Every finding on record at White Oak of Waxhaw

Based on resident interview, staff interview, and record review, the facility failed to provide sufficient staff to provide care planned restorative services for ambulation and range of motion for 3 of 3 residents (Resident #4, Resident #30, Resident #35) due to restorative staff being pulled to cover for nurse aide staff. Findings included: This citation was cross-referenced to: F688- Based on resident interview, staff interview, resident council meeting and record review the facility failed to provide care planned restorative services for ambulation and range of motion for 3 of 3 residents (Resident ' s #4, #30, #35) due to restorative staff being pulled to cover for nurse aide staff.

Based on resident interview, staff interview, resident council meeting and record review the facility failed to provide care planned restorative services for ambulation and range of motion for 3 of 3 residents (Resident ' s #4, #30, #35) due to restorative staff being pulled to cover for nurse aide staff. Findings included: 1.a. Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was cognitively intact. Resident #4 required the supervision of one staff member with bed mobility. He required supervision and set up help for transfers, toilet use, and personal hygiene. Resident # 4 required limited assistance from one staff member for dressing, bathing, and walking in corridor. Further review revealed resident #4 had no impairment for range of motion. Resident #4 ' s mobility devices used included a walker, and wheelchair. The yearly MDS assessment dated [DATE] indicated Resident #4 was cognitively intact. Resident #4 required the supervision of one staff member for bed mobility, and transfers. Further review revealed Resident #4 did not walk in the corridor. Resident #4 ' s mobility device used during this MDS assessment included a wheelchair. A review of the active care plan originally created in (YEAR) and last updated in (MONTH) (YEAR) had a focus area for Resident #4 being at risk for decreased mobility due to muscle weakness. The goal was for the resident to be able to complete active range of motion every day six days per week for up to 20 minutes each through the next review. Interventions included restorative active range of motion program every day up to 20 minutes, 6 days per week due to muscle weakness. Resident #4 also had a focus area for decreased mobility. The goal was for the resident to be able to tolerate up to 150 ft ambulation program every day with a rolling walker and left foot orthoses brace six days per week until the next review on 12/04/18. Interventions included restorative ambulation program with rolling walker and left foot orthoses brace up to 150 ft every day for six days per week due to muscle weakness. An interview on 09/07/18 at 12:40pm with Nurse #1 revealed resident # 4 had an active care plan for restorative therapy. She stated she reviews the residents care plan which is printed by the restorative nursing supervisor and delivered to the resident ' s unit. She stated the restorative aides are often pulled to work on the resident halls. A review of the Occupational Therapy and Physical Therapy discharge summary revealed Resident #4 was discharged from physical therapy services on 06/28/18. Review revealed Resident #4 had discharge instructions to remain in long term care with restorative therapy to maintain ambulation and strength. A review of the restorative therapy logs for the dates of 07/06/18 through 09/05/18, revealed Resident #4 missed 17 days of restorative therapy out of the 61 days scheduled. An interview was conducted on 09/07/18 at 11:02 am with Resident #4. He stated when the restorative nurse aides are pulled to work on the resident halls he doesn ' t receive therapy. Resident #4 stated it had been a week since he received restorative therapy. He stated since being in the facility, physical therapy had helped him gain the ability to ambulate. Resident #4 stated he needed help maintaining his ability to ambulate. 1.b. Resident #30 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] indicated Resident #30 was cognitively intact. Resident #30 required extensive assistance of one staff member for bed mobility and transfers. He required limited assistance of one staff member for locomotion on the unit and walking in the corridor. Resident #30 did not walk in his room. Mobility devices used included a cane and wheelchair. A review of the Care Plan initiated on 03/15/18, had a focus area for Resident #30 being at risk for decreased mobility due to muscle weakness as related to [MEDICAL CONDITION]. The goal was for Resident #30 to be able to tolerate restorative active range of motion daily 6 days per week up to 20 minutes through the next review dated of 10/03/18. Interventions included restorative active range of motion daily up to 20 minutes 6 days per week due to [MEDICAL CONDITION]. Other interventions included restorative aids to offer praise, encouragement, and rest periods as needed. Resident # 30 was discharged from occupational therapy services on 07/31/18. Resident #30 had discharge instructions to return to restorative services. Resident #30 was discharged from physical therapy services on 8/30/18. Resident #30 had discharge instructions to participate in restorative therapy to maintain ambulation and mobility for transfers. A review of the restorative therapy logs for the dates of 07/06/18 through 09/05/18, revealed Resident # 30, missed 29 days of restorative therapy out of the 61 days scheduled. An interview on 09/07/18 at 10:47am with Resident # 30 revealed restorative therapy had walked with him using his cane in the hallway for the first time in a month. Resident #30 stated his mobility had declined due to being unable to walk with restorative therapy. 1.c. Resident # 35 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated Resident #35 was cognitively intact. Resident #35 required extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, walking in the corridor and bathing. Resident #35 did not walk in his room. Further review revealed Resident #35 had range of motion limitations to his upper and lower extremities on one side. Mobility devices included cane/crutch, and a wheelchair. A review of the Care Plan initiated on 11/09/17, had a focus area for Resident #35 being at risk for decreased joint mobility due to muscle weakness as related to a [DIAGNOSES REDACTED].#35 was to be able to tolerate up to 15 minutes at parallel bars with minimum assist and weight bearing through left upper extremity while reaching with right upper extremity daily 6 days per week through the next review date of 10/10/18. Interventions included restorative transfer program standing at parallel bar with minimum assist and weight bearing through left upper extremity while reaching with right upper extremity up to 15 minutes. Other interventions included the restorative aids to offer praise, encouragement and rest periods as needed. An interview on 09/07/18 at 12:47pm with Nurse #2 revealed resident #35 had an active care plan for restorative therapy per physician orders. She stated the restorative aides are often pulled to work on the resident halls. A review of the restorative therapy logs for the dates of 07/06/18 through 09/05/18, revealed Resident # 35, missed 21 days of restorative therapy out of the 61 days scheduled. Resident #35 was discharged from occupational services on 11/15/17. Resident #35 had discharge instructions to continue receiving restorative therapy. Resident #35 was discharged from physical therapy services on 07/16/18. Resident #35 had discharge instructions to remain in current skilled nursing facility and transfer to the restorative therapy program. An interview on 09/06/18 at 3:14pm with Resident #35 revealed resident received restorative therapy for the first time today in 3 weeks. 1.d. A meeting with the facility resident council on 09/06/18 at 3:14 pm revealed resident concerns regarding restorative therapy services. Resident #4, #30, and #35 stated the restorative therapy nurse aides (NA) were often pulled to work on the hallways and the residents were not receiving restorative therapy. An interview on 09/06/18 with the Restorative Nursing Supervisor revealed Resident ' s #4, #30, and #35 were currently receiving restorative care. The interview further revealed she had received complaints about residents not receiving restorative care. She stated the restorative therapy nurse aides are often pulled to work on the facility units as NA ' s due to short staffing in the facility. An interview on 09/07/18 at 10:15am with the Rehabilitation Manager confirmed Residents #4, #30, and #35 were to be receiving restorative therapy services. She stated the restorative therapy program is initiated by occupational therapy and physical therapy. She stated the facility therapist train the restorative nurse aides (NA ' s) on how to provide restorative services to each individual resident. An interview on 09/07/18 at 10:35am with the facility MDS nurse revealed Resident # 4, #30, and #35 each had an active restorative therapy care plan. An interview on 09/07/18 at 10:46am with a Restorative Therapy NA revealed she had been pulled to work as a NA on the resident halls every day for the past 2 weeks. She stated she was unable to complete her restorative therapy task when pulled to work as a NA on the resident halls. An interview on 09/07/18 at 11:12am with the Director of Nursing revealed the expectation of the facility was for the resident to receive therapy as much as they can. She stated she needed to obtain more knowledge of the facilities restorative therapy program since she was newly hired. An interview on 09/07/18 at 12:56pm with the Administrator revealed the facility is having issues regarding staffing. She stated she is having orientations weekly to attempt to gain staff. She stated she had investigated further options regarding staffing recruitment.

Based on resident interview, staff interview, resident council meeting and record review the facility failed to implement the care planned interventions for 3 of 3 sampled residents (Resident's #4, #30, #35) to maintain ambulation and range of motion with Restorative Therapy. Findings included: 1.a. Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was cognitively intact. Resident #4 required the supervision of one staff member with bed mobility. He required supervision and set up help for transfers, toilet use, and personal hygiene. Resident # 4 required limited assistance from one staff member for dressing, bathing, and walking in corridor. Further review revealed resident #4 had no impairment for range of motion. Resident #4's mobility devices used included a walker, and wheelchair. The yearly MDS assessment dated [DATE] indicated Resident #4 was cognitively intact. Resident #4 required the supervision of one staff member for bed mobility, and transfers. Further review revealed Resident #4 did not walk in the corridor. Resident #4's mobility device used during this MDS assessment included a wheelchair. A review of the active care plan originally created in (YEAR) and last updated in (MONTH) (YEAR) had a focus area had a focus area for Resident #4 being at risk for decreased mobility due to muscle weakness. The goal was for the resident to be able to complete active range of motion every day six days per week for up to 20 minutes each through the next review. Interventions included restorative active range of motion program every day up to 20 minutes, 6 days per week due to muscle weakness. Resident #4 also had a focus area for decreased mobility. The goal was for the resident to be able to tolerate up to 150 ft ambulation program every day with a rolling walker and left foot orthoses brace six days per week until the next review on 12/04/18. Interventions included restorative ambulation program with rolling walker and left foot orthoses brace up to 150 ft every day for six days per week due to muscle weakness. An interview on 09/07/18 at 12:40pm with Nurse #1 revealed resident # 4 had an active care plan for restorative therapy. She stated she reviews the residents care plan which is printed by the restorative nursing supervisor and delivered to the resident's unit. She stated the restorative aides are often pulled to work on the resident halls. A review of the restorative therapy logs for the dates of 07/06/18 through 09/05/18, revealed Resident #4 missed 17 days of restorative therapy out of the 61 days scheduled. An interview was conducted on 09/07/18 at 11:02 am with Resident #4. He stated when the restorative nurse aides are pulled to work on the resident halls he doesn't receive therapy. Resident #4 stated it had been a week since he received restorative therapy. He stated since being in the facility, physical therapy had helped him gain the ability ambulate. Resident #4 stated he needed help maintaining his ability to ambulate. 1.b. Resident #30 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual MDS assessment dated [DATE] indicated Resident #30 was cognitively intact. Resident #30 required extensive assistance of one staff member for bed mobility and transfers. He required limited assistance of one staff member for locomotion on the unit and walking in the corridor. Resident #30 did not walk in his room. Mobility devices used included a cane and wheelchair. A review of the Care Plan initiated on 03/15/18, had a focus area for Resident #30 being at risk for decreased mobility due to muscle weakness as related to [MEDICAL CONDITION]. The goal was for Resident #30 to be able to tolerate restorative active range of motion daily 6 days per week up to 20 minutes through the next review dated of 10/03/18. Interventions included restorative active range of motion daily up to 20 minutes 6 days per week due to [MEDICAL CONDITION]. Other interventions included restorative aids to offer praise, encouragement, and rest periods as needed. A review of the restorative therapy logs for the dates of 07/06/18 through 09/05/18, revealed Resident # 30, missed 29 days of restorative therapy out of the 61 days scheduled. An interview on 09/07/18 at 10:47am with Resident # 30 revealed restorative therapy had walked with him using his cane in the hallway for the first time in a month. Resident #30 stated his mobility had declined due to being unable to walk with restorative therapy. 1.c. Resident # 35 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated Resident #35 was cognitively intact. Resident #35 required extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, walking in the corridor and bathing. Resident #35 did not walk in his room. Further review revealed Resident #35 had range of motion limitations to his upper and lower extremities on one side. Mobility devices included cane/crutch, and a wheelchair. A review of the Care Plan initiated on 11/09/17, had a focus area for Resident #35 being at risk for decreased joint mobility due to muscle weakness as related to a [DIAGNOSES REDACTED].#35 was to be able to tolerate up to 15 minutes at parallel bars with minimum assist and weight bearing through left upper extremity while reaching with right upper extremity daily 6 days per week through the next review date of 10/10/18. Interventions included restorative transfer program standing at parallel bar with minimum assist and weight bearing through left upper extremity while reaching with right upper extremity up to 15 minutes. Other interventions included the restorative aids to offer praise, encouragement and rest periods as needed. An interview on 09/07/18 at 12:47pm with Nurse #2 revealed resident #35 had an active care plan for restorative therapy per physician orders. She stated the restorative aides are often pulled to work on the resident halls. A review of the restorative therapy logs for the dates of 07/06/18 through 09/05/18, revealed Resident # 35, missed 21 days of restorative therapy out of the 61 days scheduled. An interview on 09/06/18 at 3:14pm with Resident #35 revealed resident received restorative therapy for the first time today in 3 weeks. 1.d. A meeting with the facility resident council on 09/06/18 at 3:14 pm revealed resident concerns regarding restorative therapy services. Resident #4, #30, and #35 stated the restorative therapy nurse aides (NA) were often pulled to work on the hallways and the residents were not receiving restorative therapy. An interview on 09/07/18 at 10:15am with the Rehabilitation Manager confirmed Residents #4, #30, and #35 were to be receiving restorative therapy services. She stated the restorative therapy program is initiated by occupational therapy and physical therapy. She stated the facility therapist train the restorative nurse aides (NA's) on how to provide restorative services to each individual resident. An interview on 09/06/18 with the Restorative Nursing Supervisor revealed Resident's #4, #30, and #35 were currently receiving restorative care. The interview further revealed she had received complaints about residents not receiving restorative care. She stated the restorative therapy nurse aides are often pulled to work on the facility units as NA's due to short staffing in the facility. An interview on 09/07/18 at 10:35am with the facility MDS nurse revealed Resident # 4, #30, and #35 each had an active restorative therapy care plan. An interview on 09/07/18 at 10:46am with a Restorative Therapy NA revealed she had been pulled to work as a NA on the resident halls every day for the past 2 weeks. She stated she was unable to complete her restorative therapy task when pulled to work as a NA on the resident halls. An interview on 09/07/18 at 11:12am with the Director of Nursing revealed the expectation of the facility was for the resident to receive therapy as much as they can. She stated she needed to obtain more knowledge of the facilities restorative therapy program since she was newly hired. An interview on 09/07/18 at 12:56pm with the Administrator revealed the facility is having issues regarding staffing. She stated she is having orientations weekly to attempt to gain staff. She stated she had investigated further options regarding staffing recruitment.

Based on observations and staff interviews, the facility failed to discard expired nutritional supplements in 1 of 4 medication storage rooms (300 Hall). Findings included: An observation, on [DATE] at 08:30 AM, was conducted of the medication storage room on the Maple Terrace (300 Hall). There were 15 out of 15 unopened cans of the [MEDICATION NAME] (1.5 High Protein, High Calorie, 8 fluid ounce) nutritional supplement found in the cabinet of the 300 Hall medication storage room with an expiration date of (MONTH) (YEAR). An interview was conducted with Nurse #3 on [DATE] at 08:30 AM. She stated that none of the residents on the 300 Hall had received any [MEDICATION NAME]. She had no knowledge of those cans being stored in the medication storage room. She revealed that her expectation, regarding expired nutritional supplements, was to discard the supplements immediately. An interview with the Director of Nursing (DON) was conducted on [DATE] at 12:00 PM. She indicated that the consultant pharmacist performed routine monthly audits of the medication storage rooms and medication carts. The DON revealed that the expectation was that the pharmacist reported any expired nutritional supplements and medications to the nurses. She further revealed that the expectation of the nurses on each hall was to check the medication storage rooms on a weekly basis and discard any expired nutritional supplements and medications immediately.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide nail care for 1 of 4 dependent residents (Resident # 166) reviewed for activities of daily living (ADL). The findings included: Resident #166 was admitted to the facility on [DATE] with hypertension, [MEDICAL CONDITIONS] with left-sided [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of Resident #166's care plan dated 08/08/17 for ADL revealed that he was dependent on staff for assistance with all ADL care related to his [DIAGNOSES REDACTED]. Additionally, review of his care plan dated 08/08/17 for skin breakdown related to decreased mobility, incontinence and [DIAGNOSES REDACTED]. Review of Resident #166's admission Minimum Data Set ((MDS) dated [DATE] revealed an assessment of intact cognition. The MDS indicated Resident #166 required extensive to total assistance of 1 person with all ADL. An observation and interview of with Resident #166 on 09/19/17 at 10:43 am revealed his toe nails had not been trimmed since he was admitted and they were long and touching the inside of his shoe. He stated that he had mentioned it to the Social Worker and she had told him to talk with nursing about trimming his toe nails. He stated that he had mentioned it to the nurse (could not remember which one) and she had told him the Podiatrist would need to cut his nails. The resident stated he did not understand why the Podiatrist had to cut his toe nails since he was not diabetic. An observation of Resident #166 on 09/21/17 at 10:16 am revealed him sitting in his wheelchair in the common area watching TV. Nursing Assistant (NA) #1 assisted Resident #166 to his room and removed his brace, sock and shoe on his left leg and his sock and shoe on his right leg. His toe nails on both feet were observed to be approximately ¼ inch beyond the end of his toes. NA #1 stated the nursing assistants were not allowed to cut toe nails but they could file them. She stated that nail care was typically done after bath or shower and Resident #166 received his showers on 2nd shift. An interview on 09/21/17 at 10:20 am with Nurse #1 revealed that the Podiatrist typically cuts the resident's toe nails. She stated that she would have to check to see if the nurses were supposed to cut the toe nails of residents who were not diabetic. An interview on 09/21/17 at 12:13 pm with the Social Worker revealed the process for referral to the Podiatrist was for the family to sign a consent to see the Podiatrist. The Social Worker stated all diabetics were referred to the Podiatrist for nail care and the treatment nurse also made referrals for residents that may not be diabetic to see the Podiatrist if their nails were thick. The Social Worker stated that Resident #166 did not currently have a Podiatry referral in place. An interview on 09/21/17 at 12:21 pm with the Treatment Nurse revealed that she did make referrals to Podiatry for residents. She also stated the nurses should be able to assess toe nails to determine if they could cut them or if they would need to be cut by Podiatry and make the referral. An interview on 09/21/17 at 3:40 pm with Nurse #2 revealed that she had not trimmed the resident's toe nails and was not aware that they needed to be trimmed. Nurse #2 stated Podiatry services usually trimmed the resident's toe nails. An interview on 09/22/17 at 3:01 pm with the Director of Nursing (DON) revealed her expectation was for all residents to have their toe nails trimmed and/or filed by the nurses or the Podiatrist. The DON stated she would expect the nurses to trim the resident's toe nails that are not referred for Podiatry services.

Based on observation, record review, resident and staff interview, the facility failed to assess the skin and identify the formation of a pressure ulcer for 1 of 3 residents (Resident #166) reviewed with splint devices. The findings included: Resident #166 was admitted to the facility on [DATE] with hypertension, [MEDICAL CONDITIONS] with left-sided [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of Resident #166's care plan dated 08/08/17 for risk of skin breakdown revealed he was at risk due to decreased mobility, incontinence and [DIAGNOSES REDACTED]. The goal was for Resident #166 to be free from any areas of skin breakdown through the next review date of 11/15/17. Interventions included in part: monitor skin daily with ADL care and notify nurse of any changes. Review of History and Physical by the facility physician dated 08/08/17 revealed under Musculoskeletal the resident had his left leg in a brace and was non-ambulatory. Review of a Skin Risk Data Collection Form dated 8/10/17 revealed the resident was at risk of skin breakdown and preventive interventions were required. Review of Resident #166's admission Minimum Data Set ((MDS) dated [DATE] revealed an assessment of intact cognition. The MDS indicated Resident #166 was at risk of skin breakdown due to decreased mobility, incontinence and left-sided [MEDICAL CONDITION] which resulted from [MEDICAL CONDITION]. Review of Resident #166's admission Care Area Assessment (CAA) summary dated 08/22/17 for risk of pressure ulcers revealed his skin was intact but was at risk of skin breakdown due to decreased mobility, incontinent episodes and [MEDICAL CONDITION]. An observation and interview of Resident #166 on 09/21/17 at 10:16 am revealed him sitting in his wheelchair in the common area watching TV. Nursing Assistant (NA) #1 assisted Resident #166 to his room and removed his ankle foot orthotic (AFO) brace, sock and shoe on his left leg. His left leg was noted to have an indentation where his brace had been on his leg, his left foot was [MEDICAL CONDITION] and [DIAGNOSES REDACTED]tous and there was an area of skin breakdown on his left medial leg below the level of the knee. NA #1 stated that she had not placed the brace on the resident this morning but had been placed by the NA on 3rd shift (11:00 PM - 7:00 AM) who got him up and dressed him. The resident was also noted to have a 2 inch x 2 inch absorbent dressing on his left shin. NA #1 stated she had placed it there to cover a sore on his leg several days earlier and removed the dressing. The left shin area was [DIAGNOSES REDACTED]tous. NA #1 stated she could not remember if she had reported the area on his shin to the nurse. NA #1 left to find the nurse to evaluate the resident's skin breakdown. The resident stated that he was not aware the brace was tight on his leg because he did not have feeling in his affected leg. He stated however, the brace was removed every night before he went to bed because it was so uncomfortable he could not stand to wear it in bed. He stated it did not hurt but was uncomfortable and he could not move or rest with it on his leg. An interview on 09/21/17 at 10:20 am with Nurse #1 revealed that she was not aware of the resident's brace being tight on his leg, but observed the indented skin where the brace had been and measured the skin breakdown on his left medial leg to be 1.5 centimeters (cm) x 1.5 cm. Nurse #1 contacted Physical Therapy to come look at the brace. An interview on 09/21/17 at 10:40 am with the Rehabilitation Director revealed the brace was too tight for the resident. The Rehab Director stated to Nurse #1 the resident should only wear his sock and shoe and she would arrange for the resident to be evaluated by the orthotics specialist to see if he needed another type of AFO brace or if adjustments could be made to the one that he was wearing. She instructed Resident #166 not to wear the brace and she would have him evaluated for a toe lift that would attach to his shoe to help with foot drop until the brace could be altered. An interview on 09/21/17 at 12:21 PM with the Treatment Nurse revealed that she had just been notified of the pressure area by Resident #166's nurse and was there to evaluate the area. She evaluated the skin breakdown on the resident's medial leg and stated it was a Stage 2 pressure ulcer that measured 1.5 cm x 1.5 cm. The Treatment Nurse stated she had not been previously notified of any issue with his skin. She stated and demonstrated the area on top of his left foot was blanchable and the area on his shin that was previously bandaged was blanchable. The Treatment Nurse stated she would have expected the NAs to assess his skin as they were bathing or dressing the resident and report any changes to the nurse for treatment. The Treatment Nurse stated the NAs were supposed to fill out a skin assessment every time they bathed or showered a resident and if for some reason the resident is not bathed or showered the NAs should be looking at the skin when they are dressing the resident. The Treatment Nurse stated the NAs should report any skin changes to the nurse or to her as soon as possible. An interview on 09/21/17 at 3:40 PM with Nurse #2 revealed that she was not aware the resident had any issues with his skin. A telephone interview on 9/21/17 at 10:00 PM with NA #2 revealed he had not noticed any reddened areas or any skin breakdown on the resident's leg when he had put his brace on earlier in the morning. An interview on 09/22/17 at 3:01 PM with the Director of Nursing (DON) revealed her expectation was for skin assessments to be done on admission, weekly for 4 weeks, and daily if the resident was at risk of skin breakdown. The DON stated she expected the NAs and nurses to identify any concerns with the resident's skin, initiate treatment and notify the Treatment Nurse.

Based on record reviews and staff interviews the facility failed to ensure a Nurse Aide had renewed her Nurse Aide certification when her certification expired for 1 of 5 personnel files reviewed for abuse prohibition. (NA #1). The findings included: A review of a facility policy titled Plan for the Prevention of Elder Abuse that was not dated indicated in part the facility would conduct state licensure and registry board verification. A review of personnel files on [DATE] at 9:11 AM revealed Nurse Aide (NA) #1 was hired by the facility on [DATE]. A document inside the file titled North Carolina Nurse Aide I Registry indicated the registry listing for NA #1 had expired and the listing expiration date was [DATE]. During an interview on [DATE] at 9:12 AM the Human Resource Manager verified the North Carolina Nurse Aide I Registry listing indicated the NA certification for NA #1 had expired. She explained the Staff Development Coordinator was in charge of ensuring that licenses and certifications were up to date. During an interview on [DATE] at 9:27 AM the Director of Nursing verified NA # 1's certification had expired on [DATE]. She explained the Staff Development Coordinator was responsible for checking licenses and certifications and was to follow up with staff before their certification expired. She stated it was her expectation that prior to the end of each month certifications would be checked to ensure that every staff had an up to date certification. During an interview on [DATE] at 9:38 AM the Staff Development Coordinator confirmed she was responsible for reviewing licensure and certifications on a monthly basis but did not realize NA #1's certification had expired until after the expiration date. She explained when staff were hired the human resources department staff printed a copy of the license or certification for her and she filed them in a notebook. She stated she had a section labeled for nurses and a separate section labeled for Nurse Aides (NAs) and the notebook was divided by month and she highlighted who was due for renewal of their license or certification. She explained when the time came for renewal, NAs usually brought their paper work to her so she could complete a section that verified the number of hours they had worked and NAs were responsible for mailing the paper work to the North Carolina Nurse Aide I Registry. She stated most of the time NAs told her they had sent their paper work to the registry and then she checked their website and printed the renewed certification for their personnel file. She explained NA #1 had not brought her paper work to her and when she asked her why her certification had expired NA #1 stated she had forgotten to send her paper work in to the registry and that's why it had expired.

Based on observation and staff interview the facility failed to maintain two entrée items at a temperature of 140 degrees or above before plating and failed to use the steam table to help ensure foods remained above 140 degrees before plating for three entrée items and for gravy on 1 of 4 halls (300 hall/Maple Terrace). The findings included: On 06/03/15 at 5:30 PM the 300 hall food dinner service was observed. Dietary Aide #1 was plating food from a portable steam table. There were also 4 food items that were observed on the cart for the steam table. These food items were in uncovered metal containers beside the steam table; they were not on or being warmed by the steam table. Dietary Aide #1 was observed preparing a plate for a resident which included one of the food items not on the steam table (regular diet pork entrée). Interview with Dietary Aide #1 at this time revealed these food items had been off the steam table for the entire meal service. She added that they were not on the steam table because it was full and she did not have room for them. On 06/03/15 at 5:40 PM the Dietary Supervisor measured the temperature of the 4 food items not on the steam table. The following was observed: Regular diet pork entrée (145 degrees F/Fahrenheit) Puree shrimp (135 degrees F) Ground pork (the thermometer was observed to stay at a temperature of 98 degrees however was left in without observation of the temperature reading for approximately an additional 15 seconds) Gravy (temperature was not measured) Interview with the Dietary Supervisor at this time revealed the ground pork temperature reached a maximum of 112 degrees F. She stated that the food items that were not on the steam table should have been on the steam table and that if she had arranged the food items herself they would have been. Interview with the Dietary Manager on 06/03/15 at 6:00 PM revealed that it was his expectation that all foods that should be kept warm (above 140 degrees F) prior to plating should be on the steam table. He added that the foods that had not been on the steam table were above 140 degrees F prior to leaving the kitchen but acknowledged that at least two of the food items that were not on the steam table did not maintain a temperature of above 140 degrees F, according to the temperatures observed with the Dietary Supervisor. Interview with the Dietary Consultant on 06/04/15 at 9:30 AM revealed that the facility had taken steps to ensure all foods that should be maintained above 140 degrees F prior to plating would fit on the steam table. She added that the foods that had not been on the steam table had not been under 140 degrees F for an amount of time that would be considered hazardous.

Based on observation, staff interview and record review the facility failed to label a medication syringe with the medication name, date of dispensing, and/or expiration date in 1 of 4 medication refrigerators (400 hall medication refrigerator) reviewed for medication storage and labeling. Findings included: On 06/04/15 at 2:45 PM an observation was made of the medication refrigerator on the 400 resident hall. The controlled medications used for the residents on the 400 hall were kept together in a locked refrigerator. One medication syringe with 0.1 cubic centimeters (cc) of a clear liquid was found in a pill crushing bag with a resident's first initial and last name (Resident #107) written on the bag. Nurse #1, who was present in the medication room when the syringe was discovered, stated it may have fallen out of her box or an old box and was not noticed. A record review of Resident #107's Physician order [REDACTED]. On 06/04/15 at 3:46 PM, Nurse #2 reported that Resident #107's Ativan was scheduled for 1st shift, and she had never administered a dose of Ativan to Resident #107. Nurse #2 reported that the dispensing dropper for the liquid Ativan was attached to the top, or lid, of the medication bottle. She stated that if she administered a dose she would replace the lid containing the dispensing dropper back into the bottle. Nurse #2 reported she would have wasted, with another nurse, a dose of Ativan that had been pulled up in a syringe and not administered. On 06/04/15 at 3:30 PM, an interview was conducted with the Director of Nursing who stated, I don't know that it (the clear liquid) is a medication in the syringe. They (the nurses) rinsed the syringe. It might just be water. That might have been a syringe that fell out of the box of Ativan. The syringe was most likely inserted into the pill crusher bag to keep the syringe clean, or it could have been from an old box. If a nurse pulls a medication, but doesn't give it they should dispose of it or waste it.

Based on observations and staff interviews the facility failed to disinfect a blood glucose meter per facility policy between each resident use for 4 residents during medication pass for 1 of 3 nurses interviewed regarding disinfecting blood glucose meters (Resident #92, #101, #111, and #113). The findings included: A facility policy titled "Fingerstick Blood Sugar" dated 01/22/14 read in part: "10. Clean glucometer (blood glucose meter) with bleach wipe. a. Clean glucometer with one wipe and discard. b. Cover glucometer with a clean wipe for 4 minutes. c. After 4 minutes, remove the bleach wipe, place the glucometer on a clean barrier (ie: paper towel), and allow to dry prior to using again and/or storing in medication cart. Note: 1. Glucometer to be cleaned using PDI saniwipe 1:10 bleach dilution only. 2. Glucometer to be cleaned (per procedure #10 above) between resident use or after use of individual resident. 3. Glucometer must remain visibly wet with 1:10 bleach solution for minimum of 4 minutes." Observations of the 200 hall nurse's station on 05/13/14 at 3:50 PM revealed instructions for cleaning/disinfecting blood glucose meters as outlined in the facility policy were posted at eye level at the desk. On 05/13/14 at 3:55 PM Nurse #2 was approached for observations of medication pass and had just placed a blood glucose meter in the top drawer of the medication cart. Nurse #1 indicated she had completed all her afternoon finger stick blood sugars and did not have any insulin to administer at that time. When asked how she had disinfected the blood glucose meter Nurse #1 opened the top drawer of the medication cart and showed the surveyor an alcohol wipe. Nurse #1 then asked this surveyor if she had answered correctly. It was suggested to her she ask a supervisor for information regarding the facility's policy for cleaning and disinfecting blood glucose meters. A follow up interview was conducted with Nurse #2 on 05/13/14 at 4:02 PM when she returned to the 200 hall medication cart. She was carrying a container of 1:10 bleach dilution wipes and when she opened the bottom drawer of the medication cart a container of the bleach wipes was observed already in the drawer. Nurse #1 stated she had just been instructed by a supervisor how to use 1:10 bleach dilution wipes to clean/disinfect blood glucose meters and did not recall being instructed to use anything other than alcohol wipes to disinfect blood glucose meters. Nurse #2 further stated she worked as needed for the facility and the last time she worked was four months ago. Nurse #2 confirmed she had disinfected the blood glucose meter between resident use with an alcohol wipe when she completed her finger stick blood sugars on Resident #92, #103, #111, and #113 that afternoon. The interview further revealed she had never noticed the instructions for cleaning/disinfecting blood glucose meters posted in the nurse's station. During an interview on 05/13/14 at 4:30 PM the Director of Nursing (DON) stated she expected staff to clean/disinfect blood glucose meters between each resident use with 1:10 bleach dilution wipes per the facility's policy. A follow up interview was conducted with the DON on 05/14/14 at 10:13 AM. A copy of the instructions for cleaning and disinfecting blood glucose meters used during Nurse #2's orientation on 11/01/11 revealed nurses were instructed to use a disinfectant wipe of at least 10% bleach concentration for disinfecting blood glucose meters utilized for multiple residents. The interview further revealed the instructions for cleaning and disinfecting blood glucose meters as outlined in the facility policy were posted at each nurse's station on 11/26/13.

Based on observation, record review, and staff interviews the facility failed to provide nail care to 1 of 5 sampled residents reviewed for activities of daily living (Resident #23). The findings included: An interim care plan for ADLs dated 03/31/14 indicated Resident #23 required staff assistance with all ADL care. The goal stated Resident #23 would be able to participate in part of ADL care through next review. The ADL care plan included approaches to assist Resident #23 by setting up personal grooming items within reach in front of sink and encouraging the resident to wash her face and complete oral care. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#23 was severely cognitively impaired and was unable to make her needs known. The admission MDS further revealed Resident #23 required extensive assistance of staff for personal hygiene, dressing, and transfer. Rejection of care was not noted during the assessment period. The Care Area Assessment (CAA) summary for activities of daily living (ADL) dated 04/07/14 revealed Resident #23 required extensive staff assistance with ADL tasks. The CAA summary did not address assistance with personal hygiene and bathing. A review of a nurse aide assignment sheet dated 05/08/14 and 05/12/14 identified Resident #23 received her showers on Monday and Thursday during the 3:00 PM to 11:00 PM shift. The assignment sheet noted Resident #23 had received her shower on 05/08/14 and 05/12/14. During an observation on 05/12/14 at 3:20 PM revealed Resident #23 had all 10 fingernails extended approximately 1/8 inch beyond the end of her finger tips with uneven edges and had brown colored debris under her nails. During an observation on 05/13/14 at 2:20 PM revealed Resident #23 had all 10 fingernails extended approximately 1/8 inch beyond the end of her finger tips with uneven edges and had brown colored debris under her nails. During an observation on 05/14/14 at 8:49 AM revealed Resident #23 had all 10 fingernails extended approximately 1/8 inch beyond the end of her finger tips with uneven edges and had brown colored debris under her nails. During an observation on 05/14/14 at 2:32 PM revealed Resident #23 had all 10 fingernails extended approximately 1/8 inch beyond the end of her finger tips with uneven edges and had brown colored debris under her nails. On 05/14/14 at 3:07 PM Nursing Aide (NA) #1 stated she was familiar with Resident #23 and had assisted with her care. NA #1 described the system for showers noting residents would get showers at least 2 times a week. She further explained during a shower, residents would get their faces and hair washed, their body washed head to toe, shaving as appropriate and nail care provided. NA #1 said they made sure fingernails were clean, cut, and filed to ensure the residents looked nice. NA #1 stated she had only assisted with showers for Resident #23. On 05/15/14 at 9:47 AM NA #2 stated he was familiar with Resident #23, was assigned to her care and confirmed Resident #23's morning care was completed. NA #2 also confirmed Resident #23 was totally dependent on staff for ADL care. When asked about the resident's fingernails, NA #2 said her fingernails needed to be cleaned and trimmed. On 05/15/14 at 9:50 AM Nurse #1 stated she was familiar with the care of Resident #23. Nurse #1 stated it was her expectation residents' nails were clean and trimmed. Nurse #1 confirmed Resident #23 ' s nails needed to be cleaned and trimmed. During an interview on 05/15/14 at 2:21 PM the Director of Nursing (DON) stated it was her expectation residents' nails were clean and filed smooth.

Based on medical record review and staff interviews the facility failed to discontinue administration of an anti-coagulant medication as instructed by the physician for 1 of 1 sampled residents on dual anticoagulant medications. The findings are: Resident #76 was admitted to the facility 02/11/14 with [DIAGNOSES REDACTED]. The initial care plan dated 02/11/14 for Resident #76 included the problem area, At risk for signs/symptoms of abnormal bleeding related to use of anticoagulant medication secondary to [DIAGNOSES REDACTED]. admission orders [REDACTED]. In addition to the [MEDICATION NAME], Resident #76 was on [MEDICATION NAME] (an anticoagulant which is dosed based on INR results). Review of labwork in the medical record of Resident #76 noted INR results on 02/24/14 with an INR level of 2.6. Review of the Medication Administration Record [REDACTED]. Nurse #3 had initialed on the MAR indicated [REDACTED]. On 05/15/14 at 9:08 AM Nurse #3 stated labwork was done by an outside contract agency and the lab results were communicated to the facility nursing supervisors electronically. Nurse #3 stated after the nursing supervisors received labwork, the physician was notified of results and the paper copy of the labwork was placed in the physicians book for signature. Nurse #3 stated the labs for INRs are typically drawn in the morning with the results available by shift change at 2:00-3:00 PM. Nurse #3 reviewed the 02/24/14 INR lab results for Resident #76 which noted they had been received at the facility on 02/24/14 by Nursing Supervisor #1. Nurse #3 stated she always checked labwork in the residents medical record to determine what the current INR results were when there was an order like the [MEDICATION NAME] for Resident #76. Nurse #3 stated she did not know what the delay was in her receiving the paperwork with the INR results; noting the paperwork could have been in the physician's book or medical records before it was placed on the medical record of Resident #76. Nurse #3 stated there could have been a delay in receipt of the lab work because after the supervisor calls the physician with results lab work was placed in the physicians book for signature. Nurse #3 noted after the physician signed the lab work it was given to medical records for placement in the individual resident's chart. Nurse #3 stated she could not access lab results via the electronic record, that nursing staff was dependent on the paperwork to know lab results. On 05/15/14 at 11:05 AM the Administrator, Nurse Consultant, Director of Nursing (DON), Consultant Pharmacist and Assistant Director of Nursing (ADON) discussed the facility procedure for receiving labwork from the contract agency that provided services. The DON stated the nursing supervisors received lab results and notified physicians to determine if there needed to be any change in resident orders. The DON stated if there was a change in orders those were given immediately to the nurse in charge of the individual resident. The DON noted the nursing supervisor was the only person who could access lab results. The ADON reviewed the 02/24/14 INR lab results for Resident #76. The ADON noted Nursing Supervisor #1 wrote the last order for [MEDICATION NAME] on the lab result so this could be communicated to the physician along with the INR. The last dose change was noted as 02/20/14 with 7.5 milligrams of [MEDICATION NAME] ordered daily. The ADON stated the nursing supervisor signed the labwork noting the physician was notified with a telephone order to check the INR level again on Thursday (02/27/14). The lab work was signed by the physician on 02/25/14. The ADON stated after the physician signed the labwork it was delivered to medical records and medical records placed lab results in the residents medical record. The ADON stated because of the system there was a delay in lab results being available in each residents' medical record which was most likely why the [MEDICATION NAME] had been given through 02/26/14 for Resident #76. On 05/15/14 at 2:30 PM the medical records director stated she worked Monday-Friday. The medical records director stated lab results were delivered to her after signed by the physician and she attempted to file the paperwork in each residents medical record on a daily basis. The medical records director stated she could not recall when the 02/24/14 INR lab work for Resident #76 was placed in the medical record. On 05/15/14 at 3:46 PM Nursing Supervisor #1 stated she worked second shift, Monday through Friday. Nursing Supervisor #1 stated the electronic system to obtain lab results was stored in the supervisors office which was why all lab results were received and processed by the supervisors. Nursing Supervisor #1 stated it was her practice to notify the residents physician of lab results, process any telephone orders and then place the labwork in the physician's book for their signature. Nursing Supervisor #1 stated she wrote any prior medication orders pertinent to the lab so it would be available when the physician was notified. Nursing Supervisor #1 stated it was her practice to only write the prior [MEDICATION NAME] dose on the labwork for INR results. Nursing Supervisor #1 stated the nurses could access the lab results located in the physician's book or call her for the current results if the latest results were not available in the medical record. Nursing Supervisor #1 verified she wrote the last dose of [MEDICATION NAME] (from 02/20/14) on the 02/24/14 INR labwork for Resident #76 and the telephone order for another INR level on Thursday, 02/27/14. Nursing Supervisor #1 stated after receiving the telephone order the lab results would have been placed in the doctors book (located at each nursing station) for the physician to sign. Review of labwork in the medical record of Resident #76 noted on 02/27/14 (after the [MEDICATION NAME] had been given 2/25/14 and 2/26/14) the INR was 7.8. The physician of Resident #76 was notified of the critical lab value and orders were received to hold the [MEDICATION NAME] and administer Vitamin K.

Based on record reviews and staff interviews the facility failed to provide supervision and place a sensor pad alarm in a wheelchair to alert staff of unsafe transfers for a resident who had a fall with injury in 1 of 3 residents with a history of falls. (Resident #1). The findings included: Resident #1 was admitted to facility on 12/21/12 with heart disease, osteoarthritis, osteoporosis, dementia, anxiety and Alzheimer's disease. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had no short term or long term memory problems and was cognitively intact for daily decision making. The MDS also indicated Resident #1 required limited assistance with 1 person physical assistance with transfers and had impairment in her upper extremities on 1 side. A review of a physician's orders [REDACTED]. A review of a care plan titled fall risk indicated Resident #1 had a history of [REDACTED]. The goal indicated Resident #1 would not have any falls through the next review date of 03/06/14 and the approaches indicated in part to monitor for changes in condition that may warrant increased supervision/assistance and notify the physician; keep call bell within reach and instruct to use it for assistance; keep environment well lit and clutter free; keep personal items within easy reach; monitor for unsafe acts and redirect as needed for safety; monitor for placement of bed/chair alarms. A review of nurses notes dated 01/23/14 at 1:51 PM indicated Nurse #1 was called into Resident #1's room by Nurse Aide (NA) #1 at approximately 9:00 AM and Resident #1 was observed lying face up on the floor next to wheelchair. The notes further indicated Resident #1 was alert and verbal but was complaining of pain in her right hip. The notes revealed a Physician's Assistant (PA) was in the building and assessed Resident #1 and ordered for her to be transported to the emergency room for evaluation. A review of a physician's orders [REDACTED]. A review of a facility occurrence report dated 01/23/14 indicated NA #1 called Nurse #1 into Resident #1's room at approximately 9:00 AM and the resident was noted lying on floor face up next to a wheelchair. The report indicated Resident #1 was alert and responded to touch, voice and painful stimuli and had pain that was severe in intensity in her right hip. The report also indicated Resident #1's fall was unwitnessed and she was found on the floor face up and her wheelchair was nearby. The report revealed Resident #1 had a wheelchair as an assistive device and an alarm sensor as a protective physical device. A hand written statement dated 01/23/14 by NA #2 indicated she walked into Resident #1's room on 01/23/14 and Resident #1 had got up by herself and was seated in her wheelchair at the closet getting clothes. The statement indicated she asked Resident #1 if she needed anything and she said no because she could do it on her own and the next time she walked in Resident #1's room she had slid out of the wheelchair on the floor. A hand written statement dated 01/23/14 by NA #1 indicated when breakfast was being served on 01/23/14 she was taking vital signs on a resident when she noticed the door of Resident #1's room was closed. She stated she stopped doing the vital signs and went to open Resident #1's door and when she did she saw Resident #1 lying on the floor. She stated she reported to the nurse immediately and took the Resident #1's vital signs and stayed with Resident #1 until emergency medical services arrived. A review of a hospital discharge summary dated 01/24/14 indicated Resident #1 was admitted to the hospital on [DATE] with a fracture of right hip with no plan for surgery because of advanced heart disease. A review of physician's orders [REDACTED]. During an interview on 02/17/14 at 11:55 AM Nurse #1 explained Resident #1 was very alert and independent and wanted to do everything for herself. She stated Resident #1 was at risk for falls and had a bed/chair alarm and a motion sensor at her bathroom door. She explained Resident #1 would transport herself in her wheelchair to the bathroom and the motion sensor alarm would sound to alert staff to assist her. She stated on the morning of 01/23/14 she noticed the door to Resident #1's room was closed but that was odd because the door was always left open so staff could keep a close eye on her since she was a fall risk. She further stated NA #1 went into Resident #1's room and then called her into the room. She explained when she went in the room she saw Resident #1 lying face up on the floor of her room and was complaining of pain in her right hip. She stated it looked like Resident #1 might have been trying to get something out of her dresser. Nurse #1 explained Resident #1 had a sensor pad alarm on her bed that was supposed to be placed in her wheelchair when staff got her out of bed but on 01/23/14 the sensor pad alarm was not in place in her wheelchair and there was no alarm sounding when they found Resident #1 lying in the floor. She further explained NA #2 who no longer worked at the facility had been assigned to Resident #1's care on 01/23/14 but did not usually work on that hall and did not put the alarm in Resident #1's chair when Resident #1 got up that morning. During an interview on 02/17/14 at 12:48 PM with NA #1 she stated Resident #1 was independent and wanted to do things for herself. She explained she was at the nurses station on the morning of 01/23/14 and noticed Resident #1's door was closed and thought that was strange because Resident #1 was a fall risk and staff were supposed to supervise her and her door was not supposed to be closed. She stated Resident #1 was supposed to use her call bell for assistance but she would often stand up from her wheelchair to get clothes out of her closet or try to get things out of her dresser and would not call for assistance because she wanted to do it herself. She explained she was not assigned to Resident #1 on 01/23/14 but was assigned to other residents on her hall and went to Resident #1's room because she wanted to check on her since the door was closed. She further explained when she opened the door there were no staff in the room and Resident #1 was lying on the floor. She stated she she called for Nurse #1 and she came in the room and assessed Resident #1. She explained Nurse #1 called for the PA and Resident #1 was sent to the hospital. NA #1 stated Resident #1 was supposed to have a bed/chair alarm because Resident #1 frequently tried to transfer by herself but there was no alarm sounding when she went in Resident #1's room on 01/23/14 and found her lying in the floor. She stated Nurse Aides (NAs) had assignment sheets to indicate which residents had alarms and the type of alarm and NA #2 should have placed the sensor alarm from Resident #1's bed in her wheelchair when Resident #1 got out of bed on 01/23/14. During an interview on 02/17/14 at 2:25 PM the Restorative Director indicated she was responsible for investigation of falls. She explained it was her understanding that NA #2 was assigned to care for Resident #1 on 01/23/14 but did not know Resident #1 had an alarm. She further explained the NA's have a written assignment sheet that tells them what each resident needs and any alarms they have. She stated the electronic documentation system NAs used to document care provided also had a lot of detailed information for each resident and the alarms were listed for each resident. She explained NAs were expected to check alarms when they started their shift and nurses were also supposed to check them. During an interview on 02/17/14 at 2:39 PM the Director of Nursing explained NA #1 went into Resident #1's room because she saw the door was closed and when she opened the door Resident #1 was lying on the floor. She further explained they investigated the fall and determined that NA #2 was assigned to care for Resident #1 on 01/23/14 and did not move the alarm from Resident #1's bed to her wheelchair. She stated staff was supposed to move the sensor pad alarm from Resident #1's bed to her wheelchair because Resident #1 would stand from her wheelchair to get clothes out of her closet or dresser because she wanted to do it herself. She explained it was her expectation that nursing staff was supposed to look at their assignment sheets to see what each resident required and which residents had alarms and she expected them to do walking rounds to check alarms. She stated it was also her expectation for all nursing staff to provide supervision of residents who were a fall risk and ensure safety devices such as alarms were in place and turned on.

Based on observation, staff and family interviews, and record review, the facility failed to provide a wheelchair at the proper seat height for 1 of 3 sampled residents (Resident #79). The findings are: Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #79's quarterly Minimum Data Set ((MDS) dated [DATE] revealed severely impaired cognition and required the limited assistance of one person with locomotion. Observation on 03/04/13 at 12:07 PM revealed Resident #79 seated in a wheelchair at a table and both feet did not touch the floor. There were no foot rests on the wheelchair. Observation on 03/04/13 at 2:40 PM revealed Resident #79 seated in a wheelchair at a table with both feet dangling. There were no foot rests on the wheelchair. Observation on 03/04/13 at 3:23 PM revealed Resident #79 seated in a wheelchair at a table with both feet dangling. There were no foot rests on the wheelchair. Observation on 03/05/13 at 9:41 AM revealed Resident #79 self propelled in the wheelchair using hands on both wheels and the toes of the left foot. Resident #79's right foot did not touch the floor. There were no foot rests on the wheelchair. Observation on 03/05/13 at 9:48 AM revealed Nurse Aide #2 transported Resident #79 to the activity area. Resident #79's feet did not touch the floor. There were no foot rests on the wheelchair. Observation on 03/05/13 at 3:02 PM revealed Resident #79 seated in a wheelchair in an activity area and both feet do not touch the floor. There were no footrests on the wheelchair. Observation on 03/06/13 at 8:36 AM revealed Resident #79 seated in a wheelchair at a table with the tips of both feet touching the floor. There were no foot rests on the wheelchair. Observation on 03/06/13 at 10:02 AM revealed the activity aide transported Resident #79 to a musical activity. Resident #79's feet did not touch the floor and there were no foot rests on the wheelchair. Interview with Nurse Aide (NA) #2 on 03/06/13 at 11:13 AM revealed Resident #79 always used the wheelchair and never used foot rests. NA #2 explained Resident #79 used both hands to turn the wheels of her wheelchair in order to self propel. Observation on 03/06/13 at 11:35 AM revealed Resident #79 seated in the wheelchair at the table with both feet on the table pedestal. Interview on 03/06/13 at 2:21 PM with Resident #79's family member revealed Resident #79's current wheel chair was a new one. The family member explained Resident #79's feet could reach the floor in the previous wheel chair and did not know the reason for the change. Interview with Nurse #1 on 03/06/13 at 2:25 PM revealed Resident #79 should be in a different wheelchair with a lower seat. Nurse #1 explained she did not notice the seat height and the wheelchair in use was not Resident #79's usual wheelchair. Interview with the Director of Nursing on 03/06/13 at 2:54 PM revealed nursing staff to ensure the proper wheelchair seat height for Resident #79.

Based on resident and staff interviews, and record review, the facility failed to offer a choice in the type and frequency of baths for 3 of 3 sampled residents (Residents #17, #76 and #107). The findings are: 1. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's activity interview dated 11/06/12 revealed Resident #17 indicated a choice between a tub bath, shower, bed bath or sponge bath was marked as very important to Resident #17. There was no type of bath indicated on the activity interview. Review of Resident #17's quarterly Minimum Data Set ((MDS) dated [DATE] revealed moderately impaired cognition. Resident #17 could understand and be understood by others and required the physical assistance of one person with bathing. Resident #17's care plan updated 02/11/13 directed staff assistance with showers. Review of the nurse aide assignment sheet for Resident #17 revealed twice weekly scheduled bath days on Monday and Thursday. There was no indication of the type of bath. Interview with Resident #17 on 03/05/13 at 10:01 AM revealed a preference for tub baths. Resident #17 reported staff did not give a choice between a shower and bath. Resident #17 explained a tub bath might take "too long" for the staff since assistance was required. Resident #17 explained she did not know if a tub bath was available due to her [MEDICAL CONDITION]. Interview with Nurse #1 on 03/06/13 at 2:30 PM revealed residents can receive either a tub bath or shower. Nurse #1 explained she did not know if staff offered a choice each time but residents could "speak up" and tell the staff their choice. Interview with Nurse Aide (NA) #1 on 03/06/13 at 3:27 PM revealed Resident #17 received assistance with showers on Monday and Thursday evenings. NA #1 explained Resident #17 transferred from another unit in the facility and always received showers. NA # 1 reported she did not ask Resident #17's preference of a tub or shower. Interview with the Director of Nursing on 03/06/13 at 3:45 PM revealed staff should give residents a choice between a tub bath and shower. Interview with the Administrator on 03/07/13 at 10:15 AM revealed residents were given a choice between a tub bath and shower upon admission and annually when asked importance of choice between types of bath which included tub and shower. 2. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #76's activity interview dated 09/13/12 revealed Resident #76 indicated a choice between a tub bath, shower, bed bath or sponge bath was marked as very important to Resident #76. A shower type bath was circled on the activity interview. Review of Resident #76's quarterly Minimum Data Set ((MDS) dated [DATE] revealed intact cognition with the ability to understand and be understood by others. Resident #76 required the physical assistance of one person with bathing. Resident #76's care plan directed staff to assist activities of daily living. Review of the nurse aide assignment sheet for Resident #76 revealed twice weekly scheduled bath days on Monday and Thursday. There was no indication of the type of bath. Interview with Resident #76 on 03/05/13 at 10:25 AM revealed a preference for "a good old fashioned tub bath where I could soak" Resident #76 explained she would require more assistance with a tub bath due to a fear of falling. Interview with Nurse Aide (NA) #2 on 03/05/13 at 2:50 PM revealed she assisted Resident #76 with twice weekly showers. NA #2 explained Resident #76 never requested a tub bath and did not ask Resident #76 which bath type was preferred. NA #2 explained a choice would not be routinely given and she never thought about offering a choice. Interview with Nurse #1 on 03/06/13 at 2:30 PM revealed residents can receive either a tub bath or shower. Nurse #1 explained she did not know if staff offered a choice each time but residents could "speak up" and tell the staff their choice. Interview with the Director of Nursing on 03/06/13 at 3:45 PM revealed staff should give residents a choice between a tub bath and shower. Interview with the Administrator on 03/07/13 at 10:15 AM revealed residents were given a choice between a tub bath and shower upon admission and annually when asked importance of choice between types of bath which included tub and shower. 3. Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #107's quarterly Minimum Data Set ((MDS) dated [DATE] revealed intact cognition with the ability to understand others and be understood. Resident #107 required the physical assistance of one person with bathing. Review of Resident #107's care plan dated 01/31/13 revealed direction for staff to assist with bathing. Review of the nurse aide assignment sheet for Resident #107 revealed twice weekly scheduled bath days on Monday and Friday. There was no indication of the type of bath. Interview with Resident #107 on 03/04/13 at 2:39 PM revealed a preference for daily showers. Resident #107 explained he received showers twice weekly and "would settle for three times a week." Resident #107 reported he did not receive a choice and thought he could not showers more than twice a week. Interview with Nurse Aide (NA) #2 on 03/05/13 at 2:55 PM revealed Resident #107 received twice weekly showers. NA #2 explained the nurse aide assignment sheet directed twice weekly showers on the day shift so did not ask Resident #107 if he preferred more frequent showers. NA #2 explained if Resident #107 asked for a shower on a non-shower day she would try to work him into her schedule. Interview with Nurse #1 on 03/06/13 at 2:30 PM revealed residents can receive either a tub bath or shower. Nurse #1 explained she did not know if staff offered a choice each time but residents could "speak up" and tell the staff their choice. Interview with the Director of Nursing on 03/06/13 at 3:45 PM revealed staff should give residents a choice between a tub bath and shower. Interview with the Administrator on 03/07/13 at 10:15 AM revealed residents were given a choice between a tub bath and shower upon admission and annually when asked importance of choice between types of bath which included tub and shower.

Based on observation, staff interview and facility record review, the facility failed to 1) maintain potentially hazardous hot foods (scrambled eggs, fried eggs, pureed eggs, pureed sausage) on the breakfast tray line at least 135 degrees Fahrenheit, 2) remove expired dairy products from refrigerated storage and 3) date opened refrigerated items. The findings are: 1. A facility policy "Storage of Food and Supplies", revised 1/10, recorded in part, "All opened items will be labeled to identify the product as well as the 'use by date'. During an initial facility tour, the walk-in refrigerator was observed on 1/9/12 at 9:45 AM with the following items: a. Twelve quart containers of a dairy product (half and half) were observed stored on the bottom shelf. The containers were observed with a manufacturer's expiration date stamp of 1/7/12. Each container was also observed with a bulging, inflated appearance. b. A plastic five pound container of fresh, peeled garlic was observed with one-fourth of the container remaining. There was no date of storage recorded on the opened container of peeled garlic. An interview with the assistant nutritional director at the time of the observation revealed that the usual practice for the facility was to label and date all items stored in refrigeration with the date of opening and date of storage. The refrigeration units were monitored each Wednesday for items that were out-of-date, or were not labeled with the date of storage/opening. She further stated that she expected any expired items would be discarded when identified. She stated that the expired containers of half and half were identified on the previous Wednesday, but had not been discarded yet, but should have been discarded. A follow-up interview with the assistant nutritional director on 1/12/11 at 10:30 AM revealed that the dietary staff made more foods from scratch now and the half and half was used during the holidays to make a cream soup and a dessert for the residents. 2. A follow-up observation occurred on 1/11/12 at 8:00 AM during the breakfast tray line. The steam table was observed turned on to its highest setting. All of the breakfast foods were observed uncovered on the breakfast tray line. Temperature monitoring occurred on 1/11/12 at 8:23 AM. The following foods were observed being served from the tray line at temperatures below 135 degrees Fahrenheit: ? Scrambled eggs, 120 degrees Fahrenheit ? Pureed sausage, 100 degrees Fahrenheit ? Pureed eggs, 130 degrees Fahrenheit ? Egg and cheese English muffin, 100 degrees Fahrenheit ? Fried eggs, 80 degrees Fahrenheit During an interview with dietary staff #1 (cook) on 1/11/12 at 8:26 AM he stated that eggs should be served 130 degrees Fahrenheit and meats should be served at 145 degrees Fahrenheit. He stated that the tray line started at 7:45 AM and he monitored food temperatures before the tray line started, but it was not his practice to conduct temperature monitoring during the tray line. The breakfast tray line was observed to resume at 8:29 AM. The items identified with temperatures less than 135 degrees Fahrenheit remained on the breakfast tray line and were served. The assistant nutritional director entered the kitchen at 8:30 AM and the consulting dietitian entered the kitchen at 8:45 AM; they were interviewed at 8:48 AM. The interview revealed that it was difficult to keep some breakfast items at 140 degrees Fahrenheit or above. The consulting dietitian stated that the tray line system included a hot pellet and a dome lid/bottom and would help to keep hot foods hot. She also stated that more fried eggs would be prepared to replace the ones on the tray line. She further added "There are some things we can do" to keep foods at least 140 degrees Fahrenheit, staff would place pureed foods on the tray line in smaller portions and keep the hot foods covered during the meal service. A follow-up interview with the consulting dietitian on 1/11/12 at 10:26 AM revealed that she would expect that if foods were identified during the tray line to be less than 140 degrees Fahrenheit that staff would pull those items and restock the line if the item was to be served.

Based on observations, record review and staff interviews the provider pharmacy failed to label accurately, a topical non-steroidal anti-inflammatory drug (NSAID) gel indicating the accurate dose for each application per manufacturer instructions (Voltaren Gel- Diclofenac Sodium topical Gel) for one (1) of one (1) resident observed for gel application during medication administration. (Resident #98) The findings are: A review of the manufacturer's product insert under dosage and administration, included a statement to use proper amount of 1% Volaren Gel with the help of an enclosed dosing card measuring 2 grams or 4 grams for each application to the affected part of the body. A review of the medical records revealed that Resident #98 was readmitted to the facility on [DATE] and the admitting [DIAGNOSES REDACTED]. A review of the original physician orders [REDACTED]. Resident # 98 was observed for medication administration on 1/10/12 at 4:00 PM. Licensed Nurse (LN) #1 was observed administering medications including 1% Voltaren Gel application per request of Resident #98. A review of the pharmacy dosing instruction label failed to indicate how much of 1% Volataren Gel had to be used for Resident #98 and the nurse squeezed the Gel to her gloved finger tip and applied to Resident #98's shoulder. An interview with LN#1 on 1/10/12 at 4:04 PM revealed that the Resident had been using 1% Voltaren Gel from previous admission and she was aware how much Gel to be used for each application but stated that pharmacy label did not disclose the dose. An interview with the consultant pharmacist on 1/11/12 at 9:40 AM revealed that the pharmacy label should have indicated the accurate dose of the medication. The consultant pharmacist confirmed from the pharmacy manager and the dispensing pharmacist had omitted to enter the dose while dispensing the Voltaren Gel to Resident #98

Based on observations, staff interviews and record review, the facility failed to maintain a catheter below the bladder level for one of five residents with an indwelling catheter (Resident #3). The findings are: Review of the facility's procedure for Foley catheter maintenance revealed the procedure included: "Never elevate the drainage bag to or above bladder level." The explanation listed was "to avoid back flow of urine." Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's admission Minimum (MDS) data set [DATE] assessed Resident #3 was totally dependent for transfers and non-ambulatory. The care plan dated 7/21/10 specified Resident #3 was to be transferred with 2 persons and a mechanical lift. An update of the care plan dated 9/27/10 documented catheter placement to promote healing of a pressure ulcer. There was no specific catheter care listed on the care plan. Review of Resident #3's record revealed Resident #3 was placed on [MEDICATION NAME] 250mg (an antibiotic) daily for 7 days for a Urinary Tract Infection [MEDICAL CONDITION] on 9/22/10. This was in response to a foul odor of urine. An indwelling catheter was inserted on 9/23/10 for promotion of wound healing. Further review of Resident #3's record revealed a family member's request for a repeat urinalysis with culture and sensitivity. A physician's orders [REDACTED]. There were no documented signs and symptoms of a UTI. Observation at 10:10 AM on 10/27/10 revealed Nursing Assistant (NA) #1 and NA #2 positioned a sling under Resident #3 for transfer by mechanical lift. NA #1 emptied Resident #3's catheter bag prior to the transfer. Resident #3 was lifted by mechanical lift onto a shower stretcher. The catheter bag was placed at the level of Resident #3's waist during the transfer at 10:20 AM. The catheter bag was placed approximately three inches above Resident #3's waist on the shower stretcher. Upon arrival to the shower room at 10:23 AM, the catheter bag was positioned on a lower bar of the stretcher and below bladder level during the shower. There was clear, yellow urine in the catheter tubing. Observation at 10:45AM on 10/27/10 revealed Resident #3 was transferred to the bed by mechanical lift. The catheter bag was placed below the bladder next to Resident #3's right leg. Interview at 10:50AM on 10/27/10 with NA #1 revealed she was not aware the catheter bag had been at Resident #3's waist during the transfer and above the waist on the shower stretcher. NA #1 explained she was aware the catheter bag should have been below the bladder. Interview with NA #2 at 10:55AM on 10/27/10 revealed she had received training on proper catheter bag placement and the catheter bag should be below the bladder level. NA #2 reported she had not noticed the catheter bag had been above Resident #3's waist. She explained the sling had a cloth hook for the bag. She was not able to explain why the cloth hook was not used. Observation at 3:35 PM on 10/27/10 revealed NA #3, NA #4 and NA #5 transferred Resident #3 with a mechanical lift to chair. During the transfer, NA #4 hung the catheter bag on the mechanical lift's bar. When Resident #3 was lowered into the chair, the catheter bag was above the Resident's shoulders. There was clear yellow urine in the tubing. NA #4 removed the catheter bag from the lift and placed the catheter bag on the chair below the bladder level.. Interview at 3:40 PM on 10/27/10 with NA #4 revealed he "sometimes hooks it (catheter bag) on the bar of the lift." This bar is below the Resident during the transfer from the bed but is above the Resident's when the Resident is seated. He explained he thought placement on the bar ensured the tubing would not be twisted during the transfer. NA #4 was aware the catheter bag required placement below the bladder level. Interview at 3:45 PM on 10/27/10 with NA #3 revealed she routinely placed the catheter bag on Resident #3's lap during transfers. Interview at 4:15 PM on 10/27/10 with Licensed Nurse (LN) # 1 revealed she did not monitor resident transfers. LN #1 explained she would assist in transfers if the nursing assistants requested her help. Interview at 10:30 AM on 10/28/10 with Resident #3's physician revealed Resident #3 was predisposed to UTIs. The physician reported the catheter bag should not be placed above the bladder level. Interview at 1:05 PM and 2:10 PM on 10/28/10 with the Director of Nursing (DON) revealed she expected nursing staff to keep the catheter bag below the bladder level during transfers. She reported she had not observed Resident #3's transfers and was not aware of the different placements of the catheter bag.

Based on medical record reviews and staff interviews the facility failed to follow physician orders [REDACTED]. (Resident #2) The findings are: Resident #2 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. Further review of the medical record revealed that Resident #2 was refusing medications and care. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #2 took only fourteen (14) of thirty (30) doses of [MEDICATION NAME] in the month of September 2010. A continued review revealed that a TSH ([MEDICAL CONDITION] Stimulating Hormone) and T4 (Throxine free) levels to monitor the use of [MEDICATION NAME] was ordered on [DATE] following a physician visit. Review of the laboratory data did not reveal any TSH/T4 results in the month of October 2010. Further it revealed that this physician order [REDACTED]. An interview with the nursing supervisor #1 on 10/26/10 at 5:31 PM revealed that there were no pending lab results for Resident #2 and the lab order for Resident #2 was not transcribed to the calendar and the testing was missed. A continued interview with the nursing supervisor #1 on 10/27/10 at 10:05 AM confirmed that it was the responsibility of the nurse who received the order to transcribe to the lab calendar to complete the paper work to draw the sample of blood the following lab day. An interview with Licensed Nurse #3 (LN #3) on 10/27/10 at 9:29 AM confirmed that all lab orders had to be transcribed to the laboratory calendar and the third shift supervisor who reviewed all the new orders completed the paper work for laboratory staff to draw the blood next day. LN#3 confirmed that the second shift nurse who received the order for Resident #2 failed to transcribe it accurately. An interview with the Director of Nursing (DON) on 10/27/10 at 12:50 PM confirmed that for Resident #2 the order was missed due to incomplete paper work and the nurse failed to transcribe the order.