Every finding on record at White House Health Care Inc

Based on policy review, medical record review, observation, and interview, the facility failed to provide an environment free of hazardous materials for 6 of 74 (Resident #5, #9, #30, #65, #75, and #78) sampled residents reviewed for accident hazards. The findings include: 1. Review of the facility policy titled, Environmental Safety Policy, dated 1/31/2025, revealed .The purpose of this policy is to provide a safe, clean, and hazard-free environment for residents, staff, visitors, and contractors within the long-term care (LTC) facility.Hazardous Materials Management All chemicals stored in labeled, locked, and ventilated areas. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Epilepsy, Diabetes, and Vascular Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #5 was cognitively intact. Observation in Resident #5's room on 11/16/2025 at 1:55 PM and 3:05 PM, revealed 2 orange disposable razors in an opened bag on top of a small table in the resident's room. During an observation and interview in Resident #5's room on 11/16/2025 at 3:08 PM, Licensed Practical Nurse (LPN) B was asked if disposable razors should be left out unsecured and unattended in a resident's room. LPN B stated, No, they should not. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Diabetes, and Bipolar Disorder. Review of the annual MDS assessment dated [DATE], revealed Resident #9 scored a 6 on the BIMS assessment, which indicated Resident #9 was severely cognitively impaired. Observation in Resident #9's shared bathroom on 11/16/2025 at 1:16 PM, revealed 2 blue disposable razors on the bathroom sink. During an observation and interview in Resident #9's shared bathroom on 11/16/2025 at 3:10 PM, revealed 2 blue disposable razors remained on the resident's bathroom sink. LPN B was asked if razors should be left out unattended and unsecured in a resident's bathroom. LPN B stated, No, they should not. 4. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Dementia, Depressive Disorder, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #30 scored a 3 on the BIMS assessment, which indicated Resident #30 was severely cognitively impaired. Observation in Resident #30's bathroom on 11/16/2025 at 2:07 PM and 2:59 PM, revealed 1 pink disposable razor and 1 blue and green disposable razor in a cup on the bathroom counter and 1 blue and green disposable razor in a small dish on the bathroom counter. During an observation and interview in Resident #30's bathroom on 11/16/2025 at 3:01 PM, LPN C was asked if disposable razors should be left out unsecured and unattended in a resident's room or bathroom. LPN C stated, No. 5. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses including Right Femur Fracture, Anxiety, and Depressive Disorder. Review of the admission MDS assessment dated [DATE], revealed Resident #65 scored an 11 on the BIMS assessment, which indicated Resident #65 was moderately cognitively impaired. Observation in Resident #65's shared bathroom on 11/16/2025 at 2:03 PM, revealed a bottle of (Named) cool mint mouthwash on the resident's bathroom counter. During an observation and interview in Resident #65's shared bathroom on 11/16/2025 at 4:33 PM, revealed the bottle of (Named) cool mint mouthwash remained on the bathroom counter. LPN C was asked how should the (Named) mouthwash be stored. LPN C stated, It should be locked up in the cart. 6. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Heart Failure, and Unsteadiness on Feet. Review of the quarterly MDS assessment dated [DATE], revealed Resident #75 scored an 8 on the BIMS assessment, which indicated Resident #75 was moderately cognitively impaired. Observation in Resident #75's bathroom on 11/16/2025 at 1:23 PM and 4:57 PM, revealed an orange can of aerosol disinfectant spray on the bathroom counter. During an observation and interview in Resident #75's bathroom on 11/16/2025 at 5:05 PM, LPN B was asked if the aerosol disinfectant spray should be left out in the resident's bathroom unsecured and unattended. LPN B stated, No it should not be left out. 7. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Osteoarthritis, Neuropathy, and Atrial Fibrillation. Review of the annual MDS assessment dated [DATE], revealed Resident #78 scored a 14 on the BIMS assessment, which indicated Resident #78 was cognitively intact. Observation in Resident #78's bathroom on 11/16/2025 at 2:01 PM and 4:42 PM, revealed a can of (Named) aerosol air sanitizer spray on the bathroom counter, a bottle of (Named) stain remover spray, and a container of lemon scented disinfecting wipes on top of a 3-drawer cabinet. During an observation and interview in Resident #78's bathroom on 11/16/2025 at 5:10 PM, LPN B was asked if the aerosol air sanitizer spray, stain remover spray, and disinfecting wipes should be left out unsecured and unattended in the resident's bathroom. LPN B stated, No, they shouldn't. During an interview on 11/18/2025 at 3:35 PM, the Director of Nursing (DON) was asked if disposable razors should be left out unsecured and unattended in resident rooms or bathrooms. The DON stated, .no. The DON was asked if razors should be stored and secured out of reach. The DON stated, Yes. The DON was asked if disinfectant spray, disinfecting wipes, and mouth wash, should be left out unsecured and unattended in resident rooms or bathrooms. The DON stated, It should be stored out of reach.

Based on policy review, medical record review, observation, and interview, the facility failed to store medications in accordance with facility policy when medications were found unsecured and unattended in resident's rooms and bathrooms for 3 of 74 (Resident #45, #75, and #87) residents. The findings include: 1. Review of the facility policy titled, Storage of Medications, with a revised dated of 4/2019, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .nursing staff is responsible for maintaining medication storage . 2. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE], with diagnoses including Supraventricular Tachycardia and Sepsis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #45 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #45 was moderately cognitively impaired. Review of the Physician's Order dated 11/26/2024, revealed Cleanse sacral area with NS [normal saline], apply [Named Menthol and Zinc Oxide cream] [a cream used to protect and heal skin irritation] q [every] shift to affected area and as needed.every shift. Observation in Resident #45's shared bathroom on 11/16/2025 at 1:14 PM and 4:55 PM, revealed a tube of (Named Menthol and Zinc Oxide cream) on the back of the toilet. During an observation and interview in Resident #45's bathroom on 11/16/2025 at 5:01 PM, Licensed Practical Nurse (LPN) B was asked if the tube of (Named Menthol and Zinc Oxide cream) should be left unsecured in the resident's bathroom on the back of the toilet. LPN B stated, No it should not. 3. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Heart Failure, and Unsteadiness on Feet. Review of the quarterly MDS dated [DATE], revealed Resident #75 scored an 8 on the BIMS assessment, which indicated Resident #75 was moderately cognitively impaired. Review of the Physician's Orders dated November 2025, revealed no order for antifungal powder spray. Observation in Resident #75's bathroom on 11/16/2025 at 1:23 PM and 4:57 PM, revealed an aerosol can of antifungal powder spray on the back of the toilet. During an observation and interview in Resident #75's bathroom on 11/16/2025 at 5:05 PM, LPN B was asked if aerosol antifungal powder spray should be left out unsecured and unattended on the back of a resident's toilet. LPN B stated, No it should not be left out. 4. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE], with diagnoses including Chronic Pulmonary Disease, Emphysema, Pneumonia, Acute Respiratory Failure, Muscle Weakness, and required assistance with personal care. The admission MDS assessment for Resident #87 was in the completion process at the time of the survey. Observation in Resident #87's room on 11/16/2025 at 5:06 PM and 11/17/2025 at 7:37 AM, revealed an Albuterol Sulfate Inhalation Aerosol inhaler (used to treat breathing difficulty) on Resident #87's nightstand. During an observation and interview in Resident #87's room on 11/16/2025 at 5:09 PM, LPN D verified the medication left on top of Resident #87's nightstand was an albuterol inhaler. LPN D asked Resident #87 when he got the albuterol inhaler. Resident #87 stated .she [wife] brought it in today and I have another in the drawer that I took one puff of .I will take it [albuterol inhaler] when I need it . LPN D confirmed the medication in the resident's drawer was Trelegy Ellipta, a powder inhaler used to treat breathing difficulty. LPN D verified the medications were opened and the dosage indicators revealed usage of the medications. LPN D was asked where residents' medications should be stored. LPN D stated, In the med cart . Review of a progress note dated 11/16/2025 at 10:22 PM, revealed Resident has orders to keep Albuterol Nebulizer at bed side. Review of the Physician's Telephone Order dated 11/16/2025, revealed an order for Trelegy Ellipta and to self-administer 2 puffs of the albuterol inhaler every 6 hours as needed. The resident may keep at bedside and self-medicate. The untimed telephone order had a Physician's signature, dated 11/16/2025. Review of the Physician's Telephone Order dated 11/16/2025, revealed May self-administer albuterol inhaler at his preference. The untimed telephone order had a Physician's signature, dated 11/19/2025. The telephone order to self-administer medication was written after the observation on 11/16/2025. The facility failed to provide an evaluation for self-administration of medication for Resident #87. During an observation and interview in Resident #87's room on 11/17/2025 at 7:37 AM, LPN E confirmed the albuterol inhaler was on the resident's nightstand. LPN E was asked how medication should be stored. LPN E stated, .it should be in the med drawer unless he can self-administer .I did not get report that he had the medication . LPN E was asked if the resident does have an order to self-administer where should the medication be stored. LPN E stated, At the bedside in the drawer . During an interview on 11/18/2025 at 3:35 PM, the Director of Nursing (DON) was asked if antifungal powder spray or prescription creams/ointments should be left in the resident's rooms or bathrooms unsecured and unattended. The DON stated, It should be stored out of reach. During an interview on 11/18/2025 at 3:43 PM, the DON was asked how medications should be stored. The DON stated, They should be stored in a med cart .some residents request to be stored at bedside. The DON was asked to explain to be stored at bedside. The DON stated, An alert and oriented resident may request meds at bedside for treatment .the nurse will complete a self-administration record and place in the chart. The DON was asked if the resident can self-administer how should the med be stored. The DON stated, The medication should be stored in the residents' room in personal belongings. The DON was asked to explain personal belongings. The DON stated, In there beside drawer . The DON was asked should residents have medications stored on top of their nightstand. The DON stated, Typically, not on top of the nightstand.

Based on policy review, record review, and interview, the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 3 of 24 (Resident #6, #17, and #36) residents reviewed for advance directives. The findings include: 1. Review of the facility ' s policy Resident' s Rights Regarding Treatment and Advance Directives dated 7/26/2024, revealed It is the policy of this facility to support and facilitate a resident ' s right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. Advance directive is a written instruction, such as a living will or durable power of attorney for healthcare, recognized under state law relating to the provision of health care when the individual is incapacitated On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dementia, Cerebral infarction, and Traumatic Brain Injury. Review of the LETTERS OF CONSERVATORSHIP dated 4/18/2011, revealed no documentation of instructions for advance directives. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #6 was severely cognitively impaired. There was no documentation in the medical record if Resident #6 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 3. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Hypertension, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated Resident #17 was severely cognitively impaired. There was no documentation in the medical record if Resident #17 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 4. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Hypertension, and Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #36 was cognitively intact. There was no documentation in the medical record if Resident #36 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 5. During an interview on 9/10/2024 at 1:54 PM, the Administrator confirmed that she was unable to provide any further documentation regarding advance directives. 49311

Based on facility policy, medical record review, and interview, the facility failed to conduct quarterly care conference meetings for 4 of 21 sampled residents (Resident #18, #33, #36, and #54) reviewed. The findings include: 1. Review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered revealed The IDT [Interdisciplinary Team] includes .the resident and the resident's legal representative .Each resident ' s comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation .including the right to .participate in the planning process .See the care plan and sign it .resident will be informed of his or her right to participate in his or her treatment .The Interdisciplinary Team must review and update the care plan .At least quarterly, in conjunction with the required quarterly MDS assessment .The resident has the right to refuse to participate in the development of his/her care plan and medical nursing treatments. Such refusals will be documented in the resident ' s clinical record . 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Dementia, and Anxiety. Review of the Care Conference Report for Resident #18 revealed the last Care Conference was conducted on 12/22/2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #18 was cognitively intact. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #18 was cognitively intact. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #18 was cognitively intact. The facility was unable to provide documentation that a quarterly Care Conference was conducted with the Resident or Responsible Party (RP). 3. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Chronic Obstructive Pulmonary Disease and Depression. Review of the Care Conference Report for Resident #33 revealed last Care Conference was conducted on 1/23/2024. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #33 was cognitively intact. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #33 was cognitively intact. The facility was unable to provide documentation that quarterly Care Conferences were conducted with the Resident or RP. 4. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Polyneuropathy, Neuromuscular Dysfunction of Bladder and Chronic Kidney Disease. Review of the Care Conference Report for Resident #36 revealed last Care Conference was conducted on 2/2/2024. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #36 was conatively intact. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #36 was conatively intact. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #36 was conatively intact. The facility was unable to provide documentation that quarterly Care Conferences were conducted with the Resident or RP. 5. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Dysphagia, and Vascular Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated resident #54 had severe cognitive impairment, was dependent on staff for all care, and was on a mechanical diet. Resident was coded for oxygen and was not receiving any therapy. The facility was unable to provide documentation of quarterly Care Conferences with the Resident ' s RP. 6. During an interview on 9/11/2024 at 4:09 PM the Director of Nursing (DON) stated she was unable to provide quarterly care plan meetings documentation and stated, that is something that we will have to work on .

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when unlabeled and undated items were found in 2 of 3 (Dogwood Hall and Central) nourishment refrigerators observed. The findings include: 1. The facility's undated policy titled, FOODS BROUGHT IN FROM OUTSIDE SOURCES revealed .When food(s) is brought in from outside sources for the residents .require refrigeration .food items should be labeled with .resident ' s name .date the item(s) was purchased or prepared .and the name of the item . The facility ' s undated policy titled, Refrigerator Food Storage Policy Summary .Labeling & Dating . revealed .Before putting anything in the refrigerator, please ensure the food is in a tightly sealed container and there is a label and date on the product with the resident ' s name and current date . 2. Observation in the Dogwood Hall Nutrition Refrigerator on 9/11/2024 at 12:15 PM and 3:15 PM, revealed an open unlabeled and undated bag of radishes. 3. Observation in the Central Nutrition Refrigerator on 9/11/2024 at 12:21 PM and 3:19 PM, revealed a bag containing undated food. 4. During an interview on 09/11/24 03:22 PM, the Registered Dietician confirmed all items in the nutritional refrigerators should be labeled and dated.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were stored properly in 3 of 8 medication storage areas (Palm Medication Cart, Dogwood Medication Cart, and the Supply Room). The findings include: Review of the facility's policy titled, Storage of Medication, revised [DATE], showed that discontinued and outdated medications should be returned to the dispensing pharmacy or destroyed. Observation of the Palm Medication Cart on [DATE] at 11:20 AM, showed the following: a. 1 bottle of Humalog insulin with an open date of [DATE] b. 2 open and undated bottles of [MEDICATION NAME]. c. 1 bottle of [MEDICATION NAME] with an open date of [DATE] Observation of the Dogwood Medication Cart on [DATE] at 12:16 PM, showed 4 open and undated bottles of [MEDICATION NAME] sublingual tablets. Observation in the Supply Room on [DATE] at 7:37 AM, showed: a. 1 bottle of [MEDICATION NAME] with an expiration date of ,[DATE] b. 1 bottle of Optimum multi-vites (vitamin) liquid with an expiration date of ,[DATE] c. 2 bottles of [MEDICATION NAME] packing strips (medicated wound dressing) with an expiration date of ,[DATE] d. 3 bottles of liquid [MEDICATION NAME] sodium with an expiration date of ,[DATE] e. 2 bottles of liquid [MEDICATION NAME] sodium with an expiration date of ,[DATE] During an interview conducted on [DATE] at 7:57 AM, the Director of Nursing (DON) confirmed that there should not be expired, opened, or undated medications in the medication storage areas.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection during medication administration when 1 of 4 nurses (Licensed Practical Nurse (LPN) #1) allowed the tip of the eye drop applicator to touch the top of the eyelid for 1 of 4 residents (Resident #221) during medication administration. The findings include: 1. The facility's policy titled, Instillation of Eye Drops, revised 1/2014 documented, .Do not touch the eye or eyelid with the dropper . Review of the medical record, showed Resident #221 had [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].[MEDICATION NAME] 0.3% (sign for percent) Eye Drops .Both Eyes Daily for Chronic [MEDICAL CONDITION] . Observation in the resident's room on 3/17/2020 at 8:46 AM, showed LPN #1 administered one eyedrop into Resident #221's right eye, and touched the top of the right eyelid with the tip of the applicator. LPN #1 administered one eyedrop into Resident #221's left eye, and touched the tip of the applicator to the top of the left eyelid. LPN #1 recapped the medication, placed the medication back into the medication cart, and failed to clean the tip of the applicator. During an interview conducted on 3/17/2020 at 10:03 AM, the Director of Nursing (DON) was asked should nursing staff touch the top of the eyelid with the tip of the applicator when administering eye drops. The DON stated, No, ma'am.

Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 1 of 3 (Resident #36) sampled residents reviewed for transfer/discharge requirements. The findings include: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Interdisciplinary Notes dated 11/8/18 documented, .Skin tear noted to right calf with some heavy bleeding. Pressure applied .EMS (Emergency Medical Services) called and pt (patient) transfer to .ER (emergency room ) for further eval (evaluation) . The facility was unable to provide documentation that the Ombudsman had been notified of the resident's transfer to the emergency roiagnom on [DATE]. Interview with the Administrator on 3/26/19 at 5:24 PM in the Activity Room, the Administrator was asked if Resident #36 should have been on the transfer list. The Administrator confirmed that Resident#36 should have been on the transfer form sent to the Ombudsman.

Based on policy review, observation, and interviews, the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by 1 of 4 (dietary staff #1) failed to practice hand hygiene while serving meal trays, and 1 of 4 (dietary staff #2) handled food with bare hands while serving meal trays in the kitchen, and 3 of 4 (dietary staff #2, 3, and 4) with hair exposed while preparing trays on the tray line, This had the potential to affect 63 of the 66 residents receiving meal trays from the kitchen. The findings included: 1. Review of the facility's Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices policy documented, .Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment .Food service employees will be trained in the proper use of utensils such as tongs . 2. Review of the facility's Handwashing/Hand Hygiene policy revealed, .This facility consider hand hygiene the primary means to prevent the spread of infection .5. Employees must wash their hands .using antimicrobial or non-antimicrobial soap and water under the following conditions .f. Before and after assisting with meals .t. After removing gloves or aprons .in the most situations, the preferred method of hand hygiene is with and alcohol-based hand rub .d. Before preparing or handling medications . After contact with objects ( .medical equipment) in the immediate vicinity of the resident . Observation in Resident #19 room 4/24/17 at 11:46 AM, dietary staff #1 delivered a tray to residents room and returned the tray to the bottom of the rack without performing hand hygiene. Observation in Resident #79 room on 4/24/17 at 11:52 AM, dietary staff #1 set up resident tray and return to cart without performing hand hygiene. Observation in Resident #90 room on 4/24/17 at 11:54 AM, dietary staff #1 delivered tray and returned to the cart without performing hand hygiene. Observations in the kitchen beginning on 4/25/17 at 5:10 PM, revealed dietary staff #2, 3, and 4 with hair was not completely covered. Dietary staff #2 handled food with bare hands while checking food temperatures on the tray line. Interview with the Certified Dietary Manager (CDM) on 4/25/17 at 5:58 PM, in the Conference Room, the CDM was asked should hair be completely covered or restrained in the kitchen. The CDM stated yes, ma'am. Interview with the CDM on 4/26/17 at 3:10 PM, outside of the kitchen, the CDM was asked if it was acceptable for dietary staff to handle food with bare hands. The CDM stated, .no it is not .

Based on medical record review, observation and interview the facility failed to obtain a physician's order for self administration of medication for 1 of 23 (Resident #77) sampled residents reviewed in the Stage 2 review. The findings included: Medical record review revealed Resident #77 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physicians order dated 11/14/16 documented, .[MEDICATION NAME]-[MEDICATION NAME] 0.5 mg (milligram)-3 mg (2.5 mg base)/3 ml (milliliter) Neb (Nebulizer) solution .one vial INH (INHALATION) q (every) 6 hrs (hours) . Observations in Resident #77's room on 4/24/17 at 11:53 AM, revealed Resident #77 was self-administering a nebulizer treatment without staff present in the room. Interview with the Director of Nursing (DON) on 4/26/17 at 1:40 PM, in the Gathering Room, the DON was asked if a patient should self administer a nebulizer treatment, the DON stated, no, the patient should not be left alone.

Based on policy review, observation, and interview, the facility failed to promote care that ensured the residents were treated with dignity and respect when staff failed to knock on the residents' doors before entering the resident's room, when 1 of 2 Nurses (Registered Nurse (RN)#1) failed to close the door during medication administration, and the staff were referring to residents as honey, sweetie, and baby during 2 of 2 (4/24/17 and 4/25/17) days observed during dining. The findings included: 1. The facility's Resident's Rights and Facility Responsibilities policy documented, .Residents Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents individuality The facility's Policy on Courtesy Titles documented, .It is the policy of White House Health Care and Rehab to use courtesy titles, such as Mr., Mrs., or Miss, when our employees are addressing department supervisors, patients, and visitors . The facility's Quality of Life-Dignity policy documented, .1. Residents shall be treated with dignity and respect at all times .2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 2. Observation in Resident #8's room on 4/24/17 at 11:45 AM, revealed Certified Nursing Assistant (CNA) #6 left resident # 8's room to get a cup of ice, returned to the room and did not knock, again exited residents #8 room to go get silverware, returned and entered the room without knocking or getting permission. Observations in Resident #48's room on 4/24/17 at 11:49 AM, revealed nursing technician #1 entered residents #48's room without knocking and getting permission. Observations in Resident #6's room on 4/24/17 at 11:50 AM, revealed nursing technician #1 entered resident #6's room without knocking and getting permission. Observations in Resident's #145's room on 4/24/17 at 11:55 AM, revealed CNA #1 entered resident #145's room, and stated, .here baby . Observations in Resident #109's room on 4/24/17 11:58 AM, revealed CNA #1 entered resident #109's room without knocking and getting permission to enter. Observations in Resident # 89's room on 4/24/17 at 11:59 AM, revealed CNA #4 entered residents # 89's room without knocking and getting permission to enter. Observations in Resident #109's room on 4/24/17 12:02 PM, revealed CNA #1 entered resident #109's room, and stated, .baby, your welcome baby . Observations in Resident #75's room on 4/24/17 at 12:05 pm, revealed CNA #1 entered resident # 75's room, and stated, .hey baby . Observation in Residents #8's room on 4/25/17 at 5:35 PM, revealed CNA #5 entered Resident #8 room, and stated, .I have your tray can I give it to you honey . Observation in Residents #81 room on 4/25/17 at 5:41 PM, revealed CNA # 5 entered resident #81's room to deliver the meal tray and stated, . alright sweetie . Observations in Resident #146's room on 4/25/17 at 5:45 PM, revealed CNA #1 entered Resident #146's room, and stated, .your welcome baby . Observations in Resident #109's room on 4/25/17 at 5:48 PM, revealed CNA #1 entered Resident #109 's room, and stated, .come on baby . Observations in Resident's #145's room on 4/25/17 at 5:50 PM, revealed CNA #1 entered Resident #145's room, and stated, .bring your legs over baby . 3. Observations during medication administration in Resident #119's room, on 4/25/17 at 2:11 PM, revealed RN #1 failed to provide privacy by not closing the resident's door during administration of medications through an enteral feeding tube and left Resident #119's abdomen exposed during the time of the medication administration. 4. Interview with the Director of Nursing (DON) on 4/25/17 at 5:55 PM, in the gathering room, the DON was asked if it was acceptable to call residents baby and sweetie. The DON stated, .yes if they like it and if it is care planned . Interview with the DON on 4/25/17 at 6:00 PM, in the gathering room, the DON was asked if it was acceptable to enter a patient's room without knocking. The DON stated I expect staff to knock on the door before entering the room .

Based on review of the Geriatric Medication Handbook, policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) #2 and #3) medication nurses administered medications with a medication error rate of less than 5 % (percent). There were 2 medication errors made out of 25 opportunities for error which resulted in a medication error rate of 8%. The findings included: 1. The Geriatric Medication Handbook, eleventh edition provided by AMERICAN SOCIETY of CONSULTANT PHARMACISTS, page 41, 64 documented, DIABETES: INJECTABLE MEDICATIONS .Humalog .Rapid-Acting Insulin Analog .ONSET .15 min (minutes) .TYPICAL ADMINISTRATION/COMMENTS 15 minutes prior to meals .Enteral Tube Medication Administration .If administering more than one medication, flush with 5 ml (millileters) of water .between each medication . 2. Medical record review revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#107 had an order for [REDACTED].= 2 units, 250-299= 3 units, 300-349= 4 units, 350-399= 5 units, > (greater than) or = 400= 6 units & call MD (Medical Doctor) for Type 2 DM (diabetes mellitus) without complications. 3. Observations on 4/25/17 at 4:35 PM in Resident #107's room revealed LPN #2 administered 1 unit of Humalog to Resident #107. Resident #107 did not receive a lunch tray or substantial snack until 5:48 PM. Resident #107 did not start eating until 5:51 PM, 1 hour and 16 minutes after the [MEDICATION NAME]was administered and before Resident #107 took the first bite of food. 4. Interview with LPN #3 on 4/26/17 at 2:27 PM, on the Dogwood Hall, LPN#3 was asked if you were administering Humalog Insulin per sliding scale to a resident what time would you be expected to delivere the meal tray to the resident. LPN #3 stated, within 30 minutes. Interview on 04/26/17 at 3:37 PM, with Director of Nursing (DON) in the Administrator office, the DON was asked when should resident who receives Humalog Sliding Scale Insulin when do you expect the resident to receive a meal tray. The DON stated, policy states within 15 minutes with a snack, drink or something like that to be given. 5. Medical record review revealed Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>Review of the physician's orders [REDACTED].#142 had the following orders to crush all medications when appropriate or give in liquid form, [MEDICATION NAME] 500mg (milligram) tablet per tube daily, [MEDICATION NAME] 10mg tablet per peg daily, [MEDICATION NAME] 75mg tablet per tube daily, [MEDICATION NAME] 5mg tablet per tube every (q) 12 hours(hrs), Carvedilol 6.25mg tablet per tube q 12hrs, [MEDICATION NAME] 100mg tablet per tube TID (three times daily), Aspirin 325mg tablet per tube daily, [MEDICATION NAME] 10mg tablet per tube TID, [MEDICATION NAME] 10mg tablet per tube daily, [MEDICATION NAME] 25mg per tube every morning at 8 AM, [MEDICATION NAME] 5mg per tube every morning at 8 AM, [MEDICATION NAME] 1 tablet per peg tube BID (twice daily) x (times) 21days. 6. Observations on 04/26/17 at 7:34 AM, LPN #3 on Dogwood Hall, LPN #3 failed to administer the medications through the peg tube individually and flush with 5ml of water in between each medication resulting in medication error #2. 7. Interview with the Assistant Director of Nursing (ADON) on 4/26/17 at 2:30 PM, on the Dogwood Hall, the ADON was asked when administering medications by peg tube should medications be administered separately. The ADON stated, They should be given separately to avoid medication interactions. Interview with the Director of Nursing (DON) on 04/26/17 at 3:39 PM, in the Administrator's office, the DON was asked how do you expect peg medications to be administered together or each medication separately. The DON stated, together unless they are contraindicated DON was asked does there need to be an order indicating the medications can be administered together. The DON stated, I think there should be order stating they can't be given together because of contraindiation.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored as evidenced by expired mediations were opened and undated in 3 of 8 (MED (medication) ROOM, Magnolia medication cart, and Dogwood medication Cart) medication storage areas and by medication left unattended in a resident's room by 1 of 1 (Licensed Practical Nurse (LPN) #4) nurses observed during dressing change. The findings included: 1. The MEDICATIONS WITH SHORTENED EXPIRATION DATES, provided by American Society of Consultant Pharmacist and MED-PASS documented, .Lantus .expire 28 days after opening .Novolin R (Regular) .Expires 42 days after opening .Novolog .expire 28 days after opening . The facility's Insulin Administration policy documented, .4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening) . 2. Observations in the MED ROOM on [DATE] at 7:41 AM, revealed one vial of Tuberculin vaccine in the medication refrigerator that was opened and undated, and one vial of Tuberculin vaccine with an open date of [DATE], which was past the 30 day recommendation. Observations on the Magnolia medication cart on [DATE] at 7:45 AM, revealed a Lantus flex pen opened and undated. Observations on the Dogwood medication cart on [DATE] at 8:12 AM, revealed one vial of Novolin R insulin with an open date of [DATE], which is past the 30 day recommendation, and one vial of Novolog that was opened and undated. 3. Interview with the Staff Coordinator, on [DATE] at 7:41 AM, in the MED ROOM, the Staff Coordinator was asked if it was acceptable to have multi-dose vials of vaccine in the refrigerator open and undated. The Staff Coordinator stated, No it should to be dated. Interview with License Practical Nurse (LPN) #3 on [DATE] at 8:12 AM, at the Dogwood nursing station, LPN # 3 was asked was there an open date on the vial. The LPN #3 stated, No ma'am. The LPN #3 was asked should the vial be dated when open. The LPN #3 stated, Yes ma'am it should. Interview with the Director of Nursing (DON) on [DATE] at 11:04 AM, in gathering room, the DON was asked if it was acceptable to have multi-dose vials on in the medication storage areas open and undated. The DON stated, No, it has to be dated. Interview with the DON on [DATE] 3:55 PM, in the Gathering Room, the DON was asked what is your policy when opening multi-dose vials and insulin in medication storage areas. The DON stated, Any time you have a multi dose vial or insulin, it should be dated on the bottles when it is opened. Interview with the DON on [DATE] at 5:52 PM, at the Dogwood nursing station, the DON was asked how long is the insulin and multi- dose vials good for after opening. The DON stated, the insulin is good for 28 days and the multi-dose vials are good for 30 days. The DON was asked if it was acceptable to have multi-dose vials beyond there expiration dates. The DON stated, No. 4. Observations in Resident #145's room on [DATE] at 2:50 PM, revealed LPN #4 performed a dressing change on Resident #145's left heel. LPN # 4 washed her hands and donned gloves, removed the old dressing and placed in a biohazard bag, removed her gloves, redone clean gloves and cleansed the wound with wound cleanser, patted the wound dry. LPN #4 then applied the Medihoney to the pressure ulcer on the left heel and covered with gauze. LPN #4 wrapped the left heel with Kerlex, secured with paper tape and replaced off-loading boot. LPN # 4 failed to perform hand hygiene between glove changes. LPN #4 then took the biohazard bag out of the room and down the hall to the biohazard room leaving the Medihoney and Wound Cleanser on the overbed table next to Resident #145 and with the resident's daughter and son in the room. Interview with LPN #4 on [DATE] at 3:10 PM, outside Resident #145's room next to the treatment cart, LPN #4 was asked what is the policy when removing gloves. LPN #4 stated, .wash hands or use a hand sanitizer .I didn't know I was supposed to hand sanitize between glove changes . LPN #4 was asked if it was ever appropriate to leave medications unattended at the bedside. LPN #4 stated, .I thought it would be alright to leave his medications and cleanser on the sterile field .

Based on review of the MED-PASS/American Society of Consultant Pharmacist Geriatric Medication Handbook, policy review, observation and interview, the facility failed to ensure practices to prevent the potential spread of infection when facility failed to ensure proper storage of oxygen tubing for 1 of 1 (Resident #94) residents observed during initial tour, failed to ensure proper hand hygiene for 1 of 18 (dietary staff #1) staff members observed during dining, failed to ensure indwelling urinary catheter bags did not touch the floor for 2 of 3 (Resident #26 and 107) residents, failed to ensure proper hand hygiene for 3 of 4 (Licensed Practical Nurse (LPN) #2, 3, 4 and 5) nurses observed during medication administration, and dressing change. The findings included: 1. The MED (medication)-PASS/American Society of Consultant Pharmacists Geriatric Medication Handbook, eleventh edition, on page 60 under eye drop administration recommendations documented, . if administering medication to BOTH eyes in resident with suspected or active eye infection, change gloves between or use a different gloved finger to apply pressure to tear duct . Review of the facility's Handwashing/Hand Hygiene policy revealed, .This facility consider hand hygiene the primary means to prevent the spread of infection .5. Employees must wash their hands .using antimicrobial or non-antimicrobial soap and water under the following conditions .f. Before and after assisting with meals .t. After removing gloves or aprons .in the most situations, the preferred method of hand hygiene is with and alcohol-based hand rub .d. Before preparing or handling medications . After contact with objects ( .medical equipment) in the immediate vicinity of the resident . 2. Observations on in Resident #94's room on 4/24/17 at 10:52 AM, revealed oxygen tubing lying in the seat of a wheelchair in a bathroom that was not covered. 3. Observation in Resident #19's room [ROOM NUMBER]/24/17 11:46 AM, revealed dietary staff #1 delivered a meal tray to the resident and returned the tray to the bottom of the rack without performing hand hygiene. Observation in Resident #79's room on 4/24/17 11:52 AM, revealed dietary staff #1 set up the resident's tray and returned to the meal cart without performing hand hygiene. Observation in Resident #90's room on 4/24/17 11:54 AM, revealed dietary staff #1 delivered a meal tray to the resident and returned to the cart without performing hand hygiene. 4. Observations on in Resident #26's room on 4/24/17 at 2:27 PM and 4:03 PM, revealed Resident #26 sitting up in bed fully dressed with indwelling foley catheter tubing on bedside not in privacy bag with the catheter tubing touching the floor. 5. Observations during medication pass on 4/25/17 at 1:30 PM, on Palm hall revealed LPN #5 knocked on the door and entered Resident #61's Room, washed her hands, entered the bathroom, donned gloves, handed Resident #61 a kleenex, and administered an ordered eye drop into Resident #61's left eye, and also administered an ordered eye drop into Resident #61's right eye. LPN #5 failed to change her gloves and perform hand hygiene prior to and in between administering the eye drops. 6. Observations in Resident #145's room on 4/25/17 at 2:50 PM, revealed LPN #4 performed a dressing change on Resident #145's left heel. LPN #4 washed her hands and donned gloves, removed the old dressing and placed it in a biohazard bag, removed her gloves, re-donned clean gloves and cleansed the wound with wound cleanser and patted dry. LPN #4 then applied the [MEDICATION NAME] to the pressure ulcer on the left heel and covered with gauze. LPN #4 wrapped the left heel with [MEDICATION NAME], secured with paper tape and replaced the off loading boot. LPN #4 failed to perform hand hygiene between glove changes. Interview with LPN #4 on 4/25/17 at 3:10 PM, outside Resident #145's room next to the treatment cart, LPN #4 was asked what is the policy when removing gloves. LPN #4 stated, .wash hands or use a hand sanitizer .I didn't know I was supposed to hand sanitize between glove changes . 7. Observations during medication administration in Willow Hall on 4/25/17 at 4:19 PM revealed LPN #2 removed a glucometer from the medication cart, cleaned it with a Super Sani Cloth and placed the glucometer on the medication cart without a barrier and stated, it has to dry for 2 minutes. LPN #2 donned gloves and assessed Resident # 107's blood glucose level appropriately. LPN #2 then exited the room and returned to the medication cart, removed a Super Sani Cloth from a drawer on the medication cart, cleansed the glucometer and placed the glucometer on the medication cart to dry without a barrier and waited 2 minutes for it to dry. LPN #2 failed to place the wet glucometer on a clean barrier to dry. 8. Observations during medication administration in the Dogwood Hall, on 4/26/17 at 7:34 AM, revealed LPN #3 removed a capsule from the medication bottle and picked the capsule up with her bare hands and placed the capsule in a medication cup. Interview with the Director of Nursing (DON) on 4/26/17 at 11:44 AM, in the Dietary Office, the DON was asked if it was standard practice for oxygen tubing to be wrapped around the arm of a wheelchair or lying in a wheelchair not contained in a bag. The DON stated, I don't think it would be a problem if it is not in use. The DON was then asked if it was standard practice for a privacy bag containing a foley catheter to be lying on the floor. The DON stated, to my knowledge that is the purpose of the privacy bag to protect the foley from being on the floor so yes that is ok. The DON was asked if it was standard practice to clean a glucometer and place it on top of the medication cart without a barrier. The DON stated, No.

Based on policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The findings included: 1. The QAA Committee failed to ensure that each resident received an accurate comprehensive assessment by a qualified professional staff. Refer to F 278 The deficient practice of F 278 is a repeat deficient practice for failure to ensure each resident received an accurate comprehensive assessment. The facility was cited F 278 on the recertification survey on 2/3/16. 2. The QAA Committee failed to ensure the resident's environment was free of accident hazards. Refer to F 323 The deficient practice of F 323 is a repeat deficient practice for failure to ensure the resident's environment was free of accident hazards. The facility was cited F 323 on the recertification survey on 2/3/16. 3. The QAA Committee failed to ensure all drugs and biologicals were safe, secure, and labeled when opened. Refer to F 431 The deficient practice of F 431 is a repeat deficient practice for failure to ensure all drugs and biologicals were safe, secure, and labeled when opened. The facility was cited F 431 on the recertification survey on 12/2014, and 2/3/16. 4. The QAA Committee failed to develop an effective Infection Control Program that provided safe and sanitary environment, and prevented the potential development and transmission of disease and infection. Refer to F 441 The deficient practice of F 441 is a repeat deficient practice for failure to develop an effective Infection Control Program that provided safe and sanitary environment, and prevent the potential development and transmission of disease and infection. The facility was cited F 441 on the recertification survey on 2/3/16. Interview with the Administrator on 4/26/17 at 4:15 PM, in the Administrator office, the Administrator was asked if the accuracy of the MDS (Minimum Data Set) coding had been QA'd. The Administrator stated, .we do have a problem sometimes with the CNA's (Certified Nursing Assistant) coding their ADL's (activities of daily living) correctly .we go to the individual and instruct them how they are to code . The Administrator was asked if they had QA'd the potential for accident hazards. The Administrator stated, .I round everyday, maybe not every room, and instruct the residents but they take offense at times .the families bring in things they are not supposed to have .it's never ending . The Administrator was asked if medication storage had ever been QA'd. The Administrator stated, No. The Administrator was asked if they had ever QA'd Infection Control. The Administrator stated, We have .this year .because we had a bug that we couldn't identify how the bug was spreading . The Administrator was asked if handwashing or Foley catheter placement had been QA'd. The Administrator stated, .we have tasks check offs to make sure the staff knows how to wash their hands but we haven't stood around observing them (staff) .

Based on policy review, observation, and interview, the facility failed to ensure residents was free from physical abuse when the facility failed to follow the facility's abuse policy to report, and thoroughly investigate an allegation of physical abuse for 1 of 1 (Resident # 8) residents who alleged abuse by a staff member. The findings included: The facility's Resident Rights policy documented, .(g) To be free from mental and physical abuse. Should this right be violated, the facility must notify the department within five (5) working days . The facility's Protection of Residents During Abuse Investigations policy documented, .1. During the abuse investigations, residents will be protected from harm by the following measures .a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator .Investigating Unexplained Injuries .An investigation of all unexplained injuries (including bruises, abrasions and injuries of unknown source), will be conducted . Medical record review revealed Resident #8 was admitted to the facility on [DATE] with last admitted [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #8 was moderately cognitively intact, and required extensive assistance with activities of daily living. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #8 was moderately cognitively intact, and required extensive assistance with activities of daily living. The facility's Grievance/Complaint Investigation Report Form dated 4/13/17 documented, .a nurse on 4/12/17 had twisted her arm and grabbed a coaster out of hand and made it bleed .has a dime sized bruise on her (symbol for right) wrist and two small cuts on her (symbol for right) 2nd and 3rd fingers . Observations in Resident's #8 room on 4/25/17 at 8:44 AM, revealed two small scabbed areas on 3rd finger on the right hand. Interview with Resident #8 on 4/25/17 at 8:44 AM in the residents room, Resident #8 was asked during stage 1 interview if she had ever been abused by staff. Resident #8 stated .the other day I guess I had been on the call light too much because I told them my oxygen wasn't working .they got mad and they came in my room .it was 3 of them and a nurse or one of them twisted my arm and snatched my coasters out of my hand making my fingers bleed and bruising my arm . Resident #8 was asked if she could identify who twisted her arm . Resident #8 stated, .No, I was so upset but they have been in here before . Resident #8 was asked if she told any one about what had happen and Resident #8 stated, Yes, the lady that runs the place I told her . Interview with the Director of Nursing (DON) on 4/26/17 at 10:43 AM, in the gathering room, the DON was asked about the incident with Resident #8. The DON stated, .Resident #8 said that the nurse took her coasters, snatched them from her and made her fingers bleed and had twisted her arm . The DON was asked if any injuries were observed to Resident #8. The DON stated, .She had 2 small scratches to her finger and a small bruise to her wrist . The DON was asked if this incident was investigated as abuse. The DON stated, .well, yes .didn't really look at it as abuse .but it was also behaviors and hallucinations .looked at it as she was having a paranoid delusional episode . Interview with the Administrator on 4/2617 at 1:45 PM, in the Administrator's office, the Administrator was asked if an abuse investigation had been completed for Resident #8 and what was the outcome. The Administrator stated, .it is completed .but not as an abuse allegation but as her having a psychotic episode, I did not see it as being abuse . The Administrator was asked if Resident #8 had reported to her that her arm was twisted by a nurse and her fingers were cut by a coaster that was snatched out of her hand. The Administrator stated .yes, she did report that to me and the Director of Nursing (DON) . The Administrator was asked if this incident was considered abuse. The Administrator stated, yes. The Administrator was asked if the staff members that were working the night of the incident were suspended during the investigation. The Administrator stated no. The Administrator was asked if the allegation had been reported to the state agency. The Administrator stated, .no it was not .

Based on medical record review and interview, the facility failed to accurately assess residents for medication use and activities of daily living for 2 of 18(Resident #40, and 74 )sampled residents of the 39 residents included in the stage 2 review. The findings included: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with a readmission on 3/14/17 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set(MDS)assessment dated [DATE] documented Resident #40 received one injection in last 7 days. The December, 2016 Medication Administration Records(MARS)documented Resident #40 did not receive an injection during the 7 day look back period for the quarterly MDS dated [DATE]. Interview with the MDS Coordinator #1 on 4/26/17 at 9:59 AM, in the MDS office, the MDS Coordinator #1 was ask if MDS dated [DATE] was coded correctly for injections. The MDS Coordinator #1 stated, No. 2. Medical record review revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission and 14 day MDS dated [DATE] and 4/12/17 documented Resident #145 had severe cognitive deficits, requires extensive to total assistance with activities of daily living, and had no functional limitations in range of motion. Interview with MDS Coordinator #1 on 4/26/17 at 8:10 AM, in the MDS Office, the MDS Coordinator #1 was asked where she got the information for coding the MDS. The MDS stated, .We go to Point of Care where the CNA's chart and verbally verify with the CNA's if it doesn't match up . The MDS Coordinator #1 was asked why there was a decline in Resident #145's eating status. The MDS Coordinator #1 stated, .He's transitioning between tube feeding and a po (by mouth) intake and eating about 75% (percent) now . The MDS Coordinator #1 was asked why there was a decline in Resident #145's toileting status. The MDS Coordinator #1 stated, .It is a coding error on the tech .he really should be dependent .it is also a MDS coding error .

Based on policy review, medical record review, observation and interview, the facility failed to revise the care plan to reflect a resident's status for [DIAGNOSES REDACTED].#107) residents of the 39 sampled residents in the stage 2 review. The findings included: 1. The facility's Care Plans-Comprehensive policy documented, .3. Each resident's comprehensive care plan is designed to .a. Incorporate identified problems areas .b. Incorporate risk factors associated with identified problem .f. Reflect treatment goals, timetables and objectives in measurable outcomes .g. Identify the professional services that are responsible for each element of each .h. Aid in preventing or reducing declines in the resident's functional status and/or functional levels .j. Reflect currently recognized standards of practice for problem areas and conditions . Medical record review revealed Resident #107 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 5 day Minimum Data Sets ((MDS) dated [DATE] and 4/11/17 documented Resident #107 was cognitively intact, had active [DIAGNOSES REDACTED]. The Care Plan dated 3/17/17 dcoumented no Diabetes care plans or interventions. Physician orders [REDACTED].Humalog KwikPen .SSI (sliding scale insulin) .AC (before meals) & HS (hour of sleep) . Physician orders [REDACTED].[MEDICATION NAME] 80 mg(milligram)/0.8 ml (milliliter) .70 mg subq (subcutaneous) daily .Post Hip Surgery . Interview with MDS Coordinator #2 (MDS) on 4/26/17 at 8:52 AM, in the MDS Coordinator's office, MDS Coordinator #2 was asked if there should be a care plan for diabetes as Resident #107 receives sliding scale insulin. The MDS Coordinator #2 stated, .It's not in there (computer) currently . The MDS Coordinator #2 was asked if there should be a care plan addressing Resident #107 diabetes. The MDS Coordinator #2 stated, .It should be .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when scissors and alcohol hand gel were found in 2 of 39 (Resident #80 and 102) sampled resident's rooms. The findings included: 1. Review of the facility's STORAGE OF MEDICATIONS policy documented, .the facility shall store all drugs and biologicals in a safe, and orderly manner .Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored in a separate compartment from regular medications . 2. Observations in resident #80's room on 4/24/17 at 11:05 AM, revealed a pair of scissors in an open bin to right of the door and a bottle of 10 oz. (ounce)hand sanitizer beside the resident's bed on the night stand. Observations in Resident #80's room on 4/24/17 at 3:55 PM, revealed 2 pairs of scissors in an open bin to the right of the door. Observations in Resident #80's room on 4/25/17 at 3:10 PM, revealed 2 pairs of scissors in an open bin to the right of the door. Observations in Resident's #80's room on 4/26/17 at 8:45 AM, revealed 2 pair of scissors in open bin to the right of the door. Observations in Resident's #102 room on 4/26/17 at 8:50 AM, revealed 2 bottles of 10 oz. hand sanitizer sitting at the bedside on top of the nightstand. Observations in Resident #80's room on 4/26/17 at 11:40 AM, revealed 2 pairs of scissors in an open bin to the right of the door. The surveyor continued to observe the scissors and hand sanitizer in resident rooms after having a discussion with the Administrator regarding hazards in the resident rooms. Interview with the Administrator on 4/26/17 at 10:30 AM, in Administrator's office, the Administrator was asked for a policy of chemical storage and accidents and hazards. The Administrator stated .I cannot find a policy specifically for sharps and storage of chemicals .we encourage to keep hazardous supplies in a locked box .Our goal is for our patients to have personal items from home and their own supplies as they request them. Interview with the Director of Nursing (DON) on 4/25/17 at 3:20 PM, in the gathering room, the DON was asked if the facility had any wanderers in and out of patient rooms. The DON stated No. Interview with the Administrator on 4/26/17 at 8:45 AM, in the Administrator's office, the Administrator was asked if the facility allowed Residents to have scissors and hand gel in their rooms. The Administrator stated, .We encourage them to keep those things locked up in their bedside table, it locks . Interview with the Administrator on 4/26/17 at 8:50 AM, in Administrator's office, the Administrator was asked if the facility had wanderer's in the the facility. The Administrator stated, Well they wander in the halls, we don't have anyone that goes in the rooms, if we did we would send them somewhere that had a locked unit. Interview with the Administrator on 4/26/17 at 10:30 AM, in Administrator's office, the Administrator was asked for a policy of chemical storage and accidents and hazards. The Administrator stated .I cannot find a policy specifically for sharps and storage of chemicals .

Based on Review of the Geriatric Medication Handbook, medical record review, observations and interview, the facility failed to ensure a resident was free from a significant medication error when 1 of 4 nurses (Licensed Practical Nurse (LPN) #2) failed to administer insulin within the proper time frame related to meals for Resident #107, who received an insulin injection. The failure to provide a substantial meal within appropriate time of the insulin administration resulted in a significant medication error. The findings included: 1. The Geriatric Medication Handbook, eleventh edition, page 41 documented, DIABETES: INJECTABLE MEDICATIONS .Humalog .Rapid-Acting Insulin Analog .ONSET .15 min (minutes) .TYPICAL ADMINISTRATION/COMMENTS 15 minutes prior to meals . 2. Medical record review revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#107 had an order for [REDACTED].= 2 units, 250-299= 3 units, 300-349= 4 units, 350-399= 5 units, > (greater than) or = 400= 6 units & call MD (Medical Doctor) for Type 2 DM (Diabetes Mellitus) without complications. 3. Observations on 4/25/17 at 4:35 PM, in Resident #107's room revealed LPN #2 administered 1 unit of Humalog to Resident #107. Resident #107 did not receive a lunch tray or substantial snack until 5:48 PM. Resident #107 did not start eating until 5:51 PM, 1 hour and 16 minutes after the [MEDICATION NAME]was administered and before Resident #107 took the first bite of food. Interview with the Director of Nursing (DON) on 4/26/17 at 3:37 PM, in the Administrator office, the DON was asked when should a resident who receives Humalog Sliding Scale Insulin receive a meal tray. The DON stated, Policy states within 15 minutes with a snack, drink or something like that to be given.