces of kitchenware on top of one another, but they should be clean and completely dry before doing so. He reported that moisture trapped between pieces of kitchenware could cause cross-contamination and had the potential for causing foodborne illness. He commented that drying racks were in place in both the main and unit/auxiliary kitchens, and kitchenware was supposed to be air-dried on these racks before being stacked in storage. At 10:58 AM on 08/23/18 Cook #1 stated she had attended dietary in-services in which the staff was educated to air-dry all kitchenware before stacking it in storage. She reported bacteria and mold could grow in trapped moisture and make residents sick. 2. On 08/22/18 between 11:38 AM and 11:55 AM, during observation of the trayline process, a dietary aide in the unit/auxiliary kitchen was taking resident plates from the cook at the steam table, placing bread with the meal, and then taking the food out to one of the unit dining rooms for the nursing assistants to distribute. The hair net worn by this employee only covered the back half of her head. The hair net did not cover the employee's bangs, which extended approximately 2 inches down her forehead, hitting just above her eyebrows. In addition, approximately two inches of hair on either side of her face was not tucked under the hair net, and hung loose, framing her face under her chin. At 10:46 AM on 08/23/18 the Food and Beverage Director stated employees working in the kitchens should have all their hair covered by a net. He reported uncovered hair posed the risk of loose hair falling into food which could cause cross-contamination and possibly make residents sick. At 10:58 AM on 08/23/18 Cook #1 stated during in-servicing dietary employees had been instructed to make sure all hair was covered when working in the kitchen. She remarked that no one liked to find hair in their food because it was unsanitary and could cause the spread of disease.

Based on record reviews and pharmacy and facility staff interviews, the facility failed to maintain documentation of the pharmacist's monthly Medication Regimen Review (MRR) within the facility and readily available for 5 of 5 sampled residents (Resident #1, #18, #36, #57, and #65) reviewed for unnecessary medications. Findings included: 1. Resident #18 was admitted to the facility on [DATE], and her documented [DIAGNOSES REDACTED]. The resident's most recent minimum data set (MDS), a quarterly assessment dated [DATE], documented Resident #18 required extensive assist for dressing and limited assistance for bed mobility, transfers, toileting and hygiene. Her cognition was severely impaired. She received antipsychotic medication and insulin for 7 out of 7 days during the assessment look-back period and antidepressant medication for 1 out of 7 days. The resident's plan of care dated 09/20/17 included interventions for cognitive fluctuations related to episodes of confusion, fluctuations in mental status and a [DIAGNOSES REDACTED]. Behaviors included hallucinations and delusions. Review of the resident's September 2017 Medication Administration Record [REDACTED]. The resident was also receiving an anti-platelet medication, an anti-hypertension medication and Insulin. Review of Resident #18's Medication Regimen Review sheet revealed that starting in December 2016 through September 2017 the facility's consultant pharmacist only signed his name and documented the date of his monthly visits rather than providing a recapitulation of his monthly medication regimen reviews (MRRs). The sheet documented the consultant pharmacist reviewed Resident #18's medications on 12/08/16, 01/09/17, 02/09/17, 03/07/17, 04/07/17, 05/04/17, 06/07/17, 07/06/17, 08/7/17, and 09/11/17. At 3:30 PM on 09/19/17 the assistant director of nursing (ADON) stated that the consultant pharmacist reviewed the medication regimens of all residents monthly. However, she reported the only information he left with the facility was pharmacy recommendations made after completion of the monthly reviews. She commented the pharmacist's actual monthly MRRs were stored in his laptop/computer, and the pharmacist could be contacted via phone to provide the information which he gathered and analyzed during those monthly reviews. The ADON clarified that the facility did not have electronic or printed copies of the MMRs on-site. At 1:00 PM on 09/20/17 the facility's Consultant Pharmacist stated when he completed monthly MRRs he assessed the residents' psychoactive medications, gradual dose reductions, labs, weights, past pharmacy recommendations, and sometimes performed a creatinine clearance calculation. He reported he printed out reports to leave with the facility each month, and the last page of the recommendations report documented, The following residents were reviewed and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the residents' medication regimens contained no new irregularities (as defined in SOM appendix PP 483.60 (c)). The pharmacist commented that following this statement there was a list of residents whose medications were reviewed, but who did not have any recommendations. According to the Consultant Pharmacist, the pharmacy for which he worked would not allow him to do double work by documenting a review in the pharmacy computer system and then having to provide the facility with a hard or electronic copy of his assessments. He stated he felt his signature and date on the Medication Regimen Review, coupled with the copies of recommendations he left with the facility each month, met the intent of the federal regulation which required MRRs be readily available to staff members and regulators who wished to review them. At 11:19 AM on 09/21/17 the State Clinical Director of Pharmacy Services stated the Consultant Pharmacist could either enter his review into the computer or write it on the monthly MRR sheet in the chart. He stated there was no policy indicating how the Consultant Pharmacist should document the information and that it was an individual choice. The Clinical Director also stated the Consultant Pharmacist could choose to document in both places. He indicated that at a minimum he would expect there to be a signature and date to show the Consultant Pharmacist had completed the review. He acknowledged that one could not tell if something was missed or not reviewed by looking at a signature and a date. He stated the Consultant Pharmacists were not on call 24 hours a day, however, Pharmacy Services could be contacted, and they would attempt to call the Consultant. He indicated the only documentation Pharmacy Services was able to access were the recommendations made by the Consultant Pharmacist and not the reviews themselves. The Clinical Director stated the monthly MRRs allowed the Pharmacy Consultant to review any issues that needed follow-up. He further stated they were to be utilized by the Consultant Pharmacist to see if recommendations needed to be made. He indicated Nurses, Dieticians, and Activity Directors could access some of the same information on the MRR by looking at behavior monitoring sheets, notebooks kept in management offices, and nursing notes. At 12:45 PM on 09/21/17 the Director of Nursing (DON) stated it was her expectation that the Consultant Pharmacist document a note regarding his or her monthly MRR for each resident. She also reported she expected this documentation to be readily available for staff to use in making medical and care decisions for the residents. 2. Resident #1 was readmitted to the facility on [DATE], and her documented [DIAGNOSES REDACTED]. The resident's most recent minimum data set (MDS), a quarterly assessment dated [DATE], documented Resident #1 required extensive assist for activities of daily living and supervison for eating. Her cognition was intact. She received Insulin and diuretics for 7 out of 7 days during the assessment look-back period and antidepressant medication for 6 out of 7 days. Review of the resident's September 2017 Medication Administration Record [REDACTED]. The resident was also receiving an anti-platelet medication, an anti-hypertension medication and Insulin. Review of Resident #1's Medication Regimen Review sheet revealed that starting in December 2016 through September 2017 the facility's consultant pharmacist only signed his name and documented the date of his monthly visits rather than providing a recapitulation of his monthly medication regimen reviews (MRRs). The sheet documented the consultant pharmacist reviewed Resident #1's medications on 12/08/16, 01/09/17, 02/09/17, 03/07/17, 04/07/17, 05/04/17, 06/07/17, 07/06/17, 08/7/17, and 09/11/17. At 3:30 PM on 09/19/17 the assistant director of nursing (ADON) stated that the consultant pharmacist reviewed the medication regimens of all residents monthly. However, she reported the only information he left with the facility was pharmacy recommendations made after completion of the monthly reviews. She commented the pharmacist's actual monthly MRRs were stored in his laptop/computer, and the pharmacist could be contacted via phone to provide the information which he gathered and analyzed during those monthly reviews. The ADON clarified that the facility did not have electronic or printed copies of the MMRs on-site. At 1:00 PM on 09/20/17 the facility's Consultant Pharmacist stated when he completed monthly MRRs he assessed the residents' psychoactive medications, gradual dose reductions, labs, weights, past pharmacy recommendations, and sometimes performed a creatinine clearance calculation. He reported he printed out reports to leave with the facility each month, and the last page of the recommendations report documented, The following residents were reviewed and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the residents' medication regimens contained no new irregularities (as defined in SOM appendix PP 483.60 (c)). The pharmacist commented that following this statement there was a list of residents whose medications were reviewed, but who did not have any recommendations. According to the Consultant Pharmacist, the pharmacy for which he worked would not allow him to do double work by documenting a review in the pharmacy computer system and then having to provide the facility with a hard or electronic copy of his assessments. He stated he felt his signature and date on the Medication Regimen Review, coupled with the copies of recommendations he left with the facility each month, met the intent of the federal regulation which required MRRs be readily available to staff members and regulators who wished to review them. At 11:19 AM on 09/21/17 the State Clinical Director of Pharmacy Services stated the Consultant Pharmacist could either enter his review into the computer or write it on the monthly MRR sheet in the chart. He stated there was no policy indicating how the Consultant Pharmacist should document the information and that it was an individual choice. The Clinical Director also stated the Consultant Pharmacist could choose to document in both places. He indicated that at a minimum he would expect there to be a signature and date to show the Consultant Pharmacist had completed the review. He acknowledged that one could not tell if something was missed or not reviewed by looking at a signature and a date. He stated the Consultant Pharmacists were not on call 24 hours a day, however, Pharmacy Services could be contacted, and they would attempt to call the Consultant. He indicated the only documentation Pharmacy Services was able to access were the recommendations made by the Consultant Pharmacist and not the reviews themselves. The Clinical Director stated the monthly MRRs allowed the Pharmacy Consultant to review any issues that needed follow-up. He further stated they were to be utilized by the Consultant Pharmacist to see if recommendations needed to be made. He indicated Nurses, Dieticians, and Activity Directors could access some of the same information on the MRR by looking at behavior monitoring sheets, notebooks kept in management offices, and nursing notes. At 12:45 PM on 09/21/17 the Director of Nursing (DON) stated it was her expectation that the Consultant Pharmacist document a note regarding his or her monthly MRR for each resident. She also reported she expected this documentation to be readily available for staff to use in making medical and care decisions for the residents. 3. Resident #57 was admitted to the facility on [DATE], and his documented [DIAGNOSES REDACTED]. The resident's most recent minimum data set (MDS), a 07/25/17 quarterly assessment, documented Resident #57 had short and long term memory impairment, was severely impaired in decision making, was completely dependent on a staff member for all his activities of daily living, received all his nutrition through tubefeeding, and received antianxiety and antidepressant medications for 6 out of 7 days during the assessment look-back period. On 07/28/17 Psychotropic Drug Use with potential drug-related complications r/t (in regard to) antidepressant and antianxiety use. [DIAGNOSES REDACTED].#57's care plan. Interventions to address this problem included Administer antianxiety and antidepressant medications as ordered. Report side effects to MD (physician). When resident has anxious complaints attempt to find cause and resolve if possible. Review of the resident's September 2017 Medication Administration Record [REDACTED]. The resident was also receiving an anti-platelet medication, medication for PBA control, a narcotic pain medication, an anti-hypertension medication. Review of the resident's September 2017 physician order [REDACTED]. Review of Resident #57's Medication Regimen Review sheet revealed that starting in December 2016 through September 2017 the facility's consultant pharmacist only signed his name and documented the date of his monthly visits rather than providing a recapitulation of his monthly medication regimen reviews (MRRs). The sheet documented the consultant pharmacist reviewed Resident #57's medications on 12/08/16, 01/09/17, 02/09/17, 03/07/17, 04/07/17, 05/04/17, 06/07/17, 07/06/17, 08/7/17, and 09/11/17. Review of the facility's pharmacy recommendation revealed that the consultant pharmacist provided the facility with recommendations regarding Resident #57's medications on 01/09/17, 02/09/17, 06/07/17, and 08/07/17. At 3:30 PM on 09/19/17 the assistant director of nursing (ADON) stated that the consultant pharmacist reviewed the medication regimens of all residents monthly. However, she reported the only information he left with the facility was pharmacy recommendations made after completion of the monthly reviews. She commented the pharmacist's actual monthly MRRs were stored in his laptop/computer, and the pharmacist could be contacted via phone to provide the information which he gathered and analyzed during those monthly reviews. The ADON clarified that the facility did not have electronic or printed copies of the MMRs on-site. At 1:00 PM on 09/20/17 the facility's Consultant Pharmacist stated when he completed monthly MRRs he assessed the residents' psychoactive medications, gradual dose reductions, labs, weights, past pharmacy recommendations, and sometimes performed a creatinine clearance calculation. He reported he printed out reports to leave with the facility each month, and the last page of the recommendations report documented, The following residents were reviewed and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the residents' medication regimens contained no new irregularities (as defined in SOM appendix PP 483.60 (c)). The pharmacist commented that following this statement there was a list of residents whose medications were reviewed, but who did not have any recommendations. According to the Consultant Pharmacist, the pharmacy for which he worked would not allow him to do double work by documenting a review in the pharmacy computer system and then having to provide the facility with a hard or electronic copy of his assessments. He stated he felt his signature and date on the Medication Regimen Review, coupled with the copies of recommendations he left with the facility each month, met the intent of the federal regulation which required MRRs be readily available to staff members and regulators who wished to review them. At 11:19 AM on 09/21/17 the State Clinical Director of Pharmacy Services stated the Consultant Pharmacist could either enter his review into the computer or write it on the monthly MRR sheet in the chart. He stated there was no policy indicating how the Consultant Pharmacist should document the information and that it was an individual choice. The Clinical Director also stated the Consultant Pharmacist could choose to document in both places. He indicated that at a minimum he would expect there to be a signature and date to show the Consultant Pharmacist had completed the review. He acknowledged that one could not tell if something was missed or not reviewed by looking at a signature and a date. He stated the Consultant Pharmacists were not on call 24 hours a day, however, Pharmacy Services could be contacted, and they would attempt to call the Consultant. He indicated the only documentation Pharmacy Services was able to access were the recommendations made by the Consultant Pharmacist and not the reviews themselves. The Clinical Director stated the monthly MRRs allowed the Pharmacy Consultant to review any issues that needed follow-up. He further stated they were to be utilized by the Consultant Pharmacist to see if recommendations needed to be made. He indicated Nurses, Dieticians, and Activity Directors could access some of the same information on the MRR by looking at behavior monitoring sheets, notebooks kept in management offices, and nursing notes. At 12:45 PM on 09/21/17 the Director of Nursing (DON) stated it was her expectation that the Consultant Pharmacist document a note regarding his or her monthly MRR for each resident. She also reported she expected this documentation to be readily available for staff to use in making medical and care decisions for the residents. 4. Resident #65 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #65's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident received an antianxiety, antidepressant, and diuretic on each of the 7 days during the look back period. A review of Resident #65's paper and electronic medical records revealed the consultant pharmacist conducted a Medication Regimen Review (MRR) on 11/15/16. However, MRR's were not available for the months of December 2016, January 2017, February 2017, March 2017, April 2017, May 2017, June 2017, July 2017, August 2017, or September 2017. Instead of a review, the MRR contained a date and the signature of the consultant pharmacist. At 3:30 PM on 09/19/17 the ADON stated that the consultant pharmacist reviewed the medication regimens of all residents monthly. However, she reported the only information he left with the facility was any pharmacy recommendations made after completion of the monthly reviews. She commented the pharmacist's actual monthly medication regimen reviews were stored in his laptop/computer, and the pharmacist could be contacted via phone to provide the information which he reviewed during those monthly reviews. The ADON clarified that the facility did not have electronic or printed copies of the monthly medication regimen reviews on-site. At 1:00 PM on 09/20/17 the facility's consultant pharmacist stated when he completed monthly medication regimen reviews (MRRs) he assessed the residents' psychoactive medications, gradual dose reductions, labs, weights, past pharmacy recommendations, and sometimes performed a creatinine clearance calculation. He reported he printed out reports to leave with the facility each month, and the last page of the recommendations report documented, The following residents were reviewed and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the residents' medication regimens contained no new irregularities (as defined in SOM appendix PP 483.60 (c)). The pharmacist commented that following this statement there was a list of residents whose medications were reviewed, but who did not have any recommendations. According to the consultant pharmacist, the pharmacy for which he worked would not allow him to do double work by documenting a review in the pharmacy computer system and then having to provide the facility with a hard or electronic copy of his assessments. He stated he felt his signature and date on the Medication Regimen Review, coupled with the copies of recommendations he left with the facility each month, met the intent of the federal regulation which required MRRs be readily available to staff members and regulators who wished to review them. In a telephone interview on 09/21/17 at 11:19 AM the State Clinical Director of Pharmacy Services stated the consultant pharmacist could either enter his review into the computer or write it on the monthly Medication Regimen Review (MRR) sheet in the chart. He stated there was no policy indicating how the consultant pharmacist should document the information and that it was an individual choice. The Clinical Director also stated the consultant pharmacist could choose to document in both places. He indicated that at a minimum he would expect there to be a signature and date to show the consultant pharmacist had completed the review. He acknowledged that one could not tell if something was missed or not reviewed by looking at a signature and a date. He stated the consultant pharmacists were not on call 24 hours a day. However, pharmacy services could be contacted and they would attempt to call the consultant. He indicated the only documentation pharmacy services would be able to access were the recommendations made by the consultant pharmacist and not the review itself. The Clinical Director stated the purpose of the monthly MRR was so that the consultant pharmacist was able to review any issues that needed follow-up. He further stated they were to be utilized by the consultant pharmacist to see if recommendations needed to be made. He indicated nurses, dieticians, and activity directors could access some of the same information on the MRR by looking at behavior monitoring sheets, notebooks kept in management offices, and nursing notes. In an interview on 9/21/17 at 12:45 PM the Director of Nursing (DON) stated that it was her expectation that the consultant pharmacist document a note regarding his or her monthly medication review for each resident. She also expected the documentation to be readily available to staff. 5. Resident #36 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #36 ' s most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairments, and received an antipsychotic, mood stabilizer, seizure medication, diuretic, and insulin. Review of Resident #36's Medication Regimen Review sheet revealed that starting in January 2017 through September 2017 the facility's consultant pharmacist only signed his name and documented the date of his monthly visits rather than providing a recapitulation of his monthly medication regimen reviews (MRRs). The sheet documented the consultant pharmacist reviewed Resident #36's medications on 01/9/17, 02/9/17, 03/6/17, 04/7/17, 05/4/17, 06/6/17, 07/6/17, 08/7/17, and 09/11/17. At 3:30 PM on 09/19/17 the assistant director of nursing (ADON) stated that the consultant pharmacist reviewed the medication regimens of all residents monthly. However, she reported the only information he left with the facility was any pharmacy recommendations made after completion of the monthly reviews. She commented the pharmacist ' s actual monthly medication regimen reviews were stored in his laptop/computer, and the pharmacist could be contacted via phone to provide the information which he reviewed during those monthly reviews. The ADON clarified that the facility did not have electronic or printed copies of the monthly medication regimen reviews on-site. At 1:00 PM on 09/20/17 the facility's consultant pharmacist stated when he completed monthly medication regimen reviews (MRRs) he assessed the residents ' psychoactive medications, gradual dose reductions, labs, weights, past pharmacy recommendations, and sometimes performed a creatinine clearance calculation. He reported he printed out reports to leave with the facility each month, and the last page of the recommendations report documented, The following residents were reviewed and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the residents' medication regimens contained no new irregularities (as defined in SOM appendix PP 483.60 (c)). The pharmacist commented that following this statement there was a list of residents whose medications were reviewed, but who did not have any recommendations. According to the consultant pharmacist, the pharmacy for which he worked would not allow him to do double work by documenting a review in the pharmacy computer system and then having to provide the facility with a hard or electronic copy of his assessments. He stated he felt his signature and date on the Medication Regimen Review, coupled with the copies of recommendations he left with the facility each month, met the intent of the federal regulation which required MRRs be readily available to staff members and regulators who wished to review them. In a telephone interview on 09/21/17 at 11:19 AM the State Clinical Director of Pharmacy Services stated the Consultant Pharmacist could either enter his review into the computer or write it on the monthly Medication Regimen Review (MRR) sheet in the chart. He stated there was no policy indicating how the Consultant Pharmacist should document the information and that it was an individual choice. The Clinical Director also stated the Consultant Pharmacist could choose to document in both places. He indicated that at a minimum he would expect there to be a signature and date to show the Consultant Pharmacist had completed the review. He acknowledged that one could not tell if something was missed or not reviewed by looking at a signature and a date. He stated the Consultant Pharmacists were not on call 24 hours a day, however, Pharmacy Services could be contacted and they would attempt to call the Consultant. He indicated the only documentation Pharmacy Services was able to access were the recommendations made by the Consultant Pharmacist and not the review itself. The Clinical Director stated the purpose of the monthly MRR was so that the Pharmacy Consultant was able to review any issues that needed follow-up. He further stated they were to be utilized by the Consultant Pharmacist to see if recommendations needed to be made. He indicated Nurses, Dieticians, and Activity Directors could access some of the same information on the MRR by looking at behavior monitoring sheets, notebooks kept in management offices, and nursing notes. An interview with the DON, on 9/21/17 at 12:45 PM, she stated that it was her expectation that the consultant pharmacist document a note regarding his or her monthly medication review for each resident. She also reported that she expected this documentation to be readily available to staff.

Based on observation and staff interview the facility failed to air dry tray pans prior to stacking them on top of one another in storage, failed to clean the faces/backs of fans blowing into the food preparation and tray line service areas of the skilled nursing kitchen, and failed to discard fry/saute pans with scratched coatings and cooking surfaces. Findings included: 1. At 9:42 AM on 08/17/16 during an inspection of kitchenware in the continuing care kitchen, used to help prepare food for the skilled nursing unit, 4 of 6 tray pans stacked on top of one another on a final storage unit were found with moisture trapped inside. At this time a dietary employee reported these tray pans were stacked in storage the night before. At 11:28 AM on 08/17/16 the director of food services stated there was a dedicated rack in the kitchen for air drying kitchenware before it was stacked in final storage. He reported stacking wet pieces of kitchenware on top of one another in storage could lead to bacterial formation that might cause foodborne illness, making residents sick. At 2:54 PM on 08/17/16 the cook in the skilled nursing kitchen stated the dietary staff had been in-serviced in the past to let kitchenware air dry before stacking pieces on top of one another in storage. She reported the staff was informed trapped moisture could breed germs that could make residents sick. 2. During the initial tour of the skilled nursing kitchen on 08/15/16, beginning at 6:40 PM, a fan sitting on a shelf above the steam table, which would have blown into food preparation and serving areas if it was turned on, was found to be dirty. There was a film and strands of dust/dirt on the front face and back sides on the fan. A second smaller fan sitting on a shelf near the hand sink, which would have blown into food preparation and serving areas if it was turned on, was found to be dirty. There was a film and strands of dust/dirt on the front face and back sides on this fan. During follow-up observations of the skilled nursing kitchen on 08/17/16 at 8:58 AM the smaller fan near the hand sink still had dust and dirt on the front face and back of the fan. At 11:28 AM on 08/17/16 the director of food services (DFS) stated employees in the dietary department cleaned the fans, but they were not on the cleaning schedule at present. He stated the two fans were put into use last summer because of the heat that built up in the small kitchen space. He commented the goal was to have the fans cleaned weekly. The DFS stated the fans needed to be clean to prevent the possibility of dust particles contaminating the food being prepared and served. At 2:54 PM on 08/17/16 the cook in the skilled nursing kitchen stated a dietary employee was responsible for cleaning the fans, but the fans had not been cleaned as frequently as usual because the dietary department had been short some key positions in the last two to three months. The cook reported dirt and dust from the fans could blow on food being prepared or on the steam table and could blow on kitchenware exiting the dish machine which could make residents sick. 3. During the initial tour of the skilled nursing kitchen and the continuing care kitchens on 08/15/16, beginning at 6:40 PM, 1 of 3 fry/saute pans in the skilled nursing kitchen had non-stick coating and cooking surfaces which were scratched, and 7 of 8 fry/saute pans in the continuing care kitchen had non-stick coating and cooking surfaces which were scratched. During a follow-up tour of the skilled nursing kitchen 1 of 3 fry/saute pans still had non-stick coating and cooking surfaces which were scratched. During a followup tour of the continuing care kitchen 7 of 8 fry/saute pans still had non-stick coating and cooking surfaces which were scratched. At 11:28 AM on 08/17/16 the director of food services (DFS) stated when kitchenware became compromised such as fry/saute pans with scratched and peeling coatings/cooking surfaces the dietary staff was supposed to reported it to the lead cook or himself so it could be replaced. The DFS reported he kept back-up sets of cookware on the premises. He commented the Teflon surface of the fry/saute pans could peel or flake off in resident foods which had the potential of making them sick. At 2:54 PM on 08/17/16 the cook in the skilled nursing kitchen stated damaged kitchenware was to be removed immediately, reported to the DFS, and replaced. She reported damaged kitchenware posed a health and safety risk to residents.