Every finding on record at Wilson Healthcare and Rehabilitation Center

Based on observations, staff interviews, and record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 2 of 4 residents (Resident #86 and Resident #13) reviewed with urinary catheters. The findings included: 1. Resident #86 was admitted to the facility on [DATE] with diagnoses that included retention of urine, benign prostatic hyperplasia (a non-cancerous condition that causes the prostate gland to enlarge), and obstructive and reflux uropathy (urinary tract conditions that occur when urine can't flow normally). An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was moderately cognitively impaired. The assessment indicated Resident #86 was dependent upon staff for all his activities of daily living (ADL). Resident #86 was coded for an indwelling catheter. Resident #86's care plan dated 11/2/24 revealed focus areas for catheter care and at risk for infection. An initial observation was conducted on 1/6/25 at 10:40 AM of Resident #86. He was observed lying in his bed. His urinary catheter bag was inside a blue privacy bag and was hanging off the bed frame on the resident's left side of the bed resting on the floor. Additional observations of Resident #86 were conducted on 1/6/25 at 11:27 AM and 2:33 PM. Resident #86's urinary catheter bag remained inside a blue privacy bag and was hanging off the bed frame on the resident's left side of the bed resting on the floor. An interview was conducted on 1/6/25 at 2:37 PM with Nurse #1. She stated the urinary catheter bag was in the privacy bag. An interview was conducted with the Director of Nursing (DON) on 1/8/25 at 1:59 PM. She stated her expectation was that urinary catheter bags were kept off the floor to prevent infection. An interview was conducted with the Infection Preventionist (IP) on 1/9/25 at 10:22 AM. She stated the blue privacy bag was on the urine bag itself and served as a layer of protection between the urine collection bag and the floor to prevent infection. An interview was conducted on 1/9/25 at 11:01 AM with the Administrator. He stated the urinary catheter bag should not touch the ground and if it did, it was changed out immediately to prevent infection. On 1/10/25 at 12:04 PM, the Administrator provided documentation from the manufacturer of the urinary catheter bag utilized for Resident #86 that indicated the catheter bag had an anti-reflux chamber that prevents urine from flowing back into the bladder, which can reduce the risk of infection. 49502 2.Resident #13 was readmitted to the facility on [DATE] with diagnoses which included congestive heart failure, recurrent urinary tract infections (UTI), and neuromuscular dysfunction of the bladder. A quarterly Minimum Data set (MDS) dated [DATE] revealed Resident #13 was cognitively intact. She was dependent upon staff for toileting hygiene and was incontinent of urine. Resident #13's care plan dated 11/15/24 revealed a focus for bladder incontinence with a history of urinary tract infections (UTIs). Physician orders revealed Resident #13 had an order to insert an indwelling urinary catheter on 1/3/25 for urinary retention. An additional review of physician orders revealed the indwelling urinary catheter was discontinued on 1/6/25. An initial observation was conducted on 1/6/25 at 11:40 am of Resident #13 as she was lying in her bed. A urinary catheter bag inside a privacy bag was observed to be hanging off the bed frame on the resident's right side of the bed. The entire bottom of the privacy bag was resting on the floor. An additional observation was conducted on 1/6/25 at 12:25 pm, Resident #13's urinary catheter bag was inside a privacy bag and was observed to be hanging off the bedframe on the resident's right side of the bed. The entire bottom of the privacy bag was resting on the floor. In an interview with Nurse #3 on 1/7/25 at 9:15 am, she stated she was the hall nurse assigned to care for Resident #13. Nurse #3 was asked what her thoughts were about the position of the resident's urinary catheter bag. She replied, It shouldn't touch the floor to prevent infection. During an interview with Nurse Aide (NA) #2 on 1/8/25 at 8:47 am, she stated the catheter bag and tubing should not be on the floor to reduce the risk of infection. An interview was conducted with the Director of Nursing (DON) on 1/8/25 at 1:59 PM. She stated her expectation was that urinary catheter bags were kept off the floor to prevent infection. An interview was conducted with the Infection Preventionist (IP) on 1/9/25 at 10:22 AM. She stated the blue privacy bag was on the urine bag itself and served as a layer of protection between the urine collection bag and the floor to prevent infection. An interview was conducted on 1/9/25 at 11:01 AM with the Administrator. He stated the urinary catheter bag should not touch the ground and if it did, it was changed out immediately to prevent infection.

Based on observation and staff interviews the facility failed to a) ensure that prepared foods were labeled and dated when stored in the walk-in refrigerator and, b) failed to date leftover foods stored for use. These practices had the potential to affect food served to residents in the facility. Findings included: During the initial tour of the kitchen on 09/17/23 at 12:30 PM the following was observed in the presence of the Kitchen Manager: a. The walk-in refrigerator was observed with the following: a 4-quart plastic container of macaroni salad covered with clear plastic wrap with no date, a metal container covered with clear plastic wrap labeled Pureed Pork for Dinner with no date, and a metal container covered with clear plastic wrap and labeled Pureed Food for Dinner with no date or food specification. b. The reach-in refrigerator was observed with the following: a partially used thickened lemon-flavored water with no open date, a container of apple sauce partially used with no open date, a container of vanilla yogurt partially used with no open dated, and 3 small Styrofoam bowls filled with a cream-colored food and covered with clear plastic wrap with no open date or food specification. In an interview with the Dietary Manager-in-Training (MIT) on 09/17/23 at 12:30 PM during the inspection of the food storage, he stated he had made rounds that morning and checked foods for dates. He explained that he thought the food in the reach in fridge that had been opened did not need to be labeled with a date. He noted it was his second day of employment at the facility. In an interview with the Kitchen Manager on 09/17/23 at 12:30 PM she stated all the kitchen staff had been educated and knew that any food in storage that had been opened or prepared had to be identified, labeled, and dated. In an interview with the Administrator on 09/20/23 at 12:15 PM he stated the Dietary MIT told him he had not had a chance to check food storage for labeling on the morning of 9/17/23 and he felt that was the reason open food items in the refrigerators were not dated.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) Assessments for 4 of 30 residents reviewed in the areas of dialysis, wandering, weight, and discharge (Resident #145, Resident #91, Resident #33, and Resident #94). Findings included: 1. Resident #145 was admitted to the facility on [DATE]. Diagnoses included, in part, end stage renal disease (ESRD) with hemodialysis. Review of a physician order dated 09/07/23 revealed an order for dialysis treatments on Tuesday, Thursday, and Saturday for Resident #145. A nursing progress note written on 09/09/23 at 7:38 AM revealed Resident left the facility via wheelchair to go to dialysis. Resident was alert and verbal and vital signs were stable. The MDS 5-day admission assessment dated [DATE] revealed Resident #145 was moderately cognitively impaired and was not coded as receiving dialysis. Review of Resident #145's care plan dated 09/13/23 revealed a plan of care for hemodialysis related to ESRD. Interventions included after returning from dialysis check for thrill and bruit 2 times per shift on dialysis days Tuesday/Thursday and Saturday and daily. An interview was conducted with the MDS Nurse #1 on 09/20/23 at 12:30 PM. MDS Nurse #1 revealed when she completed the MDS assessments she reviewed the electronic medical record (EMR) to include the discharge summary, the nursing progress notes and physician orders to determine how to accurately code for dialysis residents. She stated she should have coded Resident #145 for receiving dialysis services and added, there was an error in coding and she missed it. An interview was conducted with the Administrator on 09/20/23 at 2:00 PM. The Administrator stated the MDS should have been coded accurately to reflect the resident's care. The Administrator further added he felt that the mistake was human error and not a breakdown in MDS. 2. Resident #91 was admitted to the facility on [DATE]. Diagnoses included, in part, dementia with agitation, restlessness and agitation, and altered mental status. A nursing progress note written on 09/02/2023 by Nurse #1 revealed Resident #91 was having increased agitation, wandering into rooms, attempting to stand/walk, and unable to redirect. The physician was notified, and an order was obtained for 0.25 milligrams of alprazolam (an antianxiety medication) as needed every 12 hours for one week. The MDS 5-day admission assessment dated [DATE] revealed Resident #91 was severely cognitively impaired. The MDS was not coded to reflect Resident #91 had any wandering behaviors. A review of Resident #91's care plan dated 09/06/23 revealed the resident was an elopement risk due to impaired cognitive status secondary to dementia as evidenced by wandering aimlessly and potential for attempt to leave facility. Interventions included, in part, initiating safety checks as indicated, observe for exit seeking behaviors and provide diversion activities. An interview with Nurse #1 on 09/19/23 at 11:35 AM revealed when Resident #91 was first admitted he was very confused and had exit seeking behaviors and required a wander guard (a wearable bracelet which alerts staff if the resident wanders close to a monitored door) which was placed on him on 09/08/23. An interview with MDS Nurse #1 on 09/20/23 at 12:30 PM revealed when she completed the MDS assessments she reviewed the electronic medical record (EMR) to include the nursing progress notes, and physician orders, to determine how to accurately code behaviors. She stated she should have coded Resident #91 for wandering based on the nursing note written by Nurse #1. She stated she just missed it and it was an error. An interview was conducted with the Administrator on 09/20/23 at 2:00 PM. The Administrator stated the MDS should have been coded accurately to reflect the resident's care. The Administrator further added he felt that the mistake was human error and not a breakdown in MDS. 44890 3. Resident #33 was admitted to the facility 08/01/2023 with a diagnosis of cerebral infarction (stroke). Resident #33's electronic medical record (EMR) revealed he weighed 192.0 pounds on 08/01/2023. The admission Minimum Data Set (MDS) assessment dated [DATE] listed Resident #33's weight as 058 pounds. An interview was completed with MDS Nurse #1 on 09/20/2023 at 10:42 AM. MDS #1 stated that 058 pounds was not an accurate weight for Resident #33. She further stated that the Dietary Manager was responsible for filling in the weight on the MDS assessment. MDS #1 indicated that she was responsible for making sure the MDS assessment was coded accurately. An interview was conducted with the Administrator on 09/20/2023 at 2:00 PM. The Administrator stated that Resident #33's weight of 058 pounds was just a human error. He further stated he didn't think there was a breakdown in the MDS process, just a human mistake. 45044 4. Resident #94 was admitted to the facility on [DATE]. A progress note dated 08/16/23 stated Resident #94 was scheduled to discharge home on 08/17/23. A progress note dated 08/17/23 stated the Resident discharged from the facility at 12:30 PM. The note indicated discharge papers were signed by the Resident and no problems or concerns were voiced by the Resident. A Discharge Return Not Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and was coded as being discharged to an acute hospital. An interview was completed on 09/20/23 at 11:42 AM with MDS Nurse #2. The Nurse reviewed Resident #94's Discharge MDS and confirmed the discharge status was coded incorrectly and should have been coded as a discharge to the community. An interview was completed on 09/20/23 at 12:25 PM with the Administrator. He indicated the MDS assessment should accurately reflect the discharge status of a resident. The Administrator stated the incorrect documentation was due to human error and not a breakdown in the MDS process.

Based on record review and staff interview the facility failed to report a staff to resident abuse allegation to the state agency, Adult Protective Services, and law enforcement as required for 1 of 1 resident (Resident #1) reviewed for abuse. Findings included: Resident #1 was admitted to the facility on [DATE]. During an interview with Nurse #1 on 8/9/23 at 10:05 AM who stated she was working on 7/23/23 and observed Nurse Aide #1 (NA #1) hit Resident #1. She stated she ensured the resident was safe and NA #1 was off the hall and was not working with any residents. Nurse #1 stated she contacted the Staff Development Nurse at approximately 7:30 PM who stated she would contact the Administrator. Nurse #1 stated she told the Administrator she had witnessed NA #1 strike Resident #1. An interview was conducted with the Administrator on 8/9/23 at 11:30 AM. He reported he was contacted by the Staff Development Nurse on 7/23/23 at 7:50 PM about potential abuse and immediately began an investigation. He reported he interviewed Nurse #1, NA #1, other staff on duty and residents. The Administrator indicated after he conducted the investigation, he determined the abuse was unsubstantiated. He finished his investigation on 7/23/23 at 9:15 PM. He reported he did not report the abuse allegation to the State because he determined no abuse had occurred. The Administrator stated Nurse #1 and NA #1 had a dispute over patient assignments the night before and he felt it was retaliation. He stated he consulted with the facility Nurse Consultant on 7/23/23 at approximately 9:30 PM, and they determined a report to the state agency, Adult Protective Services, and law enforcement was not necessary. During an interview with the facility Nurse Consultant on 8/9/23 at 2:49 PM she stated she spoke with the Administrator and the [NAME] President of Operations on 7/23/23 at 9:30 PM, and they concluded reporting to the state agency, Adult Protective Services and law enforcement was not necessary because the Administrator completed the investigation within two hours and did not substantiate the allegations.

Based on observations, record review, and staff interviews the facility failed to date insulin pens when opened and failed to dispose of expired insulin pens in 1 of 4 medication carts inspected (300 hall back cart). Findings included: On [DATE] at 2:00 PM the 300 hall back medication cart was inspected with the Unit Coordinator. One Novalog [MEDICATION(S)] (a diabetic medication) was observed opened with no open date documented. One Insulin [MEDICATION(S)] [MEDICATION(S)] (a diabetic medication) was observed with an expiration date of [DATE]. The Unit Coordinator stated the insulin pens should not be in the medication cart. A review of the manufacturer's recommendations for the use of Novalog [MEDICATION(S)] and Insulin [MEDICATION(S)] [MEDICATION(S)] revealed they can be used up to 28 days after the initial opening. The Unit Coordinator was interviewed on [DATE] at 2:40 PM and stated it was the morning nurse's responsibility to discard the expired insulin. She stated the morning nurses should have filled out the Insulin Cart Audit Tool which included writing down the insulins in the cart with open and expiration dates and the expired insulin should have been thrown out. On [DATE] at 2:50 PM an interview was conducted with Medication Aid #1 who was working with the 300 hall back cart and stated she was responsible for filling out the Insulin Cart Audit Tool. She stated she had forgotten to do it this morning.

Based on observations, record review and staff interviews, the facility failed to ensure a bottle of tube feeding formula was discarded within twenty-four hours when opened for use. The facility also failed to label the storage package for tube feeding syringe when opened for use and failed to label the water bag for flushes with a date when opened for use for 1 of 1 resident reviewed for tube feedings (Resident #40). This practice had the potential for causing contamination. Findings included: Manufacturer guidelines for the tube feeding formula stated tube feeding formula containers must be discarded at twenty-four hours after opening. Resident #40 was admitted to the facility 4/3/2020. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40's initial care plan dated 4/3/2020 revealed he required a tube feeding due to dysphagia. Interventions included checking for tube placement and gastric contents and checking physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #40 was severely cognitively impaired and required total assistance with eating by receiving tube feedings and fluids through a gastrostomy tube (GT). Resident #40's tube feeding formula was observed on 4/25/2022 at 10:39 a.m. infusing at 40 milliliters per hour via pump, and the tube feeding formula bottle was labeled 4/23/2022 with a black sharpie. The opened tube feeding syringe storage packet and a thousand milliliter bag of water connected to infuse flushes every four hours were observed hanging beside the tube feeding formula with no date or label indicating when they were opened for use. The unit coordinator stated on 4/25/2022 at 10:45 a.m. in an interview, 4/23/2022 labeled on the tube feeding formula bottle indicated when the tube feeding formula was started. She stated tube feeding formula was changed every twenty-four hours on the night shift and should had been changed by the assigned night shift nurse and dated 4/25/2022. On 4/26/2022 at 8:30 a.m. in an interview with the unit coordinator, she stated the bag for water flushes and the tube feeding syringe were to be changed and dated also daily on the night shift. On 4/27/2022 at 4:57 p.m. in an interview with Nurse #1, she stated she worked night shift the weekend of 4/23/2022 and 4/24/2022 and was assigned Resident #40. She stated the tube feeding formula bottle, administration tubing, and water bag was changed nightly every twenty-four hours and it was scheduled on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the daily staffing assignment sheets revealed Nurse #1 worked a twelve-hour night shift both 4/23/2022 and 4/24/2022. Review of the March 2022 and April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of changing the tube feeding formula bottle every night shift. The Director of Nursing (DON) stated in an interview on 4/28/2022 at 4:15 p.m. tube feeding formulas were changed out every twenty-four hours, and nursing staff were to write date and time when formula was started on the bottle. She stated tube feeding syringe and bag of water was also changed every twenty-four hours and was to be dated or labeled with date when started. She stated a set of tube feeding orders populated in the computer, and nurses were to check tube feeding orders based on needs of the resident. She stated she thought the nurse placed the wrong date on the tube feeding formula because the formula would have run out if started on 4/23/2022 as the formula bottle was marked.

Based on staff interviews and record review, the facility failed to address a weight loss issue for one of three residents (Resident #46). Findings included: A review of the medical record indicated Resident #46 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] noted Resident #46 was moderately impaired for cognition and needed extensive assistance for all daily care with the help of one person. The MDS noted Resident #46 could feed himself. The section of the MDS about weight loss indicated no or unknown weight loss. There was no care plan for Resident #46 for nutrition. A review of weights in the resident record revealed a weight of 154 lbs. on 10/6/21 with a gradual loss each month until 4/8/22 when the weight was listed as 136 lbs. This was a loss of 11.4 % in six months. There was no recorded weight for the month of March. In an interview on 4/27/22 at 7:46 AM, the Dietary Manager (DM) stated monthly weights are done by the first Wednesday of every month. The DM noted she meets with the RD when the RD comes to the facility. The DM noted the person who records the weights for the Director of Nursing gives them to her (the DM), and the DM makes a list or texts the RD and lets the RD know which residents need to be seen by the RD. The DM also said the Director of Nursing may let her know a resident that the RD needs to see. The DM stated she puts the weights into a program called Mealtracker when she gets them. A dietary note written on 3/25/22 included information from the Dietary Manager on Resident #46 and his weight loss and that Resident #46 would be referred to the Registered Dietician (RD). On 4/26/22 at 4:00 PM, an interview was conducted with the RD who stated she comes to the facility weekly. The RD stated she did not know why there was no weight for Resident #46 for March, she did not do weights, the nurses did weights. In a telephone interview of 4/27/22 at 11:11 AM, the RD stated she usually runs a report on Tuesdays. The RD stated she did not know why she did not see that Resident #46 had been indicated for weight loss after the DM wrote the note on 3/25/22. The RD stated she did not see it until Friday April 22, called and talked to the nurses on Monday April 25, and was told he was eating, the RD wrote a note and ordered fortified foods. I guess I just didn ' t see it the RD stated about the weight loss.

Based on observations, record review and staff interviews, the facility failed to post complete and accurate nurse staffing data summaries for 11 of 118 days reviewed for nurse staffing data. (1/3/2022, 2/12/2022, 2/18/2022, 2/20/2022, 2/25/2022, 3/19/2022, 3/20/2022, 4/2/2022, 4/25/2022. 4/26/2022, and 4/27/2022) Findings included: On 4/25/2022 at 9:30 a.m., a nurse staffing data summary for 4/25/2022 was observed in a clear plastic folder hanging on the bulletin board at the beginning of the 300-hall behind the nursing station. Nurse staffing data summaries dated 4/25/2022 to 4/29/2022 were observed located in the plastic folder, and each one was dated printed on 3/25/2022. Nurse staffing data summary dated 4/25/2022 revealed 1-certified medication aide (CMA), 5- nurse aides (NA), 3- licensed practical nurse (LPN), 1- restorative aide, 1- unit coordinator and 1-wound nurse for the 7a.m. to 3p.m. shift. The 3p.m. to 11p.m. shift indicated 1-CMA, 2- NA and 2-LPN, and the 11p.m. to 7a.m. shift indicated 5-NA and 1-LPN. There was no registered nurse (RN) coverage indicated on the nurse staffing data summary dated 4/25/2022. The daily nursing assignment sheet dated 4/25/2022 revealed the following were scheduled: 7a.m. to 3p.m. shift indicated 2-CMA, 7-NA, 2-LPN, 1-restorative aide, 1- unit coordinator and 2- treatment nurses (LPN); 3p.m. to 11p.m. shift indicated 1-CMA, 6-NA and 3-LPN; 11p.m. to 7a.m. shift indicated 5-NA and 1-LPN and 2-RN. Based on the daily nursing assignment sheet, the posted staffing data summary dated 4/25/2022 did not include one CMA, two nurse aides for the 7a.m. to 3p.m. shift, did not included four nurse aides and one LPN for the 3p.m. to 11p.m. shift and did not include two registered nurses (RN) for the 11p.m. to 7a.m. shift. On 4/26/2022 at 8:30 a.m., nursing staffing data summary dated 4/26/2022 was observed posted. Census was listed as 76, and the 7a.m. to 3p.m. shift included 1-CMA, 4-NA, 4-LPN, 1- restorative aide and 1-unit coordinator. The 3p.m. to 11p.m. shift indicated 1-CMA, 3-NA and 2-LPN, and the 11p.m. to 7a.m. shift indicated 5-NA and 1-LPN. There was no RN coverage noted on the posted nurse staffing summary dated 4/26/2022. The daily nursing assignment sheet dated 4/26/2022 revealed the following were scheduled: 7a.m. to 3p.m. shift indicated 1-CMA, 8-NA, 3- LPN, 1- restorative aide, 1-unit coordinator, 1-treatment nurse (LPN) and 1-Assistant Director of Nursing (House-RN); 3p.m. to 11p.m. indicated 1-CMA, 7-NA and 3-LPN; 11p.m.to 7a.m. shift indicated 5-NA, 1-LPN and 2-RN. Based on the daily nursing assignment sheet, the posted staffing data summary dated 4/26/2022 did not include four nurse aides and one RN for the 7a.m. to 3p.m. shift, did not include four nurse aides and one LPN for the 3p.m. to 11p.m. shift and did not included two RNs for the 11p.m. to 7a.m. shift. On 4/27/2022 at 9:00 a.m. nursing staffing data summary dated 4/27/2022 was observed posted. Census was recorded as 76, and the 7a.m. to 3p.m. shift included 1-CMA, 4-NA, 4-LPN, 1-restorative aide and 1 unit coordinator. The 3p.m. to 11p.m. shift indicated 1-CMA, 1-NA and 2-LPN, and the 11p.m to 7a.m. shift indicated 5-NA and 1-LPN. There was no RN coverage recorded on the nursing staffing data summary dated 4/27/2022. The daily nursing assignment sheet dated 7/27/2022 revealed the following were scheduled: 7a.m. to 3p.m. shift indicated 1-CMA, 7-NA, 2-LPN, 1-restorative aide, 1 unit coordinator, 1 treatment nurse(LPN) and 1-staff development coordinator (House-RN); 3p.m. to 11p.m. shift indicated 1-CMA, 8-NA and 3-LPN; 11p.m. to 7a.m. shift indicated 4-NA, 1-LPN and 2-RN. Based on the daily nursing assignment sheet, the posted staffing data summary dated 4/27/2022 did not include three nurse aides and one RN and listed an additional LPN for the 7a.m. to 3p.m. shift, did not include seven nurse aides and one LPN for the 3p.m. to 11p.m. shift and did not included two RNs and listed an additional nurse aide for the 11p.m. to 7a.m. shift. On 4/27/2022, a review of posted nurse staffing data summaries and daily nursing assignment sheets dated January 2022 to April 24, 2022 revealed inaccurate completion of the posted nurse staffing data summaries for RN coverage for the following dates: 1/3/2022, 2/12/2022, 2/18/2022, 2/20/2022, 2/25/2022, 3/19/2022, 3/20/2022, 4/2/2022. On 4/27/2022 at 9:04 am updated posted nurse staffing data summary dated 4/25/2022 and 4/26/2022 revealed hand-written corrections with a black ink pen. Corrections included circling the number printed, marking through the number printed and writing a different number and circling, and writing RN as a category and marking the hours the RN worked. On 4/27/2022 at 9:04 a.m. in an interview with the Director of Nursing (DON), she stated she printed posted nurse staffing data summaries two to three weeks in advance, and the scheduler printed daily nursing assignment sheets on the evening prior to the next day and recorded the census. She stated nursing schedules changed daily and posted nurse staffing data summaries dated 4/25/2022, 4/26/2022 and 4/27/2022 did not reflect accurate nurse staffing data because the posted nurse staffing data summary was not updated to reflect changes in the daily nursing assignments sheets until the day after posted. She stated posted nurse staffing data summaries dated 1/3/2022, 2/12/2022, 2/18/2022, 2/20/2022, 2/25/2022, 3/19/2022, 3/20/2022, 4/2/2022 were inaccurate because a computerized scheduling program did not recognize and list office personnel staffing as registered nurses on the daily nursing assignment sheets. On 4/28/2022 at 8:53 a.m. during an interview with the scheduler, she stated she or the DON posted the nurse staffing data summaries ahead of time. She stated she printed the posted nurse staffing data summaries about one week before and placed in the designated area. She stated she printed the daily staff assignment sheets at five o ' clock daily and left at the nurse's station for the next day, and the census was completed every twenty-four hours at midnight. She stated when MDS nurses (both RN) and ADON worked as a staff nurse, the computerized scheduling program did not generate a posted nurse staffing data summary that reflected RN coverage. She stated posted nurse staffing data summaries were updated by the DON. On 4/28/2022 at 4:24 p.m. during an interview with the Administrator, she stated posted nurse staffing data summary was to be complete and accurate when posted.

Based on observations, staff interviews, and review of the facility's policy and procedures and in-servicing records, 2 of 2 staff (Physical Therapy Assistant #1 and Resident Care Specialist #1) who worked on the facility's quarantine unit failed to implement the facility's infection control policies and procedures. Physical Therapy Assistant #1 failed to doff personal protective equipment (PPE) and perform hand hygiene when she exited the room of a resident who was on enhanced contact droplet precautions and resided on the facility's quarantine unit. Resident Care Specialist #1 failed to disinfect shared resident equipment between use on residents (Resident #7 and Resident #3) who were on enhanced contact droplet precautions and resided on the quarantine unit. This failure occurred during the COVID-19 pandemic. Findings included: 1. The facility's Hand Hygiene policy revised February 2018 revealed that Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. The facility's in-servicing record dated 09/08/20 included a hand out titled How to Safely Remove Personal Protective Equipment (PPE) Example 1. The hand out read, Remove all PPE before exiting the patient room except a respirator, if worn. There were 5 steps and step number 5 read (in all capital letters): WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE. Physical Therapy Assistant (PTA) #1 signed the in-service form indicating that she had read the information provided. In an observation of the quarantine unit (400 hall) on 11/18/20 at 11:59 AM PTA #1 was observed coming out of room [ROOM NUMBER] wearing an isolation gown, goggles, and a mask. Enhanced droplet contact precaution signage was posted outside room [ROOM NUMBER]. PTA #1 removed the isolation gown in the hallway and disposed of it in the resident's room. She did not wash her hands or use alcohol-based hand rub (abhr) after doing so. PTA #1 pushed an overbed table that had a laptop computer on it, down the quarantine hallway still without performing hand hygiene. In an interview on 11/18/20 at 12:01 PM PTA #1 stated that she always removed her isolation gown in the hallway and not in resident's rooms. She confirmed that she had not washed her hands or used abhr and that she became nervous when she realized she was being observed and forgot to wash her hands. In an interview on 11/18/20 at 12:11 PM the Administrator stated that isolation gowns should be removed while staff were in the resident's room, they should then wash their hands, and then leave the room. In an interview on 11/18/20 at 12:20 PM the Infection Control (IC) Nurse/Assistant Director of Nursing (ADON) stated that in-servicing had been done with the therapy department on PPE and handwashing. She indicated that they had been instructed to dispose of contaminated isolation equipment in the bins in the resident's room and then to wash their hands or use abhr prior to leaving the room. The IC Nurse/ADON indicated it was important for staff to wash their hands so that other items were not contaminated. In an interview on 11/18/20 at 12:39 PM Nurse #1, who worked on the quarantine unit at the time of the incident, stated that PTA #1 may have been in a hurry because Resident #1 was going out for an appointment. She indicated that all staff had been in-serviced on hand washing and the correct procedures for putting on and taking off PPE. In a telephone interview on 11/19/20 at 1:19 PM the Director of Nursing (DON) stated that the purpose of the quarantine unit was to separate new hospital admissions from the general population to monitor them for 14 days for COVID-19 symptoms. The DON confirmed that the resident in room [ROOM NUMBER] was a new admission and that the resident was on enhanced droplet contact precautions. She stated that staff were required to follow the facility policy for handwashing and to follow the instructions on all transmission-based precaution signs to help prevent the spread of diseases like COVID-19. She indicated that not following the facility policies could put residents and staff at risk for contracting the disease. 2. The Lippincott Procedures revised 11/15/19 titled: Disinfection, noncritical patient care equipment and presented as facility policy read, If dedicated disposable items aren't available for a patient who requires contact precautions, disinfect reusable noncritical patient care equipment after using it on the patient before using it for another patient. The in-service titled: Cleaning All Equipment B/T (between) Patient Use read: *All equipment must be cleaned between each resident use. Lifts, scales, vital sign equipment etc . The Attendance Form was dated 06/05/20 and was signed by Resident Care Specialist (RCS) #1. An observation of the facility's quarantine unit (400 hall) on 11/18/20 at 5:01 PM revealed RCS #1 opened the door of room [ROOM NUMBER] and pushed the vital sign equipment that was on a wheeled stand out of the room. RCS #1 wheeled the cart to the door of room [ROOM NUMBER] and put on PPE. She then knocked on the door, opened it, and started to enter the room. RCS #1 was stopped before the equipment entered the room. There was enhanced droplet contact precaution signage posted outside room [ROOM NUMBER] and room [ROOM NUMBER]. In an interview on 11/18/20 at 5:06 PM RCS #1 confirmed that she was going into room [ROOM NUMBER] to take the resident's vital signs. When asked, she stated that she had not disinfected the vital sign equipment after using it to obtain the residents vital signs in room [ROOM NUMBER] but that she should have. She indicated that disinfecting wipes were not kept with the equipment or in resident rooms and that she had forgotten to disinfect the equipment after exiting room [ROOM NUMBER] and before being stopped from entering room [ROOM NUMBER] with the vital sign equipment. In an interview on 11/18/20 at 5:13 PM the Infection Control (IC) Nurse/Assistant Director of Nursing (DON) stated the equipment disinfecting wipes were kept on the covered cart on the hallway and was located next to room [ROOM NUMBER] and across from room [ROOM NUMBER]. She indicated that staff were required to disinfect shared equipment prior to using on another resident. The IC Nurse/ADON stated that RCS #1 had been in-serviced on disinfecting equipment between being used on residents and that she did not understand why RCS #1 did not disinfect it as required because both residents were on enhanced contact droplet precautions. In a telephone interview on 11/19/20 at 1:19 PM the Director of Nursing (DON) stated that shared equipment should be sanitized and disinfected prior to and after use on residents. She stated that staff were required to follow the facility policy for disinfecting equipment between residents. She indicated that not following the policies could put residents and staff at risk of contracting a disease. The DON stated that she did not know why RCS #1 did not disinfect the vital sign equipment, but it was her expectation that all shared equipment be disinfected between resident uses especially when the residents were on enhanced contact droplet precautions.

Based on observation, record review, and staff interviews, the facility failed to follow infection control procedures when a staff member entered the room of a resident who was on contact precautions for [MEDICAL CONDITIONS] without wearing Personal Protective Equipment (PPE) and failed to wash their hands prior to entering and exiting the resident ' s room after contact with the resident ' s television remote control for 1 of 2 residents. This failure occurred during a COVID-19 pandemic. Resident #1 The findings Included: An unannounced onsite COVID-19 focused Infection Prevention survey was conducted on May 19, 2020. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Date Set ((MDS) dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance with personal hygiene, toilet use, dressing and bed mobility. Resident #1 also required set-up only for eating and needed limited assistance with transfer. A record review revealed Resident #1 was ordered oral antibiotics on 5/14/2020, [MEDICATION NAME] 125mg every 6 hours for 10 days, for positive [MEDICAL CONDITION] and ordered to be placed on contact precautions. A review of the facility ' s policy entitled Infection Prevention & Control Policies & Procedures, last revised on 02/2018, revealed Contact Precautions: It is the intent of this facility to use contact precautions in addition to standard precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident ' s environment. Facility policy also indicated for [MEDICAL CONDITION] infection, hands were to be washed with warm soap and water due to alcohol-based rubs were ineffective for [MEDICAL CONDITION] infection. A review of Resident #1 ' s care plan dated 4/16/2020 revealed Resident #1 was at risk for complications of current [MEDICAL CONDITION] infection and would be minimized with interventions. Interventions included staff would wear appropriate PPE for Resident #1 ' s contact precautions. Appropriate PPE per policy for contact precautions were defined as a mask, gown and gloves. Facility policy also indicated for [MEDICAL CONDITION] infection, hands were to be washed with warm soap and water due to alcohol-based rubs were ineffective for [MEDICAL CONDITION] infection. An observation was made at 9:22 AM on 5/19/2020 of maintenance worker #1 (MW #1) entering the resident hall from an outside entrance leading into the hallway. He then entered Resident #1 ' s room without sanitizing or washing his hands, did not don PPE, and did not put on gloves. The resident ' s door was marked with a contact isolation sign and PPE was hanging on the outside of the door. MW#1 began using the resident ' s television remote control to program the television and handed it to the resident when he was finished. There was no observation of the television remote being sanitized after MW#1 ' s handling of it. He exited the room without washing his hands and did not use any type of hand sanitizer upon exiting into the hallway. An interview with MW#1 at 10:05 AM on 5/19/2020 revealed he stated he did not see the contact isolation sign on the outside of Resident #1 ' s door. When asked why he entered the resident ' s room, he stated he needed to program the television remote control for Resident #1. He also stated when he finished programming it, he handed it back to the resident. He continued to say if he had noticed the contact isolation sign on the outside of Resident #1 ' s door, he would have put on PPE before entering. When asked why he didn ' t sanitize or wash his hands prior to entering or exiting the resident ' s room, he stated he just didn ' t do it. An interview with the Infection Prevention Nurse at 9:50 AM on 5/19/2020 revealed education was provided to all staff regarding infection control practices, policies and procedures including contact isolation requirements. She also stated for contact isolation for [MEDICAL CONDITION] infections, staff are required to don the proper PPE prior to entering and wash hands with warm soap and water before exiting all [MEDICAL CONDITION] contact isolation rooms. An interview with the Director of Nursing (DON) at 10:35 AM on 5/19/2020 revealed staff are required to don the proper PPE when entering a contact isolation room to provide direct patient care or handle a resident ' s personal items. An interview with the Administrator at 9:40 AM on 5/19/2020 revealed all staff are required to sanitize hands, and don PPE prior to entering a contact isolation room and must remove PPE and wash hands prior to exiting the room. She also added if the contact isolation room is for [MEDICAL CONDITION] infection, staff must wash hands with warm soap and water prior to exiting the room.

Based on observation, staff interview and record review, the facility failed to dispose of expired medications in one of two medication storage rooms (room [ROOM NUMBER]). Findings included: On 10/25/2018 at 4:35 PM, the second medication storage room was checked for expired medications. There was one bottle of 100 tablets of Aspirin 325mg, with an expiration date of 7/2018. There was one container of 25 tablets of acid controller 20mg, lot 7BE1247 with an expiration date of 9/2018. There were 10 bottles of anti-diarrheal oral suspension four ounces each, lot 6GK0696 with an expiration date of 6/2018. On 10/25/2018 at 455 PM, the Administrator stated her expectation was expired medications would be disposed of in a timely manner.

Based on observations, resident, family and staff interviews, the facility failed to have an effective pest control program to prevent flies from entering 7 of 92 sampled resident rooms and facility common areas (Residents #26, #53, #56, #18, #28, #42 and #49). Findings included: 1a.A review of the medical record revealed Resident #26 was admitted [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] noted Resident #26 to be cognitively intact and needed limited to extensive assistance for all Activities of Daily Living (ADLs) with the physical help of one person. On 10/23/2018 at 10:28 AM an interview was conducted with Resident #26, in Resident #26's room. Flies were observed throughout the room. Resident #26 was sitting in a wheelchair and appeared to be clean and neatly dressed. Throughout the interview, Resident #26 was noted to be swatting at flies with a thin sheet of newspaper. Resident #26 stated these flies are awful, I wish they would do something about this. Seven flies were counted. Two flies would land on Resident #26's head, which was covered with a bandana, and also lite in different places on her body and bed covers. The facility Administrator was interviewed 10/23/2018 at 12:00 PM, and stated the flies needed to be taken care of and the facility had a plan in place to work on the problem. But, the administrator confirmed the facility's plan had not been implemented. 1b.A review of the medical record revealed Resident #53 was admitted [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] noted Resident #53 to be severely impaired for cognition and needed extensive to total assistance for all ADLs with the physical help of one to two persons. On 10/23/2018 at 2:00 PM, in an interview, Resident #53's family member stated she had seen flies in the room of Resident #53 and pointed to a fly swatter on the bedside table. The family member stated Resident #53 could not even wave her hand to keep flies away from her face. The family member indicated she had spoken to the administrator about the flies, but nothing had been done. In an interview on 10/23/2018 at 2:20 PM, Nursing Assistant #3 stated she had seen flies on the 200 hall for a few weeks. 2. Record review indicated Resident #56 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of a readmission Minimum Data Set ((MDS) dated [DATE] indicated he had no cognitive impairment. The MDS also indicated his vision was adequate. An observation was conducted on 10/24/2018 at 10:30 AM on the 300 Unit. Resident #56 was observed in his room lying on his bed on his back. Head of bed was elevated 30 degrees, and the resident appeared sleeping. The resident was wearing a hospital gown and a brief. The bottom of the gown was up above the brief, so the entire front of the brief was exposed. Five flies were observed flying around the resident and lighting on his legs and arms. A second observation was conducted of the resident on 10/24/2018 at 11:30 AM. He was lying on his bed and was awake. His privacy curtain was pulled around his bed, and there was a pan of soapy water on the table at his bedside. He was wearing a brief, and flies were observed on parts of his person and flying around him. When asked about the flies, the resident stated he had poor eyesight and didn't see the flies. He also stated the flies didn't bother him, because he did not see them. Numerous flies were also seen flying around his room. The resident's Nursing Assistant (NA#1) was interviewed on 10/24/2018 at 11:45 AM and stated she took him a pan of water earlier and was going to assist him to wash himself. The NA denied seeing any flies. The Administrator was interviewed on 10/24/2018 at 12:00 PM and stated the facility was aware of the fly situation and was working on eliminating them. 3. A Resident Council Meeting was conducted on 10/23/2018 that included eight residents. Four of the eight residents who attended the Resident Council Meeting reported there had been a problem with flies in the past four weeks in the facility. (Residents #18, 28, 42, and 49.) These four residents stated there had been flies in their rooms and also in common areas of the facility, such as the dining room and hallways, over the past month. The facility administrator was interviewed on 10/24/2018 at 10:45AM regarding the residents' report of flies in the facility. She reported there had been an increase in flies in the facility following the recent storms. She reported the pest control company used by the facility had been contacted about the problem. She also stated the pest control company had visited the facility since the recent storm.

Based on record review and staff interviews, the facility failed to accurately assess falls on a Minimum Data Set (a tool used for resident assessment) for 1 (Resident #1) of 3 sampled residents reviewed for falls. Findings included: Resident #1 was admitted to the facility 4/23/18. The latest Minimum Data Set ((MDS) dated [DATE] and coded as a 5 day assessment revealed Resident #1 was cognitively intact, displayed physical behaviors directed towards others, and required extensive assistance for all activities of daily living (ADLs) except eating. Resident #1 was not steady for ambulation (walking) or transfers without staff assistance, had no limb impairments, and was frequently incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. No falls prior to, or since admission were indicated on the MDS. A review of Resident #1's electronic medical record (EMR) revealed a user defined assessment (UDA) titled Interdisciplinary Post Fall Review dated 4/23/17. The post fall review revealed Resident #1 had a witnessed fall, without injury, on 4/23/18 while being assisted to the commode. Further review of the EMR revealed Resident #1 had 2 additional falls on 4/27/18 at 2:27 AM and 4:03 AM. An interview was conducted with the MDS Coordinator on 5/9/18 at 12:40 PM. He stated his sources of information for the MDS were P[NAME] (Point of Care- the system used by nursing assistants to chart ADLs), hospital records, bedside assessments, family interviews, MARs (Medication Administration Records), TARs (Treatment Administration Records), user defined assessments-which included Interdisciplinary Post Fall Reviews, nursing notes, and therapy notes. He agreed the MDS dated [DATE] was incorrect and falls were not coded in the assessment. An interview was conducted on 5/9/18 at 12:43 PM with the Administrator. She agreed falls were not coded on the MDS dated [DATE] but should have been.

Based on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission with measureable objectives and timetables to address the immediate needs of 1 (Resident #1) of 3 sampled residents reviewed for falls. Findings included: Resident #1 was admitted to the facility 4/23/18. The latest MDS (Minimum Data Set-a tool used for resident assessments) dated 4/27/18 and coded as a 5 day assessment revealed Resident #1 was cognitively intact, displayed physical behaviors directed towards others, and required extensive assistance for all activities of daily living (ADLs) except eating. Resident #1 was not steady for ambulation (walking) or transfers without staff assistance, had no limb impairments, and was frequently incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. No falls prior to or since admission was indicated on the MDS. A review of Resident #1's electronic medical record (EMR) revealed an assessment titled Interdisciplinary Post Fall Review dated 4/23/17. The post fall review revealed Resident #1 had a witnessed fall, without injury, on 4/23/18 while being assisted to the commode. Further review of the EMR revealed Resident #1 had 2 additional falls on 4/27/18 at 2:27 AM and 4:03 AM. An interview was conducted with the MDS Coordinator on 5/9/18 at 12:40 PM. He stated his sources of information for the MDS were P[NAME] (Point of Care- the system used by nursing assistants to chart ADLs), hospital records, bedside assessments, family interviews, MARs (Medication Administration Records), TARs (Treatment Administration Records), User Defined Assessments-which included Interdisciplinary Post Fall Reviews, nursing notes and assessments, and therapy notes. He agreed the MDS dated [DATE] was incorrect and should have had falls included in the assessment. An interview was conducted on 5/9/18 at 12:43 PM with the Administrator. She agreed falls were not coded on the MDS dated [DATE] but should have been.

Based on observation, staff interviews and record review, the facility failed to maintain services to meet professional standards for two of two residents receiving supplements that were not available (Residents #3 and #4). Findings included: 1. A review of the medical record revealed Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #3 to be severely impaired for cognition and needed extensive assistance for all Activities of Daily Living (ADLs) with the physical assistance of one to two persons. The Care Area Assessment (CAA) noted areas of concern about pressure ulcers and nutritional status, and these areas went to care plan. The care plan dated 4/10/2017 noted a focus of potential for nutritional problems related to poor intake. The goal was Resident #3 would have no significant weight changes through next review. The interventions included: due to significant weight loss, Resident #3 receives fortified foods and supplements. In an observation of a medication pass on 6/15/2017 at 9:05 AM, Nurse #1 stated Resident #3 was supposed to get liquid protein nutritional supplement, but there was none on the medication cart. Nurse #1 proceeded to give Resident #3 the other medications that were ordered. Nurse #1 stated there was none of the liquid protein supplement in the facility. Nurse #1 indicated she had not worked for 3 weeks and there had been none of the supplement since she had returned to work. Nurse #1 marked the supplement as not given and in the explanation area typed not available. Nurse #1 stated she did not call the physician. A review of the Medication Administration Record (MAR) for June 2017, revealed Resident #3 was to receive liquid protein supplement 30 milliliters (ml) by mouth twice daily at 8:00 AM and 6:00 PM. The MAR indicated Resident #3 had received the supplement on 6/13/2017 for both the AM and PM doses. Resident #3 had received the AM dose on 6/14/2017 and refused the PM dose on 6/14/2017. The AM dose on 6/15/2017 was indicated as other on the MAR. On 6/15/2017 at 11:30 AM, Nurse #1 stated Resident #3 did not receive the AM supplement on 6/13/2017 and 6/14/2017. Nurse #1 noted she was in a hurry, she guessed, and signed the doses as given, but there was none on the medication cart. Nurse #1 stated she did not notify the physician. In an interview on 6/15/2017 at 11:45 AM, Nurse #2 stated she did not have liquid protein supplement on her medication cart and there were three residents scheduled to receive it. Nurse #2 stated she would document the supplement was not given and fill out the order sheet at the nurses' station so the supplement would be ordered. Nurse #2 stated she would not notify the physician. On 6/15/2017 at 12:00 noon, in an interview, Nurse #3 stated she had one resident who received liquid protein supplement, and there had been one dose on her medication cart. Nurse #3 stated the supplement comes from a different company than the pharmacy, so it is written on the order sheet at the nurses' station so it will be ordered. Nurse #3 went to the nurses' station but was unable to locate the order sheet. Nurse #3 stated the physician should be notified if the liquid supplement was not given. In a telephone interview on 6/15/2017 at 3:50 PM, Nurse #4 stated she works the 3:00 PM - 11:00 PM shift. Nurse #4 stated she thought she had borrowed the liquid protein supplement from another cart when she worked on 6/13 and 6/14/2017. Nurse #4 stated Resident #3 had refused the supplement. Nurse #4 noted she would not document the supplement as given if it was not given. Nurse #4 stated there had been times in the past when there was no liquid protein supplement available. 2. A review of the medical record revealed Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #4 was unable to be assessed for cognition, but had no memory problems, either short term or long term, and could perform normal decision making tasks. The MDS indicated Resident #4 was independent or only needed supervision for all Activities of Daily Living (ADLs) with set up help only. The Care Area Assessment (CAA) noted an area of concern for nutritional status and pressure ulcer and these areas went to care plan. The care plan dated 12/24/2015 noted a focus of a potential nutritional problem related to chronic disease. The goal was adequate nutritional status would be maintained as evidenced by no significant weight changes through next review. Interventions included: Observe/document/report when needed any signs or symptoms of choking, coughing drooling, and holding food in mouth. Observe/record/report to MD any signs of malnutrition such as significant weight loss. Registered Dietician to evaluate and make diet change recommendations when necessary. A review of the Medication Administration Record (MAR) for June, 2017 revealed Resident #4 was to receive liquid protein supplement, 30 milliliters (ml) by mouth twice daily at 8:00 AM and 9:00 PM. The MAR indicated Resident #4 did not receive the liquid supplement 6/14/2017 or 6/15/2017 for the AM doses. The MAR indicated Resident #4 did receive the liquid supplement on 6/14/2017 for the PM dose. On 6/15/2017 at 11:30 AM, Nurse #1 stated Resident #4 did not receive the liquid supplement for the AM dose on 6/13/2017, 6/14/2017 and 6/15/2017. Nurse #1 noted she was in a hurry, she guessed, and signed the dose as given on 6/13/2017, but there was none on the medication cart. Both AM doses (6/14 and 6/15) were noted as other on the MAR and the reason was documented as not available. Nurse #1 stated she did not notify the physician. In an interview on 6/15/2017 at 1:45 PM, the facility Administrator stated he expected supplies to be ordered in a timely manner, and be available for resident's needs and physician orders. The Administrator noted a quantity of the liquid protein supplement had been found in a facility storage building. When? On 6/15/2017 at 2:00 PM in a telephone interview, Resident #4's physician stated he did not remember if he was called in regard to Resident #4 not receiving the liquid protein supplement on 6/14 or 6/15/2017, but he thought he was notified. The physician stated he is usually notified and will give an order to hold the supplement until it is available. The physician indicated he expects to be notified and usually is. In a telephone interview on 6/15/2017 at 5:35 PM, the Physician Assistant (PA) for Resident #3's physician stated she was in the facility at least three times weekly and always available by phone. The PA stated, in regard to Resident #3 not receiving the liquid protein supplement, if it was one dose missed, she thought that was ok. The PA stated if it was more than one dose, the physician's office should be contacted to see what could be done or to get an order for [REDACTED]. The PA said if it is more than one dose, I expect to be notified.

Based on observation, staff, Physician Assistant and physician interviews, and record review, the facility failed to notify the physician that a prescribed liquid protein supplement was not available for one of two residents sampled (Resident #3). Findings included: A review of the medical record revealed Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] noted Resident #3 to be severely impaired for cognition and needed extensive assistance for all Activities of Daily Living (ADLs) with the physical assistance of one to two persons. The Care Area Assessment (CAA) noted areas of concern about pressure ulcers and nutritional status, and these areas went to care plan. The care plan dated 4/10/2017 noted a focus of potential for nutritional problems related to poor intake. The goal was Resident #3 would have not significant weight changes through next review. The interventions included: due to significant weight loss, Resident #3 receives fortified foods and supplements. On 6/15/2017 at 11:30 AM, Nurse #1 stated Resident #3 did not receive her AM supplement on 6/13/2017, nor did Resident #3 receive the AM dose of the supplement on 6/14/2017 or 6/15/2017. Nurse #1 noted she was in a hurry, she guessed, and signed the doses as given, but there was none on the medication cart. Nurse #1 stated she did not notify the physician. In an interview on 6/15/2017 at 11:45 AM, Nurse #2 stated she did not have liquid protein supplement on her cart, that there were three residents scheduled to receive it. Nurse #2 stated she would document the supplement was not given and fill out the order sheet at the nurse station so the supplement would be ordered. Nurse #2 stated she would not notify the physician. On 6/15/2017 at 12:00 noon, in an interview, Nurse #3 stated she had one resident who received liquid protein supplement, and there had been one dose on her cart. Nurse #3 stated the physician should be notified if the liquid supplement was not given. In an interview on 6/15/2017 at 1:45 PM, the facility Administrator stated he expected supplies to be ordered in a timely manner, and be available for resident's needs and physician orders In a telephone interview on 6/15/2017 at 5:35 PM, the Physician Assistant (PA) for Resident #3's physician stated she was in the facility at least three times weekly and always available by phone. The PA stated, in regard to Resident #3 not receiving the liquid protein supplement, if one dose was missed, she thought that was ok. The PA stated if it was more than one dose, the physician's office should be contacted. The PA said if it is more than one dose, I expect to be notified.

Based on record review, staff interviews and family interview, the facility failed to ensure family notification for 1 of 1 residents transferred to the hospital by a [MEDICAL TREATMENT] center (Resident # 154). Findings included: 1. Resident # 154 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 5-Day Minimum Data Set assessment dated [DATE] revealed Resident # 154 was able to understand others and communicate effectively. Resident # 154 was listed as his own Responsible Party with four family members listed as contacts. A review of the Progress Notes for 9/22/16 at 11:06 AM revealed Resident # 154 was sent to hospital from [MEDICAL TREATMENT] after treatment. The entry was written by Nurse # 1. On 9/22/16 at 2:26 PM, Nurse # 1 documented Resident # 154 was sent to hospital after [MEDICAL TREATMENT], advised unresponsive, called (hospital) ER (emergency room ) who advised res(resident) admitted d/t (due to) unstable vs (vital signs). A review of the Progress Notes for 9/22/16 at 5:34 PM revealed Nurse # 2 documented sent to (hospital) ER from [MEDICAL TREATMENT] for unresponsiveness and [MEDICAL CONDITION]. On 9/22/16 at 9:09 PM, Nurse # 2 documented, Resident was admitted to (hospital) intensive care unit. Resident's (family member) called to inform this RN (Registered Nurse) that resident was in intensive care and on ventilator at this time and in critical condition. (Family member) states that he was not notified by [MEDICAL TREATMENT] center of (Resident # 154) being sent to hospital. DON (Director of Nursing) notified of situation. During an interview on 11/17/16 at 11:45 AM, Nurse # 1 stated she worked the 7-3 shift on 9/22/16. Nurse # 1 stated she did not call the family because the resident left the facility and was sent to the hospital from [MEDICAL TREATMENT]. Nurse # 1 stated if she had sent Resident # 154 out or if he left from the facility, she would be responsible to call to notify the family. During an interview on 11/17/16 at 11:26 am, Nurse # 2 stated she worked the 3-11 shift on 9/22/16. Nurse # 2 stated she did not call Resident # 154's family when she learned the resident was sent from [MEDICAL TREATMENT] to the hospital because [MEDICAL TREATMENT] notified the family when they sent a resident to the hospital. Nurse # 2 stated she did not know the details and would not be able to answer family questions. Nurse # 2 stated, [MEDICAL TREATMENT] always calls the family. At 3:00 PM, I assume care of my residents and am responsible for them. If I send a resident out, I call the family. When a resident leaves the facility for a consultation or other medical service, the resident is in the care of that facility and that facility is responsible for calling the family. During an interview on 11/17/16 at 11:09 AM, the [MEDICAL TREATMENT] Nurse Clinical Director (NCD) stated [MEDICAL TREATMENT] staff notified residents' family if there was a change in status or if they were sent to the hospital because [MEDICAL TREATMENT] staff were responsible for the resident while the resident was in their care. The NCD stated she spoke to Resident # 154's (family member) and explained they took full responsibility for not notifying him. It got crazy here and it was overlooked. Everyone thought everyone else had called. During an interview on 11/17/16 at 11:50 AM, the Director of Nursing (DON) stated the first they knew of Resident # 154's hospitalization was when the (family member) came telling them he was not notified of the resident being transferred to the hospital. The DON stated they do not call families if a resident is sent from [MEDICAL TREATMENT] to the hospital because they are not responsible for the resident after the resident leaves the facility and is under the care of another medical facility. During an interview on 11/17/16 at 2:05 PM, Resident # 154's Family Member stated the family was not notified by the nursing home, the [MEDICAL TREATMENT] center, or the hospital of the resident's hospitalization or that he was placed on a ventilator. He stated if (another family member) had not happened to visit the nursing home that evening, the family would not have known Resident # 154 was in the hospital. He stated the nursing home's administrative staff were not aware of the hospitalization until he told them. During an interview on 11/17/16 at 2:45 PM, the Administrator stated when the facility recently sent Resident # 154 to the ER for evaluation, the facility notified the family. However, when the [MEDICAL TREATMENT] center sent the resident to the hospital of 9/22/16, it was the responsibility of the [MEDICAL TREATMENT] center to notify the family of Resident # 154's hospitalization as the resident was under their care at the time of transfer to the hospital.

Based on observation and staff interviews, the facility failed to post nurse staffing in an area in the facility where it would be visible to residents and visitors. Findings included: On 11/14/2016 at 9:30 AM during a tour of the facility, the nurse staffing for the facility was not posted. A second attempt was made to locate the staffing on 11/14/2016 at 2:30 PM. In an interview on 11/15/2016 at 10:30 AM, the Director of Nursing (DON) stated either the Assistant Director of Nursing (ADON) or herself posted the staffing. The DON noted the ADON was busy and did not post the staffing. The DON stated her expectation was the staffing would be posted daily. On 11/17/2016 at 2:00 PM, in an interview, the Administrator stated his expectation was the staffing would be posted daily.

Based on record review, staff and resident interview it was determined that the facility failed to provide pain medication as ordered by the physician for 1of 3 resident ' s (Resident #2) interviewed regarding pain medications. Findings include: Record review revealed the resident had a [DIAGNOSES REDACTED]. Record review revealed the physician ordered [MEDICATION NAME] sulfate 15 mg 1 tablet twice a day for pain on 5/26/16. Per review of the minimum data set assessment 6/27/16 the resident ' s brief interview of mental status score was 15, indicating that the resident was alert and oriented. Review of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] was also listed as not available on 7/17/17 at 8:54 AM. During Interview with resident #2 at 1:40 pm on 7/17/16 he stated that the facility was out of [MEDICATION NAME]. He stated that the nurse told him that morning that they did not have any [MEDICATION NAME] at the facility and it was on order. The resident stated he was supposed to receive [MEDICATION NAME] twice a day. He stated that he was having pain in his hands. Interview with the Assistant Director of Nurses (ADON) on 7/17/16 at 3:03 PM revealed that orders were put in for [MEDICATION NAME] every 4 hours until the MS Contin, ([MEDICATION NAME]) arrived. She stated the resident was given Tylenol which he said was effective. The ADON stated that the resident gave out of [MEDICATION NAME] late yesterday evening. The ADON reported that the [MEDICATION NAME] was reordered for the resident on 7/16/16. She stated that staff is supposed to pull from the striker and reorder medication from the pharmacy when the resident gets down to 4 tablets. Interview with the resident at 4:41 pm revealed that the Tylenol relieved the sharp piercing pain but the throbbing still came through. The resident stated that he requested [MEDICATION NAME] yesterday (7/16/16) twice between medications and was given Tylenol. He stated that he asked for [MEDICATION NAME] twice on 7/17/16. Interview with the Director of Nurses on 7/17/16 at 5:30 PM revealed that the resident took [MEDICATION NAME] for chronic pai[DIAGNOSES REDACTED]. Interview with the facility pharmacy staff at 5:42 PM on 7/17/16 revealed that he had documentation of the request 6/30/16 when the [MEDICATION NAME] was filled initially and the request that was received on 7/17/16. He stated did not see any other requests for the [MEDICATION NAME].

Based on observations, record review, and staff, pharmacist, and MD interviews, the facility did not accurately transfer a medication order for eye drops onto the resident ' s Medication Administration Record, [REDACTED]. Findings included: A review of the Nursing Admission Data Collection assessment dated [DATE] revealed Resident #224 was admitted from a local hospital on [DATE], that he was cognitively intact, and that he required limited assistance with bed mobility and transfers. A review of the discharge summary and medication orders dated 12/01/2015 from the hospital revealed an order for [REDACTED]. In an observation of medication administration for the resident on 12/03/2015 at 10:00 AM, Nurse #3 checked the Medication Administration Record [REDACTED]. Nurse #3 noted that there were no [MEDICATION NAME]-[MEDICATION NAME] eye drops or ointment in the cart. Nurse #3 also noted that the [MEDICATION NAME] eye drop medication order on the administration record was as follows: [MEDICATION NAME] Ointment 0.3-0.1%, instill 0.3 drop in both eyes four times a day for dry eyes. Nurse #3 stated she would need to clarify the number of drops to administer before administration and also would need to check the availability of the eye drops. Nurse #3 left the medication cart at 10:10 AM and then returned to the cart at 10:20 AM, stating that the order was clarified to be [MEDICATION NAME], 0.3-0.1%, one drop in both eyes four times per day, and that the eye drops were on order. Nurse #3 then entered the Resident #224 ' s room and administered his oral medications. While Nurse #3 was in the resident ' s room, she noted a bottle of eye drops on the bedside table. Nurse #3 collected the eye drops and placed the eye drop bottle in a clean plastic glove, then asked the resident why these eye drops were in his room. Resident #224 replied that he had been taking them because his eyes felt gritty, and that he had taken them about 6:00 AM that day, 12/03/2015. An observation of eye drop medication bottle which had been on Resident #224 ' s bedside table revealed it was a non-antibiotic eye drop. It was not [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]), the ordered eye medication. Nurse #3 stated in an interview on 12/03/2015 at 10:35 AM that she checked the availability of the [MEDICATION NAME] eye drops and learned that they were on order but had evidently not arrived yet. Nurse #3 explained that day (12/03/2015) was the first day she had administered medications to Resident #224 since his admission on 12/01/2015. Nurse #3 further explained that the Medication Administration Record [REDACTED]. In an interview with the pharmacist on 12/03/2015 at 1:40 PM, he stated that generally, if a medication was ordered from the pharmacy before 5:00 PM, it would be supplied the same day, and that if it is ordered after 5:00 PM, it would probably be delivered the next day. The pharmacist also stated that an order could still be filled after 5:00 PM on the same day if the nurse in the facility called to alert the pharmacy that it was needed. In addition, the pharmacist stated that MEDICATION ORDERS FOR [REDACTED]. In an interview with the Medical Director on 12/03/2015 at 1:55 PM, he stated that he would expect for medications to be given as ordered, and that if a medication for a new admission needed clarification, he would expect the nurse to contact him. The Medical Director also stated that if a clarification needed to be made with the pharmacy so that a medication could be supplied, he would expect the nurse to contact the pharmacy. The Medical Director also stated that if a resident had previously been taking a different eye drop than what was ordered, he would want to be notified so that he could evaluate whether the new eye drop medication was necessary, or if the resident ' s eye drops were sufficient. An interview was conducted with the pharmacy technician on 12/03/2015 at 2:22 PM. During the interview, she stated that the pharmacy received an order for [REDACTED]. She explained that the original order was to instill 0.3 drops of [MEDICATION NAME] ointment, which did not make sense. The pharmacy technician added that the order was updated with the pharmacy on 12/03/2015 to instill 1 drop for each eye instead of 0.3 drops, but that the order was still written as an ointment instead of drops. She explained that an alert was placed with the facility electronically after the original order on 12/01/2015 to clarify the order so that the eye drops could be supplied to the facility. The pharmacy technician stated she spoke with Nurse #3 on 12/03/2015 and that she informed her that the [MEDICATION NAME] eye medication might be discontinued. In an interview with Nurse #5 on 12/03/2015 at 2:52 PM, she stated that Nurse #4 had completed the first check of admission orders [REDACTED]. Nurse #5 explained that the MEDICATION ORDERS FOR [REDACTED]. She explained that Nurse #4 must have entered the eye drop strength (0.3-0.1 %) instead of the correct number of eye drops (1) to be administered in the electronic system. Nurse #5 stated she did not see this error when she checked the orders for the second time. Nurse #5 also stated she did not see the incorrect form of the eye drop medication as an ointment instead of eye drops on the MAR indicated [REDACTED] dry eyes, as was reflected on the MAR. In an interview with the Director of Nursing on 12/03/2015 at 3:00 PM, she stated that there was an action plan in place to facilitate the transition from the paper MAR indicated [REDACTED].